Medicare Advantage Prompts Strategic Considerations

Medicare expenditures have been increasing since the program’s inception in 1965. Notably, the program’s cost tripled from $2.7 billion in 1967 to $8 billion in 1973.(1) The federal government has implemented several measures to reign in growing expenditures and alleviate the anticipated tax burden, such as the 1972 Social Security Amendments, which allowed for the reimbursement of clinical services with capitated payments.

By 1976, the Health Care Financing Administration (HCFA), now known as the Centers for Medicare and Medicaid Services (CMS), was conducting demonstration projects to determine whether contracting with commercial insurance firms would curtail growing expenditures. One such project revealed that inpatient hospitalizations could be reduced by 8 percent over a two-year period if Medicare beneficiaries were managed by Health Maintenance Organizations (HMOs).(2)

Given the apparent success of HMOs, with their narrow provider networks and judicious application of utilization management, HCFA believed that commercial firms would deliver care to beneficiaries more efficiently than traditional Medicare (TM).

Adoption

After passage of the Tax Equity and Fiscal Responsibility Act in 1982, HCFA formally adopted the managed Medicare program and mandated that HMOs receive an annual capitation fee equivalent to 95 percent of the TM beneficiary’s adjusted average per-capita cost. Firms providing care to Medicare beneficiaries for less than the 95 percent rate could keep the difference but were required to reinvest the funds in additional services, reduce cost-sharing, or reduce premiums.

The prospect of receiving additional services such as dental or vision care at no additional cost was very attractive to beneficiaries. Consequently, managed Medicare enrollment grew dramatically to 5.2 million beneficiaries by 1997.(3)

Unfortunately, managed Medicare was susceptible to favorable selection, which had thrived in the private health insurance market. Favorable selection occurs when healthier beneficiaries enroll in one managed care plan over other competing plans, resulting in a disproportionately greater share of healthy individuals in the managed care plan. For example, managed Medicare beneficiaries, compared to TM beneficiaries, are less-frequent users of healthcare services and self-report a better health status.(4) Managed Medicare beneficiaries also tend to have lower relative odds of mortality, suggesting that they are healthier than their counterparts.(5) Therefore, managed Medicare plans were positioned to profit through the lower utilization of services by healthier enrollees.

The unintended consequence of favorable selection was that Medicare overpaid HMOs. In 1997, the Congressional Budget Office estimated that Medicare paid 8.3 percent more to provide services for HMO beneficiaries than it would have paid to care for the same beneficiaries if they had been enrolled in TM.(6) Older beneficiaries with chronic health conditions preferred TM over managed Medicare because they could keep their physicians and use services without the restrictions imposed by utilization management.

The cost to Medicare likely was exacerbated as healthier beneficiaries enrolled in managed Medicare, leaving the more expensive beneficiaries to TM.(7) Because the reimbursement formula was regionally based, there was a wide variation across the country, leading to untenable disparities in supplemental benefits and payment rates.(8)

Adaptation

Congress adapted to this manufactured environment by deliberately reducing reimbursement rates. The Balanced Budget Act (BBA) of 1997 made changes to the program and renamed it Medicare + Choice.

First, the BBA put a limit on capitation rates by minimizing the annual percentage increase in payment rate to just 2 percent. Second, it broadened the managed care options available to beneficiaries to include HMOs, private fee-for-service plans, preferred provider organizations, and provider-sponsored organizations. A cornerstone of this program was the assumption that market forces would drive efficiency.

The federal government was committed to monitoring and reducing favorable selection by integrating patient health status into payment methodology. Risk adjustment, incorporating diagnostic encounter or claims data, was implemented to compensate commercial firms more appropriately based on the relative cost of caring for a beneficiary in TM. Furthermore, the BBA sought to foster stability by restricting beneficiaries from switching between managed Medicare and TM and requiring them to remain enrolled for at least one year.

While the market’s reaction was unanticipated, it was not surprising. The Congressional Budget Office predicted that managed Medicare plan enrollment would grow 15 percent by 2005.(9) However, rather than promote enrollment, plans reduced benefits to beneficiaries and raised premiums. Between 1999 and 2003, 122 plans withdrew en masse from Medicare and abandoned more than 2 million beneficiaries.(10) Beneficiaries scrambled to enroll in alternative plans or TM. BBA destabilized the Medicare marketplace and shook the country’s confidence in Medicare + Choice.

In 2003, Congress passed the Medicare Modernization and Improvement Act (MMA). These efforts derived from the Republican majority’s desire to foster a market-based approach to restraining costs.(11) The new plan, named Medicare Advantage (MA), modified the reimbursement structure, obligating plans to bid the estimated cost of services against the average county benchmark. If the bid was greater than the benchmark, the plan would have to cover excess costs by increasing premiums. On the other hand, if the bid was lower than the benchmark, CMS would pay the plan a rebate valued at 75 percent of the difference.

CMS refined risk adjustment of capitation payments using the hierarchical condition categories (HCC) in 2004. The HCC model was developed to discourage favorable selection and “redirect money away from managed care organizations that cherry pick the healthy.”(12) In the long run, CMS envisioned that MA plan success would be determined by its ability to compete on value rather than on selection mechanisms.

After implementation of the MMA, payments increased by 10.9 percent from 2003 to 2004.(13) Consequently, benefits expanded, premiums and out-of-pocket spending declined, and MA plans grew substantially. By 2015, MA enrollment had grown to 16.8 million from a low of 5.3 million in 2004, harboring 31 percent of all Medicare beneficiaries.(14)

Unfortunately, higher MMA payments did not produce savings for CMS, and actually increased beneficiary costs as well as federal tax expenditures.(15) MA plans, especially those entering the market after 2004, did not yield dividends with respect to their performance on quality measures.(16) In response, CMS developed annual performance measures in 2008, using the Healthcare Effectiveness Data and Information Set (HEDIS), to help beneficiaries select the best plans and prompt MA plans to pivot toward quality.

Advancement

The Patient Protection and Affordable Care Act (ACA) of 2010 was an impetus for change that profoundly impacted MA plans. Starting in 2012, MA payment was gradually reduced to achieve parity with TM benchmarks. The Medicare Payment Advisory Commission (MedPAC) recently estimated that 2018 benchmarks, bids, and payments would average 107 percent, 90 percent, and 101 percent of TM expenditures, respectively.(17)

The ACA’s impact on the financial burden to the beneficiary has been positive, with average MA enrollee premiums declining from $44 in 2010 to $34 in 2018.(18) Unlike the cost for TM beneficiaries, out-of-pocket costs for MA enrollees were capped at $5,187 in 2018.(18)

Another major achievement of the ACA was to link MA reimbursement to plan performance through the Medicare Star Ratings System (MSRS). MSRS determines performance ratings on a scale of 1 star (worst) to 5 stars (best) using numerous measures across five domains: staying healthy, access to care, managing chronic conditions, patient experience, and customer service.

The ACA established a bonus payment that qualifies plans for up to 5 percent of the TM benchmark rate if they achieve a rating of at least 4 stars (see Table 1). The ACA also associated the size of the rebate with the stars rating. Poor-performing plans with fewer than 3 stars are shunned by Medicare through letters encouraging beneficiaries to seek alternative plans.

The vibrant MA market has increased beneficiary access despite ACA payment reductions. Defying predictions, beneficiary enrollment has grown continuously, more than tripling since 2003 (see Figure 1). Between 2016 and 2017, enrollment in MA plans grew 8 percent, outpacing the 3 percent growth of the total Medicare beneficiary population.(17) MedPAC has determined that most MA enrollees start out in TM and subsequently make the switch to managed Medicare.(19) Beneficiaries who enrolled in MA plans after the ACA tend to be healthier with lower frailty risks, fewer falls, and fewer comorbidities.(20)

Figure 1. Medicare advantage growth (1997–2017)

Overall MA plan performance has improved since the ACA. The percentage of 4-star to 5-star plans increased from 31 percent in 2010 to 44 percent in 2018.(21) Similarly, the percentage of MA enrollees in 4-star or 5-star plans increased from 62 percent in 2015 to 74 percent in 2018.(18)

MA plans have performed better than TM on a variety of HEDIS measures, especially those pertaining to preventive care.(22) Beneficiaries in MA plans are less likely to be hospitalized for avoidable admissions. Some have found that MA plans have lower hospital readmission rates than TM.(23) MA plans even have been observed to have a spillover effect on hospital use, resulting in lower costs and shorter hospitalizations for all Medicare beneficiaries and non-Medicare populations.(24) A recent study associated lower mortality with beneficiary enrollment in MA plans, especially for nonwhite, low-income, high-morbidity populations.(25)

Provider System Strategies

MA has evolved considerably since the 1970s and is firmly embedded in our healthcare delivery system. The Congressional Budget Office projects that MA will continue to grow, with 42 percent of the Medicare population belonging to an MA plan by the year 2028 (see Figure 2).(26) In combination with anticipated federal outlays of several hundred billion dollars for the program, demand is stimulating health plans to enter the market. This complex and dynamic MA environment now compels provider systems to make strategic considerations that will enable them to thrive despite payment reform.

Figure 2. Medicare advantage enrollment projections

Join MA Networks

The most common strategy provider systems use is to join MA networks, facilitating their ability to capture market share and expand reliable revenue stream; however, provider systems are expected to assume greater financial risk in the future. Value-based contracting between MA plans and provider systems has been accelerating since passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, which strives to increase the number of providers participating in Advanced Alternative Practice Models (Advanced APMs).(27) Value-based payment methodologies reside along a reimbursement continuum (see Figure 3) with gradually increasing accountability, and include payment for specific services (i.e., care coordination), pay-for-performance, shared savings, shared savings with downside risk, partial capitation, and global capitation.

Figure 3. The reimbursement continuum

Provider systems should optimize clinical capabilities before determining to what extent they will integrate with MA plans through value-based contracts. Experience in population health management, which identifies high-risk patients to coordinate care and control costs, will be critical to managing risk. Physician leaders play a pivotal role in reconfiguring the value chain to develop population health management across the health system.

First, physician leaders can ensure that the medical staff is clinically adept at managing beneficiaries with complex comorbid conditions and well-versed in process and outcome measures. Physician leaders also can maintain a robust and customizable information technology (IT) infrastructure that facilitates care in the ambulatory setting. By providing access to actionable clinical and financial information, physician leaders can empower medical staff with the IT tools necessary for improving clinical outcomes.(28) Physician leaders can collaborate with other health system leaders to rally around the patient, coordinating care proactively across the continuum to ensure high-risk beneficiaries have easy access to clinical services.

Provider systems on a quest to bearing greater financial risk should view value-based contracts as an opportunity for innovation and experimentation. One study based in Portland, Oregon, comparing a capitated provider group with a fee-for-service provider group, found a significant difference in clinical outcomes, including a 6 percent survival benefit for the capitated group.(29) The capitated group had increased office visits and decreased emergency department visits and hospital admissions, yielding a savings of more than $2 million per 1,000 enrollees. Even if provider systems are not prepared to participate in Advanced APMs, such contracts may be an effective vehicle to ease the transition to full capitation.

Pursue a Joint Venture

Another strategic consideration is the pursuit of a joint venture. During the past several years, numerous provider systems and commercial insurance firms have formally collaborated to establish MA plans.(30) For example, Ascension and Centene announced an intent to partner in multiple geographic markets by 2020. Such partnerships give provider systems access to the insurance management and consumer service capabilities of commercial firms. Commercial firms benefit by shifting the financial risk to the partnering providers and using the provider system’s brand and geographic reach to grow MA market share.

A joint venture can function as a hedge against dwindling reimbursement and regulatory uncertainty. Unfortunately, shared governance can undermine the venture’s ability to successfully execute strategies, especially if culture or objectives are misaligned. Physician leaders can overcome this by enhancing the alignment between physicians and MA plans. Physician leaders can:

• Articulate the shared vision with medical staff members and obtain a commitment to practice resource stewardship.

• Educate medical staff about utilization management and foster an understanding of how clinical practices impact cost. For example, physician leaders can work closely with colleagues to analyze cost drivers, such as name-brand prescription practices, and achieve obtainable performance targets.

• Optimize operations to maximize financial performance for both provider systems and health plans. For example, they can engage medical staff, through education or incentives, to accurately code all relevant HCC diagnoses with comprehensive documentation during annual wellness visits. This will ensure the capacity to achieve the highest risk-adjustment factor and secure the greatest rebate payment.

Establish Provider-Sponsored MA Plans

Top-performing provider systems serving beneficiaries effectively along a care continuum and prepared for full accountability over the premium dollar also might consider establishing provider-sponsored MA plans (PSMPs). Vertically integrated contracts, which comprised 22.5 percent of all MA contracts in 2015, have been associated with higher quality ratings when compared to other contracts.(31) The revenue potential and financial risk will be greatest for provider systems that are structured for global capitation. Provider systems that can provide high-quality care at the lowest cost will be capable of competing against other commercial firms by offering insurance products at a lower price.(32)

Despite having to compete against large commercial firms like UnitedHealthcare, Humana, and BlueCross and BlueShield, which together control more than a 50 percent market share, PSMPs can be advantageous.(18) One advantage is the direct connection between the provider and MA plan that bypasses traditional commercial firms. Provider systems would benefit by capturing the entire premium dollar instead of settling for a percentage of it.

Another advantage is the ability to reinvest portions of health plan revenues in value-adding service delivery strategies such as chronic disease management. Such a feat would be more challenging for provider systems relying entirely on a fee-for-service reimbursement model. A third advantage is the capitated payments to a PSMP that can offset any declining health system reimbursements.

A provider system interested in establishing a PSMP should contemplate a number of factors that will influence the likelihood of success. This is evident given the recent finding that only four of the 37 provider-sponsored plans established between 2010 and 2015 were profitable.(32)

First, MA market entry will demand a significant capital investment of between $15 million and $25 million.(33) In addition, operations will need to be supported by up to 15 percent of premium payments until profitability can be achieved. The time required for the PSMP to achieve economies of scale is typically between three and five years. A PSMP should target a minimum of 25,000 lives in order to remain financially viable. Finally, a provider system will need to develop new capabilities such as insurance product development, price setting, claims processing, and risk management.

Successful PSMPs will differentiate themselves from traditional MA plans by achieving tight integration with the provider system’s clinical enterprises. Kaiser Permanente’s MA plan, which has successfully achieved complete integration around a unifying vision with Kaiser Permanente’s hospitals and medical groups, now commands an 8 percent market share.(18)

Integration enables PSMPs to become adept at best practices. One best practice is revenue optimization through the MSRS quality bonus payment and rebate. Physician leaders overseeing a clinical enterprise can leverage direct access to PSMP performance metrics to enhance policies and procedures, thereby improving clinical outcomes more efficiently. Supported by population health initiatives, performance measures that drive star ratings must be continuously monitored and enhanced. Achieving 4-star performance or better will give a PSMP a competitive advantage over commercial competitors, maximizing quality bonus payments and rebates (see Figure 1). This will also make the PSMP more attractive to beneficiaries, which can accelerate enrollment and enable the PSMP to achieve economies of scale more quickly.

Another critical best practice is claims cost management. For example, physician leaders can develop utilization management programs that are well aligned with the overall provider’s population health system to control claims costs. Medical staff can be given opportunities to participate in PSMP governance, fostering collaboration and communication between the health plan and physicians.

The ACA promoted a shift to value through a provision mandating the application of the medical loss ratio (MLR). MA plans are now expected to incur a minimum claim expense in health benefits relative to the premium dollar earned that achieves an 85 percent threshold. Physician leaders can achieve this threshold by influencing physician behavior across the integrated delivery system to use the premium dollar judiciously while minimizing risk, medical claims, and costly prescription drug practices.

Network development based on value-based provider contracting is another best practice. In 2015, an Oliver Wyman study found a near-perfect correlation between provider-driven star ratings and overall star ratings across the United States.(34) This supports the conclusion that an MA plan’s star rating — and financial success — are driven by the behavior of its physician network.

Ongoing Evaluation

Strong physician-plan partnerships have been identified as a dominant factor driving high performance.(28) Physician leaders are best suited to develop and strengthen these relationships throughout the organization. Physician leaders also can assess medical staff readiness to embrace value-based initiatives. Many provider systems will need to consider expanding their PSMP beyond the immediate geographic area to remain competitive. Physician leaders can be invaluable in identifying capable partners, willing to align with the provider’s vision and receptive to value-based incentives, that can join a diffuse network of independent physicians or clinically integrated network.

Provider systems should consider engaging MA if they intend to deliver the high-quality, cost-effective care that the government pursues and patients deserve. Unfortunately, the paucity of relevant data has made evaluation of MA plans difficult. Future research should determine to what extent healthcare quality depends on MA plan size, regionality, and degree of plan alignment with provider systems. It is important to ascertain whether the inroads made so far are sustainable, especially as successful MA plans continue outperforming while laggards fall by the wayside.

While the federal government has made progress in reducing the overall cost of MA plans, it has taken over 40 years to do so. One area to be explored is whether government policies can continue promoting a market-based approach to restrain Medicare expenditures. For example, CMS recently announced implementation of a new payment model for TM beneficiaries: CMS Primary Care Initiative. Direct value-based contracts with CMS undoubtedly will continue incentivizing provider systems to transition away from fee-for-service and influence evolution of the MA environment in unforeseen ways. Some provider systems have successfully established PSMPs; others have been unable to leverage their brand and services to guarantee PSMP viability. Future research could further characterize how PSMPs may be promoting higher quality care delivery compared to their commercial MA counterparts.

As Medicare enrollment grows and the MA program continues to evolve, provider systems must continuously evaluate how they are positioned and what strategies can be implemented to adequately manage risk and thrive in a market that rewards value-based care.

References

1. White House Office of Management and Budget. Budget of the United States Government: Historical Tables Table 3.2—Outlays by Function and Subfunction: 1962–2024. https://www.whitehouse.gov/wp-content/uploads/2019/03/hist03z2-fy2020.xlsx. Accessed April 2, 2019.

2. McGuire TG, Newhouse JP, Sinaiko AD. An Economic History of Medicare Part C. Milbank Q. 2011;89(2):289-332.

3. Medicare Payment Advisory Commission. A Data Book: Health Care Spending and the Medicare Program. Washington, DC: MedPAC; 2017. http://medpac.gov/docs/default-source/data-book/jun17_databookentirereport_sec.pdf. Accessed April 2, 2019.

4. Mello MM, Stearns SC, Norton EC, Ricketts TC. Understanding Biased Selection in Medicare HMOs. Health Serv Res. 2003;38(3):961-92.

5. Maciejewski ML, Dowd B, Call KT, Feldman R. Comparing Mortality and Time until Death for Medicare HMO and FFS Beneficiaries. Health Serv Res. 2001;35(6):1245-65.

6. Christensen S. CBO Memorandum: Predicting How Changes in Medicare’s Payment Rates Would Affect Risk-Sector Enrollment and Costs. Washington D.C.: Congressional Budget Office; 1997. https://www.cbo.gov/sites/default/files/105th-congress-1997-1998/reports/medcrpay.pdf . Accessed April 2, 2019.

7. Barr DA. Introduction to US Health Policy: The Organization, Financing, and Delivery of Health Care in America. 4th ed. Baltimore, MD: John Hopkins University Press; 2016.

8. Berenson RA, Dowd BE. Medicare Advantage Plans at a Crossroads—Yet Again. Health Aff (Millwood). 2009;28(1):w29-w40.

9. Christensen S. Medicare+ Choice Provisions in the Balanced Budget Act of 1997: CBO staff memorandum. Washington D.C.: Congressional Budget Office; 1997. https://www.cbo.gov/sites/default/files/105th-congress-1997-1998/reports/1997_11_12_choice.pdf . Accessed April 2, 2019.

10. Gold M, Achman L, Mittler J, Stevens B. Monitoring Medicare+Choice: What Have We Learned? Findings and Operational Lessons for Medicare Advantage. Mathematica Policy Research Published Reports; 2004. http://ezproxy.fiu.edu/login?url=https://search-proquest-com.ezproxy.fiu.edu/docview/2080863931?accountid=10901 .

11. Oberlander JB. Through the Looking Glass: The Politics of the Medicare Prescription Drug, Improvement, and Modernization Act. J Health Polit Policy Law. 2007;32(2):187-219.

12. Pope GC, Kautter J, Ellis RP, et al. Risk Adjustment of Medicare Capitation Payments Using the CMS-HCC Model. Health Care Financ Rev. 2004;25(4):119-41.

13. Achman L, Gold M. Medicare Advantage 2004 Payment Increases Resulting from the Medicare Modernization Act. Mathematica Policy Research Published Reports; 2004. http://ezproxy.fiu.edu/login?url=https://search-proquest-com.ezproxy.fiu.edu/docview/2080829853?accountid=10901 .

14. Jacobson G, Damico A, Neuman T, Gold M. Medicare Advantage 2015 Spotlight: Enrollment Market Update. Kaiser Family Foundation; 2015. https://www.kff.org/medicare/issue-brief/medicare-advantage-2015-spotlight-enrollment-market-update . Accessed March 31, 2019.

15. Zarabozo C, Harrison S. Payment Policy and the Growth of Medicare Advantage. Health Aff (Millwood). 2008;28(1):w55-w67.

16. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Washington, DC: MedPAC; 2008. http://www.medpac.gov/docs/default-source/reports/mar08_entirereport.pdf?sfvrsn=0. Published March 2008. Accessed March 31, 2019.

17. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Washington, DC: MedPAC; 2018. http://www.medpac.gov/docs/default-source/reports/mar18_medpac_entirereport_sec.pdf. Published March 2018. Accessed March 31, 2019.

18. Jacobson G, Damico A, Neuman T. A Dozen Facts About Medicare Advantage. Kaiser Family Foundation. https://www.kff.org/medicare/issue-brief/a-dozen-facts-about-medicare-advantage . Published November 13, 2018. Accessed April 1, 2019.

19. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy. Washington, DC: MedPAC; 2015. http://www.medpac.gov/docs/default-source/reports/mar2015_entirereport_revised.pdf. Accessed March 31, 2019.

20. Natafgi N, Nattinger M, Ugwi P, et al. The Impact Of The Affordable Care Act (ACA) on Favorable Risk Selection and Beneficiaries’ Health Status in Medicare Advantage: A Preliminary Assessment. BMC Health Serv Res. 2016;16(1):404. https://doi.org/10.1186/s12913-016-1663-4 . Accessed March 31, 2019.

21. BHM Healthcare Solutions. Fact Sheet—2018 Part C and D Star Ratings. BHM Healthcare Solutions. http://www.bhmpc.com/pdfs/2018_Star_Ratings_Fact_Sheet_2017_10_10.pdf . Accessed April 1, 2019.

22. Gold M, Casillas G. What Do We Know about Health Care Access and Quality in Medicare Advantage versus the Traditional Medicare Program? Kaiser Family Foundation; 2014. https://www.kff.org/medicare/report/what-do-we-know-about-health-care-access-and-quality-in-medicare-advantage-versus-the-traditional-medicare-program . Accessed March 31, 2019.

23. Lemieux J, Sennett C, Wang R, Mulligan T, Bumbaugh J. Hospital Readmission Rates in Medicare Advantage Plans. Am J Manag Care. 2012;18(2):96-104.

24. Baicker K, Chernew ME, Robbins JA. The Spillover Effects of Medicare Managed Care: Medicare Advantage and Hospital Utilization. J Health Econ. 2013;32(6):1289-1300.

25. Beveridge RA, Mendes SM, Caplan A, et al. Mortality Differences Between Traditional Medicare and Medicare Advantage: A Risk-Adjusted Assessment Using Claims Data. INQUIRY: The Journal of Health Care Organization, Provision, and Financing. 2017; 54: p.0046958017709103.

26. Congressional Budget Office. Medicare-Congressional Budget Office’s April 2018 Baseline. Washington D.C.: Congressional Budget Office; 2018. https://www.cbo.gov/system/files?file=2018-06/51302-2018-04-medicare.pdf . Accessed April 2, 2019.

27. Dong L, Pelizzari PM. Advanced APMs and Qualifying APM Participant Status. Milliman; 2016. http://www.milliman.com/insight/2016/Advanced-APMs-and-Qualifying-APM-Participant-status . Accessed June 8, 2019.

28. Berenson RA, Coughlin TA. Success Factors in Five High-Quality Low-Cost Health Plans. The Commonwealth Fund; 2011. https://www.commonwealthfund.org/publications/fund-reports/2011/mar/success-factors-five-high-quality-low-cost-health-plans . Accessed June 8, 2019.

29. Mandal AK, Tagomori GK, Felix RV, Howell SC. Value-Based Contracting Innovated Medicare Advantage Healthcare Delivery and Improved Survival. Am J Manag Care. 2017;23(2):e41-e49.

30. Baumgarten A, Hempstead K. New Provider-Sponsored Health Plans: Joint Ventures Are Now the Preferred Strategy. Health Affairs Blog; February 23, 2018. https://www.healthaffairs.org/do/10.1377/hblog20180216.720494/full . Accessed June 8, 2019.

31. Johnson G, Lyon ZM, Frakt A. Provider-Offered Medicare Advantage Plans: Recent Growth and Care Quality. Health Aff (Millwood). 2017;36(3):539-547.

32. Baumgarten A. Analysis of Integrated Delivery Systems and New Provider-Sponsored Health Plans. Robert Wood Johnson Foundation; 2017. https://www.rwjf.org/en/library/research/2017/06/analysis-of-integrated-delivery-systems-and-new-provider-sponsor.html . Accessed April 1, 2019.

33. Hegwer LR. Key CFO Considerations for Implementing Provider-Sponsored Health Plans. Hfma; 2017. https://www.hfma.org/Content.aspx?id=57021&pagesid=3 . Accessed June 8, 2019.

34. Abbot T, Durr Melinda, Graf M. Winning on Stars: It Starts and Ends with Providers. Oliver Wyman. https://www.oliverwyman.com/our-expertise/insights/2015/oct/winning-in-medicare-advantage.html