Transcript focus on excellence independent evaluation

SOONERCARE PCMH REDESIGN
STAKEHOLDER MEETINGS
March 1 – 2, 2017
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
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AGENDA
Topic
Approximate Time
1. Introduction and background
10 minutes
2. PCMH redesign overview
10 minutes
3. Quality measures
90 minutes
4. Transition from current model to new model
5 minutes
5. Next steps
5 minutes
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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
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INTRODUCTION & BACKGROUND
Tier 1
Entry Level
•
•
•
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
•
•
•
•
•
•
•
•
•
•
Tier 2
Advanced
•
•
•
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
PCMH Redesign Stakeholder Meeting
cont’d
Tier 3
Optimal
•
•
•
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
5
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
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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.
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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
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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
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PCMH REDESIGN – OVERVIEW cont’d
Base
Requirements
•
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
•
•
•
•
•
•
•
•
PCMH Redesign Stakeholder Meeting
Add-on Payments
•
Payments per additional activity (upon
meeting criteria)
•
•
•
•
Patient portal
Accreditation
HIE
Extended hours outside of core
business hours
o 4 – 8 or
o 9 or more
Integrated behavioral health and
substance use
Population health management
o Disease registry
o Risk stratification
o Standards of care
o Outreach/follow-up
Care coordination across the medical
neighborhood: Integrated care plans
•
•
•
10
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
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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
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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
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PCMH REDESIGN – QUALITY MEASURES cont’d
Adult Preventive Care Measure
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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.
100.0%
90.4% 90.3%
90.0%
83.3% 83.1%
81.2% 80.9%
77.3% 77.5%
80.0%
70.0%
60.0%
50.0%
20 - 44
45 - 64
2015 (SFY 2015)
65+
Total
2016 (SFY 2016)
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
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PCMH REDESIGN – QUALITY MEASURES cont’d
Child/Adolescent Preventive Care
Measures
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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.
100.0%
96.1% 96.3%
95.0%
94.7%
89.7% 90.0%
90.0%
92.0% 92.1%
93.1% 92.9%
90.2%
87.2%
88.6%
85.0%
80.0%
75.0%
70.0%
65.0%
60.0%
55.0%
50.0%
12 - 24 mos.
25 mos. - 6 yrs.
2015 (SFY 2015)
2016 (SFY 2016)
7 - 11 years
12 - 19 years
Nat'l Benchmark
* Note: scale is not 0 – 100.
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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.
97.5% 97.7%
100.0%
90.0%
69.6% 70.1%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
3.2%
3.1%
3.5% 3.4%
4.0%
3.9%
5.3% 5.4%
6.2%
8.9% 9.0%
5.9%
0.0%
0 Visits
1 Visit
2 Visits
2015 (SFY 2015)
3 Visits
2016 (SFY 2016)
4 Visits
5 Visits
6+ visits
1+ visits
Nat'l Benchmark
* Note: no national benchmark was available for this measure.
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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.
70.0%
61.3%
61.6%
2015 (SFY 2015)
2016 (SFY 2016)
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
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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.
66.5%
70.0%
60.0%
47.9%
48.3%
2015 (SFY 2015)
2016 (SFY 2016)
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Nat'l Benchmark
* Note: scale is not 0 – 100.
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PCMH REDESIGN – QUALITY MEASURES cont’d
Annual Dental Visit
The percentage of members 2 - 20 years of age who had at least one
dental visit during the measurement year.
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
57.6%
48.9%
43.7%
43.9%
47.0%
48.6%
40.0%
46.7%
60.6%
55.8%
46.2%
46.3%
42.1%
42.5%
35.3%
47.4%
38.5%
39.1%
32.7%
26.1%
26.8%
30.0%
20.0%
10.0%
0.0%
Total
2- 3
4-6
2015 (SFY 2015)
PCMH Redesign Stakeholder Meeting
7 - 10
2016 (SFY 2016)
11 - 14
15 - 18
19 - 21
Nat'l Benchmark
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PCMH REDESIGN – QUALITY MEASURES cont’d
Adult Chronic Care Measure
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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.
100.0%
86.0%
90.0%
80.0%
71.0% 71.2%
70.9% 71.1%
HbA1c
18 - 64
76.7% 76.7%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
2015 (SFY 2015)
PCMH Redesign Stakeholder Meeting
2016 (SFY 2016)
65 - 75
Nat'l Benchmark
23
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.
60.0%
52.7%
50.0%
40.0%
27.8%
28.0%
2015 (SFY 2015)
2016 (SFY 2016)
30.0%
20.0%
10.0%
0.0%
Nat'l Benchmark
* Note: scale is not 0 – 100.
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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.
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
90.0%
52.6%
52.8%
2015 (SFY 2015)
2016 (SFY 2016)
Nat'l Benchmark
* Note: Nephropathy screening or monitoring test is a urine protein test.
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PCMH REDESIGN – QUALITY MEASURES cont’d
Adult/Child/Adolescent Chronic Care
Measure
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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.
80.0%
74.7% 74.7%
70.0%
60.0%
59.3% 59.3%
59.7% 59.6%
61.2% 61.0%
Total (5 to 20)
Total (5 to 64)
5 to 11
60.8% 60.4%
56.7% 56.9%
58.7% 58.6%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
2015 (SFY 2015)
12 to 18
19 to 20
19 to 50
51 to 64
2016 (SFY 2016)
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
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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.
60.0%
54.4%
54.5%
50.1%
50.0%
40.0%
38.2%
37.8%
38.6%
38.2%
39.0%
38.7%
36.9%
37.8%
37.9%
41.4%
41.5%
37.7%
36.4%
32.8%
28.3%
30.0%
26.3%
20.0%
10.0%
0.0%
Total (5 to 20)
Total (5 to 64)
5 to 11
2015 (SFY 2015)
12 to 18
2016 (SFY 2016)
19 to 20
19 to 50
51 to 64
Nat'l Benchmark
* Note: scale is not 0 – 100.
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PCMH REDESIGN – QUALITY MEASURES cont’d
Tobacco Measures
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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.
10.0%
8.0%
9.3%
8.8%
7.5%
8.4%
8.0%
7.7%
6.0%
4.0%
2.0%
0.0%
12 - 20
20+
2015 (SFY 2015)
Total
2016 (SFY 2016)
* Notes: Scale is not 0 – 100; no national benchmark was available for this measure.
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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.
8.0%
7.0%
6.0%
7.4%
6.9%
5.8%
6.7%
6.3%
6.1%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
12 - 20
20+
2015 (SFY 2015)
Total
2016 (SFY 2016)
* Notes: Scale is not 0 – 100; no national benchmark was available for this measure.
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PCMH REDESIGN – QUALITY MEASURES cont’d
Obesity Measures
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PCMH REDESIGN – QUALITY MEASURES cont’d
Adult BMI Assessment
The percentage of members 18-74 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.
90.0%
80.8%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
11.0% 11.0%
10.4% 10.5%
10.4% 10.5%
0.0%
18 to 64
65 to74
2015 (SFY 2015)
2016 (SFY 2016)
Total
Nat'l Benchmark
* Note: scale is not 0 – 100.
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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.
70.0%
64.4%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
3.1%
3.7%
3.6%
4.0%
3.3%
3.7%
0.0%
3 to 11
12 to 17
2015 (SFY 2015)
2016 (SFY 2016)
Total
Nat'l Benchmark
* Note: scale is not 0 – 100.
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PCMH REDESIGN – QUALITY MEASURES cont’d
Behavioral Health Measures
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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).
60.0%
54.5%
50.0%
40.0%
34.9% 34.7%
34.9% 34.7%
30.0%
20.0%
20.0%
8.3%
10.0%
0.0%
18 - 64
65+
2015 (SFY 2015)
2016 (SFY 2016)
Total
Nat'l Benchmark
* Note: scale is not 0 – 100.
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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).
50.0%
45.0%
39.5%
40.0%
35.0%
30.0%
25.0%
22.8% 22.1%
22.8% 22.1%
20.0%
15.0%
10.0%
10.0%
5.0%
0.0%
18 - 64
65+
2015 (SFY 2015)
2016 (SFY 2016)
Total
Nat'l Benchmark
* Note: scale is not 0 – 100.
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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.
50.0%
43.6%
45.0%
40.0%
35.0%
30.0%
25.0%
25.1% 25.9%
20.0%
20.0%
17.2% 17.4%
15.0%
22.5% 23.2%
11.1%
10.0%
5.0%
0.0%
6 to 20
21 to 64
2015 (SFY 2015)
65+
2016 (SFY 2016)
Total
Nat'l Benchmark
* Note: scale is not 0 – 100.
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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.
70.0%
61.2%
60.0%
50.0%
48.7% 48.1%
45.1% 44.8%
37.8% 37.9%
40.0%
30.0%
30.0%
22.2%
20.0%
10.0%
0.0%
6 to 20
21 to 64
2015 (SFY 2015)
65+
2016 (SFY 2016)
Total
Nat'l Benchmark
* Note: scale is not 0 – 100.
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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.
50.0%
40.0%
36.3%
36.6%
36.0%
37.0%
36.3%
36.6%
38.2%
30.0%
20.0%
10.0%
0.0%
18-64
65+
2015 (SFY 2015)
2016 (SFY 2016)
Total
Nat'l Benchmark
* Note: scale is not 0 – 100.
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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.
50.0%
40.0%
36.0%
30.0%
30.0%
20.0%
11.7%
11.8%
11.8%
11.9%
10.2%
10.0%
0.0%
18-64
65+
2015 (SFY 2015)
2016 (SFY 2016)
Total
Nat'l Benchmark
* Note: scale is not 0 – 100.
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PCMH REDESIGN – QUALITY MEASURES cont’d
Utilization Measure
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PCMH REDESIGN – QUALITY MEASURES cont’d
Ambulatory Care Visits*
This measure summarizes utilization of ambulatory care in the following
categories: Outpatient Visits, ED Visits.
400.0
350.0
342.3
340.9
2015 (SFY 2015)
2016 (SFY 2016)
300.0
250.0
200.0
150.0
100.0
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
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PCMH REDESIGN – QUALITY MEASURES cont’d
Emergency Department Visits*
This measure summarizes utilization of ambulatory care in the following
categories: Outpatient Visits, ED Visits.
90.0
80.0
77.6
76.7
2015 (SFY 2015)
2016 (SFY 2016)
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0
* Notes: scale is not 0 – 100; no national benchmark was available for this measure.
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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
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PCMH REDESIGN – QUALITY MEASURES cont’d
Domain
Preventive Care
Chronic Care
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
• Comprehensive Diabetes Care:
HbA1c
• Comprehensive Diabetes Care: Eye
Exam
• Comprehensive Diabetes Care:
Nephropathy
• Medication Management for People
with Asthma
• Adult
PCMH Redesign Stakeholder Meeting
• Child/Adolescent
• Child
• Child
• Child
• Child/Adolescent
• Adult
• Adult
• Child/Adolescent/Adult
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PCMH REDESIGN – QUALITY MEASURES cont’d
Domain
Tobacco
Obesity
Behavioral Health
Utilization
Measure(s)
Demographic
• Tobacco
Assessment/Counseling
• Prescribing for Tobacco
Cessation Aids
• Adolescent/Adult
• Adult BMI Assessment
• BMI Assessment for Children
and Adolescents
• Antidepressant Medication
Management
• Follow-Up After Hospitalization
for Mental Illness
• Initiation and Engagement of
Alcohol and Other Drug
Dependence Treatment
• Ambulatory Care/Emergency
Department Visits
• Adult
• Children/Adolescen
t
• Adult
PCMH Redesign Stakeholder Meeting
• Adolescent/Adult
• Child/Adolescent/Adult
• Adult
• Child/Adolescent/Adult
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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
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PCMH REDESIGN – TRANSITION

Existing SoonerCare PCMH providers - 2017

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
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PCMH REDESIGN – TRANSITION

Existing SoonerCare PCMH providers - 2018

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
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PCMH REDESIGN – TRANSITION

Providers new to SoonerCare - 2018





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
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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
March 2017
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
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WRITTEN COMMENTS & QUESTIONS

Written comments and questions are welcome

Comments/recommendations should be sent by
March 15, 2017

Email to: [email protected]
PCMH Redesign Stakeholder Meeting
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