1/16/20161 Presented at OHCA Sept. 12, 2008 An Improved Medical Home for Every SoonerCare Choice Member

1/16/20162 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 Transition TimelineTransition Timeline Part II – Financing the PCMHPart II – Financing the PCMH Questions and CommentsQuestions and Comments

1/16/20163 What is SoonerCare Choice Today? SoonerCare Choice is a managed care model in which each member is linked to a primary care provider who serves as their “medical home”.SoonerCare Choice is 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.

1/16/20164 PCP Network SoonerCare Choice has over 400,000 members enrolled statewideSoonerCare Choice has over 400,000 members enrolled statewide Over 1,000 PCPs (up from 800+ in 2003)Over 1,000 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

1/16/20165 Who Can be a PCP Today? Physicians General Practitioners Family Practice Internal Medicine OB/GYNsPediatricians Physician Assistants (PA) Advanced Practice Nurses (APN) FQHCsRHCs IHS Facilities

1/16/20166 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

1/16/20167 Medical Advisory Taskforce Four Top Priorities Change in current payment structureChange in current payment structure Medical homeMedical home AutoassignmentAutoassignment CredentialingCredentialing

1/16/20168 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

1/16/20169 Patient Centered Medical Home Builds on successes already achieved in SoonerCare Choice patterned after North Carolina and Alabama’s medical home model  Medicare  Private Payers  Large, Self Insured Employers  State Government  Patient-Centered Primary Care Collaborative Adopted by other payers:

Current 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) 1/16/201610

1/16/ Recommended 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:

1/16/ 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 Online provider enrollment Current funding remains the same Provider determines medical necessity Federal restriction (e.g. EMTALA, co-pays) What Stays the Same? What Changes?

1/16/ Proposed 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

1/16/ Other Initiatives Foster Care Pilot ProjectFoster Care Pilot Project Outreach to households with newbornsOutreach to households with newborns Electronic NB-1Electronic NB-1 Transformation GrantTransformation Grant –“No Wrong Door” eligibility enrollment enhancement. Target date October 2009 Health Access Networks PilotHealth Access Networks Pilot

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

1/16/ Proposed Timeline Target date January 2009Target date January 2009 All eligible members rolled over with current PCPAll eligible members rolled over with current PCP Seamless for members, PCPsSeamless for members, PCPs Contract updates needed by November 1, 2008Contract updates needed by November 1, 2008

Medical Home Part II Financing the New Model 1/16/201617

1/16/ 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

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 1/16/201619

Definition of Capitation: A fixed payment for treating a fixed number of individuals whether they are ill or well…..A fixed payment for treating a fixed number of individuals whether they are ill or well….. Rate paid on entire panel whether member is seen or notRate paid on entire panel whether member is seen or not 1/16/201620

Current Primary Care Payment Structure Capitated Bundled Rates include payment for: Monthly case management based on age/sex cells – Weighted average = $2.23 pmpmMonthly case management based on age/sex cells – Weighted average = $2.23 pmpm E&M Visits based on 100% of Medicare fee schedule and actuarial based utilization assumptions (somewhat higher than actual encounter data received)E&M Visits based on 100% of Medicare fee schedule and actuarial based utilization assumptions (somewhat higher than actual encounter data received) 1/16/ Average total payment for physicians = $24 pmpm

1/16/ Proposed New 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

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 1/16/ Case Management/ Care Coordination Fee

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 1/16/201624

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 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

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 1/16/201627

1/16/ 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

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

1/16/ 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) $4.25 million set aside Payments made quarterly. First payment made in April 09 based on claim dates of service Oct – Dec and adjudicated through March 2009.

1/16/ 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 $3.75 million set aside Transitional Payments; Qualifications

Transitional Payments; Distribution 1/16/ 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 provider’s financial response to the medical home modelThis 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 classificationThere 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 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

Increased Encounter data (20%) for: –Increased Utilization –Underreporting –Improved coding –New Codes 1/16/ Budget Assumptions Conversion from Capitation to FFS

1/16/ 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

1/16/ 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