A Medical Home for Every SoonerCare Choice Member

1. Presented to name group date, 2008 A Medical Home forEvery SoonerCare Choice Member

2. Objectives • SoonerCare Choice Today • Medical Advisory Task Force (MAT) • Enhancing the SoonerCare Choice Medical Home • Transition Timeline • 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) Advance 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 • Partial capitation vs. primary care case management and fee-for-service payments • Medical home • Autoassignment • Credentialing

8. 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 PC-MH. • 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 Adopted by other payers: • Medicare • Private Payers • Large, Self Insured Employers • Patient-Centered Primary Care Collaborative • State Government

10. Proposed Re-aligning Reimbursement • 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:

11. Proposed New SoonerCare Choice Medical Home Reimbursement • Case Management Fee • PMP determines based on self-declared components • Office Care • Fee for service • Payments for Excellence

12. Draft Case Management Components

13. Proposed Excellence Payments Tentative $5 m pool to distribute first year • 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 Payments made quarterly. First payment made in April 09 based on claim dates of service Oct – Dec and adjudicated through March 2009.

14. Proposed Transitional Payments Tentative $3 m pool to distribute first year • 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

15. 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

16. Proposed Additional Changes • Eliminating default autoassignment • Coverage of new codes • OB/GYN providers will not be PCPs • Members may change PCPs within the month • Case Mgmt payment will be based on date processed

17. Other Initiatives • Foster Care Pilot Project • Outreach to households with newborns • Electronic NB-1 • Transformation grant • “No Wrong Door” eligibility enrollment enhancement. Target date March 1, 2009

18. Questions Comments • Request your input • Updates in global and banner messages, provider letters, OHCA public website • Contact OHCA Melody Anthony Provider Services Director 405.522.7360 / Melody.Anthony@okhca.org Provider Services 877-823-4529, option 2