Transcript Oregon APM Overview - Oregon School

Oregon FQHC/RHC Alternative Payment Method
Presentation for APIP Stakeholder Meeting
October 28, 2014
Jamal Furqan, Policy & Planning, Medical Assistance Programs
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
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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
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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
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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
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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
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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,
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the state will pay the difference
Touches Reports
• Touches are also known as:
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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 nonbillable 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
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Quality Metric Reports
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UDS quality metrics are collected from each clinic to ensure that at a minimum
care does not worsen, and at best, improves.
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Metrics align with HRSA, Health Home (and soon CCO metrics, as well).
Unlike the CCOs, there are no financial incentives tied to the metrics
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Each APM HC currently submits quarterly reports on the following metrics:
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No financial incentives due to the state’s need to have the APM be budget neutral.
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
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
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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
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
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
Questions?