Oregon APM Overview - Oregon School

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
– 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
Safety Net Providers & PPS Payment
• 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
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
• 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
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
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
• The health centers now have a tangible list of patients for
whom they are responsible for improving health and
• 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
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,
the state will pay the difference
Touches Reports
• Touches are also known 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
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:
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
• 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
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
• 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

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