1. Oregon FQHC/RHC Alternative Payment Method
Presentation for APIP Stakeholder Meeting
October 28, 2014
Jamal Furqan, Policy & Planning, Medical Assistance Programs

2. Safety Net reforms part of Current innovations
Health Homes also part of transformation efforts
Patient-Centered Primary Care Homes (PCPCHs)
2703 Health Home SPA (8 quarters ended 2013)
Currently have shifted from targeted high cost/high need population to broader, population-based effort
More than 400 clinics have applied and been certified as PCPCHs in Oregon and many of them are FQHCs and RHCs
All Oregon FQHCs in the safety-net Alternative Payment Method pilot are certified PCPCHs and changed their model of care due to this certification and opportunities presented by pilot 2

3. Safety Net Providers & PPS Payment Methodology
Paid at prospective payment system (PPS) rates for Oregon Health Plan people not enrolled in CCOs (fee-for-service (FFS))
We make wrap-around payment for coordinated care organization (CCO)/managed care enrollees to bring total payment for managed care clients to the FFS prospective payment system (PPS) equivalent
Wrap payments are retrospective, quarterly payments, which may be as much as eighteen months in arrears

4. Why Alternative Payment Methodology
Initiated by the Oregon Primary Care Association in partnership with member FQHCs and the Oregon Health Authority (OHA)
Driven by difficulty in recruitment and retention of physicians & low physician satisfaction
De-links treadmill of churning office visits for payment by paying a per-member per-month (PMPM) payment
Needed to be budget neutral to the state, but Federal requirements mandate payment at least equal to PPS
In September 2012, a State Plan Amendment was approved to transition FQHCs to an APM
3 large FQHCs went live with pilots 3/1/2013
Budget neutral to the state means that didn’t have MORE $$ to pay for financial incentives above what PPS would have paid.
Each FQHC has multiple clinic sites

5. Alternative Payment Methodology: Basics
Initially, only “medical” visits will be paid on a PMPM basis – mental health and OB services to follow
Attribution of members:
The monthly payment is based on attributed members to the specific FQHC using an18-month office visit look back to determine the “active patients” of those clinics
Patient lists are uploaded by the health center using MMIS Provider Web Portal each month
Whenever eligibility for an “active patient” is terminated, the PMPM payment is stopped automatically
If a patient begins to see a different primary care provider, or is no longer on the OHP, or in that service area

6. Attribution, continued…
NEW patients may be enrolled with the health center after an encounter is registered
PMPM payments begin on the day patient is established at health center
Patients are moved by the state when they establish care with a different primary care provider, so they retain choice of providers- PMPM payments stop and/or are recouped
The health centers now have a tangible list of patients for whom they are responsible for improving health and outcomes
With revenue delivered on time each month, health centers may focus on delivering the right care at the right time for the patient and their family 6

7. Alternative Payment Methodology: Rates
Used historical utilization of a defined assigned population and current PPS rates to develop a monthly PMPM rate for FQHCs
Two rates are developed for the monthly prospective payment for “active patients” from the active patient list:
Non-CCO enrolled patients: Medicaid revenue/number of established patients member months = PMPM rate
CCO enrolled: PMPM based on the state’s supplemental wraparound payments for CCO encounters to calculate an average “wrap-cap”.
Reconciliation is done so no downside risk: APM payments compared to what the clinic would have received in total payments; if APM payments are less, the state will pay the difference
Whenever eligibility for an “active patient” is terminated, the PMPM is stopped
Analyses done to determine if and how much primary care services were delivered at other primary care sites: duplication of payment or “leakage”; patients with a different health home
New patients are submitted by the clinic when they establish care

8. Touches Reports Touches are also known as: as:
Enabling Services
Flexible Services (CCOs)
Core Services (PCPCHs)
Alternative Services
Non billable, non-reimbursable services
The OHA has encouraged FQHCs to focus on the non-billable services (touches) that drive transformation of the delivery model, and improve patient health outcomes and quality of life.
Developing “touches” report to capture data on how care is being delivered 8

9. Quality Metric Reports
UDS quality metrics are collected from each clinic to ensure that at a minimum care does not worsen, and at best, improves.
Metrics align with HRSA, Health Home (and soon CCO metrics, as well).
Unlike the CCOs, there are no financial incentives tied to the metrics
No financial incentives due to the state’s need to have the APM be budget neutral.
Each APM HC currently submits quarterly reports on the following metrics:
Tobacco Screenings
Depression Screenings
Diabetes Control
Cervical Cancer Screenings
Weight Control: Adults and Kids
HTN Controlled (most recent BP less than 140/90)
Childhood Immunizations
% of patients that would recommend their care team
% of patient visits with assigned care team
% of patients assigned by CCO that have been established 9

10. OHA Challenges
Developing the methodologies for patient attribution, payment methods, touches reports and quality reporting has taken longer and been more complicated than initially imagined
System changes in our MMIS for this type of alternative payment method
Evaluation and development of “total cost of care” analysis
Being budget neutral for the state Medicaid program, and budget neutral per the APM in not paying less than PPS does not create total alignment in financial incentives
State fund (GF) budget impact of pre-APM wraparound settlements and post-APM PMPM payments occurring at same time 10

11. FQHC/RHC Challenges
Required reports and data, including patient panel management is new work that sometimes frustrate business office staff
The attribution model, and patients that may not commit to a medical home- impacts health center’s quality performance
Some clinics are challenged capturing data needed for the important Touches Reports from their EHR.
This issue will likely increase as pilot expands to additional clinics

12. Preliminary Results from 1st Year
Optumas analyzed the 1st year of the APM pilot for Inpatient and ER Utilization
Across all three FQHCs, inpatient utilization decreased compared to the prior two years
Aggregate decrease in inpatient utilization trend is 20.3%
“Year 3 Pre APM” is counter-factual projection (trend), post APM is actual pilot year data

13. Preliminary Results from 1st Year
Across all three FQHCs, emergency room utilization decreased compared to the prior two years
Aggregate decrease in ER utilization trend is 5.6%
“Year 3 Pre APM” is counter-factual projection (trend), post APM is actual pilot year data

14. Questions?