1. SOONERCARE PCMH REDESIGN STAKEHOLDER MEETINGS
March 1 – 2, 2017

2. BEFORE WE GET STARTED… What will the PCMH redesign do? (we hope)
Build on the existing “value-based” reimbursement system by strengthening the relationship between payment and quality/outcomes
Simplify the “recognition” criteria for PCMH participation and process for earning incentive payments
What will the PCMH redesign not do? (we promise)
It will not reduce the amount of funding for PCMH providers from what would be paid under the current system
PCMH Redesign Stakeholder Meeting

3. AGENDA Topic Approximate Time Introduction and background 10 minutes
PCMH redesign overview
Quality measures
90 minutes
Transition from current model to new model
5 minutes
Next steps
PCMH Redesign Stakeholder Meeting

4. INTRODUCTION & BACKGROUND
Patient-centered medical home (PCMH) providers are responsible for the care of most SoonerCare members
515,000 children and adolescents (Nov 2016)
88,000 adults (Nov 2016)
The current PCMH design 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 on the next slide
The design includes three payment components:
Case management fee paid on a per member per month basis
Fee-for-service payments for patient visits
SoonerExcel incentive payments for meeting/exceeding program targets
PCMH Redesign Stakeholder Meeting

5. INTRODUCTION & BACKGROUND cont’d
Tier 1 Entry Level
Tier 2 Advanced
Tier 3 Optimal
13 Required Activities
20 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 24/7
BH screening annually
17 Required Activities + 3 of 5 Optional Activities
30 Hours/Week
CM $4.36-$6.13 PMPM
Required
Tier 1 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
23 Required Activities + 3 Optional Activities
30 Hours/Week
CM $5.81-$8.15 PMPM
Required
Tier 2 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
PCMH Redesign Stakeholder Meeting

6. INTRODUCTION & BACKGROUND cont’d
Tier 1 accounts for slightly over half of PCMH providers
PCMH Providers by Tier - June 2016*
*Total provider count is 889. Clinics count as a single provider
PCMH Redesign Stakeholder Meeting

7. INTRODUCTION & BACKGROUND cont’d
Tier 2 and 3 providers account for most of the membership
TANF Members by Tier – SFY 2016
Providers with the greatest concentration of members have strived to meet the higher tier requirements.
PCMH Redesign Stakeholder Meeting

8. 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
Recognizes and rewards higher quality and improved outcomes
Promotes integration of primary care with the broader “medical neighborhood” and with behavioral health
Acknowledges the importance of social determinants of health to improving outcomes
The current PCMH model:
Has three tiers, even though Tier 1 incorporates over one-half of the Tier 3 recognition requirements and Tiers 2/3 account for most of the membership
Pays incentives for some “process” (e.g., performing assessments) that more logically belong as recognition requirements
PCMH Redesign Stakeholder Meeting

9. PCMH REDESIGN – OVERVIEW cont’d
The new PCMH model will:
Include one level for PCMH certification
Ensure that ALL providers meet “base” payment (care management fee) requirements
Enable providers to supplement the base payment by electing one or more “add-on” payment activities
Reward providers for meeting/exceeding program targets
The new design will include four payment components:
Base case management fee paid on a per member per month basis
Add-on payment
Fee-for-service payments for patient visits
Quality incentive for meeting/exceeding program targets
PCMH Redesign Stakeholder Meeting

10. PCMH REDESIGN – OVERVIEW cont’d
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 EHR
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
4 – 8 or
9 or more
Integrated behavioral health and substance use
Population health management
Disease registry
Risk stratification
Standards of care
Outreach/follow-up
Care coordination across the medical neighborhood: Integrated care plans
PCMH Redesign Stakeholder Meeting

11. The new PCMH model will NOT:
PCMH REDESIGN – OVERVIEW cont’d
The new PCMH model 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)
Add to provider or OHCA administrative burdens
PCMH Redesign Stakeholder Meeting

12. Areas of focus – defining OK quality priorities
PCMH REDESIGN – QUALITY MEASURES
Areas of focus – defining OK quality priorities
Metrics with relationship to base requirements (e.g., preventive and chronic care)
Metrics aligned with Comprehensive Primary Care+ (CPC+) measures (those relevant to TANF)
Metrics aligned with Healthy Oklahoma 2020/OHIP areas of focus
Child preventive and oral health
Tobacco cessation
Obesity
Behavioral Health
PCMH Redesign Stakeholder Meeting

13. Areas of focus – defining OK priorities cont’d
PCMH REDESIGN – QUALITY MEASURES cont’d
Areas of focus – defining OK priorities cont’d
Possible measures for inclusion in the PCMH redesign are presented starting on the next slide (along with baseline data)
The OHCA is interested in stakeholder recommendations regarding which measures should be part of the quality data set
The list is not exhaustive – stakeholders are welcome to recommend other measures
There will be six to ten measures selected for Year 1
Providers will report on all measures appropriate to the populations they serve
Measures selected at the outset may later be retired, as improvement occurs, and replaced with new measures focused on areas of greatest concern
PCMH Redesign Stakeholder Meeting

14. Adult Preventive Care Measure
PCMH REDESIGN – QUALITY MEASURES cont’d
Adult Preventive Care Measure
PCMH Redesign Stakeholder Meeting

15. Adults’ Access to Preventive/Ambulatory Health Services*
PCMH REDESIGN – QUALITY MEASURES cont’d
Adults’ Access to Preventive/Ambulatory Health Services*
The percentage of members 20 years and older who had an ambulatory or preventive care visit.
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
PCMH Redesign Stakeholder Meeting

16. Child/Adolescent Preventive Care Measures
PCMH REDESIGN – QUALITY MEASURES cont’d
Child/Adolescent Preventive Care Measures
PCMH Redesign Stakeholder Meeting

17. Children & Adolescents’ Access to PCP*
PCMH REDESIGN – QUALITY MEASURES cont’d
Children & Adolescents’ Access to PCP*
The percentage of members 12 months–19 years of age who had a visit with a PCP.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

18. Well-Child Visits in the First 15 Months of Life*
PCMH REDESIGN – QUALITY MEASURES cont’d
Well-Child Visits in the First 15 Months of Life*
The percentage of children that turned 15 months old during the measurement year and had zero, one, two, three, four, five, or six or more well child visits with a PCP during their first 15 months of life.
* Note: no national benchmark was available for this measure.
PCMH Redesign Stakeholder Meeting

19. Well-Child Visits in the 3rd, 4th, 5th, & 6th Years of Life*
PCMH REDESIGN – QUALITY MEASURES cont’d
Well-Child Visits in the 3rd, 4th, 5th, & 6th Years of Life*
The percentage of members 3-6 years of age who received one or more well child visits with a PCP during the measurement year.
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
PCMH Redesign Stakeholder Meeting

20. Lead Screening in Children*
PCMH REDESIGN – QUALITY MEASURES cont’d
Lead Screening in Children*
The percentage of children two years of age who had one or more capillary or venous lead blood test for lead poisoning by their second birthday.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

21. Annual Dental Visit PCMH REDESIGN – QUALITY MEASURES cont’d
The percentage of members years of age who had at least one dental visit during the measurement year.
PCMH Redesign Stakeholder Meeting

22. Adult Chronic Care Measure
PCMH REDESIGN – QUALITY MEASURES cont’d
Adult Chronic Care Measure
PCMH Redesign Stakeholder Meeting

23. Comprehensive Diabetes Care – HbA1c
PCMH REDESIGN – QUALITY MEASURES cont’d
Comprehensive Diabetes Care – HbA1c
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had Hemoglobin A1c (HbA1c) testing.
PCMH Redesign Stakeholder Meeting

24. Comprehensive Diabetes Care – Eye Exam*
PCMH REDESIGN – QUALITY MEASURES cont’d
Comprehensive Diabetes Care – Eye Exam*
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had an eye exam (retinal) performed.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

25. Comprehensive Diabetes Care – Nephropathy
PCMH REDESIGN – QUALITY MEASURES cont’d
Comprehensive Diabetes Care – Nephropathy
The percentage of members 18–75 years of age with diabetes (type 1 and type 2) who had a nephropathy screening or monitoring test* or evidence of nephropathy.
* Note: Nephropathy screening or monitoring test is a urine protein test.
PCMH Redesign Stakeholder Meeting

26. Adult/Child/Adolescent Chronic Care Measure
PCMH REDESIGN – QUALITY MEASURES cont’d
Adult/Child/Adolescent Chronic Care Measure
PCMH Redesign Stakeholder Meeting

27. Medication Management for People with Asthma – 50%*
PCMH REDESIGN – QUALITY MEASURES cont’d
Medication Management for People with Asthma – 50%*
The percentage of members 5–64 years of age who were identified as having persistent asthma and were dispensed appropriate asthma controller medications that they remained on for at least 50 percent of their treatment period.
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
PCMH Redesign Stakeholder Meeting

28. Medication Management for People with Asthma – 75%*
PCMH REDESIGN – QUALITY MEASURES cont’d
Medication Management for People with Asthma – 75%*
The percentage of members 5–64 years of age who were identified as having persistent asthma and were dispensed appropriate asthma controller medications that they remained on for at least 75 percent of their treatment period.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

29. Tobacco Measures PCMH REDESIGN – QUALITY MEASURES cont’d
PCMH Redesign Stakeholder Meeting

30. Tobacco Assessment/Counseling*
PCMH REDESIGN – QUALITY MEASURES cont’d
Tobacco Assessment/Counseling*
The percentage of members 12 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
* Notes: Scale is not 0 – 100; no national benchmark was available for this measure.
PCMH Redesign Stakeholder Meeting

31. Prescribing for Tobacco Cessation Aids*
PCMH REDESIGN – QUALITY MEASURES cont’d
Prescribing for Tobacco Cessation Aids*
The percentage of member 12 years and older who were prescribed tobacco cessation aids.
* Notes: Scale is not 0 – 100; no national benchmark was available for this measure.
PCMH Redesign Stakeholder Meeting

32. Obesity Measures PCMH REDESIGN – QUALITY MEASURES cont’d
PCMH Redesign Stakeholder Meeting

33. Adult BMI Assessment PCMH REDESIGN – QUALITY MEASURES cont’d
The percentage of members years of age who had an outpatient visit and whose body mass index (BMI) was documented during the measurement year or the year prior to the measurement year.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

34. BMI Assessment for Children and Adolescents
PCMH REDESIGN – QUALITY MEASURES cont’d
BMI Assessment for Children and Adolescents
The percentage of children ages 3 to 17 that had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation during the measurement year.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

35. Behavioral Health Measures
PCMH REDESIGN – QUALITY MEASURES cont’d
Behavioral Health Measures
PCMH Redesign Stakeholder Meeting

36. Antidepressant Medication Management – Acute Treatment
PCMH REDESIGN – QUALITY MEASURES cont’d
Antidepressant Medication Management – Acute Treatment
Percentage of members 18 years and older with a diagnosis of major depression, who were newly treated with antidepressant medication and remained on their antidepressant medication for at least 84 days (12 weeks).
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

37. Antidepressant Medication Management – Continuation Treatment
PCMH REDESIGN – QUALITY MEASURES cont’d
Antidepressant Medication Management – Continuation Treatment
Percentage of members 18 years and older with a diagnosis of major depression, who were newly treated with antidepressant medication and remained on their antidepressant medication for at least 180 days (6 months).
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

38. Follow-Up After Hospitalization for Mental Illness – 7 Days*
PCMH REDESIGN – QUALITY MEASURES cont’d
Follow-Up After Hospitalization for Mental Illness – 7 Days*
The percentage of discharges for children ages 6 to 20 that were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 7 days of discharge.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

39. Follow-Up After Hospitalization for Mental Illness – 30 Days*
PCMH REDESIGN – QUALITY MEASURES cont’d
Follow-Up After Hospitalization for Mental Illness – 30 Days*
The percentage of discharges for children ages 6 to 20 that were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient encounter, or partial hospitalization with a mental health practitioner within 30 days of discharge.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

40. Initiation of Alcohol and Other Drug Dependence Treatment*
PCMH REDESIGN – QUALITY MEASURES cont’d
Initiation of Alcohol and Other Drug Dependence Treatment*
The percentage of members 18 years and older with a new episode of alcohol or other drug (AOD) dependence who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the diagnosis.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

41. Engagement of Alcohol and Other Drug Dependence Treatment*
PCMH REDESIGN – QUALITY MEASURES cont’d
Engagement of Alcohol and Other Drug Dependence Treatment*
The percentage of members 18 years and older with a new episode of AOD dependence who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit.
* Note: scale is not 0 – 100.
PCMH Redesign Stakeholder Meeting

42. Utilization Measure PCMH REDESIGN – QUALITY MEASURES cont’d
PCMH Redesign Stakeholder Meeting

43. Ambulatory Care Visits*
PCMH REDESIGN – QUALITY MEASURES cont’d
Ambulatory Care Visits*
This measure summarizes utilization of ambulatory care in the following categories: Outpatient Visits, ED Visits.
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
PCMH Redesign Stakeholder Meeting

44. Emergency Department Visits*
PCMH REDESIGN – QUALITY MEASURES cont’d
Emergency Department Visits*
This measure summarizes utilization of ambulatory care in the following categories: Outpatient Visits, ED Visits.
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
PCMH Redesign Stakeholder Meeting

45. Selecting Year 1 Quality Measures
PCMH REDESIGN – QUALITY MEASURES cont’d
Selecting Year 1 Quality Measures
Stakeholder feedback desired on what measures seem most appropriate
Select 6-10 measures to target in Year 1
Breakdown of the 18 measures for consideration
6 Preventive Care (1 Adult, 5 Child/Adolescent)
4 Chronic Care (3 Adult, 1 Child/Adolescent/Adult)
2 Tobacco cessation (Adolescent/Adult)
2 Obesity (1 Adult, 1 Child/Adolescent)
3 Behavioral Health (2 Adult, 1 Child/Adolescent/Adult)
1 Utilization (Child/Adolescent/Adult)
Measures and their domains are shown on the following slides
PCMH Redesign Stakeholder Meeting

46. PCMH REDESIGN – QUALITY MEASURES cont’d
Domain
Measure(s)
Demographic
Adults' Access to Preventive / Ambulatory Health Services
Children and Adolescents' Access to Primary Care Practitioners
Well-Child Visits in the First 15 Months of Life
Well-Child Visits in the 3rd, 4th, 5th, & 6th Years of Life
Lead Screening in Children
Annual Dental Visit
Adult
Child/Adolescent
Child
Preventive Care
Chronic Care
Comprehensive Diabetes Care: HbA1c
Comprehensive Diabetes Care: Eye Exam
Comprehensive Diabetes Care: Nephropathy
Medication Management for People with Asthma
Adult
Child/Adolescent/Adult
PCMH Redesign Stakeholder Meeting 46

47. PCMH REDESIGN – QUALITY MEASURES cont’d
Domain
Measure(s)
Demographic
Tobacco Assessment/Counseling
Prescribing for Tobacco Cessation Aids
Tobacco
Adolescent/Adult
Obesity
Adult BMI Assessment
BMI Assessment for Children and Adolescents
Adult
Children/Adolescent
Antidepressant Medication Management
Follow-Up After Hospitalization for Mental Illness
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Adult
Child/Adolescent/Adult
Behavioral Health
Utilization
Ambulatory Care/Emergency Department Visits
Child/Adolescent/Adult
PCMH Redesign Stakeholder Meeting 47

48. PCMH REDESIGN – QUALITY MEASURES cont’d
Payment of Incentives
For Year 1, the OHCA will use administrative (claims) data to calculate individual provider rates
Oklahoma benchmarks will be developed for each quality measure based on historical rates, national benchmarks or a mix
Payments will be awarded for absolute performance in meeting/exceeding program targets (benchmarks) and year-over-year improvement
Thresholds will be developed for year-over-year improvement
If year-over-year improvement is within the threshold, the provider will get a partial incentive payment, even if the provider does not meet or exceed the benchmark
Stakeholder feedback is desired on the quality incentive payment structure
As the OHCA moves to “outcomes-based” measures, the majority of rates are calculated and reported on an annual basis
PCMH Redesign Stakeholder Meeting

49. PCMH REDESIGN – TRANSITION
Existing SoonerCare PCMH providers
Contracts need to be renewed no later than 11/30/17
The OHCA will perform an onsite review for all practices
If provider passes an onsite review performed in 2017, the provider will get the full base plus any add on payment, if applicable, starting 1/1/18
If provider fails the onsite review, the provider will receive 50 percent of their base payment and no add-on payments until they are reviewed and are in full compliance with the base requirements
If provider does not have an onsite review in 2017, the provider will need to have an onsite review prior to January 2019 or they will receive 50 percent of their base payment and no add-on payments until they are reviewed and are in full compliance with the base requirements
PCMH Redesign Stakeholder Meeting

50. PCMH REDESIGN – TRANSITION
Existing SoonerCare PCMH providers
Prior to 2019, all existing providers who did not have an onsite review in 2017 will have an onsite review
Existing providers will be paid 50 percent of their base payment until an onsite review is completed
If provider passes the onsite, the provider will get the full base plus any add on payment, if applicable
If provider fails the onsite, their payment will continue at 50 percent of the base payment (even if they have add on elements). The provider will have three months to achieve compliance as part of a follow-up onsite review. If the provider fails this review, the provider will be referred to the OHCA Medical Director
PCMH Redesign Stakeholder Meeting

51. PCMH REDESIGN – TRANSITION
Providers new to SoonerCare
If a new provider is added to an existing SoonerCare Choice PCMH group, then there is no need for an onsite review
If there is an existing SoonerCare Choice PCMH group but the panel is assigned to a new individual provider, then the provider will require an onsite review
New providers will be paid at fee-for-service rates until they have an onsite review
Providers who are entirely new to SoonerCare will be given six months to achieve certification and will be permitted to enroll members in their panels, following a successful onsite review by the OHCA
New providers have to pass every element in the base requirements to obtain 100 percent of the base payment plus any add-on payments, if applicable
PCMH Redesign Stakeholder Meeting

52. PCMH REDESIGN – NEXT STEPS
Activity/Milestone
Date(s)
Continue gathering stakeholder recommendations (meetings and written)
January – March 2017
Finalize recommended recognition criteria and case management payment rates
March 2017
Finalize quality measures, benchmark values and thresholds for incentive payments
Prepare updated provider agreements and educational materials
April 2017
Conduct provider outreach and education
May 2017 (ongoing)
Updated provider agreements take effect
January 1, 2018
PCMH Redesign Stakeholder Meeting

53. Written comments and questions are welcome
WRITTEN COMMENTS & QUESTIONS
Written comments and questions are welcome
Comments/recommendations should be sent by March 15, 2017
to:
PCMH Redesign Stakeholder Meeting