A Medical Home for Every SoonerCare Choice Member

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Presented to Presented to name groupname groupdatedate, 2008, 2008

A Medical Home forA Medical Home forEvery SoonerCare Every SoonerCare Choice MemberChoice Member

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ObjectivesObjectives• SoonerCare Choice TodaySoonerCare Choice Today• Medical Advisory Task Force (MAT)Medical Advisory Task Force (MAT)• Enhancing the SoonerCare Choice Enhancing the SoonerCare Choice

Medical HomeMedical Home• Transition TimelineTransition Timeline• Questions and CommentsQuestions and Comments

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What is SoonerCare Choice What is SoonerCare Choice Today?Today?• SoonerCare Choice SoonerCare Choice is a is a

managed care model in managed care model in which each member is which each member is linked to a primary care linked to a primary care provider who serves as provider who serves as their “medical home”. their “medical home”.

• PCPs manage the basic PCPs manage the basic health care needs, health care needs, including after hours care including after hours care and specialty referral of the and specialty referral of the members on their panel.members on their panel.

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PCP NetworkPCP Network• SoonerCare Choice has over 400,000 SoonerCare Choice has over 400,000

members enrolled statewidemembers 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 Average panel size of 300 members per

PCPPCP

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Who Can be a PCP Who Can be a PCP Today?Today?

PhysiciansPhysiciansGeneral PractitionersGeneral PractitionersFamily PracticeFamily PracticeInternal MedicineInternal MedicineOB/GYNsOB/GYNsPediatriciansPediatricians

Physician Assistants (PA)Physician Assistants (PA)Advance Practice Nurses Advance Practice Nurses

(APN)(APN)

FQHCsFQHCsRHCsRHCsIHS FacilitiesIHS Facilities

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Medical Advisory Task Medical Advisory Task Force CreatedForce Created

• At the request of providers the At the request of providers the MAT was created February 2007MAT was created February 2007

• Representatives delegated by Representatives delegated by provider associationsprovider associations– OOAOOA– OSMAOSMA– OAFPOAFP– AAP, OklahomaAAP, Oklahoma

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Medical Advisory Taskforce Medical Advisory Taskforce Four Top PrioritiesFour Top Priorities

• Partial capitation vs. primary Partial capitation vs. primary care case management and care case management and fee-for-service paymentsfee-for-service payments

• Medical homeMedical home• AutoassignmentAutoassignment• CredentialingCredentialing

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Joint Principles of the Joint Principles of the Patient-Centered Medical Patient-Centered Medical

HomeHomeIn March 2007 the AAP, AAFP, ACP, and In March 2007 the AAP, AAFP, ACP, and AOA, representing approximately 333,000 AOA, representing approximately 333,000 physicians, developed the following joint physicians, developed the following joint principles to describe the characteristics of principles to describe the characteristics of the PC-MH.the PC-MH.

Personal PhysicianPersonal Physician Physician Directed Physician Directed PracticePractice Whole Person OrientationWhole Person Orientation Adequate PaymentAdequate Payment

Quality and SafetyQuality and Safety Enhanced AccessEnhanced Access

Care is coordinated and / or Care is coordinated and / or integratedintegrated

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Patient-Centered Medical Patient-Centered Medical HomeHome

Builds on successes already Builds on successes already achieved in SoonerCare achieved in SoonerCare

Choice Choice MedicareMedicare Private PayersPrivate Payers Large, Self Insured Large, Self Insured EmployersEmployers State GovernmentState Government Patient-Centered Primary Care Patient-Centered Primary Care CollaborativeCollaborative

Adopted by other payers:Adopted by other payers:

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Proposed Re-aligning Proposed Re-aligning ReimbursementReimbursement

• A monthly care coordination payment A monthly care coordination payment

• A visit-based fee-for-service component A visit-based fee-for-service component

• A performance-based componentA performance-based componentSource:Source: The Patient Centered Primary Care Collaborative The Patient Centered Primary Care Collaborative http://http://

www.patientcenteredprimarycare.orgwww.patientcenteredprimarycare.org//

The most effective way to re-align payment The most effective way to re-align payment incentives to support the PCMH would be to incentives to support the PCMH would be to combine traditional fee-for-service for office visits combine traditional fee-for-service for office visits with a three part model that includes:with a three part model that includes:

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Proposed Proposed New SoonerCare Choice New SoonerCare Choice

Medical Home Medical Home ReimbursementReimbursement• Case Management FeeCase Management Fee

– PMP determines based on PMP determines based on self-declared componentsself-declared components

• Office CareOffice Care– Fee for serviceFee for service

• Payments for ExcellencePayments for Excellence

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Draft Case Management Draft Case Management ComponentsComponents

Provides preventive servicesProvides preventive services $.20$.20Provides EPSDT / immunizationProvides EPSDT / immunization .25.25VFC participant VFC participant .10.1024 / 7 voice-to-voice coverage24 / 7 voice-to-voice coverage .75.75Provides hospital discharge follow-upProvides hospital discharge follow-up .20.20Provides continuity of careProvides continuity of care .20.20Actively participates in HMPActively participates in HMP .15.15Maintains / intends to maintain EMRMaintains / intends to maintain EMR .30.30Uses / intends e-prescribingUses / intends e-prescribing .10.10Provides open schedulingProvides open scheduling .30.30Receives electronic informationReceives electronic information .05.05Participates in “pay for excellence”Participates in “pay for excellence” .10.10Serves special health care needsServes special health care needs .30.30

TOTALTOTAL $3.00$3.00

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Proposed Excellence Proposed Excellence PaymentsPayments

• Child Health Exams (EPSDT) and DTaP • Chronic Conditions; High Risk Members • Generic Drug Prescribing • ER utilization • Breast and cervical cancer screenings• Physician inpatient admitting and visits

Tentative $5 m pool to distribute first Tentative $5 m pool to distribute first yearyear

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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Proposed Transitional Proposed Transitional PaymentsPayments

• At least 20% of their practice must consist of SoonerCare members

• Not on the QA/QI noncompliance list for medical reasons

• Average office visit per member must be within one standard deviation of the average utilization for their specialty

Tentative $3 m pool to distribute first Tentative $3 m pool to distribute first yearyear

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Proposed TimelineProposed Timeline• Target date January 2009Target date January 2009• All eligible members rolled All eligible members rolled

over with current PCPover with current PCP• Seamless for members, PCPsSeamless for members, PCPs• Contract updates needed by Contract updates needed by

November 1, 2008November 1, 2008

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Proposed Additional Proposed Additional ChangesChanges

• Eliminating default autoassignmentEliminating default autoassignment• Coverage of new codesCoverage of new codes• OB/GYN providers will not be PCPsOB/GYN providers will not be PCPs• Members may change PCPs within Members may change PCPs within

the monththe month• Case Mgmt payment will be based on Case Mgmt payment will be based on

date processeddate processed

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Other InitiativesOther 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 No Wrong Door” eligibility enrollment enhancement. Target date March 1, 2009enhancement. Target date March 1, 2009

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Questions CommentsQuestions Comments• Request your inputRequest your input

• Updates in global and banner messages, Updates in global and banner messages, provider letters, OHCA public websiteprovider letters, OHCA public website

• Contact OHCAContact OHCAMelody AnthonyMelody AnthonyProvider Services DirectorProvider Services Director405.522.7360 / 405.522.7360 / [email protected]@okhca.orgProvider ServicesProvider Services877-823-4529, option 2877-823-4529, option 2