Government Healthcare Consulting Solutions

Government / Public Healthcare

Government / Public Healthcare

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State Government Practice

Payment Transformation

The Guidehouse team works with state government healthcare and social services agencies to develop rational payment models that balance the need to control expenditures with the need to maintain the quality of care and access to the unique services required by certain populations. We help states transitioning to capitation, accountable care organizations and other coordinating care entities and medical homes.  Our solutions include:

Inpatient and Outpatient Services Payment Models
Guidehouse’s extensive experience designing, implementing and supporting inpatient All Patient Refined Diagnosis Related Group (APR DRG) models and outpatient Enhanced Ambulatory Patient Grouping System (EAPG) is unparalleled in the industry. We design, develop, and implement new methodologies, working with stakeholders across the state to address state-specific needs. In addition, we help states track the performance of providers, managed care plans, and coordinated care and accountable care organizations. Our work also includes Medicaid bundling initiatives, analytics and payment policies designed to reduce preventable readmissions and utilization. Our methodologies include the design of outcomes-based payment incentive models that focus on reducing avoidable costs, such as readmissions and complications. 

Federal Funding and Compliance
As state payers struggle to find the appropriate balance between state and federal financing of public healthcare programs, federal demonstration and reporting requirements have increased significantly. New reporting requirements can impact financing of services, regardless of whether states have expanded their programs under the Affordable Care Act—especially if they have transitioned to new service delivery models. 

Our consulting team works with states to understand and support these new reporting requirements. Our team also provides assistance to state agencies and providers to design financing strategies to optimize federal funding opportunities. Our team successfully developed and supported funding programs that have increased the federal dollars available for the delivery of critical services for the Medicaid and uninsured populations, and conducted the analyses required to support the federal compliance demonstration requirements related to these programs.

Delivery System Reform Incentive and other Supplemental Payment Programs
Medicaid transformation focuses on population health management rather than fee-for-service or episodic treatment models. Delivery System Reform Incentive (DSRIP) programs allow states to use 1115 demonstration waivers to fund these transformations and demonstrate that they are meeting their objectives. Guidehouse guides state Medicaid agencies through this entire process, from gaining preliminary CMS approval and developing program administration to developing provider metrics and identifying projects for funding using data analysis. Our team works to develop state legislatively-mandated studies that address CMS requirements regarding the use of supplemental payment funds within states. We help develop programs to establish or preserve the use of federal matching funds for services to the uninsured; and assist states in obtaining renewal of these programs by CMS.

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