Did you know? April is Medicaid Awareness Month.
Medicaid Matters. It’s a lifeline for millions of Americans and is especially critical as the nation responds to the pandemic, providing key funding for hospitals and helping patients get the support they need.
Medicaid is the country’s most extensive health care program specifically designed to meet the needs of low-income individuals who have disproportionate medical needs and health challenges. Medicaid provides high-quality, affordable coverage to nearly 80 million low-income individuals and families, including 10 million people with disabilities. The program is the main source of long-term care coverage for millions of older adults and, along with the Children’s Health Insurance Program (CHIP), provides access to care for over 40 million children.
Why is Medicaid Awareness Month important?
One of the key goals of Medicaid Awareness Month is to raise understanding about the program and the services it provides. Many people may not realize that they are eligible for Medicaid or may not be aware of the range of services that are covered. By increasing awareness, we can help ensure that more people are able to access the care they need to stay healthy.
It has been proven that Medicaid expansion efforts have increased access to care, improved financial security and led to better health outcomes. The Medicaid expansion has played a pivotal role in reducing racial disparities in obtaining healthcare access.
The Public Health Emergency (PHE) is set to expire on May 11, 2023. The PHE has been in place since 2020 due to the Covid-19 pandemic. During this time, Medicaid/CHIP enrollment grew by more than 20 million. The PHE gave the federal government flexibility to waive or modify Medicaid and CHIP programs. Starting this Spring, States will begin the process to determine who will no longer be eligible for coverage. It is estimated that up to 15 million Medicaid and CHIP enrollees will lose coverage over the next 12 months.
It is expected that up to a third of those losing coverage will turn to Health Insurance Exchange Marketplaces. Consumers who have lost coverage during the Medicaid unwinding process will be eligible to apply for immediate coverage through a Special Enrollment Period (SEP). While many Issuers are scrambling to replace lost Medicaid revenue, ACA Marketplaces are a strategic place to look.
How Can ProspHire Help?
At ProspHire, our approach is to gain a fundamental understanding of your existing business, operations and goals and then develop the best strategy to achieve your ACA goals quickly and effectively. We can assist your health plan with conducting an assessment and instituting change management throughout the Medicaid unwinding’s and help to ensure ACA and other products are optimized to secure continued coverage for those losing Medicaid.
Imagine a world in which every person, from infants to seniors, can achieve and maintain their highest level of health. This goal is health equity and while it should be a societal norm, many obstacles make it difficult to reach.
These barriers lead to health disparities, which are differences in the health statuses of varying groups of people. Health disparities are avoidable distinctions in the burden of illness, injury, disease, violence or chances to attain good health that socially disadvantaged groups face.
Health inequities are linked closely to the disproportionate allocation of social, economic and environmental resources. However, health professionals can work to address these disparities by understanding why social health determinants are important and what support services can help.
What Are 5 Social Determinants of Health?
Social determinants of health are the nonmedical circumstances in our environment that impact our well-being. Factors present in the places where we are born, live, play, learn, work, and age can profoundly influence our overall quality of life.
Social determinants of health also cover a broader set of systems and forces that shape daily life. These health determinants can comprise economic policies, development agendas, social and cultural norms, racism, climate change and politics.
To understand social determinants of health, consider the following examples:
Safe housing, transportation and neighborhoods
Discrimination, racism and violence
Education, job opportunities and income
Access to nutritious foods and opportunities for physical exercise
Clean air and water
Language and literacy skills
Professionals group the social determinants of health into five domains, which we’ll explore below.
1. Economic Stability
Economic stability means having enough secure, reliable income to meet your fundamental needs. Being economically stable can help you achieve a better quality of life by allowing you to access essential resources for your health and well-being.
Factors that influence economic stability include:
Affordable housing
Employment that provides a living wage
Employment benefits, like worker protections, paid sick leave and child care
Reliable transportation
It’s crucial to address economic instability as a social determinant of health because daily challenges surrounding unemployment, poverty, housing and food insecurity can elevate the risk of poor health outcomes for vulnerable populations.
2. Education Access and Quality
Education equips people with the tools they need to live fulfilling lives, thrive personally and contribute to their communities. Moreover, an educated person is more likely to access elements that contribute to their well-being, like quality healthcare, jobs that pay a living wage and safe living environments.
People with access to a good education tend to stay healthier throughout their lives than those without. Education gives people the opportunity for upward mobility, placing them in the financial circumstances necessary to access quality healthcare and support services.
People with low education levels contend with unemployment and low income, which are associated with poorer health. Data indicates that people of lower socioeconomic status experience more health problems like obesity, asthma, diabetes and heart disease than people of higher socioeconomic status.
Finally, having a college education helps job seekers obtain higher-paying work that poses fewer safety risks.
Ultimately, people with higher levels of education have more means to afford things that promote their health, like quality housing in toxin-free environments and expert primary care physicians trained in the most successful techniques.
3. Healthcare Access and Quality
Access to quality healthcare means services like the prevention, diagnosis, treatment and management of diseases, illnesses, disorders and other health-impacting conditions are readily available to you. These healthcare services must also be affordable and convenient.
Unfortunately, many people encounter obstacles that make it challenging to obtain health care services, which may increase the risk of poor health outcomes and disparities. Such barriers include a lack of health insurance, inadequate healthcare resources and limited access to transportation.
Little or no health insurance coverage significantly hinders healthcare access. High costs may cause people to put off necessary medical treatment or avoid it altogether. Lower-income families often go without insurance and minority groups constitute over half of the uninsured population.
Inadequate health insurance coverage can adversely impact a person’s health. Adults without insurance are less likely to receive preventive care for chronic conditions like diabetes, cancer and heart disease. Likewise, uninsured children are less likely to get treated for conditions like asthma or receive critical services like dental care, immunizations and well-child visits.
Sometimes, a limited availability of resources and support services further reduces people’s access to health services, increasing the likelihood of adverse health outcomes. For example, a shortage of doctors and primary care providers may mean patients wait longer to receive care.
Unreliable or inconvenient transportation can also make it difficult for people to receive consistent healthcare, potentially contributing to adverse health outcomes.
4. Neighborhood and Built Environment
The neighborhoods and built environments in which people live, work, play and learn can strongly influence their health and well-being for better or worse, depending on the circumstances.
Many people live in communities or work in jobs that present health risks like high rates of violence, pollution, unsafe water and others. Minorities and low-income people are more likely to live in neighborhoods and work in environments that present these risks.
The factors that make neighborhoods and built environments a social determinant of health fall into the following four groups.
Access to healthy foods: Access to nutritious foods is crucial to a sensible eating pattern. A lack of access to healthy foods can result in malnutrition, higher obesity levels and other diet-related conditions because low-income people tend to live in “food deserts.” However, accessing healthy food depends on more than having a grocery store nearby. People must also be able to afford it and affordability closely relates to employment rates and job quality.
Quality of housing: A home’s design and structure can significantly impact housing quality. Unsafe conditions such as the presence of asbestos, mold, lead, substandard air quality and overcrowding can lead to adverse physical and mental health outcomes.
Crime and violence: Whether experienced directly or indirectly, crime and violence can cause injury, mental distress and reduced quality of life. Some communities and groups are more likely to encounter crime and violence than others, such as low-income neighborhoods and Black adolescents.
Environmental conditions: Environmental conditions like water quality, air quality and the weather can influence a person’s health. Some groups are more vulnerable to poor environmental conditions and their associated health disparities. These include people of color, low-income families, the homeless, the elderly, pregnant women and children.
5. Social and Community Context
Social and community situations are vital aspects of a person’s health status. Relationships and interactions between people and their family, friends, colleagues and community can shape their health priorities and well-being.
Public health advocates classify social and community contexts into the following four categories.
Civic participation: Civic participation comprises activities like voting, volunteering, recreational sports, community gardening and more. Civic participation benefits the community and the participants by building social capital, expanding social networks and helping foster a sense of purpose.
Discrimination: Discrimination is a stressor that affects a person’s health by barring access to resources, dignity and quality of life.
Incarceration: People are more likely to develop chronic conditions like high blood pressure, cancer, asthma and arthritis. Black and Hispanic populations and people with low education levels have higher incarceration rates.
Social cohesion: Relationships are an essential part of physical and psychosocial wellness. Social cohesion is the strength of relationships and the perception of harmony within a community. High levels can positively influence health outcomes.
The Impact of Social Determinants of Health in Patients
Social determinants can dramatically impact physical and mental health outcomes, especially for vulnerable populations. Providers must account for circumstances like patient income, education and environment to deliver the holistic care necessary for health equity and well-being.
The public health sphere widely understands that poverty impedes access to nutritious foods and safe neighborhoods, and that higher educational levels contribute to better overall health.
If means are available to overcome adverse social determinants of health, populations can experience better health. But without resources, social determinants can foster troublesome circumstances like discrimination and disparities. Moreover, undesirable social health determinants can affect a person’s knowledge of healthcare and resources and restrict access to them.
The Truth About Negative Social Determinants of Health
Children of adults who did not earn a high school diploma are more likely to grow up in areas with barriers to healthcare and health topics.
As income levels decrease, the risk of premature death increases.
There is a direct connection between lower income, smoking and shorter life expectancy.
Poor white people are less likely to live in neighborhoods of concentrated poverty.
A person’s living environment may influence that of future generations.
Disparity-related stress relates to health and is often the result of overlapping factors.
Stress harms children and adults throughout their lives. Repeated exposure to environmental and social stressors may result in a cumulative burden that puts people’s health at risk.
Social determinants that result in health disparities are expensive and can hinder the quality of care that people receive, leading to additional healthcare expenditures, loss of efficiency and early death.
Research related to the price of health disparities puts the situation into perspective. For Black people, Hispanics and Asian Americans, 30% of direct medical costs relate to health inequities. On a broader scale, the U.S. loses approximately $309 billion each year to the direct and indirect costs of health disparities.
How ProspHire Can Help You Provide Quality Patient Care
As our population diversifies, it becomes more vulnerable to the concerns associated with adverse social determinants of health. One straightforward path to addressing this issue is coordinating services across the spectrum of care. Merging social support and assistance with healthcare delivery is vital for providers to confront the various social determinants that have such a bearing on patients’ wellness.
ProspHire prioritizes helping you provide high-quality healthcare to your patients, and we tailor solutions to do that. We understand the far-reaching effects that nonmedical factors have on a person’s health, so we’ve implemented strategies to help healthcare professionals address them.
Below are the services we offer related to social determinants of health.
SDoH solutions: These solutions allow you to look beyond the point of care and address all areas that impact health outcomes, such as housing, food insecurity, transportation and improving access to needed community programs.
Population health assessment and transformation: Assess your population, understand the underlying drivers of health and implement change to address social determinants and equitable health outcomes through turnkey interventions.
Organizational strategic planning: Drive organizational transformation through defined goals and a developed playbook for change management and actionable strategies to address health disparities.
Community-based partnership development: Evaluate, align and partner with community-based organizations to address social determinants and close care gaps to improve equitable outcomes and increase community-based care management.
Maternal health equity: Address inequities and improve outcomes in maternal health through population-based interventions and recommendations curated to meet the needs of vulnerable patients and members.
Quality accreditation achievement: Be a leader in the industry through the pursuit and award of health equity and other quality accreditations.
With these services, health providers can build a more comprehensive awareness of the biological, behavioral and social components that shape wellness and health systems. The result is an equitable healthcare system that makes better health outcomes attainable for everyone.
Address Social Determinants of Health with ProspHire
Tackling the challenges presented by negative social determinants of health is no small undertaking, but patients deserve your best effort. A multifaceted approach is necessary to make the changes that will allow our society to find health equity. ProspHire has the expertise and enthusiasm to develop a solid plan for your organization.
ProspHire helps our clients provide better access to quality healthcare. We’re here to help you implement the strategies and interventions needed to fight health disparities and achieve health equity.
With our commitment to culture, leadership, diversity, equity and inclusion, our minority-owned business is a leader in healthcare strategy and execution. Contact the experts at ProspHire today to learn more.
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
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
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
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 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
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.
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.
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.
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.
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.
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
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.
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 measuresinclude:
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.
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 prescribersand4 or more different pharmacies during the measurement year.
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 below1is a list of 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.
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.”
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.
New and Revised Measures
The period of effect is beginning on or after January 1, 2024.
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).
Timeline Impact
Proposed Stars changes will set in starting in MY2022 (SY2024), with tiered rollout continuing through MY2026 (SY2028).
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.
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
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.
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.
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!
