Presented at OHCA

1
An Improved Medical Home forEvery SoonerCare
Choice Member

• Presented at OHCA
• Sept. 12, 2008

2
Objectives

• Part I Program
• SoonerCare Choice Today
• Medical Advisory Task Force (MAT)
• Enhancing the SoonerCare Choice Medical Home
• Transition Timeline
• Part II Financing the PCMH
• Questions and Comments

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What is SoonerCare Choice Today?

• SoonerCare Choice is a managed care model in
  which each member is linked to a primary care
  provider who serves as their medical home.
• PCPs manage the basic health care needs,
  including after hours care and specialty referral
  of the members on their panel.

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PCP Network

• SoonerCare Choice has over 400,000 members
  enrolled statewide
• Over 1,000 PCPs (up from 800 in 2003)
• Each PCP has a max panel of 2,500
• PA or APN PCPs have a max panel of 1,250
• Average panel size of 300 members per PCP

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Who Can be a PCP Today?

• Physicians
• General Practitioners
• Family Practice
• Internal Medicine
• OB/GYNs
• Pediatricians

FQHCs RHCs IHS Facilities
Physician Assistants (PA) Advanced Practice
Nurses (APN)
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Medical Advisory Task Force Created

• At the request of providers the MAT was created
  February 2007
• Representatives delegated by provider
  associations
• OOA
• OSMA
• OAFP
• AAP, Oklahoma

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Medical Advisory Taskforce Four Top Priorities

• Change in current payment structure
• Medical home
• Autoassignment
• Credentialing

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Joint Principles of the PatientCentered Medical
Home
In March 2007 the AAP, AAFP, ACP, and AOA,
representing approximately 333,000 physicians,
developed the following joint principles to
describe the characteristics of the PCMH.

• Personal Physician

• Enhanced Access

• Physician Directed Practice

• Quality and Safety

• Whole Person Orientation

• Adequate Payment

• Care is coordinated and / or integrated

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Patient Centered Medical Home
Builds on successes already achieved in
SoonerCare Choice patterned after North Carolina
and Alabamas medical home model
Adopted by other payers

• Medicare

• Private Payers

• Large, Self Insured Employers

• Patient-Centered Primary Care Collaborative

• State Government

10
Current SoonerCare Choice Reimbursement

• Monthly Capitated Bundled payment
• Case Management / Care Coordination Fee
• Primary care office visits
• Limited lab services
• Other codes paid on FFS basis
• Incentive Payments
• EPSDT / 4th DTaP bonus
• (lump sum payments)

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

• A monthly care coordination payment
• A visit-based fee-for-service component
• A performance-based component
• Source The Patient Centered Primary Care
  Collaborative
• http//www.patientcenteredprimarycare.org/

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SoonerCare Choice Comparison
What Stays the Same?
Current funding remains the same Provider
determines medical necessity Federal restriction
(e.g. EMTALA, co-pays)
What Changes?
Prepayment for case management only Referrals
only needed for specialty care Group contracts
must designate a medical director Elimination of
default autoassignment Online provider enrollment
11/14/2009
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Proposed Additional SoonerCare Choice Changes

• Coverage of new codes (e.g. after hours)
• OB/GYN specialists that do not provide primary
  care may no longer be PCPs
• Members may change PCPs within the month
• Case Mgmt payment will be based on date processed

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Other Initiatives

• Foster Care Pilot Project
• Outreach to households with newborns
• Electronic NB-1
• Transformation Grant
• No Wrong Door eligibility enrollment
  enhancement. Target date October 2009
• Health Access Networks Pilot

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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 Timeline

• Target date January 2009
• All eligible members rolled over with current PCP
• Seamless for members, PCPs
• Contract updates needed by November 1, 2008

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Medical HomePart II

• Financing the New Model

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SoonerCare Choice Demographics
Source OHCA Annual Report, SFY07
Average Monthly Enrollment 84 are children
11/14/2009
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SoonerCare Choice Demographics,(contd)
Approximately 44 of adults may require ongoing
care coordination 4 of children
11/14/2009
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Definition of Capitation

• A fixed payment for treating a fixed number of
  individuals whether they are ill or well..
• Rate paid on entire panel whether member is seen
  or not

11/14/2009
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Current Primary Care Payment Structure

• Capitated Bundled Rates include payment for
• Monthly case management based on age/sex cells
  Weighted average 2.23 pmpm
• EM Visits based on 100 of Medicare fee schedule
  and actuarial based utilization assumptions
  (somewhat higher than actual encounter data
  received)

Average total payment for physicians 24 pmpm
11/14/2009
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Proposed New SoonerCare Choice Reimbursement
Unbundled to incorporate PCMH principles

• Monthly Case Mgmt / Care Coordination Fee
• Peer grouped by type of panel and capabilities of
  practice
• Visit based component
• Fee for service
• Expanded Performance Component (SoonerExcell)
• Transitional Payments in Year 1

11/14/2009
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Case Management/Care Coordination Fee

• Peer Grouped based on type of practice
• Children only
• Adults and Children
• Adults Only
• FQHCs/RHCs
• And
• Level of Medical Home
• Tier 1 Entry Level Medical Home
• Tier 2 Advanced Level Medical Home
• Tier 3 Optimal Level Medical Home

11/14/2009
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Case Management/Care Coordination Fee Summary
Rates based on a blend of the recommended rates
for the Medicare medical home demonstration and
the current SoonerCare rate for case
management Tier 1 includes additional add on
payments for 24/7 voice to voice and electronic
communication from OHCA
11/14/2009
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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

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

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

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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

11/14/2009
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Tier 3 Optimal Medical Home Requirements
These requirements are in addition to tier 1 and
2 requirements

• 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 followup 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

11/14/2009
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Tier 3 Optional Criteria
OHCA encourages providers to choose one or more
of the following as further enhancements to tier 3

• 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

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Incentive Component(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.
11/14/2009
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Transitional Payments Qualifications

• 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

11/14/2009
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Transitional PaymentsDistribution

• Total pool divided by total eligible member
  months
• Per Member amount is multiplied by actual MM in
  quarter
• This amount is multiplied by a factor determined
  by a providers financial response to the medical
  home model
• There are two categories of factors determined by
  the providers rural/urban classification
• Providers with above average utilization will
  receive an additional payment equal to 50 of the
  initial payment
• No provider will be made more than 90 whole with
  transitional payments

33
Budget Assumptions Conversion from Capitation to
FFS

• Increased Encounter data (20) for
• Increased Utilization
• Underreporting
• Improved coding
• New Codes

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Questions Comments

• Request your input MedHomeComments_at_okhca.org
• Updates in global and banner messages, provider
  letters, OHCA public website at
  www.okhca.org/medical-home
• Contact OHCA
• Melody Anthony
• Provider Services Director
• 405.522.7360 / Melody.Anthony_at_okhca.org
• Provider Services
• 877-823-4529, option 2

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Additional Resources

• Patient-centered primary care collaborative
  http//www.pcpcc.net/
• AAFP patient-centered medical home
  http//www.aafp.org/online/en/home/membership/init
  iatives/pcmh.html
• AAP medical home news http//www.aap.org/