1. Andrea Galgay December 2015
Update on OHIC Care Transformation Plan and Cost Containment Strategies
Andrea Galgay
December 2015

2. Survey Time
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3. Background Affordability Standards Planning committees
Build off the standards introduced in 2009
Continue emphasis on improving primary care infrastructure
PCMH Expansion Goal of 80% of all PCPs by December 31, 2019!
Require collaboration among stakeholders for success
Planning committees
Primary Care Transformation Committee
Alternative Payment Methodology Committee
Alignment with other initiatives
SIM
CTC

4. Primary Care Transformation Committee
2016 Care Transformation Plan
Defines PCMH
Sets PCMH Growth target for 2016
Identifies stakeholder activities to promote PCMH adoption
Identifies activities to promote PCMH transformation
Outlines a sustainable PCP financial model

5. Primary Care Transformation Committee
2016 Care Transformation Plan
Defines PCMH
Sets PCMH Growth target for 2016
Identifies stakeholder activities to promote PCMH adoption
Identifies activities to promote PCMH transformation
Outlines a sustainable PCP financial model

6. Primary Care Transformation Committee
Definition of “PCMH” - Practice is participating in, or has completed, a formal transformation initiative and/or practice has obtained NCQA Level 3 AND is engaged in specific cost containment strategies:
The practice develops and maintains a high-risk patient registry
The practice offers Care Management/Care Coordination Services with a focus on high-risk patients
The practice improves access to and coordination with behavioral health services
The practice expands access to care both during and after office hours
The practice refers patients to providers who provide value-based care

7. How about all the work I do for NCQA?!?
Don’t worry…Many of the PCMH Cost Containment Strategies correlate directly with 2011 and/or 2014 NCQA standards
Differences/additions reflect areas where payers feel NCQA falls short:
More restrictive timeframes for TOC follow-up and care plan development
Expanded access requirements, including evening and weekend availability
More prescriptive on referral protocols
Progressively more stringent requirements over a three year period, with prescribed Year 1, 2, and 3 goals
Weekend access and be with relationship with other practice or UCC as long as there is access to the medical record.

8. Timeline – What should CTC practices expect?
January 2016 – Payers will notify groups/practices they intend to include in their PCMH target for OHIC
Throughout 2016, established PCMH practices should track adherence to Year 1 cost containment strategies
Ensure your practice is continuing to adhere to NCQA standards
Self-attestation survey to be completed in September 2016 by groups or practice
PCMH Kids practices will not be held to Year 1 standards until September 2017 survey

9. Sustainable PCP Financial Model
OHIC Mandated Two Stage Funding Model
Required for all practices counting towards insurer’s PCMH target
First Stage – Infrastructure and Care Management Per Member Per Month (CM PMPM) for first two years of program participation
Second Stage – Ongoing CM PMPM with an opportunity for a performance bonus
Details of the ongoing funding model have not been finalized

10. We Need Your Input
Many important initiatives occurring concurrently across the state
Although clinicians are in the room, we need the voice of the full-time practicing provider
Be sure you know who is representing your interests at these meetings

11. Key Links

12. Questions/Comments/Applause??