Oct 13 2015 | Lumeris News | By

News Release: Lumeris’ Client Essence Healthcare Receives Rare CMS 5-Star Rating

Extraordinary Rating Validates Trailblazer Lumeris Collaborative Model While Creating a Scalable Playbook for Every Healthcare Organization in the U.S.

ST. LOUIS Essence Healthcare, a long-standing Lumeris client, has been awarded the highest rating available from the Centers for Medicare and Medicaid Services (CMS), 5-Stars, for the quality of services it delivers to its Medicare Advantage (MA) members. Essence Healthcare is a rare and unique success story because it earned this distinction without owning hospitals or employing physicians. The 5-Star award was given to only 3 percent of all the plans in the U.S.

“The Star Rating system is all-encompassing and not only requires a plan to operate on all cylinders, but also one that effectively engages physicians and consumers to drive adherence to important clinical and quality measures,” said Martha Butler, chief operating officer of Essence Healthcare. “Lumeris’ operational capabilities, engagement services and technology platform have been fundamental to our success and 5-Star rating.”

“We congratulate Essence Healthcare,” said Mike Long, chief executive officer of Lumeris. “This achievement signals the path forward for the transformation of healthcare in the U.S. Together, we’ve proven that collaboration benefits all participants in the delivery of care.”

Lumeris Collaborative Model Is a Game-Changer

The Lumeris Collaborative Model aligns the interest of everyone in the healthcare delivery supply chain around better clinical outcomes with lower costs. The industry’s best quality results also produce cost reductions of 30 percent, achieved through increased investment in preventive care, elimination of unnecessary and inefficiently delivered care, and lower administrative costs.

For Essence, Lumeris provides technology-enabled services to run its MA plan, including operations, business model alignment, physician and consumer engagement, and enhanced care delivery, all backed by the power of Lumeris’ population health technology and data management platform.

“The Lumeris Collaborative Model is the most ambitious effort I know of to bring collaboration and excellence to our country’s healthcare system,” said John Doerr, Lumeris’ largest investor and board member. “This convergence of information, behavior change and technology is vital — and working.”

Breaks the Cost Curve

“Historically, when healthcare organizations focus on improving quality, they expect costs to increase. In our case, we improved quality while lowering costs for both patients and providers,” said Richard Jones, CEO of Essence Healthcare.

For example, an Essence Healthcare provider, verified by a third party actuary, lowered costs an average of 2.5 percent annually over a three-year period compared to projected annual cost increases of 3.7 to 4 percent. This resulted in a 17 percent improvement in medical cost during the same period.

In another example, also validated by the same third party, four years of claims were studied, comparing Medicare fee-for-service against the Lumeris approach. The results showed 30 percent lower costs and 18 percent fewer readmissions for populations using the Lumeris Collaborative Model.

Physician Engagement Is Key

A key to the success of value-based arrangements is physician engagement. A research project published in the American Journal of Accountable Care (“The Accountable Primary Care Model: Beyond Medical Home 2.0,” December 2014) examined three years of Essence Healthcare data and found that how a plan engages and prepares physicians has a significant positive impact on outcomes and ultimately on their career satisfaction.

Lumeris Collaborative Model Validated by Ten Years of Research

A decade ago, Lumeris had a vision that payers, providers and consumers should collaborate to help the U.S. become healthier. Since then, the organization has pursued a strategy to transform healthcare called the Triple Aim +1™. The Triple Aim +1™ focuses on delivery of better health outcomes with lower costs and improved patient satisfaction. By adding “Plus One,” higher physician satisfaction, Lumeris enables physician engagement to be a key driver of success.

“Lumeris engages and rewards physicians, integrates data from across the continuum of care, and helps physicians incorporate best practices into their daily workflows,” said Jones. “This collaboration proves the business case for value-based care for organizations of all sizes and types.”

Proves Better Financial Performance is Compatible with Higher Quality Care

“This 5-Star rating demonstrates that quality outcomes and positive financial results are not mutually exclusive,” said Debbie Zimmerman, chief medical officer for Lumeris. “Very few can balance the Triple Aim +1™ to achieve what Lumeris has, and it is indeed transferrable, scalable and affordable for other clients, with guaranteed results.”

“With this 5-Star rating as validation, we’re now partnering with other payer and provider clients to launch, manage, operationalize and enhance their value-based care plans. We’ve recently announced new payer/provider collaborative plans in Kansas City, Louisiana, and Pennsylvania, and expect to announce additional client relationships very soon. And, we’re confident that we’ll help them achieve top Star ratings in the very near future,” said Long.

“We’ve changed healthcare delivery in the U.S. forever. The Lumeris Collaborative Model ensures everyone benefits. Our scalable model can be implemented in any geography, for any population to help any healthcare organization achieve results like Essence Healthcare,” Long said.


Lumeris serves as a long-term operating partner for organizations that are committed to the transition from volume- to value-based care and delivering extraordinary clinical and financial outcomes. Lumeris enables clients to profitably achieve greater results through proven playbooks based on collaboration, transparent data and innovative engagement methodologies. Lumeris offers comprehensive services for managing all types of populations, including launching new Medicare Advantage Health Plans, Commercial and Government Health Plan Optimization, and Multi-Payer, Multi-Population Health Services Organizations (PHSOs) for provider organizations. Currently, Lumeris is engaged with health systems, provider alliances and payers representing tens of millions of lives moving to value-based care. Lumeris has nearly 800 employees.

For 2016 annual enrollment, Essence Healthcare, a Lumeris client, was rated “Excellent” by the Centers for Medicare and Medicaid Services. Essence was Lumeris’ pioneer client and has been leveraging Lumeris for more than a decade to operate its Medicare Advantage plans, which serve more than 52,000 Medicare beneficiaries in various counties throughout Missouri and southern Illinois.


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