Author: LBodnarchuk

Trump’s Presidency 2.0: What Medicaid Rollbacks Mean for the Healthcare Landscape

Written by LBodnarchuk on . Posted in Insights, Medicaid.

Donald J. Trump’s return to the White House has already ushered in sweeping discussions about the future of healthcare policy in the United States. Among the administration’s top priorities is a renewed push to reform Medicaid, aiming to curb federal expenditures and reshape the program’s scope. With millions of Americans relying on Medicaid for essential healthcare, these proposed rollbacks carry profound implications for beneficiaries, providers, insurers and state governments.

As the Trump administration begins its second term, understanding the potential changes to Medicaid and preparing for their consequences is crucial for stakeholders across the healthcare system.

Medicaid Rollback Policy Changes

Areas of Focus for Medicaid Rollback Policy Changes

Medicaid Under the Trump Administration: A Second Chapter

Trump’s earlier presidency laid the groundwork for what could come next. Efforts to repeal the Affordable Care Act (ACA) and introduce work requirements showcased the administration’s focus on limiting Medicaid’s reach and increasing state-level control. Key initiatives included:

  1. Work Requirements: The Trump administration previously encouraged states to implement work or community engagement conditions for Medicaid eligibility. While these measures faced legal challenges and were ultimately overturned in many cases, the administration has signaled plans to reintroduce them.
  2. Block Grants and Per Capita Caps: The administration continues to support converting Medicaid funding into block grants, giving states fixed allocations instead of the open-ended federal matching system.
  3. Revisiting ACA Repeal: With Congress now more favorable to Trump’s policies, there is renewed momentum to dismantle ACA provisions, including Medicaid expansion.

These initiatives reflect a fundamental shift in Medicaid’s structure, moving from a broad federal safety net to a more state-driven and restricted program.

What Could Medicaid Rollbacks Look Like?

Under the current administration, we might see several key policy shifts:

  • Reduced Federal Contributions: Block grant or per capita cap proposals are likely to resurface, forcing states to shoulder more financial responsibility. This could lead to scaled-back services or reduced coverage for millions.
  • Increased Eligibility Barriers: Work requirements, stricter income verifications and time-limited benefits could exclude a significant portion of current Medicaid recipients.
  • Erosion of Medicaid Expansion: If ACA repeal efforts succeed, states that expanded Medicaid could see a significant reduction in funding, directly impacting low-income adults who gained coverage under the expansion.
  • Broader State Waiver Flexibility: Expanded use of Section 1115 waivers would allow states to experiment with benefit reductions or new eligibility rules, creating further disparities in Medicaid access across the country.
Challenges for providers after changes in Medicaid Rollbacks

Challenges for Providers

For providers, Medicaid rollbacks could destabilize financial sustainability and disrupt care delivery. Likely challenges include:

  • Rising Uncompensated Care: As more individuals lose Medicaid coverage, hospitals and clinics would see an increase in unpaid bills, straining resources.
  • Staffing Shortages: Reduced reimbursement rates could force providers to limit services or stop accepting Medicaid patients altogether, worsening provider shortages.
  • Impact on Rural Health: Rural hospitals, which rely heavily on Medicaid funding, could face heightened risk of closure, leaving rural communities with limited access to care.
  • Shift in Primary Care Utilization: Primary Care providers could see a decrease or inconsistencies in utilization as uninsured or underinsured individuals migrate toward emergency services and other means of care rather than preventative care due to financial restraints.

Insurer Impacts

Medicaid managed care organizations (MCOs) and insurers would also face significant challenges, including:

  • Smaller Risk Pools: With reduced enrollment, MCOs may experience decreased revenue and heightened risk exposure as healthier populations leave the system.
  • Operational Complexity: Administering programs under new eligibility rules and work requirements could increase administrative burdens and costs.
  • Market Volatility: Shrinking Medicaid markets might prompt insurers to scale back their participation, reducing options for states and beneficiaries.

State-Level Consequences

Medicaid rollbacks will place immense pressure on state governments, which share responsibility for funding and administering the program. Impacts could include:

  • Budgetary Strain: States may need to find new funding sources—potentially raising taxes or cutting other programs—to compensate for reduced federal support.
  • Policy Disparities: Increased reliance on state-level waivers could deepen regional inequities in Medicaid coverage and benefits.
  • Political Challenges: States with large Medicaid populations may face intense political backlash if significant cuts or changes are implemented.
Graphic outlining the ways ProspHire can help with Medicaid Rollbacks

How ProspHire Can Help Clients Navigate Medicaid Rollbacks

In this rapidly shifting environment, ProspHire is uniquely positioned to support clients in adapting to Medicaid reforms. As a healthcare consulting firm with extensive experience in Medicaid program delivery, ProspHire partners with health plans, providers and state agencies to mitigate risks, enhance efficiency and maintain compliance.

ProspHire’s tailored strategies focus on:

  • Operational Readiness: Helping clients streamline workflows and optimize processes to manage reduced funding while sustaining quality care.
  • Data-Driven Insights: Leveraging analytics to identify cost-saving opportunities, monitor compliance and support decision-making.
  • Member-Centric Solutions: Developing approaches to preserve access and improve outcomes for vulnerable populations.
  • Regulatory Expertise: Guiding clients through complex policy changes and ensuring readiness for evolving requirements.

With ProspHire’s dedicated expertise, healthcare organizations can adapt to these changes, enabling financial sustainability and member satisfaction despite unprecedented challenges.

The return of the Trump administration marks a critical juncture for Medicaid, as potential rollbacks threaten to reshape one of the nation’s most important safety-net programs. While these changes present significant risks, they also offer an opportunity for healthcare stakeholders to rethink strategies, prioritize efficiency and advocate for sustainable solutions.

Navigating this uncertain landscape requires proactive planning, collaboration and innovation. With the right partnerships and expertise, healthcare organizations can weather these reforms while maintaining their commitment to delivering high-quality care. ProspHire stands ready to lead clients through these challenges, ensuring resilience in the face of transformation.

Elevating Healthcare: A Deep Dive with Medicare Advantage Innovator Melissa Newton Smith

Written by LBodnarchuk on . Posted in Insights.

We had the pleasure of speaking with Melissa Newton Smith, a renowned expert in Medicare Advantage and Star Ratings, who recently announced a strategic alliance with ProspHire. Melissa brings three decades of experience in healthcare strategy, operations and quality improvement, with a particular focus on Medicare Advantage. Her expertise has been instrumental in driving innovation and excellence across the industry. In this interview, we’ll explore Melissa’s insights on the evolving landscape of healthcare, the impact of this new partnership and her vision for the future of Medicare Advantage.

Background and Expertise

Can you tell us about your background and how you became an expert in Medicare Advantage and Stars?

As a lifelong learner, it’s very humbling and a little awkward to be called an “expert.” It’s not a title I readily embrace because my goal has never been to become or be an expert, but rather to do meaningful work for my clients by staying curious, knowledgeable and focused on their goals and needs. Every day I dedicate time to exploring the latest regulatory updates, industry news, research publications and insights from others to keep pace with this constantly evolving field.

My journey into Medicare Advantage (MA) and Star Ratings was unplanned and unexpected. As a CPA, my background initially focused on managing federally funded grants and contracts. In 2008, when my children were young, I chose to scale back to a part-time role and a former KPMG colleague graciously created a position for me in a Part D plan. At the time, I knew nothing about Medicare Advantage, but I quickly leveraged my business acumen and innate curiosity to learn and eventually excel in the growing MA and Part D landscape. As CMS transitioned the Star Ratings program from the Demonstration stage, I saw an exciting opportunity to make an impact in a nascent field. I joined an MA-PD plan’s Star Ratings team, where I embraced the challenge of building impactful programs and delving into the complexities of health plan quality from the ground up. My passion for learning fuels me. I am an avid reader and genuinely enjoy dedicating the time required to quickly absorb, comprehend and, more importantly, apply the vast body of knowledge needed to succeed in this industry. I knew nothing about the terms, industry norms and technicalities when I began my Star Ratings journey in 2011. My learning journey was, and still is, vast and my expertise is the product of consistent and persistent learning alongside the relentless pursuit of success for my clients.

The Strategic Alliance

Congratulations on the alliance with ProspHire! What inspired the alliance and what excites you about working with ProspHire?

This alliance is a natural fit of my long-standing belief in the power of partnerships and the reality that organizations need more expertise and support than ever before. This is an exciting time in our industry, filled with rapid, sweeping and frankly existential changes for health plans, providers and vendors.

Our team has increasingly been asked to provide expanded, sustained personnel and support to manage implementations, augment staff capacity and drive routine operations for our clients. By combining our team’s insights and advice alongside ProspHire’s strong project delivery capabilities, we will be able to offer even greater value to our clients as they navigate significant changes in MA, Medicaid and the broader healthcare sector.

Our clients thrive on teamwork and collaboration and this alliance reflects the same spirit of working together for shared success. 

ProspHire has a strong reputation for delivering transformative project outcomes in healthcare. How does your expertise complement their approach and what unique value do you believe this collaboration will bring to the industry?

My expertise lies in optimizing performance using curiosity, creativity and personal experiences to design and implement innovative strategies for success. ProspHire’s reputation for delivering transformative project outcomes perfectly complements my work and approach. Together, we bring a powerful combination of strategic consulting and operational excellence, focused on driving measurable, sustainable improvements in healthcare quality. This collaboration will allow us to design and implement solutions to the industry’s most pressing challenges, from improving member experiences to transitioning to digital quality measurement which will ultimately raise the bar for healthcare outcomes across the board.

Healthcare Innovation and Operational Excellence

The healthcare industry is rapidly evolving, especially with the growing focus on quality and efficiency. How do you envision this partnership helping healthcare organizations navigate these changes and achieve their goals?

Healthcare organizations today are under immense pressure to balance quality with efficiency while navigating regulatory changes. Almost every organization needs some combination of strategic foresight and operational agility to help understand the changes and adapt quickly enough to achieve corporate objectives. Our focus on data-driven strategies, innovative care models and member-centric solutions will enable healthcare organizations to not only meet but exceed their quality and operational goals, ensuring long-term success.

In your opinion, what are the biggest challenges you’re seeing in the Medicare Advantage space and how do you plan to address these through your collaboration with ProspHire?

The nature and number of changes in Medicare Advantage has introduced a complicated web of interrelated changes required for organizations to both survive and thrive. We are seeing plans, providers and vendors struggle to fully understand these changes and design operational adaptations to cope with them as fast as will be necessary for success. We plan to help plans address these challenges by bringing technical expertise and skilled staff to customers to accelerate and enhance operational activities and adaptation.

The alliance between ProspHire and the Newton Smith Group is described as a significant step toward advancing healthcare innovation. What does healthcare innovation mean to you and what areas are you most focused on?

For me, healthcare innovation is about creating solutions that not only address immediate challenges but also anticipate future needs. It’s about making care more accessible, efficient and person-centered. In this alliance, I’m particularly focused on innovations that improve access to care and member experiences, such as integrating technology to achieve personalized engagement at scale in alignment with CMS and NCQA regulatory and quality requirements. We’re also increasingly helping plans, providers and vendors redesign and leverage new payment models to better align incentives across the care continuum, ensuring that both quality and value are rewarded.

Goals and Vision

Looking ahead, what are your long-term goals for this partnership and how do you see it evolving to meet the future needs of the healthcare industry?

Our long-term goal is to build a framework that allows health plans, providers and vendors to continuously adapt to the evolving healthcare landscape, particularly as Star Ratings, regulations and the healthcare environment in general become more complex. We want to ensure that organizations are not just reactive but proactive in their approach to care delivery and quality improvement. As the healthcare industry continues to evolve, I see this partnership expanding into new areas, such as personalized care models, digital quality measurement, advanced analytics to improve health outcomes and deeper integrations of member experience tools to drive outcomes at scale.

Are there any upcoming projects or initiatives with ProspHire that you are particularly excited about?

YES! Just as we support clients in designing and deploying innovations, we are designing some innovations of our own within our practices. We have exciting plans for 2025 and can’t wait to share them soon!

Industry Trends

What trends do you see emerging in the healthcare industry that will impact Star ratings?

We expect continued technological modernization, which is occurring alongside tighter margins and an unprecedented pace of regulatory changes to continue in the coming years. These interrelated, sometimes competing forces, will require significant examination by leaders and experts to ensure effective decisions are made with reasonable risks.

As Medicare plans prepare to navigate the regulatory changes ahead, what are the 3 areas Health Plans need to consider?

Health plans will need to strengthen the degree to which they focus on access to care, sustained health improvements and well-managed costs. Plans will need to prioritize access to care as the most critical aspect of member experience and health outcomes to drive continued Star Ratings success.

Second, they must invest in real-time data infrastructure to ensure that care gaps (not just HEDIS gaps) are closed quickly and efficiently.

Finally, plans need to focus on sustainable, mass-personalized care interventions that address both clinical and social needs, especially as CMS continues to emphasize health equity and outcomes.

As we wrap up our conversation with Melissa Newton Smith, it’s clear that her insights and experience will be invaluable in guiding healthcare organizations through an era of transformative change. Her commitment to innovation, operational excellence and patient-centered care aligns seamlessly with ProspHire’s mission to drive impactful improvements in healthcare quality. This alliance brings together Melissa’s strategic vision and ProspHire’s project delivery strengths, forming a powerful partnership poised to address the most pressing challenges in Medicare Advantage and beyond. With this combined expertise, we are well-positioned to create a lasting positive impact on healthcare outcomes, ushering in a future where quality and efficiency go hand in hand for the benefit of members and the industry.

Ready to take your Medicare Advantage strategy to the next level? Partner with ProspHire and leverage Melissa Newton Smith’s unparalleled expertise in healthcare innovation and quality improvement. Connect with us today to discuss how we can help you drive operational excellence, optimize your Star Ratings and meet the challenges of a rapidly evolving healthcare landscape. Together, let’s build a tailored roadmap for success. Reach out now and let’s get started on your journey to measurable, sustainable outcomes.

SY2025 Data Insights

Written by LBodnarchuk on . Posted in Insights.

The Centers for Medicare & Medicaid Services (CMS) released the 2025 Star Ratings for Medicare Advantage plans on October 10th, 2024.

Following the dramatic impact of Tukey outlier deletion in Star Year 2024, Star Year 2025 didn’t face uncertainties or shock in methodology. Instead, we realized an upswing in cut points and the knock-on effect of Tukey and compressed distribution of scores. The guardrails, restricting the majority of measure cut point movement (+/- 5 pts) were in place and had impacts on Stars ratings and plan performance. In a year-over-year trend, the Medicare Advantage Prescription Drug (MAPD) contract enrollment weighted average for Star ratings decreased and faced one of the lowest levels in nearly a decade – shifting from 4.07 to 3.92.

The Star performance ratings also showed that 40% of MAPD plans earned an overall rating of 4 stars or higher for Star Year 2025, down slightly from 42% in Star Year 2024. When weighted by enrollment, 62% of MAPD enrollees are currently in 4+ Star plans for Star Year 2025 which is a significant drop from last year’s 74%.

Seven MAPD contracts earned 5 stars, marking them as the highest quality “high performing” Medicare Advantage plans. The Centers for Medicare & Medicaid Services highlighted these plans on the Medicare Plan Finder website to help beneficiaries identify top-rated options. This is a stark reduction from the 38 5-star plans in 2024. Medicare Advantage Prescription Drug plans with longer tenure also scored higher relative to newer plans, with five of the seven 5-Star plans being established programs for 10+ years. We’ve seen the number of 5-Star plans decrease steadily over the past few years, but with the removal of the reward factor starting in SY26 and the introduction of the health equity index, achieving that 5 Star rating will likely continue to prove more and more difficult.

Our team put together our SY2025 Insights and Analysis to begin to “tell the story” for Star Year 2025. If you have any questions or are curious to speak about your plan’s Star Rating, contact ProspHire to see how we can help improve your Star ratings.

Rating Swing Distribution from Prior Year1

Graph Description:

  • Compares Health Plans Overall Star Rating between SY2024 and SY2025.
  • Only includes Local CCP, Regional CCP, PFFS and 1876 Cost. Excludes MSA, PDP, Employer Group.
  • Excludes Contracts that did not have a Star Rating in SY2024 or did not have enough data available.

Distribution of Star Rating SY2024 and SY20251

Graph Description:

  • Identified the total count of contract that received a Star Rating in Star Year 2024 and Star Year 2025 and shows the distribution over each year.
  • Only includes Local CCP, Regional CCP, PFFS and 1876 Cost. Excludes MSA, PDP, Employer Group.
  • Excluded any plans that were too new to be measured, not enough data available, or not applicable.

Distribution of Domain Level Performance

Using the data presented in the tables below, our team conducted a comprehensive analysis on the distribution of overall plan ratings in correlation with a plan’s performance in five domains: Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Effectiveness Data and Information Set (HEDIS), Pharmacy, Operations and Health Outcomes Survey (HOS).

Key Highlights:

  • The Operations domain demonstrated a more concentrated performance range for high-performing plans, with 75% of 4.0+ Star plans achieving a score of 4.0 or higher in the designated measures.
  • In order to achieve 4.0+ Stars, plans were required to succeed in CAHPS. Of the 189 plans that received a 4.0+ star, 82% of them had a minimum CAHPS scoring average of 3.5 Stars.
  • In line with CMS methodology weighting, HEDIS, Pharmacy, and HOS showed a more expected spread in overall health plan performance based on the domain’s average Star rating.

In summary, the health plan operations domain stands out as a consistent and influential factor driving higher Star ratings for health plans. With the shift in weighting moving away from the 4x in the member experience focused measures in operations (e.g., Members Choosing to Leave the Plan, Complaints, and TTY/FLI) the question becomes, “How will performance be impacted for SY26?” A strong focus on HEDIS and HOS will be required especially with the return of the two tripled weighted (x3) Improving/Maintaining Physical/Mental Health measures in HOS for SY2027.

As we enter the final stretch of the performance year SY2024, it is essential to place significant emphasis on the efforts of Q4. Health plans should arrange all available resources and make every effort, giving special attention to driving improvements in HEDIS performance. This Q4 push can act as an additional safeguard prior to the CAHPS survey distribution in March 2025. The MA marketplace faces many headwinds, including benefit reductions across many of the health plans and how plans communicate these changes broadly to their membership could have a significant impact on CAHPS results.

As we look ahead to the future of Stars and the “new normal” we continue to see tremendous value in investing in digital measurement transformation, electronic clinical data systems optimization, interoperability and health data exchanges. The industry will continue to shift this way and the health plans that invest now in this will end up being the biggest winners long term.

Plan Count by Overall Rating & Average CAHPS Rating1,2,3

Graph Description:

  • ProspHire categorizes the CAHPS domain based on the following 9 measures: Annual Flu Vaccine, Getting Needed Care, Getting Appointments and Care Quickly, Customer Service, Care Coordination, Rating of Heath Care Quality, Rating of the Health Plan, Rating of the Drug Plan, Getting Needed Rx Drugs
  • Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
  • Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Plan Count by Overall Rating & Average HEDIS Rating1,2,3

Graph Description:

  • ProspHire categorizes the HEDIS domain based on the following 13 measures: Breast Cancer Screening, Colorectal Cancer Screening, Care for Older Adults – Medication Review, Care for Older Adults – Pain Assessment, Osteoporosis Management in Women who had a Fracture, Diabetes Care – Eye Exam, Diabetes Care – Blood Sugar Controlled, Controlling High Blood Pressure, Medication Reconciliation Post-Discharge, Plan All-Cause Readmissions, Statin Therapy for Patients with Cardiovascular Disease, Transitions of Care, Follow-up after Emergency Department Visit for People with Multiple High-Risk Chronic Conditions
  • Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
  • Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Plan Count by Overall Rating & Average Pharmacy Rating1,2,3

Graph Description:

  • ProspHire categorizes the Pharmacy domain based on the following 5 measures: Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension (RAS antagonists), Medication Adherence for Cholesterol (Statins), MTM Program Completion Rate for CMR, Statin Use in Persons with Diabetes (SUPD)
  • Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
  • Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Plan Count by Overall Rating & Average Operations Rating1,2,3

Graph Description:

  • ProspHire categorizes the Operations domain based on the following 10 measures: Special Needs Plan (SNP) Care Management, Plan Makes Timely Decisions about Appeals, Reviewing Appeals Decisions, Call Center – Foreign Language Interpreter and TTY Availability, Complaints about the Health Plan, Complaints about the Drug Plan, Members Choosing to Leave the Plan – Part C and Part D, MPF Price Accuracy.
  • Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
  • Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Plan Count by Overall Rating & Average HOS Rating1,2,3

Graph Description:

  • ProspHire categorizes the Health Outcome Survey (HOS) domain based on the following 3 measures: Reducing the Risk of Falling, Improving Bladder Control, Monitoring Physical Activity
  • Measures that were noted by CMS as ‘Not enough data available’, ‘No data available’, ‘Plan too small to measure’ did not count in the domain calculation per plan due to CMS methodology of excluding those measures in the overall Star rating calculation.
  • Totals will vary across graphics as some health plans may not have been able to score for some domain categories due to unavailable data as noted in item 2.

Q&A with ProspHire’s Tim Calhoun on Project Delivery

Written by LBodnarchuk on . Posted in Insights, Insights on Healthcare Project Delivery.

Healthcare is an industry that touches every one of our lives and behind the scenes there’s a complex world of projects and initiatives aimed at improving patient care. ProspHire’s Tim Calhoun sheds light on the intricate world of healthcare project delivery. 

Can you provide an overview of ProspHire’s Project Delivery practice and its role within healthcare consulting? 

ProspHire’s Delivery Practice first and foremost is focused on the desired outcomes of our clients and providing the right level of expertise in terms of talent and experience. When a client engages ProspHire we seek to understand the need and then align our team to support several types of projects including Large Scale System Implementations, Health Plan Integrations, Establishing/Enhancing EPMO capabilities, as well as Program and Project Management. Our team consists of certified Project Management Professionals (PMP), Six Sigma Green Belt and Certified Scrum Masters who offer industry expertise in the payer and provider sectors.  

What are some key challenges that healthcare organizations typically face when it comes to project delivery and how does ProspHire address these challenges?  

Our goal is to partner with our stakeholders, understand their expectations and give them time back. All organizations are working with keeping their operations functioning, competing priorities/projects and resource constraints. Our Delivery practitioners utilize our delivery and industry expertise, allowing our stakeholders to focus on their numerous priorities.

Could you share a success story that highlights the impact of the Project Delivery practice on a healthcare client’s operations or outcomes?  

One of our clients is currently going through rapid growth and transformation. With that comes the need to connect business and technical process/decision making and manage decisions/dependencies. The client engaged ProspHire to manage several of those programs and that required us to utilize our strong execution skills and our strong relationships to identify risk and act as an extension of our stakeholders. What we like to hear from our clients is that they can’t tell the difference between our teams and their full-time employees, and we bring value by giving them back time.  

In the rapidly evolving healthcare landscape, how does ProspHire stay ahead of the curve in terms of project management methodologies and industry best practices?  

We understand current methodologies utilized by our clients. ProspHire collaborates with some of the largest healthcare organizations in the country and that entails many customized ways to deliver projects using agile, hybrid and waterfall methodologies. Several factors contribute to selecting the right delivery methodology for a specific client and initiative, including understanding the organization’s current capabilities, the evolving implementation journey, complexity, scale, speed and specific goals of the company. To keep up with the ever-changing delivery landscape, ProspHire invests in our employees through continuing education and certifications through ProspHire University (PMP, Agile, etc.). 

What role does technology play in optimizing project delivery within healthcare organizations and how does ProspHire leverage technology in its consulting services? 

Technology always plays a critical role in project delivery. From a macro level, this starts with an organization’s ability to manage strategic portfolios of projects that align to the long-term vision and goals. It’s key to keeping leadership informed on desired outcomes by continually tracking the demand, the portfolios, the capacity to support them as well as accurate KPIs to overall performance. At the project level, we utilize various Project Portfolio Management (PPM) applications to manage project status and financials for our clients.  

Collaboration is crucial in project delivery. How does ProspHire develop collaboration among cross-functional teams within healthcare organizations to ensure successful project outcomes? 

Working in any sized organization, project execution rarely impacts a single business area and with that highlights the importance of building trust and relationships. It is critical to understand how people like to communicate and their leadership styles and set clear expectations for the team’s relationship. Projects are not all filled with good news as dependencies, resource constraints and competing priorities also become a factor. Setting clear expectations and building a strong relationship up-front goes a long way to staying aligned and gaining respect with our clients.  

Healthcare projects often involve complex regulatory and compliance requirements. How does ProspHire ensure that its clients navigate these challenges effectively?   

Regulatory and compliance projects always start with an understanding of the requirements and how these requirements impact the current processes, workflow and technology. Even the smallest change impacts the business and with the heightened compliance or regulatory impact it’s critically important to establish strong collaborative governance models that hold people accountable, communicate an accurate status, empower the right people to make decisions and share a transparent risk assessment with clear mitigation strategies.  

Can you share some insights into the skills and expertise that your Project Delivery practice team brings to the table to make a difference in healthcare projects?  

At ProspHire, our practitioners have experience in Payor, Provider, Dental and even post-acute projects. That experience helps us work side by side with our business technical and regulatory compliance stakeholders to inform decision making, provide recommendations and ultimately give our clients time back to focus on the business. In no way are we replacing our stakeholders, but rather allowing our experience to build the trust they seek when delivering projects. Our clients seek a partner with a proven reputation for delivering complex and priority initiatives, effectively planning and managing progress and risks and understanding implications to processes, technology and regulatory demands

Risk management is vital in any industry. How does the PMO identify and mitigate potential risks that could impact the success of healthcare consulting projects? 

Risk management and communication are critical to managing a program/project and building trust with your clients. Risk is going to happen on every project and how that is documented and communicated is vitally important. Risk is not about calling teams or individuals out but rather a way to communicate what is causing the risk, the impact and the mitigation to manage the risk. By not sharing or communicating risks, it is likely going to grow into something more unmanageable thus further impacting the project and resources supporting the desired outcome. At ProspHire, we run towards the risk and aim to understand the root cause, the impact of the project and defining a clear strategy for managing the risk.  

Looking ahead, what trends and innovations do you foresee shaping the future of project delivery in healthcare and how is ProspHire preparing to adapt to these changes?

Digital transformation, data analytics and AI and process automation are all new trends and innovations that are now impacting project delivery in healthcare. It is important that we understand the needs and capabilities of every organization we work with to gauge their ability to evolve. And as important in understanding the technology, equal importance is understanding how operational processes may need to be examined and redesigned to complement and gain further efficiencies and quality gains that technology brings. At ProspHire, we are continuously training and upskilling our practitioners in emerging technologies and healthcare trends and regulations. We collaborate with technology companies and healthcare providers to develop innovative solutions that help to stay current with industry developments and we tailor solutions to the unique needs and challenges of every healthcare client.

ProspHire will work with you to understand your unique circumstances and identify the best methods to achieve your goals. Connect with us today to learn more.

Innovations in ACA Plan Design

Written by LBodnarchuk on . Posted in Blog.

The Affordable Care Act (ACA), commonly known as “Obamacare,” is a transformative law that makes health insurance coverage more accessible and affordable. This guide highlights the importance of innovative ACA plan designs, explores current trends shaping the ACA marketplace and offers key considerations for developing and expanding your ACA plan to meet the evolving consumer needs and regulatory changes.  

Importance of Health Insurance Plan Design Innovations

There are numerous opportunities to enhance your existing ACA plans and make healthcare more accessible and affordable.  For example, some Americans still don’t qualify for ACA subsidies leaving them without viable insurance options.  Additionally, consumers often face challenges in navigating enrollment windows and comparing plans, products and issuers due to complex information and formats. Innovation in ACA plans not only address these gaps by simplifying the consumer experience but also adapts to evolving patient needs, making healthcare more efficient and user friendly. These innovations also help health providers remain relevant and competitive in an ever-changing industry, ensuring that coverage is both comprehensive and affordable while improving health outcomes.

Transformative Trends in ACA-Compliant Health Plans

Innovation in ACA plan design is driving new concepts and strategic approaches that aim to enhance patient care standards and integrate advanced technologies. Here are six trends in the ACA marketplace and healthcare industry.

1. Specialized Plans Cater to Unique Healthcare Needs

Health insurance companies are now breaking ground within the ACA framework to develop specialized plans, for mental health and substance use services, chronic condition management, maternity care and personalized medicine based on molecular and genetic insights. Mental health services are now a priority, with many ACA plans expanding coverage and ensuring parity between mental and physical health care.

2. Technology Continues to Shape ACA Plans

Numerous technology solutions and AI-powered tools are transforming the accessibility and convenience of ACA plans. Newer AI-powered diagnostic tools enhance care plan precision and health policy design. They can analyze vast healthcare data sets to predict costs, identify trends, create more tailored and efficient health policies, lower costs and potentially improve outcomes. Advanced AI and machine learning algorithms may also streamline administration processes such as claims management and patient record-keeping, while enhancing decision-making in patient care and policy design, making the entire system more responsive and effective.

Virtual care options are becoming a standard feature in ACA plans, enhancing accessibility and reducing costs for both patients and providers. Telehealth platforms and digital health records help improve healthcare accessibility. Patients in underserved or rural areas can now consult physicians remotely with telehealth services. Mobile apps and online portals for managing health plans also allow patients access to their healthcare information and services.

3. Major Industry Players Lead the Way in Innovation

The need for new approaches to healthcare has prompted several companies to develop transformative insurance models. For example, Aetna collaborated with Banner Health to combine groundbreaking approaches with traditional insurance expertise. Tech giants and startups are also contributing with digital health initiatives, telemedicine and health data analytics, creating an excellent opportunity for insurance companies to build relationships with tech companies that may aid in digital health initiatives.

4. Personalized Services and Integrated Systems

The evolving healthcare industry is moving toward personalized services for patients with tailored coverage and customized wellness programs based on individual health data. Integrated systems with insurance data, health records and real-time metrics in one place also offer an all-inclusive view of a patient’s health to enhance acute and preventive care.

5. Increased Focus on Patient Outcomes

ACA plan design innovations can now directly influence patient outcomes. For example, plans incorporating advanced care coordination strategies may encourage patients to receive timely and efficient treatment to enhance overall health outcomes. Plans that emphasize wellness and preventive care may influence healthier lifestyles for enrollees. While each example addresses a specific health need, both influences overall positive health outcomes.

6. Opportunities for Cost Savings and Improved Patient Care

Telemedicine and AI technology have significantly lowered healthcare costs while enhancing patient care. When designing your next ACA plan, prioritizing expanded access through telemedicine is a strategic move. Telemedicine enables patients to consult healthcare providers remotely, reducing barriers to care, such as geographic limitations or transportation issues. By incorporating telehealth services, ACA plans can help patients manage chronic conditions, receive preventive care, and address urgent health concerns without the need for costly emergency room or hospital visits.  

Considerations and Solutions When Designing a New ACA Plan  

Before designing your new ACA plan, you must understand the challenges of implementing innovations and how to counter them.

Adapting to Technological Advancements

Technology, including telemedicine and AI, is rapidly advancing and plans must keep pace to stay relevant and improve efficiency. Implementing advanced technologies like AI-powered tools can be costly and require significant infrastructure. Plans need to incorporate telehealth services and AI-powered diagnostic tools to enhance care delivery. Plans should also leverage data analytics to identify cost-saving opportunities and improve patient outcomes through personalized care plans.

Compliance With Regulations and Industry Standards

Regulatory bodies may still need to release standards regarding newer technologies and innovations in the ACA marketplace. Regularly review insurance, ACA and healthcare regulations to stay updated on and compliant with the latest rules. You may also need to review industry standards to confirm whether the new ACA plan design maintains medication adherence.

Impact on Insurers and Providers

It is crucial to account for how innovative ACA plan designs may impact stakeholders. Insurers must ensure regulatory compliance while managing the cost implications of innovations such as AI-driven tools and telehealth services, which can affect pricing and risk management. They need to balance these factors with maintaining affordable premiums and competitive positioning. On the other hand, providers must adapt to new care delivery models like value-based care and telemedicine, which require significant changes in workflows, skills and payment structures. Effective training and support are crucial to help providers integrate these innovations seamlessly. Collaboration between insurers and providers, along with thoughtful implementation and support strategies, is essential to successfully navigate these challenges and enhance the overall effectiveness of ACA plans.

Patient Education About New Plan Features

Patients may need extra guidance on your new ACA plan design and how to access and pay for care. Be transparent with patients and introduce your new plan features early on, gradually explaining different concepts to them so they fully understand how to use the plan when it launches. This may involve creating user-friendly materials and platforms that outline how these features work, their benefits and how to utilize them effectively. By ensuring that patients are well informed, healthcare providers and insurers can enhance engagement, improve health outcomes and ensure a smoother transition to new plan features.

Potential Disruptions in Traditional Care Patterns

Technology may change how medical professionals deliver healthcare by streamlining and automating previously manual tasks. Help existing workers adapt and create alternative responsibilities for an easier transition.

Develop Your ACA Health Plan Design with ProspHire

Improving the value of your organization’s ACA plan is critical to standing out among the competition and improving patient care. Still, challenges with plan design innovations make it essential to establish worthwhile and compliant ACA plans. At ProspHire, our expert ACA consultants work closely with healthcare organizations to understand their unique needs, obstacles and growth aspirations to help them develop comprehensive strategies to deliver and execute meaningful plans. To learn more about how our knowledgeable team can assist you, contact us about our ACA plan development services today.

Linked Sources
  1. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/
  2. https://www.aafp.org/about/policies/all/direct-primary-care.html
  3. https://adasoutheast.org/resources/effective-systems-for-providing-accommodations-or-modifications-for-people-with-disabilities-in-the-healthcare-setting/
  4. https://www.americanprogress.org/article/the-behavioral-health-care-affordability-problem/
  5. https://www.aamc.org/news/personalized-medicine-coming-who-will-have-access-it
  6. https://www.prosphire.com/blog/the-importance-of-system-integration-in-healthcare/
  7. https://www.aha.org/aha-center-health-innovation-market-scan/2022-03-15-banner-aetna-aligns-incentives-drive-innovation
  8. https://www.prosphire.com/blog/creating-competitive-aca-plans-balancing-affordability-and-coverage-quality/
  9. https://www.prosphire.com/blog/business-growth-and-expansion/aca-compliance-requirements/
  10. https://www.prosphire.com/blog/benefits-optimization-in-healthcare-application-and-timeline/
  11. https://www.prosphire.com/services/aca-plan-development-and-expansion/
  12. https://www.prosphire.com/contact-us/
Unlinked Sources
  1. https://www.decent.com/blog/understanding-the-impact-of-health-insurance-plan-design-innovation
  2. https://www.prosphire.com/blog/creating-competitive-aca-plans-balancing-affordability-and-coverage-quality/
  3. https://www.decent.com/blog/how-innovations-in-health-benefit-plans-are-transforming-healthcare
  4. https://www.prosphire.com/services/aca-plan-development-and-expansion/
  5. https://www.ama-assn.org/health-care-advocacy/access-care/understanding-affordable-care-act
  6. https://nap.nationalacademies.org/read/13056/chapter/5

Navigating the Affordable Care Act with ProspHire’s ACA Leader

Written by LBodnarchuk on . Posted in Insights.

The Affordable Care Act (ACA) has significantly transformed healthcare in the United States with its far-reaching provisions designed to expand access to insurance, eliminate discriminatory practices, enhance preventive care, reduce costs and elevate the quality of healthcare services. In this Q&A, ProspHire’s ACA practice leader, Caitlin Nicklow, offers expert insights into the complexities of ACA compliance. She discusses the critical rules and requirements for health insurance providers, key dates to keep in mind and the essential steps for successfully launching an ACA-compliant health plan.

How does the ACA impact healthcare? 

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

  • Increased access to health insurance: The ACA has expanded access to health insurance by creating marketplaces where individuals can purchase affordable health insurance plans and by expanding eligibility for Medicaid. As a result, millions of previously uninsured Americans gained access to health insurance.
  • Prohibiting insurance discrimination: The ACA prohibits health insurance providers from discriminating against individuals with pre-existing conditions and it also prohibits health insurance providers from charging higher premiums based on factors such as gender or health status.
  • Enhancing preventative care: The ACA has emphasized the importance of preventative care and it requires most health insurance providers to cover preventative services such as cancer screenings and immunizations without cost-sharing.
  • Lowering healthcare costs: The ACA includes provisions that aim to lower healthcare costs, including measures to reduce waste, fraud and abuse in the healthcare system and initiatives to encourage more efficient and coordinated care. Many individuals are also eligible for financial assistance in the form of subsidies and cost sharing reductions.
  • Improving healthcare quality: Insurers offering Plans on the ACA Marketplace receive a Quality Rating Score (QRS). This score not only measures the quality of healthcare received by members, but also the administration of the Health Plan. Members can compare scores when shopping for the best Plan.
How does the ACA impact healthcare?

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

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

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

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

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

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

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

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

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

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

Providers should be familiar with several important dates:

  • Open Enrollment: Open Enrollment is the period when individuals can enroll in or change their health insurance plans for the following year. The dates for Open Enrollment may vary from year to year, but it generally takes place in the fall. For 2025 coverage, Open Enrollment begins November 1, 2024 and ends January 15, 2025, in most states.
  • Special Enrollment Periods: Special Enrollment Periods (SEPs) allow individuals to enroll in or change their health insurance plans outside of Open Enrollment if they experience certain qualifying life events such as getting married, having a baby or losing their job-based health coverage. SEPs are available throughout the year but individuals typically have a limited amount of time to enroll after their qualifying event.
  • Tax Season: Health insurance providers need to be aware of the ACA-related tax forms that must be issued to individuals and the IRS during tax season. For example, individuals who received premium tax credits to help pay for their health insurance during the year will need to file Form 8962 to reconcile the amount of the credit they received with their actual income for the year.
  • Plan Year Renewals: Health insurance providers must renew their ACA-compliant health plans each year. The certification process typically runs May through September.
  • Regulatory Changes: The ACA is subject to ongoing regulatory changes, which can affect health insurance providers and their customers. Providers should stay up to date on any regulatory changes and be prepared to make changes to their plans or operations as necessary.
Providers should be familiar with several important dates

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

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

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

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

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

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

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

Does ProspHire have experience launching ACA-Compliant plans?

ProspHire has launched fully certified and accredited ACA plans in 6 states, with additional growth in our portfolio of existing clients. We have extensive experience driving end-to-end current state assessments to analyze the regulatory and operational gaps organizations must fulfill in pursuit of an ACA-compliant plan and we have the implementation and change management knowledge to close those gaps in limited timelines. Additionally, our subject matter expertise in guiding organizations to achieve success in medical management and quality care delivery can help to get the plan firmly grounded at launch.

ProspHire seeks to understand your unique circumstances

How can ProspHire help you throughout this process?

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

Impact of Risk Adjustment Revenue Payments & Quality Bonus Payments

Written by LBodnarchuk on . Posted in Insights.

In a competitive marketplace, it is more vital than ever for Medicare Advantage Organizations (MAOs) to maximize the Medicare Advantage reimbursement mechanisms created by CMS. The Stars Quality Bonus Program (QBP) is a well-known lever utilized by MAOs. Most MAOs are not aware that optimizing another area of the business can produce similar if not more revenue as the QBP. MAOs with risk scores below 1 in the current benefit year are the most likely candidates for this additional payment. How might this be true? The Medicare Payment Advisory Commission (MedPAC) March 2023 Report to the Congress: Ch11 Medicare Payment Policy outlines the impact a more accurate risk score can have, analogous to a second bonus payment in the form of additional Risk Adjustment revenue payment. This interesting illustration provided in the MedPAC report is worth a closer look.

Impact of Coding Intensity on Monthly Rebate Amount per Beneficiary

A plan that codes diagnoses more aggressively can offer it's enrollees more extra benefits

This table illustrates the relationship between Risk Adjustment coding intensity and rebate amounts using a hypothetical example of three plans covering the same set of enrollees for whom the expected cost of care is the same, at $900 per member per month.

Plans A and Z have an expected risk score of 0.97 and Plan B has an expected risk score of 1.03 due to more aggressive diagnostic coding. All three plans have bids below the risk-adjusted benchmark and must provide extra benefits funded by rebates. However, because Plan B has a higher risk score, its rebate is larger than Plan A’s rebate ($52 per month vs. $15 per month); so it can offer enrollees more extra benefits than that provided through quality bonuses.

As portrayed in the table, a .06 increase in risk score from Plan A to Plan B was associated with a substantial increase in rebates, resulting in greater total revenue than a 5-star plan with a lower risk score (equivalent to Plan A). MAOs with a risk score of >1, should look at the current risk as an opportunity to increase risk score accuracy and completeness. This evaluation not only signals increased revenue opportunity, but improved member experience through benefit planning and delivery.

Best-in-class Risk Adjustments utilize four levers to achieve an improvement in risk coding accuracy and completeness (measured by risk score).

  • Accurate Risk Adjustment coding process and quality assurance
  • Member and provider education on comprehensive medical assessments and accurate coding of members health status
  • Review and reconciliation of diagnostic coding from member’s past medical encounters
  • 100% of encounter data submitted to CMS ahead of submission deadlines with 99.5% accepted and used in the model run

By optimizing Risk Adjustment operations, the MAO is leveraging a more stable and timelier reimbursement mechanism compared to Stars. Risk Adjustment model changes do not impact operations as drastically as Stars reforms. Investment in the optimization of Risk Adjustment operations is more durable as a result. Risk score adjustments are reimbursed earlier, in the form of monthly premiums and annual readjustment payments. Also, Risk Adjustment reimbursements are not an all or nothing proposition, allowing your MAO to realize value incrementally with investment.

How ProspHire Can Help

All Medicare Advantage revenue streams are important. ProspHire is well positioned to assist with any area to strengthen the performance of a Plan.

  • Identify Risk Adjustment operational gaps and accelerate optimization
  • Conduct comprehensive or specific program operation assessments
  • Provide project management and staff augmentation resources to accelerate infrastructure upgrades or operational improvements
  • Vendor Management
  • Assess, enhance and maintain quality standards for maximum Stars Quality Bonus Payment in tandem or separately

ProspHire Earns a Spot on the Inc. 5000 List for 5th Consecutive Year

Written by LBodnarchuk on . Posted in News.

PITTSBURGH, PA – ProspHire proudly announces its placement of #4792 on Inc. Magazine’s prestigious 2024 Inc. 5000 list of America’s Fastest-Growing Private Companies. Additionally, the Firm ranks #20 in Pittsburgh, #151 in Pennsylvania and #571 in the nation for business products and services. Companies on the 2024 Inc. 5000 are ranked according to percentage revenue growth from 2020 to 2023. The recognition highlights ProspHire’s exceptional growth trajectory amidst economic challenges such as inflationary pressures, rising capital costs and workforce shortages during that time period.   

“Securing a place on the Inc. 5000 list for the fifth consecutive year is a tremendous honor, attributable to our dedicated team,” remarked Lauren Miladinovich, Managing Principal and CEO of ProspHire. “Their hard work across all departments is the cornerstone of our success and ongoing expansion.”  

Chris Miladinovich, ProspHire’s Principal and Chief Strategy Officer at ProspHire added, “Being consistently recognized among the most innovative and fastest growing companies in the U.S. for the 5th consecutive year is a testament to our resilience that we celebrate. This accolade showcases not just our success but demonstrates our ability to navigate economic uncertainties.”  

Dan Crogan, Principal and Senior Vice President of Consulting expressed gratitude, stating, “We extend sincere thanks to our exceptional team members and loyal clients whose collaboration has been instrumental in achieving this remarkable milestone. Our unwavering commitment to the healthcare sector and our expertise in project execution have built enduring partnerships. We pride ourselves on acting as an extension of our clients’ teams, helping them overcome their most critical business challenges.”  

Complete results of the Inc, 5000, including company profiles and an interactive database that can be sorted by industry, region, and other criteria can be found at www.inc.com/inc5000. 

ProspHire & Medicare Expert Team Up to Propel Healthcare Innovation

Written by LBodnarchuk on . Posted in News.

(Pittsburgh, PA) – ProspHire, a leading healthcare consulting firm specializing in transformative project delivery, proudly announces a strategic alliance with Melissa Newton Smith and the Newton Smith Group, a distinguished authority in Medicare Advantage with extensive Star Ratings, operational and strategic expertise. This collaboration marks a significant milestone in advancing healthcare innovation and enhancing excellence across the industry.

Melissa brings extensive experience and insight into Medicare Advantage and Star Ratings strategies and initiatives, contributing invaluable knowledge to healthcare organizations nationwide. Her expertise aligns perfectly with ProspHire’s commitment to driving impactful change through optimized healthcare operations and strategic solutions.

“We are thrilled to embark on this strategic alliance with Melissa,” said Lauren Miladinovich, Co-founder and CEO of ProspHire. “Her deep expertise will enrich our capabilities, enabling us to deliver even greater value and innovation to our clients.”

The Newton Smith Group will collaborate closely with ProspHire’s team of experts to develop and implement tailored strategies that optimize healthcare performance, elevate quality outcomes and maximize efficiency. Together, this new alliance is poised to redefine standards of excellence in healthcare consulting.

“I am excited about the opportunities this alliance will create,” said Melissa Newton Smith. “By combining our strengths, we aim to drive meaningful improvements in healthcare delivery, ultimately benefiting patients and providers alike.”

For more information on ProspHire’s Stars Performance Practice, visit Stars Performance Improvement Services | ProspHire.

For more information on Newton Smith Group’s Medicare Advantage and Star Ratings practice, visit https://newtonsmithgroup.com.

About ProspHire

ProspHire is a dedicated healthcare consulting firm renowned for its expertise in project delivery and execution. Founded with a vision to transform healthcare through precise, expert-led strategies, ProspHire partners with clients nationwide to navigate complex challenges and achieve sustainable success.

About Newton-Smith Group

Newton Smith Group is an expert advisory services firm known for providing exceptional consulting services to health plans, health systems and provider groups, vendors, VC/PE firms, associations and trade groups to optimize Medicare Advantage and Star Ratings performance. Newton Smith Group’s team of experienced former health plan leaders uses its deep expertise to support clients and solve problems with a forward-looking lens on regulatory and technical requirements with efficient, sustainable, future-proofed solutions to their most challenging problems.

Championing Minority Mental Health: Reflections and the Road Ahead

Written by LBodnarchuk on . Posted in Insights.

Reflecting on National Minority Mental Health Awareness Month in July, it’s a time to focus on the unique mental health challenges faced by underrepresented minority communities. Mental health encompasses emotional, psychological and social well-being, affecting how individuals think, feel and act. It also plays a crucial role in managing stress and making informed decisions1. Effective mental health care is essential for helping people navigate life’s challenges and stresses.

Minority mental health emphasizes improving outcomes for racial and ethnic minority populations by addressing the effects of Social Determinants of Health (SDOH) on mental well-being. These communities often face significant disparities, including higher rates of suicide attempts among adolescents and lower treatment rates for conditions like depression among adults2. By acknowledging these unique challenges, efforts can be made toward providing more equitable mental health care.

2022 Statistics for adults less likely to receive mental health services

The Critical Need for Minority Mental Health Awareness

With over 40% of the U.S. population identifying as Black, Indigenous and People of Color (BIPOC), addressing the mental health needs of these communities is essential3. Mental health services are disproportionately less accessible to minority groups, with 2022 statistics showing that Hispanic (40%), Black (38%) and Asian (36%) adults are less likely to receive mental health services compared to White adults (56%)4. In 2020, fewer than half of African American adults received mental health care and in 2018, Asian Americans were 60% less likely to receive treatment compared to non-Hispanic Whites. Factors such as lack of health insurance, limited access to treatment and stigma significantly contribute to these disparities1. Raising awareness about these issues is crucial for advocating better mental health care and support for minority communities.

How ProspHire Can Help

Promoting Equitable Care with ProspHire

In alignment with shifts in industry trends and government policies, our team is committed to working alongside our clients to promote equitable care that improves access to services to manage mental health and substance use disorders in all their patient populations. Technological and clinical investments in behavioral health disorder identification, treatment and prevention services can help health systems overcome long-standing challenges to providing integrated and comprehensive care for the traditionally hardest-to-reach patients. ProspHire has the responsibility to our clients and communities to enable equitable adoption, marketing and utilization of services to capture those of greatest need. This improves the opportunity for members to see improved health and social-related outcomes and health plans to realize improved quality measure performance in their government programs.

ProspHire has extensive experience in implementing behavioral health tools for Medicaid programs, specifically in areas that address minority and high-risk patient populations. Our experience includes the coordination of vendor relationships for various initiatives, such as applications that address youth mental health, transitional housing for individuals in recovery, sobering centers for those dealing with acute issues and tools for youth managing their transition into adulthood. From initial vendor outreach, contracting and vendor risk assessments to implementation of the product, ProspHire has experience navigating behavioral health program design and implementation from start to finish. Serving as the vendor managers, ProspHire will be with you every step of the way to launch new Behavioral health programs that address patients with mental health and substance use disorders.

Recognizing that access to behavioral health resources remains a significant challenge for minorities facing mental health issues, ProspHire is well-equipped to implement these initiatives within your health plan to promote more equitable care. ProspHire understands that coordination and collaboration with community service organizations and vendors involved in the continuum of care is key to offering a sustainable service model. It is crucial for health plans to address the mental health and substance use disorder needs of minority populations and ProspHire offers proven success in behavioral health that can be leveraged to enhance care delivery at your organization.

  1. https://www.fda.gov/consumers/knowledge-and-news-women-owh-blog/national-minority-mental-health-awareness-month
  2. National Minority Mental Health Awareness Month 2024  | Office of Minority Health (hhs.gov)
  3. https://www.census.gov/quickfacts/fact/table/US/PST045221
  4. Key Takeaways – Key Data on Health and Health Care by Race and Ethnicity | KFF