Rate Setting & Payment Reform

Hilltop is at the forefront of national efforts to find data-driven solutions to complex problems facing state policymakers as publicly funded health care systems transition to new payment models that reward quality and value over volume.

Each year, Hilltop works with the Maryland Department of Health to develop risk-adjusted capitation payments for managed care organizations (MCOs) participating in HealthChoice, Maryland’s Medicaid managed care system. Hilltop conducts financial analyses to inform HealthChoice payment policy, develop capitation rates for MCOs, conduct financial monitoring of MCOs, and assist the Department with capitation rate recovery. Hilltop manages a collaborative process—recognized nationally for its transparency and cost-effectiveness—involving Department officials, MCOs, and an actuarial firm responsible for certifying rates.

Maryland’s 2017 Joint Chairmen’s Report from the Senate Budget and Taxation Committee and the House Appropriations Committee required a study of the effectiveness of the state’s Medicaid managed care rate setting system in assuring access to high quality, cost-effective health care. Hilltop assisted in procuring the study and is currently working with the Department to consider the study’s recommendation to develop a standardized framework for paying for high-cost pharmaceuticals and mitigating the risk to the state.

Featured Work

The Hilltop Institute conducted an analysis of the demographics, service utilization, and expenditures of Maryland’s dual-eligible population. The analyses focus on Medicare beneficiaries in Maryland who also receive full Medicaid benefits. The findings, published in a chart book and three reports provide an overview of how this population accesses health care services, the types of services used, and where the services are provided.

Staff Expert

Todd Switzer

Chief Actuary/Director of Rate Setting and Financial Analysis

Contact

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