The Affordable Care Act (ACA) revolutionized healthcare in the United States by prohibiting insurers from denying coverage or charging higher premiums based on pre-existing conditions, leading to an increase in health insurance coverage amongst United States residents. A key process that was introduced with the creation of State ACA Marketplaces was the implementation of a Risk Adjustment transfer payment model. Each year, Department of Health and Human Services (HHS) completes a risk adjustment calculation which redistributes a percentage of premium revenue from ACA insurers with lower risk scores to ACA insurers with higher risk scores within their respective state markets. Failure to capture an accurate and complete risk score exposes an ACA insurer to the risk of understating the health risk of the population. Understating member health risk will lead to redistributing premium revenue needed for member care, causing an operational budget shortfall. A large value fund transfer may indicate a Health Information Oversight System (HIOS) contract was unable to capture an accurate and complete risk score for its population and signal financial headwinds entering the next benefit year.
ACA enrollment continues to grow as seen by the surge in 2024 numbers increasing to 21.3 million people, up from 16.4 million people in 2023 (Jared Ortaliza, 2024). The recent increase in enrollment signals a potential increase in ACA Marketplace insurers. Insurer participation in the ACA Marketplace has been variable since the start in 2014. (McDermott & Cox, 2020) The highest level of participation was in 2015, at an average of 6 insurers per state (ranging from 1 insurer in West Virginia and New Hampshire to 16 insurers in New York). Insurer participation declined after 2015 to 4.3 insurers per state in 2018 with the change being attributed to insurance company losses. The process of launching a product is complex from the initial application and benefit design through to operations. Insurers entering the market may face financial headwinds within the first few years unless the appropriate strategies and operations are deployed. Risk adjustment might contribute to financial headwinds if not appropriately planned and executed during the preparation and operations of the first year.
ACA Marketplace participation has been increasing since 2018, reaching 5 insurers per state in 2021. As the market approaches the high-water mark set in 2015, one might wonder if a market contraction is coming. ProspHire was interested to understand if risk adjustment outcomes are a contributor to new HIOS contract financial performance. ProspHire conducted a simple analysis by comparing the HHS Summary Report on Permanent Risk Adjustment Transfers for the 2022 and 2021 benefit years to answer two questions:
Was there an increase in new HIOS contracts and new insurers from 2021 to 2022?
How did the new HIOS contracts and new insurers fare in their first year of operations?
In 2022, there were 346 non-catastrophic individual ACA Market HIOS contracts compared to 294 in 2021, indicating a net growth of 17% (346/294). Of the 346 plans, 39 were new HIOS contracts in 2022 of which 11 were HIOS contracts given to new insurers (Table 1). New HIOS contracts were more likely to have a risk adjustment transfer payment to the state. Of new HIOS contracts, 82% (9/11) of new insurers and 89% (25/28) of existing insurers completed transfer payments to the stat compared to the national market rate of 57% (197/346).
Table 1: Frequency of Transfer Payments to the State in 2022 by New versus Existing Status
This simple analysis indicates new HIOS contracts entering the ACA Marketplace are more vulnerable than the existing HIOS contracts to completing transfer payments back to the state at the end of the year for risk adjustment. Past history as an ACA insurer does not seem sufficient to avoid a yearend transfer payment to the state. This analysis indicated that new and existing insurers with new HIOS contracts had similar likelihood for risk adjustment transfer payments. Insurers preparing to enter the ACA Marketplace with a new HIOS contract should consider two items. First, the revenue return is a cash transfer from the ACA insurer to the state and it cannot be avoided, even if the ACA insurer elects not to participate in the subsequent year. Second, many operational pieces must be implemented in quick succession to improve the opportunities to capture an accurate and complete risk score in the first year of operations:
Prospective programs to increase provider and member engagement in completion of comprehensive examinations.
Encounter submission platform implementation and calibration with a corresponding error correction management workflow.
Retrospective program chart retrieval targeting, chart retrieval vendor selection and implementation, and a highly accurate chart review vendor.
Risk Adjustment Diagnosis Validation (HHS-RADV) vendor selection and management process.
Whether an Insurer is already established in the ACA Marketplace, or looking to join for the first time, a thoughtful risk adjustment strategy is just one piece of the puzzle to ensure success. ProspHire is uniquely positioned to support your organization through the QHP application process, operational readiness, vendor implementation and strategy advisory. Connect with us to learn more.
ProspHire, a prominent national healthcare consulting firm, announces the appointment of Tim Calhoun as Managing Director. With his extensive experience in healthcare consulting, Tim will be driving senior-level executive and client relationships, focusing on client retention and growth and identifying new opportunities.
Tim joins ProspHire from Ernst & Young (EY), where he held a pivotal role in serving commercial, nonprofit and governmental healthcare clients. With more than two decades of experience in consulting services, Tim brings a wealth of knowledge, particularly in healthcare, with more than 15 years dedicated to this dynamic industry. His track record includes collaborating with health plans and state health agencies to streamline administrative processes, enhance operational efficiency and drive transformative business and system initiatives.
Lauren Miladinovich, CEO, Managing Principal and Co-founder of ProspHire, expressed her enthusiasm about Tim’s appointment stating, “Tim is a compelling addition to our executive leadership team at ProspHire and will bring strong focus on further evolving our consulting practice to help our clients provide better access to healthcare.”
Tim’s appointment reflects ProspHire’s commitment to providing unparalleled expertise and leadership to its clients, further solidifying its position as a leader in the healthcare consulting domain.
The standardization and alignment of administrative and clinical processes to current state best practices and technological advances is a core but often overlooked part of dental practice management. Your practice management standards of practice involve the processes, resources and management strategies involved in driving your daily workflows and patient care. This includes everything from patient and insurance data management to your financial reporting and resource allocation. The management of a dental practice may look different for a privately owned practice or practice group versus a dental service organization. Ultimately, no matter the type of operational model of your organization, it helps you run efficiently, stay compliant and maintain above average patient satisfaction on a consistent basis.
Every dental practice needs careful organization to run smoothly. You can deliver the dental experience your patients and team deserve with a streamlined approach to dental practice management — starting by updating your standards of practice playbook. This document covers compliance, employee training, dental procedures, reporting recommendations and more. Refreshing it will help you deliver a higher quality of care while making everything at your practice as straightforward as possible.
Your Dental Practice’s Standards of Practice Playbook
A practice’s SOP playbook is your guiding document. It sets up everything in your practice — how to handle treatment plans, patient intake and more. A SOP sets a high bar for care at your operation and keeps a consistent quality standard. While your SOP is essential for streamlining care and maximizing efficiency, it can become outdated. Neglecting to keep up with your SOP playbook can leave you with outdated, inefficient standards that decrease your service quality.
How to Upgrade Your SOP Playbook
Your SOP may be responsible for a dip in customer satisfaction or practice efficiency. Taking time to revamp your playbook is an excellent way to cut inefficiencies and improve your practice. Use these steps to bring your playbook into the present, ensuring your staff and customers get top-notch oral care.
1. Review Your Current Document
First, look at your current document. Carefully review every section, looking for improvement areas, inconsistencies, unclear procedures or outdated information. You can ask one or two employees to help you with this task. Your team members are an invaluable resource — they work with the playbook every day and may give you a fresh perspective you haven’t considered.
Reassessing your existing document gives you a better idea of what needs work, simplifying the rest of the process.
2. Define Your Objectives
Next, it’s time to define your objectives. What specific goals do you want to achieve with this update? What experience do you want to deliver? Whether you’re looking to enhance patient safety, streamline administrative processes or ensure compliance with the latest privacy and industry standards, realistically achievable goals will help you pinpoint where to look for assistance and let you anticipate whether the ultimate outcome meets your needs. Plus, you’re less likely to forget something critical if you set goals upfront.
3.Gather Input
Since your staff deals with patients and procedures daily, talking to them is critical. Encourage open communication from your team during and after updating your document. Their experience-based feedback can make your playbook as valuable as possible. Additionally, reach out to customers or read their reviews. You might find a common complaint you can resolve with simple tweaks and improvements. A playbook that accurately reflects your team and customer experience will be more practical for daily use.
4. Research Applicable Regulations and Guidelines
Make sure your playbook is up to date on the latest changes in safety protocols, dental practices and other compliance requirements. You want your playbook to be as accurate as possible — failing to stay current with legal requirements can put you at risk for compliance-related issues and mean your dental care may be out-of-date with current clinical guidelines.
5. Simplify Language and Structure
Your playbook should be unambiguous and easy to read for maximum usefulness. Use simple language throughout to prevent misunderstandings. Additionally, consider visual aids, illustrations and flowcharts for improved accessibility. These tools make your playbook more reader-friendly, usable and memorable.
6. Include Comprehensive Information
A thorough SOP playbook covers everything your practice might need to deal with. Include employee training, dental procedures, privacy requirements, ethics standards, infection control protocols and more. Everything your dental practice offers and promises should be up to date and accurate. A playbook that mentions every detail is more relevant for your team.
7. Customize Your Practice
Someone else’s playbook can be a good reference point, but no practice is identical to yours. Read your document to ensure it covers your team’s specific specialties, needs and workflows. Remember, a more effective playbook equals a more effective dental service.
8. Get Feedback
Once you’ve completed the new playbook, ask for more team feedback. Encourage employees to take notes on the update and how well it works with their day-to-day needs. Did you mention something that’s impractical in real life? What processes are more efficient thanks to the update? Emphasizing collaboration lets you use your team’s strengths to create the best possible document.
9. Regularly Update and Review
Your playbook should be a living, evolving document — never set in stone. Letting it stagnate allows it to become outdated and inaccurate. You should establish a review schedule to help you address any emerging issues, add new industry best practices and adapt to technological advancements. A dynamic playbook reflects your commitment to quality in customer service and dental practice.
10. Use a Management Partner
While good dental practice management starts with your playbook, investing in a partnership can take your practice to the next level. Working with a dental practice management service lets you streamline your operations through automation, reducing errors and improving efficiency. It also enables employees to leave feedback on training sections and allows you to standardize your operation further. When paired with your playbook, a partnership delivers a better experience for your employees and customers.
Why ProspHire?
Choose ProspHire for industry-leading innovation that optimizes your dental practice management. We understand and meet healthcare consulting’s evolving needs. Our team’s dedication to service has earned us spots on the Inc. 5000 and Pittsburgh Business Times‘ Fastest-Growing Companies list.
We specialize in addressing the challenges dental service organizations and dental providers face. ProspHire offers cutting-edge solutions for PMS implementation, SOP playbook transformation, workflow redesign and more. Contact us online to learn more about how we can help you.
The Medicaid population is one of healthcare’s most vulnerable populations requiring unique, frequent and customized delivery of care to provide the resources and services necessary to address health disparities. This leads to significant challenges for care providers in navigating the continuously evolving and regionally unique Medicaid environment. With escalating pressure to contain costs, adapt to Medicaid expansion, address health equity and social risk factors and improve quality performance, the call for effective strategies has never been more pressing.
At ProspHire, our team of Medicaid specialists and project executors offers innovative solutions tailored to the needs of federal and state healthcare agencies, Medicaid health insurers, health systems and pharmacy benefit managers. In this Q&A session, we engage with our Medicaid Practice Leader Julie Evans to dive into various topics spanning delivery, implementation, operations, organization, strategy and technology, offering insights and expertise to address the complexities of the Medicaid landscape.
Can you provide an overview of ProspHire’s approach to how you help clients drive innovation and sustainable improvement in Medicaid?
One of ProspHire’s core values is relationships. As we seek to drive innovation and sustainable improvement in Medicaid, our first step is to understand each health plan’s unique population and regional priorities through relationships with Medicaid beneficiaries, customer facing teams and community-based providers.
State regulations and region-specific needs are the foundation of Medicaid services and pose unique guardrails for our clients. While state regulations are rigid and defined, region-specific needs vary and evolve leaving room for innovation. Through a customer-centered approach, we seek to understand, rather than assume, and drive innovations that are inspired by the customer, leading to desirable and sustainable improvement.
ProspHire partners with our clients to amplify the voice of the customer through the ideation and execution of their innovations by means of strategic initiatives in alignment with organizational priorities.
What are some of the most pressing challenges that healthcare organizations face in navigating Medicaid landscape, particularly considering recent regulatory changes?
The Covid-19 pandemic started 4 years ago, yet today we continue to see the continuous impact on the Medicaid population and landscape. The pandemic inspired an increased focus on health equity, as those affected by Social Determinants of Health, such as the Medicaid population, saw a compounded impact of the pandemic on health outcomes. Healthcare organizations have faced several challenges in appropriately addressing individual needs within the confines of their services and finances given the vast number of challenges impacting health outcomes.
Since the pandemic, we have seen a shift in policy expanding Medicaid coverage and access to care through Section 1115 waivers. Through the current administration, states are permitted to propose Section 1115 waivers focused on new approaches to reduce health disparities and expand coverage and benefits. As a Small Diverse Business (SDB) in Pennsylvania working alongside several of the state’s Medicaid Managed Care Organizations, we have had a particular interest in the pending Pennsylvania Keystones of Health submission.
The approval of the Pennsylvania Keystones of Health waiver focuses on the Social Determinants of Health to improve the health of Pennsylvanians through new and innovative programs. Ultimately, these provisions will funnel additional opportunities and implementation challenges through Managed Care Organizations whose beneficiaries will greatly benefit in the long-term.
How does ProspHire stay on top of the evolving Medicaid regulations and policies and how do you ensure your clients remain compliant?
Read, watch, listen and react. Like many of our clients, we stay up to date on the industry changes, trends and discussions to prepare ourselves and others to react to our evolving environment. This includes the ever-changing needs and priorities of the unique populations that make up a plan’s membership and there is no one who knows their membership better than our clients. Although it isn’t always the most fun activity, our attention to detail and quality assurance practices help us work in partnership with our clients and their legal and compliance teams to drive results.
Can you share a success story or case study where ProspHire’s Medicaid consulting services have significantly benefitted healthcare organizations?
It’s hard to choose just one… so I’ll have to give two. One is tied to a state-wide initiative in Pennsylvania focused on addressing health equity through a collaborative bringing together health systems, managed care organizations, community-based partners and other care providers. Our team facilitated the efforts to address health equity through regional population health assessments and intervention planning across stakeholder groups. This led to regional playbook development that was eventually adopted by the Department of Health for future state implementation. The opportunity to collaborate across healthcare organizations, build meaningful partnerships and drive patient-centered change was of benefit to those engaged in the collaborative and the communities to be impacted.
The second is an engagement that has been in existence almost as long as ProspHire, where we are partnered with a Medicaid Managed Care Organization’s quality team to provide project management services. By offering project management support, our team can support the planning, design and implementation of Medicaid Quality initiatives year-over-year, continuously collaborating with the client to drive improved health plan performance.
Medicaid expansion has brought significant changes in the healthcare industry. How does ProspHire assist clients with adapting to these changes and leveraging opportunities for growth?
Medicaid expansion, in addition to Medicaid unwinding, has led to a series of fluctuations in Medicaid membership. Since 2014, the Affordable Care Act opened the door to Medicaid expansion and many but not all states have taken the opportunity to do so. During the pandemic, continuous enrollment protections were put in place to maintain enrollment of and protect health coverage for almost all Medicaid enrollees. In April 2023, this condition was lifted, reverting states back to business as usual and causing all Medicaid enrollees to be reevaluated for eligibility.
Through these changes, ProspHire supports health plans prepare for scalability or sustainability through operations, improve member transition from Medicaid to marketplace or vice versa with a focus on continuity of care and continuously evaluate operating model and administrative costs as required.
For plans that are looking to enter the Medicaid market within a state or increase Medicaid enrollment through growth strategies, our team is equipped and prepared to support health plan expansion into new lines of business or regions. From operationalization to delivery, our industry knowledge and experience position us to support across all government programs.
Technology plays a crucial role in modernizing healthcare delivery. How does ProspHire integrate technology solutions into its Medicaid services to improve efficiency and outcomes?
Technology is continuously increasing in significance across healthcare delivery. Most recently, our team supported the integration of a new clinical platform to enhance care management, utilization management and reporting capabilities. From requirements gathering to go-live and post go-live risk management and resolutions, our team has been in the weeds, working alongside the client to deliver a multi-state clinical solution. This tool improves efficiency of workflows, decision making and ultimately the delivery of care to the Medicaid population and those who are most vulnerable to adverse health outcomes.
Plans have different technological needs depending on the current state of their operations and we partner with our clients to integrate the solutions that are prioritized in alignment with organizational goals to deliver improved member outcomes.
Can you talk about the importance of data analytics in Medicaid projects and how you use data-driven insights to inform decision-making and strategy development?
Social Determinants of Health (SDOH) and health equity are buzz-worthy terms that have led to a shift in the way specific care needs are identified and delivered. A challenge posed by SDOH and ultimately health equity, is the variation in need based on environmental factors. Through partnerships with community-based organizations and our clients, mutual goals can be achieved by addressing social needs and downstream health outcomes.
To do so, data analytics is crucial. Who is our population of focus? Where do they live? What impact will our intervention have? These are all questions that data can provide insight to. Knowing this, ProspHire has supported population health assessments and data dashboards focused on marrying publicly available data and internal clinical data to support data-driven decision making. These tools support strategic development and inform the who, what and where of many Medicaid projects, specifically those focused on quality.
With the rise of value-based care models, how do you assist clients in transitioning from fee-for-service to value-based reimbursement structures within the Medicaid space?
Pay for performance models, shared savings programs, patient centered medical homes, Medicaid ACOs… the many value-based care models, continue to evolve and demonstrate their effectiveness. Our focus is to support the readiness and feasibility of transition followed by the monitoring and controlling of care model commitments. The continuous need to reduce costs and deliver improved quality of care poses a challenge to both providers and payors and leads to the continuous need to reevaluate and refine our reimbursement structures.
Looking ahead, what trends do you anticipate shaping the future of Medicaid consulting and how is ProspHire positioned to address these trends proactively?
Although predictable to say, quality improvement and cost reduction are and will continue to be a focus in Medicaid. I anticipate that these competing priorities will continue to be an area of focus, but rather than feeling miles apart, will slowly feel more symbiotic.
Let’s use maternal morbidity and mortality as an example. The cost of maternal morbidity and mortality in the U.S. is tens of billions of dollars a year. The cost savings that would come from quality improvement are substantial and in the developed or industrialized world, we have the highest maternal mortality rate that continues to increase and inequitably impact black women. A priority such as this seems unquestionable.
As we continue to look at high-cost low-quality outcomes, we begin to see the vast opportunity for all. Our hope is to continuously be aware of and prepared to address these areas of need, evaluate trends, think innovatively and strategically and ultimately drive change for our clients and the Medicaid population.
Long Term Services and Supports (LTSS) include a variety of care activities focused in medical and personal care including activities of daily living (ADL) and instrumental activities of daily living (IADL). Managed Long Term Services and Supports (MLTSS) is the delivery of LTSS through capitated Medicaid Managed Care programs.
Under the responsibility of Managed Care Organizations (MCO), MLTSS moves away from the Medicaid fee-for-service model that continues to exist today. States may leverage one or both systems to deliver LTSS to beneficiaries. Over time, states have been increasingly adopting the MLTSS model alongside the increase of home- and community-based services (HCBS). LTSS has continuously shifted toward HCBS, with the support of legislature, allowing health services to be delivered outside of the institutional care setting and reducing costs of care. Through MLTSS, states are able to encourage an increase in HCBS and predict budget while incentivizing MCOs for improved care coordination.
As states continuously initiate, enhance and expand their MLTSS programs to accommodate the evolving care model and permissions, MCOs will be challenged to think strategically and innovatively to offer tailored person-centered services plans that accommodate the home-and community-based care model.
Why is MLTSS Important?
The growth of the aging population in the U.S. is unseen in U.S. history. Projections estimate a 26% increase in the number of Americans ages 65 and older over the next 20 years, equaling approximately 17 million people1. As our population ages, and lives longer through medical and technical advances, there is an increasing need to improve the LTSS care model with a focus on HCBS. Through HCBS, beneficiaries can continue life at home and in the community while receiving necessary care without the need for an increase in institutional care facilities. MLTSS creates an environment for specialized care coordination and services to meet the needs of our growing elderly population.
Managed Care Organizations are being tasked by states to operate long term services and support under a capitated payment model, leading plans to think strategically to position themselves for optimal margins and performance.
As a consultancy 100% focused on healthcare, ProspHire is equipped to support MCOs navigate the MLTSS model through gap analysis, plan design, operational readiness, program optimization and innovation. Our industry experience and commitment to serving the community provides a unique perspective and patient-centered approach. Whether your plan is looking to enter the MLTSS market, improve performance or execute a large-scale strategic initiative, our team is equipped and committed to work in partnership with our clients and drive results.
In the world of healthcare, so many things are interconnected – between technology systems, platforms and other business operational functions. If errors, shutdowns or broad sweeping external factors disrupt operations, the impacts can be far reaching and significant to members and providers.
What are some of the ways that systems, technology and platform disruption can have on the healthcare ecosystem?
Health Insurers:
Operational Disruptions: Delays in claims processing and increased manual workloads can lead to operational inefficiencies and higher administrative costs.
Financial Impact: Increased claims processing times and potential for fraud during disruption could lead to financial losses.
Regulatory Compliance Risks: Difficulty in meeting regulatory reporting requirements and compliance deadlines could result in penalties and reputational damage.
Member Satisfaction: Delays in claims processing and potential confusion about coverage could lead to decreased member satisfaction and trust.
Health Plan Beneficiaries:
Access to Care: Delays in prior authorization and claims processing may temporarily limit access to necessary medical services or medications.
Financial Burden: Beneficiaries might face higher out-of-pocket costs or delays in reimbursement for healthcare services.
Confusion and Anxiety: Lack of clear information and potential disruptions in service could lead to confusion and anxiety among patients regarding their care continuity and coverage.
Providers:
Revenue Cycle Management: Delays in claims submissions and reimbursements can strain financial liquidity and impact the overall financial health of healthcare providers.
Administrative Burden: Increased administrative work to manage manual claims processing and communications with health insurers can divert resources from patient care.
Patient Care Impact: Potential delays in receiving payments may affect the ability of providers to offer timely and comprehensive care, especially for smaller practices with limited financial reserves.
Pharmacies:
Prescription Processing Delays: Disruptions in electronic prescription services and insurance verification processes can lead to delays in dispensing medications to patients.
Financial Impact: Cash flow issues may arise from delays in reimbursement from insurers, affecting the operational stability of pharmacies.
Customer Service Challenges: Pharmacies may face increased pressure from customers experiencing delays or issues with medication access, impacting customer satisfaction and loyalty.
Downstream Entities (e.g., labs, medical device companies):
Operational Disruptions: Entities reliant on timely data exchange and payment processes may experience operational delays and inefficiencies.
Supply Chain Impact: Disruptions in payment and ordering processes could affect the supply chain, leading to delays in delivering medical supplies and devices.
Financial Strain: Delays in payments for services or products could impact on the financial stability of these entities, particularly those with tight operating margins.
If your plan is ever impacted by these types of disruptions, ProspHire is equipped to support you. Our deep expertise in strategy, operations and technology within the healthcare sector positions us perfectly to assist health plans in navigating the complexities. Here are several ways we could provide valuable assistance:
Strategic Response and Recovery Planning
Rapid Impact Analysis:
Our team of payor experts and delivery consultants can quickly produce an impact analysis with plans for developing or executing your existing downtime procedures. We’ll aim to establish governance and track business needs until normal operations proceed.
Identify services of most impact (Prior Authorizations, Claims, etc.)
Rapidly develop, review and execute business continuity procedures.
Establish governance processes and tracking to minimize operational impacts.
Establish transition procedures to return to normal operations.
Incident Response Strategy:
Help develop or refine an incident response plan tailored to cyberattack scenarios, ensuring quick and effective action to minimize damage. Enhanced with agile capabilities and processes to continually prioritize pain points.
Business Continuity Planning:
Assist in creating or updating business continuity plans that specifically address cyber threats, ensuring that critical operations can continue with minimal disruption.
Compliance and Risk Management: Guide health plans through the complex landscape of healthcare regulations (such as HIPAA) related to cybersecurity, helping them to meet compliance requirements and manage risks effectively.
Technology Implementation Support: Advise on the selection and implementation of advanced cybersecurity technologies and practices, including encryption, multi-factor authentication and network segmentation.
Process Optimization: Review and optimize operational processes to enhance efficiency and resilience, ensuring that manual processes are in place to maintain operations during digital system outage and robust planning to ensure a swift return to operational effectiveness.
Communication Planning: Help develop communication plans that clearly outline how to communicate with internal and external stakeholders during and after a cyberattack.
If you or your health plan leadership needs support to navigate technological or system disruption, connect with us today.
The release of ProspHire’s first Diversity, Equity and Inclusion Transparency Report marks a critical milestone in our continuous commitment of fulfilling our core purpose of helping people prosper. This report provides transparency into our DEI initiatives, workforce composition, recruitment and retention efforts and areas of external engagement. We are holding ourselves accountable to taking the steps we know are essential to continue to strengthen our culture, empower our people and drive positive change.
At ProspHire, we firmly believe that initiatives and action on DEI require unwavering support from executive leadership. We leverage firm wide programs to create platforms for intimate dialogues and individual avenues for personal development, which allow for an ongoing evolution of our DEI approach to address the ever-changing conversations essential to all the facets of diversity within our organization.
“We understand that organizations enriched by diverse voices and perspectives are better positioned for success. They build quicker innovation, make smarter risk assessments, exhibit deeper resilience and are better equipped to turn challenges into opportunities. We have seen the advantages of advancing DEI within our operations and therefore, we remain committed to continually prioritizing DEI at every level of our firm.”
Lauren Miladinovich CEO, Managing Principal and Co-Founder
Welcome to Season 2 of ProspHire’s Soaring to New Health podcast. In this episode, Star Quality Healthcare, we dive deep into the world of healthcare analytics and quality improvement with our special guests, Ally Thomas, PhD., AVP of Quality Improvement at UPMC Health Plan and Rebecca Yarish, ProspHire Rising Medicare Stars performance expert.
A Journey of Innovation and Insight
Ally Thomas shares her journey, transitioning from academia to the dynamic world of healthcare analytics at UPMC Health Plan. Drawing from her background in research psychology, Ally found her passion in applying analytical skills to solve real-world business challenges, particularly in the realm of Medicare Stars. She emphasizes the crucial role of analytics in monitoring performance, strategic planning and driving impactful decision-making.
The Power of Analytics in Healthcare
Analytics isn’t just about crunching numbers; it’s about strategically leveraging data to improve outcomes. Ally discusses the foundational pillars of analytics at UPMC Health Plan, emphasizing the importance of scenario-based planning and continuous monitoring. By harnessing data-driven insights, UPMC Health Plan can proactively adapt to changes in the healthcare landscape and ensure quality care for its members.
Navigating Change and Prioritizing Innovation
With healthcare regulations constantly evolving, Rebecca Yarish highlights the importance of staying ahead of the curve. She emphasizes the need for continuous gap closure and forward-thinking strategies, especially in anticipation of upcoming changes like the Health Equity Index and the transition to digital quality measurement. By embracing innovation and focusing on member preferences, healthcare organizations can better serve their communities and drive meaningful improvements in care delivery.
Building Strong Partnerships for Quality Care
At the heart of quality healthcare are strong partnerships between health plans, providers and members. Ally and Rebecca emphasize the importance of collaboration and communication, whether it’s working closely with healthcare concierge teams or supporting smaller provider practices. By building meaningful relationships and understanding the unique needs of each stakeholder, UPMC Health Plan is able to deliver personalized, high-quality care to its members.
As we navigate the complexities of the healthcare landscape, one thing remains clear: innovation and collaboration are key to unlocking quality healthcare for all. By harnessing the power on analytics, embracing change and prioritizing member preferences, organizations like UPMC Health Plan are paving the way for a brighter, healthier future.
Thank you for tuning into this episode of ProspHire’s Soaring the New Health podcast. Stay tuned for more insights and inspiration as we continue to explore the ever-evolving world of healthcare. For the more in-depth discussion on Stars Performance Improvement download the Soaring to New Healthpodcast, Star Quality Healthcare, where you find your podcasts.
Welcome to our Q&A session with Dan Crogan, a Principal and the Senior Vice President of Consulting at ProspHire. The Firm takes a distinctive approach to healthcare organization transformations, centered on expert delivery and execution. We view our teams as extensions of our clients, measuring success not just by project completion but by seamless integration of change into daily business activities. With a commitment to understanding the client’s vision and tailoring innovative ideas to accelerate plans, ProspHire collaborates closely with clients, recognizing the unique nuances within each organization. We’ll explore how ProspHire’s healthcare exclusive focus, collaborative approach and emphasis on how driving adoption sets us apart in the healthcare consulting industry. You’ll also learn about methodologies, success stories and the role technology plays in achieving impactful healthcare transformations.
ProspHire emphasizes expert delivery and execution in healthcare organization transformations. Can you share examples of how this commitment has led to successful outcomes for your clients and what strategies your team uses to ensure excellence in delivery and execution throughout the project lifecycle?
Our dedication to expert delivery and execution has consistently driven successful outcomes for our clients. We understand that the healthcare industry is complex and every health plan has unique member needs and unique challenges. Our team leverages our client’s expertise because no one knows their members and challenges better than them. We approach each engagement as if we are an extension of their team and utilizes our experiences to customized solutions, continuous improvement and transparent communication. Together they help us deliver exceptional results for our clients and drive positive transformation and sustainable growth in the industry.
Approach and Philosophy: Can you elaborate on ProspHire’s approach to viewing the internal teams as an extension of clients that are healthcare organizations? How does this approach contribute to successful transformations?
We look at each healthcare organization as if we are an extension of their team. The way we measure success isn’t just when the project is completed or goes live, it’s when the change is adopted as a business-as-usual activity. By doing this, we’re able to work with the leader to understand their vision and why it’s important to the company. With their vision and our experience, we can bring innovative ideas to accelerate their plans and develop the roadmap with the client’s delivery teams on how the project can be completed. An important thing for us to remember is, even though we may have successfully completed the same project 100x elsewhere, how it gets done within each client’s walls can be drastically different and we need to adapt to those differences.
Differentiation in the Industry: ProspHire prides itself on being 100% healthcare focused. How does this exclusive focus differentiate you from other consulting firms in the industry?
ProspHire distinguishes itself in the consulting industry through an unwavering dedication to healthcare. It’s a commitment that sets us apart from many of our competitors. We approach our engagements as being an extension of the clients’ teams, building a deep understanding of their needs and objectives. We take pride in our unique capability to enhance our clients’ strategies, executing projects with precision and efficiency. Our measure of success goes beyond project completion; it is defined by the seamless adoption and transition of projects to the client, ensuring they can independently operate without external assistance. This approach emphasizes long-term effectiveness over short-term milestones, reinforcing ProspHire’s reputation for delivering value to our clients.
Success Stories: Can you share a recent success story where ProspHire partnered with a healthcare client to achieve significant transformational outcomes? What were the key factors that contributed to that success?
We’ve been dedicated to delivering transformative outcomes in healthcare for nearly a decade and every project has its own unique significance. Whether it’s a small, two-person engagement lasting just a few weeks to swiftly address a client’s immediate needs or a complex project like launching a new ACA product or helping a client in achieving a coveted 4-star rating for Quality Bonus Payment (QBP) or helping a dental client integrate other DSOs as part of acquiring new practices, we approach each with the same level of commitment and pride. What sets us apart is our understanding that every client has choices when it comes to selecting consulting firms and we are honored when we earn their trust to partner together on any engagement. It’s the combination of dedication, adaptability and trustworthiness that consistently contributes to our clients’ success and sets us apart in the industry.
Methodologies and Frameworks: ProspHire adapts methodologies to the client’s environment. Can you provide examples of the diverse methodologies and frameworks your teams leverage to ensure effective delivery and execution?
We pride ourselves on our ability to tailor methodologies to suit each client’s unique environment and references for project execution. One of the key approaches we take is to leverage the delivery model that best aligns with the specific needs of the client and the type of engagement. Our diverse team is equipped with a range of certifications including PMPs, CSM and can provide expertise in agile methodologies, waterfall, scrum, ITIL, among others. Additionally, we have certified nurses on staff, further enhancing our capacity to understand and address healthcare-specific challenges. Over the past five years, we have extended the certifications to our clients through our ProspHire University.
Keeping Up with Trends: How does ProspHire stay up to date with the latest trends and regulations to provide clients with the most relevant and impactful solutions?
Staying on top of the latest trends and regulations in healthcare is fundamental to our mission of helping our clients provide better access to quality healthcare. First and foremost, we prioritize listening to our clients, striving to understand their pain points and how we can alleviate them, enabling to focus on future planning. Secondly, our exclusive focus on healthcare allows us to closely monitor changes from entities like CMS and government agencies, translating them into actionable insights for our clients. Additionally, we actively participate in conferences and maintain a robust network of partners, creating an environment to discuss public insights and their implications. Lastly, our commitment to innovation ensures that we continuously evolve to meet our clients’ changing needs. With a dedicated innovation team, we transform ideas into tangible solutions, addressing both current challenges and anticipating future requirements. This multi-faceted approach ensures that ProspHire remains at the forefront of industry trends, equipping our clients with the tools and strategies they need to succeed.
Technology and Transformation: Given ProspHire’s technology-agnostic approach, how does technology play a role in healthcare transformation projects and how do you ensure its seamless integration for project success?
Our world is enabled by technology one way or another. At ProspHire, our approach is to be technology agnostic and apply proven methods of delivery and implementation to any engagement we earn. We aim to be fluid with the market and products so we can provide a neutral opinion to our clients based on what they need vs. products we’re tied to. Not every client needs the exact same solution, even if the problem is similar. There are enterprise-wide factors that need to be accounted for before making these decisions and spending a lot of time and money implementing the change.
Collaboration Strategies: Collaboration is crucial in solving complex challenges. How does ProspHire develop strong collaboration between its consultants and the client’s internal teams to ensure seamless execution?
Building strong collaboration between our consultants and our clients’ internal teams is paramount to driving seamless execution in tackling complex challenges. We approach every client engagement as an extension of their team, rather than as an external group. We recognize that no one understands our clients, their team dynamics and their challenges better than they do themselves. Therefore, our focus remains on integrating seamlessly into their operations, rather than drawing attention to any perceived differences. The ultimate testament to our collaborative approach is when our clients tell us that they can’t distinguish our consultants from their own full-time employees. This feedback reaffirms our commitment to working hand-in-hand with our clients, leveraging our expertise to support their goals while maintaining a unified and cohesive team dynamic.
Change Management: Large-scale healthcare transformation projects often require changes at various levels of an organization. How does ProspHire manage change management strategies to ensure smooth transitions and adoption of new processes?
Managing change in large-scale healthcare transformation projects begins with a strategic approach embedded withing our contracts. While contractual obligations provide a framework for change management, our motivation extends beyond mere legal requirements. We prioritize clarity in our contracts to underscore our ultimate objective: to alleviate our clients’ pain points, effect transformation and facilitate the smooth transition of responsibilities back to their teams. Our emphasis is not on prolonging our involvement but rather on empowering our clients to operate their programs independently. This approach reflects our commitment to responsible and efficient project execution, ensuring that that our clients can quickly adapt to new processes while positioning us as trusted partners for future initiatives.
Leadership and Differentiation: As a principal and the Senior VP of Consulting, what key qualities and expertise you believe your team brings to the table that truly differentiates ProspHire in the healthcare consulting arena?
I firmly believe that our team’s key qualities and expertise set us apart in the healthcare consulting arena. One of our core strengths lies in our unwavering commitment to a shared end goal. This may seem straightforward, but as our firm expands, the importance of over communication becomes paramount in ensuring alignment among our leadership and staff. Our overarching objective is clear: to serve our clients’ needs without exception. This means sometimes referring them to another resource or competitor if we can’t address their problem responsibly and promptly. We refuse to allow our clients to remain in pain or wait for solutions that may not materialize. This dedication to client-centric service underscores our leadership approach and distinguishes ProspHire as a trusted partner in healthcare consulting.
The RFA for Pennsylvania’s MLTSS services was released on January 30th, opening the door for Pennsylvania Managed Care Organizations to plans to apply to provide unique services to the 400,000+ eligible Pennsylvanians. Shifting away from statewide contracts, Community HealthChoices (CHC) awards will occur by zone, following a model similar to the physical HealthChoices program.
Since the Last RFA
Following the initial launch of the Community HealthChoices program, DHS has included notable changes to the program objectives in alignment with greater department goals going into this RFA:
Expanding from the Triple to the Quintuple aim, reflecting improved population health and addressing health equity
Emphasizing equity, social determinants of health and cultural competency with a “zone” approach to address the needs of Pennsylvania’s communities
Encouragement of Participant directed model services, allowing individuals to have more control over where, when and how some of their services and supports are delivered by increasing Participant understanding of benefits
Strengthening collaboration with and coordination of behavioral health services
A Regional Approach
The governance of the CHC program is a significant change for applicants, particularly incumbents, as a criterion for this RFA is to clearly and specifically develop an approach to address the “particular and unique demographic, cultural, economic, geographic, or other relevant characteristics of the regions, counties, and municipalities comprising the zones(s)”. As a key element of the applicant’s Soundness of Approach there are several opportunities to complete an application for statewide coverage while following the technical submission opportunities to highlight the regional approach to care. This will be particularly of interest to DHS to address access to care in rural and underserved areas of the Commonwealth.
MLTSS Distinctions
While incumbents focus on program enhancements and changes, new applicants focus on adaptation of current lines of business to meet MLTSS requirements.
Unique Provider Network: Establish or enhance provider networks by contracting with LTSS providers to meet network adequacy with cultural competency in mind, leading to new partnerships and potential value-based contracts that do not currently exist
Person-Centered Service Plans: Develop or improve internal staffing to meet CHC requirements for care coordination, enabling tailored whole-person, or patient-centered, service plans that address participants’ needs, goals and preferences
Rebalancing of Services: Seek to implement and enhance options for least restrictive, community-based living support for members to experience uninterrupted, patient directed, high-quality care
Care Coordination & Integrated Services: Understand the integration of existing services (Medicare, Behavioral and MA) to enable appropriate utilization of clinical and other LTSS services, increasing member satisfaction and quality scores
