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.

Authored Content


Plans adapt to market changes in risk adjustment coding. Interviews with plan professionals reveal three trends for efficiency, effectiveness, and compliance.

Due to increasing the portion of plan payments subject to risk adjustments in 2025, CMS proposed aligning the risk adjustment model with Part D redesign.

Join Avalere’s healthcare policy experts as they dissect the Advance Notice of Methodological Changes for CY 2025 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and discuss the future trajectory of Medicare Advantage (MA) in Part D and potential outcomes, headwinds, and tailwinds for health plans.

Payments to off-campus hospital sites affected by site-neutral payment policy amount to only 2.3% of Medicare outpatient spending.

Avalere experts explore how key policy changes, such as the Risk Adjustment Data Validation final rule, Inflation Reduction Act, and Medicare Advantage payment shifts, are shaping the landscape for health plans.

Updated Avalere analysis finds MA beneficiaries with chronic conditions had fewer inpatient stays and ED visits than FFS Medicare beneficiaries.

The accuracy of the CMS-HCC model differs by beneficiaries’ race and ethnicity.

168 million individuals could lose access to $0 preventive services, creating pressure for healthcare stakeholders to address access and equity concerns.

Due to changes proposed in the CY 2024 Advance Notice, enrollees in Medicare Advantage could have higher premiums and fewer benefits in 2024 than 2023.

Avalere expert Sean Creighton explains key policy changes proposed in the Advance Notice for Medicare Advantage and Part D Payment for Plan Year 2024.

Policy changes included in the final MA RADV rule will substantially affect the MA program, plan benefit design, and operations.

Proposed technical changes to the MA risk adjustment model would have major implications if finalized.

CMS is expected to publish a final MA RADV rule by February 1. Policy changes could have a substantial impact on 2024 bids, plan benefit design, and operations.

If finalized as proposed, the changes to the Risk Adjustment Data Validation process could have a substantial impact on Medicare Advantage plans and enrollees.

Tune into the third episode in our video series focused on Medicare Advantage. In this segment, Avalere quality measures experts, Michael Lutz and Taylor Musser, discuss the shift toward member-reported measures and implications of recent measure reporting methodology updates.

Tune into the second episode in our video series focused on Medicare Advantage. In this segment, Avalere experts and former Center for Medicaid and Medicare (CMS) employees Sean Creighton and Tom Kornfield discuss their thoughts on the best ways for health plans to influence CMS decision making, including timing of engagement and critical messaging elements.

Tune into the first episode in our video series focused on Medicare Advantage. In this segment, Avalere experts and former Centers for Medicare & Medicaid Services (CMS) employees, Sean Creighton and Tom Kornfield, discuss the outlook for Medicare Advantage, factors that will influence growth of the program, and a behind-the-scenes look at CMS policymaking considerations.

Join Avalere’s healthcare policy experts for an analysis of the final rate announcement and a discussion on the future of Medicare Advantage (MA) and potential outcomes for health plans.

Sean brings more than 2 decades of Medicare Advantage experience in industry and government.

This month, the Centers for Medicare & Medicaid Services (CMS) proposed changes to Medicare Advantage (MA) through the annual Advance Rate Notice and Proposed Rule. These proposals impact MA in many ways, including changes to quality bonus payments, network adequacy requirements, coverage of End Stage Renal Disease (ESRD), plans targeting dual eligibles, and supplemental benefit offerings. Stakeholders should examine each of these areas closely as they respond to CMS.

CMS is considering changes to its commercial market Risk Adjustment Data Validation (RADV) program to improve the accuracy of risk adjustment transfers and to increase stability and predictability for issuers. This follows issuer experiences with the 2017 RADV process in which some issuers saw substantial, unforeseen changes to their risk adjustment transfers. These RADV changes have the potential to impact issuer participation and premiums in future years depending on the direction (positive or negative) and magnitude of those transfers.

In a recent post on the RISE website, Sean Creighton examines the methodology and evidence behind CMS’s proposal to eliminate the Fee-for-Service (FFS) Adjuster from Risk Adjustment Data Validation (RADV) audit methodology.

Medicare Advantage (MA) plans continue expanding coverage of supplemental benefits following administration’s policy changes from a year ago.

In 2018, CMS proposed to revise its Risk Adjustment Data Validation (RADV) methodology to exclude the FFS Adjuster in its payment recoupment calculations. New analysis from Avalere finds that the payment impact associated with fee-for-service (FFS) Medicare coding discrepancies would be greater for certain subgroups of beneficiaries (e.g., dual-eligible, those with certain common and potentially serious health conditions) enrolled in the MA program.

In February 2012, the Centers for Medicare & Medicaid Services (CMS) announced a final payment error calculation methodology for its contract-level Risk-Adjustment Data Validation (RADV) audits of Medicare Advantage (MA) plans.

As CMS continues to transition from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS) for Medicare Advantage (MA) risk score calculation, plans must evaluate operations and close gaps to minimize the impact of risk score differences using this claims data source.

In a recent post on the Health Affairs Blog, we examine the potential uses and limitations of Medicare Advantage (MA) encounter data.

In episode 1 of our series Fred Bentley, Sean Creighton, and Kenny Kan discuss the new supplemental benefits offered through Medicare Advantage plans for 2019.

Our analysis finds there will be winners and losers at the plan level under the new models.

Join Avalere experts for our analysis of CMS’ 2019 Star Ratings and a look at what’s to come for 2020 on our webinar on November 1, 2018.

MA plans expand coverage of supplemental benefits following administration’s policy change.

Following its recent announcement to grant Medicare Advantage (MA) plans the flexibility to use step therapy techniques for Part B drugs beginning in January 2019, the Centers for Medicare & Medicaid Services (CMS) released an FAQ with additional guidance on its implementation.

New research from Avalere finds that Medicare Advantage (MA) beneficiaries with hypertension, hyperlipidemia, and diabetes experienced significantly fewer inpatient stays and emergency room visits relative to those in traditional fee-for-service (FFS) Medicare.

Earlier this year, the administration granted Medicare Advantage plans greater flexibility to target benefit designs for individuals with certain high-risk health conditions. These changes are expected to position the program for continued growth.

In its 2018 Report, the Medicare Trustees issued a Medicare funding warning, citing concerns over the program's near-term financial health and spending impact on the federal budget.

Yesterday, the Centers for Medicare & Medicaid Services (CMS) released Part II of the Advance Notice and Call Letter (ANCL), describing the Agency's proposed 2019 payment policies and other policy updates for the upcoming plan year for Medicare Advantage (MA) and Part D plans.

In February 2017, Avalere, an Inovalon company, analyzed data from eight Medicare Advantage Organizations (MAOs) representing 1.1 million beneficiaries in more than 30 unique plans operating across the country to understand the impact of shifting the determination of plan risk scores from the traditional Risk Adjustment Processing System (RAPS) to the new Encounter Data System (EDS).

Avalere analyzed data from eight Medicare Advantage Organizations (MAOs) representing 1.1 million beneficiaries in more than 30 unique plans operating across the country to understand the impact of shifting the determination of plan risk scores from the traditional Risk Adjustment Processing System (RAPS) to the new Encounter Data System (EDS).

Avalere analyzed data from eight Medicare Advantage Organizations (MAOs) representing 1.1 million beneficiaries in more than 30 unique plans operating across the country to understand the impact of shifting the determination of plan risk scores from the Risk Adjustment Processing System (RAPS) to the new Encounter Data System (EDS).

According to a new Avalere analysis of data from the Centers for Medicare & Medicaid Services (CMS), premiums for stand-alone prescription drug plans (PDPs) will increase and the number of PDPs available in 2017 will decrease. Conversely, the Medicare Advantage market appears strong as 8 in 10 beneficiaries have access to MA plans that offer prescription drug benefits with a zero premium.

The Centers for Medicare & Medicaid Services (CMS) just released the annual Landscape Files containing data on plan participation, beneficiary premiums, and benefit designs for the 2017 Part D and Medicare Advantage (MA) markets. Avalere offers the following observations on key trends in the MA and Part D programs that are likely to influence the 2017 market.

In late August, CMS released its proposed Notice of Benefit and Payment Parameters (NBPP) for the 2018 plan year.

In 2016, more than 18 of 56 million Medicare beneficiaries receive their benefits from Medicare Advantage (MA) plans. MA plans are private managed care organizations that contract with the federal government to coordinate care for Medicare beneficiaries.

New Avalere report identifies opportunities to refine the risk-adjustment model that could improve the way Affordable Care Act plans are paid

Percentage of Medicare Advantage enrollees in plans with at least four stars continues to grow.

A new analysis from Avalere Health finds that hospitals and health systems are increasingly taking risk for the cost of Medicare patients and the quality of the care they receive.

A new analysis by Avalere finds that the Centers for Medicare and Medicaid Services (CMS) underpay Medicare Advantage (MA) plans for the costs of treating individuals with multiple chronic conditions.

Medicare Advantage HMO offerings grow while PPO and PFFS offerings are exiting the market. Analysis also shows significant variation in PDP premiums in 2014; five out of top 10 prescription drug plans have double digit increase