Welcome to ProspHire’s Soaring to New Health podcast. In this episode, we dive into the transformative power of Data Analytics in Healthcare, joined by Toby George, Co-Founder of Data Ideology. Toby’s expertise sheds light on how data analytics is reshaping healthcare delivery, improving patient outcomes and driving efficiency across the industry.
The Journey of Data Ideology
Data Ideology is a leading firm specializing in Data Analytics solutions for healthcare organizations. Toby explains that their focus lies in helping companies navigate their data and analytics journey, from strategy to execution. They assist organizations in developing a plan and implementing it, particularly aiding those between one and five billion dollars in size that are looking to leverage data as a strategic asset.
Challenges and Solutions in Healthcare Analytics
One of the significant challenges Toby highlights is the slow adoption of advanced technologies like AI and machine learning due to foundational data issues. Many organizations lack a solid data foundation, hindering their ability to adopt these technologies effectively. Data silos, data quality issues and the lack of interoperability pose significant barriers that must be addressed.
The Impact on Patient Outcomes
Despite these challenges, Data Analytics holds immense potential for improving patient outcomes. Toby discusses how predictive analytics can identify potential issues like readmissions, enabling proactive interventions. Machine learning in radiology and natural language processing (NLP) in clinical notes are other areas driving improvements in patient care and satisfaction.
Navigating the Data Journey
For organizations embarking on this data journey, Toby offers valuable advice. Defining a clear vision, understanding the current state and designing a roadmap that avoids overwhelming initiatives are key steps. Cultivating talent, measuring success and iterating are vital for long-term success in data analytics endeavors.
The Future of Healthcare Analytics
Looking ahead, Toby envisions a future where AI, IoT and personalized treatment plans based on data-driven insights play a pivotal role. The Internet of Medical Things (IOMT) presents opportunities for remote monitoring and diagnosis, revolutionizing how healthcare is delivered and experienced.
Data Analytics is not just a tool but a transformative force in healthcare. As organizations embrace data-driven strategies, they stand to enhance patient care, operational efficiency and overall outcomes. With the right approach, partnerships and technologies, the future of healthcare analytics holds immense promise for bettering the lives of patients worldwide.
In a nation where the joy of childbirth should be universally celebrated, the harsh reality persists as maternal mortality rates continue to rise and disproportionately impact black women. The Centers for Disease Control and Prevention (CDC) reported 32.9 deaths per 100,000 live births in 2021, highlighting a concerning trend from 20.1 in 2019 and 23.8 in 2020. This disparity underscores systemic healthcare inequalities. However, amidst these challenges, hope emerges with a transformative initiative led by the Centers for Medicare and Medicaid Services (CMS).
As per a report from Modern Healthcare, CMS introduced a pioneering initiative in 2023 allocating $17 million over a decade to reshape maternal healthcare, covering both physical childbirth aspects and mental and social needs. With Medicaid funding 40% of childbirths nationally, these grants have transformative potential. The initiative aims to revolutionize maternal care by promoting collaboration among healthcare providers and increasing access to complementary services like midwives and doulas. Particularly focused on underserved rural and low-income communities, it aims to establish birth centers and minimize unnecessary cesarean sections.
Critical to this endeavor is the integration of screening programs for Social Determinants of Health, nutrition, housing, substance use and the facilitation of connections to community-based resources. States accepting CMS funds are mandated to develop health equity plans and extend Medicaid coverage for a full year postpartum, recognizing the significance of continued care beyond childbirth.
Strategies to Improve Maternal Health Equity
Navigating the complexities of systemic change is crucial as the United States grapples with a concerning increase in maternal mortality rates, particularly affecting black women. CMS’s Medicaid maternal health grants mark a pivotal step towards achieving equity in maternal care. However, sustained efforts, driven by a commitment to justice and inclusivity, are essential to ensure every mother receives the care and support she deserves, regardless of race or socioeconomic status.
At ProspHire, we specialize in driving impactful change across healthcare. Our teams closely monitor the Medicaid landscape, shaping quality enhancements and financial progress. With our deep industry expertise and focus on building crucial connections with underserved populations, we are positioned at the forefront of the field. As you explore avenues to integrate maternal health care and SDOH management, connect with us.
Welcome to Season Two of ProspHire’s Soaring to New Health podcast! In this episode, we delve into the critical impact of Social Determinants of Health (SDOH) on our communities, particularly focusing on housing and its implications for the well-being of children and families. Joining us today are two distinguished guests: Stephanie Meyer from the Pennsylvania Department of Human Services and Chris Watts, the CEO of the Boys and Girls Clubs of Western Pennsylvania.
Chris Watts shares insights into the Boys and Girls Clubs’ mission, serving over 7,500 kids annually in Western Pennsylvania. Their programs focus on providing safe environments, academic support, character development, healthy lifestyles and career readiness to help children reach their full potential.
Stephanie Meyer highlights the role of the Pennsylvania Department of Human Services in supporting over 3 million Pennsylvanians through various programs, including Medicaid, nutrition assistance and housing initiatives. The department’s focus on addressing housing instability and providing critical resources during the pandemic reflects their commitment to a thriving Pennsylvania for all.
Tackling Barriers: The conversation shifts to addressing housing barriers, with Stephanie discussing initiatives like the Emergency Rental Assistance Program and efforts to increase access to affordable housing. Chris Watts emphasizes the Boys and Girls Clubs’ commitment to reducing barriers for families, including transportation and paperwork processes, to ensure all children have access to quality programs.
The Impact of Social Determinants: Both Stephanie and Chris emphasize the tangible impact of Social Determinants of Health, such as homelessness and housing instability, on children and families. They paint a vivid picture of the challenges faced by those experiencing housing insecurity and underscore the need for collaborative efforts to address these disparities.
Investing in Quality and Access: Both community leaders highlight the importance of investing in quality childcare and early learning programs. Stephanie praises the Boys and Girls Clubs’ commitment to quality, as evidenced by their high accreditation rating, while Chris emphasizes the need to ensure access to high-quality programs for all children, regardless of their circumstances.
It’s evident that addressing Social Determinants of Health requires a multifaceted approach involving government agencies, community organizations and stakeholders. By working together and investing in quality programs and resources, we can create a healthier and more equitable future for our communities. To learn more about how you can get involved, listen to the entire episode here: Listen to the Soaring to New Health Series | ProspHire
The beginning of the calendar year means it is HEDIS/Medical Record Review season and within this timeframe; everyday matters, so make them count. With approximately a month left, health plans need to leverage their strategic provider partnerships and utilize data reporting and tracking to optimize opportunities for quality improvement (QI) and ultimately achieve their year-end Stars’ goal.
Leveraging provider partnerships: Now is the time to lean in on your plans’ relationship with providers who care for your members. Utilizing your previously developed provider repository, accessing provider group Electronic Medical Records (EMRs), and knowing when to escalate in areas needing additional support is key.
Data reporting and tracking: Real-time data updates regarding chart chase status, measure-level gap analysis/forecasting and identifying key opportunities for broad chart closure efforts are critical to ensuring a successful close-out to Hybrid season.
SY2026 Strategic Plan and Execution
As we enter a new Stars Year, it is critical that your plan is poised for success by setting clear and achievable goals. This year presents the opportunity to innovate and refine your plan’s approach, particularly with new interventions targeting both identified priorities and newly introduced measures. As we navigate the ever-evolving Stars landscape, it is key to maintain alignment across all areas of the organization to effectively adapt to industry changes and emerging trends. By fostering collaboration and strategic alignment, your plan can maximize its potential, achieve the goals set forward and make a meaningful impact on the health of your members.
Ensure your goals are set: Conduct goal setting activities to achieve your contract-level goals and establish priority measures that will have significant impact on your plans performance if the goals are achieved.
Develop new interventions for priority measures: Plans must look ahead and continue to be innovative with interventions, relying on what got you here will not get you to where you want. Develop key strategies around the priority measures to ensure continuous improvement is driven forward.
Alignment across the organization of industry changes for SY2026: Plans must understand how the industry is changing every year in Stars. With the weighting shifting away from member experience, success in HEDIS will be more necessary to drive a plan’s performance. Key changes for this SY are outlined below:
Addition of Kidney Health for Patients with Diabetes (1x weight)
Colorectal Cancer Screening removed from Hybrid Reporting – moved to Electronic Clinical Data Systems (ECDS)
Introduction of Health Equity Index – monitoring applicable HEDIS measures for Social Risk Factors
At ProspHire, we continue to partner with health plans, to offer insights, analysis and execution strategies to improve Star ratings. Do you need support developing the right SY2026 execution strategy? Let’s have a conversation.
The Affordable Care Act (ACA) revolutionized healthcare in the United States by prohibiting insurers from denying coverage or charging higher premiums based on pre-existing conditions, leading to an increase in health insurance coverage amongst United States residents. A key process that was introduced with the creation of State ACA Marketplaces was the implementation of a Risk Adjustment transfer payment model. Each year, Department of Health and Human Services (HHS) completes a risk adjustment calculation which redistributes a percentage of premium revenue from ACA insurers with lower risk scores to ACA insurers with higher risk scores within their respective state markets. Failure to capture an accurate and complete risk score exposes an ACA insurer to the risk of understating the health risk of the population. Understating member health risk will lead to redistributing premium revenue needed for member care, causing an operational budget shortfall. A large value fund transfer may indicate a Health Information Oversight System (HIOS) contract was unable to capture an accurate and complete risk score for its population and signal financial headwinds entering the next benefit year.
ACA enrollment continues to grow as seen by the surge in 2024 numbers increasing to 21.3 million people, up from 16.4 million people in 2023 (Jared Ortaliza, 2024). The recent increase in enrollment signals a potential increase in ACA Marketplace insurers. Insurer participation in the ACA Marketplace has been variable since the start in 2014. (McDermott & Cox, 2020) The highest level of participation was in 2015, at an average of 6 insurers per state (ranging from 1 insurer in West Virginia and New Hampshire to 16 insurers in New York). Insurer participation declined after 2015 to 4.3 insurers per state in 2018 with the change being attributed to insurance company losses. The process of launching a product is complex from the initial application and benefit design through to operations. Insurers entering the market may face financial headwinds within the first few years unless the appropriate strategies and operations are deployed. Risk adjustment might contribute to financial headwinds if not appropriately planned and executed during the preparation and operations of the first year.
ACA Marketplace participation has been increasing since 2018, reaching 5 insurers per state in 2021. As the market approaches the high-water mark set in 2015, one might wonder if a market contraction is coming. ProspHire was interested to understand if risk adjustment outcomes are a contributor to new HIOS contract financial performance. ProspHire conducted a simple analysis by comparing the HHS Summary Report on Permanent Risk Adjustment Transfers for the 2022 and 2021 benefit years to answer two questions:
Was there an increase in new HIOS contracts and new insurers from 2021 to 2022?
How did the new HIOS contracts and new insurers fare in their first year of operations?
In 2022, there were 346 non-catastrophic individual ACA Market HIOS contracts compared to 294 in 2021, indicating a net growth of 17% (346/294). Of the 346 plans, 39 were new HIOS contracts in 2022 of which 11 were HIOS contracts given to new insurers (Table 1). New HIOS contracts were more likely to have a risk adjustment transfer payment to the state. Of new HIOS contracts, 82% (9/11) of new insurers and 89% (25/28) of existing insurers completed transfer payments to the stat compared to the national market rate of 57% (197/346).
Table 1: Frequency of Transfer Payments to the State in 2022 by New versus Existing Status
This simple analysis indicates new HIOS contracts entering the ACA Marketplace are more vulnerable than the existing HIOS contracts to completing transfer payments back to the state at the end of the year for risk adjustment. Past history as an ACA insurer does not seem sufficient to avoid a yearend transfer payment to the state. This analysis indicated that new and existing insurers with new HIOS contracts had similar likelihood for risk adjustment transfer payments. Insurers preparing to enter the ACA Marketplace with a new HIOS contract should consider two items. First, the revenue return is a cash transfer from the ACA insurer to the state and it cannot be avoided, even if the ACA insurer elects not to participate in the subsequent year. Second, many operational pieces must be implemented in quick succession to improve the opportunities to capture an accurate and complete risk score in the first year of operations:
Prospective programs to increase provider and member engagement in completion of comprehensive examinations.
Encounter submission platform implementation and calibration with a corresponding error correction management workflow.
Retrospective program chart retrieval targeting, chart retrieval vendor selection and implementation, and a highly accurate chart review vendor.
Risk Adjustment Diagnosis Validation (HHS-RADV) vendor selection and management process.
Whether an Insurer is already established in the ACA Marketplace, or looking to join for the first time, a thoughtful risk adjustment strategy is just one piece of the puzzle to ensure success. ProspHire is uniquely positioned to support your organization through the QHP application process, operational readiness, vendor implementation and strategy advisory. Connect with us to learn more.
The standardization and alignment of administrative and clinical processes to current state best practices and technological advances is a core but often overlooked part of dental practice management. Your practice management standards of practice involve the processes, resources and management strategies involved in driving your daily workflows and patient care. This includes everything from patient and insurance data management to your financial reporting and resource allocation. The management of a dental practice may look different for a privately owned practice or practice group versus a dental service organization. Ultimately, no matter the type of operational model of your organization, it helps you run efficiently, stay compliant and maintain above average patient satisfaction on a consistent basis.
Every dental practice needs careful organization to run smoothly. You can deliver the dental experience your patients and team deserve with a streamlined approach to dental practice management — starting by updating your standards of practice playbook. This document covers compliance, employee training, dental procedures, reporting recommendations and more. Refreshing it will help you deliver a higher quality of care while making everything at your practice as straightforward as possible.
Your Dental Practice’s Standards of Practice Playbook
A practice’s SOP playbook is your guiding document. It sets up everything in your practice — how to handle treatment plans, patient intake and more. A SOP sets a high bar for care at your operation and keeps a consistent quality standard. While your SOP is essential for streamlining care and maximizing efficiency, it can become outdated. Neglecting to keep up with your SOP playbook can leave you with outdated, inefficient standards that decrease your service quality.
How to Upgrade Your SOP Playbook
Your SOP may be responsible for a dip in customer satisfaction or practice efficiency. Taking time to revamp your playbook is an excellent way to cut inefficiencies and improve your practice. Use these steps to bring your playbook into the present, ensuring your staff and customers get top-notch oral care.
1. Review Your Current Document
First, look at your current document. Carefully review every section, looking for improvement areas, inconsistencies, unclear procedures or outdated information. You can ask one or two employees to help you with this task. Your team members are an invaluable resource — they work with the playbook every day and may give you a fresh perspective you haven’t considered.
Reassessing your existing document gives you a better idea of what needs work, simplifying the rest of the process.
2. Define Your Objectives
Next, it’s time to define your objectives. What specific goals do you want to achieve with this update? What experience do you want to deliver? Whether you’re looking to enhance patient safety, streamline administrative processes or ensure compliance with the latest privacy and industry standards, realistically achievable goals will help you pinpoint where to look for assistance and let you anticipate whether the ultimate outcome meets your needs. Plus, you’re less likely to forget something critical if you set goals upfront.
3.Gather Input
Since your staff deals with patients and procedures daily, talking to them is critical. Encourage open communication from your team during and after updating your document. Their experience-based feedback can make your playbook as valuable as possible. Additionally, reach out to customers or read their reviews. You might find a common complaint you can resolve with simple tweaks and improvements. A playbook that accurately reflects your team and customer experience will be more practical for daily use.
4. Research Applicable Regulations and Guidelines
Make sure your playbook is up to date on the latest changes in safety protocols, dental practices and other compliance requirements. You want your playbook to be as accurate as possible — failing to stay current with legal requirements can put you at risk for compliance-related issues and mean your dental care may be out-of-date with current clinical guidelines.
5. Simplify Language and Structure
Your playbook should be unambiguous and easy to read for maximum usefulness. Use simple language throughout to prevent misunderstandings. Additionally, consider visual aids, illustrations and flowcharts for improved accessibility. These tools make your playbook more reader-friendly, usable and memorable.
6. Include Comprehensive Information
A thorough SOP playbook covers everything your practice might need to deal with. Include employee training, dental procedures, privacy requirements, ethics standards, infection control protocols and more. Everything your dental practice offers and promises should be up to date and accurate. A playbook that mentions every detail is more relevant for your team.
7. Customize Your Practice
Someone else’s playbook can be a good reference point, but no practice is identical to yours. Read your document to ensure it covers your team’s specific specialties, needs and workflows. Remember, a more effective playbook equals a more effective dental service.
8. Get Feedback
Once you’ve completed the new playbook, ask for more team feedback. Encourage employees to take notes on the update and how well it works with their day-to-day needs. Did you mention something that’s impractical in real life? What processes are more efficient thanks to the update? Emphasizing collaboration lets you use your team’s strengths to create the best possible document.
9. Regularly Update and Review
Your playbook should be a living, evolving document — never set in stone. Letting it stagnate allows it to become outdated and inaccurate. You should establish a review schedule to help you address any emerging issues, add new industry best practices and adapt to technological advancements. A dynamic playbook reflects your commitment to quality in customer service and dental practice.
10. Use a Management Partner
While good dental practice management starts with your playbook, investing in a partnership can take your practice to the next level. Working with a dental practice management service lets you streamline your operations through automation, reducing errors and improving efficiency. It also enables employees to leave feedback on training sections and allows you to standardize your operation further. When paired with your playbook, a partnership delivers a better experience for your employees and customers.
Why ProspHire?
Choose ProspHire for industry-leading innovation that optimizes your dental practice management. We understand and meet healthcare consulting’s evolving needs. Our team’s dedication to service has earned us spots on the Inc. 5000 and Pittsburgh Business Times‘ Fastest-Growing Companies list.
We specialize in addressing the challenges dental service organizations and dental providers face. ProspHire offers cutting-edge solutions for PMS implementation, SOP playbook transformation, workflow redesign and more. Contact us online to learn more about how we can help you.
Long Term Services and Supports (LTSS) include a variety of care activities focused in medical and personal care including activities of daily living (ADL) and instrumental activities of daily living (IADL). Managed Long Term Services and Supports (MLTSS) is the delivery of LTSS through capitated Medicaid Managed Care programs.
Under the responsibility of Managed Care Organizations (MCO), MLTSS moves away from the Medicaid fee-for-service model that continues to exist today. States may leverage one or both systems to deliver LTSS to beneficiaries. Over time, states have been increasingly adopting the MLTSS model alongside the increase of home- and community-based services (HCBS). LTSS has continuously shifted toward HCBS, with the support of legislature, allowing health services to be delivered outside of the institutional care setting and reducing costs of care. Through MLTSS, states are able to encourage an increase in HCBS and predict budget while incentivizing MCOs for improved care coordination.
As states continuously initiate, enhance and expand their MLTSS programs to accommodate the evolving care model and permissions, MCOs will be challenged to think strategically and innovatively to offer tailored person-centered services plans that accommodate the home-and community-based care model.
Why is MLTSS Important?
The growth of the aging population in the U.S. is unseen in U.S. history. Projections estimate a 26% increase in the number of Americans ages 65 and older over the next 20 years, equaling approximately 17 million people1. As our population ages, and lives longer through medical and technical advances, there is an increasing need to improve the LTSS care model with a focus on HCBS. Through HCBS, beneficiaries can continue life at home and in the community while receiving necessary care without the need for an increase in institutional care facilities. MLTSS creates an environment for specialized care coordination and services to meet the needs of our growing elderly population.
Managed Care Organizations are being tasked by states to operate long term services and support under a capitated payment model, leading plans to think strategically to position themselves for optimal margins and performance.
Contact ProspHire Today
As a consultancy 100% focused on healthcare, ProspHire is equipped to support MCOs navigate the MLTSS model through gap analysis, plan design, operational readiness, program optimization and innovation. Our industry experience and commitment to serving the community provides a unique perspective and patient-centered approach. Whether your plan is looking to enter the MLTSS market, improve performance or execute a large-scale strategic initiative, our team is equipped and committed to work in partnership with our clients and drive results.
In the world of healthcare, so many things are interconnected – between technology systems, platforms and other business operational functions. If errors, shutdowns or broad sweeping external factors disrupt operations, the impacts can be far reaching and significant to members and providers.
What are some of the ways that systems, technology and platform disruption can have on the healthcare ecosystem?
Health Insurers:
Operational Disruptions: Delays in claims processing and increased manual workloads can lead to operational inefficiencies and higher administrative costs.
Financial Impact: Increased claims processing times and potential for fraud during disruption could lead to financial losses.
Regulatory Compliance Risks: Difficulty in meeting regulatory reporting requirements and compliance deadlines could result in penalties and reputational damage.
Member Satisfaction: Delays in claims processing and potential confusion about coverage could lead to decreased member satisfaction and trust.
Health Plan Beneficiaries:
Access to Care: Delays in prior authorization and claims processing may temporarily limit access to necessary medical services or medications.
Financial Burden: Beneficiaries might face higher out-of-pocket costs or delays in reimbursement for healthcare services.
Confusion and Anxiety: Lack of clear information and potential disruptions in service could lead to confusion and anxiety among patients regarding their care continuity and coverage.
Providers:
Revenue Cycle Management: Delays in claims submissions and reimbursements can strain financial liquidity and impact the overall financial health of healthcare providers.
Administrative Burden: Increased administrative work to manage manual claims processing and communications with health insurers can divert resources from patient care.
Patient Care Impact: Potential delays in receiving payments may affect the ability of providers to offer timely and comprehensive care, especially for smaller practices with limited financial reserves.
Pharmacies:
Prescription Processing Delays: Disruptions in electronic prescription services and insurance verification processes can lead to delays in dispensing medications to patients.
Financial Impact: Cash flow issues may arise from delays in reimbursement from insurers, affecting the operational stability of pharmacies.
Customer Service Challenges: Pharmacies may face increased pressure from customers experiencing delays or issues with medication access, impacting customer satisfaction and loyalty.
Downstream Entities (e.g., labs, medical device companies):
Operational Disruptions: Entities reliant on timely data exchange and payment processes may experience operational delays and inefficiencies.
Supply Chain Impact: Disruptions in payment and ordering processes could affect the supply chain, leading to delays in delivering medical supplies and devices.
Financial Strain: Delays in payments for services or products could impact on the financial stability of these entities, particularly those with tight operating margins.
If your plan is ever impacted by these types of disruptions, ProspHire is equipped to support you. Our deep expertise in strategy, operations and technology within the healthcare sector positions us perfectly to assist health plans in navigating the complexities. Here are several ways we could provide valuable assistance:
Strategic Response and Recovery Planning
Rapid Impact Analysis:
Our team of payor experts and delivery consultants can quickly produce an impact analysis with plans for developing or executing your existing downtime procedures. We’ll aim to establish governance and track business needs until normal operations proceed.
Identify services of most impact (Prior Authorizations, Claims, etc.)
Rapidly develop, review and execute business continuity procedures.
Establish governance processes and tracking to minimize operational impacts.
Establish transition procedures to return to normal operations.
Incident Response Strategy:
Help develop or refine an incident response plan tailored to cyberattack scenarios, ensuring quick and effective action to minimize damage. Enhanced with agile capabilities and processes to continually prioritize pain points.
Business Continuity Planning:
Assist in creating or updating business continuity plans that specifically address cyber threats, ensuring that critical operations can continue with minimal disruption.
Compliance and Risk Management: Guide health plans through the complex landscape of healthcare regulations (such as HIPAA) related to cybersecurity, helping them to meet compliance requirements and manage risks effectively.
Technology Implementation Support: Advise on the selection and implementation of advanced cybersecurity technologies and practices, including encryption, multi-factor authentication and network segmentation.
Process Optimization: Review and optimize operational processes to enhance efficiency and resilience, ensuring that manual processes are in place to maintain operations during digital system outage and robust planning to ensure a swift return to operational effectiveness.
Communication Planning: Help develop communication plans that clearly outline how to communicate with internal and external stakeholders during and after a cyberattack.
If you or your health plan leadership needs support to navigate technological or system disruption, connect with us today.
Welcome to Season 2 of ProspHire’s Soaring to New Health podcast. In this episode, Star Quality Healthcare, we dive deep into the world of healthcare analytics and quality improvement with our special guests, Ally Thomas, PhD., AVP of Quality Improvement at UPMC Health Plan and Rebecca Yarish, ProspHire Rising Medicare Stars performance expert.
A Journey of Innovation and Insight
Ally Thomas shares her journey, transitioning from academia to the dynamic world of healthcare analytics at UPMC Health Plan. Drawing from her background in research psychology, Ally found her passion in applying analytical skills to solve real-world business challenges, particularly in the realm of Medicare Stars. She emphasizes the crucial role of analytics in monitoring performance, strategic planning and driving impactful decision-making.
The Power of Analytics in Healthcare
Analytics isn’t just about crunching numbers; it’s about strategically leveraging data to improve outcomes. Ally discusses the foundational pillars of analytics at UPMC Health Plan, emphasizing the importance of scenario-based planning and continuous monitoring. By harnessing data-driven insights, UPMC Health Plan can proactively adapt to changes in the healthcare landscape and ensure quality care for its members.
Navigating Change and Prioritizing Innovation
With healthcare regulations constantly evolving, Rebecca Yarish highlights the importance of staying ahead of the curve. She emphasizes the need for continuous gap closure and forward-thinking strategies, especially in anticipation of upcoming changes like the Health Equity Index and the transition to digital quality measurement. By embracing innovation and focusing on member preferences, healthcare organizations can better serve their communities and drive meaningful improvements in care delivery.
Building Strong Partnerships for Quality Care
At the heart of quality healthcare are strong partnerships between health plans, providers and members. Ally and Rebecca emphasize the importance of collaboration and communication, whether it’s working closely with healthcare concierge teams or supporting smaller provider practices. By building meaningful relationships and understanding the unique needs of each stakeholder, UPMC Health Plan is able to deliver personalized, high-quality care to its members.
As we navigate the complexities of the healthcare landscape, one thing remains clear: innovation and collaboration are key to unlocking quality healthcare for all. By harnessing the power on analytics, embracing change and prioritizing member preferences, organizations like UPMC Health Plan are paving the way for a brighter, healthier future.
Thank you for tuning into this episode of ProspHire’s Soaring the New Health podcast. Stay tuned for more insights and inspiration as we continue to explore the ever-evolving world of healthcare. For the more in-depth discussion on Stars Performance Improvement download the Soaring to New Healthpodcast, Star Quality Healthcare, where you find your podcasts.
Welcome to our Q&A session with Dan Crogan, a Principal and the Senior Vice President of Consulting at ProspHire. The Firm takes a distinctive approach to healthcare organization transformations, centered on expert delivery and execution. We view our teams as extensions of our clients, measuring success not just by project completion but by seamless integration of change into daily business activities. With a commitment to understanding the client’s vision and tailoring innovative ideas to accelerate plans, ProspHire collaborates closely with clients, recognizing the unique nuances within each organization. We’ll explore how ProspHire’s healthcare exclusive focus, collaborative approach and emphasis on how driving adoption sets us apart in the healthcare consulting industry. You’ll also learn about methodologies, success stories and the role technology plays in achieving impactful healthcare transformations.
ProspHire emphasizes expert delivery and execution in healthcare organization transformations. Can you share examples of how this commitment has led to successful outcomes for your clients and what strategies your team uses to ensure excellence in delivery and execution throughout the project lifecycle?
Our dedication to expert delivery and execution has consistently driven successful outcomes for our clients. We understand that the healthcare industry is complex and every health plan has unique member needs and unique challenges. Our team leverages our client’s expertise because no one knows their members and challenges better than them. We approach each engagement as if we are an extension of their team and utilizes our experiences to customized solutions, continuous improvement and transparent communication. Together they help us deliver exceptional results for our clients and drive positive transformation and sustainable growth in the industry.
Approach and Philosophy: Can you elaborate on ProspHire’s approach to viewing the internal teams as an extension of clients that are healthcare organizations? How does this approach contribute to successful transformations?
We look at each healthcare organization as if we are an extension of their team. The way we measure success isn’t just when the project is completed or goes live, it’s when the change is adopted as a business-as-usual activity. By doing this, we’re able to work with the leader to understand their vision and why it’s important to the company. With their vision and our experience, we can bring innovative ideas to accelerate their plans and develop the roadmap with the client’s delivery teams on how the project can be completed. An important thing for us to remember is, even though we may have successfully completed the same project 100x elsewhere, how it gets done within each client’s walls can be drastically different and we need to adapt to those differences.
Differentiation in the Industry: ProspHire prides itself on being 100% healthcare focused. How does this exclusive focus differentiate you from other consulting firms in the industry?
ProspHire distinguishes itself in the consulting industry through an unwavering dedication to healthcare. It’s a commitment that sets us apart from many of our competitors. We approach our engagements as being an extension of the clients’ teams, building a deep understanding of their needs and objectives. We take pride in our unique capability to enhance our clients’ strategies, executing projects with precision and efficiency. Our measure of success goes beyond project completion; it is defined by the seamless adoption and transition of projects to the client, ensuring they can independently operate without external assistance. This approach emphasizes long-term effectiveness over short-term milestones, reinforcing ProspHire’s reputation for delivering value to our clients.
Success Stories: Can you share a recent success story where ProspHire partnered with a healthcare client to achieve significant transformational outcomes? What were the key factors that contributed to that success?
We’ve been dedicated to delivering transformative outcomes in healthcare for nearly a decade and every project has its own unique significance. Whether it’s a small, two-person engagement lasting just a few weeks to swiftly address a client’s immediate needs or a complex project like launching a new ACA product or helping a client in achieving a coveted 4-star rating for Quality Bonus Payment (QBP) or helping a dental client integrate other DSOs as part of acquiring new practices, we approach each with the same level of commitment and pride. What sets us apart is our understanding that every client has choices when it comes to selecting consulting firms and we are honored when we earn their trust to partner together on any engagement. It’s the combination of dedication, adaptability and trustworthiness that consistently contributes to our clients’ success and sets us apart in the industry.
Methodologies and Frameworks: ProspHire adapts methodologies to the client’s environment. Can you provide examples of the diverse methodologies and frameworks your teams leverage to ensure effective delivery and execution?
We pride ourselves on our ability to tailor methodologies to suit each client’s unique environment and references for project execution. One of the key approaches we take is to leverage the delivery model that best aligns with the specific needs of the client and the type of engagement. Our diverse team is equipped with a range of certifications including PMPs, CSM and can provide expertise in agile methodologies, waterfall, scrum, ITIL, among others. Additionally, we have certified nurses on staff, further enhancing our capacity to understand and address healthcare-specific challenges. Over the past five years, we have extended the certifications to our clients through our ProspHire University.
Keeping Up with Trends: How does ProspHire stay up to date with the latest trends and regulations to provide clients with the most relevant and impactful solutions?
Staying on top of the latest trends and regulations in healthcare is fundamental to our mission of helping our clients provide better access to quality healthcare. First and foremost, we prioritize listening to our clients, striving to understand their pain points and how we can alleviate them, enabling to focus on future planning. Secondly, our exclusive focus on healthcare allows us to closely monitor changes from entities like CMS and government agencies, translating them into actionable insights for our clients. Additionally, we actively participate in conferences and maintain a robust network of partners, creating an environment to discuss public insights and their implications. Lastly, our commitment to innovation ensures that we continuously evolve to meet our clients’ changing needs. With a dedicated innovation team, we transform ideas into tangible solutions, addressing both current challenges and anticipating future requirements. This multi-faceted approach ensures that ProspHire remains at the forefront of industry trends, equipping our clients with the tools and strategies they need to succeed.
Technology and Transformation: Given ProspHire’s technology-agnostic approach, how does technology play a role in healthcare transformation projects and how do you ensure its seamless integration for project success?
Our world is enabled by technology one way or another. At ProspHire, our approach is to be technology agnostic and apply proven methods of delivery and implementation to any engagement we earn. We aim to be fluid with the market and products so we can provide a neutral opinion to our clients based on what they need vs. products we’re tied to. Not every client needs the exact same solution, even if the problem is similar. There are enterprise-wide factors that need to be accounted for before making these decisions and spending a lot of time and money implementing the change.
Collaboration Strategies: Collaboration is crucial in solving complex challenges. How does ProspHire develop strong collaboration between its consultants and the client’s internal teams to ensure seamless execution?
Building strong collaboration between our consultants and our clients’ internal teams is paramount to driving seamless execution in tackling complex challenges. We approach every client engagement as an extension of their team, rather than as an external group. We recognize that no one understands our clients, their team dynamics and their challenges better than they do themselves. Therefore, our focus remains on integrating seamlessly into their operations, rather than drawing attention to any perceived differences. The ultimate testament to our collaborative approach is when our clients tell us that they can’t distinguish our consultants from their own full-time employees. This feedback reaffirms our commitment to working hand-in-hand with our clients, leveraging our expertise to support their goals while maintaining a unified and cohesive team dynamic.
Change Management: Large-scale healthcare transformation projects often require changes at various levels of an organization. How does ProspHire manage change management strategies to ensure smooth transitions and adoption of new processes?
Managing change in large-scale healthcare transformation projects begins with a strategic approach embedded withing our contracts. While contractual obligations provide a framework for change management, our motivation extends beyond mere legal requirements. We prioritize clarity in our contracts to underscore our ultimate objective: to alleviate our clients’ pain points, effect transformation and facilitate the smooth transition of responsibilities back to their teams. Our emphasis is not on prolonging our involvement but rather on empowering our clients to operate their programs independently. This approach reflects our commitment to responsible and efficient project execution, ensuring that that our clients can quickly adapt to new processes while positioning us as trusted partners for future initiatives.
Leadership and Differentiation: As a principal and the Senior VP of Consulting, what key qualities and expertise you believe your team brings to the table that truly differentiates ProspHire in the healthcare consulting arena?
I firmly believe that our team’s key qualities and expertise set us apart in the healthcare consulting arena. One of our core strengths lies in our unwavering commitment to a shared end goal. This may seem straightforward, but as our firm expands, the importance of over communication becomes paramount in ensuring alignment among our leadership and staff. Our overarching objective is clear: to serve our clients’ needs without exception. This means sometimes referring them to another resource or competitor if we can’t address their problem responsibly and promptly. We refuse to allow our clients to remain in pain or wait for solutions that may not materialize. This dedication to client-centric service underscores our leadership approach and distinguishes ProspHire as a trusted partner in healthcare consulting.
