Welcome to Season 1, Episode 2 of the Soaring to New Health Podcast.
This episode is Ask the Next Generation Pharmacist. We talk with ProspHire’s Mark Thomas, an experienced pharmacist and consultant in the healthcare industry and Chris Antypas, a seasoned pharmacist, executive owner and innovator, about the pharmacist’s rapidly change role, the new ways to deliver patient care and the evolvement of medication management.
Today, pharmacy is at the forefront of many conversations. Drug costs are rising at an unprecedented rate. Employers and employer sponsored plans are trying to navigate and tackle pharmacy costs; and health plans are trying to zero in on how to contain costs while also ensuring access to innovative therapies.
On the innovation side, drug manufacturers continue to bring novel and rare disease therapies to the market. This, while the payer side is addressing rising drug costs and trying to navigate how to continue to afford to pay for medications and ensure access. Plus, billionaire business owner Mark Cuban is on a mission to “disrupt” the pharmaceutical Industry and sell low-cost prescription drugs directly to Americans.
Antypas says, “We spend a lot of time talking about healthcare costs and unfortunately what I’m seeing is there’s really not been enough attention put on the role that medications play in managing total cost of care”. His personal journey in trying to disrupt healthcare and improve healthcare is focused on the relationship with his patients – knowing who they are, understanding their personal situation and providing them with meaningful solutions to access or afford a medication. You’ll find that relationship-based care blended with a custom pharmacy experience at Antypas’s Asti Pharmacy in Pittsburgh’s South Hills area. Adherence packaging is an example of this care model, where the patient receives a customized blister pack containing all their daily medications.
In the digital heath and technology space, Antypas’s Perigon Pharmacy, umbrellaed under Perigon Health 360, a 50-state licensed, dual accredited specialty pharmacy that is creating tools for patients to help them take their medications more accurately and effectively. One such device sits on a countertop in the patients’ home and intelligently dispenses medication. This intersection of healthcare and innovation optimizes the care team’s ability to track and monitor whether the patient appears to have missed a dosage and then sends reminder notifications via text message or phone call. It’s at that point the pharmacist can connect with the patient to determine the cause and a solution.
The opportunity for health plans is to view pharmacy as a strategy to address any healthcare gaps and help manage member health. Thomas talks about the opportunity for the next generation pharmacist to think differently and outside of the box when it comes to drug delivery models. Antypas says those new ideas and pathways to success are built from being brave and having the courage to advocate and make a difference in a patient’s life. To hear more about today’s pharmacy trends and what some pharmacists are doing to push the boundaries of the traditional pharmacy practice, download Soaring to New Health’s episode two, Ask the Next Generation Pharmacist here.
Welcome to Season 1, Episode 1 of the Soaring to New Health Podcast.
This episode is Don’t be a Pain in the ACA. ProspHire’s Affordable Care Act (ACA) experts, Caitlin Nicklow and Matt Dauffenbach, talk about what it is, why it’s important, the timeline for launching a plan, how to get started and the impact on health plans.
When we’re talking about ACA, we’re normally talking about the individual exchange. This is an insurance marketplace for those who don’t have employer sponsored health care and don’t qualify for Medicaid or Medicare. To obtain coverage, individuals log on to their state or federal exchange and you shop for health care. It’s as simple as that.
The ACA has benefitted both members and Health Plans. The biggest advantage for members is the essential health benefits that each plan must include. It’s a safeguard for members. When you shop for a plan, you know that each one has, at minimum, the same core benefits, including preventative care and emergency services. Health Plans benefit from launching ACA plans because it’s an opportunity to stay with a member through all the phases of their life. When health plans launch an ACA plan, it keeps that revenue stream within the organization. Those health plans also immediately benefited from the Medicaid Redetermination because those members could move from Medicaid to their ACA plan. If your health plan doesn’t have an ACA plan, there is still an opportunity to launch one because the Medicaid Regermination process is going to take a year to unwind. Open Enrollment for Plan Year 2024 will be key for members who shop around for plans and want to make a switch.
Health plans shouldn’t underestimate the time it takes to set up an ACA Plan. The timeline varies and it depends on whether you are a brand-new plan or a mature plan that has already obtained NCQA or URAC accreditation. That could mean the difference between 12 months and 18 to 24 months. At ProspHire, we tell our clients not to rush… plan out those processes, make sure you have the infrastructure to support the potential number of member growth.
Demographics and competition are important. You could have a plan that launches with 5,000 members and quickly grows to 50,000. Realistic short term and long-term goals are all a part of planning conversations. It’s important to understand what your strengths as a plan are, how strong your brand is and what differentiators will attract members.
Staying on top of ACA compliance and regulations can be a full-time job. At the foundation, the biggest requirement is Qualified Health Plan (QHP) certification. Any plan in the marketplace in any U.S. state must have this certification and you must renew it annually. The process looks at the bones of the operation of the plan, starting in May and wrapping up in September. In addition, every state will have their own specific requirements to operate in that state. Third is a must have – accreditation. That looks at the inside of the plan, the policies and procedures. Beware that NCQA or URAC is very time intensive and involves more than 100 requirements for the plan to be in compliance.
Prioritization is key when launching an ACA plan. During the assessment phase, we talk with you about competing projects and resources. We look for ways to align your priorities and leverage existing projects and resources in your organization to avoid duplication of efforts across multiple programs.
For more details on the challenges and solutions once the plan is established and enrollment period begins, download Soaring to New Health’s episode one, Don’t be a Pain in the ACA here.
As payers and providers continue to manage the impact of COVID-19 on their populations, social determinants of health (SDOH) remain a focus for improving population health. Addressing SDOH has become even more vital as the pandemic had a disproportionate effect on the most vulnerable populations who are also greatly impacted by SDOH-related issues. While it remains at the forefront of strategy across the healthcare industry, it is imperative that interventions targeting SDOH are measurable and evidence-based to draw insights into conclusive results. In doing so, organizations will be better equipped to implement successful SDOH initiatives driving improved health outcomes.
SDOH describe the conditions in which people are born, live, learn and play, among other things and impact a wide range of health, functioning and quality of life concerns.[1] The Centers for Disease Control has identified five key areas of focus including healthcare access and quality, economic stability, education access and quality, neighborhood and built environment, and social and community context.[2] There is consensus regarding the need for consideration of these factors when measuring health; however, success has been varied with decision makers often crafting solutions from afar and without local and member-level input or data to support their efforts. While traditional healthcare services remain vital to measuring health, it is only one piece in a complex web of factors that impact health costs and outcomes. Studies show that social determinants can have a greater impact than healthcare or lifestyle choices in influencing a person’s health with some showing that they can account for as much as 80% of health outcomes.[3] This includes food insecurity, job security, education, among others; however, efforts to address these issues have largely been unsuccessful. There are programs across the country targeting these various issues and it is important that they be measured for impact and success.
A common SDOH highlighting this issue is food security, defined as a household-level economic and social condition of limited or uncertain access to adequate food.[1] Food security can be temporary or long term and is influenced by various social factors including job security, disability and income, among others. When crafting interventions to target food security, it’s important to think broadly about the surrounding factors that influence it. Access to food is crucial, but so is consideration of the transportation needed to acquire that food (or lack thereof) and an intervention that targets food distribution without consideration of the related factors is doomed to fail. One organization working to address food security is Feeding America, which manages a nationwide network of food banks and other community-based agencies to feed more than 46 million people yearly.[2] The organization has developed a Framework to mitigate the implementation of unhelpful or unsuccessful interventions targeting food security[3]
Feeding America highlights the Supplemental Nutrition Assistance Program (SNAP) as an example of a ‘proven’ SDOH framework – one that has demonstrated consistent positive improvement to accessing healthy food through multiple studies. It has accomplished this through local networks of food banks, despite being a national program. This local approach allows for tailored outreach activities, utilizing community networks and unique language and cultural needs to deliver services that are useful for the communities needing it the most.[1]
Despite this, it is important to note that while the intervention itself may be evidence-based in its implementation, it is not immune to external factors that could limit its effectiveness. The framework also takes into account those conditions that could impact an intervention’s success such as the high cost of food. Considering the rising food prices in 2022, approximately 10% higher according to the USDA, this would have a direct impact on a program like SNAP’s success, as the benefits are not regularly adjusted to reflect variation in food costs or cost-of-living. Therefore, when evaluating an intervention on its effectiveness in addressing SDOH, it is imperative to remember that they don’t exist in isolation and are continuously impacted by our changing world.
There is a growing recognition that building strategies that incorporate SDOH are beneficial for both providers and payors. These initiatives provide opportunities to address population health needs in communities across the country, which can improve care for members while reducing costs, if done correctly. To accomplish this, it is essential that SDOH interventions be evidence-based and both collaborative and customized to local communities, enabling organizations to increase the effectiveness of their initiatives while improving care for the most vulnerable populations.
At ProspHire, we want to ensure your programs have the greatest impact on members and patients, while simultaneously addressing the disparities that exist across our communities. Our team’s extensive knowledge in this topic can help your organization optimize strategies and deliver effective programs that support the most vulnerable populations. We understand the challenges and solutions to drive change through social determinants with a focus on your unique member and patient needs. Reach out today for more information to partner in this important work.
Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Retrieved [May 18, 2023], from https://health.gov/healthypeople/objectives-and-data/social-determinants-health
https://www.rwjf.org/en/insights/our-research/2019/02/medicaid-s-role-in-addressing-social-determinants-of health
Social determinants of health (SDOH) are conditions in the environment that affect individuals’ wellbeing, quality of life and health outcomes. They are commonly grouped into domains that include economic stability, education access, healthcare access, living environment and social support. It is important to screen for these determinants in clinical settings because research shows that social determinants of health are linked to negative health outcomes. Standardizing screening tools and providing appropriate community-based resources to patients will help decrease negative health outcomes (Sokol, 2020).
The Institute of Medicine (IOM) recommends that screening tools include common domains such as educational attainment, financial status, social isolation and median income levels as social stability domains (National Academies of Sciences, Engineering, and Medicine, 2016). A review of the literature found that 70% of screening tools measure at least 8 out of the 15 recommended domains and that only 66% of the tools that were reviewed were commonly used in clinical practices (Meon et al., 2020). Although payers and providers recognize social determinants of health as a problem, organizations still struggle to implement and accurately report SDOH data. How can implementation be improved? What makes screening programs successful?
Source: Meon et al., (2020). A review of tools to screen for social determinants of health in the United States: A practice brief. Population health management, 23(6), 422-429.
Screening Tools and Barriers to Implementation
There are a wide range of screening tools being used in clinical settings to identify at-risk members. Common screening tools such as Health Leads and PRAPARE are used to assess and address patients’ social determinants of health.
Health Leads screens an individual for adverse social determinants across 13 social needs domains (Health Leads, 2019). The questionnaire is evidence-based and is used in clinical settings. PRAPARE is also a nationally standardized tool used to assess patients’ risks and experiences (PRAPARE, 2022). The standardization of both tools allows them to be easily used by practitioners and integrated into EHR platforms. Despite having standardized tools, without a standardized approach, providers struggle to accurately capture, report and provide appropriate community-based resources for their most vulnerable patients (Fitzhugh et al., 2021; Meon et al., 2020). Standardization is a challenge because tools screen across different domains and lack a common approach to measure duration of time that patients experience social determinants of health. Although these challenges exist, providers have found success by utilizing evidence-based screening tools and developing a community-based approach to provide patients with needed resources (Bleacher et al., 2019).
Health Plans Combatting Social Determinants of Health
University of Pennsylvania Medical Center (UPMC) implemented “Cultivating Health for Success”, a program that partners with community organizations to provide permanent housing to members (Sokol, 2020). The program saw a savings of $6,384 for each of their participating members. UPMC was able to identify their at-risk population and provide them with a permanent solution to better control their social environment and health outcomes. Since the initiation of this program, several other programs at UPMC have been implemented to combat social determinants of health.
The success of the initiatives at UPMC was driven by practitioners recognizing that social determinants of health are interconnected and the importance of screening and identifying at-risk members. By providing members with the necessary community-based resources, UPMC saw significant cost savings because members were better able to manage their health. UPMC also recognized that data collection is paramount to understanding the “full picture” of a member to drive change.
How ProspHire Can Help
The first step to addressing health disparities in your community and across patient or member populations is to understand the underlying drivers of health in your population. That understanding will allow you to execute targeted programming that positively impacts your patients and their health outcomes, driving cost savings related to these disparities. At ProspHire, we have the experience and skillset to help you take that first step. We can partner with your teams to help you implement strategies that drive health equity forward. Connect with us today to learn more.
Resources:
Bleacher, H., Lyon, C., Mims, L., Cebuhar, K., & Begum, A. (2019). The feasibility of screening for social determinants of health: seven lessons learned. Family Practice Management, 26(5), 13-19.
Health Leads Screening Toolkit. Health Leads. (2019). Retrieved April 20, 2022, from https://healthleadsusa.org/resources/the-health-leads-screening-toolkit/
Fitzhugh, C. D., Pearsall, M. S., Tully, K. P., & Stuebe, A. M. (2021). Social Determinants of Health in Maternity Care: A Quality Improvement Project for Food Insecurity Screening and Health Care Provider Referral. Health Equity, 5(1), 606-611.
Meon, M., Storr, C., German, D., Friedmann, E., & Johantgen, M. (2020). A review of tools to screen for social determinants of health in the United States: A practice brief. Population health management, 23(6), 422-429.
Sokol, E. (2020, January 29). How UPMC coordinates compounding social determinants of health. HealthPayerIntelligence. https://healthpayerintelligence.com/news/how-upmc-coordinates-compounding-social-determinants-of-health
PITTSBURGH, PA – ProspHire, a national healthcare consulting firm, is pleased to announce Co-founder and Principal, Chris Miladinovich, has been named the Firm’s first Chief Strategy Officer. In this new role, he is responsible for overseeing business development, client relationships, strategic partnerships and the Firm’s long-term strategic plan. Prior to this, Chris was ProspHire’s Chief Operating Officer in charge of the operational business units, including Finance, IT and Administrative Operations.
“I am ecstatic for the opportunity to take on this new role. ProspHire has an incredible culture that has led to tremendous growth all with an eye on improving the client experience,” said Chris Miladinovich. “My passion has and always will be to help our people and our clients succeed. Today our clients are searching for innovative solutions for their complex healthcare problems and we are focused on helping them improve their organizations in order to help their healthcare members.”
Chris brings over 20 years of experience leading large-scale, complex business transformation programs from a billion dollar, Big 4, consulting organization to an emerging business. His leadership has been focused on developing and delivering technology-driven business services and solutions in the healthcare industry and he has been responsible for managing over $20 million in annual revenue, providing outstanding client experiences and driving profitable growth.
“We are excited to have Chris take on this new role as he brings an invaluable blend of industry experience and execution,” said Lauren Miladinovich, ProspHire’s Co-founder, Managing Principal and Chief Executive Officer. “With his extensive knowledge, industry partnerships and strategic vision, Chris has stood by my side leading and growing ProspHire since 2015. We look forward to achieving that same level of success as he executes on ProspHire’s long-term strategy in the years ahead.”
Chris and Lauren have recently been named Entrepreneur of the Year® 2023 East Central Finalists.
Healthcare organizations today are under pressure to deliver quality care while managing costs. Benefits optimization in healthcare is one strategy that can help achieve these goals. By evaluating and optimizing product benefits, organizations can provide their members with favorable core and supplemental benefits based on market trends while also managing costs.
One of the key drivers of increased enrollment for healthcare organizations is the benefits optimization cycle. The application of benefits optimization in healthcare can lead to significant increases in enrollment, improvements in operational efficiency and financial improvements over time.
In this blog post, we’ll explore the concept of benefits optimization in healthcare, including its definition, examples of its applications and the timeline for its implementation. Understanding the benefits optimization cycle can help you make informed decisions about your product benefits.
What Is Benefits Optimization in Healthcare?
Benefits optimization refers to the process of maximizing the value of plan benefits an organization offers to their members. It aims to strike the balance between offering competitive benefits while keeping costs manageable.
Through data analysis, healthcare companies can identify areas where they can reduce costs while still providing valuable benefits by examining an organization’s enrollment and benefit utilization data. For example, an organization can identify trends based on what plans are receiving greater enrollment or which benefits are the most utilized by plan. Additionally, healthcare consulting firms can help organizations assess and optimize their product benefits to ensure they align with their short and long-term business goals.
Overall, benefits optimization in healthcare is all about finding the right balance between member need, member satisfaction, and cost control. By leveraging data analysis and expert guidance from healthcare consulting firms, organizations can ensure they’re providing competitive benefits while keeping costs manageable.
Examples of Benefits Optimization Applications
Benefits optimization is a vital aspect of healthcare management that can help organizations maximize the value of their product benefits while reducing costs. Here are a few examples of how healthcare providers can apply benefits optimization:
1. Cost Analysis and Benchmarking
Organizations can use cost analysis and benchmarking techniques to identify areas of high healthcare spending and compare their product benefits to industry standards. This helps them understand where their healthcare dollars are being spent and identify opportunities to reduce costs while still providing high-quality benefits to members.
2. Plan Design and Strategy
Benefits optimization also applies to plan design and strategy. By analyzing healthcare data and member utilization patterns, organizations can tailor their benefits programs to meet the specific needs of their enrollees. This can include offering more flexible benefits options, such as telemedicine or wellness programs, to encourage healthier lifestyles and reduce healthcare costs.
3. Vendor Management
Optimizing vendor management is another way to reduce healthcare costs while still providing high-quality benefits. By negotiating better contracts with vendors, organizations can save money on healthcare expenses and offer more comprehensive benefits to their members.
4. Compliance and Reporting
Compliance and reporting are critical components of benefits optimization in healthcare. Organizations must comply with state and federal regulations and report accurate data to regulatory agencies. Benefits optimization consultants can help organizations navigate these requirements and ensure they comply with all applicable regulations.
Overall, benefits optimization can provide significant benefits to healthcare organizations. By analyzing data, tailoring benefits programs to member needs and negotiating better vendor contracts, organizations can save money while still offering high-quality benefits to their members.
What is the Benefits Optimization Cycle?
The healthcare benefits optimization cycle is a systematic approach to improving healthcare benefits programs, encompassing various stages from assessment to measurement. By following this cycle, healthcare organizations can effectively analyze, strategize and optimize their benefits offerings.
Let’s explore each stage of the benefits optimization cycle and understand how it aligns with the Centers for Medicare and Medicaid Services (CMS) deadlines.
Assessment
The first step in the cycle is conducting a comprehensive assessment of current and emerging market benefits. This involves analyzing data on healthcare costs, member utilization patterns and satisfaction levels. Leveraging publically available data, one can quickly and efficiently have a strong grasp of the current marketplace. By understanding the existing program’s strengths and weaknesses, organizations can identify areas for improvement.
Strategic Planning
Based on the assessment, organizations develop a strategic plan to design new plan benefits or modify existing ones. This includes setting clear goals, defining strategies to achieve those goals and outlining the necessary steps for implementation.
Also, organizations might develop new products, expand their provider network or implement new healthcare technologies. Strategic planning also involves considering CMS deadlines, such as the Initial Enrollment Period, Annual Enrollment Period, Open Enrollment Period and Special Enrollment Period.
Implementation
In the implementation stage, healthcare organizations roll out their new or modified benefits programs to members. This step may include communicating with members to explain changes to their benefits packages, training healthcare providers on new processes or technologies or implementing new member engagement programs. Timely execution is crucial to meet CMS deadlines and ensure a seamless transition for members.
Measurement
The final stage of the benefits optimization cycle is measuring the outcomes and effectiveness of the implemented strategies. Organizations track key metrics such as cost savings, member satisfaction and healthcare utilization to assess the success of the optimized benefits program. This data-driven evaluation enables continuous improvement and helps organizations refine their strategies for future optimization cycles.
By following this cycle, healthcare organizations can optimize their benefits programs to increase enrollment, operational efficiency and financial performance.
The Benefits Optimization Cycle Timeline
The benefits optimization cycle timeline can vary depending on the healthcare organization and the specific benefits program the organization is optimizing. However, most benefits optimization cycles follow some general timelines:
Assessment: The assessment stage of the cycle typically takes place at the beginning of the year and typically takes one to two months to complete.
Strategic planning: The design stage typically follows the assessment stage and may take anywhere from two to four months to complete.
Implementation: The implementation stage typically takes place in the latter half of the year and generally takes one to three months to complete.
Measurement: The measurement stage typically takes place at the end of the year and can take one to two months to complete.
Here’s an example of the CMS application and bid submission timeline to understand how it aligns with the benefits optimization cycle:
November to February (Q4 to Q1): During this period, organizations submit a notice of intent to apply and complete the CMS application by mid-February.
March (Q1): The bid kickoff takes place, initiating the bidding process.
End of March (Q1): The first draft of benefits is completed, outlining the proposed benefits, coverage options, and associated costs.
April (Q2): Value-Based Insurance Design applications and the second draft of benefits are due.
Before May (Q2): The third draft of benefits is finalized.
May (Q2): The final proposed benefit review and assumptions finalization takes place.
June (Q2): The bid submission deadline arrives, and organizations submit their finalized bid packages to the CMS.
By aligning the benefits optimization cycle with the CMS application and bid submission timeline, healthcare organizations can ensure a comprehensive and compliant approach to optimizing their benefits programs in order to achieve strategic institutional goals.
Remember, the specific timeline may vary based on organizational needs, CMS requirements and other factors. However, following a structured timeline is key to achieving successful benefit optimizations in healthcare.
Maximize Your Healthcare Benefits With ProspHire
Benefits optimization in healthcare can help organizations maximize their benefits, reduce costs and increase member satisfaction. By following the benefits optimization cycle, organizations can continuously evaluate their product benefits, identify opportunities for improvement and implement changes to achieve their desired outcomes.
ProspHire offers expert benefits optimization services to help organizations navigate the complexities of healthcare benefits and achieve their goals. If you’re interested in learning more about how ProspHire can help your organization optimize its benefits, fill out our contact form today.
Value-based care (VBC) connects financial incentives to patient outcomes associated with care delivery. These include quality, equity and cost of care. Greater accountability is on display as systems, plans and providers are incentivized to improve patient outcomes while ensuring that quality care is provided. Reconciling a transition to value-based care within a fee-for-service environment has proved to be a challenging industry shift for key healthcare stakeholders, a reality that has become increasingly stark since the end of the COVID-19 Public Health Emergency (PHE). Providers must now accommodate to the changes in revenue streams, data collection and analyzation requirements and cost of care inherent to a transition to value-based healthcare systems. Accommodation begins by reassessing current operational strategies. The foundation of reassessment begins with the identification of high-cost drivers which enables a better understanding of target populations and develop targeted interventions and strategies around cost containment, member experience and quality outcomes. To be successful in VBC, effective care continuum partnerships are critical as members navigate through increasing healthcare touchpoints.
VBC Capabilities Assessment Components
The essentials of a capabilities assessment catered towards value-based care begin with the following components. A thorough understanding of these levers will enable organizations to understand current state capabilities to desired future state advancements.
Public Health Emergency and Behavioral Health
The Public Health Emergency (PHE) was passed to mitigate challenges related to care delivery, financing and acute staffing constraints associated with the global pandemic. The waivers and regulatory flexibilities alleviated healthcare system challenges and accelerated change in a positive manner. Three years later, components of the PHE come to an end with CMS implementing a streamlined approach to reestablish certain health and safety standards and other financial and program requirements related to coverage and screening, claims appeals, provider licensure and enrollment, patient and provider safety, COVID-19 testing protocols, data reporting and telehealth flexibilities. The pandemic further exacerbated the demand for behavioral health services highlighting many of the shortcomings associated with overall behavioral health care. There are significant gaps between behavioral healthcare needs and availability. As the industry continues to see a rise in individuals experiencing behavioral health problems, access to care remains limited, wait times continue to rise, network adequacy, and virtual health. With the PHE’s expiration on May 11, 2023, many questions and concerns arise associated with access, covered services and expenditure specifically as it relates to behavioral health. Organizations may need to make drastic changes as the regulatory enforcement returns to normal and ensure minimal disruption to their billing and operations.
Industry Statistics
Behavioral health will continue to evolve as Value-Based Care matures. It is critical to maintain a thorough understanding of industry shifts and trends to ensure your organization does not fall behind and become exposed to internal and external risks.
Trickle-Down Impact of Public Health Emergency on Behavioral Health
The expiration of the Public Health Emergency (PHE) caused industry leaders to reengage in long-term strategies. In particular, the PHE impacts Behavioral Health in the following manner:
Value-Based Care Outlook
Healthcare providers face a litany of uncertainty. Key stakeholders should remain proactive and understand the changing regulatory landscape on their current operations and develop system-wide strategies to mitigate operational, financial and compliance-related risks to minimize the potential negative downstream impacts on patient outcomes. People with behavioral health conditions are at greater risk of developing chronic diseases such as heart disease or diabetes and are connected to social determinants.
It is imperative stakeholders take a plan of action to align on strategies and make adaptations that will improve member outcomes.
Assessment of internal processes, technology, resources and operational capabilities to increase behavioral health screening, interventions, medication management and adequate referrals
Provider shortages, case management and care coordination strategies
Marketplace enrollment fluctuations
Optimization of current mental health product offerings, benefits, and cost-sharing strategies
Education, engagement, and services for family members
Reimbursement strategies and policy changes providers became accustomed to during the pandemic
Why ProspHire
As we have seen in the Health Care Payment Learning & Action Network (HCPLAN), the evolution of current payment models is on the rise from FFS without a link to quality and value to innovative APMs and population-based payments. ProspHire has the subject matter experts to help clients achieve value-based quality outcomes and savings by participating in various value-based arrangements. We have the right team to deliver a transformative solution that will yield positive results.
Wear BLUE for Men’s Health! Whether it’s your friend, brother, dad, boyfriend, spouse, or boss, show them you care about them and their health by wearing blue on Friday,June 18th. This day raises awareness of making healthy lifestyle choices, making regular annual visits to the doctor, and getting educated on prevalent health conditions that predominately affect men.
Why is Wear Blue Day important?
Wear Blue Day is an important opportunity to highlight the importance of men’s health and to promote and support the health and well-being of men and boys in our communities.
It was created by the Men’s Health Network, a non-profit organization focused on educating people on men’s health conditions, preventative measures, and healthy habits. The color represents the conditions that primarily affect men, such as testicular cancer, stroke, lung cancer, diabetes, cardiovascular disease, prostate cancer, and other illnesses that arise within the male population.
Show your support, by wearing blue, and displaying the #ShowUsYourBlue on social media platforms.
Over the last decade, there has been increasing research and awareness surrounding the impact of Social Determinants of Health (SDOH) on health. The Centers for Disease Control (CDC) reports that SDOH have a greater impact on health than genetics or access to healthcare services.1 Organizations from the international level to the local level are prioritizing interventions that advance health equity by producing policies and increasing funding for programs and interventions with an SDOH focus. The World Health Organization (WHO) defines SDOH as “non-medical factors that influence health outcomes”2 and the US Department of Health and Human Services (HHS) has grouped SDOH into 5 domains: Economic Stability, Education Access and Quality, Health Care Access and Quality, Neighborhood and Built Environment and Social and Community Context.3 The Centers for Medicare and Medicaid Services (CMS) is also showing their commitment to SDOH through their updates to the Medicaid and Medicare programs.
Medicare Advantage Plans’ Opportunity to Support SDOH
Prior to 2019, Medicare Advantage (MA) supplemental benefits had to be primarily health-related and offered on a uniform basis to all plan enrollees; but in 2019 CMS updated these guidelines to allow MA plans to cover benefits tailored to certain populations that address social needs or long-term care needs. MA plans can now offer benefits to enrollees who have a specific health status (Special Supplemental Benefits for the Chronically Ill or SSBCI) and offer benefits that directly address SDOH.4 Some of these benefits cover food insecurity, home safety, transportation and non-opioid pain management. Since these guidelines were updated, there has been a continued increase in organizations offering these benefits. According to research by ATI Advisory, in 2022 the number of plans offering SSBCI increased by almost 40%.5
Figure 1. Special Supplemental Benefits for the Chronically Ill (SSBCI) that were offered the most by Medicare Advantage Organizations in 2022
As shown in Figure 1, the most common SSBCI benefits offered in 2022 were categorized as food and produce, pest control, transportation for non-medical needs, meals, social needs benefit and general supports for living.5 Figure 2 reports the number of plans that offered these SSBCI supplemental benefits to their members in 2022.
Figure 2. Number of Medicare Advantage Plans Offering Select SSBCI Supplemental Benefits in 20226
Health plans serving the Medicare population are critical to driving health equity. In 2022, there were more than 28 million people enrolled in a MA plan and over half of these enrollees had at least one unmet SDOH need (AARP).7 By designing their supplementary benefits, these organizations prioritize what services are valued and have the opportunity to greatly impact members’ health outcomes and even their own Return on Investment (ROI). Offering benefits that impact SDOH can reduce the total cost of care, improve utilization, increase member satisfaction and result in higher member retention. In a study conducted by WellCare Health Plans and the University of South Florida College of Health, they found that people who were successfully connected to social services had a 10% reduction in healthcare costs.8
SDOH is innately complex and a study by NORC at the University of Chicago points out that there are further complexities in addressing SDOH. The study suggests that providers don’t have difficulties understanding what benefits each plan offers, who is eligible and what is necessary for their patients to sign-up.9 The article even suggests that providers feel they need to become experts in supplemental benefits to fully support their patients.9 Similarly, beneficiaries have limited awareness of what they have access to. Care Managers become increasingly important in identifying eligibility and enrolling in services. Therefore, organizations that choose to offer these supplementary benefits need to understand how to effectively manage them to fully see the benefits for their members and their ROI.
The Challenges to Implementing SDOH Supplemental Benefits
Like many of the governing agencies throughout the United States, SDOH is at the forefront of many payer organizations’ goals for the coming years. Even America’s Health Insurance Plan (AHIP) launched “Project Link” which aims to bring together payer organizations across the United States to build sustainable SDOH solutions.10 In 2019, their board said that SDOH is an “essential part of the industry’s long-term vision for improved health and financial security.”10 There has been an increase in supplemental benefit offerings impacting SDOH each year since 2019.11 Thoughtful and deliberate implementation of the benefits is critical to success for the payer organization, the provider and the members themselves. Benefit design and selecting which benefits to offer is often the first hurdle for payer organizations. The ability to understand the SDOH impacting the organization’s members allows the organization to use these benefits as a differentiator from competing plans – these benefits can entice members and increase enrollment. The benefits can also serve members in a way that improves their health outcomes and eventually decreases medical costs and increases the ROI.8 After the supplemental benefits are chosen, it’s also important to roll them out in a way that providers, care managers and members can understand. Availability, eligibility, the process to use the benefits and the potential benefit of the benefits need to be well-communicated.
How ProspHire Can Help
At ProspHire, we understand the importance of SDOH and strive to promote health equity. We also understand the complexities and barriers that healthcare organizations face when trying to do the same for their customers. Our team of practitioners have extensive healthcare industry knowledge and are ready to discuss your SDOH goals and how we can help you reach them. Connect with us today.
May is Mental Health Awareness Month – a reminder to all of us that checking in on your mental health is just as important as your physical health. Nationwide mental health trends reveal an increasing concern. The Substance Abuse and Mental Health Services Administration (SAMHSA) notes that one in five adults in the United States have a mental health or substance abuse disorder1. Nationwide trends in rates of mental illness reveal a rapid increase of instance over the past decade, as illustrated in Figure 1.
The American Medical Association defines behavioral health as encompassing the following conditions: mental health disorders, substance use disorders, life stressors and crises and stress-related physical symptoms2. For health plans and patients alike, often the first solution that comes to mind when addressing behavioral health issues is to focus on psychiatric interventions. Despite this assumption, mental and physical health are often intrinsically related and influenced by similar environmental factors. As a result, programs that utilize comprehensive Social Determinants of Health (SDOH) data to address behavioral health are often overlooked.
Behavioral Health and Social Determinants of Health
Social determinants, or drivers, are a useful indicator to identify factors which contribute to poor mental health in communities and individuals. Addressing health equity in all forms, including behavioral health, and SDOH factors are intrinsically related. Poor mental health can cause poor SDOH outcomes or vice versa. The National Library of Medicine3 notes that these outcomes are largely tied to food scarcity, inadequate housing, lower socioeconomic status and trauma among additional factors.
Expanding access to quality behavioral health services is a necessary component of efforts to address behavioral health and SDOH outcomes. The following indicators are associated with limited access to behavioral health services and present an opportunity for intervention:
Health Care, including insurance coverage and provider availability
Stable Housing – a significant contributor to mental stress
Education, especially from an early age
Income and Employment
Social Support
Clinical systems are still assessing ways to measure SDOH factors to inform behavioral health policies as there are still shortfalls in assessing these metrics4. Ideally, health plans, providers and communities can partner to address these issues.
Approaches to Target Behavioral Health through SDOH
Understanding and targeting the causal factors of mental health related to SDOH is critical in enabling mental health equity. The importance of various social determinants and their continuous evidence of impact on mental health is a call to action for improved whole-person care. Housing and food access highlight the whole-person impact of SDOH on health:
Stable Housing
Inadequate and unaffordable housing can result in poor mental health5. Increased access to affordable housing and adequate living conditions present examples of interventions focused on SDOH that would directly impact mental health. Poor living conditions such as mold, lack of heating and dampness can impact both mental and physical health. Overall, a lack of affordable housing within a community causes increased rates of homelessness which can lead to even greater mental health issues and physical health risks. An intervention to offer housing programs to those with mental health illness or housing vouchers to access affordable housing are examples of efforts to drive change.
Food Security and Healthy Diet
Access to food and a healthy diet are intrinsically tied to physical health and wellness; however, evidence suggests that unhealthy eating is also a contributor to poor mental health. Having a whole-person approach to care presents a potential intervention. Individuals with illnesses such as diabetes are more likely to have depression, highlighting the correlations between mental and physical health6. Increasing food security by delivering healthy food to farmers markets, community gardens, corner stores or through home delivery offers alternative opportunities for individuals struggling with poor nutrition due to lack of access.
Evidence of successful programs continues to arise as health plans, providers and communities’ partner to address social determinants of health. Pyx Health’s Loneliness Assessment is an example of a successful intervention.
Pyx Health Loneliness Assessment
Providers can also look to interventions which work in conjunction with health plans to address behavioral health and SDOH outcomes. Pyx Health, based in Arizona, is a healthcare company which works with Medicaid and Medicare plans to support individuals experiencing loneliness. Their process involves identifying vulnerable members through SDOH screening tools and offering vulnerable members 24/7 support7. Members use the app to express their needs and are subsequently connected with resources within their health plan and community. The approach improves behavioral health outcomes and reduces stress on clinical health resources. Given the limited amount of multi-dimensional approaches which specifically address behavioral health utilizing social determinants of health, this approach serves as inspiration for similar interventions.
How ProspHire Can Help
Through ProspHire’s Addressing Health Disparities service offering, we strive to support our neighbors and clients to achieve more equitable whole-person care. Through population health assessments, targeted Social Determinant of Health interventions and innovative solutions to support behavioral health needs, we hope to enable positive change for your customers and our communities.
