1. A Medical Home for Every SoonerCare Choice Member
Presented to name group
date, 2008
2/15/2019

2. Objectives SoonerCare Choice Today Medical Advisory Task Force (MAT)
Enhancing the SoonerCare Choice Medical Home
Transition Timeline
Questions and Comments
2/15/2019

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.
2/15/2019

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
2/15/2019

5. Who Can be a PCP Today? Physicians FQHCs Physician Assistants (PA)
General Practitioners
Family Practice
Internal Medicine
OB/GYNs
Pediatricians
FQHCs
RHCs
IHS Facilities
Physician Assistants (PA)
Advance Practice Nurses (APN)
2/15/2019

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
2/15/2019

7. Medical Advisory Taskforce Four Top Priorities
Partial capitation vs. primary care case management and fee-for-service payments
Medical home
Autoassignment
Credentialing
2/15/2019

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
2/15/2019

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
2/15/2019

10. Proposed Re-aligning Reimbursement
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:
A monthly care coordination payment
A visit-based fee-for-service component
A performance-based component
Source: The Patient Centered Primary Care Collaborative
2/15/2019

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
2/15/2019

12. Draft Case Management Components
Provides preventive services
$.20
Provides EPSDT / immunization
.25
VFC participant
.10
24 / 7 voice-to-voice coverage
.75
Provides hospital discharge follow-up
.20
Provides continuity of care
Actively participates in HMP
.15
Maintains / intends to maintain EMR
.30
Uses / intends e-prescribing
Provides open scheduling
Receives electronic information
.05
Participates in “pay for excellence”
Serves special health care needs
TOTAL
$3.00
2/15/2019

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.
2/15/2019

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
2/15/2019

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
2/15/2019

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
2/15/2019

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
2/15/2019

18. Questions Comments 877-823-4529, option 2 Request your input
Updates in global and banner messages, provider letters, OHCA public website
Contact OHCA
Melody Anthony
Provider Services Director /
Provider Services
, option 2
2/15/2019