Transcript Every Child Deserves a Medical Home”

An Improved
Medical Home for
Every SoonerCare
Choice Member
Presented at OHCA
Sept. 12, 2008
7/16/2015
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Objectives
•
•
•
•
Part I – Program
SoonerCare Choice Today
Medical Advisory Task Force (MAT)
Enhancing the SoonerCare Choice
Medical Home
• Transition Timeline
• Part II – Financing the PCMH
• Questions and Comments
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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”.
• PCPs manage the basic
health care needs, including
after hours care and
specialty referral of the
members on their panel.
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PCP Network
• SoonerCare Choice has over 400,000
members enrolled statewide
• Over 1,000 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
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Who Can be a PCP Today?
Physicians
General Practitioners
Family Practice
Internal Medicine
OB/GYNs
Pediatricians
Physician Assistants (PA)
Advanced Practice Nurses
(APN)
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FQHCs
RHCs
IHS Facilities
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
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Medical Advisory Taskforce
Four Top Priorities
• Change in current payment
structure
• Medical home
• Autoassignment
• Credentialing
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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
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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

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Current 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)
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Recommended PCMH
Reimbursement
The most effective way to re-align payment incentives to
support the PCMH would be to combine traditional feefor-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
http://www.patientcenteredprimarycare.org/
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SoonerCare Choice Comparison
What Stays the Same?
Current funding remains the same
Provider determines medical necessity
Federal restriction (e.g. EMTALA, co-pays)
What Changes?
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
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Proposed 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
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Other Initiatives
•
Foster Care Pilot Project
•
Outreach to households with newborns
•
Electronic NB-1
•
Transformation Grant
–
“No Wrong Door” eligibility enrollment enhancement.
Target date October 2009
•
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Health Access Networks Pilot
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Health Access Networks
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•
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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
Proposed Timeline
• Target date January 2009
• All eligible members rolled
over with current PCP
• Seamless for members, PCPs
• Contract updates needed by
November 1, 2008
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Medical Home
Part II
Financing the New Model
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%
Adults % Children
Eligibility Category
Adults
Children
Total
TANF
34,392
318,801
353,193
10%
90%
ABD/SSI
26,759
11,974
38,733
69%
31%
-
-
-
-
-
-
-
-
-
-
391,926
16%
84%
Children in Custody
Adults, Duals and
HCBW
Total
61,151 330,775
Source: OHCA Annual Report, SFY07
Average Monthly Enrollment:
84% are children
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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%
Total
353,193
38,733
391,926
90%
10%
Approximately 44% of adults may require
ongoing care coordination; 4% of children
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Definition of Capitation:
• 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 not
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Current Primary Care
Payment Structure
Capitated Bundled Rates include payment
for:
• Monthly 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)
Average total payment for physicians =
$24 pmpm
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Proposed New 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
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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
–
–
–
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Tier 1 = Entry Level Medical Home;
Tier 2 = Advanced Level Medical Home;
Tier 3 = Optimal Level Medical Home
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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
$3.00
$3.00
FQHCs/RHCs
$0.00
$0.00
$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
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Tier 1: Entry Level medical
Home Requirements
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•
•
•
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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
Tier 2: Advanced Medical Home
Requirements
Tier 1 Mandatory requirements plus the following:
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•
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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
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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
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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
Incentive Component
(SoonerExcell)
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•
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•
•
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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.
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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
• $3.75 million set aside
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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
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Budget Assumptions
Conversion from Capitation to
FFS
Increased Encounter data (20%) for:
– Increased Utilization
– Underreporting
– Improved coding
– New Codes
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Questions Comments
• Request your input:
[email protected]
• Updates in global and banner messages,
provider letters, OHCA public website at
www.okhca.org/medical-home
• Contact OHCA
Melody Anthony
Provider Services Director
405.522.7360 / [email protected]
Provider Services
877-823-4529, option 2
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Additional Resources
• Patient-centered primary care collaborative
http://www.pcpcc.net/
• AAFP patient-centered medical home
http://www.aafp.org/online/en/home/membership/initiat
ives/pcmh.html
• AAP medical home news http://www.aap.org/
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