05/03/23 1

Presented at OHCASept. 12, 2008

An Improved An Improved Medical Home forMedical Home forEvery SoonerCare Every SoonerCare Choice MemberChoice Member

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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

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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 the and specialty referral of the members on their panel.members on their panel.

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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 Average panel size of 300 members per

PCPPCP

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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

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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

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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

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Joint Principles of the Joint Principles of the PatientPatient

Centered Medical HomeCentered Medical HomeIn 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 PCMH.the PCMH.

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

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Patient Centered Medical Patient Centered Medical HomeHome

Builds on successes already achieved Builds on successes already achieved in SoonerCare Choice patterned after in SoonerCare Choice patterned after North Carolina and Alabama’s medical North Carolina and Alabama’s medical

home modelhome model 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 FeeCase Management / Care Coordination Fee• Primary care office visitsPrimary care office visits• Limited lab servicesLimited lab servicesOther 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)

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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 component

Source: The Patient Centered Primary Care CollaborativeSource: The Patient Centered Primary Care Collaborativehttp://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:

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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 necessitynecessityFederal 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?

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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

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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

Health Access Networks

• Additional payment to the network• Network will be approved by the MAT• Must provide access to all levels of care• Develops business relationships with

– Primary care providers– Specialty providers– Outpatient, inpatient – Ancillary providers– RHC, FQHC

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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

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Eligibility Category Adults Children Total

% Adults

% Children

TANF 34,392

318,801

353,193

10%

90%

ABD/SSI 26,759

11,974

38,733

69%

31%

Children in Custody

-

-

-

-

-

Adults, Duals and HCBW

-

-

-

-

-

Total 61,151

330,775

391,926

16%

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 56%

44%

Children

318,801

11,974

330,775 96%

4%

Total

353,193

38,733

391,926 90%

10%

Approximately 44% of adults may require ongoing care coordination; 4% of children

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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

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

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Average total payment for physicians = Average total payment for physicians = $24 pmpm$24 pmpm

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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

practicepracticeVisit based componentVisit based component

– Fee for serviceFee for serviceExpanded 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 practicePeer Grouped based on type of practice– Children only;Children only;– Adults and Children;Adults and Children;– Adults OnlyAdults Only– FQHCs/RHCsFQHCs/RHCs

AndAndLevel 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

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Case Management/Case Management/Care Coordination FeeCare Coordination Fee

Type of Practice

Tier 1 Tier 2 Tier 3

Children Only $3.58 $ 4.65 $6.19Children & Adults $4.33 $ 5.64 $7.50Adults Only $5.02 $6.53 $8.69IHS $3.00 $3.00 $3.00FQHCs/RHCs $0.00 $0.00 $0.00

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

SummarySummary

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

and the current SoonerCare rate for case and the current SoonerCare rate for case managementmanagement

Tier 1 includes additional add on payments for Tier 1 includes additional add on payments for 24/7 voice to voice and electronic communication 24/7 voice to voice and electronic communication

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Tier 1: Entry Level medical Home Requirements

• Provides/coordinates all medically necessary primary and preventive services

• Participates in VFC and meets all reporting requirement for OSIIS• Organizes clinical data in paper or electronic format• Reviews all medications a patient is taking and maintains a medication

list• Maintains a system to track test and follow-up on results• Maintains a system to track referrals including self reported referrals• Provides care coordination and continuity including family participation• Provides patient education and support

Upon CMS approval additional payment for coordinating care for children in state custody will be available

Additional Add-on Payments• Accepts electronic communications (0.05)• Provides 24/7 voice-to-voice (0.50)

Tier 2: Advanced Medical Home Requirements

Tier 1 Mandatory requirements plus the following:• Obtains mutual agreement on medical home with patients• Accepts electronic communications from OHCA• Provides 24/7 voice to voice coverage. PAL does not meet

qualifications• Makes after hours care available to patients. Provider is

available at least 30 hours per week. Uses open scheduling and walk-ins to provide continuity of care

• Uses mental health and substance abuse screening and referral

• Uses data from OHCA to identify and track patients inside and outside the PCP

• Coordinates care for patients who receive care outside the PCP location

• Promotes access and communication with patients

Tier 2: Optional CriteriaMust Select Three

• Develop a PCP led health care team• Provides after-visit follow up for medical home patients• Adopts evidence-based clinical practice guidelines on

preventive and chronic care• Uses medication reconciliation to avoid interactions or

duplications• Serves children in state custody• Uses a personalized screening brief intervention and referral

for treatment (SBIRT)• Participates in practice facilitation • Makes after hours care available at least four hours each

week outside 8am-5pm, M-F

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Tier 3: Optimal Medical Tier 3: Optimal Medical Home RequirementsHome Requirements

These requirements are in addition to tier 1 and 2 These requirements are in addition to tier 1 and 2 requirementsrequirements

• Organizes and trains staff in roles for care management, creates and maintains a prepared and proactive care team, provides timely call back to patients, adheres to evidence-based clinical practice guidelines on preventive and chronic care.

• Uses health assessment to characterize patient needs and risks

• Documents patient self management plan for those with chronic disease

• Develops a PCP led health care team• Provides after visit follow–up for patients• Adopts specific evidence based clinical practice guidelines

on preventive and chronic care• Uses medication reconciliation to avoid interactions• Serves children in state custody• Uses SBIRT

Tier 3: Optional Criteria

• Uses integrated care plan to guide patient care• Uses secure systems that provide for patient

access to personal health information• Reports to OHCA on PCP performance• Accepts and engages a practice facilitator

OHCA encourages providers to choose one or more of the following as further

enhancements to tier 3

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Incentive ComponentIncentive Component(SoonerExcell)(SoonerExcell)

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

• Generic Drug Prescribing (1 m)• Cervical cancer screenings (.3 m)• Breast cancer screenings (.05 m)• Physician inpatient admitting and visits (.85

m)• ER utilization (.5 m)• $4.25 million set aside

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

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• 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

• $3.75 million set aside

Transitional Transitional Payments; Payments;

QualificationsQualifications

Transitional Payments;Transitional Payments;DistributionDistribution

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•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 (20%) for:Increased Encounter data (20%) for:– Increased UtilizationIncreased Utilization– UnderreportingUnderreporting– Improved codingImproved coding– New CodesNew Codes

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Budget Assumptions Budget Assumptions Conversion from Capitation Conversion from Capitation

to FFSto FFS

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

MedHomeComments@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-home

• Contact OHCAContact OHCAMelody AnthonyMelody AnthonyProvider Services DirectorProvider Services Director405.522.7360 / 405.522.7360 / Melody.Anthony@okhca.orgProvider ServicesProvider Services877-823-4529, option 2877-823-4529, option 2

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Additional ResourcesAdditional Resources• Patient-centered primary care collaborative Patient-centered primary care collaborative

http://www.pcpcc.net/• AAFP patient-centered medical home AAFP patient-centered medical home

http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html

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