Oregon – Medical Homes

Oregon Patient-Centered Primary Care Home (PCPCH) Program

Chapter 595 of the 2009 Oregon Laws established the Oregon Patient-Centered Primary Care Home (PCPCH) Program within the Office for Oregon Health Policy and Research (OHPR). The law required OHPR to:

  1. Define core attributes of the patient centered primary care home;
  2. Establish a simple and uniform process to identify patient centered primary care homes that meet the core attributes;
  3. Develop uniform quality measures (including acute-care hospital and ambulatory measures) that build from nationally-accepted measures and allow for standard measurement of performance;
  4. Develop policies that encourage the retention of, and the growth in the numbers of, primary care providers.

Chapter 602 of the 2011 Oregon Laws, creating the Oregon Integrated and Coordinated Health Care Delivery System, requires Coordinated Care Organizations (CCOs) deliver care to medical assistance beneficiaries and dual eligibles. This law requires the Oregon Health Authority (OHA) to establish standards for using PCPCHs within CCOs and requires CCOs to implement PCPCHs to the extent possible. Standards may require the use of FQHCs, rural health clinics, school-based health clinics and other safety net providers that qualify as PCPCHs.

Oregon’s first wave of Coordinated Care Organizations (CCOs) launched August 1, 2012. The state plans a staggered roll out of CCOs; 16 are currently active. Learn more about CCOs on the Oregon page of NASHP’s State Accountable Care Activity Map.

Federal Support: 

  • Oregon is one of six states selected in February 2013 by the Centers for Medicare and Medicaid Innovation (CMMI) to receive a State Innovation Model (SIM) Model Testing Award. Oregon received $45 million to implement and test its State Health Care Innovation Plan, which builds on the state’s CCO and PCPCH programs.
  • Oregon 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 Oregon, CPCi launched in November 2012, bringing together seven payers, as well as 67 participating primary care practices with 552 providers across the state.
  • On March 13, 2012, CMS approved a Section 2703 health home state plan amendment for Medicaid enrollees with chronic conditions that builds upon the state’s PCPCH program. It is through this state plan amendment that Oregon Health Authority is making payments to practices participating in its PCPCH Program. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
  • Oregon is also participating in the Tri-State Child Health Improvement Consortium (T-CHIC), a CHIPRA Quality Demonstration Project funded by the Centers for Medicare & Medicaid Services (CMS), in collaboration with Alaska and West Virginia.

Last Updated: April 2014

Forming Partnerships
Oregon Patient-Centered Primary Care Home (PCPCH) ProgramChapter 595 of the 2009 Oregon Laws created a 15-member advisory committee and required a diverse constituency (e.g., payers, practices, third-party administrators) guided by public input. In fact, the Director of the Oregon Health Authority convened two advisory committees: a Standards Advisory Committee and the Pediatric Standards Advisory Committee.
OHA has also partnered with the Northwest Health Foundation (NWHF) to convene the NWHF PCPCH Task Force. The task force, made up of clinicians (both primary care and mental health), patients, public health experts, and healthcare delivery technical experts, developed recommendations and action steps to support broad implementation of Patient-Centered Primary Care Homes (PCPCH) in the state.
Defining & Recognizing a Medical Home
Definition:
Oregon Patient-Centered Primary Care Home (PCPCH) ProgramChapter 590 of the 2009 Oregon Laws statutorily defines “primary care home” as a delivery system that promote the minimum elements:
  • A patient-provider relationship at the center of all health care activities;
  • Patient access, including same-day visits;
  • A team approach to care, with all team members utilizing the full scope of their license;
  • Behavioral health integration (need not be colocation);
  • Culturally competent care, with translation and other culturally sensitive services provided as necessary;
  • Managed and coordinated care across the community services system;
  • Proactive, comprehensive care
  • Expanded nursing roles, including, but not limited to: care coordination; telephone outreach; school-based health; home visits; telephone triage and clinical case management; and coordination of information-sharing among community providers;
  • Patient accountability for adhering to said patient’s health goals; and
  • Efficient and timely case management for managing chronic diseases, behavioral health and end-of-life care.
Recognition
Oregon Patient-Centered Primary Care Home (PCPCH) Programand ACA Section 2703 Health HomesThe Standards Advisory Committee enumerated the core attributes and standards (standards in parenthesis) of a PCPCH as follows:
  1. Access to Care (In-person, Telephone/electronic, Administrative)
  2. Accountability (Performance Improvement, Cost and Utilization)
  3. Comprehensive Whole Person Care (Scope of Services)
  4. Continuity (Provider, Information, Geographic)
  5. Coordination and Integration (Data management, Care coordination, Care planning)
  6. Person and Family Centered Care (Communication, Education and self-management support, Experience of Care)
See the full report for more information.
Like NCQA, Oregon uses  a three tiered approach to provide incentives for practice transformation, but the state developed criteria within each tier differ from NCQA. Oregon will accept NQCA-recognized practices at the NCQA level provided that the practice contractually attests to NCQA recognition and submits additional information on specific areas where the two recognition models diverge. See the 2014 Technical Specifications and Reporting Guidefor more information.
Comprehensive Primary Care Initiative (CPCi): Practices were selected for participation in CMS’s Comprehensive Primary Care Initiative through a competitive application process. Under CPCi, 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
Oregon Patient-Centered Primary Care Home (PCPCH) Programand ACA Section 2703 Health HomesChapter 595 of the 2009 Oregon Laws authorized Medicaid reimbursement for Patient-Centered Primary Care Home (PCPCH) services. The law also authorized reimbursement for interpretive services provided to medical assistance beneficiaries if such services qualified for federal financial participation.
With approval of Oregon’s state plan amendment to implement Section 2703 Health Homes for Medicaid enrollees with chronic health conditions, recognized PCPCH health homes will receive per-member per-month payments of $10, $15, or $24 for health home enrollees, provided that the health home provides a core health home service for that enrollee at least once per quarter. Payment amounts vary based on PCPCH tier.
A learning collaborative created by the law was charged with coordinating efforts to develop and test methods to align financial incentives to support PCPCHs. Chapter 595 also provided Parker antitrust immunity to public payers, private health carriers, third party purchasers and providers, allowing collaboration to identify appropriate reimbursement methods to align incentives in support of patient centered primary care homes.
Chapter 590 of the Acts of 2009 required that, if feasible, the PCPCH reimbursement system include:
  • Valuing services performed by nurses and behaviorists;
  • Payment for the establishment and use of team-based care
  • Preventive, educational, diagnostic care, care management and follow-up social services coordination; and
  • Home visits for case management services
Chapter 590 also granted the Department of Human Services authority to develop additional incentive payments to transform the current primary care delivery system and improve the population’s health outcomes, such as:
  • Integrating primary, oral and behavioral health care;
  • Utilizing evidence-based best practices;
  • Improving health outcomes; and/or
  • Learning collaborative participation.
Oregon plans to reimburse providers for currently care coordination services that were previously non‐reimbursable. The Oregon Health Policy Board has directed the Oregon Health Authority to pursue innovative payment methodologies. Such innovative payment methodologies must:
  • Provide financial support for meeting PCPCH standards;
  • Recognize the three levels of PCPCH tiering; and
  • Base reimbursement on the quality rather than the quantity of services provided.
If an MCO or carrier does not pursue an innovative payment arrangement, a specific additional payment is made to practices meeting PCPCH criteria. This payment corresponds to the PCPCH Tier for which a practice qualifies (Tier 3 > Tier 2 > Tier 1). When developing the payment rate, the MCO and/or carrier must consider the costs practices incur for meeting the PCPCH criteria, including, but not limited to:
  • Electronic medical record implementation and upgrade;
  • Care coordination; and
  • Dedicated time to quality improvement.
Comprehensive Primary Care Initiative (CPCi): This four-year multi-payer initiative, launched in November 2012, includes seven payers in the Oregon market: Medicare, Oregon Health Authority, CareOregon, Providence Health Plans, Regence BlueCross BlueShield, Teamsters Multi-Employer Taft Hartley Funds, and Tuality Health Alliance.
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.
Supporting Practices
Oregon Patient-Centered Primary Care Home (PCPCH) Program:Chapter 595 of the 2009 Oregon Laws required OHPR to establish a learning collaborative for state agencies, payers, providers, and third party administrators to:
  1. Share information about quality improvement;
  2. Share best practices that increase access to culturally competent and linguistically appropriate care;
  3. Share best practices that increase the adoption and use of the latest techniques in effective and cost-effective patient centered care;
  4. Coordinate efforts to develop and test methods to align financial incentives to support patient centered primary care homes;
  5. Share best practices for maximizing the utilization of patient centered primary care homes by individuals enrolled in medical assistance programs, including culturally specific and targeted outreach and direct assistance with applications to adults and children of racial, ethnic and language minority communities and other underserved populations;
  6. Coordinate efforts to conduct research on patient centered primary care homes and evaluate strategies to implement the patient centered primary care home to improve health status and quality and reduce overall health care costs; and
  7. Share best practices for maximizing integration to ensure that patients have access to comprehensive primary care, including preventative and disease management services.
Measuring Results
Oregon Patient-Centered Primary Care Home (PCPCH) ProgramChapter 595 of the 2009 Oregon Laws requires practices receiving Patient-Centered Primary Care Home (PCPCH) reimbursement to report quality measures specified by OHPR. Proposed PCPCH measures vary by tier, and can be found in Appendices C and D of the Standards Advisory Committee’s final report.
Under the upcoming Integrated and Coordinated Health Care Delivery System, CCOs will be required to report uniform quality measures for PCPCHs to OHA.
PCPCH efforts will be included in a statewide scorecard to measure success for the Action Plan for Health across the OHA lines of coverage as well as statewide.
ACA Section 2703 Health HomesOregon will use the state’s Medicaid Management Information System to collect population-level data to measure success toward the state’s five goals for this state plan amendment:
  1. Reduce the rate of potentially avoidable hospital readmissions;
  2. Reduce the number of potentially avoidable hospitalizations and increase the ratio of ambulatory care to emergency room visits;
  3. Improve care transitions between primary care and inpatient facilities;
  4. Improve care transitions for people with mental health conditions; and
  5. Improve documentation, tracking, and reporting of health risks and use or preventive services.
The state will also use AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys to measure care coordination and implement learning collaborative with health home providers and high-risk enrollees to discuss program successes, challenges, and lessons learned.