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Pharmacy Benefit Management (PBM)

Does Your Plan’s Performance Align with Your Pharmacy Strategy?

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Does Your Plan’s Performance Align with Your Pharmacy Strategy?

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The Centers for Medicare and Medicaid Services (CMS) National Health Expenditure (NHE) data
highlights the excellent healthcare spending growth year over year. Up nearly 10% from 2019, the U.S.
spent $4.1 T on healthcare costs in 2020, and prescription drugs accounted for 8% of the total spend
(roughly $348B).

As stricter regulations, innovations and other drivers rise, plan sponsors should evaluate their strategy
and key priorities regarding pharmacy benefits and prescription drug costs. The ever-changing pharmacy
landscape supports the importance of a tailored pharmacy strategy.

What does your current pharmacy strategy look like? Is it a robust plan with a clear direction? Are the
appropriate levers in place to meet quality standards and optimize plan performance?

You could be leaving money on the table by not having a defined strategy. This gap opens the door for
poor member experience, unoptimized clinical programs, over-utilization of prescription drugs, and a
lesser quality of care. It ultimately impacts the financial and operational performance of your plan’s
pharmacy offering.

Below we explore pharmacy strategy considerations in three areas, along with how market trends are
driving many plans to reconsider their strategic priorities.

Pharmacy Benefit Management (PBM)

Pharmacy Benefit Management (PBM):

The Pharmacy Benefit marketplace continues to evolve through plan benefit design, innovative pricing
strategies and more educated purchasers of PBM services. Many plan sponsors are reevaluating their
approach and priorities for managing prescription drug spending. The renewed priorities are improved
cost containment strategies and pricing transparency. Recent findings from audits of pharmacy benefit
pricing practices in several state Medicaid programs have uncovered considerable opportunities for cost
savings to the plans. These findings have created an opportunity for plan sponsors to evaluate the
appropriateness of their potential pricing efficiencies and PBM contract performance.

Many traditional PBM contracts are written with somewhat vague and complex language, creating
ambiguity. By framing your pharmacy benefit strategy through transparency and accountability, your
plan becomes better positioned to work with a PBM that shares aligned incentives. Performing a
contract review and assessing how your PBM contract is performing against adjudicated claims serves as
a practical exercise for identifying pricing inefficiencies and determining your future strategy.

Specialty Pharmacy Optimization

Specialty Pharmacy Optimization:

Prescription drug costs continue to be a concern for plan sponsors. The past ten years have brought revolutionary, life-sustaining and life-changing treatments to market; however, it has brought higher price tags.

Moving forward, plan sponsors seek innovative approaches and solutions to review the costs associated with these specialty therapies. One key strategy for approaching specialty treatment costs is value- based arrangements. This has been somewhat controversial over the past few years but remains a hot topic and key priority for many plans. Getting the best price on the wrong drug is a bad deal for everyone. Therefore, plans must gain the ability to measure the effectiveness of these treatments and member outcomes.

One market trend to watch in 2023 is biosimilars. Biosimilars have the opportunity to be the gateway to value-based outcomes. Though biosimilars exist today, several are scheduled to come to market and contest the world’s top-selling prescribed therapy, Humira, in 2023. To date, we’ve seen mixed reactions on biosimilars' uptake or interchangeability, but Humira's biosimilars can change this narrative and create enhanced price modeling for future therapies.

In the meantime, plan sponsors are evaluating their current specialty strategy. One example is assessing benefit designation for high-cost specialty treatments. A plan can identify potential cost-saving opportunities by comparing reimbursement determination with differing benefits. Typically, this approach is deployed for high-cost therapies being managed under the medical benefit and assessing the clinical and economic value of transitioning them to the pharmacy benefit.

Medicare Part D Enhancement

Medicare Part D Enhancement:

Medicare Part D spending has grown faster than the rest of Medicare due in part to increasing prescription drug prices. Estimates show that approximately $111B will be spent by the program to provide coverage for more than 2 billion prescriptions in 2022.

Amending the design of the Medicare Part D benefit, the Inflation Reduction Act of 2022 (IRA) Prescription Drug Provisions are being considered a milestone achievement for lowering prescription drug costs. Several vital provisions were included in this act to reduce prescription drug spending by Medicare. At this time, the most publicized achievement limited the price of insulin products to no more than $35 per month in all Part D plans. In addition, the act will allow the Secretary of the Department of Health and Human Services to negotiate the price of some drugs covered under the Medicare D plans, leading to additional realized savings to plan beneficiaries.

The Inflation Reduction Act will financially impact health plans. More responsibility will be shifted to Part D plans and drug manufacturers for beneficiary coverage in the catastrophic phase. Drug manufacturers will be required to pay a rebate to the federal government if the prices of medications covered under Part D outpace the inflation rate. A cap will also be placed on out-of-pocket drug spending by eliminating the 5% coinsurance requirement of the beneficiary in the catastrophic phase.

Health plans should begin developing strategies to address the potential loss of revenue associated with the Inflation Reduction Act. Resources should be utilized to focus on total patient care and appropriate disease state management with the most cost-effective medications for beneficiaries. The understanding of how well Part D meets the needs of Medicare patients will be highly scrutinized, with these rolling provisions starting as early as the calendar year 2023.

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Create a Strategic Pharmacy Plan with ProspHire

ProspHire is dedicated to helping clients across the country to provide the solutions needed to execute their strategic pharmacy vision. We understand the dynamic nature of the pharmacy landscape and have experience in solving unique healthcare and pharmacy challenges. Contact us here to learn more about how ProspHire can help your organization deliver on its pharmacy strategy.

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How to Improve Clinical Care and Healthcare Performance Metrics

Written by oadmin on . Posted in Insights.

Improve Clinical Care and Performance Metrics in Healthcare

Each year most hospitals in the United States are subject to significant impacts on their revenues based on their performance in three Centers for Medicare and Medicaid programs. These programs are based on the concept of moving from volume to value-based reimbursements. The programs include the Hospital-Acquired Conditions Reduction Program (HACs), Hospital Readmission Reduction Program (HRRP) and the Value-Based Purchasing Program (VBC). These performance-based programs require hospitals to report specific quality and cost metrics yearly. Their numbers are weighted against the performance of all other hospitals required to participate.

CMS changed the program requirements for reporting and performance during the COVID-19 pandemic, but many of these supportive changes will expire for future performance years. As hospitals struggle with maintaining revenue, now is the time to revisit historical and future performance opportunities to ensure that penalties are avoided and potential additional revenue can be secured. This focus must persist despite hospitals’ staffing and patient care challenges in the post-pandemic environment.

Baseline Performance Evaluation is the best place to start

Baseline performance evaluation is the best place to start with a deep understanding of the program benchmarks, methodology and reporting structure. Hospitals should examine their pre- and post-pandemic performance to gauge future performance improvement opportunities. The programs are designed to reward based on both current evaluation period performance and improvement in some cases. The information is available in hospital-specific reports provided to the facility. 

Performance-Based Programs

The second step in improvement should focus on each program and developing an in-depth understanding of how the data is governed, captured and reported in the facility.

Hospital-Acquired Conditions (HAC) Program

The first program to review is the Hospital-Acquired Conditions (HAC) program that involves understanding the reporting of the CMS Patient Safety and Adverse Composite score (PSI-90) and infection measures, including Central Line Associated Blood Stream Infections (CLABSI), Catheter-Associated Urinary Tract Infections (CAUTI), Surgical Site Infections (SSI), Methicillin-resistant Staphylococcus aureus bacteremia (MRSA) and Clostridium difficile infection (CDI). Hospitals that perform above the 75th percentile, allowing for winsorization and comparative performance, will be penalized after FY 2023 by a 1% payment reduction.   

The second program to focus on it the HRRP

Hospital Readmissions Reduction Program (HRRP)

The second program to focus on is the Hospital Readmissions Reduction Program (HRRP). It is based on a 30-day risk-standardized unplanned readmission ratio that includes acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), Pneumonia (excluded in FY 2023 payment), coronary artery bypass graft surgery and total hip and knee arthroplasty (THA/TKA). Payment penalties are calculated based on peer performance and can represent a 0-3% payment reduction. Much of the program is also about ensuring that the provider is capturing and coding all comorbid conditions that could impact the readmission risks. 

Value-Based Purchasing (VBP) Program

The third program to analyze is the Value-Based Purchasing (VBP) program. It is divided into four categories, including:

  • Clinical Outcomes 25%
  • Person and Community Engagement 25%
  • Safety 25%
  • Efficiency and Cost Reduction 25%

The VBP program is the only program that may allow a hospital to gain greater reimbursement than is withheld from the facility at the beginning of the fiscal year.  If the facility’s performance values are higher than the benchmark, achievement thresholds may receive more than the 2% withholding from the facility. The VBP metrics include some metrics utilized in the other programs along with performance on measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and the Medicare Spending per Beneficiary (MSPB) measure. 

Once the historical and current performance is understood, the task of developing performance improvement plans for each area could potentially impact scoring in the three programs. This involves bringing together multidisciplinary teams from across the hospital and educating the team members on the metrics, performance and opportunities for improvement. It is common for a facility to involve several workgroups to brainstorm, test and implement performance improvement projects in each critical area. While a significant undertaking, the financial impact of successful improvement can make a substantial difference in the hospital’s bottom line. 

ProspHire Can Help

The team at ProspHire has worked with hospitals on performance improvement in these areas. Our deep clinical knowledge, clinical staff experts and project management specialists have helped hospitals realize substantial enhancements tied to CMS programs. We can help your hospital focus on improving clinical care and performance metrics in the future. To connect with a ProspHire professional, fill out the form in the right column.    

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Did your Star Rating drop?

Written by oadmin on . Posted in Insights.

Did Your Healthcare Organization’s Star Rating Drop?

What to know and what to do now

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On October 6th, 2022, the Centers for Medicare and Medicaid (CMS) released the official Star Year 2023 Data – including contract and measure level detail to the public. As we’ve talked about for some time now, the industry did observe a great Stars recession with average ratings plummeting year over year and returning to pre-pandemic levels (SY2020). With many important regulatory changes already in place and several on the way (Tukey Outlier Deletion), Health Plans can anticipate more disruption in the marketplace.

Graph compares health plans overall star rating between SY2022 and SY2023

Distribution of Star Rating Change from Prior Year

Nearly 20% of Health Plans experienced a drop out of the Quality Bonus Payment (QBP) range in SY2023. Last year, about 70% of contracts achieved the QBP whereas in 2023 only about half of contracts got the QBP. This drop will put added financial pressure on health plans to achieve cost savings either through improved medical management or enhanced revenue capture. More importantly, this negative shift represents the new Stars reality, where CAHPS and Member Experience performance will drive the bulk of the marketplace and will force plans to invest more time and effort into benefits, personalized member experiences, and improved operational excellence.

Graph showing average star rating year over year

Average Star Rating Year Over

Since the programs’ inception, Star Ratings have steadily increased year over year. Due to COVID guardrails and other “better of” protections, SY2022 was the highest on record and for many, was quite anomalistic. The SY2023 drop off was quite precipitous, with average ratings falling to near pre-pandemic levels. What does this all mean? It’s hard to say in the long run, but we cannot discount the impact that Member Experience and CAHPS will have on the programs overall average rating for the foreseeable future. Perhaps with these weighting changes, the program will see a ‘leveling off’ for the next few years as average scores remain neutral. In any case, those Health Plans that saw massive drop offs in scoring will have plenty of opportunity to rescue their scores in SY2024 and beyond.

Distribution of Star Rating SY 2023

Distribution of Star Rating SY2023

When analyzing the distribution of Star Ratings for SY2023, the biggest takeaway are the tail ends of the distribution. We saw a big drop off in 5-Star plans (year over year) and a massive increase in 2- and 2.5-Star plans (year over year). With almost 50% of plans facing a drop in Star Rating year over year, the distribution of ratings returned to a somewhat more normal distribution.

Average Domain Rating: CAHPS with the Health Plan and Drug Plan

Plan Count by Overall Rating & Average Member Experience Rating

In SY2023, CMS adjusted the weighting of CAHPS and Member Experience measures to account for ~60% of the Overall Star Rating, shifting Health Plan’s focus away from majority gap closure efforts to putting member experience at the forefront of strategies. 254 contracts were able to achieve a 4.0 Star Rating with this adjustment in the Star rating landscape. Approximately 60% of contracts with 4.0 Stars or greater, scored >=4.0 Stars in the CAHPS Domains. This further emphasizes that CAHPS/Member Experience are major drivers in overall contract rating performance and failing to succeed in those areas will hurt your plan performance. Bottom line, 70% of plans with <4.0 Stars in CAHPS were not able to achieve the QBP and did not receive 4.0+ Stars at the contract level.

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Are you at risk of a drop in your Stars Rating? We are here to help…

Written by oadmin on . Posted in Insights.

At Risk of a Drop in Your Stars Rating? ProspHire is Here to Help

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It is imperative that organizations continually have a focus on Medicare Stars to achieve optimal success and reach their contract goals. Is your organization currently experiencing pain points within your Stars Program? At ProspHire, we’ve been partnering with health plans to conduct comprehensive Stars Capability Assessments. These assessments enable us to produce sustainable strategic plans to achieve contract level success.

Below we detail some common organizational challenges facing low performing or at-risk Stars contracts.

Common Organizational Challenges

  • Lack of Organizational Wide Buy-In
  • Siloed Entities with the Health Plan
  • Lack of Stars Education and Awareness
  • Poor or Weak Governance Structure
  • Limited Stars Budget and Dedication
  • Lack of Spotlight on Medicare Line of Business
  • Reactive not Proactive Program Actions
  • Poor Measure and Contract Level Forecasting
  • Lack of Analytics Driving Decision Making
  • Poor Priority Measure Identification
  • Lack of CMS Guidelines and Regulatory Understanding
  • Competing Priorities Drawing Away Focus

Within a Stars Program Capability Assessment there are six core items that our team at ProspHire evaluates to identify the current state of a Stars program. Measuring a plans capabilities focused through these six areas empowers us to uncover insights and determine pathways forward to improve Stars measure and contract level performance.

6 Core Items to Identify the current state of a Stars program

Connect with ProspHire Today

At ProspHire, we’ve successfully partnered with a number of health plans to improve their Stars capabilities. Is your plan in need of a Stars Program Capability Assessment? Fill out the short form in the right column and connect with one of ProspHire’s experienced leaders.

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Have You Identified Strategies to Address Maternal Health Equity?

Written by oadmin on . Posted in Insights.

At ProspHire, we partner with Health Plans and Health Systems to offer insights, analysis and execution strategies to improve Maternal Health outcomes through social determinant of health and health equity focused solutions. Using evidence-based improvement strategies and population health analyses, ProspHire can evaluate and drive change in maternity outcomes.

As you may know, among developed countries, the United States has the highest maternal mortality rate1. The variation in this rate, however, is dramatically different when assessed by race and ethnicity. Variation also exists regionally. Both claims and publicly available data can help your organization prioritize and strategize to improve maternal outcomes.

Let’s take a look at ProspHire’s home state of Pennsylvania:

Non-Hispanic Black Women compared to White Women (PA)

Consider the data above where we see low rates of prenatal care among Non-Hispanic Black Women. Taking this data a step further, Philadelphia County experiences the highest rates of low-birth-weight incidence in the state. These metrics can drive additional analyses to understand potential interventions and community needs for the Philadelphia region.

Driving change can take different shapes and forms. To drive change in the right direction, consider your population of focus. This ensures that interventions cater to those in need, when in need.

At ProspHire we utilize a four-pronged approach:

Maternal Health Graphic Four Pronged Approach

For more information on how you can address Maternal Health Equity, connect with one of ProspHire’s professionals by filling out the short form in the right column.

What to know about contracting with a Pharmacy Benefit Manager

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What is a PBM and what are their roles and responsibilities?

PBMs are intermediary companies that administer and manage pharmacy benefits
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Pharmacy Benefit Managers, or PBMs, are intermediary companies that administer and manage the pharmacy benefits (prescription drug plans) within the healthcare ecosystem. Pharmacy Benefit Managers work on behalf of Payors such as Medicare Part D Plans, Employer Sponsored Plans, Managed Medicaid Plans and Health Plans. 

Without stringent oversight, pharmacy spend can rise uncontrollably, which is why PBMs have become a necessary stakeholder in healthcare. Operating behind the scenes, PBMs are tasked with controlling prescription drugs costs, which they can accomplish in a variety of ways.

What is a PBM and what are the ir roles and responsibilities?

In managing the pharmacy benefit plan, PBMs’ core responsibilities include:

  • Development of formularies, drug lists, utilization management (UM) strategies and prior authorization (PA) criteria – all of which have influence in determining members out-of-pocket costs
  • Negotiating discounts and rebates from drug manufacturers
  • Negotiating with the large matrix of the pharmacy network to ensure best pricing for Plans and pharmacies and improved access to care for members

These require coordination across many stakeholders and are often complex in nature.

There are several items to be considered when a PBM bears these responsibilities.

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What are the Types of PBM Contracts?

The marketplace has shifted dramatically in the past few years as more health insurers and health plans move their attention to challenging status quo and seek greater accountability, more transparency and superior performance from their PBM. It’s important to note that a one-size-fits-all approach is typically not in the best interest of the clients. Each plan has varying mix of demographics and aging populations, as well as risk-tolerance.

What are the types of PBM contracts

The types of pharmacy contracts include:

  • Traditional PBM Contracts
    Most agreements existing today fall under this bucket and often require the most oversight for measuring contract adherence due to the lack of transparency. Traditional PBM contracts focus on delivering higher rebates to drive “cost savings”. Additionally, under this model, administrative fees are not collected from the client by the PBM. However, masked under the terms of the contract is something called “spread pricing”, which is a large revenue driver for PBMs. Spread pricing can be defined as the difference between what the PBM reimburses the pharmacy that provided the drug to a given member versus the amount a PBM charges the client for that same transaction. Noteworthy is the potential conflicts of interests under this type of arrangement.
  • Pass-through Contracts 
    In a pass-through contract, the PBM transitions to a fully transparent model that may benefit the client via the (full) pass-through rebates and other cost savings. Pass-through PBMs thrive on showcasing their transparent nature; therefore, any or all fees or charges are typically disclosed up front. Under a pass-through arrangement, one may experience a greater depth of customization for utilization management strategies and formulary control.
  • Hybrid Contracts
    A hybrid contract offers a blend of pass-through and traditional modeling. PBMs may still earn revenue through spread pricing and charge fees; however, they disclose these practices in a more visible manner. That stated, clients are better positioned for receiving a portion of the revenues generated from, for example, rebates passed on from the manufacturer to the PBM. It’s worth noting that incentives may remain somewhat misaligned under a hybrid model by not offering full transparency into true cost-savings potential.

PBM Contracts

PBM contracts can quickly become overwhelming and managing them carefully is no small task. It’s critical to the Plan’s performance to ensure the contract is explicit and does not include potentially damaging loopholes. Understanding the entire agreement is essential for the Plan’s protection. Often these contracts contain lengthy sections filled with nuances that dictate the type of arrangement the Plan and PBM are entering. Definitions are one key section that requires complete understanding and agreement. Sometimes vague, the definitions enable many levers that can result in unnecessary spend. It is essential to ensure definitions align in the Plan’s favor and are best described to protect the Plan. 

Financial and performance guarantees are additional contractual focal points that require attention. Whether financial or performance based, clients need to A) understand exactly what the guarantees entail/cover, B) understand how exactly these will be measured and monitored and C) ensure the client has full control for auditability. This degree of oversight enables the PBM to assume more of the accountability and risk-sharing.

Financial and performance guarantees are additional contractual focal points that require attention.
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PBM Contract Lifecycle

The healthcare industry is rapidly changing and much of this is driven by the pharmaceutical industry.  As such, it’s imperative for Plan Sponsors to approach their PBM contract with the fluid nature of the industry in mind. Lengthy contract terms may limit the ability for Plans to renegotiate when changes in the market occur. 

The PBM contract contains procurement or monitoring. Ideally, the contract also contains flexibility for optimization as the industry evolves over time.

  • Procurement can be very involved and is typically a lengthy process. Plan Sponsors in the Medicare or Medicaid space have significantly more considerations to evaluate in the RFP process as compared to Commercial or Employer sponsored plans – compliance and reporting to name a few. However, the complexity and details of the process should not overshadow the need for flexible contract provisions that allow both monitoring and optimization. This requires the inclusion of certain language, as well as the elimination of loopholes that protect PBM interests.
  • Monitoring of plan performance could arguably be as important as the negotiated terms. Just because a PBM agreed to certain terms does not mean that they will deliver in their performance. It is incumbent on the Plan Sponsor to hold their vendor accountable to the agreed upon terms and rates. Success here is entirely dependent upon access to timely information and once that data is obtained – having systems to review performance.  As claim volumes increase so does the possibility (and likelihood) of errors in processing and payments. It may seem obvious but Plans should never assume that claims are processing as planned.
  • Optimization should not occur strictly at contract renewal. There is simply too much innovation in the marketplace to not take advantage of it in “real time”. With an understanding that significant changes cannot occur in the middle of a plan year, Plan Sponsors should not be limited to grow and evolve with the market around them. 

Whether you are still within the walls of your current agreement or are in the marketplace for a new PBM, it’s important to understand the lifecycle of PBM contracting. Understanding that procurement of the contract is the just a starting point and not the finish line empowers the Plan to deliver better results to all stakeholders.

How Can ProspHire Help?

The complexity involved when evaluating an agreement with a Pharmacy Benefit Manager is no small task and there are many nuances that dictate real-life outcomes. One bulletproof method to improving value within your Pharmacy Benefits plan is understanding the strategies available, along with having a playbook to deploy during the different phases of the contract lifecycle.

ProspHire has the expertise to augment and support you to ensure all blind spots are covered when it comes to PBM contracting. Regardless of the stage in the PBM contract lifecycle, we will meet you where you are. Get support by filling out our form below.

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How to Improve Vendor Management

Benefits of Vendor Management & How to Improve the Process

Written by oadmin on . Posted in Blog, Stars Performance Improvement.

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The companies or individuals that provide your healthcare organization with services, technologies and other goods are its vendors. Healthcare providers rely on vendors to provide services, technologies and goods so they can grow and scale their businesses and provide excellent service or care to consumers. For example, health plans may leverage vendors to assist with administration of Health Risk Assessments or utilize vendor outsourcing arrangements to efficiently scale their sales contact center on a seasonal basis. Without vendors, healthcare organizations face costly decisions to build capabilities outside of their core competencies and risk continued investments to keep capabilities up-to-date and compliant with changes in regulatory requirements.

The vendors your healthcare organization chooses significantly impacts the quality of care and service that you can offer. The right healthcare vendors also help save your organization money, enable you to grow and allow you to maintain compliance. Learn more about the importance of vendor management and what your healthcare organization can do to improve it.

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What is Vendor Management in Healthcare?

Vendor is a broad term for the entity in the supply chain that sells a product or service directly to a user. In healthcare, the user is the health plan, hospital system, medical practice or another healthcare organization. Healthcare vendors can include any of the following:

  • Software vendors including EHR or ERP systems
  • Functional or process outsourcing such as contact center
  • Professional consulting services
  • Health risk assessment vendors
  • Staffing services
  • Accounting services

When a healthcare organization chooses the vendors it wants to work with, it needs to consider the potential cost of the relationship and any compliance issues with the vendor. If your organization participates in Medicare or Medicaid, the vendors you choose can’t be on the Office of the Inspector General’s exclusion list.

Vendor management is the process of controlling costs and minimizing risks to your organization. It also helps you maximize value from the companies you choose to work with and potentially improves the service you get.

Usually, vendor management is a multi-stage process.

  • Discovery and selection: The first step is to research your vendor options and choose potential companies to work with. A request for proposals is typically part of this process. 
  • Negotiation: The next stage is to negotiate and build relationships with the desired vendors to come to an agreement that benefits both parties. 
  • Implementation: During implementation, your organization starts to work with the vendor. At this stage, you can evaluate whether the services or products benefit your organization or if working with them creates more challenges. Also in this phase, you need to ensure your vendors comply with HIPAA or HITECH regulations.
  • Assessment: After working with the vendor for a while, it’s critical to evaluate the relationship. Look at how the vendor performs, how much your organization spends and other factors to determine if the partnership helps you reach your goals or costs more than you anticipated. At this point, you might try to renegotiate with the vendor if things aren’t working out, or part ways with one vendor and continue to work with another.


The Benefits of Strategic Vendor Management

The benefits of strategic vendor management

There are many advantages of developing a vendor management strategy for your healthcare organization.

  • Reduced risk: A vendor management strategy reduces risk to your organization and the consumers you serve. For example, it can help you steer clear of vendors on the excluded list. It also helps you avoid companies that may underperform and provides you with a cushion if one vendor closes or has supply chain issues. 
  • Improved quality: Vendor management can help your organization select specialized and best-in-class vendors who improve the quality and consumer experience that your organization provides. Having a vendor management plan in place also streamlines the process of dealing with vendors, so your teams can focus on your organization’s core competencies and strategic goals.
  • Better negotiating position: Vendor management gives your organization leverage. After years of working with Vendor A, you might receive a considerably more cost-effective proposal from Vendor B, but you’ve spent time nurturing a relationship with Vendor A and want to maintain it. With a management system in place, you have the option of going to Vendor A and negotiating with them to get a better price. The vendor gets to keep your business, and you can save money.
  • Improved reputation: Vendor management enhances or preserves your organization’s reputation. You don’t want people to think of you as the hospital that pays late or the medical practice that abruptly stops working with vendors. You can keep a positive relationship with everyone when you know who you’re working with, when invoices will arrive and when they’ll be due.
  • Improved diversity and compliance: Vendor management can help your organization to set and execute a strategy to work with Small and Diverse Businesses (SDBs), which provides important support to SDB organizations. Supplier diversity programs also drive and monitor compliance with SDB spend that may be required under selected government contracts.

How to Improve the Vendor Management Process in Healthcare

Establishing a set of vendor management best practices can help improve the process at your organization. One best practice to follow is to use a centralized model. Healthcare organizations may take a siloed approach to vendor management, leaving each department responsible for separate vendors. That can lead to missed opportunities, such as savings and can also lead to duplication.

Developing a centralized model integrates your vendors into your organization and gives you a reliable way to track performance. A centralized approach also makes it easier to remain in compliance with regulations.

Continuous monitoring of vendors should also be part of the vendor management process. A vendor-organization relationship that starts well could end up on shaky ground for various reasons. A vendor might struggle to send timely shipments or change manufacturers, resulting in a lower-quality product. Keeping tabs on your vendors allows you to adjust as needed to maintain your organization’s reputation and continue providing the best care possible.

ProspHire can help your healthcare organization develop a centralized vendor management office

ProspHire Can Help Your Organization Develop a Centralized Vendor Management Office

ProspHire wrote the playbook on using a centralized vendor management office, and we can help your organization do the same. To learn more about our approach and how we can help you develop a winning vendor management strategy, contact us below.

"What is the Medicare Star Rating?" cover photo

What Is the Medicare Star Rating?

Written by oadmin on . Posted in Blog, Stars Performance Improvement.

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The Medicare Star Rating System evaluates the performance of health insurance providers’ Medicare Advantage — also known as Medicare Part C — and Part D plans. Rated from one to five, with one being “poor” and five being “excellent,” the rating system ensures the quality of services insurance providers offer their clients while providing patients a way to evaluate and compare plans to find the best option for them.

The Star Ratings of participating insurance providers are annually reviewed and updated each fall through the Healthcare Effectiveness Data and Information Set (HEDIS). However, the Star Rating System is also graded against a curve each year, which adds an element of competition.

Furthermore, the measures used to evaluate any insurance plan’s Medicare Star Rating are not static. On the contrary, certain measures get retired while others are added depending on the events of each year and developments in medical care and technology. For example, COVID-19 has prompted various changes in the Medicare Star Rating System to ensure insurance providers respond well to the current health crisis and its ongoing effects.

What Measures Are Included in the Medicare Star Ratings?

The quality measures used to evaluate a plan’s Star Rating are different for Medicare Advantage and Part D. As mentioned, the total number of measures included varies from year to year. In 2021, there were 46 measures used for the Star Rating evaluation — 32 for Medicare Advantage and 14 for Medicare Part D. The measures for each plan are grouped into different subcategories. Moreover, numerous considerations go into the weighting and scoring of each measure.

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The subcategories for the Medicare Advantage Plan include:

Staying Healthy (Screenings, Tests and Vaccines): This subcategory includes measures for the percentage of members who had their flu vaccine, underwent cancer screenings for breast and colorectal cancer and went through monitoring for physical activity and average body mass index (BMI).

Managing Chronic (Long Term) Conditions: The measures here include special needs plan (SNP) care management for members who require an assessment of their health needs and risks, care for older adults, which involves medication review, pain assessments and functional status assessments, osteoporosis management in women who have had a fracture, diabetes care and more.

Member Experience With the Health Plan: These include the rate at which members get the care they need, get appointments and care quickly, receive information from the health plan when they need it and more.

Member Complaints and Changes in Plan Performance: The three main measures here are member complaints about the health plan, members choosing to leave the health plan and improvements (if any) in the quality of the health plan’s performance.

Health Plan Customer Services: There are three measures here, including the timeliness of the plan’s appeal decisions, how fairly they review appeals and the availability of foreign language and teletypewriter (TTY) services.

For Part D, which only covers prescription drugs, the subcategories include:

Drug Plan Customer Service: The measures evaluating drug plan customer service mirror the ones for the Health Plan Customer Services subcategory for Medicare Advantage Plans.

Member Complaints and Changes in Plan Performance: These reflect the related subcategory for Medicare Advantage Plans.

Member Experience With the Drug Plan: These measures include members’ rating of the drug plan and the ease of refilling prescription drugs with the plan.

Drug Safety and Accuracy of Pricing: These include accurate drug pricing information on the plan’s website, medication adherence for diabetes medications, blood pressure medications and cholesterol medications, statin use in members with diabetes and the percentage of members enrolled in a Medication Therapy Management (MTM) program who have received a Comprehensive Medication Review (CMR).

How Can You Improve Your Rating?

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Given the number of measures involved with evaluating a health plan’s performance and Medicare Star Rating, the first thing you can do to improve your rating is to become familiar with the details of each measure and how they contribute to the overall rating.

However, familiarizing yourself in such a way can be a tedious process, let alone developing a strategy to score well with each measure. With that in mind, it can be extraordinarily helpful to enlist the services of a healthcare consulting firm that can help you develop and execute a strategy for improving your rating.

At ProspHire, we use a phased, data-backed approach to partner with and help healthcare companies develop and execute their star performance improvement strategy. The outcomes we aim to establish include:

  • Assessing each measure and prioritizing those that are most pertinent or likely to affect your star rating and return on investment (ROI)
  • Analysis of ROI and intervention business cases
  • Designing a foundational and operational model that works for you
  • Developing a stars roadmap and implementation plan
  • Delivery plans and strategies for Part D
  • Planning for HEDIS seasons when ratings are reviewed and updated
  • Analyzing and predicting adjustments to the grading scale and developing risk mitigation plans
  • Helping you achieve your goals with a math- and data-backed approach

Read about one of our many success stories in a case study!

Why Would You Want to Improve Your Rating?

There are several reasons why you’d want to improve your Medicare Star Rating when you provide Medicare Advantage and Part D plans, not the least of which is the quality bonus payment (QBP) for high-ranking plans. The Medicare Star Rating system rewards high-ranking plans with three or more stars with annual bonus payments from the Centers for Medicare and Medicare Services (CMS). Note that plans with higher star ratings receive a bigger bonus, so stopping at three stars isn’t necessarily in your best interest, either.

While medical law requires plans to spend the annual bonus on extra benefits for members, the extra benefits increase the attractiveness of the plan to prospective members. This will help draw in more members to the plan, enable you to care for your members more effectively and ultimately increase your profit margin. In other words, improving your Medicare Star Rating is essential to maximizing your rebate potential.

In addition to increasing the attractiveness of your plan, the Medicare Star Rating is a tool for prospective members to compare your health plan against others. While the star rating is not the only relevant factor in comparing the fit of a certain plan for a prospective member, as network considerations, coverage details and premiums come into play, having a high star rating can give your health plan the upper edge on competitors with similar plan structure to yours.

Contact ProspHire to Maximize Your Medicare Star Rating

Both maintaining and improving your Medicare Star Rating is something that requires effort and innovation as the ratings renew and evolve each year. The healthcare management consultants at ProspHire have extensive industry knowledge on Medicare Star Rating trends and are continuously improving their insight to help health plans meet the needs of their clients and strengthen their Medicare Star Rating.

If you’d like to learn more about the Medicare Star Rating and how ProspHire can help you reach the next level, we’d love to hear from you. Let’s start the conversation about how ProspHire can take you where you want to go with your Medicare Star Rating! Fill out our form below.

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five small wooden stars

CMS Final Rule Stars Program Update

Written by oadmin on . Posted in Insights.

Overview: Changes to STARS Program

On Jan. 15, The Centers for Medicare and Medicare Services (CMS) announced changes to Calendar Year (CY) 2022 Medicare and Medicaid Programs. On Jan. 19, the Federal Registrar published the Final Rule detailing those regulatory and measure level updates for the Stars program beginning in Measurement Year (MY) 2022. These changes will force health plans to reevaluate their Stars intervention strategies and better communicate to both providers and members. The recalibrated measure weighting toward CAHPS will also put more emphasis on member experience and prove pivotal to overall contract success. The final rule also includes changes to the Quality Bonus Payment Rules. The methodology outlined by CMS clarified that the enrollment figures used in the enrollment weighted QBP rating calculations are the Nov. enrollment in the year the Star Ratings are released. This new methodology will take effect during in the 2023 Quality Bonus Payment period. It’s important to remember that success in Stars is a continuous effort. But the health of a Stars program is critical to a health plan’s growth and sustainability. These new measures are complex and can require adjustments to your in-flight strategies. But don’t worry, you are not alone! ProspHire is adept at helping our clients quickly assess the impacts of CMS measure updates and developing strategies for continuous improvement. The recent changes are summarized below:

MeasuresDescription of Change
• Improving or Maintaining Physical Health
• Improving or Maintaining Mental Health		These measures will be retired to the Display Page for at least two years (beginning in MY2022); These measures will be retired at least for SY2024 and SY2025, with the earliest return to Star Ratings in SY2026 at a weight of 1, and Star Ratings in SY2027 and beyond will be a weight of 3
Medication Reconciliation Post Discharge (MRP)This measure will be retired as a standalone measure in MY2022, SY2024
Follow-up after Emergency Department Visit for Patients with Multiple Chronic Conditions (FMC)This measure will be added in MY2022, SY2024, with a permanent weight of 1 as a process measure
Controlling Blood Pressure Measure (CBP)This measure will be added beginning in MY2021, SY2023 with a 1x-weight, increasing to 3x-weight in MY2022, SY2024
Plan All-Cause Readmissions (PCR)This measure will be added in MY2022, SY2024 with a 1x-weight, increasing to a 3xc-weight in MY2023, SY2025
  1. MY = Measurement Year, the calendar year the measures are tracked and calculated for Star Ratings; SY = Star Year, the year that the official Star Ratings are received
  2. Source: CMS-provided information and documentation

ProspHire Is Here to Help

Unlike other improvement programs, when Stars interventions are executed, they do not always create savings. Many require reinvestment to drive continued improvement. Stars is also graded against a curve. What was good enough last year, may not be good enough the next. ProspHire excels at driving continuous improvement to optimize Stars performance. Through data driven analyses and clearly defined strategies, our team of seasoned subject matter experts implement interventions to increase Stars ratings and maximize rebate potential. Our practitioners have years of experience helping large MCOs enhance quality improvement programs. If you would like to learn more about the Stars Program or have any additional questions about how ProspHire can assist, let’s have a conversation!

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ProspHire Named to 2020 Inc. 5000 List

Written by oadmin on . Posted in News.

The woman-owned, national Firm is one of the fastest growing private companies in America.

PITTSBURGH, PA., Aug. 12, 2020 – ProspHire has made the 2020 Inc. 5000 list of the fastest-growing private companies in America. The Pittsburgh-based, national healthcare consulting firm ranks #790, landing in the top 16% of companies for its continued exponential revenue growth.

The Inc. 5000 award ranks companies by overall revenue growth over a three-year period. This prestigious list of the nation’s most successful private companies has become the hallmark of entrepreneurial success and the place where industry superstars first make their mark. ProspHire now stands alongside companies like Microsoft, Vizio, Patagonia and numerous other big industry names.

“We are thrilled to receive renowned national recognition for our commitment to sustainable growth,” said Lauren Miladinovich, ProspHire’s Managing Principal and CEO. “While many companies lost serious footing due to the COVID-19 global pandemic, ProspHire was tested but refortified by the challenge. We let our core values and commitment to our people guide us. We stayed true to our value proposition and worked with our clients who were going through financial difficulties and we came out stronger for it. I don’t have many peers who can say they grew their companies during a pandemic.”    

Christopher Miladinovich, ProspHire’s Principal and SVP of Consulting, said, “We have been honored twice by Inc. as a Best Workplace and are very pleased to now be recognized for our exponential growth. For five years, ProspHire has grown by more than 600% and now clears nearly $10m in annual revenue. We have created 80+ jobs across the state of Pennsylvania, achieved 49% diversity and currently have 50+ practitioners.  It’s hard to say what the future holds, but we plan to continue to grow our headcount and to diversify our already national client base. We are truly proud of our responsible growth and have no plans to slow down.”

ProspHire is no stranger to workplace accolades. The Firm was just named one of Modern Healthcare’s Best Places to Work (2020). In 2019, the Pittsburgh Business Times ranked ProspHire #4 on their Fast 50 list of the fastest growing private companies in western Pennsylvania, and #1 mid-size company on their Best Workplaces list. ProspHire was also named one of Inc. Magazine’s Best Workplaces for two consecutive years (2018 and 2019).

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