SOONERCARE PCMH REDESIGN STAKEHOLDER PRESENTATION Oklahoma Health Care

SOONERCARE PCMH REDESIGN STAKEHOLDER PRESENTATION Oklahoma Health Care Authority/Pacific Health Policy Group January 2020

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 - Jan 2020 2

WHY ARE WE HERE TODAY? Patient Centered Medical Home (PCMH) providers are the heart of the SoonerCare program Neighborhood Medical Specialists Hospitals Health PCMH Behavior al Health PCMH Redesign - Jan 2020 Other (including social services) 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 - Jan 2020 4

TODAY’S 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 5. Discussion 15 minutes 15 minutes Questions are welcome throughout the presentation PCMH Redesign - Jan 2020 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 - Jan 2020 6

ADDITIONAL BACKGROUND cont’d 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 - Jan 2020 7

ADDITIONAL BACKGROUND Tier 1 Entry Level Required 20 hours/week Primary/preventive care 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 PCMH Redesign - Jan 2020 Tier 2 Advanced 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 cont’d Tier 3 Optimal 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 8

ADDITIONAL BACKGROUND cont’d The design includes three payment components: Case management (care coordination) 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 - Jan 2020 9

ADDITIONAL BACKGROUND cont’d 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 - Jan 2020 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 - Jan 2020 11

PCMH REDESIGN - OVERVIEW Principles cont’d 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 - Jan 2020 12

PCMH REDESIGN - OVERVIEW cont’d Component Change Tier Participation Standards Moving to a single, enhanced tier that builds on current Tier 3 standards Monthly per member case management fee Changing as part of the redesign, including the chance to receive add-on fees for optional activities SoonerExcel Incentive Payment Providers who meet quality/ performance targets will receive a higher case management fee Payment for services (medical claims) The OHCA approved a five percent rate increase effective October 1, 2019 to 93.63% of Medicare PCMH Redesign - Jan 2020 13

PCMH REDESIGN - APPROACH Continuing or New Standards Continuin g Supply all medically necessary primary and preventive services Continuin g 30 hours/week maintain open appointment slots for same day/urgent care Continuin g Provide 24-hour/7-day voice-to-voice telephone coverage (30-minute call-back) Continuin g Maintain paper or electronic clinical data/charting system Continuin g Maintain medication list within the medical record Continuin g Maintain step-by-step process to track lab/diagnostic tests Continuin g Maintain step-by-step process to track referrals Continuin g Perform care coordination Continuin g Supply patient/family education and support regarding member’s medical care PCMH Redesign - Jan 2020 Continuin Explain “medical home” expectations to patient; obtain signed 14

PCMH REDESIGN – APPROACH cont’d Continuing or New Standards Continuin g Use data from OHCA (e.g., rosters, immunization reports) to track members Continuin g Provide transitional care coordination from inpatient/outpatient facilities Continuin g Promote access to care and communication through email, mailings etc. Continuin g Develop a healthcare team to meet needs/plan-of-care of each member Continuin g Conduct post-visit outreach (e.g., telephone call to monitor medication change) Continuin g Implement evidence-based, clinical practice guidelines Continuin g Implement medication management procedure to avoid interactions/ contraindications Continuin g Offer at least four hours of after-hours care in addition to 30 hour minimum Continuin g Use health assessment tools (in addition to BH) to identify patient needs/risks PCMH Redesign - Jan 2020 15

PCMH REDESIGN – APPROACH cont’d Continuing or New Standards New - Required Screening for Substance Use and Social Determinants of Health (social service needs) New - Required Outreach to patients due for well-care screenings, with the OHCA’s support New - Required Linkage to statewide Health Information Exchange (HIE), when one is identified by the OHCA New - Required Reviewing information about the patients in PCMH practice and undertaking quality improvement as appropriate Optional – Add-on PMPM 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 only) ( 0.50) Optional – Add-on PMPM Extended office hours: 31 – 39 ( 0.50) OR 40 (additional 1.00) Optional – Add-on PMPM Onsite behavioral health care manager ( 0.50) OR Formal referral arrangement to a behavioral health practice ( 0.25) and/or Use of standardized trauma screening tool ( 0.25) Optional – Add-on Affiliated with a HAN and participate in OHCA-sanctioned Health PCMH Redesign - Jan Neighborhood (to be established by HANs) ( 0.50) 2020 16

PCMH REDESIGN – APPROACH Core (Base PMPM) Current Tier 3 Standards Primary/preventive care VFC participant Clinical data in paper or electronic format Maintains medication list Tracks lab/diagnostic tests Tracks referrals Care Coordination Patient/family education Medical Home Agreement Maintains open schedule E-Comm. from OHCA Phone coverage 24/7 BH screening annually Minimum 30 hours per week Track panel members inside/outside practice Transitional care Multi-modal communications PCMH Redesign - Jan 2020 cont’d Optional (Add-on PMPM) Healthcare team led by PCP Post-visit outreach Evidence based guidelines Medication Management Minimum 4 hours after hours Health assessment tools (nonBH) to identify patient needs and risks New Standards OHCA SUD screening, brief intervention and referrals OHCA SDOH screening and referrals Outreach to patients due for well-care screening Secure, interactive website Link to State HIE, when identified Review patient quality for QI opportunities Add-on Practice accreditation OR Use of 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 (nonHAN/HMP-affiliated practices) 31 – 39 OR 40 hours per week On-site BH care manager OR formal referral arrangement and/or use of standardized trauma screening tool HAN-affiliated and participation in OHCA-sanctioned Health Neighborhood 17

PCMH REDESIGN – APPROACH cont’d Transition to New System - Payment All certified PCMH providers will receive a base PMPM case management fee set equal to the current Tier 3 rate minus 0.50 (new: child only - 5.60, child/adult - 6.89, adult only 8.07) Providers 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 - Jan 2020 18

PCMH REDESIGN – APPROACH cont’d Performance Measures Providers will receive 0.20 PMPM performance payments for each measure on which the provider has surpassed the threshold, up to a maximum of four measures, or 0.80 PMPM. The additional PMPM 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 October 2020 rates will include payments for meeting targets in calendar year 2019 Note: SoonerCare Choice rates presented on the next slide are for calendar year 2018; rates for 2019 will be generated in the spring of 2020, at which time performance payment thresholds will be finalized PCMH Redesign - Jan 2020 19

PCMH REDESIGN – APPROACH cont’d Child/Adolescent Measures National Benchmark Rate* Current SoonerCare Choice Rate** PMPM Add-on Threshold ** Adolescent Well Care Visits 53.0% 45.7% 54.0% 3.0% points 47.0% Developmental Screening First 3 Years 42.2% 18.1% 30.0% 3.0% points 20.0% Weight Assessment and Counseling for Nutrition and Physical Activity for Children*** 74.3% 5.2% 35.0% 3.0% points 15.0% Measure Improvement versus Prior Year & Minimum to Qualify** Metabolic Monitoring for Children and * National Medicaid HMO rate as reported by NCQA exceptTBD Developmental Screening, 29.8% TBD which is national TBD Medicaid median TBD Adolescents on2018 Anti* Current rate is CY and will be updated with CY 2019 data; thresholds will be adjusted, as appropriate ** SoonerCare Choice rate is based on administrative data only, while national rate includes medical record data; this Psychotics accounts for the significant discrepancy PCMH Redesign - Jan 2020 20

PCMH REDESIGN – APPROACH cont’d Adult Measures National Benchmark Rate* Current SoonerCare Choice Rate** PMPM Add-on Threshold ** Improvement versus Prior Year & Minimum to Qualify** 5 A’s Tobacco Cessation Counseling N/A N/A 60 paid claims 20 paid claims 20 paid claims Adult BMI Assessment*** 86.6% 20.8% 40.0% 3.0% points 25.0% Adult patients using High Dose Opioids 6.5 per 1,000 25.6 per 1,000 15.0 per 1,000 - 3.0 points 20.0 per 1,000 76.3% 82.0% 3.0% points 77.0% Measure Diabetes Care – 87.8% HbA1c * NationalTesting Medicaid HMO rate as reported by NCQA * Current rate is CY 2018 and will be updated with CY 2019 data; thresholds will be adjusted, as appropriate ** SoonerCare Choice rate is based on administrative data only, while national rate includes medical record data; this accounts for the significant discrepancy PCMH Redesign - Jan 2020 21

PCMH REDESIGN – APPROACH cont’d 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 Performan ce Total Children only 5.78 2.50 0.80 9.08 Children and adults 7.11 2.50 0.80 10.41 Adult only 8.32 2.50 0.80 11.62 PCMH Redesign - Jan 2020 22

PCMH REDESIGN - EXAMPLE Michaela Quinn – Current Tier 2 HAN Pediatrician 1,000 SoonerCare Choice members Potential Add-on/ P4P Previous Case Mgmt Fee: 4.73 PMPM Certification/Accreditation Status Base Rate Add-on Activities Accreditation or Comprehensive Assessment Extended Hours 31-39 OR Extended Hours 40 BH - Onsite CM OR Formal Referral Arrangement and/or Trauma Screen HAN-affiliated and Participate in Health Neighborhood Performance Measures (Payment capped at 0.80) Child/Adolescent Measures Adolescent Well Care Visits Developmental Screening First 3 Years Weight Assessment and Counseling All values are for illustration only New Model No Doctor Qualifies? 0.50 0.50 1.00 0.50 / 0.25 0.25 0.50 No Yes No 0.00 0.50 0.00 None 0.00 Yes 0.50 Doctor Qualifies? Metabolic Monitoring for Children/Adolescents on Anti-Psychotics 0.20 0.20 0.20 0.20 Yes Yes Yes No Adult Measures 5 A's Tobacco Cessation Counseling Adult BMI Assessment Adult Patients using High Dose Opioids Diabetes Care – HbA1c Testing 0.20 0.20 0.20 0.20 N/A N/A N/A N/A TOTAL Total Payments 5.78 Tier 3 minus 0.50 0.20 0.20 0.20 0.00 7.38 Previous Case Mgmt Fee 56,760 New Case Mgmt Fee 88,560 (Excludes SoonerExcel) PCMH Redesign - Jan 2020 23

PCMH REDESIGN – EXAMPLE cont’d John McIntyre – Current Tier 3 non-HAN Family Practice 500 SoonerCare Choice members Previous Case Mgmt Fee: 7.61 PMPM Certification/Accreditation Status Base Rate Add-on Activities Accreditation or Comprehensive Assessment Extended Hours 31-39 OR Extended Hours 40 BH - Onsite CM OR Formal Referral Arrangement and/or Trauma Screen HAN-affiliated and Participate in Health Neighborhood Performance Measures (Payment capped at 0.80) Child/Adolescent Measures Adolescent Well Care Visits Developmental Screening First 3 Years Weight Assessment and Counseling Potential Add-on/ P4P All values are for illustration only New Model Yes 7.11 Tier 3 minus 0.50 Doctor Qualifies? 0.50 0.50 1.00 0.50 / 0.25 0.25 0.50 Yes No No 0.50 0.00 0.00 Yes - Referral 0.25 No 0.00 Doctor Qualifies? Metabolic Monitoring for Children/Adolescents on Anti-Psychotics 0.20 0.20 0.20 0.20 Yes Yes Yes No 0.20 0.20 0.20 0.00 Adult Measures 5 A's Tobacco Cessation Counseling Adult BMI Assessment Adult Patients using High Dose Opioids Diabetes Care – HbA1c Testing 0.20 0.20 0.20 0.20 No Yes No No 0.00 0.20 0.00 0.00 TOTAL Total Payments 8.66 Previous Case Mgmt Fee 45,660 New Case Mgmt Fee 51,960 (Excludes SoonerExcel) PCMH Redesign - Jan 2020 24

PCMH REDESIGN – APPROACH cont’d 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 - Jan 2020 25

PCMH REDESIGN – APPROACH cont’d Transition to New System - Timeline 2019 Spring 2020 OHCA finalizes new PCMH program standards with stakeholder participation Target for federal approval Summer 2020 OHCA reports 2019 performance measure results Summer 2020 PCMH providers apply to participate in new program and identify add-on activities October 2020 New program takes effect Providers must undertake add-on activities within nine months PCMH Redesign - Jan 2020 26

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 set of slides show a potential report format with sample data for a pediatric practice PCMH Redesign - Jan 2020 27

PCMH REDESIGN – SHARING DATA cont’d 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 - Jan 2020 28

PCMH REDESIGN – SHARING DATA cont’d Practice Summary PCMH Region: Greer, Harmon and Jackson Counties Your Practice Serves: Adults and Children Number of Clinicians in Your Practice: 3 Total Practices Serving Adults and Children in Region: 18 Total Clinicians Serving Adults and Children in Region: 56 Total Practices Serving Adults and Children Statewide: 342 Total Clinicians Serving Adults and Children Statewide: 876 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 Female 58% Male 42% Female 55% Male 45% Female 53% Male 47% Distribution by Age PCMH Redesign - Jan 2020 29

PCMH REDESIGN – SHARING DATA cont’d Utilization Summary Your Practice Your PCMH Region Statewide 2.34 2.18 1.98 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% Percentage of SoonerCare Patients Seen in Last 15 Months Average Number of Visits per Patient, Last 12 Months Average Monthly Emergency Department (ED) Visits per 100 Patients Percentage of Patients with 3 or More ED Visits in Quarter PCMH Redesign - Jan 2020 30

PCMH REDESIGN – SHARING DATA cont’d 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 - Jan 2020 31

PCMH REDESIGN – SHARING DATA cont’d Cost Summary (All Claims - PCMH-Submitted and Others) 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 - Jan 2020 32

PCMH REDESIGN – SHARING DATA cont’d Cost Summary (PCMH-Submitted Claims Only) 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 - Jan 2020 33

PCMH REDESIGN – SHARING DATA cont’d PCMH Practice X: Enrollment and "Add-On" Care Standard 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 2,077 6,000 Qualifying Add-On Activity Optional PCMH Care Standards Qualified for Payment 1. Comprehensive Assessment and Care Planning A. NCQA, The Joint Commission or AAAHC Accreditation Yes B. OHCA-Sanctioned Comprehensive Assessment and Care Planning N/A 2. Extended Hours A. Extended Hours: 31 - 39 Hours per Week No B. Extended Hours: 40 or More Hours per Week No 3. Behavioral Health Care Management A. On-Site Behavioral Health Care Manager No B. Formal Referral Arrangement for Behavioral Health Yes C. Standarized Trauma Screening No 4. HAN-Affiliated and Participate in Health Neighborhood No PCMH Redesign - Jan 2020 34

PCMH REDESIGN – SHARING DATA PCMH Performance Performance Measure Change from Current Period Previous Results Period Threshold Qualification cont’d Improvement Qualification Established Threshold Meets Threshold Minimum Rate Minimum Rate of Improvement Meets Improvement Targets Adolescent Well Care Visits 55.0% 2.5 % Pts 45.7% Yes 47.0% 3.0 % Pts N/A Developmental Screening First 3 Years 26.2% 4.6 % Pts 30.0% No 20.0% 3.0 % Pts Yes Weight Assessment and Counseling 37.5% 2.4 % Pts 35.0% Yes 15.0% 3.0 % Pts N/A TBD TBD TBD TBD TBD TBD TBD 12 Claims 4 Claims 60 Claims No 20 Claims 20 Claims No 41.0% 2.4 % Pts 40.0% Yes 25.0% 3.0 % Pts N/A 29.0 per 1,000 -3.4 % Pt 15.0 per 1,000 No 20.0 per 1,000 -3.0 % Pts No 66.8% 2.7 % Pts 82.0% No 77.0% 3.0 % Pts No Metabolic Monitoring for Children and Adolescents on Anti-Psychotics 5 A's Tobacco Cessation Counseling Adult BMI Assessment Adult Patients Using High Dose Opioids Diabetes Care - HbA1c Testing PCMH Redesign - Jan 2020 35

PCMH REDESIGN – SHARING DATA cont’d Payment Summary PCMH Practice X: Payment Summary Total Qualifying Member Months Monthly Base Rate Qualifying Activities Accreditation Formal Referral for Behavioral Health Value-Based Payments Adolescent Well Care Visits Developmental Screening First 3 Years Weight Assessment and Counseling - Children and Adolescents Adult BMI Assessment PMPM Total Total Payments in the Previous Three Months PCMH Redesign - Jan 2020 6,000 7.11 0.50 0.25 0.20 0.20 0.20 0.20 8.66 51,960 36

WRITTEN COMMENTS & QUESTIONS Written comments and questions are welcome Comments/recommendations should be sent over the next 30 days Email to [email protected] PCMH Redesign - Jan 2020 37