Trekking Towards Value Based Payments

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1 Trekking Towards Value Based Payments October 5, 07 Melody Anthony, MS Deputy State Medicaid Director Agenda Overview SoonerCare s Beginning Current Patient Centered Medical Home Delivery System CPC Classic and CPC+ Changes and Future Plans Anthony

2 SoonerCare Program SoonerCare Plus SoonerCare Choice Managed Care Organization (MCO) Full Risk Expanded benefits Primary Care Case Management (PCCM) Partial Risk Some adult limits Anthony SoonerCare Choice Partially-capitated primary care case management (PCCM) program Average PMPM payment was $4 Primary and preventive services Medically necessary office visits to the PCP with no co-pay Well-child screenings (EPSDT) Injections, immunizations Limited CLIA waived lab services Case management including referrals Anthony 4

3 Current Patient Centered Medical Home Delivery System Anthony 5 Medical Advisory Task Force At the request of providers, the MAT was created in February 007 Comprised of physician representatives delegated by state professional associations MAT Top Priorities Change in current payment structure Medical home / accountability Elimination of default auto-assignment Anthony 6

4 Reimbursement Realignment A monthly care coordination payment A visit-based fee-for-service component A performance-based component Anthony 7 Fee-for-Service Component % of the Physicians Medicare Fee Schedule % of Physicians Medicare Fee Schedule Coverage of new codes for PCPs SBIRT screening brief intervention referral for treatment After hours codes (99050 and 9905) Anthony 8

5 Medical Home Tiers and CM Fee Tier Entry Level Tier Advanced Tier 3 Optimal 3 Required Activities 0 hours/week CM Fee $3.36-$4.70 PMPM Primary/preventive care VFC participant Clinical data in paper or electronic format Maintains medication list Tracks lab/diagnostic tests Tracks referrals Care Coordination Patient and Family Education Medical Home Agreement Maintains open schedule E-Comm. from OHCA Phone coverage 4/7 BH screening annually 7 Required Activities + 3 of 5 Optional Activities 30 Hours/Week CM $4.36-$6.3 PMPM Required Tier plus Minimum 30 hours/week Track panel members inside/outside of practice Transitional Care Multi-modal communication Optional (3 of 5 required) Healthcare team led by PCP Post-visit outreach Evidence based guidelines Medication Management Minimum 4 hours after hours 3 Required Activities + 3 Optional Activities 30 Hours/Week CM $5.8-$8.5 PMPM Required Tier plus Healthcare team led by PCP Post-visit outreach Evidenced based guidelines Medication Management Minimum 4 hours after hours Health Assessment Tools Optional (3) Secure interactive web site Integrated care plans Performance improvement Anthony 9 SoonerCare Choice: Medical Home Tier Changes Jan. 009 Tier = 445 Tier = 3 Tier 3 = 3 Sept. 07 Tier = 464 Tier = Tier 3 = 90 Anthony 0

6 SoonerExcel Incentive Payments 009 $5 million available to distribute 07 $.9 million available to distribute Child health exams (EPSDT) and DTaP Generic drug prescribing ER Utilization Breast and Cervical Cancer Screenings Physician inpatient admitting and visits Anthony Health Access Networks Total Summary Report September 07 Provider Name Central Communities HAN OSU Center for Health Sciences OU HAN Initial Date July 0 Sept 0 July 00 Total Membership Total Number of Providers Unduplicated Providers PCMH Locations 3, , , Total 45, Anthony

7 Health Access Networks Organized to enhance the capabilities of the network s affiliated PCPs Organized to restructure and improve the access, quality, and continuity of care Separate PMPM payment to the network only Must offer these core components Assist in transformation of medical home structure Improved access to specialty care Expanded quality improvement strategies Care management/coordination to persons with complex health needs Anthony 3 Health Access Network (HAN) Service Locations - August HAN Service Locations: 8 total locations OU HAN 03 locations OSU HAN 0 locations Central Communities HAN 5 locations **DRAFT** This Document Was Created by Provider Services for Internal Use Only. Anthony Not intended for external distribution. Please do not share without OHCA permission. This document is based on data within the system at the time of compilation and is a 'point of time' representation of the specific month. 4

8 Anthony 5 Anthony 6

9 Anthony 7 CPC Classic and CPC+ Anthony 8

CPC Classic Regions Current Comprehensive Primary Care Initiative (National) Anthony 9 Comprehensive Primary Care Classic : 03-06 8 4 CPC Practice Locations 36 CPC Practices 3 3 IHS Practices 33

10 CPC Classic Regions Current Comprehensive Primary Care Initiative (National) Anthony 9 Comprehensive Primary Care Classic : CPC Practice Locations 36 CPC Practices 3 3 IHS Practices 33 Participating Patient Centered Medical Homes (PCMHs) 9 Individual Participating Providers Anthony **DRAFT** This Document Was Created by Provider Services for Internal Use Only. Not intended for external distribution. Please do not share without OHCA permission. This document is based on data within the system at the time of compilation and is a 'point of time' representation of the specific month. 0

11 CPC Classic s primary focus for the providers Multi-payers Primary/Preventive Care Transformation at the Primary Care Site Covered Lives Actionable Data Anthony CMS Shared Savings 04 Greater Tulsa Region was the only location that received shared savings from Medicare Medicare distributed more than $547K dollars to 49 CPC classic locations 4 of our 37 SoonerCare Choice locations received a payment 05 Total savings for Medicare Part A and B in year two was 57.7M Greater Tulsa, Colorado, Arkansas and Oregon has enough shared savings to off set the net loss of the other 3 regions Greater Tulsa, Colorado, Arkansas and Oregon shared in distribution of $3M to 40 practices. BCBSOK and Community Care also distributed shared savings payments BCBSOK and Community Care will be distributing shared savings payments. Anthony

CPC+ Selected Regions Anthony 3 Care Management Fee Major Differences between CPC Classic and CPC+ for Medicare $0 PBPM PY - CPC CPC +Track CPC+ Track $5 PBPM PY 3-4 $5 PBPM on average $8 PBPM on

12 CPC+ Selected Regions Anthony 3 Care Management Fee Major Differences between CPC Classic and CPC+ for Medicare $0 PBPM PY - CPC CPC +Track CPC+ Track $5 PBPM PY 3-4 $5 PBPM on average $8 PBPM on average; $00 for highest-risk tier Office Visit Payments 00 percent FFS 00 percent FFS 00 percent FFS for non-e&m services. Reduced FFS+ upfront PCP payments for E&M Incentive payments Shared savings based on quality metrics and total cost of care $.50 PBPM based on quality and utilization metrics $4 PBPM based on quality and utilization metrics HIT Partners Not required Not required Required Anthony 4

13 About CPC+ in Oklahoma 7 locations completed participation agreements with CMS, 76 Track 96 Track Quarterly payers meetings with Arkansas, Kansas City and Oklahoma. CPC+ 86 locations are SoonerCare Choice 35 are Track and 5 are Track serving 65,780 SoonerCare Choice-covered lives Medicare, SoonerCare, Community Care, BCBSOK, Advantage Medicare Plan (CC) and United HealthCare are the state wide payer participants. Anthony 5 Comprehensive Primary Care + - August CPC+ Practice Locations 86 CPC+ Practices 07 Participating Providers **DRAFT** This Document Was Created by Provider Services for Internal Use Only. Not intended for external distribution. Please do Anthony not share without OHCA permission. This document is based on data within the system at the time of compilation and is a 'point of time' representation of the specific month. 6

14 Changes and Future Plans Anthony 7 Changes Beginning on August, 07, all new SoonerCare Choice providers must have an on-site visit prior to the contract being finalized. September, 07, increased outreach to additional high risk SoonerCare Choice ABD members. Effective January, 08, care coordination payments will only be distributed if the member has established a relationship with their primary care provider. Anthony 8

15 FUTURE PLANS PCMH REDESIGN Base Requirements Add-on Payments Base case management fee Onsite inspection Outcomes-based QI Health risk assessment Social determinants of health assessment Mental health substance use screening Minimum of 30 office hours per week Open scheduling Preventive service EPSDT outreach and education, as applicable Certified EMR Post-visit follow-up Care coordination across the medical neighborhood Payments per additional activity (upon meeting criteria) Patient portal Accreditation HIE Extended hours outside of core business hours o 4 8 or o 9 or more Integrated behavioral health and substance use Population health management o Disease registry o Risk stratification o Standards of care o Outreach/follow-up Care coordination across the medical Anthony neighborhood: Integrated care plans 9 PCMH REDESIGN CON T Reimbursement - The redesign will not reduce payments to PCMH providers in aggregate but will be budget neutral versus what is projected to be spent under the current model (approximately $500 million per year for claims + PCMH/HAN case management + SoonerExcel) Administration The system will not add to provider or OHCA administrative burdens Quality The metrics selected for measuring quality/performance will: Reflect Oklahoma priorities Be related to PCMH activities Be measurable through claims data or medical records without increasing administrative burden Be quantifiable in terms of estimating the financial impact to the program associated with improved outcomes (wherever possible) Anthony 30

16 PCMH Redesign Rewarding Quality Potential areas of focus defining OK priorities Metrics with relationship to base requirements (e.g., preventive and chronic care) Metrics aligned with Comprehensive Primary Care+ (CPC+) measures Metrics aligned with Healthy Oklahoma 00/OHIP areas of focus: Obesity Tobacco cessation Maternal-Child health (MCH) including child preventive and oral health Behavioral Health Measures within all of the above areas for which Oklahoma lags national benchmarks Anthony 3 Thank You Contact Information melody.anthony@okhca.org medicalhomecomments@okhca.org Anthony 3

Oklahoma Health Care Authority

Oklahoma Health Care Authority SoonerCare Choice and Insure Oklahoma 1115(a) Demonstration 11-W-00048/6 Application for Extension of the Demonstration, 2016 2018 Submitted to the Centers for Medicare and