Oregon Primary Care Association s APCM Introduction/Overview
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1 APM Rate Setting Process 1 Oregon Primary Care Association s APCM Introduction/Overview Laura Sisulak, Strategic Projects Senior Director Oregon Primary Care Association
2 APM Rate Setting Process 2 Oregon Primary Care Association State Primary Care Association 32 Community Health Centers (CHCs) Statewide Serve 1/10 Oregonians (over 420,000 individuals) Serve ¼ patients on the Oregon Health Plan 72% of patients are below the poverty line. 93% below 200% FPL.
3 3 OPCA North Star Lead the transformation of primary care to achieve health equity for all
4 How we got here: APCM development HOW WE GOT HERE 4
5 HOW WE GOT HERE 5 VISION OF A BETTER WAY Oregon FQHC leaders & stakeholders Pivotal site visit: 2006 Model of excellence in medical home practice» Patient & population centered» Team-based» Data-driven» Integrated
6 HOW WE GOT HERE 6 EVOLUTION OF APPROACH Medical care focus Connection is key! Patient-centered & team-based care Psychosocial and environmental factors as important as health care Holistic customer orientation
7 BRIDGE TO VALUE-BASED PAY 7 PRESSURE ON THE SYSTEM Cost increases Budget deficit System reform Need to show value
8 ALTERNATIVE PAYMENT ADVANCED CARE MODEL 8 OPCA s GOAL FOR ALTERNATIVE PAYMENT ADVANCED CARE MODEL (APCM) Lead the development of and align payment with an efficient, effective, and emerging care model that achieves the Quadruple Aim in Oregon CHCs
9 APCM What is IN and what is OUT of the payment model? BRIDGE TO VALUE-BASED PAY 9
10 APM Rate Setting Process 10 THE CALCULATION Applicable wrap and reconciliation revenue» (Total PPS payments Managed Care payments) PPS payments for OB, Dental, and MH» Carved out services defined by procedure or diagnosis codes» Member month calculation tracks active patients and their movement to other providers
11 FINANCIAL MODEL DETAILS 11 TECHNICAL CONSIDERATIONS LEGAL REQUIREMENTS OF AN ALTERNATIVE PAYMENT METHODOLOGY IN FEDERAL LAW Legal authority is Federal PPS law State Plan Amendment to CMS = or > PPS Reconcile to PPS Voluntary participation
12 APM Rate Setting Process 12 TECHNICAL CONSIDERATIONS BASIC FACTS ABOUT THE RATE Wrap payment converts to PMPM payment Ability to attribute based on primary care claim (active patients) MCO payment remains unchanged Wrap based on prior year payment Managed care bonus payments are outside of the model Budget-neutral design (state stipulation) Includes:» Physical health services for managed care, FFS, Medi-Medi, SBHC patients Currently carved out:» Mental health services» Dental services» Prenatal/deliveries Change-in-scope process» Conceptual agreement with State to align with PPS change in scope
13 APM Rate Setting Process 13 Considerations for inclusions/exclusions Technical Issues and Definitions Attribution Scope and Scale Included Services
14 APM Rate Setting Process 14 Key Decision Points: Inclusions and Exclusions Patients Dual Eligible Open Card (FFS) CAWEM Plus and CAWEM Services/ Scope Sites Primary Care OB Mental Health Oral Health Single site v Organization School Based Health Centers Urgent Care HIV Specialty Site
15 APM Rate Setting Process 15 Carve Out Details: Mental Health Similar process for Dental and OB/Prenatal Behavioral Health» Carved IN APCM» Behavioral health codes» Primary diagnosis is medical Specialty Mental Health» Carved OUT of APCM» Primary mental health diagnosis plus list of CPT/ICD 10 codes.» Paid outside of wrap cap through PPS reconciliation.
16 APM Rate Setting Process 16 Modifications to rate process over time Carve outs more specific (codes, ICD 10) Clinic exceptions (HIV clinic; urgent care) Open card (FFS) transition ACA expansion potentially Align with changes to attribution policy, patient engagement, carve outs.
17 APM Rate Setting Process 17 Revisit the Calculation take out exclusions! Applicable wrap and reconciliation revenue» (Total PPS payments Managed Care payments) PPS payments for OB, Dental, and MH» Carved out services defined by procedure or diagnosis codes» Member month calculation tracks active patients and their movement to other providers
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