Oregon FQHC/RHC Alternative Payment Method Presentation for APIP Stakeholder Meeting October 28, 2014 Jamal Furqan, Policy & Planning, Medical Assistance Programs Safety Net reforms part of Current innovations • Health Homes also part of transformation efforts – Patient-Centered Primary Care Homes (PCPCHs) • 2703 Health Home SPA (8 quarters ended 2013) • Currently have shifted from targeted high cost/high need population to broader, population-based effort – More than 400 clinics have applied and been certified as PCPCHs in Oregon and many of them are FQHCs and RHCs – All Oregon FQHCs in the safety-net Alternative Payment Method pilot are certified PCPCHs and changed their model of care due to this certification and opportunities presented by pilot 2 Safety Net Providers & PPS Payment Methodology • Paid at prospective payment system (PPS) rates for Oregon Health Plan people not enrolled in CCOs (fee-for-service (FFS)) • We make wrap-around payment for coordinated care organization (CCO)/managed care enrollees to bring total payment for managed care clients to the FFS prospective payment system (PPS) equivalent – Wrap payments are retrospective, quarterly payments, which may be as much as eighteen months in arrears 3 Why Alternative Payment Methodology • Initiated by the Oregon Primary Care Association in partnership with member FQHCs and the Oregon Health Authority (OHA) – Driven by difficulty in recruitment and retention of physicians & low physician satisfaction • De-links treadmill of churning office visits for payment by paying a per-member per-month (PMPM) payment • Needed to be budget neutral to the state, but Federal requirements mandate payment at least equal to PPS • In September 2012, a State Plan Amendment was approved to transition FQHCs to an APM • 3 large FQHCs went live with pilots 3/1/2013 4 Alternative Payment Methodology: Basics • Initially, only “medical” visits will be paid on a PMPM basis – mental health and OB services to follow • Attribution of members: – The monthly payment is based on attributed members to the specific FQHC using an18-month office visit look back to determine the “active patients” of those clinics – Patient lists are uploaded by the health center using MMIS Provider Web Portal each month – Whenever eligibility for an “active patient” is terminated, the PMPM payment is stopped automatically 5 Attribution, continued… • NEW patients may be enrolled with the health center after an encounter is registered – PMPM payments begin on the day patient is established at health center • Patients are moved by the state when they establish care with a different primary care provider, so they retain choice of providers- PMPM payments stop and/or are recouped • The health centers now have a tangible list of patients for whom they are responsible for improving health and outcomes • With revenue delivered on time each month, health centers may focus on delivering the right care at the right time for the patient and their family 6 Alternative Payment Methodology: Rates • Used historical utilization of a defined assigned population and current PPS rates to develop a monthly PMPM rate for FQHCs • Two rates are developed for the monthly prospective payment for “active patients” from the active patient list: – Non-CCO enrolled patients: Medicaid revenue/number of established patients member months = PMPM rate – CCO enrolled: PMPM based on the state’s supplemental wraparound payments for CCO encounters to calculate an average “wrap-cap”. • Reconciliation is done so no downside risk: APM payments compared to what the clinic would have received in total payments; if APM payments are less, 7 the state will pay the difference Touches Reports • Touches are also known as: – – – – – as: Enabling Services Flexible Services (CCOs) Core Services (PCPCHs) Alternative Services Non billable, non-reimbursable services • The OHA has encouraged FQHCs to focus on the nonbillable services (touches) that drive transformation of the delivery model, and improve patient health outcomes and quality of life. • Developing “touches” report to capture data on how care is being delivered 8 Quality Metric Reports • UDS quality metrics are collected from each clinic to ensure that at a minimum care does not worsen, and at best, improves. • • Metrics align with HRSA, Health Home (and soon CCO metrics, as well). Unlike the CCOs, there are no financial incentives tied to the metrics – • Each APM HC currently submits quarterly reports on the following metrics: – – – – – – – – – – 9 No financial incentives due to the state’s need to have the APM be budget neutral. Tobacco Screenings Depression Screenings Diabetes Control Cervical Cancer Screenings Weight Control: Adults and Kids HTN Controlled (most recent BP less than 140/90) Childhood Immunizations % of patients that would recommend their care team % of patient visits with assigned care team % of patients assigned by CCO that have been established OHA Challenges • Developing the methodologies for patient attribution, payment methods, touches reports and quality reporting has taken longer and been more complicated than initially imagined • System changes in our MMIS for this type of alternative payment method • Evaluation and development of “total cost of care” analysis • Being budget neutral for the state Medicaid program, and budget neutral per the APM in not paying less than PPS does not create total alignment in financial incentives – State fund (GF) budget impact of pre-APM wraparound settlements and post-APM PMPM payments occurring at same time 10 FQHC/RHC Challenges • Required reports and data, including patient panel management is new work that sometimes frustrate business office staff • The attribution model, and patients that may not commit to a medical home- impacts health center’s quality performance • Some clinics are challenged capturing data needed for the important Touches Reports from their EHR. – This issue will likely increase as pilot expands to additional clinics Preliminary Results from 1st Year • Optumas analyzed the 1st year of the APM pilot for Inpatient and ER Utilization – Across all three FQHCs, inpatient utilization decreased compared to the prior two years • Aggregate decrease in inpatient utilization trend is 20.3% – “Year 3 Pre APM” is counter-factual projection (trend), post APM is actual pilot year data Preliminary Results from 1st Year – Across all three FQHCs, emergency room utilization decreased compared to the prior two years • Aggregate decrease in ER utilization trend is 5.6% – “Year 3 Pre APM” is counter-factual projection (trend), post APM is actual pilot year data Questions?