Oregon Health Authority Patient-Centered Primary Care Home - PowerPoint PPT Presentation

Oregon Health Authority Patient-Centered Primary Care Home Initiative School-Based Health Center Summit March 15, 2012

Presentation Objectives • Provide a brief background on Oregon’s Patient -Centered Primary Care Home program and vision for practice transformation • Outline goals and strategies for spreading access to primary care homes across the OHA • Explain payment reform objectives and how recognized clinics can receive supplemental payments to support primary care home activities • Understand linkages between PCPCH Program and larger Health System Transformation/Coordinated Care Organizations • Identify technical assistance resources

PCPCH Program • HB 2009 established the PCPCH program within the Office for Oregon Health Policy and Research – Create access to patient-centered, high quality care and reduce costs by supporting practice transformation • Key Functions: – PCPCH Recognition – Technical assistance development – Refinement and evaluation of the PCPCH Standards over time – Communication and provider outreach – Coordination across OHA divisions, CCO development and health reform initiatives

Oregon Health Policy Board Subcommittee Recommendation on PCPCHs Move forward decisively to transform the primary care delivery system. • Adopt the PCPCH standards and proposed structure for aligning payment to the tiers as the model for primary care home redesign in Oregon. • Sponsor development of the measurement, reporting, and feedback infrastructure necessary to implement the standards as a basis for payment. • Assist primary care practices to develop the capacity to measure and report in accordance with the standards. • Restructure primary care payment to align with the PCPCH standards framework.

Primary Care Home Standards Advisory Committee • 15 members, 6 ex-officio content experts • Multiple stakeholders (patients, providers, plans, employers, health authority, public health) • 7 public meetings Nov 2009 - Jan 2010 • Reviewed past work in Oregon, other state, federal and private efforts across the country • Three principle products • PCPCH Core Attributes and Standards • PCPCH Measures • Guiding Principles for Implementation • Reconvened second group in Fall 2010 with focus on pediatric and adolescent populations

PCPCH Core Attributes and Standards Oregon’s PCPCH Model is defined by six core attributes, each with specific standards and measures: • Access to Care • Accountability • Comprehensive Whole Person Care • Continuity • Coordination and Integration • Person and Family Centered Care

Different Tiers of Primary Care “Home -ness ” • Proactive patient and population management Tier 3: • Accountable for quality, utilization and cost Advanced Primary Care Home of care outcomes • Demonstrates performance improvement Tier 2: Additional structure and process • improvements Intermediate Primary Care Home • Foundational structures and processes Tier 1: Basic Primary Care Home

OHA PCPCH Initiative • Goals: – All OHA covered lives receive care through a PCPCH • Includes Medicaid, public employees, Oregon educators, Oregon high-risk pool, Family Health Insurance Assistance Program, and Healthy Kids – 75% of Oregonians have access to care through a PCPCH by 2015

OHA PCPCH Initiative • Alignment is critical – Contract language and expectations among OHA programs – OHP Implementation and CMS approvals – Other quality improvement initiatives – Other primary care home initiatives

OHA Implementation Team OHA Implementation Team developed operational PCPCH model, further defining both the PCPCH Standards and Payment Reform Objectives • PCPCH Standards – Phased implementation approach – Informed by internal and external technical expertise – Flexibility in model to allow small and rural practices to achieve the standards • Payment Objectives – Provides financial support for meeting the PCPCH standards; – Distinguishes providers for meeting the increasingly robust levels of standards; and – Is responsive to the OHA goal of pursuing payment reforms and moving away from a fee-for-service reimbursement model.

OHA Implementation Team • Recognition process – OHA developed a centralized, web-based process for data reporting and recognition of PCPCHs – Application includes: • Attestation to meeting individual PCPCH Standards • Health care quality data reporting • Resources available online – Implementation Guide – Technical Assistance and Reporting Guidelines – Self-assessment Form – Application

PCPCH Recognition Process Step 1) Review the PCPCH Implementation Guide and the PCPCH Technical Assistance and Reporting Guidelines. Step 2) Complete the PCPCH Self-Assessment Tool. Step 3) Complete and submit the PCPCH Application electronically. Step 4) Supplemental Payment Options: Information is now available on payments for OHP patients served at recognized clinics. Payment packet available to download on program website.

Step 1: Review PCPCH Implementation Guide and Technical Assistance and Reporting Guidelines Implementation Guide: • Reference for a wide variety of stakeholders outlining the requirements and standards for a practice to be recognized as a PCPCH by the OHA • Provides brief overview of the history of PCPCH development in Oregon and the PCPCH recognition process TA and Reporting Guidelines: • For each standard, the guidelines contain: – Corresponding measures – Intent behind each measure – Documentation requirements – Examples of strategies practices use that would/would not meet the intent of this measure • Technical Specifications for PCPCH Quality Measures – Standard 2.A requires practices to track and/or report on a set of quality measures – For each measure, the guidelines describe how practices should calculate the numerator and denominator

Step 2: Complete the PCPCH Self-Assessment Tool • Designed in tandem with the PCPCH Implementation Guide and the PCPCH Technical Assistance and Reporting Guidelines. • Recommend that practices use this Self-Assessment Tool to work with staff to accurately answer all questions and gather the required data in advance of filling out the PCPCH recognition application • Will allow practices to see what is required as well as potential tier level that is achievable

Step 3: Complete PCPCH Application • Electronic application available: www.primarycarehome.oregon.gov • OHA will recognize at the practice site level • Practices will receive notification in writing of results within 60 days of application submission • At this time, entities applying on behalf of multiple practice sites will have to submit separate applications; however, if policies are identical across these sites, application submission should not be overly burdensome • Practices are subject to random on-site verification process

Aligning Payment with Quality Payment objective to move away from the current FFS model and reimburse for services and activities currently not paid for Supplemental Payment Options for Recognized PCPCH Clinics: • For OHA-covered lives: - Oregon Health Plan (Medicaid) - In planning stages with Public Employees Benefit Board, Oregon Educators Benefit Board, and Office of Private Health Partnerships • Also working with private payers to align payment methods to support the primary care home model

Supplemental Payments for Recognized Clinics Serving Medicaid Patients Seeking federal approval to make per-member-per-month (PMPM) payments through two State Plan Amendments (SPA): • SPA #1: ACA “health homes” for individuals with certain chronic health conditions ACA-Qualified Individuals have: – More than one chronic condition – One chronic condition at risk of others – A serious mental health disorder • SPA #2: PMPM payments for non-ACA qualified OHP patients will be phased in over next 6 months. SPA currently being reviewed by CMS. ACA-qualified Non-ACA-qualified (subject to CMS approval) Tier 1 PCPCH $10 PMPM $2 PMPM Tier 2 PCPCH $15 PMPM $4 PMPM Tier 3 PCPCH $24 PMPM $6 PMPM

Enroll with DMAP as a Recognized Clinic  Be a DMAP enrolled Medicaid provider  Enroll with DMAP as a recognized clinic – All recognized primary care homes must complete the PCPCH Provider Enrollment Attachment.  Identify eligible fee-for-service OHP patients & note ACA- qualified status – Submit initial and updated fee-for-service patient list so the appropriate payments can be made. For managed care- enrolled patients*, work directly with the managed care organization so they can submit the patient list on behalf of your clinic.  Meet the service and documentation requirements *MCOs will provide information to DMAP about patient attribution and ACA-Qualified status, and DMAP will provide payment to the plans. MCOs are expected to reimburse PCPCH providers in their networks with strategies that reflect the Tier of the primary care home.