We Support The Healthcare Industry! For this event, SSN is proud to offer FREE admission
to employees of health plans and hospitals as a thank you for all you do for all of us.


Speaker Presentation
Monday, January 27, 2020
Pre-Conference In-depth Workshop Series
($300 ALL ACCESS WORKSHOP PASS to any or all 3 of the pre-conference workshops)



Workshop A:
Stars Tutorial: An In-depth Look at Preparing for and Implementing New and Proposed CMS Measures

When talking about Star Ratings, the question is often asked, "what year are we talking about?" The Stars work being done today may be for ratings that may be 3 years away. In this workshop, we will discuss potential changes coming in the next two years, and share what workshop participants are doing to prepare. Some of the topics will include:

  • Impact of measures that are being removed
  • Changes in weight for experience measures
  • Going away and coming back with changes for the Plan All Cause Readmission measure
  • Polypharmacy measures
  • Transitions of Care measures
We look forward to a lively conversation and sharing of information and approaches to addressing potential changes.

Noreen Hurley,Manager, Product Strategy, Member Experience and Star Quality,Harvard Pilgrim Health Care

Gregory A. Hanley, FACHE, CPHQ,Vice President, Quality Management & Pharmacy,UCare


Workshop B:
Integrating Telehealth Benefits – Improving Member Satisfaction & Outcomes While Decreasing Costs

Telehealth – from face-to-face synchronous video to remote patient monitoring to provider-to-provider consults – is growing in popularity with consumers and providers across the country. Delivering care remotely can allow plans to see cost savings, increased satisfaction, and improved outcomes. Traditionally, Medicare policy has held back the adoption of telehealth, but new federal policy changes are opening the door to innovation. This session will focus on new and upcoming opportunities for MA plans to incorporate telehealth and how the industry is responding. The facilitator will provide an overview of updated regulations and policies that expand access to telehealth in MA and then open it up to a dynamic discussion about what types of telehealth plans have had success or failures with, what is in the pipeline given the new flexibility, and what barriers remain.

Megan S. Herber,Director, Faegre Baker Daniels Consulting,Policy Consultant, American Telemedicine Association


Workshop C:
Competitive Planning for Success Amidst Emerging Opportunities and Challenges:
SDOH, New Star Measures, Supplemental Benefits and Data Interoperabilty

As the industry experiences an era of unprecedented change, successfully operating an MA plan has never been more challenging. We’ll talk about pragmatic approaches being used to evolve with the industry and how to prioritize efforts and investments among competing priorities. This session will focus on topics such as:

  • New and changing Star measures
  • Expanded health-related supplemental benefits and special supplemental benefits for the chronically ill
  • Data interoperability
  • Emerging investments and solutions to solve for SDOH

Melissa Smith,Senior Vice President, Stars & Strategy,Gorman Health Group


Close of Workshops

Tuesday, January 28, 2020
Industry Firsts: Top Quality Innovations to Boost Plan Performance

Registration & Continental Breakfast


Chairperson’s Welcome and Opening Remarks

Christine Leo, Vice President, Senior Products,Cigna


Person-Centric Value-based MA Models Focused on Core Benefit Design, Healthy Members and Communities

UPMC is an integrated delivery system having world-class hospitals and clinics combined with a 4.5 STAR Rated health plan; however, it is not a staff model like Kaiser. There is a working tension between the two so the need to foster alignment is incredibly important. To that end, UPMC has worked to create and foster mutual incentives and value structures designed to systematically promote personalization and patient-centeredness for years.
This synergistic approach informs how we view “health.”
The future we are creating today is being designed with health at its core rather than conditions or social determinants or any other influencing factor as the driver of effort…
This session will explore how to overcome the payment model tension; redefining health; and how those actions produce quality outcomes and cost effectiveness.

Angela Perri, Vice President, Strategic Alignment, Transformation & Consumer Innovation, (Business Transformation Office),UPMC Health Plan


The Business Case for Population Health:  How Humana Integrates Social Determinants of Health to Reduce Costs, Boost Quality of Care and Enhance Member Experience

In 2015, Humana created a Bold Goal to improve the health of the communities it serves by 20 percent by 2020 and beyond. This means improving Health-Related Quality of Life, measured using CDC’s Healthy Days tool, by addressing social and clinical needs that impact physical and mental health. By collaborating with community-based organizations, Humana works to address Health-Related Social Needs (HRSN) - the social determinants of an individual’s health.
Social needs gaps can prevent people from accessing healthy food, physical activity and social connections critical for a happy, healthy and purposeful life. The prolongation and exacerbation of social needs gaps puts individuals at higher risk for new chronic conditions, progression of current disease, and is strongly associated with higher healthcare resource utilization and total cost of care.  We are integrating Social Determinants of Health and Health-Related Social Needs into everything we do at Humana – from developing advanced analytic tools to working with physicians to testing new interventions to integrating into current clinical operating models. 

By addressing Social Determinants of Health and improving Healthy Days, we expect to lower healthcare resource utilization and lower total cost of care. This creates the business model that allows us to sustain and scale our population health strategy.

Caraline Coats, Vice President, Bold Goal & Population Health Strategy,Humana


Panel Discussion: Designing, Implementing and Managing New Quality Initiatives that Increase Plan Performance


Kevin Barton, Area Vice President for Business Development,Tabula Rasa HealthCare


Amy Sepko, Medicare Program Manager,Health New England

Scott Mancuso, MD, Chief Clinical Officer,Landmark Health

Christine Muldoon, VP Marketing & Strategy,WebMD Health Services

Chris Nicholson, Co-Founder and CEO,mPulse Mobile


Networking Refreshment Break


Challenges, Opportunities and Strategies for Payers Looking to Grow Medicare Advantage Lines of Business

With 11,000 Baby Boomers turning 65 every day, it’s no wonder health plans are actively growing their Medicare Advantage businesses. To learn more about how payers are approaching this growing market, HealthEdge and independent research firm Survata surveyed more than 200 Medicare executives on their growth plans and strategies around Medicare Advantage. This session will explore the drivers, considerations and strategies that health plans are considering to capitalize on this significant opportunity.

  • The value-based model of care for Medicare Advantage is a considerable factor in health plans’ decisions to grow their Medicare Advantage line of business and helps support healthcare’s triple aim
  • Health plans must consider that Baby Boomers are digitally-savvy and use online means to shop for coverage and participate in their healthcare; a poor member experience will send Boomers elsewhere, and this trend is only going to grow as younger, more tech-savvy generations age
  • Considering social determinants of health - as newly emphasized by CMS and supported by the value-based nature of Medicare Advantage - will play a critical role in keeping Medicare Advantage beneficiaries in good health, as the Boomer population is and will continue to be affected by socioeconomic and demographic factors

Harry Merkin,Vice President, Marketing,HealthEdge


Quality Innovations for Special Needs Plans – CSNPs, DSNPs, ISNPs

Every plan faces a variety of challenges to growing membership, achieving performance objectives, balancing costs and care, but Special Needs Plans face challenges that can be even more daunting. Overcoming those challenges requires innovation and strategic planning. This session will provide a high-level overview of Special needs plans and their unique challenges and provide insights that have helped Gateway Health plan achieve performance goals and build a strategic plan for a successful future.

Dan Weaver Vice President,Stars Quality,Gateway HealthFormerly Director of Program Management, Government Business, Quality ImprovementHighmark

Kent Holdcroft,EVP, Enterprise Accounts & Strategic Partnerships,AdhereHealth


Using Technology to Democratize Care and Improve Health Outcomes

While the trend in healthcare insurance is to move towards value-based care and risk-based contracting, the side effect of this approach is a narrowing of the provider network. At Clover, in contrast, we want our members to be able to go to any doctor who will accept our payments. But how?

This session will explore how Clover is using technology -- not contracting -- to improve health outcomes in its MA population, regardless of the provider network. It will also cover technologies aimed at predicting and preventing adverse health events in chronically ill seniors.

Aaron Berry,Director, Tech Strategy + Product Portfolio,Clover Health


Solving Medicare Advantage Operational Challenges with AI

MA plans are under increasing pressure to provide correct, timely reporting to CMS around patient risk and quality performance, and to reduce abrasion with provider partners. Artificial Intelligence (AI) is being deployed by leading MA plans across the nation to streamline workflows and improve the accuracy of key operational activities. This session will explore how AI can support risk, quality, and provider outreach programs and showcase some of the AI applications available in the market today.

Terry WardSenior Vice President of SolutionsApixio


Networking Lunch

Sponsored By: Strategic Solutions Network (SSN), based in Boca Raton, FL, is the parent company of the Medicare Risk Adjustment & Revenue Management Management, Plus Quality and Star Ratings and a series of related conferences.


How In-Home Care Can Help Improve Outcomes and Reduce Potentially Avoidable Hospitalizations

NY-Based Premier Home Health Care found a recipe for success by utilizing real-time data from the home, collected by home health aides, to drive positive outcomes, meet quality incentive measures and help reduce potentially avoidable hospitalizations in the post-acute setting.

Jennifer Gentzlinger,Vice President, Strategic Development,Premier Home Health Care Services

New Product Development – Supplemental Benefits Including Social Determinants of Health (SDoH) and Flexible Benefits in the New Value–Based Care Environment

What Consumers Want from Value-adds and (New) Supplemental Benefits

Get new research study results on Medicare Advantage consumer preferences for supplemental and value-added benefit offerings on a national, regional and local level. Explore the variations between what is offered and what consumers expect from their insurance coverage. Get new data on rising senior populations’ interests from a recent consumer insights online panel.

Michael Spicer,Director of Product Innovation & Research,Capital District Physicians’ Health Plan


Flexible Benefits: Targeting the Right Customers With the Most Relevant Benefits

  • What do your customers think they want?
  • What do you think or know your customers need?
  • How do you bring those two perspectives together to create value for your customers and for your plan.

Christine Leo, Vice President, Senior Products,Cigna


Networking Refreshment Break


Panel Discussion: Social Determinants of Health -- Focus On Implementation & ROI

There are many factors woven into the success of SDoH programming including (but not scratching the surface) accessibility, affordability, willingness to change, support system to sustain the changes. How are others addressing these factors and leading programs at scale?


Harry Merkin,Vice President, Marketing,HealthEdge


Amanda Hazer,Director of Population Health,Oscar Health

Kevin Moore,Vice President, Policy – Health and Human Services,UnitedHealthcare

Catherine Macpherson,VP, Product Strategy and Development, Chief Nutrition Officer,Mom’s Meals

Patrick Finnerty,Senior Advisor for Oral Health Programs,DentaQuest

Boosting Plan Performance Measures: STARS, HEDIS and More

Product Strategy, Member Experience & Star – Working Together For Success

Medicare Advantage success relies on leveraging multiple components. Organizational alignment will vary with each company and “optimal” organizational structure is not easily defined. Harvard Pilgrim has recently created a new department that combines Product Strategy, Member Experience and the Star Program. We have found synergies between these areas that were not initially expected that will enable us to improve our overall performance. These are dynamics that can be leveraged in any MA plan regardless of “official” organization, and we would like to share them with you.

Noreen Hurley,Manager, Product Strategy, Member Experience and Star Quality,Harvard Pilgrim Health Care


Not Just Growth. Profitable Growth!

Health plans must discover and satisfy the complex and varied preferences of current and potential members in order to sustain profitable operations and achieve strategic growth. This requires a 360- degree view of each member that accounts for personal differences, predicts choices, and determines health risk factors – while also engaging them more productively in their own health. In this session, you will learn:

  • How to go beyond survey response reporting by utilizing data visualization dashboards and predictive models that dynamically add demographic, socioeconomic, SDoH, and geographic data
  • How to capture the direct voice of the consumer through targeted email surveys delivered strategically during the plan year
  • New strategies for achieving a granular, data-driven complete view of your plan consumers
  • Tactics for optimizing plan performance and member engagement for sustainable growth

Kurt Waltenbaugh,CEO,Carrot Health

Tim Brousseau,Vice President Client Services,Deft Research


Deliver an Enhanced Member Experience by using Design Thinking Strategies to Streamline Processes and Improve Employee Engagement

Across healthcare, organizations are hyper focused on the member experience. We talk a lot about member engagement, but how can organizations make forward progress that is cost neutral, and a win for employees? When employees are satisfied, the member experience improves. We’ll talk about opportunities to streamline internal operations and how decisions to be more efficient help both your employees and the customer. We’ll focus on opportunities to support member facing employees as they resolve complex member issues.

Jenny Graham,Partner,Zelus Consulting Group


Networking Reception

Wednesday, January 29, 2020

Networking Continental Breakfast


Chairperson's Remarks

Gregory A. Hanley, FACHE, CPHQ,Vice President, Quality Management & Pharmacy,UCare


“And the Winner Is…”
An Awards Presentation for 2020’s Best Performers in Open Enrollment and Benefit Innovations

By late January 2020, we will know which Medicare Advantage Organizations gained the most enrollment and which MAOs are offering the most interesting new benefits. In this session, see who gained in 2020 enrollment, who is offering the most innovate benefits, and consider the correlation between the two. Discuss with Mike Adelberg, former Director of Medicare Advantage Operations at CMS, what we might see from CMS in 2020 and what benefit trends might influence 2021 bids.

Michael S. Adelberg,Principal, Lead, Healthcare Strategy Practice,Faegre Baker Daniels ConsultingFormerly, Director of Medicare Advantage Operations CMS


Innovative Benefit Designs with Automated Competitive Analysis, Underwriting, CMS PBP Submissions, Doc Generation (ANOC, EOC, SB, Kits, Highlight sheets)

  • How to create innovative benefit designs
  • Automated Competitive analysis
  • Integrated Underwriting/Actuarial engagement
  • Automating the CMS PBP submissions
  • Enable collaboration across all stakeholders through efficient workflows
  • Faster speed-to-market with 75% reduction in time and eff­ort required to build Medicare / Medicare Advantage products
    • Leverage source of truth for plan & benefit information to achieve improved accuracy, consistency & efficiency
    • Accommodate last minute changes and generate CMS PBP output and documents with the push of a button
    • Faster speed-to-market with 75% reduction in time and eff­ort required to build Medicare / Medicare Advantage products
    • Reduce benefit and compliance errors, benefit inquiry call time, and administrative costs

Mohammed Vaid,CEO and Chief Solution Architect,Simplify Healthcare


Cross-Functional Stars Improvement:  Moving Beyond Clinical Measures to CAHPS, HOS and Operational Measures

As the weight of Star ratings moves to outcome and patient reported measures, there is a greater need to include the entire organization in the effort to maintain and improve Star ratings.  This includes specific efforts on CAHPS, HOS, Pharmacy and operational measures.  In this session, we will discuss organizational strategies to engage cross-departmental support to improve performance.  Additionally, we will discuss approaches to impacting CAHPS and HOS results.

Gregory A. Hanley, FACHE, CPHQ,Vice President, Quality Management & Pharmacy,UCare


Technology-Enabled Care Management Program to Achieve the Triple Aim for Members with Dementia

This session will provide insights into how to determine the prevalence and utilization for members with dementia from claims data, and detail an approach and outcomes for improving members’ cost and quality outcomes by empowering and supporting their family caregivers.

Dirk Soenksen,Co-founder & CEO,Ceresti Health


Networking Refreshment Break

Focus on the Pharmacy Benefit: Preparing for Regulatory and Industry Change

Integrating Part B Office Administered Medications with Retail Pharmacy Benefits Using Prior Authorization – Plus Preparing for Rebates

How are you promoting your pharmacy benefit to members and brokers? Are you looking at integrating the Part D benefit with the Part B office administered medications? How do you work through the objections that may be encountered from the provider office or the member? Who do you partner with to make this possible? Will recently approved bio-similar medication change the formulary structure?  How rebates impact your formulary design and what happens to your formulary if rebates go away? Share your ideas as we take the next step in managing the prescription benefit.

Gary Melis,Clinical Pharmacist,Network Health

Harnessing Technology Innovations to Cut Costs
and Drive Quality of Care and Member Satisfaction

Telemedicine to Reduce Readmissions and ER Visits

This session will explore ways that plans can work at the intersection of technology, data, and human systems to improve healthcare value. Examples include helping members safely recover at home after hospital stays and preventing avoidable ER visits. The use an integrated team of telemedicine physicians, nurses, social workers, and non-clinical care guides will be described as well as the data and technology stack that enables their work.

Kurt R. Herzer, MD, PhD, MSc,Director of Population Health,Oscar Health Insurance


Key Points to Understand and Tips for Navigating CMS Rule 6058

As CMS continues to strengthen efforts to stop fraud and expand oversight, who you have in your network, on your staff, and who you contract with (vendors, delegates and entities) must come under much greater scrutiny. Through a brief summary you can better understand how it impacts your organization. You will also be introduced to key strategies to address and protect your organization as this rule is in effect and continues to evolve.
  • What the final rule means.
  • How it affects your organization.
  • What solutions to implement.
  • Process considerations

Jan Smith Reed,VP Payor Solution,Verisys

Provider and Member Engagement & Incentives

Gain Share Risk Model Linked to Quality -- Value Based Contracting, Alternative Payment Model

As health care moves along the continuum from volume to value, providers are still not ready to take on risk. Upside risk sharing, better known as Gain Share, is a key alternative payment model (APM) in which the providers get to share in a portion of savings achieved against a cost target if they are also able to achieve certain quality measures.
This model aligns the incentives of the provider and payor by focusing on the following:

  • Using timely and actionable data to address gaps in care
  • Through predictive analytics and population health management, determine future cost and care complexity and proactively implement programs to get members to the right care setting to achieve more efficient outcomes
  • Reducing readmissions and inappropriate emergency room use 
  • Improve the Health Plan’s overall HEDIS and Stars measure by offering the right incentives for each provider partner to improve their respective performance around these quality measures

Randy Walker,Vice President, Provider Network Management & Partnerships,Health Alliance Medical Plan


Networking Lunch

Operational Strategies and Tools that Drive Plan Performance

Compliance Training in Action: Using Learned Leadership Tools to Affect Positive Change

Using your leadership tool box to turn compliance issues into compliance success stories.  In this session you will hear examples and studies of how using the skills found in Crucial Conversations and Crucial Accountability workshops can help build relationships between Compliance and Operational areas from one of adversarial to mutual respect.

  • Safety Problems: Defending, accusing or debating
  • Shared Pool of Meaning: It’s not about what I want
  • Root Cause Analysis – What is lying below the surface

Tracy Jones,Senior Compliance Coordinator, SummaCare Health Plan


Integrating Risk Adjustment Objectives Plan-Wide: Ensuring Accurate and Meaningful Data Capture, Maximizing Provider Engagement and Understanding Risk Adjustment and Revenue Reconciliation

  • What risk adjustment is and what it is not
  • The purpose of data integrity -- different approaches that drive risk adjustment: suspecting, financial, and operational reporting
    • EMR and Chart Retrieval
  • Focus on health plan departments that impact and are impacted by risk adjustment (Working cooperatively towards the common goal of quality improvement and cost management)
  • To vend or not to vend (or both): In-house vs. vending various risk adjustment elements
    • Full vended, hybrid, and full in house
    • Plug and play with EMR (Industry view: where we are and where we want to be)
    • Machine Learning and NLP: plus/deltas
  • Engagement approaches to include risk adjustment in risk agreements with network partners
    • How to increase shared ownership in risk adjustment documentation and coding practices with provider partners
    • Provider engagement approaches and incentives to support code recapture

Dawn Peterson,Director of Risk Adjustment, Martin’s Point Health Care


Close of Conference