1. ECHO Optional Call- April 26, 2012 Practice-level Implications of the State Medicaid Rule to Allow for PCPCH Enhanced Payment

2. Objectives By the end of this call, we hope you will be able to: Demonstrate an improved understanding about the difference between PCPCH certification and rules that apply in order to receive enhanced payment Demonstrate an improved understanding of the implications of the Medicaid rule in order for a practice to receive enhanced reimbursement Recognize important next steps in obtaining Medicaid payments for ACA qualifying patients

3. Important Context: Difference between Certification & Payment Within the OHA: OHPR oversees PCPCH Standards and Certification Process THEN, each payer has a set of rules/policies that allow them to provide enhanced reimbursement by the tiers  Medicaid (DMAP) is one of the payers  Therefore, DMAP has rules to allow them to pay  Other payers down the road may have other rules  E.g. Future groups may be PEBB, OEBB, Office of Private Health Partnerships Medicaid (DMAP) needed CMS approval for enhanced payments based on PCPCH Designation Some of the funding is supported within the ACA, Section 2703 is the legislation Therefore, some parts of the enhanced payment process are therefore INFLEXIBLE because they were written into ACA by Congress

4. Activities over the last month DMAP submitted a Medicaid waiver amendment to allow for enhanced payments CMS approval is needed; therefore certain practice-level activities were required by CMS The rule reflects the compromise between DMAP-OHA and CMS to ensure it met CMS expectations As part of CMS and Quality Review requirements, there will be audits of compliance with the Medicaid Rule Currently, it sounds like this audit will happen by Medicaid at the time that OHPR does its audits of PCPCH certification (This mentioned in meetings, not listed publicly) This audit would involve medical chart reviews given the documentation requirements

5. Review of the Medicaid Rule: OPIP Review - Big Things to “Notice” 1. ACA qualifying conditions 2. Six “core” services provision 3. Person-centered plan 4. PCPCH Team definition 5. Generation of patient list and Enhanced Payment FFS: ACA and Non-ACA MCO: ACA 5. Patient agreement to participate in PCPCH 6. Documentation requirements at the patient level 7. Panel management

6. ACA Qualified Patients (Page 1 of Rule) Defined as individuals with: 1) A serious mental health condition 2) A least two chronic conditions proposed by state and approved by CMS 3) One chronic condition and at risk of another qualifying conditions as described above

7. Serious Mental Health Conditions in ACA

8. ACA TOPIC I How State Operationalized

9. At-Risk: Opportunities for Identifying Children RELIES ON CLINICAL JUDGEMENT EXAMPLE: As part of Bright Futures You Do BMI Assessment: At risk for overweight (NOT obese) Family risk factor screening: If parent smokes, at risk for asthma

10. At-Risk: Opportunities for Identifying Children Look closely at DX code for: 995.52 Child neglect (nutritional) 995.53 Child sexual abuse 995.54 Child physical abuse

11. Six Core Services (Page 1-2) Important to understand these services as quarterly provision of at least one is required, documentation required: 1. Comprehensive care management 2. Care Coordination 3. Directly collaborating or co-managing clients with specialty mental health/substance abuse/developmental disabilities and long term care 4. Comprehensive transitional care 5. Individual and family support services 6. Referral to community and social support services

12. Six Core Services Some things to notice: 1. Comprehensive care management Includes population panel management That said, documentation needs to be chart of population panel management (a grey area – see later re: Documentation) 2. Care Coordination Strong emphasis on person-centered plan (later on required separately) 3. Comprehensive transitional care Current rule notes and emphasis on improving the % of patients seen or contacted within one week of discharge

13. PCPCH Team definition Page 2 Must include non-physician health professionals, such as Nurse care coordinator Nutritionist Social worker Behavioral health professional Community health workers Personal health navigators Peer wellness specialist authorized by state plan or waiver These professionals can operate in variety of ways: such as free standing, virtual or based at any of the clinic and facilities

14. Person-Centered Plan Page 3 Defined as the plan that shall be developed by the PCPCH and reflect the client and family/caregiver preferences for: education, recovery and self-management as well as management of care coordination functions. Peer supports, support groups and self care programs shall be utilized to increase the client and caregivers knowledge about the client’s health and health-care needs. The person-centered plan shall be based on the needs and desires of the client including at least the following elements: (i) Options for accessing care; (ii) Information on care planning and care coordination; (iii) Names of other primary care team members when applicable; and (iv) Information on ways the team member participates in this care coordination; Later on in documentation, required for all clients (Not just ACA) Here there is an opportunity to share with Medicaid how this would apply and be documented for healthy, normally developing clients

15. Generation of Patient Lists Lists need to be generated quarterly The file should be a comma-delimited file Need to send it via secure file – see FAQ FFS Submit a list of FFS clients in format approved by Division Identify ACA and Non-ACA patients MCOs Consult with MCO on their procedures MCO then submits to OHA Non-ACA PCPCH Payment will be integrated into MCOs capitation payments and covered services at next opportunity (July 2012) MCOs must use alternative payment methodology. Rule notes that PMPM is an alternative methodology.

16. Generation of Patient Lists Consider opportunities to leverage entities and data sources they have Consider others may have data about services that you do not have in your systems Consider how to improve diagnostic code labeling in your processes of care For example, when using the CAHMI screener consider a part of the interpretation process labeling visits with related dx codes

17. Patient agreement to participate in PCPCH Ensure patient engagement, education and agreement to participate in the PCPCH program are documented within six months of initial participate PCPCH shall assure that for each patient providers working to develop a person-centered plan within six months * Important to look at FAQ for definition and documentation requirements around this.

18. Patient agreement to participate in PCPCH: Documentation Requirements See page 7 of FAQ o Examples of engagement include a phone call during which the patient agrees to be part of the program, or a brief conversation with a patient during an office visit. o The clinic should document in the patient’s medical record the date the patient was engaged and their agreement to participate. o A passive opt-out provision would not meet the intent of clinics actively engaging with patients. o A recognized clinic may submit an eligible patient name for PCPCH payment while attempting to complete and document the patient’s engagement, education, and agreement to participate. o After 6 month, if the clinic is unable to complete this requirement for a particular patient, the clinic should not include that patient’s name in the next quarterly patient list and not request PCPCH payment for that patient. o Efforts to engage a patient, even if unsuccessful, should be documented. o It is not the Oregon Health Authority’s intent to recoup payment for patients that were unable to be engaged within the initial 6 months. o The Oregon Health Authority is developing educational patient brochures about the program that can be used for the patient education requirement. These will soon be available to all recognized clinics.

19. Documentation Requirements (Page 5 and 6) (OPIP Advice: VERY Important to Read) Documentation is at the client/person level – not at the practice level Person-centered plan developed with the client or clients caregiver and in chart This is for all clients – not just ACA Must provide ONE of the six core services each quarter AND document the services in the medical recor

20. Documentation Requirements (Page 5 and 6) (OPIP Advice: VERY Important to Read) Documentation of Care Coordination Panel management is included in the definition However, documentation has to be in medical chart. Medicaid has not specifically addressed in the rule how panel management, as a population based analysis, would comply with the requirement of being documented in the medical record. Since they have not specified exactly how this function would end up documented in a patients record they wish to be as flexible a possible Open to recommendations from participating practices.

21. Generation of Patient Lists: Patient Lists Need to Be for People for Whom You Meet the Documentation Requirements Any patients the clinic asks us to assign a retro date on, clinic is attesting that they have complied with the service and documentation requirements. Time frame for developing a Person Centered Plan within six months: For those patients enrolled with a retro date, start the six month clock on the date the state made the enrollment in the MMIS system. Each clinic will receive confirmation of the enrolled patients and DMAP would not expect a plan to have been developed in the past, we would expect the other service delivery and documentation requirements to be made. During the first six months if a clinic finds they have PCPCH patients they have not been able to collaborate on a Person Centered Plan. Current DMAP Suggestion (One solution – not a requirement): Develop a preliminary plan and note in the medical record of attempts to collaborate with patient, or plan to do so in near future Revise that preliminary plan after the patient has been able to be involved

22. Panel Management Requirements (Page 7) Required to log on to Provider Portal Logging on serves as evidence that the clinic has complied with the service AND documentation requirements Here you have the opportunity to track quality measures AND use as a panel management tool If clinics have their own information technology, can use their own systems as an alternative. Need to meet specified requirements. A clinic can satisfy the required quarterly panel management documentation by having one team member log on to the provider portal offered by the Quality Corporation.

23. Important Documents to Review DMAP PCPCH Program Rule: http://www.dhs.state.or.us/policy/healthplan/guides/aian/141- 146-147_032212.pdf http://www.dhs.state.or.us/policy/healthplan/guides/aian/141- 146-147_032212.pdf Oregon Health Plan, 410-141-0860 (primary rule) http://www.dhs.state.or.us/policy/healthplan/guides/ohp/main.html http://www.dhs.state.or.us/policy/healthplan/guides/ohp/main.html FAQ:http://health.oregon.gov/OHA/OHPR/HEALTHREFOR M/PCPCH/docs/pcpch-med-faq.pdfhttp://health.oregon.gov/OHA/OHPR/HEALTHREFOR M/PCPCH/docs/pcpch-med-faq.pdf Supplemental Payment Option Packet, includes the diagnosis code list for qualified chronic conditions http://www.oregon.gov/OHA/OHPR/HEALTHREFORM/PC PCH/docs/dmap-enrollment-packet.pdf?ga=t http://www.oregon.gov/OHA/OHPR/HEALTHREFORM/PC PCH/docs/dmap-enrollment-packet.pdf?ga=t

24. So now what? At our next learning session, shared care plans will be a major part of the material delivered Technical assistance on other activities (e.g. panel management, measurement assessment, identification of SHCN, Bright Futures and related screening)

25. Clinical example JH is a 15 month old Hispanic female. Problems include: Prematurity Persistent Pulmonary Hypertension Patent Ductus Arteriosus Developmental Dysplasia of the hip GERD Due to her complexity, she needs cardiology, orthopedics, Early Intervention, home health nursing, ophthalmology, etc. In her first year she was on two chronic medications, oxygen therapy, needed serial bracing for her hips, required surgical repair of her PDA, and received monthly Synagis injections this winter. Total cost for first year (excluding NICU stay, home health nursing, and EI) was over $160K. She averages three visits and eight phone calls per month in just my office. Every Synagis visit the parents need to pull me aside for additional questions and support However, she has no ACA qualifying diagnoses…

26. Clinical Example BR is a 4 year old male with ASD and resulting developmental delay. He is lucky enough to be enrolled in a preschool that gives 30 hours of intensive therapy a week. He is on no additional medications. I receive one letter a quarter from the preschool, and see him for annual routine well visits and occasional ill visits (he’s had two in the last year). However, he has an ACA-qualifying diagnosis…

27. The punch line? ECHO Staff maintains its commitment to the need for a non- condition specific approach to identification of CYSHN and care coordination services. ECHO staff maintains the commitment to a focus in this learning collaborative on the broader concept of medical home – all of which are reflected and map to the rule

28. Next Steps Learning Session scheduled for May 19 Location: World Forestry Center Carl Cooley, MD visiting as part of TCHIC conference in June Grand Rounds 6/28 from 8-9 am Webinar availability Training for PCPs on Adolescent SHCN Needs within a Medical Home Sponsored by OCCYSHN 1:30-3:00