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An Improved Medical Home for Every SoonerCare Choice Member

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Presentation on theme: "An Improved Medical Home for Every SoonerCare Choice Member"— Presentation transcript:

1 An Improved Medical Home for Every SoonerCare Choice Member
3/22/2017

2 Objectives Part I – Program SoonerCare Choice Today
Medical Advisory Task Force (MAT) Enhancing the SoonerCare Choice Medical Home Part II – Financing the PCMH Questions and Comments 3/22/2017

3 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”. PCPs manage the basic health care needs, including after hours care and specialty referral of the members on their panel. 3/22/2017

4 PCP Network SoonerCare Choice has over 400,000 members enrolled statewide Over 1,200 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 3/22/2017

5 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 3/22/2017 5

6 Medical Advisory Taskforce Four Top Priorities
Change in current payment structure Medical home Autoassignment Credentialing 3/22/2017

7 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 Enhanced Access Physician Directed Practice Quality and Safety Whole Person Orientation Adequate Payment Care is coordinated and / or integrated 3/22/2017

8 Patient Centered Medical Home
Builds on successes already achieved in SoonerCare Choice patterned after North Carolina and Alabama’s medical home model Adopted by other payers: Medicare Private Payers Large, Self Insured Employers Patient-Centered Primary Care Collaborative State Government 3/22/2017

9 Previous 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) 3/22/2017

10 PCMH Reimbursement 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 3/22/2017 10

11 SoonerCare Choice Comparison
What Stayed the Same? Current funding remains the same Provider determines medical necessity Federal restriction (e.g. EMTALA, co-pays) What Changed? Prepayment for case management only Referrals only needed for specialty care Group contracts must designate a medical director Elimination of default autoassignment 3/22/2017 11 11

12 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 3/22/2017 12

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 Implementation Timeline
Effective January 2009 720 Contract renewals completed between October 9 and December 15 64% were tier 1, entry level medical home 32% were tier 2, advanced medical home 4% were tier 3, optimal medical home 3/22/2017 14 14

15 Financing the New Model
Medical Home Part II Financing the New Model 3/22/2017

16 SoonerCare Choice Demographics
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 61,151 330,775 391,926 16% 84% Source: OHCA Annual Report, SFY07 Average Monthly Enrollment: 84% are children 3/22/2017 16 16

17 SoonerCare Choice Demographics, (cont’d)
Age Group TANF ABD/SSI Total %TANF % ABD/SSI Adults 34,392 26,759 61,151 56% 44% Children 318,801 11,974 330,775 96% 4% 353,193 38,733 391,926 90% 10% Approximately 44% of adults may require ongoing care coordination; 4% of children 3/22/2017 17

18 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 3/22/2017 18 18

19 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 3/22/2017 19

20 Case Management/Care Coordination Fee Summary
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 FQHCs/RHCs $0.00 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 3/22/2017 20

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 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

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 3/22/2017 23

24 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 3/22/2017 24 24

25 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

26 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. 3/22/2017 26 26

27 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 3/22/2017 27

28 Transitional Payments; Distribution
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 provider’s financial response to the medical home model There are two categories of factors determined by the provider’s 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 3/22/2017

29 Questions Comments 877-823-4529, option 2
Request your input: Updates in global and banner messages, provider letters, OHCA public website at Contact OHCA Melody Anthony Provider Services Director / Provider Services , option 2 3/22/2017

30 Additional Resources Patient-centered primary care collaborative AAFP patient-centered medical home AAP medical home news 3/22/2017


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