Medicaid
Driving innovation and sustainable improvement in Medicaid and dual eligibility for enhanced health outcomes, experience, and value creation
We draw on extensive industry knowledge; a deep pool of clinical, actuarial, policy, and technology experts; and advanced-analytics capabilities to help institutions across the Medicaid ecosystem deliver higher-quality healthcare at a reasonable cost to high-needs populations.
We advise federal and state healthcare agencies, Medicaid health insurers, health systems, investors, and pharmacy benefit managers and have led projects in a variety of topics, including delivery, implementation, operations, organization, strategy, and technology.

What we do

Innovation and transformation in state healthcare

Our support to state healthcare agencies extends across program redesign, waiver development, managed-care contracting and performance management, program governance, and value assurance on integrated eligibility systems (IESs) and Medicaid-management information systems (MMISs). Our work includes statewide, value-based payment-model implementation; Medicaid-expansion planning; managed-care transition; and business-process redesign related to IT transitions.

Medicaid managed-care-organization transformation

We help set and achieve ambitious agendas across growth, operational excellence, and innovation. . Our work spans national and local organizations, provider-led entities, and organizations focused on addressing special needs populations (e.g., behavioral health, long term service and supports, and dual eligible individuals). We deploy analytics to support MCOs to identify the areas where they can best impact the quality and efficiency of care; expanding member access to high-value care; and enhancing member experience of care.

Financially sustainable care delivery

We help health systems that serve Medicaid beneficiaries in transforming their care-delivery and financial-management models to provide optimal care.

Investment and value creation

We support investors in creating value in the Medicaid ecosystem in a way that fits with their portfolio goals. Our work includes market scans prior to due diligence, asset due diligence, valuation, negotiation, and value capture after due diligence.

>200

engagements

with Medicaid and adjacent programs across 20 states over past 5 years

100

terabytes

of deidentified claim/encounter data in our secure, Health Insurance Portability and Accountability Act (HIPAA)-compliant database

Featured capabilities

We invest heavily in developing proprietary tools and databases.

Landscape analysis: Our analysis covers state-specific Medicaid and dual-eligible landscapes—and projected coverage shifts. We also develop policy and economic outlook and scenarios to assess impact on Medicaid programs, including the implications for each type of stakeholder.

Proprietary tools to assess and improve quality and value: Our library of readily available algorithms and queries enables value assessment and intervention design by subsegment (for example, for behavioral-health and long-term-care services and supports).

Program-integrity tools and algorithms: We use machine-learning models to detect potential cases of fraud, waste, and abuse.

Network of experts: We gather insights from a network of Medicaid and plan-eligibility experts, including former officials of federal and state health-services agencies.

Examples of our work

Transformation diagnostic for a mixed fee-for-service and managed-care state Medicaid program

We worked with a state Medicaid program to improve quality and health outcomes. By deploying claims analytics, referencing our library of clinical concepts, and mobilizing a team of data scientists, clinicians, operations and IT practitioners, and medical-policy experts, we conducted a diagnostic to pinpoint efficiency-improvement opportunities. Areas we explored included fee for service, managed-care delivery, acute care, long-term care, behavioral health, and Medicaid financing. The long-term-improvement potential we identified ranged from 5 to 10 percent of total program expenditure.

Transformation of healthcare delivery and payment for a state Medicaid program

We supported a state Medicaid program in applying for a State Innovation Model Test Award. We helped the client implement a statewide program for complementary population- and episode-based care-delivery and payment models, enabling the associated technology-infrastructure and solution design, and managing stakeholder relations, regulatory analysis, program management, and governance. An evaluation of the program’s impact identified cost-trend improvement of 1.9 percent for participating providers while achieving an annual quality improvement of 2.2 percent on priority measures over a three-year period.

Modernization of managed-care-organization operations

We supported a multistate MCO looking to transform its operations by removing cross-functional silos and accelerating implementation of operational and clinical best practices across states. The program went beyond rapid saving opportunities to focus on deep systematic changes and the development of new capabilities for the organization. As a result, the MCO rapidly modernized its operations while generating savings equivalent to around 10 percent of the gross margin.

End-to-end transformation for a Medicaid and duals MCO focused on high-needs populations

We supported a regional duals MCO to develop a strategy to enhance its growth and diversification, including exploring opportunities to expand its mission. This journey began with a strategic diagnostic which included an environmental landscape, capabilities assessment, and an evaluation of potential avenues in line with the organization’s mission and strengths. We then supported the organization on diversified business-building, claims-based population analytics, and medical cost transformation. The result of this work was a road map to grow the enterprise by 3-5x over five years.

Developed Medicaid strategy for a multi-line health plan

We supported a multi-line health plan looking to enter Medicaid and identify opportunities to rapidly accelerate growth while protecting the core business and engage their stakeholder group. Through this work, we conducted a diligence and post-acquisition strategy including the integration of acquisitions with the core business, including developing an organic growth pipeline for Medicaid RFPs and a capability assessment of the investments required to scale in the space. The work resulted in the successful build and scale of the enterprise’s Medicaid business – supported by the capabilities required to sustain growth.

Featured insights

Article

Insights into better integrated eligibility systems

– Implementing integrated eligibility systems can be fraught with challenges, making it difficult for states to claim success. However, there are five observations they can use to ensure triumphant future execution.
Article

Five trends shaping the future of Medicaid

– The Medicaid program has experienced significant changes since 2010, when the Affordable Care Act was passed. Five trends are... likely to affect how the program will change over the next five to ten years.
Article

Ten insights on the US opioid crisis from claims data analysis

– Careful analysis of health insurers’ claims data can provide important insights into the opioid crisis by identifying patterns... that could help shape strategies to combat opioid dependence and abuse.
Article

The granularity of Medicaid MCO growth

– Despite present uncertainties, MCO leaders can still aspire to grow—and make decisions to support that aspiration. Our research... shows that the key sources of growth for Medicaid MCOs are strategic, not operational.

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