Oklahoma – Medical Homes

SoonerCare Choice

The Oklahoma Health Care Authority (OHCA) provides medical homes to most Medicaid enrollees through SoonerCare Choice, a primary care case management (PCCM) program. In January 2009, using recommendations from the provider community, the program underwent extensive revisions and identified the following goals:

  1. Enhance patient choice and participation in health decisions;
  2. Assure all members receive all necessary preventive and primary care;
  3. Increase the provider network
  4. Reduce inappropriate emergency department visits and hospitalizations;
  5. Realign payment incentives to improve cost effectiveness and quality; and
  6. Promote the use of health information.

In 2008, the Oklahoma Legislature expressed their support for patient-centered medical homes (PCMH) by passing House Concurrent Resolution 1058, concurring with PCMH principles and encouraging their study and use. During the same session, the Oklahoma Legislature also enrolled Chapter 144 of the 2008 Session Laws, which encouraged a collaborative study of medical homes, and Chapter 166 of the 2008 Session Laws, which created a Medical Home Task Force.

OHCA also promulgated rules establishing a pilot program for Health Access Networks (HANs), non-profit, administrative entities that work with providers to coordinate and improve the quality of care.

Federal Support: 
  • The greater Tulsa region is one of seven markets participating in CMS’s Comprehensive Primary Care Initiative (CPCi). In this multi-payer initiative, Medicare is collaborating with public and private insurers in the selected states or regions with the goal of strengthening primary care. In Oklahoma, CPCi launched in October 2012, bringing together four payers, as well as 68 participating primary care practices with 280 providers in the greater Tulsa region.
  • Oklahoma has received a duals demonstration grant from the Centers for Medicare & Medicaid Services (CMS) to “coordinate care across primary, acute, behavioral health and long-term supports and services for dual eligible individuals,” who are currently unable to participate in SoonerCare Choice.
  • The Greater Tulsa Health Access Network (Greater THAN), now known as MyHealth Access Network, has received a Beacon Community Grant.

Last updated: October 2013

Forming Partnerships
SoonerCare ChoiceIn 2007, an 11-member Medical Advisory Task Force, comprised of provider organization representatives and staffed by Medicaid, was formed and recommended providing every SoonerCare Choice member with a patient-centered medical home model.
Chapter 166 of the 2008 Session Laws established a temporary 16-member Medical Home Task Force staffed by the Insurance Department to study implementation of patient-centered medical homes (PCMH) for private and public payers.
Town hall meetings were convened across the state in Fall 2008.
Defining & Recognizing a Medical Home
SoonerCare ChoiceOklahoma has developed a three-tiered recognition tool for Medicaid providers. The Physician’s Agreement Addendum (attachment B-MH) contains the entire list of requirements for each tier.
Comprehensive Primary Care Initiative (CPCi): Practices were selected for participation in CPCi through a competitive application process. Under CMS’s Comprehensive Primary Care Initiative, practices are not required to attain formal PCMH recognition; however, formal PCMH recognition through NCQA, AAHCC, the Joint Commissioner, URAC, or a state-based recognition program was viewed favorably in practice selection. Additional criteria included:
  • Health information technology, including attestation to Stage 1 Meaningful Use and engagement with local Regional Extension Center (REC);
  • Percentage of practice revenue earned from participating payers; and
  • Participation in practice transformation programs through organizations like quality improvement organizations, RECs, or learning collaboratives.
Aligning Reimbursement & Purchasing
SoonerCare ChoiceSoonerCare Choice utilizes multiple payments to incentivize practice transformation. These payments include:
  • Quarterly per-member “transitional” payments to support practice transformation (only available during the first year of the program);
  • Traditional fee-for-service reimbursement for visits*;
  • A tiered per member per month (PMPM) care management payment that ranges from $3.03 to $8.69; and
  • Quarterly SoonerExcel performance-based incentive payments.
*Providers can use additional codes to bill for enhanced reimbursement when providing care outside of normal business hours.
Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in October 2012, includes four payers in the Tulsa market: Medicare, Oklahoma Health Care Authority, CommunityCare, Blue Cross and Blue Shield of Oklahoma.
Medicare pays selected practices a per-beneficiary per-month (PBPM) risk-adjusted care management fee, which ranges from $8 to $40. CMS has indicated that it expects care management fees to average $20 PBPM during the first two years of the initiative. In Years 3 and 4, care management fees will average $15 PBPM. Medicare will also introduce a shared savings component beginning in Year 2, calculated at the market level.
The CPCi solicitation for payers indicates that participating payers (non-Medicare) are expected to follow a similar framework, paying per-member per-month (PMPM) care management fees to participating practices on top of fee-for-service and incorporating a shared savings component. Payment amounts will be negotiated individually with participating practices to comply with anti-trust laws. Payments from the Oklahoma Health Care Authority for providers caring for Medicaid enrollees in CPCi are as for SoonerCare Choice mentioned above.
Supporting Practices
SoonerCare ChoiceThe SFY2010 Performance and Quality Reportstates that the Oklahoma Health Care Authority (OHCA) Quality Assurance and Improvement Department conducted 557 visits to educate providers on the medical home requirements from July 1, 2009 – June 30, 2010.
Oklahoma provides four profiles to selected providers biannually that give information about their patients’ utilization and health care needs. Also, SoonerExcel, a pay-for-performance program, provides practice feedback on targets for Child Health Exams (Early Periodic Screening, Diagnosis, and Treatment [EPSDT]) and Breast and Cervical Cancer screenings.
Oklahoma is currently piloting three non-profit, administrative Health Access Networks (HANs) to support care coordination and quality improvement. According to Oklahoma Health Care Authority’s 2012 Annual Report, the state’s three HANs served 382 practices and over 78,000 SoonerCare Choice members as of June 2012.
Practices participating in the SoonerCare Health Management Program receive 4-6 weeks of practice facilitation services to support work with high-risk SoonerCare Choice members with chronic conditions. In addition, practices are invited to participate in regional collaboratives.
Measuring Results
SoonerCare ChoiceThe Oklahoma Health Care Authority (OHCA) uses HEDIS measures to evaluate performance.
The SFY2010 Performance and Quality Report describes that the OHCA Quality Assurance and Improvement Department uses standardized audit tools to conducts on-site reviews of contracted SoonerCare Choice providers.
Following the redesign of SoonerCare Choice, the number of patients contacting the Oklahoma Health Care Authority (OHCA) for same/next day access issues in a year decreased from 1670 in 2008 to 13 in 2009 to 4 in 2010.
The program has demonstrated a $29 decrease in per capita member costs (per patient/per year) from 2008-2010 while increasing evidence-based primary care services (including breast and cervical cancer screening).
2009 pediatric health survey showed an increase of more than 18 percent of patients between 2007 and 2009 who “always [received] treatment quickly.” A 2010 adult health survey found a similar increase of 8 percent for adults between 2008 and 2010.