04/10/23 1

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 Enhancing the SoonerCare Choice

Medical HomeMedical Home

Part II – Financing the PCMHPart II – Financing the PCMH• Questions and CommentsQuestions and Comments

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What was SoonerCare What was SoonerCare Choice Choice • SoonerCare Choice wasSoonerCare Choice was

a managed care model in a 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.

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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 1,200 PCPs (up from 800+ in 2003)Over 1,200 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

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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:

Previous SoonerCare Previous 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)04/10/23 9

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PCMHPCMHReimbursementReimbursement

• 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/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:

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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 autoassignmentautoassignment

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 Stayed the What Stayed the Same?Same?

What What Changed?Changed?

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Additional SoonerCare Additional SoonerCare Choice ChangesChoice 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

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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ImplementationImplementation Timeline Timeline

• Effective January 2009Effective January 2009• 720 Contract renewals completed 720 Contract renewals completed

between October 9 and between October 9 and December 15December 15

• 64% were tier 1, entry level 64% were tier 1, entry level medical homemedical home

• 32% were tier 2, advanced 32% were tier 2, advanced medical homemedical home

• 4% were tier 3, optimal medical 4% were tier 3, optimal medical homehome

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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SoonerCare Choice SoonerCare Choice ReimbursementReimbursement

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

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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 $6.19

Children & Adults $4.33 $ 5.64 $7.50

Adults Only $5.02 $6.53 $8.69

IHS $3.00 $3.00 $3.00

FQHCs/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

from OHCAfrom OHCA04/10/23 20

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 RequirementsTier 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)

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

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

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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

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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/