KPMG US

As a Principal at KPMG, my role revolves around using my management consulting skills to provide financial analysis and strategic business planning guidance. I work closely with healthcare executives, empowering them to navigate the complexities of budgeting within the evolving landscape of healthcare payments. By cultivating leadership development and leveraging my analytical skills, I help these professionals sustain and grow their organizations effectively.

Principal

Managing Director

Director

American Heart Association

As a member of the executive leadership team for the American Heart Association's Heart Walk, I leverage my skills in management consulting and leadership development to drive fundraising efforts, community engagement, and awareness campaigns. I am deeply involved in budgeting and financial planning for fundraising activities, utilizing my analytical skills to maximize efficiency and reach. My role is focused on raising awareness about the impact of heart disease and stroke in Maryland, forging strong connections with the community, and providing strategic guidance to optimize our mission's impact.

Heart Walk Executive Leadership Team Member

Healthcare Financial Management Association (HFMA)

In my previous role as President of the Maryland Chapter of the Healthcare Financial Management Association (HFMA), I led a professional network of financial executives in the healthcare sector. I applied my management consulting expertise and financial analysis skills to oversee educational development and foster leadership development within the organization. A significant part of my work involved guiding members in comprehending and navigating the intricacies of healthcare payments, budgeting, and analytical techniques, thus contributing to their individual growth and the overall advancement of the chapter.

President of Maryland Chapter of HFMA

I am a Principal at KPMG, where I use my management consulting skills to provide financial analysis and strategic business planning guidance to healthcare executives. With a Masters of Health Science from The Johns Hopkins University, I have a strong background in health finance and management, which enables me to navigate the complexities of budgeting within the evolving landscape of healthcare payments.

My role is focused on empowering healthcare professionals to sustain and grow their organizations effectively, by cultivating leadership development and leveraging my analytical skills. I have delivered keynote speeches at healthcare conferences, trained professionals at Johns Hopkins Bloomberg School of Public Health, and advised executives on payment policy design for maximum community impact. I am also a member of the executive leadership team for the American Heart Association's Heart Walk, where I drive fundraising efforts, community engagement, and awareness campaigns. I am passionate about collaborating for a sustainable future.

James Case

Chief Consulting Officer, HealthMine

Melissa Newton Smith

Earlier this week, #CMS released new research which challenges much of the recent discussions surrounding #MedicareAdvantage #RiskAdjustment and the comparative cost of #MA compared to Traditional #Medicare.

In short, the dominant recent narrative has been that MA “over-codes” by ~10% relative to Original Medicare. This new analysis using PY2022 data and the now-fully-implemented V28 RA model indicates only 1.5-2% “uncorrected” coding intensity in MA after statutory and policy adjustments.

Especially given recent signals of looming RA reform, supported by the 2027 MA RFI, this 5-7x difference between the new study compared to that used in recent policy considerations is worth all plans, risk- and #VBC providers, and vendor stakeholders paying close attention to ~ and commenting to CMS if this alters or reinforces your existing posture on the RFI.

In particular, this study:
➡️ Suggests V28 may have already neutralized most of the historical coding differential
➡️ Signals that the cost differential between MA and TM may now be due to actual clinical signal
➡️ Contradicts much of the evidence used to support the storyline justifying future RA redesign
➡️ Raises a real question about whether CMS should continue accelerating risk adjustment overhauls as suggested in November’s RFI

In and of itself, this study may not make headlines, but it certainly has the potential to reshape or delay significant risk adjustment model changes a bit.

This is important because Risk Adjustment isn’t just an exercise in coding. It’s how we thoughtfully fund the health care for aging, ill persons fairly in ways (1) they are entitled to receive, and (2) which ensure MA plans can confidently enroll all beneficiaries and reasonably pay for the care and medications they need. If CMS over-corrects, it wouldn’t just tackle coding behavior, but rather it could punish plans serving sicker, more complex beneficiaries.

At a minimum, this paper likely slows the conversations down. Worth reading carefully. And worth watching the next steps very closely.

Link to article:

Government Programs Advisor & Consulting Leader: MA Expert with Expertise #BeyondStarRatings

Open article: An Updated Analysis of Coding Pattern Differences in Medicare Advantage by academic.oup.com

An Updated Analysis of Coding Pattern Differences in Medicare Advantage

Today's #MedPAC #MedicareAdvantage Program Status Report is, as expected, heavily focused on coding intensity in #MA and the resultant costs of MA vs Traditional #Medicare. With MA spending almost $80 billion higher than it would have been in FFS, and with the heavy dose of coding and #RiskAdjustment analysis in the report, this all but guarantees we'll see Risk Adjustment, rate and potentially #StarRatings #QBP reform sooner rather than later as this administration tackles payments to "insurance companies" before their tenure ends.  Buckle up, friends. Solutions to this issue are gonna be bumpy....

Most #MedicareAdvantage #StarRatings conversations skip HR entirely. Which is wild, because aligned effort is the single most impactful #Stars execution lever #MA plans have, and misaligned labor is the most easily leveraged investment to sustain 4+ stars and reduce Stars team burnout.

Here are 5 things #HR can do right now for sustainable Stars (and P&L) success:
1️⃣ Integrate Stars into Job Descriptions and Performance Reviews
We can’t expect people to prioritize Stars needs/nuances when their pay, bonuses and job security anchor to other priorities. JDs and bonuses often use criteria different from Star needs and nuances, leaving the Stars team to rely on personal influence and superhuman effort to coax people into doing the work needed to hit goal. Aligned JDs and annual reviews results in fewer Stars emergencies and reduced unplanned spending.

2️⃣ Hire for MA needs, not generic org charts
Hiring people without knowing whether they can relate to and help old, frail and disabled people (and their scared, worried, frustrated caregivers) is how plans end up with smart people who can’t move measure scores. Hiring for MA prowess and knowledge is a crucial aspect of a sustainable Stars strategy.

3️⃣ Educate continuously; Start at Onboarding
Every CEO says “Stars is a top priority.” Yet, now that MA and Stars are mature, most staff are not taught how measures relate to routine operations or daily duties. Professional development and education is an HR function, not a default duty of the Stars team. (#StarsProTip: If you’ve outsourced core activities rather than staff internally, include all vendor personnel.)

4️⃣ Teach managers to manage to Stars
Stars misses don’t usually happen because people don’t care. They usually come from misaligned priorities and vague expectations. As an example, in CS, #CAHPS measures CSRs’ courtesy, respect and provision of info/services needed during calls. But KPIs often focus on ASA, handle time and FCR from the PLAN’s perspective. When job expectations conflict with measure needs, staff follow HR not the Stars team.
 
5️⃣ Eliminate Single Points of Failure 
A person who knows they are the only person who knows something critical is a massive risk. Losing the one person who knows how to run HEDIS, who understands your providers, your data quirks or history often results in multiple years of Stars misses. Examine every role to identify SPOFs (your Star leader likely knows who they are), then accelerate remediation. 

None of this shows up as “Stars HR” in the Stars workplan. It shows up as:
⭐ Fire drills owned/paid for by the Stars department.
⭐ Redundant vendors.
⭐ Volatile performance.
⭐ Executive confusion when ratings miss goal.
Everyone has a role. This is how HR shows up in its role without ever having to say “quality culture” again.

#RadicalExecution > #StarsUnicornsandRainbowDust 
If you need help aligning operations with Star needs, please reach out. We’d love to help.
#EveryDepartmentHasARole ⭐❤️

Heads Up #MedicareAdvantage #StarRatings teams! The news below will undoubtedly expand your cash claims leakage on
#PartD Medication Adherence measures (which has been the bane of my Stars passion projects in the last decade!), and will likely introduce enough noise to render those measures removable from #Stars for MY2026. If you are still formulating your feedback to #CMS regarding the 2027 Proposed #MA rule, please share this with your policy/federal team to make sure your voice and requests are heard for Star-related relief!

Updated to add a few additional crucial links to related information for those incorporating this into their CMS feedback:
-MedPAC is increasingly focusing on direct-to-consumer medication fills (and the new CMMI GLP-1 model formally adopts payment policies outside of Part D benefit coverage which will compound this): www.medpac.gov and https://lnkd.in/gFa9hjFz
-Per WSJ: Early mail-order refills, especially by vertically integrated plans and their PBMs are driving $3 billion of #Medicare costs, including some degree of unarguable waste per FWA guidelines, with commentary from both a National plan and industry actuaries indicating that these early fills are impacting MA Star Ratings: https://lnkd.in/ghkNFpke
- Per Forbes, Mark Cuban's direct to consumer (and risk-bearing provider) drug fulfillment increasingly resonates with providers and consumers: https://lnkd.in/ghkNFpke


#IYKYK .....

https://lnkd.in/gr6rRCvW

Open article: Surescripts and GoodRx Partner to Advance Patient Price Transparency by surescripts.com

Surescripts and GoodRx Partner to Advance Patient Price Transparency

#ICYMI : Heads Up #MA friends: If QBP is the only ROI you’re using to justify #Stars spending or FTEs, the article below is worth your time to read. 

The Paragon Institute just dropped a new exposé on #MedicareAdvantage Quality Bonus Payments attached to 4+ #StarRatings which should give every MA plan leader pause.

For the last decade, QBPs have quietly become an easy, default business case for #QualityImprovement:
⭐ “We need to do this to earn QBP.”
⭐ “The ROI is QBP preservation…if we don’t, we might lose QBP.”
⭐ “Without this, we risk our bonus.”

That logic has been fragile for several years. It’s now increasingly politically fragile too.

This administration has shown clear philosophical and policy alignment with Paragon’s views on a wide array of issues. And with this new posture on MA Quality incentives, any workplan elements using QBP as the sole ROI likely warrant rapid redesign to harvest other ROI as primary and/or to bolster QBP ROIs with expanded design/tactics.

This doesn’t mean stopping improving quality improvement activities, walking away from Stars tactics or panicking. But it does mean:
✅ Re-interrogating your Stars investments and activities.
✅ Enhancing  efforts for “ROI impact” beyond QBP.
✅ Pressure-testing what activities would still makes sense to invest in if QBP was reduced, reshaped, or removed entirely.

➡️ Stars work that truly improves #accesstocare, #memberexperience, coding/documentation and health outcomes will survive any administration.
➡️ Stars work justified solely by QBP math may not survive this one.

Please read Paragon’s piece. Then ask yourself, your CEO and your CFO some harder questions. Because the ground under MA Star Ratings incentives is shifting, whether we like it or not.

Open article: Following Yonder Stars: CMS Makes Changes to MA and Part D Quality Ratings by paragoninstitute.org

Following Yonder Stars: CMS Makes Changes to MA and Part D Quality Ratings

The market’s negative reaction to yesterday’s #CMS 2027 #MedicareAdvantage Advance Notice is a stark reminder of the scale and consequences of both our work and the policies that underpin it. Nearly $90 billion in market capitalization evaporated within 24 hours of the release of the essentially flat draft 2027 payment rates, which are a warning shot from this administration to #MA plans.

While actuaries and #PartD experts unpack the rates and benefit proposals, here are 3 things to know about #Stars and #RiskAdjustment proposals:
1️⃣ The Advance Notice can only signal Star measure additions and removals; rulemaking is required to implement them. CMS floated 2 more measure removals, and several technical measure updates. #NCQA is considering changes to TRC and PCR that would trigger at least temporary retirement (see below in YELLOW).

2️⃣ CMS is exploring changing the complex cutpoint clustering methodology used to assign non-CAHPS ratings to a simpler, more easily administered method.

3️⃣ Proposed removal of HCCs from audio-only services (including at FQHCs) and removing unlinked chart review records from #RiskAdjustment is a significant headwind with impact that will vary by contract.  Silence on HCCS only from in-home assessments was surprising.

And here are 3 things you can do right now:
✅ Don’t panic. Final rates are almost always more favorable than Advance Notice draft rates. This administration has a track record of floating ideas that differ from final, codified reality.  These are just drafts for now.

✅ Get rigorous about your P&L. MA runs on tight margins, and flat rates signal that CMS expects more, and better, execution. There is no longer room for unmanaged care for members with MLR >85% (and we HAVE to get them accurately risk adjusted!) or wasteful spending on weak or fragmented engagement, interventions and outreaches. Audit all expenses and overhead allocations for technical precision and 2027-proofed impact. Eliminate redundancy. Redirect or enhance all spending toward precise, high-impact changes. Start now.

✅ Stop assuming that risk-bearing contracts alone are changing behavior. Most practices and facilities are focused on increasing throughput and revenue-cycle optimization (which increases your cost base.) There is an immense amout of backlogged modernization and alignment work to be done in the provider space, which if done well can reduce spending and reliance on chart reviews.

As always, we strongly encourage every plan and impacted providers/vendors to submit comments to CMS. CMS is required to review all comments and feedback received, but they are not mind readers. Fewer than ~170 MAOs exist, and only a small subset consistently weigh in on consequential proposals. Those who choose not to sit at the table place their fates in the hands of those who do.

If you need help modernizing your MA operations, evolving your  #StarRatings strategy or formulating a response to CMS, please reach out. We’d love to help.

Known & Proposed Changes_Jan2026

Yesterday’s #MedPAC examination of #PartD post #PartRedesign and the #IRA was excellent. The slide below, in particular, warrants attention from #MA plans.

While we often talk about SEPs and beneficiaries’ ability to move back to Traditional #Medicare if they’re unhappy with their #MedicareAdvantage plan, the real-life viability of that option has become increasingly fragile as: 
➡️ Stand-alone PDP premiums have rised sharply (even after buy-downs)
➡️ MA-PD premiums remain comparatively lower

If you’re in MA, why should you care? Because the premium differential for a beneficiary to disenroll and return to Original Medicare may be insurmountable, leaving dissatisfied members and members unable to access/afford their drugs/care in your plan as measured in #StarRatings by the #CAHPS measures. 

This is truly an excellent example of the crucial impact of formulary and bid design on #Stars which generally receives far less attention during bid season that it deserves. Essentially, this illustrates that their historical “escape hatch” is (or may already be) eroding, leaving the concept of TM as an option for unhappy members theoretical instead of realistic. #ThisIsCAHPS

What MedPAC highlighted is worth a close look…up later today is the Medicare Advantage program Status Report. Sure to be full of important insights!

Link to meeting agenda/materials: https://lnkd.in/gZPkPxBp

With P&L pressure and #Stars changes mounting, vendors are racing to #MA plans and #StarRatings teams with AI pitches. While I totally get the importance of AI in almost every activity, process and function, I’m increasingly worried about the narrowness of the Use Cases that even the best vendor can accomplish without applying their AI concepts to the customer’s “Master AI Hub.” 
Just think for a minute….even the best, most technologically progressive vendor’s application of AI is fundamentally constrained by two things:
1️⃣ The definition of services in their contractual scope, and
2️⃣ The breadth of data they possess (since the AI can only be applied to that data.)
No matter how sophisticated an #AI model is, Use Cases applied in narrow operating segments is not transformation. It’s optimization at the edges.

The real power of AI in #MedicareAdvantage or Managed #Medicaid will only be unlocked when it sits at/on a plan’s singularly-selected master source of data. That master source doesn’t need to be perfect. AI can/will navigate unreconciled, incomplete data...it doesn’t even need to be complete.

We just need to be intentional, precisely designed and owned by an Operational Leader who understands the full spectrum of health plan operations and needs.

If you’re thinking beyond demos and pilots and asking, “How do we make AI a core capability, not just another #Medicare point solution,” we’d love to chat.

While many of us put the finishing touches on our home preparations for Winter Storm #Fern, don’t forget this may add another layer of complexity to MY2026 #MA #Stars strategy.

It’s possible that between 8 and 12 states (maybe ~150-250 counties) may potentially wind up designated as FEMA disasters which trigger the Extreme & Uncontrollable Circumstances (#EUC) relief in #MedicareAdvantage #StarRatings.

Especially if your service area is looking at ice storms or historical snowfall, here are a few things you can set a reminder to do next week once we know the full extent of impact (even if #FEMA disaster declarations aren’t yet finalized): 
1️⃣ Develop a rough idea of what percentage of your members are in impacted areas. Contract-level relief is available when >25% of the contract’s members live in impacted areas.

2️⃣ If your contract is at/above 25% of impacted membership, assign someone to track FEMA disaster declarations. If counties known to be impacted don’t receive FEMA declarations with Individual Assistance (which are different than state declarations), work to get them properly declared as qualifying disasters.

3️⃣ Do not wait to adapt! Once you know your contract qualifies for EUC relief, revisit MY2026 Stars strategy implications. Incorporate “EUC relief scenarios” into initial MY2026 Stars dashboards, and revisit budget/investment decisions once the measures receiving relief are known. 

Plans who understand EUC mechanics, including impact on cutpoints, and leverage them as soon as they are known often benefit dramatically, while others are surprised months later when cutpoints and bonuses move. Details of the EUC policy are located in Attachment P of the Technical Notes (see excerpt below.)

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Performance Score.css-goub6s{font-size:var(--chakra-fontSizes-md);font-weight:500;color:var(--chakra-colors-gray-600);display:block;margin-top:var(--chakra-space-1);}Melissa Newton Smith's LinkedIn Performance

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