SoonerCare PCMH Redesign Stakeholder Meetings Insights

SOONERCARE PCMH REDESIGN STAKEHOLDER MEETINGS Oklahoma Health Care Authority/Pacific Health Policy Group September - October, 2019 (updated 9-24)

WHY ARE WE HERE TODAY? The OHCA is committed to improving the health of SoonerCare members Program-wide, this requires: Measuring how well we re doing in offering high quality, accessible care Recognizing and rewarding high achievement among our providers Working with our providers to address gaps in care PCMH Redesign Stakeholder Meeting 2

WHY ARE WE HERE TODAY? Patient Centered Medical Home (PCMH) providers are the heart of the SoonerCare program Medical Specialists Hospitals Neighborhood Health PCMH Behavioral Health Other (including social services) PCMH Redesign Stakeholder Meeting 3

WHY ARE WE HERE TODAY? Even during the State s fiscal crunch, SoonerCare members had greater access to primary care than their counterparts nationally Over 90 percent of children under age 12 saw their PCMH at least once in a year Over 80 percent of adults saw their PCMH at least once in a year The agency s goal is to redesign and introduce an enhanced PCMH program in October 2020 in partnership with providers PCMH Redesign Stakeholder Meeting 4

TODAYS AGENDA Topic Approximate Time 1. Additional background 10 minutes 2. PCMH redesign 35 minutes 3. Discussion 30 minutes 4. Sharing quality/performance data with practices 15 minutes 5. Discussion 15 minutes Questions are welcome throughout the presentation PCMH Redesign Stakeholder Meeting 5

ADDITIONAL BACKGROUND SoonerCare Choice is the OHCA s managed care program for Medicaid members who are not Medicare- eligible and do not receive long term care All SoonerCare Choice members have the opportunity to select a PCMH provider Adult Choice members with a PCMH have access to more primary care than members who do not choose a PCMH In August of this year, SoonerCare Choice included: 434,000 children and adolescents 95,000 adults, many with complex/chronic health care needs PCMH Redesign Stakeholder Meeting 6

ADDITIONAL BACKGROUND contd The PCMH program was introduced in 2009 and has been updated over time The current design has three tiers for which providers can seek recognition (certification), as shown starting on the next slide Tier 1 Entry Level Tier 2 Advanced Tier 3 Optimal PCMH Redesign Stakeholder Meeting 7

ADDITIONAL BACKGROUND contd Tier 1 Entry Level Tier 2 Advanced Tier 3 Optimal Required 20 hours/week Primary/preventive care Clinical data in paper or electronic format Maintain medication list Track lab/diagnostic tests Track referrals Care coordination Patient and family education Medical Home agreement Maintain open schedule E-Communication from OHCA Phone coverage 24/7 Behavioral health screening annually Required All Tier 1 and 2 standards Healthcare team led by PCP Post-visit outreach Evidenced based guidelines Medication Management Minimum 4 hours after hours Health assessment tools Required All Tier 1 standards 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 Optional (3) Secure interactive web site Integrated care plans Performance improvement PCMH Redesign Stakeholder Meeting 8

ADDITIONAL BACKGROUND contd The design includes three payment components: Case management fee paid on a per member per month basis (payment commences after PCMH provider sees a member for the first time and remains in effect as long as member is seen at least once every 15 months) Fee-for-service payments (medical claims) for patient visits SoonerExcel incentive payments for meeting/ exceeding program targets (e.g., conducting behavioral health or breast/cervical cancer screens) - $2.9 million earned in SFY 2018 PCMH Redesign Stakeholder Meeting 9

ADDITIONAL BACKGROUND contd Monthly per member case management fees Effective October 1, 2019 Practice Type Tier 1 Tier 2 Tier 3 Children only $3.63 $4.73 $6.28 Children and adults $4.39 $5.73 $7.61 Adult only $5.08 $6.63 $8.82 A Tier 2 PCMH with 1,000 SoonerCare Choice patients (children and adults) receives: 1,000 x $5.73 = $5,730 per month in case management fees ($68,760 per year) SoonerExcel payments, if earned Fee-for-service payments for medical care PCMH Redesign Stakeholder Meeting 10

PCMH REDESIGN OVERVIEW Building on the progress made since 2009, the time is appropriate for a broader redesign of the SoonerCare PCMH model Nationally, there is ever greater emphasis on value- based purchasing that: Establishes uniform standards for providers Measures, recognizes and rewards higher quality and improved outcomes Promotes integration of primary care with the broader health neighborhood (medical specialists, behavioral health and social services, or social determinants of health ) PCMH Redesign Stakeholder Meeting 11

PCMH REDESIGN - OVERVIEW contd Principles applied to redesign Build on the existing value-based reimbursement system by strengthening the relationship between payment and quality Focus on outcomes, rather than process Simplify and enhance the recognition criteria for PCMH participation by moving from three tiers to one and aligning more closely with NCQA accreditation domains and standards Increase overall funding for PCMH case management activities The redesign is not final it is being presented to get feedback PCMH Redesign Stakeholder Meeting 12

PCMH REDESIGN - OVERVIEW contd Component Tier Participation Standards Change Moving to a single, enhanced tier that builds on current Tier 3 standards Changing as part of the redesign, including the chance to receive add- on fees for optional activities Providers who meet quality/ performance targets will receive a higher case management fee The OHCA approved a five percent rate increase effective October 1, 2019 to 93.63% of Medicare Monthly per member case management fee SoonerExcel Incentive Payment Payment for services (medical claims) Medical claims are not affected and not part of the redesign PCMH Redesign Stakeholder Meeting 13

PCMH REDESIGN - APPROACH Continuing or New Standards Continuing Supply all medically necessary primary and preventive services Continuing 30 hours/week + maintain open appointment slots for same day/urgent care Continuing Provide 24-hour/7-day voice-to-voice telephone coverage (30-minute call-back) Continuing Maintain paper or electronic clinical data/charting system Continuing Maintain medication list within the medical record Continuing Maintain step-by-step process to track lab/diagnostic tests Continuing Maintain step-by-step process to track referrals Continuing Perform care coordination Continuing Supply patient/family education and support regarding member s medical care Continuing Explain medical home expectations to patient; obtain signed agreement Continuing Accept electronic communication from the OHCA Continuing Conduct annual behavioral health screening; brief interventions and referral PCMH Redesign Stakeholder Meeting 14

PCMH REDESIGN APPROACH contd Continuing or New Standards Continuing Use data from OHCA (e.g., rosters, immunization reports) to track members Continuing Provide transitional care coordination from inpatient/outpatient facilities Continuing Promote access to care and communication through email, mailings etc. Continuing Develop a healthcare team to meet needs/plan-of-care of each member Continuing Conduct post-visit outreach (e.g., telephone call to monitor medication change) Continuing Implement evidence-based, clinical practice guidelines Continuing Implement medication management procedure to avoid interactions/ contraindications Continuing Offer at least four hours of after-hours care in addition to 30 hour minimum Continuing Use health assessment tools (in addition to BH) to identify patient needs/risks PCMH Redesign Stakeholder Meeting 15

PCMH REDESIGN APPROACH contd Standards Continuing or New Screening for Substance Use and Social Determinants of Health (social service needs) New - Required New - Required Outreach to patients due for well-care screenings, with the OHCA s support Participation in OHCA-sanctioned Health Information Exchange (HIE), when established New - Required Reviewing information about the patients in PCMH practice and undertaking quality improvement as appropriate New - Required Accreditation from NCQA, The Joint Commission or AAAHC ($0.50) OR Use of OHCA-sanctioned comprehensive assessment with required screens (medical, BH, SUD, SDOH), problem lists, risk stratification and care plan or referral to appropriate OHCA program (Non-HAN/HMP providers) ($0.50) Optional Add-on $PMPM Optional Add-on $PMPM Extended office hours: 31 39 ($0.50) and 40+ (additional $0.50) Optional Add-on $PMPM Onsite behavioral health care manager ($0.50) OR formal referral arrangement to a behavioral health practice ($0.25) Optional Add-on $PMPM Use of integrated care plans for co-managed members within OHCA- sanctioned Health Neighborhood (to be established by HANs) ($0.50) PCMH Redesign Stakeholder Meeting 16

PCMH REDESIGN APPROACH contd Core Optional (Add-on PMPM) (Base PMPM) Current Tier 3 Standards Primary/preventive care Minimum 30 hours per week Clinical data in paper or electronic format Maintain medication list Track lab/diagnostic tests Track referrals Care coordination Patient/family education Medical Home agreement Maintain open schedule E-Communication from OHCA Phone coverage 24/7 Behavioral health screening annually Track panel members inside/ outside practice Transitional care Multi-modal communications Healthcare team led by PCP Add-on Post-visit outreach Evidence based guidelines Medication management Minimum 4 hours after hours Health assessment tools (non- BH) to identify patient needs and risks Practice accreditation or OHCA-sanctioned comprehensive assessment with problem lists, all core/transitional instrument domains, risk stratification to identify members for care management and referral to appropriate program or development of care plan New Standards OHCA SUD screening, brief intervention and referrals OHCA SDOH screening and referrals Outreach to patients due for well-care screening, using OHCA-furnished lists Participate in OHCA- sanctioned HIE Review patient quality for QI opportunities 31 39 or 40+ hours per week On-site BH care manager or formal referral arrangement (higher add-on for on-site) Integrated care plans for co- managed members and participation in OHCA-sanctioned Health Neighborhood PCMH Redesign Stakeholder Meeting 17

PCMH REDESIGN APPROACH contd Transition to New System - Payment All certified PCMH providers (excluding I/T/U) will receive a base PMPM case management fee set equal to the current (October 2019) Tier 3 rate minus $0.50 The new case management fees will be: Child only - $5.78 Child/adult - $7.11 Adult only - $8.32 The new case management fees also will apply to Insure Oklahoma members; this will be an increase from the current flat fee of $3.00 PMPM I/T/U providers will receive a case management fee of $10.00 PMPM for all SoonerCare Choice members, up from the current fee of $2.00 PMPM (children under age 1 and ABD) or $3.00 PMPM (all others) PCMH Redesign Stakeholder Meeting 18

PCMH REDESIGN APPROACH contd Transition to New System Payment cont d Providers (non-I/T/U) will receive add-on PMPM amounts based on NCQA, Joint Commission or AAAHC accreditation status, plus any optional activities being performed This means a provider who is Tier 1 or 2 today will a receive higher case management fee, while a current Tier 3 provider will receive at least the same fee, if his/her practice is accredited or s/he performs at least one of the $0.50 add-on activities Providers also will receive quality/performance payments based on meeting one or more pre-established targets in the prior year PCMH Redesign Stakeholder Meeting 19

PCMH REDESIGN APPROACH contd Performance Measures Providers will receive $0.10 PMPM performance payments for any measures on which the provider has surpassed the threshold these will be added directly into the monthly case management fee The OHCA will be measuring performance through claims data and distributing PCMH performance reports that include both practice demographic data and clinical performance measures (see mock-up later in the presentation) Providers will be eligible to earn performance payments either by: Exceeding an absolute threshold or Exceeding a target for year-over-year improvement and exceeding a minimum performance level The OHCA will publish information on how the measures are calculated prior to their implementation The proposed measures shown on the next slide are not final recommendations are welcome PCMH Redesign Stakeholder Meeting 20

PCMH REDESIGN APPROACH contd National Benchmark Rate Current OHCA Rate PMPM Add-on Threshold Improvement versus Prior Year & Minimum to Qualify +3.0% points 20 paid claims +3.0% points Measure Adolescent Well Care Visits 5 A s Tobacco Cessation Counseling Developmental Screening First 3 Years 53.0% 23.2% 38.0% 25.0% 60 paid claims 20 paid claims N/A N/A 40.3% 17.1% 30.0% 20.0% BMI Screening 5.7% 4.6% 10.0% 1.0% point 5.0% Psychotropic Medications in Children Adult patients using High Dose Opioids Diabetes Care HbA1c Testing 2.7% 3.6% 2.0% -1.0% point 4.0% 26.0 per 1,000 23.0 per 1,000 26.0 per 1,000 N/A - 2.0 points +3.0% points 83.9% 72.8% 80.0% 72.0% PCMH Redesign Stakeholder Meeting 21

PCMH REDESIGN APPROACH contd Performance Measures cont d Performance measure results will be calculated based on activity in the previous calendar year For example, calendar year 2019 results will be used to set PCMH performance add-on payments for case management fees taking effect on October 1, 2020 Calendar year 2020 results will be used for case management fees taking effect on October 1, 2021 Year 1 Performance Payments January - December 2019 Period evaluated to determine performance October 2020 - September 2021 Period to which performance add-on applies PCMH Redesign Stakeholder Meeting 22

PCMH REDESIGN APPROACH contd Current Program Effective October 1, 2019 (excluding SoonerExcel) Practice Type Tier 1 Tier 2 Tier 3 Children only $3.63 $4.73 $6.28 Children and adults $4.39 $5.73 $7.61 Adult only $5.08 $6.63 $8.82 Redesigned Program Practice Type Base Payment Potential Add-on Potential Performance Total Children only $5.78 $2.50 $0.70 $8.98 Children and adults $7.11 $2.50 $0.70 $10.31 Adult only $8.32 $2.50 $0.70 $11.52 PCMH Redesign Stakeholder Meeting 23

PCMH REDESIGN - EXAMPLE Michaela Quinn Current Tier 2 HAN Pediatrician 1,000 SoonerCare Choice members Potential Add-on/ P4P New Model Previous Case Mgmt Fee: $4.73 PMPM Certification/Accreditation Status Base Rate Add-on Activities Accreditation or Comprehensive Assessment Extended Hours 31-39 Extended Hours 40+ BH - Onsite or Formal Referral Arrangement HAN-affiliated and Participate in Health Neighborhood Performance Measures Adolescent Well Care 5 A s Tobacco Cessation Counseling Developmental Screening First 3 Years BMI Screening Psychotropic Medications in Children Adult patients using High Dose Opioids Diabetes Care HbA1c Testing All values are for illustration only No $5.78 Tier 3 minus $0.50 Doctor Qualifies? $0.50 $0.50 $0.50 No Yes No $0.00 $0.50 $0.00 $0.00 $0.50 $0.50 / $0.25 $0.50 Neither Yes Doctor Qualifies? $0.10 $0.10 $0.10 $0.10 $0.10 $0.10 $0.10 Yes Yes Yes No No N/A No $0.10 $0.10 $0.10 $0.00 $0.00 $0.00 TOTAL $7.08 Post-First Visit Member Months Previous Case Mgmt Fee $56,760 (Excludes SoonerExcel) 12,000 New Case Mgmt Fee $84,960 Total Payments PCMH Redesign Stakeholder Meeting 24

PCMH REDESIGN EXAMPLE contd John McIntyre Current Tier 3 non-HAN Family Practice 500 SoonerCare Choice members Potential Add-on/ P4P New Model Previous Case Mgmt Fee: $7.61 PMPM Certification/Accreditation Status Base Rate Add-on Activities Accreditation or Comprehensive Assessment Extended Hours 31-39 Extended Hours 40+ BH - Onsite or Formal Referral Arrangement HAN-affiliated and Participate in Health Neighborhood Performance Measures Adolescent Well Care 5 A s Tobacco Cessation Counseling Developmental Screening First 3 Years BMI Screening Psychotropic Medications in Children Adult patients using High Dose Opioids Diabetes Care HbA1c Testing All values are for illustration only Yes $7.11 Tier 3 minus $0.50 Doctor Qualifies? $0.50 $0.50 $0.50 $0.50 Yes No No $0.50 $0.00 $0.00 $0.25 $0.00 Yes - Referral No $0.50 / $0.25 Doctor Qualifies? $0.10 $0.10 $0.10 $0.10 $0.10 $0.10 $0.10 Yes No Yes Yes Yes No No $0.10 $0.00 $0.10 $0.10 $0.10 $0.00 $0.00 TOTAL $8.26 Post-First Visit Member Months Previous Case Mgmt Fee $45,660 (Excludes SoonerExcel) 6,000 New Case Mgmt Fee $49,560 Total Payments PCMH Redesign Stakeholder Meeting 25

PCMH REDESIGN APPROACH contd Transition to New System Non-Participants Current PCMH providers who do not participate in the new program (either initially or long term) can continue to treat SoonerCare Choice members These providers will not receive a case management fee but will continue to submit claims for medical care, just as today Members will be disenrolled and encouraged to select a new PCMH; however, members are free to continue seeing these providers for as long as they wish Providers can choose to re-enter the program at any time, by agreeing to participate under the revised standards PCMH Redesign Stakeholder Meeting 26

PCMH REDESIGN APPROACH contd Transition to New System - Timeline 2019 OHCA finalizes new PCMH program standards with stakeholder participation April 2020 Target date for federal approval June 2020 OHCA reports 2019 performance measure results Summer 2020 October 2020 PCMH providers apply to participate in new program and identify add-on activities New program takes effect Providers must undertake add-on activities within nine months PCMH Redesign Stakeholder Meeting 27

DISCUSSION - BASE REQUIREMENTS Current Tier 3 Standards, including 30 office hours per week SUD screening (OHCA can furnish), brief intervention and referrals SDOH screening (OHCA can furnish) and referrals Outreach to patients due for well-care screening, with OHCA support Participating in OHCA- sanctioned Health Information Exchange Reviewing patient quality data for quality improvement opportunities 1. As a group, are these appropriate standards for promoting improved quality of care and health outcomes? 2. Which standards appear most challenging to meet? 3. How can the OHCA support you in meeting standards? 4. Other standards? Questions Criteria PCMH Redesign Stakeholder Meeting 28

DISCUSSION - ADD-ON PAYMENTS Secure, interactive website (patient portal) for patient/family communication Practice accreditation OHCA-sanctioned comprehensive assessment and referral process Extended hours (31 39 or 40+) Onsite BH care manager or referral arrangement Integrated care plans for co- managed members in OHCA- sanctioned Health Neighborhood (HAN-affiliated providers) 1. As a group, are these appropriate standards criteria for promoting improved quality of care and health outcomes? 2. Which standards appear most challenging to meet? 3. How can the OHCA support you in meeting standards? 4. Other add-ons? Questions Criteria PCMH Redesign Stakeholder Meeting 29

DISCUSSION PERFORMANCE MEASURES Adolescent well-care visits 5 A s tobacco cessation counseling Developmental screening in child s first three years of life BMI screening Psychotropic medications in children (reducing) Adult patients using high dose opioids (reducing) Diabetes care HbA1c testing 1. As a group, are these appropriate measures for promoting improved quality of care and health outcomes? 2. Which measures/targets appear most challenging to meet? 3. How can the OHCA support you in meeting the targets? 4. Other measures? Questions Criteria PCMH Redesign Stakeholder Meeting 30

PCMH REDESIGN SHARING DATA The OHCA wants to support providers in meeting performance targets by sharing data on a continuous basis The data likely would be posted via an online report, with the option of having the report mailed to the practice The next slide shows a potential report format with sample data for a pediatric practice The report is in the design stage comments/recommendations are welcome PCMH Redesign Stakeholder Meeting 31

PCMH REDESIGN SHARING DATA contd SoonerCare Choice Patient-Centered Medical Home (PCMH) Program PCMH Quarterly Report January 1, 2019 - March 31, 2019 Trapper John Family Care 112 Andrews Lane, Altus, OK NPI: OVN12234 PCMH Redesign Stakeholder Meeting 32

PCMH REDESIGN SHARING DATA contd Practice Summary PCMH Region: Greer, Harmon and Jackson Counties Your Practice Serves: Adults and Children Number of Clinicians in Your Practice: 3 18 56 Total Practices Serving Adults and Children in Region: Total Clinicians Serving Adults and Children in Region: 342 876 Total Practices Serving Adults and Children Statewide: Total Clinicians Serving Adults and Children Statewide: SoonerCare Choice Enrollment Summary Your Practice Your PCMH Region Statewide Average Monthly Enrollment 2,434 2,124 2,763 Enrollment per Clinician 811 683 1,079 Distribution by Gender Male 42% Male 47% Male 45% Female 58% Female 55% Female 53% Distribution by Age PCMH Redesign Stakeholder Meeting 33

PCMH REDESIGN SHARING DATA contd Utilization Summary Your Practice Your PCMH Region Statewide Percentage of SoonerCare Patients Seen in Last 15 Months Average Number of Visits per Patient, Last 12 Months 2.34 2.18 1.98 Average Monthly Emergency Department (ED) Visits per 100 Patients Percentage of Patients with 3 or More ED Visits in Quarter Average Number of Inpatient Admissions per 100 Patients, Last 12 Months 7.5 7.2 7.8 Inpatient Readmission Percentage, Last 12 Months 14.2% 14.5% 16.2% PCMH Redesign Stakeholder Meeting 34

PCMH REDESIGN SHARING DATA contd Summary: Chronic Conditions Percentage of Patients with Chronic Conditions Condition Your Practice Your PCMH Region Statewide Asthma 12.1% 11.4% 11.5% Diabetes 12.5% 11.9% 12.3% Chronic Obstructive Pulmonary Disease (COPD) 8.1% 7.4% 7.8% Coronary Artery Disease (CAD) 4.6% 4.4% 4.5% Heart Failure 2.1% 2.0% 2.1% Hypertension 10.9% 11.4% 11.3% PCMH Redesign Stakeholder Meeting 35

PCMH REDESIGN SHARING DATA contd Cost Summary Your Practice Your PCMH Region Statewide Average Monthly Pharmacy Costs per Patient Average Monthly Medicaid Costs per Adult Patient Average Monthly Medicaid Costs per Child Patient PCMH Redesign Stakeholder Meeting 36

PCMH REDESIGN SHARING DATA contd PCMH Program: Payment and Performance Summary Enrollment Summary January, 2019 February, 2019 March, 2019 Quarterly Total Total Enrollment 2,381 2,404 2,518 7,303 Payment-Qualifying Enrollment (Patients Seen in Last 15 Months) 1,952 1,971 2,065 5,988 Qualifying Activities Activity Qualified for Payment Practice Accreditation Yes Comprehensive Assessment N/A Extended Hours: 31 - 39 Hours per Week No Extended Hours: 40 or More Hours per Week No On-Site Behavioral Health Clinician No Formal Referral for Behavioral Health Yes HAN-Affiliated and Participate in Health Neighborhood No PCMH Redesign Stakeholder Meeting 37

PCMH REDESIGN SHARING DATA contd PCMH Program: Payment and Performance Summary (Continued) Value-Based Payments PCMH Performance Threshold Qualification Improvement Qualification Change from Previous Period Minimum Rate of Improvement Meets Performance Measure Current Period Results Established Threshold Meets Threshold Minimum Rate Improvement Targets 42.0% +2.5 % Pts 38.0% Yes 25.0% +3.0 % Pts N/A Adolescent Well Care Visits 12 Claims +4 Claims 60 Claims No 20 Claims +20 Claims No 5 A's Tobacco Cessation Counseling 26.2% +4.6 % Pts 30.0% No 20.0% +3.0 % Pts Yes Developmental Screening First 3 Years 18.4% +2.4 % Pts 10.0% Yes 5.0% +1.0 % Pt N/A BMI Screening 1.8% +.1 % Pt 2.0% Yes 4.0% -1.0 % Pt N/A Psychotropic Medications in Children 29.0 per 1,000 23.0 per 1,000 26.0 per 1,000 -3.4 % Pt No -2.0 % Pt No Adult Patients Using High Dose Opioids 66.8% +2.7 % Pts 80.0% No 72.0% +3.0 % Pts No Diabetes Care - HbA1c Testing PCMH Redesign Stakeholder Meeting 38

PCMH REDESIGN SHARING DATA contd Payment Summary Total Qualifying Member Months Monthly Base Rate Qualifying Activities 5,988 $ 7.11 NCQA Accreditation Formal Referral for Behavioral Health Value-Based Payments $ $ 0.50 0.25 Adolescent Well Care Visits $ 0.10 $ $ $ $ $ 0.10 0.10 0.10 8.26 Developmental Screening First 3 Years BMI Screening Psychotropic Medications in Children PMPM Total Total Payments in the Previous Three Months 49,461 PCMH Redesign Stakeholder Meeting 39

DISCUSSION DATA SHARING 1. Is this information appropriate and useful to your practice? If so, how would you use it? 2. Is there additional information that would be useful? 3. How would you prefer to receive this information (e.g., on-line, via hard copy)? Enrollment summary Utilization summary Chronic conditions Cost summary Payment and performance data Questions Criteria PCMH Redesign Stakeholder Meeting 40

WRITTEN COMMENTS & QUESTIONS Written comments and questions are welcome Comments/recommendations should be sent over the next 30 days Email to medhomecomments@okhca.org PCMH Redesign Stakeholder Meeting 41