Podcast

March 19, 2025

Strategic Health Law

Elizabeth Lippincott (00:05)

All right, welcome back to Health Law Simplified. I’m Elizabeth Lippincott. I’m the founding member of Strategic Health Law and I’m here with my colleague Sandy Durkin. We are delighted today to have a special guest with us, Molly Turco. Molly Turco has over 15 years of experience working on Medicare policy issues. Just in January, Turco left her role as the Senior Policy Advisor on Medicare Advantage and Medicare Part D at CMS at the Center for Medicare. And before her time at Molly led Medicare policy at the Blue Cross Blue Shield Association and the Better Medicare Alliance, and previously held roles as an investor consultant and as a public health researcher. So we’re thrilled to have Molly here with us to share her insights and help our listeners think through the trends that we’re seeing in this really interesting time.

Sandy Durkin (01:03)

Thank you for joining us, Molly. We’re so happy to have you here. Before we dive in, I was hoping you could tell us about your time at CMS and any of the projects that you worked on as Senior Policy Advisor at the Center for Medicare.

Molly T. Turco (01:21)

Great. And thanks, Elizabeth and Sandy, for having me. It’s really exciting to come and chat about all these important issues. So yeah, so I recently, last month, left my time at Center for Medicare and during those few years that I was there, really had the privilege to work on the full range of M.A. Part D work that we did. you know, as you all know, we have the annual M.A. and Part D rules and we have the annual advanced notice and rate announcement. We also embarked on some requests for information.

So we did two during the time that I was there. The first one was kind of a general, you know, state of the world of MA. We really wanted to hear from folks. One thing that I felt is that sometimes the rulemaking process can be intimidating for non-plans or providers or others. So we wanted an opportunity to hear more from advocates and, you know, kind of smaller provider groups or plans or others that felt less empowered in those kind of nitty gritty policy conversations. And we had over 4,000 responses there and really kind of underscored what we already knew which were the areas that people care about, payment, prior authorization, marketing concerns, access, confusion of beneficiaries, things like that, supplemental benefits. And the second RFI that we did was focused on data. So one thing that we heard a lot in both that RFI and just kind of day-to-day work was how frustrated a lot of stakeholders, Congress, others are on the access to data publicly and concerns that CMS didn’t have all the data it needed to regulate these programs. So we heard from, kind of the full range again, of stakeholders, plans, providers, advocates, a lot from academic researchers. And so really trying to strengthen the data collection both in the building and then ways in which to grant the outside world more transparency and data and access to information, which I think goes without saying is incredibly important now that MA is half the program. You know, there’s a lot of data for traditional Medicare that informs a lot of healthcare. And so we really wanted to, and I think CMS continues to want to make sure that the outside world has access to more of that data.

Elizabeth Lippincott (03:42)

That’s interesting. So there are obviously a lot of things in flux in DC and at CMS right now, Baltimore. Is there anything you can share about what things might be like in the agency right now?

Molly T. Turco (03:58)

Yeah, I mean, I think it goes without saying it’s a pretty uncertain time in DC generally, but certainly at HHS and CMS where I used to work. You know, that being said, I think that my former colleagues are all really hopeful. They know that everyone believes that Medicare is an incredibly important program for seniors and disabled and other Medicare eligible individuals. So I think really everyone’s hopeful that the work that they do is valued and so they can continue to do that, I think, you know, anyone who has worked, no matter the administration, with the career staff at the Center for Medicare and across HHS is just always blown away by the expertise and how brilliant these folks are. I’m kind of dealing with the post CMS blues right now of I was able to just pick up the phone and call the expert on X, Y, Z on any issue. It was just an embarrassment of riches of expertise.

So really, think my hope is that there’s a recognition of that. And I think this administration is prioritizing Medicare Advantage. And I would hope that that translates to ensuring that those colleagues of mine and their expertise is valued. And I think one misperception, misconception, of the outside world about CMS is that it’s all the policy and it’s the regulations. But the majority of folks’ job is keeping the trains running. I mean, this is a $9.2 trillion over the next decade program. It serves over, what is it, 35 million beneficiaries. So a lot of the work, the day-to-day work, is really just keeping those trains running. I think people just put their head down and have to kind of push out the noise to keep that going.

Elizabeth Lippincott (05:47)

Yeah, that’s a good point.

Sandy Durkin (05:48)

Yeah, thanks for sharing about the work that you did while you were at CMS. I know from the outside, we were so impressed at just the volume of work that CMS put out on Medicare Advantage, from the RFIs to the regulations for just the calendar year policy changes.

I don’t remember the page counts, but I think the last rule was quite lengthy and really substantive. We appreciate all the work that you and your colleagues were doing. And I know, we know you don’t have a crystal ball, but what are the types of things that you think people like us and our clients and colleagues who are watching CMS should look out for over the next couple of years?

Molly T. Turco (06:35)

Yes, absolutely appreciate that. You know, I think that one thing that we really tried to focus on is making sure that, you know, there were a lot of changes and there’s a healthy conversation of, you know, how do you ensure that the regulations are where they need to be, but not too much. And, you know, I’m sure some of my plan friends would, you know, have comments on what is hard. And I think it was always top of mind that, okay, a big entity might be able to navigate a lot of things and hire outside lawyers and consultants, but smaller plans, you know, who I’ve worked with a lot at the Blues and others. I know that can be a concern. So that was something that we weighed and really tried to help through that. You know, I think that we’ll see. I’m not in the business of prediction, but I think that from, you know, the experience I have just from where CMS is generally and then individuals who are in leadership there now, it seems that there’s definitely a focus on MA and a prioritization of that. I think, you know, from everything I’ve read, there is certainly a feeling that MA is a benefit system in Medicare that they really appreciate and want to continue to grow. That being said, I don’t think there’s going to be any backwards sliding on wanting to pay accurately.

So I think that people should expect a continued focus and it likely is through the lens of fraud, waste and abuse. So, you know, making sure that the risk adjustment system’s accurate, taking a really close eye on the methods for code capture, whether it’s, you know, in home health risk assessments or chart reviews or all of that. I think there is bipartisan agreement that, you know, this is a lot of money and this is a big program. And so there needs to be scrutiny there to ensure that the payment is accurate. I think STARS continues to be something that everyone wants to streamline. There is a ton of litigation right now. So kind of weighing the pros and cons of making sure that the STARS program is driving quality, but where is their burden and is it really achieving those goals? So yeah, so I think those are some of the key things. I think that one thing that I’m interested to look to see is, we of course put in a lot of consumer protections, prior authorization marketing. I think those are things that there’s bipartisan support on. But there’s also, I think, viewpoint of some folks that they want to reduce the amount of regulation. So I think that’ll be an interesting tension of really wanting rules of the road, which frankly a lot of plans want. You we heard a lot from, you know, smaller plans that sometimes felt like they don’t like ambiguity. They want to know exactly because they felt that potentially their lawyers were less risk adverse than some of their competitors. And so, you know, I think it’s important to not think of quote unquote over regulation as just something bad for industry. I think it can also be good for industry. So that tension of those clear rules of the road with, you know, not wanting to make it too burdensome will be interesting to watch.

Elizabeth Lippincott (09:36)

That’s a really good point that clarity can be beneficial because then you don’t have this competitive environment where, you know, frankly, some larger plans are just in a better position to take on risk, you know, to assume the risk of pushing the envelope a little bit. Yeah, I totally agree. So, yeah, risk adjustment continues. And I think as long as it exists, it will be a hot button issue for Medicare Advantage and for the other federal healthcare programs that use risk adjustment. We’re interested in your perspective on what are some common misconceptions about the role that risk adjustment plays in Medicare Advantage?

Molly T. Turco (10:17)

Yeah, it will always be the hot button issue, and we certainly, as many of you know, we updated the MA risk adjustment system called version 28, V28 for short. It was really interesting during that process. So as a quick reminder, what we did essentially is recalibrate the model to updated data years. And we also mapped it to ICD 10. So there had been kind of a lag in update in mapping it from ICD-9 to ICD-10, which the US healthcare system has been using for coding since about 2015. So it needed to happen. We also did some slight tweaks to clinical categories. I think 85 to 90% of the payment impact was the updating the data years and the mapping, which my perspective is you had to do and kind of those other decisions, trying to address arbitrage codes or codes that didn’t accurately predict future costs, so things like protein malnutrition, things that you can kind of code pretty easily for a lot of people. There isn’t a clear test and then there isn’t clear treatment. So it’s something, you know, I call them arbitrage codes because you kind of get money in, but really don’t have to put money out. So trying to address those because they, you know, the way that risk adjustment works in MA is relative weight. So if you overweight something and their predictive accuracy is low, that means you’re taking money away from other things where, you know, rightfully that costs more. I always talk about it spreading the peanut butter. So you need to spread that peanut butter accurately.

So, you know, I think that sometimes there’s a misperception there. You know, we heard a lot from folks that said, oh my God, you’re, you know, you’re taking all this money out. I mean, technically you’re moving the relative weights around. So, you know, I think that’s something that we’ve to think about this as predictive costs and not about kind of going in and intentionally removing money. So I think that that sometimes can be a misperception. I mean, I think risk adjustment in general, it’s hard for me at least to talk about risk adjustment without thinking about the whole bid and rebates and all of that. And sometimes I think there’s a feeling that it’s almost like if rebates don’t keep growing and aren’t 200 plus on average PM, PM, that’s a cut. That’s certainly not a cut. A rebate is kind of intended to be, if you are able to bid below the benchmark in your county, you can keep a portion of that. But that is not saying that you don’t have enough money to cover your A and B benefits, so I think that sometimes frustrates me too, how it’s been called a cut when there’s that tension there.

I think there’s always a misconception too, sometimes, on how complex, I mean, I heard a lot of like why haven’t you guys just addressed health risk assessments or this or that and I think CMS did a report to Congress at the end of last year and we tried to kind of dig in a little bit on some of the complexity of health risk assessments. I mean, CMS has kicked the tires on everything, you know, has thought through everything. And if they haven’t proposed something, yes, of course there’s politics, but oftentimes, health risk assessments are a perfect thing. You know, technically health risk assessments aren’t a type of visit that are eligible for coding. These are ENM visits and others, annual wellness visits that then that type of behavior is there, but it’s incredibly difficult if you read the OIG report, you know, they are kind of putting parameters around certain, but it’s hard. It’s hard to define what we’re talking about versus, you know, a very beneficial kind of primary care type visit in a home where some coding happens and some care happens.Just, I think that’s the misconception often that, you know, these are no brainer things, they’re easy, they’re low hanging fruit, why haven’t you done it? And it’s just politics of why you haven’t done it and often, I think tiered coding pattern adjustment, I would put in that bucket too of like, why haven’t you just done it? And I think those are all things that CMS has thought through and they’re very complex and there’s often really good policy reasons why they have or haven’t been proposed.

Elizabeth Lippincott (14:23)

That’s really a good insight. So, you think that the idea with the HRA is the in-home risk assessments, that health assessments, that there’s a sense that there really is value potentially if those are done right and the data is used right, that those can be good for care management.

Molly T. Turco (14:40)

I don’t even necessarily, you know, I think that I was talking more just that if there were to be a decision, I mean, I think there is a view for a lot of folks that there are clearly some in-home health risk assessments where the primary reason is to code capture. And there’s a concern there that, okay, is that the best? So assuming there is a concern there and then folks want to address that, my point is that that’s easier said than done.

I think a separate question is what is the value? Because another option is just to get rid of all code capture in the home, saying it’s too hard to distinguish what is visit primarily for code capture versus another one. And there’s already an ROI on treating people in the home and avoiding a hospitalization. Therefore, maybe you don’t need a code capture.

So I think it’s almost two separate questions. What is happening in the home? And then if there is a concern that it’s used for, overly used for code capture, how do you even get at that? Or can you have a code capture and then it has to show up somewhere else, which CMS proposed many years ago. So I think it’s a healthy debate and a debate that will continue, especially under the fraud, waste and abuse discussion. But it’s just, my point is just that there’s a lot of pros and cons and concerns there. So people should be really thoughtful as they consider any potential policy.

Sandy Durkin (16:03)

I think you already touched on the V-28 model and you know our understanding is that that has had a significant impact on payments to plans and I appreciated your explanation for some of those changes which seemed like they’re just overdue they needed to be made regardless of the impact based on the data that we have.

Did you have any other insights on how the implementation of that model is changing things for either plans or providers?

Molly T. Turco (16:38)

Mm-hmm. Yeah, I mean, as I alluded to earlier, V28 was certainly an impactful change. You know, it really impacted plan payment and trickle down. We heard a lot from subcapitated provider groups who felt that this was going to be a difficult thing to navigate, you know, which I think is all fair. But again, I come back to, you know, the point of CMS, it has a statutory requirement to make sure payment is accurate. So kind of the downstream impacts are our separate conversation.

They really need to recalibrate these models for accuracy. But there was a really spirited conversation, which I think is a good one, about value-based care and providers who are kind of identifying certain diabetes codes, let’s say, to trigger care coordination. So I thought that that was interesting.

Also, just know, investing and growing these subcapitated provider models in underserved parts of the country. But again, I think that that is, it’s really CMS’s job to make sure the payment is accurate and then, you know, plans and providers can work together, whether it’s a vertically integrated system or it’s providers working with plans on a subcapitated arrangement or you know many is still just a fee for service arrangement I think that’s kind of should be viewed as separate from just CMS’s duty to to pay accurately.

I mean I think one thing that was interesting is there was a lot of hyperbole I think and I think there were a lot of groups that just hadn’t been in a tight payment environment you know MA payment had been pretty generous for a while. And so I think that that was just painful to kind of move to a different revenue environment. I have heard from some provider groups that felt that this was tough. They had to make some business decisions, but they have now had to, it’s forced them to think more about care coordination, kind of the incentives we want, how they can manage within that capitated amount.

I think a lot of groups had very low MLRs and I think their argument would be, okay, maybe it’s a 50%, 60% sub cap MLR, because as a reminder, the MLR is at that plan level. So, you may hand over 85 cents on a dollar, but then that provider group may spend 50, 60 cents of that 85 on care and the other investments. So, felt that that was being well used to grow these businesses.

But I do think it’s forced to conversation, which I think is the right one. I also think it’s interesting to see that rebates did not go down. So, there were, you know, I think hearing there was a, you know, margin went down, so it’s not like it came from nowhere, but it’s really interesting to see how it seems like this market still really prioritizes rebates, certainly duals rebates. I think that’s still remains a business strategy. you know, I do expect that maybe we’ll hit a point. I hope we hit a point of rebates. I think, you know, a lot of seniors and other people on Medicare rely on those rebates and the cost sharing reductions, but they do hit, in my view, diminishing returns. And we just can’t, you know, it’s like $70 billion we’re spending on rebates this year. I think we have to have a hard conversation about if that’s a good use of taxpayer dollars.

Elizabeth Lippincott (19:55)

Well, and it’s also subsidizing the increases in part D premiums significantly and sort of insulating MAPD members from some of those price hikes on the part D side.

Molly T. Turco (20:08)

Yeah, it’s a fair point. I will say, though, that we did not see, we actually saw a slight decrease of Part D premiums last year, which was not what people expected. So as you may all know, plans submit their bids, and they kind of have to guess what they think, like what amount of their rebates they’ll have to use to buy down their Part D premium. And then they have what’s called a rebate reallocation, because once CMS, after the bids go in, kind of hastily have to, or busily have to, calculate in June and early July what the national average bid amount is for Part D and therefore what the subsidy will be. And a lot of MA plans got a lot of rebate dollars back in their rebate reallocation for 2025 because it was a lot lower because the Part D subsidy was higher.

I think sometimes, I mean, PDP certainly saw premiums and we stood up a Part D demo. But it’s important to note that MAPD did not see these huge Part D premiums. We’ll have to see how that goes, but MA plans certainly prioritize directing manufacturer rebates to their Part D. So they did not have to use as many rebates as they thought they did on their premiums.

Elizabeth Lippincott (21:21)

That’s really interesting, Molly. I didn’t realize there was a distinction like that between the Part D bits and the MAPD side versus standalone.

Molly T. Turco (21:30)

Yeah, absolutely. are seeing a huge… Yeah. And you saw a lot of divergence in bid strategy on the PDP side and the MAPD side. And I know we’re talking about mostly MA today, but the PDP market is certainly interesting and there’s some concerns there.

Elizabeth Lippincott (21:32)

I’m learning. I’m learning a lot.

Wow. Okay.

Elizabeth Lippincott (21:46)

Yeah, definitely. We talked about that last month. And yeah, we’re gonna have to have you come back. Because there’s just too much. So back on the risk adjustment topic in MA, what do you hope to see? I know it’s hard to predict, but what would you like to see from CMS going forward on risk adjustment programs and coding practices?

Molly T. Turco (22:08)

Yeah, I really hope everyone stays the course and we’ve kind of moved past the world where we’re debating, you know, is MA cost more than fee-for-service? I think it’s established that MA costs more than fee-for-service on an individual basis and that it’s really important that payment accuracy is a priority of every administration.

And so what I would like to see, there was a section in the advance notice about moving to recalibrating the model to encounter data. I feel that that’s really the next step of payment system. So that’s as a reminder right now, risk adjustment, the diagnoses are calibrated to encounter system, but the cost of kind of every widget of those coefficients is still based on fee for service data.

So that’s really the next frontier and what CMS said in the advance notice is they’ve been working on this for multiple years and could propose as early as 2027. So I think that will be a big change. And so there should be a conversation there, should be really thoughtful, should be phased in in a way that there’s stability. Yeah.

Elizabeth Lippincott (23:14)

Can I stop you for a second? So Sandy’s nodding her head like she was a math major, math and English. So she’s like tracking. I need that unpacked a little more, especially when you said coefficient, something sort of died inside. Yeah, can you kind of break that down a little bit more?

Molly T. Turco (23:33)

Yeah, absolutely. So as a quick reminder, the way that MA risk adjustment works is your risk score is essentially all these different building blocks. So one diagnosis, know, all your codes flow through to these hierarchical condition categories, HTCs, and each of those HTCs have a weight, have a coefficient.

So it’s like, this is point two, this is point three, and you add those all up and then your risk score is whatever. If it’s double the average risk, it’s 2.0. And so, you know, V28, what we did is we took all the different costs of things and then adjusted the relative weights of those coefficients. So the thought would now be to, okay, let’s take the cost and other data of MA and counter data to do those relative weights.

For example, some of those quote unquote arbitrage quotes, you would see that there’s not a lot of cost attached to them. So it would impact what the coefficient weight would be. So you would address a lot of those concerns and the awkwardness of apples and oranges of MA and fee for service. However, CMS can’t change the benchmarks and the because that’s set in statute, benchmarks are using fee for service data. So you’d all you’d have to there’s a lot of decisions of, How do you calculate cost? What about it subcapitated, which is just a bundle? How do you disaggregate within that? How do you toggle between the fact that the benchmarks are set based on fee for service and that the new risk adjustment system would be calibrated based on MA costs? So that is a super complex conversation.

Elizabeth Lippincott (25:08)

Oh, okay, so that’s interesting. Now that subcapitation and passing the financial risk to providers is more common, you’re saying it’s harder to tease out the cost associated with different diagnoses.

Molly T. Turco (26:22)

Exactly. you know, and CMS has been thinking through this. So, yeah, again, I think one criticism that we got for V28 is there wasn’t enough of a public conversation, but that cuts both ways because you put something out and you get hammered lobbying and all sorts of stuff. So I think, you know, whatever CMS decides to do, there’s always that balance of how do you want feedback, but it also can be so you know, intense and stressful. My hope is that we could move to a world where there is more of that. You put out the white paper, you get comments on the white paper, maybe you propose it one year, but have the phase in start at a very small amount, not right away. I mean, there’s things to do. You know, but I get it. I mean, this is a big business and it’s there’s a lot of money at stake. Of course, often industry is going to say no. And so they’re less willing to tell you how to do the thing because they just don’t want you to do the thing. And so their comments aren’t that helpful. So it’s a real give and take, but it’s a really important conversation for everyone to have.

Elizabeth Lippincott (26:30)

Yeah, yeah, and it is, yeah, it makes sense. You’re kind of kicking the hornet’s nest when you mess with it in any direction.

Molly T. Turco (26:36)

Absolutely.

Sandy Durkin (26:37)

I’m reminded of the years-long litigation over the fee-for-service adjuster and appreciate that that delay did not really help anybody and the need for rules of the road even if they’re not always exactly what the industry would want. I think we’ve probably exhausted risk adjustment for now although I’m realizing we probably want to put out a whole episode on the topic. But moving on from that, you, Molly, contributed to a recent article for Health Affairs, which was a great article. And you made the point that the job of CMS is to provide clear rules of the road for plans and providers. And you were talking about utilization management and prior authorization. Can you speak more about the issues that are facing providers treating people with Medicare Advantage coverage, including rural hospitals.

Molly T. Turco (27:34)

Absolutely. Yeah, my former boss, Dr. Meena Seshamani, the former director of Medicare, and I wrote the piece and really encouraged people to read it. The intent of it was to explain what we did. I think what I found is there’s been a lot of confusion on what CMS has done over the past few years and some proposals I really hope that CMS finalizes for 2026.

But in that piece, really, what we said was the four main important steps that need to happen to improve utilization management in Prior Auth, which I think across all of industry, plans, providers, patients, advocates, everyone agrees that this is such an important issue that everyone needs to work together to improve. The real four key elements are, as you alluded to, Sandy, the clear rules of the road. Increasing transparency, number two. Number three, effective oversight and number four, really accelerating the streamlining and modernization of the processes. What I heard a lot was, okay, we don’t love PA, but if you did it really fast, we could live with it. So, you know, and I think that the important thing that intention that we really tried to be thoughtful on and I bring from my perspective, working with plans, is it’s managed care. You know, an important part of managed care is ensuring that utilization is accurate, that you’re directing individuals to high value care, you want to avoid fraud, waste and abuse. But I do feel like things have gotten out of hand and that part of it was there wasn’t clarity, there wasn’t clear rules of the road. And to your earlier point, Elizabeth, of taking on risk, I think some plans were pushing the envelope more than other plans, but not necessarily in violation of rules, just because the rules were opaque. You know, there’s always been a requirement that MA plans have to provide all A and B benefits. But A and B, fee-for-service, it doesn’t have clear rules of the road, because it’s just a different payment system. So there were situations where you could have kind of clinical criteria because there wasn’t a clear national coverage determination of in this situation you have to provide X. It was not clear, so plans were able to kind of fill in those gaps, but there weren’t clear rules on how to fill in those gaps. And so that’s what CMS has been doing over the past few years. Okay, this has to be a widely accepted treatment guideline. It has to be supported in the academic literature. So, it has to be transparent and publicly posted. So those are the types of things that CMS has done.

I also think the questions have fallen into two buckets. It’s the access issues, which I think everyone’s very familiar with, and there’s the most concern about, are people having access to the care they need? And then the second bucket is the financial impact on providers and hospitals. And Sandy, as you alluded to, we especially heard about rural hospitals.

These are situations, there’s a proposal in the 2026 rules where, for example, when you have a determination, so specific to inpatient admissions, so the person is evaluated by the physician and they feel that that person has to be admitted, the plan says, okay, we approve this, you’re not allowed to then reverse that determination, but there’s kind of a loophole where a plan can often use a third party auditor and call it a quote unquote audit and then look and say, okay, that person didn’t actually get the thing, sepsis let’s say, that admitting physician was worried about. Therefore, they didn’t need to be admitted. So we’re not gonna pay for that. Obviously that physician didn’t have a crystal ball. They were following appropriate criteria. The plan approved it. So it’s not, you can’t reverse that, but the rules weren’t clear to close that loophole. So that was just one example of where CMS is trying to close those loopholes to just make it easier for rural hospitals and others to not have these financial burden of lack of clarity on the different rules related to utilization management.

Elizabeth Lippincott (31:33)

Molly, when you say close that loophole, is that when they clarified that the two-midnight rule applies or is that something else?

Molly T. Turco (31:40)

So that’s separate. This is a proposed rule for 2026 related to reopening. Actually, technically, two midnight’s doesn’t apply in MA. That could be a whole other episode. technically, yeah, two midnight’s, that is a of a guidance to the contractor, to the MAC. So it’s not technically clinical criteria, so that is an area of a lot of confusion and tension, but ultimately, CMS has been putting changes in place to get at the spirit of two-midnights and ensure that those appropriate admissions are happening, but it’s incredibly complex. One shout out, I will say, is in that piece in health affairs, we link to FAQs that CMS put out. I think those do a really nice job. They’re weedy, but for those of you who want to do some continued learning on the nitty gritty of this PA thing, and we address that two-midnights, hopefully it’s not, yeah, so I would read through that because it’s incredibly complicated.

Elizabeth Lippincott

We do. Thank you.

Sandy Durkin (32:42)

I have to say I have looked at that frequently asked questions so many times. I think that’s the one that also talks about artificial intelligence and algorithms in UM. That was an incredibly useful document, of course. It did generate many questions. The more you say, the more questions you’re gonna generate. yeah, that is a great piece.

Elizabeth Lippincott (33:05)

Yeah. So can you tell us a little more about your perspective on the role that prior authorization should play in care management and Medicare Advantage plans?

Molly T. Turco (33:17)

I think that to my earlier point, it’s important that when we have a conversation about the give and take of prior authorization, that it is important to hear from plans and providers of where different types of utilization management can be leveraged in a way that allows MA to do the managed care and care coordination in a way that it’s meant to and that it should be incentivized to do. Ensuring that individuals are getting the care they need. They meet the requirement for what can happen. You know, I think sometimes what I worry about, and we heard a lot from plans who felt this way too, is that the way that the current incentives are in MA, it’s about, you know, code capture, getting your stars up, and maximizing your rebates. And a lot of times, plans would love to invest dollars into more care management tools and they really feel that they have to invest them in things that are code capture and that they have to maintain those rebate dollars because if they can’t attract enrollment in the door, then it’s a moot point if they have this amazing care management and also hurt a lot. There’s concerns that the STAR system doesn’t appropriately differentiate quality. So if you really feel like you are doing better than others in terms of care coordination, it’s hard to show that in the current STARS system. My feeling is that all of these different changes, payment just shouldn’t be viewed as in the silo of payment. Really making sure payment is accurate and STARS and all these other changes is about moving the incentive so individuals compete on what matters. I think a healthy conversation of rebates, as I alluded to earlier, right now, what’s happening is a lot of dollars on these cash cards, these debit cards. And so even some of the care management, social determinants of health investments that plans want to make, they know that to compete in the marketplace, they have to really have those debit cards. And so I think we need to have a conversation of, do we need to limit rebate dollars so that you maximize rebates? And that’s kind of, you need to do that to compete. But once you’ve done that, you can focus those dollars elsewhere or just feel less pressure to code. Again, that may not be the right answer, but I think these are the types of conversations we have. I certainly think we heard a lot that investments in care coordination.

And looking at care coordination truly is care coordination, not just steerage. It’s kind of the dirty word, but like steering someone to a lower cost side of care, making sure that it’s an observation stay, not an admission, not because that’s what’s right for the patient, but because of all this. And again, it’s managed care. They have to manage. They want the lower side of care. That’s not necessarily a bad thing, but making sure that there is that tension, because that’s the whole point of a capitated system is to incentivize plans and provider partners to manage within that to improve outcomes. So I think we have to take a hard look if that’s where the incentives are and that’s happening. But that’s what I hope to see in kind of this next phase of MA.

Elizabeth Lippincott (36:24)

Well, and you raise a good point about the tension between marketing pressures and the fact that I’ve been seeing commentary recently about the fact that members can move every year. And the reasons why they move may not relate to, you know, who’s managing care, who’s making those upfront investments in health for chronic conditions or things like that. Those might not be the drivers of why you moved to another plan. And that’s difficult too. You don’t want people locked in, but on the other hand, it’s a real upfront cost to invest in someone’s help.

Molly T. Turco (37:02)

Absolutely, it’s interesting. Traditionally, MA enrollees have been pretty sticky, but I think your point is well taken. We have seen more switching in the past couple years than we have, which isn’t necessarily a bad thing. I mean, that’s always the tension at CMS. think sometimes people can say, this is bad. People are switching. But it also can be a good thing if people are shopping every year.

A tension that we had to navigate at CMS is paradox of choice. So for many years, CMS would tout there’s 20, there’s 40 options in your county. And what we’re hearing a lot from ship counselors, people who man the 1-800 Medicare lines and others that if there’s not meaningful differentiation between those products, it’s really confusing. A senior might know that they want an MA plan, but feel really overwhelmed deciding what and not having the tools. So I think that’s a conversation, kind of empowering consumers, that is bipartisan. I’m sure the new leadership at CMS is looking at because, you know, yes, you want choice, but we shouldn’t always see like there was some plans who switched their offerings in different parts of the country last year. And it’s kind of always covered as, my God, this is this bad thing. CMS is so bad. But there is a give and take there where it’s not necessarily a bad thing as long as enrollees have good choices and can go to, fee for service.

I think another tension is not having a guaranteed issue MediGap. So feelings that we heard from seniors who felt trapped sometimes, which ultimately what I say to people in MA is that’s not good for MA. You want people there who want to be there and a lot of people want to be there, but if they feel like it’s not the best option for them. It’s tricky and I’m not going to hold my breath that guaranteed issue MediGap changes are going to change anytime soon, but I think that’s an important conversation too. And I think people who are advocates of MA should not view that as negative. I think most people will stay in MA, but if they don’t want to, I think that can be a real problem when they feel trapped.

Elizabeth Lippincott (39:05)

Yeah, that is another episode, guaranteed issue. You know, I had to, when my mom has a PhD, okay? And when they first started allowing the transportation benefits, her plan at that time, they added it. Plus she didn’t need transportation, but anyway, she saw ads and she’s like, should I change? I’m like, do not change your plan. So it’s tricky. I mean, you want freedom, but sometimes, yeah. It’s complicated. I would have to say, so much.

Sandy Durkin (39:38)

So we won’t ask you, Molly, to predict what is going to happen with the proposed rule that CMS put out last November for calendar year 2026. I will just ask, are there any provisions of that proposed rule that you think or particularly hope would be finalized by CMS? I know you mentioned the change to eliminate the ability of the MA organization to reopen an approved prior authorization for an inpatient hospital admission. Is that one that’s close to your heart and is there anything else you’d like to see?

Molly T. Turco (40:23)

It’s funny, I knew you were going to ask me this and I was looking back over the fact sheet and I was having trouble picking my favorite child. So if you will allow me, I will just go through a few things just so folks know what’s in there. Yes, I would say that for me personally, prior authorization changes are always top of my list. I think it’s incredibly important that individuals have access to care and you know, we, starting from Meena on down through all the staff, at the end of the day when you’re at CMS you serve the beneficiaries so they should always be number one. So anything that helps consumers and enrollees is number one in my book. I think the GLP-1 change for Part D to cover anti-obesity medication is incredibly important. I’d like to see them finalize that. As you said, the prior authorization utilization management changes. There’s some changes to the marketing of debit cards. To my earlier point, I think there really needs to be guardrails on that. I think it’s getting a little out of control. I think that that should be finalized. There’s some duals integration, which I think are really good policies that should be finalized. There’s one on the Medicare plan finder. We hear a lot that it’s really hard back to that being able to choose so allowing kind of integrated into the Medicare plan finder when enrollees are shopping so they can look at networks like in that website I think that’s important. There was a proposal to broaden the marketing definition so there’s technically, it’s super confusing, but there’s technically certain TV ads and other ads that don’t fall into the current definition I think everyone should agree that CMS should make sure that anything that’s bombarding seniors and other Medicare eligible individuals should pass a test and not be misleading and disruptive. And there’s some MLR reporting requirements and other things. I think that vertical integration is something everyone wants to really make sure we have a handle on. So I know that’s a long list and I would argue this is not quote unquote over regulation, I would say that these are, as I said earlier, this is a $9.2 trillion program that we’ll be spending over the next decade. Like this is over 2% of the US GDP. We’ve got to get serious about oversight. And I think that any MA plan that’s getting billions of federal dollars every year should be prepared to navigate these different changes. I don’t think it should be viewed as, quote, death by a thousand cuts or too many regulations. I think we have to, as a country, make sure that those dollars are being spent effectively and enrollees  are getting the care they need. So I would hope that they really finalize as many of those proposals as possible. And maybe not this year, you have three years to finalize a proposal. So if they decide to not finalize it for 2026, they don’t have to repropose them for another two years. So I will be hopeful that they’ll be finalized in other years. But I do feel like the majority of those proposals are bipartisan and good for the program.

Elizabeth Lippincott (43:23)

Thank you so much for sharing your perspective. It’s very helpful to get your insights. So we understand you’ve opened your own consulting practice. So congratulations, first of all. Can you tell us a little bit about your new role and what you want to accomplish?

Molly T. Turco (43:39)

Thanks, Elizabeth. Yes, it’s always interesting, these transitions. And I’m still sorting things out, but I think that what really motivates me is explaining a lot of what’s going on. So I think a lot of things in Medicare Advantage can be confusing.

And it’s not necessarily saying what’s the right answer. I think a lot of issues don’t have a clear right answer. So it’s understanding what are the pros and cons of different decisions and making sure that policymakers know those pros and cons. So I really enjoy sitting at that intersection of helping people know what the proposal is or connect a problem to a solution. But I think sometimes I’ve seen both when I worked in the private sector and then in CMS that people are talking past each other where there might be more common ground if there’s a better understanding. So, you in my future role, I really want to help with that. I also, you know, I’m hoping to build a practice to work with companies and others who want to kind of move MA to the next phase, you know, MA 2.0 where this is absolutely half of the MA program. We have a lot of enrollees who really like the program.

But I think that there are pressures there, hearing from small plans that are finding it harder and harder to compete. So can we think about ways for those plans to compete? Really want to work with other smaller companies navigating this space and thinking about that. I know there’s an appetite for larger plans to kind of think more longitudinally about these issues. So I’m hoping to build a practice of kind of working with different companies that want to think through that and advocates and beneficiaries where the program can serve them better and protect them better. So, you know, we’ll see. But I think it’s a really interesting time in Medicare Advantage. I don’t think anyone wants to kind of roll back, whether it’s payment policies or consumer protection policies. Working within that bipartisan conversation on things that are kind of a no-brainer for everyone is really where I’m hoping to be working.

Elizabeth Lippincott (45:41)

Well, we wish you every success and it sounds like they’re over. You know, we work with plans, small and large, but we care a lot about those small plants that are trying to make it and trying to keep up because I think that they add a lot of value in the market. So we wish you all the best. We want to conclude with some deep thoughts. So here is our question for you, Molly, as you, you know, at this juncture in your career. If you think ahead to the day you retire, whenever that may be, and you’re looking back on your career, what is one thing that you want to know looking back that you have contributed?

Molly T. Turco (46:24)

It’s a great question. I think maybe because it’s the moment that we’re in right now, but I think what I’m going to say is, what I want my career to be remembered as, is that I was a good team member and helped pull up people that came after me. I think right now we’re going through a time that’s incredibly tense in CMS and healthcare policy and other things like that. So I think what I value is, obviously we’re in healthcare to help make the system better and that’s core to what we want to do. But I think for me personally, I really value being a positive team member that helps kind of the individuals who work in this space and is collaborative across a lot of different viewpoints. And so, you know, if I can be remembered as someone who brings people together and can have those tough conversations, but also make sure that we have, you know, new perspectives coming in, I think that’s really what I value and what I think then will make the health policy conversation kind of modernize and move forward. So that would be my hope.

Elizabeth Lippincott (47:29)

Well, I can give you some feedback at this stage, Molly. We really enjoy working with you. We think you’re a great, you know, in various capacities over the years and in this podcast, you are a great team member to us. So thank you for being here.

Molly T. Turco (47:43)

Thank you. And now speaking of team, I’m going to go play some pond hockey in Vermont. So, team in all aspects of the word.

Elizabeth Lippincott (47:55)

Oh fun.

Well, good luck. Stay safe out there on the ice.

Molly T. Turco (47:58)

Thank you.

Sandy Durkin (48:00)

Thanks, Molly.

Elizabeth Lippincott (48:01)

All right. So you ready? Call after the call.

Sandy Durkin (48:06)

Yes, do you want to, Elizabeth, give a little intro to tell our listeners what’s the call after the call? What is this segment?

Elizabeth Lippincott (48:17)

Yeah, so I think everybody knows what the call after the call is, because I think everybody does it. It’s when you get off the larger call and then you talk to your peeps about how the call went. That’s the call after the call. So, with this being our first interview, and of course, we’re going to keep it positive, because what would there be not to be positive about. But yeah, so I thought that was awesome.

Sandy Durkin (48:43)

Yeah, for us, our team at Strategic Health Law, the call after the call is most often us just fangirling over our clients and our colleagues. And I think this is…

Elizabeth Lippincott (48:58)

Unless it’s a negotiation, then we’re like, oooh…

Sandy Durkin (49:00)

Yeah, maybe not with opposing counsel. But yeah, this is no different. I think Molly is so smart and she really does understand the nuances of the Medicare Advantage program in a way that very few people that I work with do. And so, yeah, she’s just such an asset.

Elizabeth Lippincott (49:26)

Yeah. It’s awesome. Yeah. I feel like when I talk to her, my brain burns extra calories. Did you hear brain is like one of the biggest calorie burners of your whole system? Yeah. No, I didn’t make that up. That’s from science. I feel like my brain, like I get to have a bigger lunch because of that call. Learn. I learn new phrases like arbitrage codes. I love it.

Sandy Durkin (49:52)

Yeah, I know.

Elizabeth Lippincott (49:53)

Protein, malnutrition, like arbitrage codes.

Sandy Durkin (49:55)

Protein calorie malnutrition. I know that’s been a hot code.

Elizabeth Lippincott (50:02)

We’ve seen that. Yeah, we’ve seen that come up.

Sandy Durkin (50:04)

Yes. I mean, it’s really great to hear what is CMS thinking about because we have a lot of plan clients and the last four years were challenging with the amount of guidance that CMS was putting out. And so it is reassuring to hear how much thought and care CMS is putting into these decisions. And that was, a couple of things that Molly said, you know, I wrote down because they were really things I want to think about. But one of the things she said was the importance of stakeholder feedback. And that was something that was notable about the last CMS was that they did specifically seek input from not just plans, but all kinds of stakeholders before they undertook the massive rulemaking that they did.

And when they put out proposed rules, they did receive so many comments, thousands of comments, and took great pains to respond to those comments, which is something that I think is helpful when we’re helping our clients navigate how to implement those rule changes.

Elizabeth Lippincott (51:27)

Well, so time will tell, because we have that new HHS policy that was just announced of not using notice and comment rulemaking. We won’t get into all the details of the technicalities of that. But as a practical matter, that could really be difficult in terms of getting that feedback of what are the implications of this going to be?

Is this going to be overkill for what you’re trying to achieve? Is there something else that would be a more streamlined approach? So I’m really curious to see what replaces that or how much that impacts day-to-day life for MA plans on their providers and others in that orbit.

Sandy Durkin (52:14)

Yeah, that is potentially going to be a huge change in how CMS does its work if, depending how broadly they apply that new policy interpretation. And you mentioned getting feedback. It’s not just feedback, but it’s buy-in. Molly mentioned that they got critique for the implementation of the V28 model because stakeholders did not feel like there was enough public discussion around it. And to the extent that the risk adjustment models are changed going forward, how are those changes going to be communicated proactively? You can’t just spring these huge changes on an industry without warning. And Molly mentioned the possibility of white papers. I think there are other vehicles for agencies to communicate their plans outside of notice and comment rulemaking. And I, for one, hope that that’s something that this administration really considers and makes an effort to do.

Elizabeth Lippincott (53:27)

Well, we’re fixin’ to find out. Let’s just stay around here. I live in North Carolina.

Sandy Durkin (53:33)

You know, I wanted to ask you, Elizabeth, you know, we talked a lot about some of the most pressing issues that are facing MA organizations, risk adjustment, prior authorization. There was some talk about the STAR ratings quality program. Are there any other developments in the news, in the industry that are on your mind that you wanted to comment on from these past couple of weeks?

Elizabeth Lippincott (54:03)

You know, one thing that Molly said that I really appreciated is about prior authorization. I understand it. It’s difficult, you know, on all sides. But her point that this is managed care, you know, that’s part of it. And I also thought it was really interesting how she said, we don’t love it, but if you did it really fast, that would be okay. You know, so interesting to get those insights. Yeah, I learned a lot. I’m still going to be digesting. I’m looking forward to listening to this episode. I might listen to it two or three times. Yeah, just to kind of take it all in because there’s so many moving parts right now.

Sandy Durkin (54:47)

Absolutely, I also, some of the notes that I took are the focus on or the concern for smaller plans and the ability of smaller organizations to quickly implement big changes or to assume the risk of taking an aggressive interpretation of a big change. So, I know that’s something that we think a lot about at Strategic Health Law, so I was reassured to hear that that’s something that CMS also is considering when they put out these rules.

Elizabeth Lippincott (55:25)

Yeah. It’s just, I feel like this time is just full of surprises. Like we talked about on previous episodes, I was really expecting accelerated enrollment growth in MA this year. And we just saw it was, there was a delay and we just saw the enrollment numbers and there was growth, but slowed from last year, which surprised me. So I think, yeah, just kind of wait and see. It’s really an interesting time in this industry.

Sandy Durkin (55:53)

Yeah, that’s why it’s hard to use our crystal ball, because we just don’t know what’s going to happen. Sometimes things take longer than we think.

Elizabeth Lippincott (56:01)

No, it’s quite a, I’ve been doing this for quite a while, and this is a unique season. Definitely, definitely. Well, yeah, well this was fun. All right, thanks.