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Oklahoma Medicaid reports on recent changes to its PCCM program
Oklahoma's Medicaid director, Lynn Mitchell, MD, says as of January 2009, the state's primary care case management (PCCM) program, called SoonerCare Choice, in which 423,000 Oklahomans participate, had "further embraced the patient-centered medical home principle, and we did that as a request from our providers. We feel that this will take even a further benefit to our members."
About two years ago, a group of physicians on the state's Medical Advisory Task Force asked that some changes be made to the PCCM program. "We listen when our providers speak. We take that very seriously, to make sure we don't lose sight of the fact that our providers are on the ground, providing services to our 660,000 members," says Dr. Mitchell. "And a lot of our providers were telling us if we can move toward a delivery model consistent with a patient-centered medical home, that's why they went to medical school. They want to be able to serve patients in that kind of a delivery model."
The providers wanted Medicaid to do away with its auto assignment process, eliminate partial capitation payments, and enhance care management and fee-for-service payments. All of these changes were made, and the program was supplemented with a pay-for-excellence program.
"We took the program that was currently in place, and we made some changes in how we pay our providers around certain quality indicators that we wanted to incentivize," says Dr. Mitchell. Providers can now self-assess their ability to be a medical home for members.
These changes were budget- neutral. "We took the dollars that were currently being expended in the program. We reconfigured some of those, and incentivized new and different things," says Dr. Mitchell. "While we are early in the program, at this point it is certainly showing to be budget-neutral and will perhaps eventually show us some mild savings."
Initially, there was a concern that SoonerCare might lose some of its primary care providers because of the change to a new payment model. "We monitored this very closely, while working to educate our providers. And we listened to providers and made some changes that they were in the driver's seat for," says Dr. Mitchell. "When the program was up and running, we actually lost less than 10 of our 850 providers. And since that time, around 70 new providers were added."
One area of focus for future improvement involves interagency collaboration and coordination. "That is an area we did OK in but could always do better with," says Dr. Mitchell. "We found it very helpful to collaborate across health agencies, and I think sometimes we miss that opportunity."
Input from other agencies was incorporated into the new delivery model. For example, a suggestion that providers screen for mental health and substance abuse was included in the outcomes measures and assessment for the ability to be a medical home.
Dr. Mitchell says one key is "enhancement of the infrastructure that is needed to wrap around our primary care providers, to allow them to be a medical home. This involves things like HIT services and care management that the providers need to have available to them to offer that level of care to the members."
Toward this end, Oklahoma is in the process of implementing its health access network. "This represents a tool that we can utilize to better meet the needs of our members and our providers," says Dr. Mitchell. "All of the network's services wouldn't be needed on a routine basis, but if a particular need arises, they would have somebody they could call to help them obtain that service on behalf of the member."
A growing number of states are implementing medical home initiatives across multiple payers, not just the Medicaid program. "Some states are moving to an all-payer model, to get a consensus among insurance companies and other payers in the state that this would be a model that would behoove all of the state citizens," says Dr. Mitchell.
Transition was smooth
Rebecca Pasternik-Ikard , RN, JD, state Medicaid chief operating officer for the Oklahoma Health Care Authority, says that medical homes are particularly important at a time when Medicaid populations are growing and budgets are shrinking.
"When members are aligned with a primary care provider of their choice, they are given access to care with a provider who knows their needs and health history," says Ms. Pasternik-Ikard.
Oklahoma Medicaid's switch to the patient-centered medical home model has cut down on inappropriate use of ED services, because members are directed to the most effective source of care when they need it. "We also know that reimbursement must be equitable if we are to recruit and retain providers throughout the state to serve our members," says Ms. Pasternik-Ikard. "We can provide more care to more people if our funds are used effectively."
SoonerCare Choice is approaching the end of its first year using the new patient-centered medical home model. "The transition was relatively easy, for two reasons," says Ms. Pasternik-Ikard. First, Oklahoma ended all of its HMO contracts as of Dec. 31, 2003, and moved all of the HMO members into the state's managed care option, SoonerCare Choice. As a result, members already were familiar with the primary care provider/medical home concept, and providers were comfortable with the mechanics of the program.
Secondly, SoonerCare Choice providers and members were prepared throughout 2008 for the transition. "One of the core recommendations from the task force was to completely eliminate auto-assignment, which we implemented," says Ms. Pasternik-Ikard. "We also added many other elements as we solicited and received new ideas from providers across the state."
New payment structure
The changes were largely invisible to members, but they had a palpable impact on providers. The previous partially capitated plan was replaced with a new payment structure including care coordination, a visit-based fee-for-service component, and payments for excellence.
The care coordination payment is based on each practice's capabilities and the member populations served. "We felt the new structure would rectify some perceived inequities in the previous plan that paid providers a bundled monthly fee for their entire panel of SoonerCare members, regardless of whether they were seen," says Ms. Pasternik-Ikard. "The new plan offers providers higher reimbursement for patients who require considerably more time and attention."
Because some providers were concerned about the effect on their income, a decision was made to offer them transitional payments for the first year to provide cash flow support during the early transition period. After six months, only 16% of providers still required assistance.
Oklahoma's new payment structure places providers in one of three medical home tiers: entry level, advanced, and optimal. This tiered, performance-based component allows providers to draw a higher per-member-per-month rate by providing additional services, such as using e-prescribing, adopting evidence-based guidelines on preventive and chronic care, and adopting a more flexible scheduling process.
Providers also will receive quarterly "payments for excellence" for child health exams, generic drug prescribing, screening for breast and cervical cancer, visits to patients in the hospital, and participation in a project to reduce inappropriate ER utilization. "We believe the financial incentives will result in improved access and care for members," says Ms. Pasternik-Ikard.
When the first quarterly payments were made in May 2009, 87% of providers received a payment. "Member calls related to access to care have declined," reports Ms. Pasternik-Ikard. "Our patient advice line and our SoonerCare Helpline now offer members who cannot schedule visits during normal office hours information about providers who do offer after-hours care."