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11/1/20131 An Improved Medical Home for Every SoonerCare Choice Member.

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Presentation on theme: "11/1/20131 An Improved Medical Home for Every SoonerCare Choice Member."— Presentation transcript:

1 11/1/20131 An Improved Medical Home for Every SoonerCare Choice Member

2 11/1/20132 Objectives 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 HomeEnhancing the SoonerCare Choice Medical Home Part II – Financing the PCMH Questions and CommentsQuestions and Comments

3 11/1/20133 What was SoonerCare Choice SoonerCare Choice was a managed care model in which each member is linked to a primary care provider who serves as their medical home.SoonerCare Choice was 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.PCPs manage the basic health care needs, including after hours care and specialty referral of the members on their panel.

4 11/1/20134 PCP Network SoonerCare Choice has over 400,000 members enrolled statewideSoonerCare Choice has over 400,000 members 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

5 11/1/20135 Medical Advisory Task Force Created At the request of providers the MAT was created February 2007At the request of providers the MAT was created February 2007 Representatives delegated by provider associationsRepresentatives delegated by provider associations –OOA –OSMA –OAFP –AAP, Oklahoma

6 11/1/20136 Medical Advisory Taskforce Four Top Priorities Change in current payment structureChange in current payment structure Medical homeMedical home AutoassignmentAutoassignment CredentialingCredentialing

7 11/1/20137 Joint Principles of the Patient Centered 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 Personal Physician Physician Directed Practice Physician Directed Practice Whole Person Orientation Whole Person Orientation Adequate Payment Adequate Payment Quality and Safety Quality and Safety Enhanced Access Enhanced Access Care is coordinated and / or integrated Care is coordinated and / or integrated

8 11/1/20138 Patient Centered Medical Home Builds on successes already achieved in SoonerCare Choice patterned after North Carolina and Alabamas medical home model Medicare Medicare Private Payers Private Payers Large, Self Insured Employers Large, Self Insured Employers State Government State Government Patient-Centered Primary Care Collaborative Patient-Centered Primary Care Collaborative Adopted by other payers:

9 Previous SoonerCare Choice Reimbursement Monthly Capitated Bundled payment Case Management / Care Coordination FeeCase Management / Care Coordination Fee Primary care office visitsPrimary care office visits Limited lab servicesLimited lab services Other codes paid on FFS basis Incentive Payments EPSDT / 4 th DTaP bonusEPSDT / 4 th DTaP bonus (lump sum payments) 11/1/20139

10 10 PCMH Reimbursement A monthly care coordination paymentA monthly care coordination payment A visit-based fee-for-service componentA visit-based fee-for-service component A performance-based componentA performance-based component Source: The Patient Centered Primary Care Collaborative 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:

11 11/1/ SoonerCare Choice Comparison Prepayment for case management only Referrals only needed for specialty care Group contracts must designate a medical director Elimination of default autoassignment Current funding remains the same Provider determines medical necessity Federal restriction (e.g. EMTALA, co-pays) What Stayed the Same? What Changed?

12 11/1/ Additional SoonerCare 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 primary care may no longer be PCPsOB/GYN specialists that do not provide primary care may no longer be PCPs Members may change PCPs within the monthMembers may change PCPs within the month Case Mgmt payment will be based on date processedCase Mgmt payment will be based on date processed

13 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

14 11/1/ Implementation Timeline Effective January 2009Effective January Contract renewals completed between October 9 and December Contract renewals completed between October 9 and December 15 64% were tier 1, entry level medical home64% were tier 1, entry level medical home 32% were tier 2, advanced medical home32% were tier 2, advanced medical home 4% were tier 3, optimal medical home4% were tier 3, optimal medical home

15 Medical Home Part II Financing the New Model 11/1/201315

16 11/1/ Eligibility CategoryAdultsChildrenTotal % Adults% Children TANF 34, , ,193 10% 90% ABD/SSI 26,759 11,974 38,733 69% 31% Children in Custody Adults, Duals and HCBW Total 61, , ,926 16% 84% Source: OHCA Annual Report, SFY07 Average Monthly Enrollment: 84% are children

17 Age GroupTANFABD/SSITotal%TANF % ABD/SSI Adults 34,392 26,759 61,151 56% 44% Children 318,801 11, ,77596% 4% Total 353,193 38, ,92690% 10% Approximately 44% of adults may require ongoing care coordination; 4% of children 11/1/201317

18 11/1/ SoonerCare Choice Reimbursement 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 Unbundled to incorporate PCMH principles

19 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 11/1/ Case Management/ Care Coordination Fee

20 Type of PracticeTier 1Tier 2Tier 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 FQHCs/RHCs$0.00 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 11/1/201320

21 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)

22 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

23 Tier 2: Optional Criteria Must 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 11/1/201323

24 11/1/ 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 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

25 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

26 11/1/ 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) Payments made quarterly. First payment made in April 09 based on claim dates of service Oct – Dec and adjudicated through March 2009.

27 11/1/ 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 Payments; Qualifications

28 Transitional Payments; Distribution 11/1/ Total pool divided by total eligible member monthsTotal pool divided by total eligible member months Per Member amount is multiplied by actual MM in quarterPer 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 modelThis 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 classificationThere 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 paymentProviders 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 paymentsNo provider will be made more than 90% whole with transitional payments

29 11/1/ Questions Comments Request your input: your input: Updates in global and banner messages, provider letters, OHCA public website at in global and banner messages, provider letters, OHCA public website at Contact OHCAContact OHCA Melody Anthony Provider Services Director / Provider Services , option 2

30 11/1/ Additional Resources Patient-centered primary care collaborative primary care collaborative AAFP patient-centered medical home ives/pcmh.htmlAAFP patient-centered medical home ives/pcmh.html ives/pcmh.html ives/pcmh.html AAP medical home news medical home news


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