Author: LBodnarchuk

Medicare Stars – SY2024 Cut Point Analysis

Medicare’s Plan Preview Period #2 data is available for Health Plans to review in HPMS. Our Medicare Stars Practice Team has been crunching the numbers to see how cut points moved from year to year. 

The below images walk you through an in-depth analysis across each Stars domain—HEDIS, HOS, CAHPS, Pharmacy, Administrative—to showcase the individual measure cut point movement across each Star level. The cut points displayed in this analysis are from the draft 2024 Technical Notes from CMS. The finalized 2024 Technical Notes will be released with the remaining public data in early October. The bottom line is that Tukey impacts are real. We observed many dramatic cut point changes at the 2- and 3- Star levels across all measure sets. The compression of cut points was stark and only puts greater pressure on Stars Programs to achieve optimal performance in their Star measures. 

We can’t wait for the public data release in early October. At that point we’ll dig into the data and get a real picture of just how dramatic of a role that Tukey Outlier Deletion played on the industry.

If you have any questions about the analysis below or larger questions about how to best achieve and sustain 4.0+ Star performance, connect with our experts today.

HEDIS Cut Point Analysis

Pharmacy Cut Point Analysis

Administrative Cut Point Analysis

HOS Cut Point Analysis

CAHPS Cut Point Analysis

Soaring to New Health Blog – Episode 5, The Glass is Half Healthy

Welcome to Season 1, Episode 5 of the Soaring to New Health Podcast.

This episode is The Glass is Half Healthy. We’re talking with Dan LaVallee, Senior Director of Social Impact from the Insurance Services Division at UPMC Health Plan along with Julie Evans, leader of ProspHire’s Social Determinants of Health (SDOH) service offering.

Social Determinants of Health are coming to the forefront of the healthcare industry for a lot of reasons – and one of those is health equity. Health equity is understanding that different individuals across the country have different health outcomes and a lot of that is determined by the zip code they live in. Part of SDOH is thinking about how we can focus our efforts on healthcare to address those specific needs and therefore address health equity as well. An example is if a child with asthma is growing up in a home with overcrowding and poor air circulation. The child will not be able to address their asthma needs without appropriate social determinants of healthcare in housing.

LaVallee says the Center for Social Impact wants to get ahead of scenarios where the population cannot access healthcare with prevention, support and listening to solutions from within those communities. Data shows that if you can find these members supportive housing for 10 months, it can change the trajectory of their healthcare. It takes a coordinated effort of community organizations that provide jobs, housing, benefits access and food programs to create a circle of member trust. The Center’s Cultivating Health for Success Program aims to get homeless Medicaid recipients in Allegheny County (and now Blair and Lawrence Counties) off the streets and into structured, long-term care by combining the resources of UPMC Health Plan and the housing-focused Community Human Services (CHS). Across the State of Pennsylvania, the Regional Accountable Health Council (RAHC) created forums for strategic health planning that provide a community-led approach to implement the planning and coordination of activities that address social determinants of health needs, reduce health disparities and promote health equity and value in health care.

At UPMC Health Plan, the Center for High Value Healthcare evaluates the impact of the programs supported by the Center for Social Impact, like the new Food is Medicine Program. They will help determine what works that is social impact related and then expand on that, all while seeking continual member feedback.

Evans talks about these types of programs helping Stars, HEDIS and CAHPS measures that tie back to the quality health incentives that are so important to health plans for their members. The investment into SDOH programs can show immediate return on investment. The impact of the pandemic is what really highlighted the needs of vulnerable individuals. Today we are seeing an influx of funding to support community-based organizations and health plans to address those needs but the concern is that as the public health emergency lifted the funds will dwindle and programs will not be sustained. That’s a huge barrier to housing and transportation challenges, which are being spotlighted right now. The future will include how to address these needs without funding.

At UPMC Health Plan’s Center for Social Impact, LaVallee says they are doing a good job of staying ahead of these challenges through investment and community partnerships and leveraging a model that can scale in one community and be replicated in others. There is no intention of slowing down.

For more on Social Determinants of Health, why they are important to measure and how they can play a role in more efficient care with better patient outcomes, download the Soaring to New Health podcast, The Glass is Half Healthy, where you find your podcasts.

Healthy Aging Awareness Month

Healthy Aging Month is observed during the month of September. This observance raises awareness on the physical, mental, social and financial wellness of older adults and serves as a reminder that as we age, our minds and bodies change. It is essential to maintain a healthy and positive lifestyle to help deal with those changes and to help prevent common age-related health problems. Even if you have not thought of these changes, it is never too late to consider ways to re-invent yourself.  

No Age Limit to Adopting Healthy Habits

The United States boasts an increasingly aging population; according to the 2020 census, 1 in 6 people are now over the age of 65[1]. This trend is largely driven by the size of the Baby Boomer generation, born 1946-1964. By the 2030’s, it is estimated that older adults (over the age of 65) will outnumber the number of children (under the age of 18)[2]. Figure 1 illustrates this trend over the past century, which further emphasizes the importance of adopting healthy aging habits[3].

Healthy Habits and Behaviors

Embrace a well-rounded approach to your well-being during Healthy Awareness Month and beyond, with a collection of empowering habits and behaviors that build lifelong health and vitality.

How Can ProspHire Help? 

ProspHire has subject matter experts working closely with Health Plans, Provider Practices and Community Specialists to enhance healthy lifestyle opportunities while optimizing current benefit offerings. The healthcare community can attain an excellent level of insight into outcomes via Quality Measures. It provides a deeper understanding of how various internal and external contributing factors play a critical role in one’s outcome.

ProspHire is continuously working with key stakeholders to leverage data indicated by these contributing factors such as Social Determinants, Health Equity and Geographical Indicators to improve Quality Measures and provide the right resources needed to maintain a healthy lifestyle.

Connect with ProspHire today.




Dental Management Services

Advancing Your Dental Practice Through Clinical Operations Support

In the rapidly evolving landscape of modern dentistry, staying ahead of the curve requires a comprehensive approach that integrates technological advancements, innovative services and streamlined clinical operations. The key to success lies in embracing these changes and leveraging them to not only enhance patient care but also boost the efficiency and profitability of your practice. Clinical operations support plays a pivotal role in achieving these goals by encompassing various elements such as technology and equipment upgrades, expanded service offerings and continuous education for both clinicians and staff.

Technological Evolution and Dental Equipment Upgrades

Technology has revolutionized nearly every industry and dentistry is no exception. The integration of advanced dental equipment has not only transformed the way procedures are conducted but has also significantly improved patient outcomes and experiences. From digital radiography and intraoral scanners to computer-aided design and manufacturing (CAD/CAM) systems, technology has expedited diagnosis and treatment planning while reducing patient discomfort.

Dentists now have access to state-of-the-art equipment that enhances precision and accuracy. For instance, cone-beam computed tomography (CBCT) provides 3D images that aid in the placement of dental implants and complex procedures, minimizing complications and increasing success rates. Similarly, CAD/CAM systems enable same-day restorations, saving time for both patients and practitioners.

Furthermore, vendor offerings and supplies have adapted to these technological changes. Companies are now providing more customizable solutions, offering dental professionals the flexibility to tailor equipment to their specific needs. This not only improves patient care but also enables practices to optimize their workflows.

Continuous Clinical Education and Staff Training

Staying current in the ever-evolving field of dentistry requires a commitment to continuous learning. Clinical education not only ensures that practitioners are delivering the highest standard of care but also empowers them to integrate new technologies and techniques effectively.

Staff training is equally crucial, as the success of any practice depends on the collaborative efforts of the entire team. Dental assistants, hygienists and front-office staff all play pivotal roles in delivering exceptional patient experiences. Providing ongoing training not only boosts their confidence and skill set but also enhances the overall efficiency of the practice.

Vendor Management and Workflow Optimization

Managing relationships with vendors is a vital aspect of clinical operations support. Partnering with reputable suppliers ensures a steady supply of quality materials and equipment, ultimately contributing to the smooth functioning of the practice. Vendor management involves negotiating favorable terms, maintaining clear communication and staying updated on the latest offerings in the market.

Integrating new equipment and software into existing workflows can be a challenging process. However, with proper planning and training, the transition can lead to increased efficiency and reduced room for errors. Workflow optimization involves assessing the current processes, identifying bottlenecks and implementing strategies to streamline operations. This might include reconfiguring operatory layouts, standardizing protocols and utilizing software solutions for appointment scheduling, treatment planning and patient communication.

Expanding Service Offerings formula

These three areas of Technological Evolution and Dental Equipment Upgrades, Continuous Clinical Education and Staff Training and Vendor Management and Workflow Optimization are all a part of the process that leads to Expanding Service Offerings. Offering new or enhanced services not only attracts a broader patient base but also positions your practice as a comprehensive solution provider. Implant placement and restoration, orthodontic treatment, sleep apnea therapy, TMJ/TMD management, general muscular pain relief and enhancements to facial aesthetics are areas that have seen significant growth.

ProspHire Helps Dental Practices Through the Process of Expanding Service Offerings

In the dynamic landscape of modern dentistry, advancing your practice through clinical operations support is a multifaceted endeavor. ProspHire’s Dental Management team will collaborate with you and lead you through technological advancements, expansion of service offerings, clinical education, staff training, vendor management and workflow optimization. Our experts will identify potential new offerings or ways to enhance your current services via a detailed assessment process of your current state business and guide you through the implementation processes and activities using best- in-class program and vendor management techniques. For more information, connect with us today.

Soaring to New Health Blog – Episode 4, This is Like Pulling Teeth

Welcome to Season 1, Episode 4 of the Soaring to New Health Podcast.

This episode is This is Like Pulling Teeth. We talk with Paul Reda, CEO, and Armanda Lester, VP of Operations, from North American Dental Group (NADG) – a dental services organization that provides nonclinical administrative services to more than 240 affiliated dental practices across 15 states and continues to expand access to care.

As NADG started to evolve the leaders looked at group dentistry practices and aimed to add best-in-class providers to the organization. Today, NADG is pioneering a new culture of dentistry… to be available to patients when it suits the patient and serve patients in the way they want to be served. It’s about providing the best patient care for every patient at every visit.

A technology that was born out of listening to their patients is a platform called Ask Nicely. The patient receives a text message after each visit that asks for a rating about the recent office visit experience. The question responses scale from one to ten and any response below a nine prompts a call to the patient within 24 hours to discuss. The goal is to ensure every patient is receiving the best care and to continue to improve the patient’s experience.

Innovation is a continuous path at NADG. In early 2023, the organization began rolling out an artificial intelligence (AI) platform for dental called Overjet. It is an intelligence support mechanism that involves an overlay of color coding that the dentist or hygienist uses to determine a treatment path and that visual makes it easier to communicate to the patient. Additionally, many of the top insurance companies are making claim decisions with this platform. Reda says, “AI is in its infancy and I think we need to use it responsibly. It’s not a replacement for human beings and it’s certainly not a replacement for a doctor. Patients want to talk to a real person and be treated like a real person rather than an object or a number.”

NADG encourages community service within its practices, participating in events such as Give Kids a Smile or local school training for teaching children how to brush their teeth. It’s a part of the culture and the core values. Every year, Paul Reda acknowledges team members who exemplify community involvement. A select group travels with him to Zurich, Switzerland for a global ceremony for the Chairman’s Award.

For more on innovative dentistry and what it takes to be a strategic partner with NADG, download the Soaring to New Health podcast, This is Like Pulling Teeth, where you find your podcasts.

ProspHire Earns Spot on the Inc. 5000 List for 4th Consecutive Year

PITTSBURGH, PA – ProspHire announced today that it ranks #4307 on Inc. Magazine’s annual list of America’s Fastest-Growing Private Companies – the 2023 Inc. 5000. The rank reveal also put ProspHire at #19 in Pittsburgh, #132 in Pennsylvania and #516 in the nation for business products and services. The list represents a unique look at the most successful companies within the U.S. economy’s most dynamic segment – independent, small businesses. ProspHire, a national healthcare consulting firm, is recognized for its rapid revenue growth while navigating inflationary pressure, the rising costs of capital and hiring challenges. In the history of Inc. 5000, only 5% of companies have made the list 4 times.

“Making the Inc. 5000 list is a huge honor that we credit to our employees,” said Lauren Miladinovich, Managing Principal and CEO of ProspHire. “The hard work and dedication from across all departments is the reason for our success and growth.”

Chris Miladinovich, ProspHire’s Principal and Chief Strategy Officer, said, “Being recognized with innovative and high growth companies across the U.S. for the 4th consecutive year is an accomplishment that we celebrate. This accolade showcases not just our success but demonstrates resilience though the threat of economic downturn, labor shortages and lasting impact of Covid-19.”

“Thank you to all our team members and clients for helping ProspHire reach this incredible milestone,” says Dan Crogan, Principal and SVP of Consulting. “Our dedication to the healthcare industry and our focus on project execution has enabled us to develop and maintain genuine partnerships with our clients where we act as an extension of their team to help them solve their most significant people, process and technology challenges.”

Complete results of the Inc, 5000, including company profiles and an interactive database that can be sorted by industry, region and other criteria can be found at

Q&A with ProspHire’s Caitlin Nicklow on the Affordable Care Act

The Affordable Care Act (ACA) has had a profound impact on the landscape of healthcare in the United States. With provisions aimed at increasing access to health insurance, preventing discrimination by insurance providers enhancing preventive care, lowering healthcare costs and improving healthcare quality, the ACA reshaped how Americans access and receive healthcare services. ProspHire’s ACA practice leader, Caitlin Nicklow delves into the intricacies of ACA compliance and the rules and requirements for health insurance providers, key dates to be aware of and the timeline for launching an ACA-compliant health plan.

How does the ACA impact healthcare? 

The Affordable Care Act (ACA) includes several provisions that have important implications for public health:

  • Increased access to health insurance: The ACA has expanded access to health insurance by creating marketplaces where individuals can purchase affordable health insurance plans and by expanding eligibility for Medicaid. As a result, millions of previously uninsured Americans gained access to health insurance.
  • Prohibiting insurance discrimination: The ACA prohibits health insurance providers from discriminating against individuals with pre-existing conditions and it also prohibits health insurance providers from charging higher premiums based on factors such as age, gender or health status.
  • Enhancing preventative care: The ACA has emphasized the importance of preventative care and it requires most health insurance providers to cover preventative services such as cancer screenings and immunizations without cost-sharing.
  • Lowering healthcare costs: The ACA includes provisions that aim to lower healthcare costs, including measures to reduce waste, fraud and abuse in the healthcare system and initiatives to encourage more efficient and coordinated care. Many individuals are also eligible for financial assistance in the form of subsidies and cost sharing reductions.
  • Improving healthcare quality: The ACA incentivizes healthcare providers to improve the quality of care they deliver by tying reimbursement to performance on quality measures.
How does the ACA impact healthcare?

Is there a mandate that all health insurance providers need to provide ACA-compliant health plans?

Yes, under the Affordable Care Act (ACA), also known as Obamacare, all health insurance providers are required to offer ACA-compliant health plans in the individual and small group markets. ACA-compliant health plans must meet certain requirements, such as covering essential health benefits, not discriminating against individuals with pre-existing conditions and capping out-of-pocket costs for covered services.

The individual mandate, which required most Americans to have health insurance or pay a penalty, was repealed in 2017. However, the requirement for health insurance providers to offer ACA-compliant plans remains in place.

It is worth noting that certain types of health insurance plans, such as short-term health plans and health care sharing ministries, are not required to comply with the ACA’s regulations. These plans may offer lower premiums but may not provide the same level of coverage or consumer protections as ACA-compliant plans.

What are the rules once you are an ACA-compliant provider? 

Once a health insurance provider offers an ACA-compliant health plan, they must adhere to certain rules and regulations. Here are some of the key rules for ACA-compliant providers:

  • Cover essential health benefits: ACA-compliant health providers must cover ten essential health benefits, which include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management and pediatric services.
  • No discrimination based on pre-existing conditions: Health insurance providers cannot discriminate against individuals with pre-existing conditions. This means they cannot deny coverage or charge higher premiums based on an individual’s health status.
  • Cap out-of-pocket costs: ACA-compliant health insurance providers must cap out-of-pocket costs for covered services. For the 2023 plan year, the ceiling for out-of-pocket services is $9,100 for individuals and$18,400 for families. In 2024, these amounts will grow to $9,450 and $18,900, respectively.
  • Cover preventive services without cost-sharing: Health insurance providers must cover certain preventive services without requiring cost-sharing, such as copays or deductibles. Examples of these services include mammograms, colonoscopies and immunizations.
  • Provide coverage for dependent children: Health insurance providers must provide coverage for dependent children up to age 26.
  • Limit annual and lifetime coverage: Health insurance providers cannot impose annual or lifetime dollar limits on essential health benefits.

These are just some of the key rules for ACA-compliant providers. There are additional rules related to network adequacy, rate review and other aspects of health insurance regulation that providers must also follow to maintain compliance with the ACA.

What are the rules once you are an ACA-compliant provider

Are there key dates that health insurance providers need to be aware of throughout the year? 

Providers should be familiar with several important dates:

  • Open Enrollment: Open Enrollment is the period when individuals can enroll in or change their health insurance plans for the following year. The dates for Open Enrollment may vary from year to year, but it generally takes place in the fall. For 2024 coverage, Open Enrollment begins November 1, 2023 and ends January 15, 2024, in most states.
  • Special Enrollment Periods: Special Enrollment Periods (SEPs) allow individuals to enroll in or change their health insurance plans outside of Open Enrollment if they experience certain qualifying life events such as getting married, having a baby or losing their job-based health coverage. SEPs are available throughout the year but individuals typically have a limited amount of time to enroll after their qualifying event.
  • Tax Season: Health insurance providers need to be aware of the ACA-related tax forms that must be issued to individuals and the IRS during tax season. For example, individuals who received premium tax credits to help pay for their health insurance during the year will need to file Form 8962 to reconcile the amount of the credit they received with their actual income for the year.
  • Plan Year Renewals: Health insurance providers must renew their ACA-compliant health plans each year. The certification process typically runs May through September.
  • Regulatory Changes: The ACA is subject to ongoing regulatory changes, which can affect health insurance providers and their customers. Providers should stay up to date on any regulatory changes and be prepared to make changes to their plans or operations as necessary.
Providers should be familiar with several important dates

What is required to set up an ACA-compliant health plan?

ACA-compliant health plans must follow rules established by the Affordable Care Act.

  • Obtain licensure: Health insurance providers must obtain licensure from the state(s) in which they operate. State insurance departments oversee the licensing process and ensure that providers comply with state regulations.
  • Cover essential health benefits: ACA-compliant health plans must cover ten essential health benefits, which include ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services.
  • Comply with rate review requirements: Health insurance providers must comply with rate review requirements, which vary by state. These requirements typically require providers to submit rate increase requests to state insurance departments for approval.
  • Limit out-of-pocket costs: ACA-compliant health plans must cap out-of-pocket costs for covered services. For the 2023 plan year, the ceiling for out-of-pocket services is $9,100 for individuals and$18,400 for families. In 2024, these amounts will grow to $9,450 and $18,900, respectively.
  • Comply with network adequacy requirements: Health insurance providers must ensure that their provider networks are adequate to meet the needs of their customers. Network adequacy requirements vary by state and may include minimum provider-to-patient ratios, distance standards and other criteria.
  • Comply with reporting requirements: Health insurance providers must comply with various reporting requirements, including the submission of data on the number of individuals enrolled in their plans, the cost of coverage, and the number of claims denied.

What is the timeline to launch an ACA-compliant health plan?

The timeline to launch an ACA-compliant health plan can vary depending on several factors such as the size and complexity of the organization, the state in which it operates and the level of existing infrastructure and resources. However, here are some general steps and timelines that healthcare insurance providers typically follow when launching an ACA-compliant health plan:

  • Develop a plan: The first step in launching an ACA-compliant health plan is to develop a business plan that outlines the goals, objectives and strategies for the new plan. This process typically takes several months and may involve market research, competitor analysis and other activities.
  • Obtain licensure: Health insurance providers must obtain licensure from the state(s) in which they operate. The licensure process can take several months and may involve completing an application, paying fees and providing documentation such as financial statements, business plans and marketing materials.
  • Develop provider networks: Health insurance providers must develop provider networks that are adequate to meet the needs of their customers. This process can take several months and may involve recruiting new providers, negotiating contracts and setting up systems for provider credentialing and claims processing.
  • Develop products and pricing: Health insurance providers must develop products and pricing that comply with the ACA’s regulations. This process can take several months and may involve developing new products or modifying existing ones, conducting actuarial analyses and setting premiums.
  • Implement systems and processes: Health insurance providers must implement systems and processes to support their new ACA-compliant health plan. This can include developing and implementing new technology systems, hiring staff and establishing procedures for claims processing, customer service and compliance.

Overall, the timeline to launch an ACA-compliant health plan can range from several months to a year or more, depending on the complexity of the organization and the state in which it operates. It is important to work closely with legal and regulatory experts to ensure compliance with all applicable regulations and to allow sufficient time for the licensure and implementation process.

Does ProspHire have experience launching ACA-Compliant plans?

ProspHire has launched fully certified and accredited ACA plans in 5 states, with additional growth in our portfolio of existing clients. We have extensive experience driving end-to-end current state assessments to analyze the regulatory and operational gaps organizations must fulfill in pursuit of an ACA-compliant plan and we have the implementation and change management knowledge to close those gaps in limited timelines. Additionally, our subject matter expertise in guiding organizations to achieve success in medical management and quality care delivery can help to get the plan firmly grounded at launch.

ProspHire seeks to understand your unique circumstances

How can ProspHire help you throughout this process?

ProspHire will work with you to understand your unique circumstances and identify the best method to achieve your ACA goals, whether as an extension of your teams or as a completely outsourced program management group while you work to hire the right people to operate the plan at go live. Following an in-depth current state assessment and comparison to State and/or Federal guidelines, you will receive a roadmap and step-by-step project plan to manage the various regulatory, operational and technological requirements necessary for certification and/or accreditation, operational readiness and plan go live. Post go live support can also ensure you are set with a clear plan on maintaining your status as a Qualified Health Plan, helping to develop the tools and practices to ensure your ACA plan is operating at its highest level and help you target and execute on plan expansions for the following years.

Q&A with ProspHire’s Julie Evans on Addressing Health Disparities

What is the difference between health equity and SDOH?

Imagine a scene where an elderly individual, a young adult and a disabled child are all provided the same level of care – that is health “equality”. Health “equity” focuses on providing unique unequal care to each individual to ensure the care they receive will result in the appropriate, desired and equal outcome. Now, taking the scene one step further, imagine the disabled child we are caring for has limited access to food at home, does not have housing that can accommodate a wheelchair and the family has minimal income. The barriers that this child faces due to the conditions in which they are born, grow, live and age, are social determinants, or drivers, of health (SDOH).

Why is addressing the role of SDOH important?

Recent studies show that SDOH can account for approximately 80% of an individual’s health. As providers, payors and supporting organizations, it simply makes sense to provide care that addresses the 80%, despite most of our efforts traditionally focusing on the other 20%. SDOH disproportionately impacts our underserved communities, which ultimately drives us toward additional discussion and consideration of health equity.

Although SDOH is no longer a new concept and our clients understand the importance of addressing SDOH, there is still a question of how. Understanding how to implement effective interventions, quantitatively assess SDOH needs, plan for a return on investment and identify partnerships for success, all pose challenges.  

What health equity issues are clients focused on today?

Health equity is a major area of focus generally for many of our clients, but today, the greatest area of focus is maternal and perinatal health equity. Inequities in maternal and perinatal health have been prevalent for some time, and unfortunately the pandemic has exacerbated some of these inequities. Many of our clients are interested in improving equity among women of color and women in rural communities. In both cases, there is a need for improved access to and quality of care. From organizational interventions to community-based partnerships, we are supporting our clients to implement strategies that best meet the needs of their most vulnerable populations.

What are CMS’s new SDOH quality measures?

CMS implemented new SDOH quality measures in their 2023 IPPS Final Rule that will be voluntary in 2023 and required in 2024. These new measures are mandated for hospitals reporting to the Inpatient Quality Reporting (IQR) program and both focus on SDOH. Separate from the existing Z-codes, these measures are flexible in their collection and give hospitals the opportunity to self-select their screening method. The two measures “SDOH-1” and “SDOH-2” have separate goals.

“SDOH-1” focuses on the rate of screening. Simply put, what percent of patients admitted to the hospital were screened for SDOH based on the five assigned domains: food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety. “SDOH-2” focuses on these domains and captures the percent of admitted patients that screen positive for any of the five SDOH domains.

Previously, CMS issued guidance to support states in addressing SDOH in Medicaid and the Children’s Health Insurance Program (CHIP) in 2021. Health plans and providers alike can continue to expect increased SDOH guidance and measures in the future.

What is SDOH 101 for health care providers who need to get started on practice improvement?

Start small and be selective! Understanding your population and the subset of individuals who may be experiencing disparate outcomes due to health inequities or a specific SDOH domain offers an opportunity to pilot a solution and measure effectiveness. One key consideration in following this method is considering the population’s location. An intervention in one community may not work in another and addressing SDOH regionally with consideration to local barriers, needs and partnership opportunities will increase the likelihood of success. Additionally, don’t feel the need to start from scratch; there are several proven strategies to address SDOH that can inspire your future work.

What is the risk of not screening patients, assessing conditions and implementing change?

Now that there is an understanding of the true impact of SDOH on an individual’s health, not screening patients, assessing conditions and implementing change is equivalent to not looking under the hood of a car during an inspection and only looking at the car’s physical appearance. SDOH are underlying conditions that directly affect an individual’s health outcomes and are a key consideration to their treatment plan. Whether it be a mechanic and their car or a provider and their patient, we don’t want to send “patients” home without an understanding of how they may operate once they leave the safety of our care. It is the responsibility of the healthcare industry to implement change in the interest of our most vulnerable populations, so when they do leave our care, we have an understanding and care plan to ensure the right supports are available at home and in the community.

Do you have any predictions for Health Equity and SDOH in 2023?

During and following the height of the COVID-19 pandemic, we saw the influence of SDOH and the disproportionate impact of the pandemic on individuals already facing barriers in relation to social determinants and the importance of community-based care and support. As economic instability is expected through 2023, I would expect to see this trend continue, but this time around there may be more limited resources to support our community-based partners. This will open the door for providers and payors to collaborate and increase their engagement in SDOH intervention. Ultimately, SDOH and health equity are tightly intertwined and with magnification on equitable outcomes, this offers an opportunity to intervene.

Contact us to help support strategy development intervention implrementation

How can ProspHire help?

ProspHire has always been in the business of assessing, understanding and implementing change across the healthcare industry. Through regional data assessments, understanding your patient population, evidence-based methodologies and community-based partnerships, ProspHire is equipped to support strategy development, intervention implementation and drive change within your organization.  As you begin to explore opportunities to effectively address health equity and SDOH impact, we hope you will include us in your journey as we bring an industry and subject matter understanding to the forefront of our work.

Q&A with ProspHire’s Luke Laurin on Vendor Management

What is Vendor Management as a Service Solution in the Healthcare Industry?

Vendor management as a service solution is providing healthcare organizations with best-practice strategies to optimize management of third-party vendors by streamlining vendor management workflows, reducing vendor costs and improving compliance with regulatory requirements.

We offer our clients a range of vendor management services, including vendor selection, contract management strategies, performance monitoring KPI definition, risk assessments and compliance monitoring. By utilizing a collaborative partner for these functions, healthcare organizations can free up internal resources focused on these efforts, reduce costs associated with vendor contracts, and improve the quality of their vendor management processes.  

Are there industry regulations around vendor management?

Vendor management is critical to ensure ongoing patient safety, regulatory compliance and operational efficiency. In healthcare, the Centers for Medicare & Medicaid Services (CMS), the Office of Inspector General (OIG) and the Joint Commission have published guidelines regarding vendor management practices. CMS requires healthcare organizations to have written policies and procedures for selecting and managing vendors, including risk assessments and ongoing monitoring of vendor performance. OIG emphasizes the need for proper due diligence before selecting a vendor, which includes a qualitative and quantitative process that should lead to a decision that best fits the needs of the healthcare organization.

The Joint Commission includes vendor management as a standard for medical equipment and facility management. In addition to regulatory requirements, many healthcare organizations also have their own internal operating procedures for vendor management. These standard operating procedures may include requirements for vendor selection, contract management and ongoing vendor performance management.

Why is coordinating services from multiple vendors so important?

In healthcare, there are many vendors that provide products and services that need to work together to support patient care. Ensuring interoperability between these vendors will help them work better together. Coordinating services from multiple vendors can help with reducing duplicate efforts and resources, which often results in reduced costs. Improving communication between vendors leads to better outcomes for a patient and a better customer experience in the often-confusing world of consumerism in healthcare. By streamlining the vendor management process, most healthcare organizations find they can reduce the number of vendors they need and will consolidate to critical mass in order to “get it done” the right way.   

Where does innovation fit into vendor management? 

Innovation can play an important role in vendor management, especially as technology and other advancements continue to shape the way products and services are developed and delivered in the healthcare industry.

Here’s where I see recent innovation fitting into the vendor management process:

  • Identifying innovative vendors: Vendor management involves selecting and managing vendors who can provide products and services that meet the needs of the healthcare organization. Innovation can be an important factor in selecting vendors who can provide cutting-edge solutions and stay ahead of industry trends.
  • Collaborating with vendors on innovation: Healthcare organizations can collaborate with their vendors to develop new products and services that can improve patient care and drive operational efficiencies. By fostering innovation in their vendor relationships, healthcare organizations can stay at the forefront of industry trends and maintain a competitive edge.
  • Incorporating innovative solutions into vendor management processes: Healthcare organizations can leverage innovative technologies and solutions to streamline their vendor management processes, automate tasks and improve data analytics.
  • Adapting to new technologies and industry changes: As new technologies and industry trends emerge, healthcare organizations must adapt their vendor management processes to stay up-to-date. By embracing innovation and being open to new ideas, healthcare organizations can stay agile and responsive to industry changes.
Where does innovation fit into vendor management?

How Can ProspHire Help?

ProspHire’s Vendor Management Office team has extensive experience in assessing current processes, identifying the gaps and developing a centralized VMO operating model strategy. That may include identifying cost saving measures and formalizing vendor management from selection to onboarding processes. We have also helped clients in developing custom analytical dashboards to monitor critical KPIs to keep our clients compliant with regulations and monitor overall vendor spend to ensure value is achieved.

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ProspHire's Vendor Management Office team has extensive experience
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Q&A with ProspHire’s Andrew Bell on Stars Performance Improvement

The importance of Medicare Stars Performance Ratings cannot be overstated, as they serve as a critical benchmark for evaluating the quality of care provided by Medicare Advantage Plans. These ratings play a pivotal role for both plan members and healthcare leaders alike. ProspHire’s Stars Performance Improvement Leader, Andrew Bell, talks about the challenges faced by healthcare organizations regarding Stars Performance, strategies to improve these ratings and insights into upcoming changes in the Medicare Stars landscape. 

Why are Medicare Stars Performance Ratings important?

Medicare Stars Performance Ratings are important because they provide a measurement of the quality of care offered by Medicare Advantage plans. From the perspective of the member, the ratings help compare the quality of different plans during enrollment periods. For Health Plan leaders, the Medicare Stars Program is important because it affects both the financial performance of their plans and their ability to attract and retain enrollees. Higher ratings can lead to enhanced benefit offerings, improved financial performance and more favorable reimbursement levels.

What are the biggest challenges your clients are facing regarding Stars Performance?

When we first engage with a client on a Stars project, they are typically lower performing or are at risk of falling below the 4.0 Stars QBP threshold. There are several commonalities in these circumstances. The first and biggest being a lack of organizational-wide awareness and priority in Stars. If Stars isn’t given the time and dedicated attention it requires and isn’t a priority of the leadership at your organization, you will be hard pressed to succeed. The second is data: data integrity and data availability. Succeeding in Stars is largely based on a plans’ ability to aggregate data and synthesize it down into an actionable plan to improve ratings.

How do organizations improve their Stars Rating?

Success in Stars starts with proper governance, accountability and data-backed decision-making capabilities. When we work with clients, we seek to understand their specific plan challenges and structure. With that as a starting point, we advise implementing a cross-functional governance structure with accountability at the domain and measure-level. We have also worked with clients to onboard them onto our proprietary forecasting and projection technology. This technology enables clients to have real-time insights into contract performance and allows leaders to make informed decisions with measure-level goal setting.

How can Stars leaders gain momentum and partnership across their organization?

One of the biggest challenges that Stars leaders have within an organization is remaining a priority. Every plan has competing priorities and strategic initiatives. As a best practice, Stars programs that remain at the forefront and an integral part of the business functions will gain leadership buy-in. It is extremely beneficial to have the backing of Senior Leadership. They will help break down barriers and ensure that the organization is aware that Stars is a priority to them.

What do health plans need to know about Star Year 2024 and beyond?

When I speak with clients and folks within the Stars and Medicare world, the Tukey Outlier deletion for SY2024 is what keeps them up at night. This methodological adjustment paired with the somewhat surprising, proposed rules for Medicare Advantage and Stars are keeping people thinking. These changes are likely going to have quite a substantial negative impact on Star Ratings industry-wide.

Can you offer insights on what can be done now to prepare for the Tukey Outlier?

At this point, most health plans and Stars leaders are aware of the Tukey outlier deletion modifications. What leaders should be doing is conducting thorough measure-level analysis to understand what measures will be impacted by Tukey and then begin to mitigate against potential measure score drops. With so many measures simultaneously in play, strong data analytics can help enable Stars programs to target the right measures for their plan to achieve their stated contract goals.

What do Stars leaders need to be thinking about in the years ahead?

To stay ahead of the Medicare Stars Program changes, Health Plan leaders need to consider several innovative strategies, including:

  • Investing in technology and data analytics to better track and evaluate quality performance, including predictive analytics and intervention effectiveness
  • Focusing on customer satisfaction, including offering telehealth services and addressing social determinants of health through community engagement or enhanced benefit offerings
  • Collaborating with healthcare providers to improve the quality of care and to gather more comprehensive data on patient outcomes
  • Regularly reviewing the Medicare Stars Program and making necessary adjustments to stay ahead of the curve and to maintain a high level of quality

Is there any risk for Stars Leaders to delay their strategy implementation 6-months or a year?

As we all know, the Medicare Stars program is a complex overlapping cycle, with two Star performance years simultaneously in play at any given moment. The truth is, that the best time to start implementing a Stars improvement plan is yesterday. Any consequences to a delay in action will not be felt immediately; however, the downstream consequences of those delays in decisions will most certainly impact the plans ability to achieve the quality bonus payment and other stated goals.

How Can ProspHire Help?

Since our inception, ProspHire has been supporting health plans in Medicare Stars. We work collaboratively with your team and seek to understand the unique circumstances at your health plan. By leveraging contract specific data and on the ground insights into plan operations and capabilities, our healthcare experts will deliver a Customized Contract Capability Assessment in tandem with a tailored Stars Strategic Roadmap and Playbook. This support will empower plans to take control of their Stars Program and enable Stars leaders to feel confident about their math-path to success and corresponding intervention plans.  

ProspHire can help by leveraging contract specific data and more.
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