04/21/23 1

Presented 2008

A Medical Home forA Medical Home forEvery SoonerCare Every SoonerCare Choice MemberChoice Member

04/21/23 2

ObjectivesObjectives

• Part I – ProgramPart I – Program• SoonerCare Choice TodaySoonerCare Choice Today• Medical Advisory Task Force (MAT)Medical Advisory Task Force (MAT)• Enhancing the SoonerCare Choice Medical Enhancing the SoonerCare Choice Medical

HomeHome• Transition TimelineTransition Timeline• Part II – Financing the PCMHPart II – Financing the PCMH• Questions and CommentsQuestions and Comments

04/21/23 3

What is SoonerCare Choice What is SoonerCare Choice Today?Today?• SoonerCare Choice SoonerCare Choice is a is a

managed care model in managed care model in which each member is which each member is linked to a primary care linked to a primary care provider who serves as provider who serves as their “medical home”. their “medical home”.

• PCPs manage the basic PCPs manage the basic health care needs, health care needs, including after hours care including after hours care and specialty referral of and specialty referral of the members on their the members on their panel.panel.

04/21/23 4

PCP NetworkPCP Network• SoonerCare Choice has over 400,000 SoonerCare Choice has over 400,000

members enrolled statewidemembers enrolled statewide• Over 1,000 PCPs (up from 800+ in 2003)Over 1,000 PCPs (up from 800+ in 2003)• Each PCP has a max panel of 2,500Each PCP has a max panel of 2,500• PA or APN PCPs have a max panel of 1,250PA or APN PCPs have a max panel of 1,250• Average panel size of 300 members per PCPAverage panel size of 300 members per PCP

04/21/23 5

Who Can be a PCP Who Can be a PCP Today?Today?

PhysiciansPhysiciansGeneral PractitionersGeneral PractitionersFamily PracticeFamily PracticeInternal MedicineInternal MedicineOB/GYNsOB/GYNsPediatriciansPediatricians

Physician Assistants (PA)Physician Assistants (PA)Advanced Practice Nurses Advanced Practice Nurses

(APN)(APN)

FQHCsFQHCsRHCsRHCsIHS IHS

FacilitiesFacilities

04/21/23 6

Medical Advisory Task Medical Advisory Task Force CreatedForce Created

• At the request of providers the At the request of providers the MAT was created February 2007MAT was created February 2007

• Representatives delegated by Representatives delegated by provider associationsprovider associations– OOAOOA– OSMAOSMA– OAFPOAFP– AAP, OklahomaAAP, Oklahoma

04/21/23 7

Medical Advisory Taskforce Medical Advisory Taskforce Four Top PrioritiesFour Top Priorities

• Change in current Change in current payment structure payment structure

• Medical homeMedical home• AutoassignmentAutoassignment• CredentialingCredentialing

04/21/23 8

Joint Principles of the Joint Principles of the Patient-Centered Medical Patient-Centered Medical

HomeHomeIn March 2007 the AAP, AAFP, ACP, and In March 2007 the AAP, AAFP, ACP, and AOA, representing approximately 333,000 AOA, representing approximately 333,000 physicians, developed the following joint physicians, developed the following joint principles to describe the characteristics of principles to describe the characteristics of the PC-MH.the PC-MH.

Personal PhysicianPersonal Physician

Physician Directed Physician Directed PracticePractice Whole Person OrientationWhole Person Orientation Adequate PaymentAdequate Payment

Quality and SafetyQuality and Safety

Enhanced AccessEnhanced Access

Care is coordinated and / or Care is coordinated and / or integratedintegrated

04/21/23 9

Patient-Centered Medical Patient-Centered Medical HomeHome

Builds on successes already Builds on successes already achieved in SoonerCare achieved in SoonerCare

Choice Choice

MedicareMedicare Private PayersPrivate Payers Large, Self Insured Large, Self Insured EmployersEmployers

State GovernmentState Government

Patient-Centered Primary Care Patient-Centered Primary Care CollaborativeCollaborative

Adopted by other payers:Adopted by other payers:

Current SoonerCare Current SoonerCare Choice Reimbursement Choice Reimbursement Monthly Capitated “Bundled” paymentMonthly Capitated “Bundled” payment• Case Management / Care Coordination Case Management / Care Coordination

FeeFee• Primary care office visitsPrimary care office visits• Limited lab servicesLimited lab services

Other codes paid on FFS basisOther codes paid on FFS basis

Incentive PaymentsIncentive Payments• EPSDT / 4EPSDT / 4thth DTaP bonus DTaP bonus

(lump sum payments)(lump sum payments)04/21/23 10

04/21/23 11

Recommended PCMHRecommended PCMHReimbursementReimbursement

• A monthly care coordination payment A monthly care coordination payment

• A visit-based fee-for-service component A visit-based fee-for-service component

• A performance-based componentA performance-based componentSource: The Patient Centered Primary Care CollaborativeSource: The Patient Centered Primary Care Collaborativehttp://www.patientcenteredprimarycare.org/http://www.patientcenteredprimarycare.org/

The most effective way to re-align payment The most effective way to re-align payment incentives to support the PCMH would be to incentives to support the PCMH would be to combine traditional fee-for-service for office visits combine traditional fee-for-service for office visits with a three part model that includes:with a three part model that includes:

04/21/23 12

SoonerCare Choice Comparison

Prepayment for case management Prepayment for case management onlyonlyReferrals only needed for specialty Referrals only needed for specialty carecareGroup contracts must designate a Group contracts must designate a medical directormedical directorElimination of default Elimination of default autoassignmentautoassignmentOnline provider enrollmentOnline provider enrollment

Current funding remains the same Current funding remains the same

Provider determines medical Provider determines medical necessitynecessity

Federal restriction (e.g. EMTALA, co-Federal restriction (e.g. EMTALA, co-pays)pays)

What Stays the What Stays the Same?Same?

What Changes?What Changes?

04/21/23 13

Proposed Additional Proposed Additional SoonerCare Choice ChangesSoonerCare Choice Changes

• Coverage of new codes (e.g. after hours)Coverage of new codes (e.g. after hours)• OB/GYN specialists that do not provide OB/GYN specialists that do not provide

primary care may no longer be PCPsprimary care may no longer be PCPs• Members may change PCPs within the Members may change PCPs within the

monthmonth• Case Mgmt payment will be based on date Case Mgmt payment will be based on date

processedprocessed

04/21/23 14

Other InitiativesOther Initiatives

• Foster Care Pilot ProjectFoster Care Pilot Project

• Outreach to households with newbornsOutreach to households with newborns

• Electronic NB-1Electronic NB-1

• Transformation GrantTransformation Grant– ““No Wrong Door” eligibility enrollment No Wrong Door” eligibility enrollment

enhancement. Target date October 2009enhancement. Target date October 2009

• Health Access Networks PilotHealth Access Networks Pilot

04/21/23 15

Proposed TimelineProposed Timeline• Target date January 2009Target date January 2009• All eligible members rolled All eligible members rolled

over with current PCPover with current PCP• Seamless for members, Seamless for members,

PCPsPCPs• Contract updates needed Contract updates needed

by November 1, 2008by November 1, 2008

Medical HomeMedical HomePart IIPart II

Financing the New ModelFinancing the New Model

04/21/23 16

04/21/23 17

Eligibility Category Adults Children Total

% Adults

% Children

TANF

34,392

318,801

353,193

0.10

0.90

ABD/SSI

26,759

11,974 38,733

0.69

0.31

Children in Custody

-

-

-

-

-

Adults, Duals and HCBW

-

-

-

-

-

Total 61,151

330,775

391,926

0.16

0.84

Source: OHCA Annual Report, SFY07

Average Monthly Enrollment: 84% are children

Age Group TANF ABD/

SSITotal %TANF

% ABD/SS

I

Adults

34,392

26,759

61,151 0.56

0.44

Children

318,801

11,974

330,775 0.96

0.04

Total

353,193

38,733

391,926 0.90

0.10

Approximately 44% of adults may require

ongoing care coordination; 4% of children

04/21/23 18

Definition of Capitation: Definition of Capitation:

• A fixed payment for treating a fixed A fixed payment for treating a fixed number of individuals whether they number of individuals whether they are ill or well….. are ill or well…..

• Rate paid on entire panel whether Rate paid on entire panel whether member is seen or notmember is seen or not

04/21/23 19

Current Primary Care Current Primary Care Payment StructurePayment Structure

Capitated Bundled Rates include payment Capitated Bundled Rates include payment for:for:

• Monthly case management based on age/sex Monthly case management based on age/sex cells – Weighted average = $2.23 pmpmcells – Weighted average = $2.23 pmpm

• E&M Visits based on 100% of Medicare fee E&M Visits based on 100% of Medicare fee schedule and actuarial based utilization schedule and actuarial based utilization assumptions (somewhat higher than actual assumptions (somewhat higher than actual encounter data received)encounter data received)

04/21/23 20

Average total payment for physicians = Average total payment for physicians =

$24 pmpm$24 pmpm

04/21/23 21

Proposed New SoonerCare Proposed New SoonerCare Choice ReimbursementChoice Reimbursement

Monthly Case Mgmt / Care Coordination FeeMonthly Case Mgmt / Care Coordination Fee– Peer grouped by type of panel and capabilities of Peer grouped by type of panel and capabilities of

practicepractice

Visit based componentVisit based component– Fee for serviceFee for service

Expanded Performance Component (SoonerExcell)Expanded Performance Component (SoonerExcell)

Transitional Payments in Year 1Transitional Payments in Year 1

““Unbundled” to incorporate PCMH Unbundled” to incorporate PCMH principlesprinciples

Peer Grouped based on type of Peer Grouped based on type of practicepractice

– Children only;Children only;– Adults and Children;Adults and Children;– Adults OnlyAdults Only– FQHCs/RHCsFQHCs/RHCs

AndAnd

Level of Medical HomeLevel of Medical Home– Tier 1 = Entry Level Medical Home;Tier 1 = Entry Level Medical Home;– Tier 2 = Advanced Level Medical Home;Tier 2 = Advanced Level Medical Home;– Tier 3 = Optimal Level Medical HomeTier 3 = Optimal Level Medical Home

04/21/23 22

Case Management/Case Management/Care Coordination FeeCare Coordination Fee

Type of Practice

Tier 1 Tier 2 Tier 3

Children Only $3.06 $ 5.08 $6.02

Children & Adults $3.53 $ 7.57 $8.92

Adults Only $5.92 $10.74 $12.60

FQHCs/RHCs $0.00 $0.00 $0.00

Case Management/Care Case Management/Care Coordination Fee Coordination Fee

SummarySummary

Draft – July 21, 2008Draft – July 21, 2008

Rates based on a blend of the recommended Rates based on a blend of the recommended rates for the Medicare medical home rates for the Medicare medical home

demonstration and the current SoonerCare demonstration and the current SoonerCare rate for case managementrate for case management

04/21/23 23

04/21/23 24

Incentive ComponentIncentive Component(SoonerExcell)(SoonerExcell)

• Child Health Exams (EPSDT) and DTaP (1.5 m)

• Generic Drug Prescribing (.5 m)• Cervical cancer screenings (.3 m)• Breast cancer screenings (.05 m)• Physician inpatient admitting and visits (.85

m)• ER utilization (.5 m)

Payments made quarterly. First payment made in April 09 based on claim dates of service Oct – Dec and adjudicated through March 2009.

04/21/23 25

Transitional Payments Transitional Payments Year 1Year 1

QualificationsQualifications• At least 250 SoonerCare members on their

panel (200 for mid-levels)• Not on the QA/QI noncompliance list for

medical reasons• Average office visit per member must be

within one office visit per year of the average utilization for their panel type

• $3 million set aside

Transitional Payments, Transitional Payments, (cont’d)(cont’d)

DistributionDistribution

04/21/23 26

•Total pool divided by total eligible member monthsTotal pool divided by total eligible member months

•Per Member amount is multiplied by actual MM in Per Member amount is multiplied by actual MM in quarterquarter

•This amount is multiplied by a factor determined This amount is multiplied by a factor determined by a provider’s financial response to the medical by a provider’s financial response to the medical home modelhome model

•There are two categories of factors determined by There are two categories of factors determined by the provider’s rural/urban classificationthe provider’s rural/urban classification

•Providers with above average utilization will Providers with above average utilization will receive an additional payment equal to 50% of the receive an additional payment equal to 50% of the initial paymentinitial payment

•No provider will be made more than 90% whole No provider will be made more than 90% whole with transitional paymentswith transitional payments

Increased Encounter data Increased Encounter data for:for:

Increased Utilization (20%)Increased Utilization (20%)

Improved codingImproved coding

New CodesNew Codes

UnderreportingUnderreporting

04/21/23 27

Budget Assumptions Budget Assumptions Conversion from Capitation Conversion from Capitation

to FFSto FFS

04/21/23 28

Questions CommentsQuestions Comments• Request your input: Request your input:

MedHomeComments@okhca.orgMedHomeComments@okhca.org

• Updates in global and banner messages, Updates in global and banner messages, provider letters, OHCA public website at provider letters, OHCA public website at www.okhca.org/medical-homewww.okhca.org/medical-home

• Contact OHCAContact OHCA

Melody AnthonyMelody AnthonyProvider Services DirectorProvider Services Director405.522.7360 / 405.522.7360 / Melody.Anthony@okhca.orgMelody.Anthony@okhca.org

Provider ServicesProvider Services877-823-4529, option 2877-823-4529, option 2

04/21/23 29

Additional ResourcesAdditional Resources

• Patient-centered primary care collaborative Patient-centered primary care collaborative http://www.pcpcc.net/http://www.pcpcc.net/

• AAFP patient-centered medical home AAFP patient-centered medical home http://www.aafp.org/online/en/home/memberhttp://www.aafp.org/online/en/home/membership/initiatives/pcmh.htmlship/initiatives/pcmh.html

• AAP medical home news http://www.aap.org/AAP medical home news http://www.aap.org/• Medicare medical home pilotMedicare medical home pilot