An Improved Medical Home for Every SoonerCare Choice Member

1. Presented at OHCA Sept. 12, 2008 An Improved Medical Home forEvery SoonerCare Choice Member

2. 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

3. 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.

4. 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

5. Who Can be a PCP Today? Physicians General Practitioners Family Practice Internal Medicine OB/GYNs Pediatricians • FQHCs • RHCs • IHS Facilities Physician Assistants (PA) Advanced Practice Nurses (APN)

6. 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

7. Medical Advisory Taskforce Four Top Priorities • Change in current payment structure • Medical home • Autoassignment • Credentialing

8. Joint Principles of the PatientCentered 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

9. 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

10. 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)

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

12. 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 5/24/2014 12

13. 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

14. 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 • Health Access Networks Pilot

15. Health Access Networks • 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

16. 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

17. Medical HomePart II Financing the New Model

18. SoonerCare Choice Demographics Source: OHCA Annual Report, SFY07 Average Monthly Enrollment: 84% are children 5/24/2014 18

19. SoonerCare Choice Demographics,(cont’d) Approximately 44% of adults may require ongoing care coordination; 4% of children 5/24/2014 19

20. 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 5/24/2014 20

21. Current Primary Care Payment Structure Average total payment for physicians = $24 pmpm 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) 5/24/2014 21

22. Proposed New SoonerCare Choice Reimbursement 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 “Unbundled” to incorporate PCMH principles 5/24/2014 22

23. 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 • Tier 1 = Entry Level Medical Home; • Tier 2 = Advanced Level Medical Home; • Tier 3 = Optimal Level Medical Home 5/24/2014 23

24. Case Management/Care Coordination Fee Summary 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 5/24/2014 24

25. Tier 1: Entry Level medical Home Requirements • 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

26. Tier 2: Advanced Medical Home Requirements Tier 1 Mandatory requirements plus the following: • 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

27. Tier 2: Optional CriteriaMust 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 5/24/2014 27

28. 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 5/24/2014 28

29. Tier 3: Optional Criteria • 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 OHCA encourages providers to choose one or more of the following as further enhancements to tier 3

30. Incentive Component(SoonerExcell) 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. 5/24/2014 30

31. 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 Transitional Payments; Qualifications 5/24/2014 31

32. 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

33. Budget Assumptions Conversion from Capitation to FFS Increased Encounter data (20%) for: • Increased Utilization • Underreporting • Improved coding • New Codes

34. Questions Comments • Request your input: MedHomeComments@okhca.org • 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 / Melody.Anthony@okhca.org Provider Services 877-823-4529, option 2

35. Additional Resources • Patient-centered primary care collaborative http://www.pcpcc.net/ • AAFP patient-centered medical home http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html • AAP medical home news http://www.aap.org/