presented at ohca sept 12 2008 n.
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Presented at OHCA Sept. 12, 2008. An Improved Medical Home for Every SoonerCare Choice Member. 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

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Presentation Transcript
  • 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
what is soonercare choice today
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.
pcp network
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
who can be a pcp today
Who Can be a PCP Today?


General Practitioners

Family Practice

Internal Medicine



  • FQHCs
  • RHCs
  • IHS Facilities

Physician Assistants (PA)

Advanced Practice Nurses (APN)

medical advisory task force created
Medical Advisory Task Force Created

At the request of providers the MAT was created February 2007

Representatives delegated by provider associations




AAP, Oklahoma

medical advisory taskforce four top priorities
Medical Advisory Taskforce Four Top Priorities
  • Change in current payment structure
  • Medical home
  • Autoassignment
  • Credentialing
joint principles of the patient centered medical home
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
patient centered medical home
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
current soonercare choice reimbursement
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)

recommended pcmh reimbursement
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

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:

soonercare choice comparison
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



proposed additional soonercare choice changes
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
other initiatives
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
health access networks
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
proposed timeline
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
medical home part ii

Medical HomePart II

Financing the New Model

soonercare choice demographics
SoonerCare Choice Demographics

Source: OHCA Annual Report, SFY07

Average Monthly Enrollment:

84% are children



soonercare choice demographics cont d
SoonerCare Choice Demographics,(cont’d)

Approximately 44% of adults may require

ongoing care coordination; 4% of children



definition of capitation
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



current primary care payment structure
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)



proposed new soonercare choice reimbursement
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



case management care coordination fee
Case Management/Care Coordination Fee

Peer Grouped based on type of practice

  • Children only;
  • Adults and Children;
  • Adults Only
  • FQHCs/RHCs


Level of Medical Home

  • Tier 1 = Entry Level Medical Home;
  • Tier 2 = Advanced Level Medical Home;
  • Tier 3 = Optimal Level Medical Home




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



tier 1 entry level medical home requirements
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

tier 2 advanced medical home requirements
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
tier 2 optional criteria must select three
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



tier 3 optimal medical home requirements
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



tier 3 optional criteria
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

incentive component soonerexcell
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.



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



transitional payments distribution
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
budget assumptions conversion from capitation to ffs
Budget Assumptions Conversion from Capitation to FFS

Increased Encounter data (20%) for:

  • Increased Utilization
  • Underreporting
  • Improved coding
  • New Codes
questions comments
Questions Comments
  • Request your input:
  • Updates in global and banner messages, provider letters, OHCA public website at
  • Contact OHCA

Melody Anthony

Provider Services Director

405.522.7360 /

Provider Services

877-823-4529, option 2

additional resources
Additional Resources
  • Patient-centered primary care collaborative
  • AAFP patient-centered medical home
  • AAP medical home news