Payment Reform

The Affordable Care Act provides financial incentives for providers to progress from relying on fee-for-service payment models to value-based payments, in which health care organizations are paid more for keeping their patients/populations healthy. Our expertise in legal analysis and financing models guides our clients in creating and implementing payment reforms.

Our experts help clients develop Alternative Payment Systems, including shared savings arrangements, bundled payments, and global payments. These Alternative Payment Systems may include opportunities or requirements for providers to accept upside and/or downside risk and risk corridors to limit provider risk. Payments may be made as per member per month (PMPM) amounts or by reconciling fee-for-service payments with bundled or global payments at the end of a year.

Senior members of our health finance team served for decades in executive and senior roles in Massachusetts' Medicaid program, with direct responsibility for developing payment methods and rates, and for managing the state-federal Medicaid relationship. Our analysis typically includes:

  • Legal, financial and policy implications of individual payment options, including the state's financial obligations and providers' risks and incentives
  • Federal compliance requirements that may be associated with a payment option, including Upper Payment Limits (UPLs) for Medicaid
  • Constructing models to assess the impact of proposed changes under various scenarios
  • Payment method modeling to evaluate how reimbursement and purchasing reforms affect system financing and service delivery
  • Alternative payment system implications for safety net providers and the uninsured
  • The use of waivers to secure federal approval for innovative approaches to providing and paying for care within the Medicaid program
  • Administrative requirements for implementing a new payment option
  • Linking payment models to care delivery and supporting clinical practices throughout implementation.