Sean Creighton serves in Avalere’s Policy practice, focusing on Medicare Advantage (MA) and Part D reform, risk adjustment, and analysis of healthcare quality and utilization.
In recent projects, Sean has helped MA plans obtain regulatory flexibility linked to enhanced benefits for members, access medical loss ratio flexibilities during the pandemic, improve bid gain/loss margin rules, and rationalize network requirements for dialysis centers. He led successful policy discussions with the Centers for Medicare & Medicaid Services (CMS) aimed at maintaining high quality of care for patients with end-stage renal disease while also reducing dialysis center network adequacy requirements, which restricted provider competition. Sean has also helped MA plans safeguard patient access by negotiating line-of-business requirements with CMS’s Office of the Actuary.
Before joining Avalere, Sean served as vice president for federal policy at Humana, working on industry initiatives related to COVID-19 and leading development and implementation of federal policy strategy. He worked as senior vice president for revenue integrity and risk adjustment product lines at Verscend (now Cotiviti) focusing on data aggregation, medical coding, and submission products for Medicare and the commercial market. Previously, Sean served as deputy group director of CMS’s Center for Consumer Information and Insurance Oversight’s Payment Policy and Financial Management Group and directed the CMS division of Payment Policy and Risk Adjustment in the Medicare Plan Payment Group, where he developed and implemented risk adjustment models for Medicare Parts C and D. Sean also served as chief architect of CMS’s Medicare Encounter Data System.
Sean holds a bachelor’s degree in European studies from the University of Limerick, a higher diploma in statistics from Trinity College, Dublin, and a master’s degree in sociology from the London School of Economics. He conducted doctoral research at Indiana University, Bloomington, and has won various awards for development and implementation of risk adjustment and payment models.