Transcript Health Information Exchange (HIE) and Health Information

COORDINATING CARE FOR
MEMBERS DUALLY ELIGIBLE FOR
MEDICARE AND SOONERCARE:
EXPLORING A NEW FRONTIER
Buffy L. Heater, MPH
Director of Planning & Development
Oklahoma Health Care Authority
Heater
1
2
Oklahoma Dual Eligible
Population
SoonerCare
727,369
Medicare
607,465
Duals
104,538
Source: SoonerCare data as of June 2011
Heater
2
Dual Eligibles by Race
Heater
3
Dual Eligible Population by Gender
•66,308 Females
•39,224 Males
Heater
4
Dual Eligibles by Region
Heater
Source: SoonerCare data as of June 2011
5
Dual Eligible Reimbursement by Quarter
Heater
Source: OHCA Fast Facts March 2011
6
Per Member Per Month Cost
(monthly average per quarter)
Heater
Source: OHCA Fast Facts March 2011
7
Reasonable Conclusions
• Services for the Duals are expensive as they
require extensive care.
• Care being rendered between two programs
results in fragmented and uncoordinated care.
• Care coordination would be a valuable added
service.
– Improved quality of care
– Positive budget impact
Heater
8
Original Proposal
• OHCA envisioned establishing a state-operated
benefit plan for duals, in lieu of Medicare
• OHCA would have been responsible for ALL CARE of
duals, demonstrating outcomes
• Would have required CMS and OHCA to agree upon
a cap rate for dual services
• Savings shared between OHCA and CMS
BUT…
CMS financing models require 3-way contracts 
Heater
9
Proposal #1
SoonerCare Silver
Heater
10
OHCA Care Management
• Why OHCA should be the solution:
– The agency already applies care coordination to
its SoonerCare members.
– Adding Care Management to the Duals doesn’t
overwhelm the SoonerCare program.
– Spreading our fixed cost over a larger population
should result in lower PMPM costs.
(economies of scale)
Heater
11
Modified Proposal
• OHCA “sells” our proven and effective managed
care services for the Dual population to CMS.
• Enhance existing care coordination efforts
– 7 Regional Nurse Care Management Teams
– 1 Health Management Team
• Intensive care management for top 5,000
utilizers
• Covers wide range of diagnosis
Heater
12
PACE - Interdisciplinary Care Team
Program
Director
Personal
Care
Attendant
Medical
Director
PACE Center
Manager
PACE
IDT
Primary
Care
Physician
Team
Master’s
Level Social
Worker
Transport.
Coord.
Physical &
Occupational
Therapy
Heater
Registered
Nurse/
Dietician
13
Proposal #3 - THIZ
•
•
•
•
University of Oklahoma – Tulsa
School of Community Medicine
Tulsa’s Health Innovation Zone (THIZ)
Create an ACO in Tulsa area serving high cost,
dual eligible patients
– Focused on providing payment models that
promote improved patient outcomes and an
overall lower cost of care.
Heater
14
No time like the present…
15
•
•
•
•
•
•
Data, data, data
Stakeholders
Develop the plan
Stakeholders
Finalize the plan
Stakeholders
And did I mention…stakeholders?
Heater
15
Oklahoma Resources
• Oklahoma Medicaid Program Fast Facts
– Opportunities for Living Life Document
– http://www.okhca.org/research.aspx?id=87&parts=7447
• Evaluation of Oklahoma’s Medicaid Service Delivery
System
– Mathematica Evaluation of SoonerCare Choice
– http://www.okhca.org/research.aspx?id=10087&parts=7447
• Annual, Performance, and Quality Reports; Strategic
Plan
– http://www.okhca.org/research.aspx?id=84&parts=7447
Heater
16
Contact Information
Buffy Heater, MPH
Director of Planning & Development, OHCA
(405) 522-7545
[email protected]
Marva Williamson
Project Manager, Dual Eligible Initiative, OHCA
(405) 522-7319
[email protected]
Heater
17