Jim Lackey

More sobering news for value-based care. Avalere's recently released analysis of 18 CMMI payment models showed that most lost money -- $6.4 billion over the last decade to be exact. A few community pilots saved around $2B, but the broader picture is less favorable. Maryland's All Payer and Total Cost of Care Models performed the best while one Medicare Advantage and two Primary Care models had the biggest losses. Only 4 of the 18 models demonstrated clear impact on quality. None of the models were endorsed by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) which "provides a forum where those in the field may directly convey both their ideas and their concerns on how to deliver high-value care." The analysis follows a 2023 CBO assessment that found CMMI increased the indirect spending by $5.4 billion over a decade. The simple truth remains: our value problem is primarily an infrastructure problem. VBC can’t be retrofit onto fragmented systems and expected to achieve its intended goals. It's time to rethink what VBC means and how to implement it effectively. Some thoughts: 1. Rethink CMMI’s role. Instead of designing and managing models, fund them. Time-limited grants. Measurable milestones. A formal fast-track for exploratory care models that are truly innovative. 2. Full support for new operators. Privately funded and independently developed platforms can build novel care systems with less bureaucracy and administrative burden. Deeply integrated, specialty-first, tech-enabled. They don’t need risk models to deliver great care; they do it inherently. 3. Reframe the narrative. Maybe it’s time to stop chasing “VBC” as a nebulous, undefinable concept and start building actual advanced care models—ones that optimize for quality, experience, and cost without needing policy tailwinds to function. Not value-based care but the natural progression of a better approach. The dream of high quality, engaging, cost-effective care isn't dead -- but it's probably due for a re-brand. #valuebasedcare #cmmi #innovation

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CMS’s final Medicare Advantage rates for 2026 came out yesterday, landing at a notably higher average increase (5.06%) than initially proposed. As always, the devil is in the details—particularly the significant upward revision of the effective growth rate, now at over 9%, balanced against continued adjustments in risk model normalization and Star Ratings pressures. For Clover, this announcement is reassuring, but not game-changing. Unlike many MA plans whose profitability hinges tightly on annual rate fluctuations, our model has always been designed differently. Our core thesis isn’t just about capturing incremental payments—it's about leveraging our technology-driven model to fundamentally improve care delivery, outcomes, and economics in ways less sensitive to policy shifts. This doesn't mean we’re indifferent to policy (far from it!), but it underscores a key distinction in how we’ve structured our business. The rate environment is always important, but our differentiation comes from deeper operational strengths: wide networks, minimal reliance on traditional risk-sharing or premium delegation, and substantial clinical and financial outcomes powered directly by Clover Assistant. For the broader MA space, this higher-than-expected rate increase may provide short-term relief and optimism. However, this is a somewhat logical fallacy - I view it instead as reinforcing the cycle many plans are caught in—reliance on favorable policy shifts rather than fundamental innovation. This is why people follow the rate so incredibly closely and use it as a bell-weather for the industry. The years where the rates are on the higher side should not be seen as a relief but instead a sign that industry medical costs are rising (not a good thing) and it's time to invest to bring costs down. Yet many will simply ride the wave. When rates inevitably tighten, those who didn't build real differentiation will face tougher waters, something we’ve seen play out very recently. In short: yesterday’s CMS announcement is good news for everyone—but a useful reminder that sustainable long-term growth in Medicare Advantage requires more than riding the annual rate. It demands investing in true differentiation, creating tangible value for members, providers, and the broader healthcare ecosystem. #MedicareAdvantage #medicarerates #CMS #ValueBasedCare #HealthcareInnovation

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Star Ratings as a Strategic Imperative and Why Alignment Sets the Benchmark   Today, star ratings in Medicare Advantage show how well plans deliver quality, build trust, and stay sustainable. CMS reviews these ratings based on clinical results, member experience, complaint handling, retention, and access to care. Managing these areas takes focus and commitment.   This is why Alignment Health Plan’s latest results stand out. For the second year in a row, 100% of members are enrolled in plans rated 4 stars or higher. Two Nevada HMO contracts earned 5 stars, and a Texas plan earned 4.5 stars. These results demonstrate that a member-first care model can be replicated and scaled, rather than being a one-time achievement.   Why This Matters   1. Sustained reliability Many plans aim for high star ratings but struggle to maintain them as CMS raises the bar. Alignment’s California HMO has held 4 or more stars for nine years in a row, which is rare. This steady performance leads to better risk management, stronger member loyalty, and more reliable bonus incentives. 2. Clear market differentiation. Medicare’s Plan Finder clearly displays star ratings, which directly impact consumers' choices. High ratings give plans a real edge over competitors, not just a mark of honor. 3. Quality as a business driver, not just compliance.   The most successful plans prioritize quality by closing care gaps, retaining valuable services, and responding promptly to members, rather than merely meeting minimum requirements.   The New Age of Medicare Advantage   New carriers are transforming the industry through flexibility, data-driven insights, digital engagement, and a focus on members. Here’s what makes them different:   * Flexible modular care models delivering individualized quality care * Bold benefit innovation that differentiates * Relentless measurement and iteration, where analytics feed continuous quality improvement * Culture-driven execution, where clinical leaders, operations, and member services act with alignment   Alignment demonstrates how these strengths can be leveraged on a large scale to consistently deliver great results across different markets.   Our Dedication to Long-Term Quality   * We invest in quality to achieve lasting results that can be replicated across different markets, yielding clear benefits from the first year. * Our benefits are tied to clear clinical and satisfaction goals, as shown by our star ratings and member feedback. * All of our members are enrolled in high-rated plans, not just a select few.   The future of Medicare Advantage will favor those who pair strong performance with new ideas that put members first. Alignment is already leading the way and setting the standard for the next generation of plans.   #AlignmentHealthPlan #AlignmentHealth #Duals #HealthcareLeadership #AdvocacyMatters #ValueBasedCare #FreedomOfChoice #LeadershipInAction #MedicareAdvantage #HealthPolicy

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For too long, our system has focused on the volume of services provided, rather than the quality of care delivered. This approach has led to higher costs and inconsistent outcomes.     I recently participated in a CEO Panel at the AHIP Medicare, Medicaid, Duals & Commercial Markets Forum, where we discussed the future of health care delivery innovations. One of the key takeaways from our conversation was the importance of shifting toward rewarding quality over quantity to improve health outcomes, reduce unnecessary costs, and create a more sustainable health care system.      By incentivizing providers based on quality rather than quantity, we can create a more sustainable and effective health care system. This approach, which we've implemented through strong partnerships in our provider networks, has led to improved health outcomes and reduced costs for our members.     For example, the value-based Sanitas care model at our Florida Blue | Sanitas Medical Centers creates more seamless and coordinated care for our members that prioritizes prevention and early intervention. As a result, we've seen measurable reductions in avoidable hospitalizations and improvements in chronic disease management.      I'm proud of the work we're doing at GuideWell to create a more sustainable and effective health care system. By working together with providers and prioritizing the needs of our members, we can create a better future for health care.     #HealthCare #HealthCareOnLinkedIn #Innovation #Sustainability 

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Opening day of the 2025 Nashville Healthcare Sessions brought together nearly 1,200 healthcare leaders for an engaging agenda focused on innovation, collaboration, and technology, highlighting their implications for the future of healthcare. Key discussions included: - The investment landscape in a new era of healthcare - The evolving role of employers in redefining provider partnerships - Strategies for redesigning community-based care These conversations set the stage for transformative ideas and solutions in the healthcare sector.

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Proud to see BAYADA CEO David Baiada speaking out on the 2026 CMS Proposed Rule during last week’s Home Health Care News webinar. His message was clear: protecting access to care at home is critical for the patients who need it most. Watch the full discussion: https://lnkd.in/e_6q6pYB #HomeHealth #HealthcareAdvocacy #HomeCareLeaders

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“ Lincoln Liberty Capital is proud to announce its platform investment in P&A Group, a leading provider of consumer-directed health benefits solutions. P&A partners with employers, brokers, and administrators to deliver flexible spending, HSA, HRA, COBRA, and other benefit programs that empower employees and simplify administration. This investment reflects our focus on partnering with exceptional management teams to build durable, scalable businesses in the employer services and healthcare ecosystem.” #betterhealth

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