Author: LBodnarchuk

Crucial Community Pharmacy Practice Changes Necessary for SDOH Success

Written by LBodnarchuk on . Posted in Insights.

Social determinants, or drivers, of health (SDOH) were brought to the forefront of healthcare news during the COVID-19 pandemic. The virus disproportionately affected individuals with lower socioeconomic status and certain racial backgrounds, with the largest impact observed within inner-city, low-income housing across the United States. Healthcare experts believe that SDOH can account for as much as 90% of health outcomes, highlighting the need to address SDOH in our communities and innovatively reimagine care delivery.

Let’s Reimagine Care Delivery Through Pharmacies

Let’s Reimagine Care Delivery Through Pharmacies

The pandemic was a catalyst for pharmacists to participate in patient-facing care on a global stage. Members of the profession were able to provide COVID-19 test administration, vaccinations and patient education surrounding the virus. Pharmacies did not close their doors during any phase of the pandemic, unlike other businesses and medical offices. Hospitals and retail pharmacies remained operational to provide access to healthcare information and life-sustaining medications while the rest of the world was on pause.      

In a perfect world, pharmacists would be able to balance medication dispensing and clinical services optimization for all patients at their practice sites. Addressing SDOH would be effortlessly placed into current workflow without disruptions in essential responsibilities and retail chain mandated vaccination quotas. The reality of the situation is that community pharmacists, often working understaffed with limited support resources, rarely have the time to complete their basic responsibilities in each shift. Many pharmacists stay after their required shifts or arrive to work hours before the pharmacy opens to complete backlogged medication dispensing from the day prior. As the world’s most accessible healthcare providers, pharmacists are often tasked to assist with patient care gap closure. Fully adopting the role of SDOH envoys is not possible under the current community pharmacy operational model. However, pharmacists can be empowered to address aspects of SDOH related to medication compliance.

Consider Practical Pharmacy Impact

Consider Practical Pharmacy Impact

One domain that pharmacists have the potential to intervene and assist patients with SDOH is financial insecurity. Prescription medication prices continue to rise year over year, impacting decisions that patients must make regarding adherence to their medication regimens. Lack of adherence can lead to decreased quality of life and increased healthcare dollar spend due to emergency room visits and hospital admissions. Upon prescription receipt, pharmacists can review applicable insurance coverage and patient copay fees to evaluate the patient’s true out of pocket expense. Pharmacists are encouraged to work as part of the patient’s healthcare team and alert prescribers to high-cost medications. Less costly therapeutic alternatives can be suggested to alleviate patients’ concerns involving pharmaceutical cost while improving healthcare outcomes.

Another common social determinant that can affect patients during a pharmacy encounter is transportation. Many patients located within urban areas of the country lack access to dependable transportation or the means to pay for this service. Rural access patients could have distances too far to travel to pick up their prescriptions on a consistent basis. Pharmacists have the capacity to check refill histories on their patients to identify compliance gaps in the current workflow. If refill disparities exist, the pharmacy has several options to consider. The pharmacist could explore the service of mail order prescription refills via the patient’s prescription drug coverage provider. However, the community pharmacy location would lose revenue from outsourced prescription fills. Many retail pharmacies offer prescription home delivery services for their patients. This option would be beneficial to both the patient and pharmacy if the service exists within the practice. Pharmacies could consider reduced or eliminated delivery charges for identified patients to further ensure medication adherence.       

Future Endeavors of SDOH

Future Endeavors

In the traditional retail pharmacy business model, pharmacists could use the Accountable Health Communities (AHC) Model1 developed by CMS for patient screening. This model contains questions that pharmacists could use to identify SDOH issues across multiple areas, including food insecurity, housing instability, lack of access to transportation, assistance with utility bills and interpersonal safety. Outpatient provider offices have used this tool in practice with mixed success rates, largely due to a lack of dedicated staff support. Pharmacists are not traditionally compensated for cognitive services, as the practice does not charge a fee-for-service (FFS) to patients receiving clinical information. Additional staffing, compensation and private counseling space would be essential to a pharmacy’s success in conducting SDOH screenings. 

Redefining the Role of a Pharmacist

Redefining the Role of a Pharmacist from Medication Dispenser to Health and Wellness Ambassador

The public perception of pharmacists’ role in healthcare is elevated above a dispensing role at this time. Pharmacists have demonstrated the ability to do more than fill prescription medications and provide recommendations for over the counter (OTC) medications. The profession has the chance to redefine its role and shift once again from practitioners behind the counter to healthcare and wellness ambassadors.  Increased effort is required to effectively address SDOH for our patients and the healthcare system. Can pharmacists effectively become innovative leaders in SDOH? Developing strong communication and information exchange with patients and their providers coupled with appropriate staffing resources in the pharmacy would be vital for success. Pharmacists can be powerful healthcare resources for addressing existing healthcare gaps. A rework of the industry business model to prioritize patient care and wellbeing would be a win for the profession and the public.

How ProspHire Can Help Your Team Enhance Healthcare Delivery

How ProspHire Can Help

At ProspHire, we want to help you and your members receive the highest quality of care. Our team’s extensive healthcare industry knowledge and commitment to valuable results can help you and your team optimize strategies to enhance healthcare delivery. Aligning analysis, insights and implementation regarding Social Determinants of Health with ProspHire’s expert team can help you address patient care as a whole. Our team is ready to have a conversation with you and understand your challenges experienced with SDOH application. Connect with us today.

What Are CMS Documentation Requirements?

Documentation Requirements You Need to Comply with The Centers for Medicare and Medicaid Services

Written by LBodnarchuk on . Posted in Blog.

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The Centers for Medicare and Medicaid Services (CMS) require Mandated Documents for Medicare and Medicaid Beneficiaries, which describe member benefits and provide clear and accurate explanations through standardized templates. Since requirements change annually, it’s important for payors to update these documents and relay them to plan beneficiaries to maintain compliance.

Learn more about CMS medical record documentation requirements with ProspHire.

Who Needs the Required CMS Documentation?

Any provider approved to offer Medicare- or Medicaid-sponsored plans to their beneficiaries must comply with CMS Mandated Documents.

If you are approved to offer Medicare Advantage plans, you must follow the directives of Medicare and share up-to-date CMS Mandated Documents with beneficiaries.

What Are the Required Documents for CMS?

While CMS Requirements may vary by plan type, there are generally two categories of required documentation for CMS — communications and marketing. If a document is classified as a communication, it provides information to current or prospective enrollees. Marketing materials might include intent and content intended to draw an enrollee’s attention to particular information.

The two categories of required documentation for CMS are communications and marketing

Plans must submit all marketing documents and some communications to the Health Plan Management System (HPMS) for review. HPMS requires some documents to be submitted by particular dates, while others are considered file and use (F&U), meaning the plan can use the materials five days after submitting them to HPMS for review. If the review finds any discrepancies, the plan may be subject to compliance actions.

These documents include the following:

Annual Notice of Change (ANOC)

Plans must send beneficiaries an ANOC each year, usually in the fall and no later than September 30. This document will detail any changes in cost or coverage that will take effect in January of the following year and is considered F&U.

ANOC and EOC Errata

If there are errors in the ANOC or EOC, plans must provide this document to enrollees immediately after they receive CMS approval.

Comprehensive Medication Review Summary

If enrollees are in a plan’s Medication Therapy Management program, they should receive this document immediately following the comprehensive medication review (CMR) or within 14 days.

Coverage/Organization Determination, Discharge, Appeals and Grievance Notices

If an enrollee has filed an appeal or someone has filed an appeal on their behalf, plans must issue this form based on the relevant time frames.

Enrollment/Election Form/Request

Plans must provide enrollment documents on request, and these materials require an HMPS review.

Enrollment and Disenrollment Notices

Medicare has very specific requirements for enrollment and disenrollment notices. Plans can find specific information on these materials in the Medicare Managed Care Manual.

Evidence of Coverage (EOC)

In the fall, plans must also send an annual EOC document that explains what the plan will cover the following year and how much beneficiaries must pay. This document falls under F&U review requirements.

Excluded Provider Notice

Providers can be subject to penalties for using individuals or entities listed in the Office of the Inspector General’s List of Excluded Individuals/Entities. CMS also keeps a list of excluded entities on the preclusion list. If an enrollee uses a provider listed on one of these excluded provider lists, plans must present them with this notice.

Explanation of Benefits — Part C

When enrollees use a Part C benefit, plans need to provide these materials monthly or per claim with a quarterly summary.

Explanation of Benefits — Part D

When enrollees use their prescription drug benefit, often referred to as Part D, plans must provide this documentation to enrollees by the end of the month following the month when they used their benefits.

Formulary

Also known as a drug list, this communication lists the prescription drugs a plan covers. Plans must make these documents available to enrollees annually by October 15.

Low Income Subsidy (LIS) Notice

If potential enrollees are eligible for Extra Help, plans must provide this document before the enrollment effective date.

Low Income Subsidy (LIS) Rider

Plans must provide this document to current Extra Help enrollees each year by September 30.

Membership ID Cards

Plans must provide both hard and digital copies of ID cards to their enrollees within either 10 calendar days of enrollment or before the end of the month before their enrollment.

Mid-Year Change Notification to Enrollees

If there is a change to the plan rules, benefits or formulary, plans must provide notice of these changes 30 days in advance, unless otherwise stated by the specific CMS regulations.

Non-Renewal Notices

If enrollees are impacted by a non-renewal or service area reduction, plans must provide this notice 60-90 days before the end of the contract year, depending on the material.

Outbound Enrollment Verification

If the enrollee is using an agent or broker enrollment, plans must provide this outbound enrollment verification by hard copy, telephone or email within 15 calendar days of the enrollment request.

Part D Transition Letter

If a beneficiary receives a transition fill for a non-formulary prescription drug, plans must send this letter within three days of adjudication.

Pharmacy Directory

All plan enrollees must receive this pharmacy directory by October 15 for the following plan year.

Plan Termination Notices

Before reaching the plan termination effective date, plans must provide this notice by hard copy and newspaper publication.

Pre-Enrollment Checklist

Plans should provide this document alongside the Summary of Benefits (SB) before enrollment, in the same format the SB is delivered.

Prescription Transfer Letter

If an enrollee’s Part D sponsor requests to fill a prescription at an alternate pharmacy than the one they currently use, plans must send this letter in a timely manner.

Provider Directory

All plan enrollees will receive a provider directory annually by October 15 for current enrollees, within 10 days of enrollment for new enrollees and within three days for current enrollees when requested.

Provider Termination Letter to Beneficiaries

If an enrollee’s provider is no longer part of the plan’s network, plans need to notify enrollees by hard copy via mail 30 days before the effective date.

Safe Disposal Information

At a minimum of once annually, plans need to distribute information on the safe disposal of prescription drugs that constitute controlled substances, including information on drug takeback sites in the enrollee’s community.

Scope of Appointment (SOA)

The SOA form provides enrollees with the opportunity to mark which products they want to discuss, and plans must provide this via signed hard or electronic copy or telephonic recording before the appointment.

Star Ratings Document

The Star Ratings document is generated from HPMS following a standard format. Plans must provide one to enrollees before enrollment and upload the document for HPMS review within 21 days of the updated information.

Summary of Benefits

Plans must provide the SB to all enrollees annually by October 15 and submit the document for HPMS review by that date.

Disclaimers

Plans must also include any relevant disclaimers in all CMS required documents for patients.

Contact us to learn how ProspHire can help optimize your required documentation processes

ProspHire Can Help With CMS Compliance

Complying with CMS document requirements often requires annual updates with the participation of various departments, which can impact an organization’s efficiency and optimization. However, failing to meet the document requirements for government programs like Medicare and Medicaid can lead to non-compliance actions like fines and member abrasion.

ProspHire can help organizations maintain compliance and streamline their required documentation delivery management systems. With resources like a Required Documents Playbook and Program Toolkit, ProspHire can help organizations create a foundational operating model to ensure plan beneficiaries receive the necessary documentation on time.

Contact us through the form below to learn how we can help optimize your required documentation processes.

Understanding Medicare Advantage Utilization Management Requirements

Written by LBodnarchuk on . Posted in Insights.

On December 14th, 2022, the Centers for Medicare & Medicaid Services (CMS) released proposed revised regulations governing Medicare Advantage (MA or Part C), the Medicare Prescription Drug Benefit (Part D), Medicare cost plans and Programs of All-Inclusive Care for the Elderly (PACE). The proposal’s focus is to increase transparency, improve health equity, reduce the cost of care and improve access to behavioral health services.

Key Medicare Advantage and Part D stakeholders will be able to provide feedback and analysis to CMS regarding the impact of these proposed changes by February 13, 2023. The proposed revisions would begin to take effect, offering guidance for the Medicare Advantage (MA) program contract year 2024.

Prior authorization can be used in a manner that results in potentially delayed patient care, burdens healthcare providers and adds unnecessary costs to the healthcare system. In summary, will focus primarily on the impact the proposed revised regulations have on utilization management and prior authorization. The effort to streamline the prior authorization process and promote healthcare is to improve the care experience across providers, patients, and caregivers.  


The goal of the changes is that enrollees will receive the same access to medically necessary care they would receive in Traditional Medicare.

Key Points

Key points to the 2023 Medicare advantage proposed rule

What does this mean for MA plans? 

For some plans, this legislative change means it is time to re-evaluate current policies and procedures in utilization management and ensure that current practices are consistent with the proposed rule. It is the time to review all existing policies and procedures related to prior authorizations, re-examine workflows and determine if staff have access and are using current traditional Medicare coverage determination materials. It is also time to establish if all coverage determination materials developed by the plan meet the requirements for development and communication. Consideration should also be given to the membership of the utilization review committee and determining if additional members are needed to cover the full scope of the specialties required to provide utilization review oversight. 

How can ProspHire help

We know that a well-functioning utilization management process can improve costs, patient and provider satisfaction and compliance with regulatory requirements. With our experience in utilization review processes, policies, procedures and medical review, ProspHire can provide a baseline assessment, change management roadmap and assist with increasing efficiency, effectiveness and compliance in your utilization management functions.  ProspHire focuses on best practices learned with plans across the country.

To connect with one of our experts, please fill out and submit the Contact Us Form.

HEDIS Opioid Measures and Strategies to Mitigate the Use of Opioids

Written by LBodnarchuk on . Posted in Insights.

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As the COVID-19 pandemic wanes through the public health lens, attention is shifting towards America’s pre-pandemic epidemic: opioid misuse.  In 2017, the US Department of Health and Human Services declared the opioid crisis a national emergency. The CDC has stated that the opioid crisis began in the late 1990s, but an increasing number of individuals affected by addiction and opioid use disorder deaths over the last decade has increased public awareness of the topic.

Opioid addiction often begins with a prescriber trying to help a patient manage pain. Patients can receive excessive amounts of opioid-containing pain medications, leading to addiction and unlawful obtainment and use of medications within this class. It is estimated that tens of thousands of Americans die every year due to opioid misuse. With this, HEDIS (Healthcare Effectiveness Data and Information Set), managed by the National Committee for Quality Assurance (NCQA), has set forth three measures specific to mitigating overprescribing, misuse, and overuse of opioids. Here, we will highlight the opioid specific HEDIS measures, along with strategies and best practices for plans to consider.

As defined by HEDIS, the opioid measures include:

  1. Use of Opioids at High Dose (HDO) – Members 18 years of age and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement year.
  2. Use of Opioids from Multiple Providers, Prescribers and Pharmacies (UOP) – Members 18 years of age and older receiving prescription opioids for ≥15 days during the measurement year from multiple providers. Three rates are reported:
    • Multiple Prescribers: The proportion of members receiving prescriptions for opioids from 4 or more different prescribers during the measurement year.
    • Multiple Pharmacies: The proportion of members receiving prescriptions for opioids from 4 or more different pharmacies during the measurement year.
    • Multiple Prescribers and Multiple Pharmacies: The proportion of members receiving prescriptions for opioids from 4 or more different prescribers and 4 or more different pharmacies during the measurement year.
  3. Risk of Continued Opioid Use (COU) – Members 18 years of age and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:
    • The percentage of members with at least 15 days of prescription opioids in a 30-day period.
    • The percentage of members with at least 31 days of prescription opioids in a 62-day period.

What Can Health Plans and Providers Do To Improve Opioid Overuse?

These three HEDIS measures create opportunities for providers and plans to control opioid utilization and identify members who are/or at risk of becoming opioid dependent. Without careful implementation and maintenance of these measures, members may face an unhindered path to becoming addicted, suffering opioid-related disorders and potential overdose deaths. Outlined below1 is a list of best practices and strategies health plans and providers can take to mitigate the risks and negative consequences of uncontrolled opioid use.

best practices and strategies health plans and providers can take to mitigate the risks and negative consequences of uncontrolled opioid use

Supporting Sensible Prescribing Practices: Health plans can support the appropriate prescribing of opioids by aligning their formulary structure and opioid monitoring system.  Members should be monitored when initiating opioid treatment or maintained on chronic therapy.  Initial prescriptions for opioids exceeding 50 MME per day should automatically flag for health plan pharmacist review. Rationale for use should be provided by the prescriber and documented in the member’s medical record regarding duration of therapy and indication for use.

Focusing on Enhanced Member Results: Promoting enhanced member results should place an emphasis on the utilization of nonopioid pain treatment regimens. Simplistic changes can consist of monitoring patients on over-the-counter (OTC) pain medications, such as acetaminophen or ibuprofen, before beginning opioid therapy. Health plans should also consider triaging patients to appropriate alternative therapy, such as chiropractic care or physical therapy. Treating the source of the pain instead of promoting medication use may prove beneficial to some members. 

Recognizing Overuse, Misuse and Fraud: To identify issues with opioid prescribing or member consumption, health plans can consider incorporating prescription drug monitoring programs into daily practice. Providers and pharmacists alike should review the local state prescription drug monitoring program prior to writing a prescription for opiate therapy or dispensing the medication to the patient. These programs have decreased the number of multiple providers writing opioid prescriptions for members and decreased substance abuse admissions. Dispensing profiles can help identify the validity of prescriptions for members or duplicative therapy that can impact the member’s overall health. 

Advocating for Safe Communities: Participating in activities, such as prescription drug takeback programs, can help to keep members of the community safe. Health plans should consider utilizing local agencies to sponsor these takeback programs. Unnecessary prescription drugs, including opioids, can be misused or abused by individuals prescribed the medications or unregulated members of the community. Increased prevalence of these programs in the community is the best way to dispose of used or expired medications.

Don’t Wait to Provide the Highest Quality Possible for your Members

At ProspHire, we want to help you provide the highest quality of care possible for your members. With our team’s extensive healthcare industry knowledge and commitment to delivering valuable results, we are here to help you optimize strategy and execution of care.

Aligning best practices with strategy can assist plans in reducing the inappropriate use of opioids. From providing current state assessments to implementation playbooks, our experienced staff can help health plans develop an improvement pathway that is tailored to meet the needs of your organization.

ProspHire’s team of clinical experts are ready to partner with your health plan and work shoulder to shoulder to improve member and community safety. Connect with us today.

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ProspHire Names First Chief Marketing & Communications Officer

Written by LBodnarchuk on . Posted in News.

PITTSBURGH, PA – Founding Principals Lauren and Chris Miladinovich today announced that ProspHire has named Tricia Egry as its first Chief Marketing & Communications Officer. Tricia was previously Senior Director and remains a member of the Firm’s Executive Leadership Team. She is responsible for enhancing and amplifying the ProspHire brand and building and driving a marketing & communications strategy and digital-first programs that drive engagement and conversation, while inspiring a team of nearly 100 employees and consultants across the U.S. ProspHire is a woman-owned and rapidly expanding Pittsburgh-headquartered management consulting firm focused on healthcare advisory, project delivery and strategic resourcing. 

“Since Tricia joined ProspHire in 2021 she has championed an aggressive multi-functional digital marketing strategy that focuses on creating a Best-in-Class client experience to drive lead generation, cross-selling and sales,” said Lauren Miladinovich, ProspHire’s Managing Principal and CEO. “Tricia’s dedication to ProspHire and its people is exceptional and we are thrilled to promote her to be our first Chief Marketing & Communications Officer.”

A proven marketing leader, Tricia brings considerable experience in delivering high-impact, integrated marketing, brand and communications strategies across diverse industries, locations and geographies. Prior to joining ProspHire, she served as National Marketing & Communications Leader of Field Teams at BDO, USA, where she led marketing & communications strategies for more than 60 U.S. offices by managing the development and execution of go-to-market plans that included digital and social media campaigns, public relations and advertising initiatives, sales enablement and bid management and event and sponsorship strategies. She came to BDO through the expansion of Alpern Rosenthal, where she led strategic marketing initiatives for numerous industries as Director of Marketing. Tricia’s career experience also includes being a journalist and news producer for NBC and a disc jockey at several radio stations in Western PA.

“The story of ProspHire is one that I can really relate to,” commented Egry. “It’s a brand that lives at the intersection of relationships and innovation and the leadership aims to help our people, our clients and our communities prosper. I look forward to continuing to evolve the Firm’s marketing and communications program and playing a critical role in our continued momentum and expansion.”

“This is a big moment for ProspHire,” said Christopher Miladinovich, ProspHire’s Principal and Chief Operating Officer. “Tricia’s extensive experience leading marketing organizations at various stages of growth will help our Firm drive revenue and accelerate as we embark on our next chapter.”

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New CMS Proposed Rule

Written by LBodnarchuk on . Posted in Insights.

The Centers for Medicare and Medicaid Services (CMS), the federal oversight body for all Medicare programs, released a proposed rule on December 14, 2022, addressing policy and technical changes to the Medicare Advantage programs including Medicare Stars. Proposed rules are not final law, but they do outline what changes CMS intends to make to existing laws impacting how Medicare programs operate.

Health plans and other affected groups can submit comments to CMS for consideration by February 13, 2023, as CMS develops the final rule, which becomes law at the time of release.

Here’s what you need to know about the latest proposed changes from CMS relevant to Medicare Stars.

Summary of Proposed Changes | Stars Program

With the CY2024 Proposed Rule Changes, CMS is once again aiming to dynamically alter the Medicare Stars Quality program. The changes, only in the “proposed” stage, are subject to commentary and public review before the final rule is codified. One of the biggest changes in the proposed rules is the proposed shift of the Member Experience: Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Administrative Measures from a weight of 4x back to the previous 2x weight in measurement year 2024 (Star Year 2026). This shift would have significant impacts on the relative scoring weight of the measure domains. 

CMS is also proposing the addition of five new HEDIS and Part D measures in measurement year 2024 (Star Year 2026). These measures, listed below, will require new member-level data analysis, internal process changes, and intervention development. 

  • Kidney Health Evaluation for Patients with Diabetes (KED)
  • Care for Older Adults (COA) Functional Status Assessment 
  • Concurrent use Opioids and Benzodiazepines (COB)
  • Polypharmacy Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH)
  • Polypharmacy Use of Multiple Central Nervous System Active Medications in Older Adults (Poly-CNS)

In addition to new measures and changing weight, another major proposed change from CMS is the replacement of Reward Factor with a Health Equity Index (HEI) Factor in measurement year 2025 (Star Year 2027). This change, further discussed below, will have significant impacts on the overall scoring of the Stars Program. This change will likely have disproportionate impacts on the higher scoring health plans (>4.0 Stars) given the nature of the reward factor calculation. Although much is not yet known regarding the specifics of the HEI Factor calculation, this shouldn’t come as a major shock to health plans. CMS has been signaling for some time now a commitment to health equity initiatives through quality programs, and this is very much so in line with that thinking. 

Lastly, CMS is proposing the risk-adjusting at the sociodemographic level of the 3x weighted Medication Adherence measures in measurement year 2026 (Star Year 2028). These potential adjustments could have tremendous impacts to plans, especially depending on the member mix (i.e. DSNP allocation, MAPD allocation, etc.).

Weighting Shift

In Star Year(SY) 2023, CMS shifted the weight of Administrative and CAHPS measures to refocus health plan’s initiatives on improving member experience.  The new CMS proposed rule will reverse this change and reduce the weight of patient experience and access measures to even the weight across domains.

Weighting Shift Key Insights

Final Proposed Weighting: (MY2024/SY2026)

  • Patient Experience/Complaints and Access Measures – 2x
  • Process Measures – 1x
  • Intermediate Outcome Measures – 3x
  • Part C and D Improvement – 5x

The current 4x weighting likely caused a shift away from health-related measures and outcome driven measures given the relative weighting importance. Reducing the weighting will better align the patient experience/complaints and access measures more closely with other domains.

Plans should continue to focus interventions around listening to the voice of the member given the important link between patient experience, retention, medication adherence, and other health outcomes.

Measure Weighting Adjustment SY2024 vs. SY2026

New and Revised Measures

The period of effect is beginning on or after January 1, 2024.

Part D and Part C Measures

Replace Reward Factor with HEI

CMS is proposing to replace the reward factor with a health equity index(HEI) reward for the 2027 Star Ratings to incentivize plans to focus on improving care for enrollees with social risk factors (SRF).

What is the Health Equity Index and Final CMS Stars Ratings for 2023

Timeline Impact

Proposed Stars changes will set in starting in MY2022 (SY2024), with tiered rollout continuing through MY2026 (SY2028).

Proposed Stars changes next few years

Is your health plan’s Stars program ready to respond to these upcoming changes? 

ProspHire’s team of Stars experts are ready to partner with your health plan to prepare and plan for these changes to the Medicare Stars program. We work shoulder to shoulder with clients to improve Star ratings and enable long-term sustainable program success.

What Is Value-Based Healthcare? 

Written by LBodnarchuk on . Posted in Blog, Clinical Services Optimization.

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Traditional fee-for-service healthcare does not always provide a desirable system for all patients. It can result in inadequate or overpriced services, making it a less attractive option for many individuals.  

Value-based care (VBC) is changing the landscape by lowering prices and boosting satisfaction for patients, payers and providers as well as aligning incentives and promoting quality care. 

We are exploring the different facets of VBC to help you better understand this care model. Learn what value-based healthcare really means, how it works, and its many benefits.  

What Is Value-Based Care and How Does It Work? 

Value-based healthcare programs are designed to reward providers for delivering the highest quality of care. They involve incentive payments for the efficiency and ultimate effectiveness of the services delivered. These systems work as a form of reimbursement and rival traditional healthcare programs that operate with retrospective payments based on bill charges.  

The U.S. federal government first introduced VBC programs in 2008 to improve healthcare services provided to people with Medicare as part of the Medicare Improvements for Patients and Providers Act (MIPPA). In 2010, the Affordable Care Act (ACA) also further advanced the development of value-based healthcare.  

Today, both federal and commercial payers are leading the way in value-based care initiatives by focusing on common areas of duplication, supporting care pathways and evidence-based medicine goals. Removing unnecessary variation in care delivery means better outcomes and lower costs. 

Examples of Value-Based Healthcare

Examples of Value-Based Healthcare 

Value-based healthcare is available in a variety of options. The following are some of the most popular programs you can choose from: 

Accountable Care Organizations 

Originally intended for Medicare patients, accountable care organizations (ACOs) coordinate various healthcare providers to offer coordinated care for a defined population of patients. Providers in the organization share not only the responsibility for improving care, but also the associated risks and incentives in quality performance metrics and lowering costs. While ACOs must invest in technology, people and processes to improve care, the risk arrangements often allow for returns on the investment. 

Bundled Payment 

A bundled payment, also called an episode-based payment, encompasses a program that allows patients to pay for an entire episode of treatment for medical and surgical care. The bundled payment methodology usually begins during hospitalization or surgical procedures and ends ninety days after the initiation of the bundle. This allows providers to emphasize not only the treatment provided within the hospital but the post-acute services, such as rehabilitation or nursing care afterward. It helps incentivize better care transitions and utilization of high-quality post-acute providers that keep the patient safe and avoid unnecessary readmissions. 

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Patient-Centered Medical Homes 

A patient-centered medical home (PCMH) is another value-based healthcare model that is centered on a team-based approach to care, anchored in the primary care setting. Providers are typically reimbursed with additional payments to support a more patient-centric and care management delivery model often including services for physical health, mental health, wellness and around-the-clock availability to meet patient and caregiver needs.    

Hospital Value-Based Purchasing 

CMS has also established metrics for most US hospitals related to penalties and risks for quality and cost of care. The programs require hospitals to improve performance on hospital-acquired conditions, value-based purchasing and readmission reduction. These programs place a significant portion of Medicare revenue at risk for hospitals and allow hospitals to grow and support other providers in value-based arrangements. 

What Does Value-Based Care Mean for Payers and Providers?

Now is the time to consider examining or re-examining these programs and the impact on quality care and lowering costs. Are the current programs effective? Are patient outcomes improving and is the expense of operating in these models truly impacting cost? While research is mixed, there is no question that rethinking healthcare reimbursement is here to stay. The most successful organizations are finding the right combinations of care management, pathways, reimbursement and patient engagement that is pushing healthcare delivery in the right direction. 

There are several challenges to success in value-based care. One challenge is access and analysis of timely data that provides the necessary feedback on what is working and what may not be working in care delivery. Often data that providers see is outdated and not well presented to allow real-time interventions or change. 

Another challenge is the lack of coordination between payers and providers and coordinated use of resources for patient/member care management. Care management services may be offered by physician practices, hospitals and payers without a patient-centric approach which can be duplicative and sometimes conflicting. In an ideal system, these important care management and care transition services should be coordinated and focusing on ensuring patients are guided through chronic and acute illnesses and services without overlap or complications. 

Working together, payers, providers and patients can optimize value-based care models by learning from past experiences and continually finding new and innovative ways to align incentives, improve engagement and concentrate on quality outcomes and appropriate costs. 

ProspHire wants to help you provide the highest quality of care.

Turn to ProspHire to Learn More 

Value-based healthcare can assist in advancing the Quadruple Aim. From providing better care at lower costs to improving health management strategies, this type of care offers many benefits. 

At ProspHire, we want to help you provide the highest quality of care possible for your patients. With our team’s extensive healthcare industry knowledge and commitment to delivering valuable results, we are here to optimize your project resource management. 

Are you interested in learning more about how ProspHire can enhance your organization’s processes and improve your performance with integrated clinical care solutions? Contact us below to get started today! 

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ProspHire Honors the Memory of Managing Director Hannah Hass

Written by LBodnarchuk on . Posted in News.

One year after ProspHire Managing Director Hannah Hass passed away, the Firm unveils ‘In Her Shoes’, a Women in Leadership Training Program, in her honor. This program is focused on inspiring and empowering the women of the Firm through professional development.

‘In Her Shoes’ is a 6-week program that aims to develop future female leaders within ProspHire, focusing on driving innovation, creating high-performing teams, managing difficult situations and developing within your leadership style. “In memory of our colleague and dear friend, Hannah Hass, the ‘In Her Shoes’ program is dedicated to making a positive impact on ProspHire’s Women in Leadership by women empowering women,” says Lauren Miladinovich, Co-founder, Managing Partner and CEO of ProspHire.

The oldest of three sisters, Hannah spent her early life exploring the hills and mountain rivers near Elkins, West Virginia. She loved being on the river and you could often find her sharing a kayak with her German Pinscher, Franz. She had a successful career as a consultant at Deloitte and moved on to build a loving work family at ProspHire, where she was admired by her colleagues for her independence, intelligence and humor. Hannah loved bringing people together.

Donations may be made in Hannah’s name to Project HEAL.

Remembering ProspHire Senior Principal Advisor Rick Dorman

Written by LBodnarchuk on . Posted in News.

It is with great sadness that we inform of the passing of our friend and colleague Rick Dorman. After facing a battle with cancer, he died on November 12, 2022, with his family by his side. Our sincere condolences go out to Rick’s family during this difficult time.

“Rick represented the best qualities of an advisor, partner, mentor and teammate,” said Lauren Miladinovich, Co-founder, Managing Principal and CEO of ProspHire. “He will be greatly missed by his colleagues across the Firm.”

Rick spent 27 years at Deloitte Consulting, becoming Principal in 1999. Upon retiring, he became an advisor at ProspHire. He was passionate about project management and business development. He was candid, but kind – he never held back. He was a man of sarcasm with much love behind it.

He was an active force on the ProspHire board of advisors and coached new and aspiring partners. Those who worked closely with Rick know how much pride he took in his profession and how he enjoyed life enthusiastically. His knowledge of wine often led to him being designated to select the wine for leadership team dinners.

“More than anyone I know, Rick loved life, he loved the profession and he loved ProspHire. He was the consummate teammate and friend and cared deeply for every staff member,” shared Chris Miladinovich, Co-founder, Principal and Chief Operating Officer of ProspHire. “Together, we remember Rick and the indelible legacy he left at the Firm.”

Rick was a mentor to many, including ProspHire’s Dan Crogan, Principal and SVP of Consulting, when he entered the Firm’s partnership. “Rick brought a wealth of business knowledge to the executive leadership team, but more importantly he was a great man and dear friend,” said Dan. “His patience and mentorship behind the scenes will be truly missed.”

Donations may be made in Rick’s memory to the Target Cancer Foundation (www.targetcancerfoundation.org) or the Woodlands (www.mywoodlands.org).

Star Year 2023 Data Insights

Written by LBodnarchuk on . Posted in Insights.

On October 6th, 2022, the Centers for Medicare and Medicaid (CMS) released the official Star Year 2023 Data – including contract and measure level detail to the public. As we’ve talked about for some time now, the industry did observe a great Stars recession with average ratings plummeting year over year and returning to pre-pandemic levels (SY2020). With many important regulatory changes already in place and several on the way (Tukey Outlier Deletion), Health Plans can anticipate more disruption in the marketplace.

Distribution of Star Rating Change from Prior Year

Distribution of Star Rating Change from Prior Year

Nearly 20% of Health Plans experienced a drop out of the Quality Bonus Payment (QBP) range in SY2023. Last year, about 70% of contracts achieved the QBP whereas in 2023 only about half of contracts got the QBP. This drop will put added financial pressure on health plans to achieve cost savings either through improved medical management or enhanced revenue capture. More importantly, this negative shift represents the new Stars reality, where CAHPS and Member Experience performance will drive the bulk of the marketplace and will force plans to invest more time and effort into benefits, personalized member experiences, and improved operational excellence.

Average Star Rating Year Over Year

Average Star Rating Year Over

Since the programs’ inception, Star Ratings have steadily increased year over year. Due to COVID guardrails and other “better of” protections, SY2022 was the highest on record and for many, was quite anomalistic. The SY2023 drop off was quite precipitous, with average ratings falling to near pre-pandemic levels. What does this all mean? It’s hard to say in the long run, but we cannot discount the impact that Member Experience and CAHPS will have on the programs overall average rating for the foreseeable future. Perhaps with these weighting changes, the program will see a ‘leveling off’ for the next few years as average scores remain neutral. In any case, those Health Plans that saw massive drop offs in scoring will have plenty of opportunity to rescue their scores in SY2024 and beyond.

Distribution of Star Rating SY2023

Distribution of Star Rating SY2023

When analyzing the distribution of Star Ratings for SY2023, the biggest takeaway are the tail ends of the distribution. We saw a big drop off in 5-Star plans (year over year) and a massive increase in 2- and 2.5-Star plans (year over year). With almost 50% of plans facing a drop in Star Rating year over year, the distribution of ratings returned to a somewhat more normal distribution.

Plan Count by Overall Rating & Average Member Experience Rating

Plan Count by Overall Rating & Average Member Experience Rating

In SY2023, CMS adjusted the weighting of CAHPS and Member Experience measures to account for ~60% of the Overall Star Rating, shifting Health Plan’s focus away from majority gap closure efforts to putting member experience at the forefront of strategies. 254 contracts were able to achieve a 4.0 Star Rating with this adjustment in the Star rating landscape. Approximately 60% of contracts with 4.0 Stars or greater, scored >=4.0 Stars in the CAHPS Domains. This further emphasizes that CAHPS/Member Experience are major drivers in overall contract rating performance and failing to succeed in those areas will hurt your plan performance. Bottom line, 70% of plans with <4.0 Stars in CAHPS were not able to achieve the QBP and did not receive 4.0+ Stars at the contract level.