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COORDINATING CARE FOR MEMBERS DUALLY ELIGIBLE FOR MEDICARE AND SOONERCARE: EXPLORING A NEW FRONTIER Buffy L. Heater, MPH Director of Planning & Development.

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Presentation on theme: "COORDINATING CARE FOR MEMBERS DUALLY ELIGIBLE FOR MEDICARE AND SOONERCARE: EXPLORING A NEW FRONTIER Buffy L. Heater, MPH Director of Planning & Development."— Presentation transcript:

1 COORDINATING CARE FOR MEMBERS DUALLY ELIGIBLE FOR MEDICARE AND SOONERCARE: EXPLORING A NEW FRONTIER Buffy L. Heater, MPH Director of Planning & Development Oklahoma Health Care Authority Heater 1

2 Oklahoma Dual Eligible Population Duals 104,538 2 Source: SoonerCare data as of June 2011 Medicare 607,465 SoonerCare 727,369 Heater 2

3 Dual Eligibles by Race Heater 3

4 Dual Eligible Population by Gender 66,308 Females 39,224 Males Heater 4

5 Dual Eligibles by Region Source: SoonerCare data as of June 2011 Heater 5

6 Dual Eligible Reimbursement by Quarter Source: OHCA Fast Facts March 2011 Heater 6

7 Per Member Per Month Cost (monthly average per quarter) Heater 7 Source: OHCA Fast Facts March 2011

8 Reasonable Conclusions Services for the Duals are expensive as they require extensive care. Care being rendered between two programs results in fragmented and uncoordinated care. Care coordination would be a valuable added service. – Improved quality of care – Positive budget impact Heater 8

9 Original Proposal OHCA envisioned establishing a state-operated benefit plan for duals, in lieu of Medicare OHCA would have been responsible for ALL CARE of duals, demonstrating outcomes Would have required CMS and OHCA to agree upon a cap rate for dual services Savings shared between OHCA and CMS BUT… CMS financing models require 3-way contracts  Heater 9

10 SoonerCare Silver SoonerCare Silver Proposal #1 Heater 10

11 OHCA Care Management Why OHCA should be the solution: – The agency already applies care coordination to its SoonerCare members. – Adding Care Management to the Duals doesn’t overwhelm the SoonerCare program. – Spreading our fixed cost over a larger population should result in lower PMPM costs. (economies of scale) Heater 11

12 Modified Proposal OHCA “sells” our proven and effective managed care services for the Dual population to CMS. Enhance existing care coordination efforts – 7 Regional Nurse Care Management Teams – 1 Health Management Team Intensive care management for top 5,000 utilizers Covers wide range of diagnosis Heater 12

13 PACE - Interdisciplinary Care Team PACE IDT Team Program Director Personal Care Attendant Primary Care Physician Transport. Coord. Registered Nurse/ Dietician Physical & Occupa- tional Therapy Master’s Level Social Worker PACE Center Manager Medical Director Heater 13

14 Proposal #3 - THIZ University of Oklahoma – Tulsa School of Community Medicine Tulsa’s Health Innovation Zone (THIZ) Create an ACO in Tulsa area serving high cost, dual eligible patients – Focused on providing payment models that promote improved patient outcomes and an overall lower cost of care. Heater 14

15 No time like the present… Data, data, data Stakeholders Develop the plan Stakeholders Finalize the plan Stakeholders And did I mention…stakeholders? 15 Heater 15

16 Oklahoma Resources Oklahoma Medicaid Program Fast Facts – Opportunities for Living Life Document – Evaluation of Oklahoma’s Medicaid Service Delivery System – Mathematica Evaluation of SoonerCare Choice – Annual, Performance, and Quality Reports; Strategic Plan – Heater 16

17 Contact Information Buffy Heater, MPH Director of Planning & Development, OHCA (405) Marva Williamson Project Manager, Dual Eligible Initiative, OHCA (405) Heater 17


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