Mason Roberts

Actuarial rigor must be applied not just to finding savings, but to ensuring that high-value care—like home care—remains accessible to those who need it most, even amid budget pressures.

Link in the comments

#Medicaid #HealthPolicy #ActuarialRigor #IDDCare #ValueBasedCare

3. Actuarial Rigor in Policy: Policy discussions must move beyond simple cost cutting to adopt predictive models that account for the unique, lifelong service needs of the I/DD population to ensure sustainable and ethical management of high-cost cohorts.

2. Transition Risk: While 82% of nonelderly Medicaid enrollees with I/DD are children (0-18), they frequently face barriers maintaining coverage and accessing essential services when they age out of child eligibility pathways and lose critical benefits like EPSDT.

1. Unmet Need as Future Cost: Nearly three-quarters (73%) of the total Medicaid home care waiver waiting list population—approximately 521,000 people—have I/DD. These waiting lists represent massive unmet needs that often compound future costs if not addressed.

These costs reflect high health care needs, chronic conditions, and critical reliance on long-term home care.

For healthcare executives and actuaries focused on risk stratification, the data highlights three critical financial and access challenges:

How do we quantify risk and manage costs for a population where the financial reality is so stark?

Medicaid spending for enrollees with I/DD is dramatically higher: annual per capita spending is four times greater for children (<19) and seven times greater for adults compared to those without I/DD

The projected $911 billion reduction in federal Medicaid spending over the next decade puts immense pressure on states to reduce costs, disproportionately threatening coverage for people with Intellectual and Developmental Disabilities (I/DD).

It'll be interesting to see who adapts and how long it takes them. It's knowable right now if you stand to lose in this program but my guess is many systems are dealing with other fires.

Kennedy Fires N.I.H. Scientist Who Filed Whistle-Blower Complaint

“In her complaint, the scientist, Dr. Jeanne Marrazzo, who had directed the National Institute of Allergy and Infectious Diseases, objected to Trump administration actions, alleging that they had endangered research subjects, defied court orders and undermined vaccine research.”

The Top 8 Reasons People are Choosing Cargo Bikes over Cars Cargo bikes, with a distinctive design and functionality, are capturing the imagination of city dwellers, eco-conscious individuals and more

The Top 8 Reasons People are Choosing Cargo Bikes over Cars.
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KFF bar graph showing the growth in D-SNP enrollment from 2.2 million in 2018 to 5.8 million in 2024, broken down by type: dual eligible SNP, chronic condition SNP, and other SNPs.

Most (82%) enrollees in Medicare Advantage special needs plans are in plans designed for "dual-eligible" individuals or people with both Medicare & Medicaid. Enrollment in such plans (known as D-SNPs) grew from 2.2 million in 2018 to 5.8 million in 2024. https://on.kff.org/4ntfc7b

TEAM is the why. VBE is the how. If your health system needs a practical path from policy to operating results, physician-led, analytics-powered, let’s talk.

#valuebasedcare #TEAM #hospitaloperations #actuarial #analytics #postacute #physicianalignment #healthcarefinance

At Paramean, we focus on: measuring ROI and readiness for TEAM and episodic models; tracking performance against baselines and settlement forecasts; pinpointing cohorts affecting episode variation and costs; and aligning with CMS rules while offering shared insights for clinicians and executives.

The difference is the operating model. Value-Based Enterprises (VBEs), a structure (enabled by the 2020 Stark/AKS updates), puts physicians and operators at the same table, aligns incentives to outcomes, and extends coordination into post-acute and community care.

Value-based care isn’t a side project anymore, it’s the operating reality.

With CMS’s TEAM model, 700+ hospitals will take two-sided risk across five surgical episodes with 30-day post-discharge accountability. That can feel like a compliance lift…or it can be a catalyst.

Workforce Innovation Reduces Medicaid Costs in Chronic Care This study of community health workers as clinical extenders demonstrates significant cost savings in managing chronic conditions among Medicaid beneficiaries.

This isn't just about reducing costs; it's about proactive, person-centered care that works.

How are you integrating innovative workforce models to address chronic care challenges and unlock similar ROI in your communities?

buff.ly/8WTEMKP

#ChronicCareManagement #Medicaid #ValueBasedCare

For healthcare executives and value-based care leaders, this offers a scalable strategy to achieve material cost savings in full-risk arrangements while enhancing chronic disease management for vulnerable populations.

This technology-enabled, community-based workforce model addresses a critical need, moving beyond traditional approaches that often miss the mark on impacts. It demonstrates how planned interactions, patient education, provider training, and tech integration can stabilize clinical status.

• 36% reduction in Medicaid expenditures compared to a control group.
• A remarkable 7:1 Return on Investment (ROI), with a first-year cost savings of $14,863 per patient for a $2125 intervention cost.
• Improved chronic disease management

A recent study published in the American Journal of Managed Care highlights a compelling model from City Health Works. They deployed highly trained nonclinical health coaches as clinical extenders for Medicaid patients with poorly controlled diabetes and hypertension in NYC. The results are striking

Managing chronic conditions effectively, especially in low-income communities, often feels like an uphill battle. But what if the solution lies in empowering a new kind of workforce, deeply integrated into primary care?

How is your organization shifting its analytics strategy from hindsight to foresight to secure future ACO success?

#ValueBasedCare #DataAnalytics #ACOs #HealthcareFinance #ActuarialScience

This will inform strategic decision-making, identify high-performing groups, and develop targeted interventions for patient care and cost management.

I urge ACOs to invest in robust data analytics capabilities and personnel, including actuarial expertise, to move beyond basic reporting. Implementing a regular cadence of detailed performance monitoring, including beneficiary-level profitability and seasonality studies, is critical.

Furthermore, incorporating experience studies and seasonality adjustments (e.g., for claims fluctuations, membership changes, and risk score variations throughout the year) can significantly improve the accuracy of financial forecasts.

Imagine the power of beneficiary-level profitability analysis to identify specific drivers of savings or losses by categories such as chronic conditions, Taxpayer Identification Number (TIN), Primary Care Provider (PCP), office, or geography.

True ACO success hinges on "functional data analytics" – processing Claims and Claim Line Feed (CCLF) or payer data before insights are needed, not after. This requires a fundamental shift from retrospective reviews to proactive, granular analysis.

In this complex landscape, reactive analysis is insufficient. Proactive data analytics are essential for identifying opportunities, mitigating risks, and truly understanding performance drivers for ACO success.

We often analyze healthcare outcomes after the fact, but how truly proactive are our data strategies in value-based care?

We didn't have smart phones the last time Congress voted to raise the minimum wage.

It's past time.