Download PACE Program Description - American Health Care Association

State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
Introduction
The Oklahoma Health Care Authority (OHCA), Oklahoma’s single state Medicaid agency, is dedicated to exploring new innovations
in health care delivery to enhance the quality of care afforded to our members. Members eligible for both Medicare and the Oklahoma
Medicaid program (namely SoonerCare) present a unique challenge as they constitute a small percentage of the SoonerCare
population, but represent a higher percentage of spending. Fragmented care and lack of coordination between providers for these
dual eligibles often leads to poor health outcomes making this an area that provides ample opportunity for improvement and change.
In response to the opportunity provided by the Center for Medicare and Medicaid Innovation, the OHCA would like to propose the
following areas of research and development as potential strategies to improve the care integration, coordination, and health
outcomes of the SoonerCare dual eligible population. The OHCA proposal involves taking a three pronged approach to determining the
most efficient methods of care integration. Each of the three concepts identifies a different aspect of care for the dual eligibles and
will be developed to identify the feasibility and effectiveness of each concept.
Concept #1- The Tulsa Health Innovation Zone’s Pilot for Dually Eligible Oklahomans
Proposal This proposal describes our efforts to create an Accountable Care Organization with embedded medical education
programs (Health Innovation Zone) that specifically serves high cost patients that are eligible for both Medicare and Medicaid. We
have successfully installed 3 regional programs that provide a foundation for this initiative including patient centered medical home
teams, a health access network care coordination initiative and a health information exchange. We propose a 4 th program to be
installed in the form of a set of teams focused on high risk high cost dually eligible patients. We would then organize these 4
components under an accountable care organization model that includes payment models that promote improved patient outcomes
and an overall lower cost of care. Over the next year, planning would require dedicated project managers, in-depth data analysis,
identification of high cost high risk patients, building of dedicated care teams, and the design of new payment methodologies.
Background: In contracts with the OHCA and the Office of the National Coordinator for Health Information Technology (ONC), the
University Of Oklahoma School Of Community Medicine has led the first three installments of an innovative health system
infrastructure in northeast Oklahoma. These are:
Installment #1 – Patient Centered Medical Home (2008) for SoonerCare members (Medicaid managed care)a system that
reformed payment to a fee for service model plus a care management, and quality payment tiered to the sophistication of the
PCMH elements of health information technology and proactive coordination of care
Installment #2 – Sooner Health Access Network (2010) created the PCMH neighborhood for providers of care to SoonerCare
members that facilitates access from the PCMH to specialty services, helps advance PCP practices of PCMH, and measures,
reports, and improves quality of care for the member PCMH practices.
Installment #3 – Greater Tulsa Health Access Network (2010) provides one of the most sophisticated health information
exchanges in the nation for 11 counties in northeast Oklahoma and is funded with a $12 million contract from ONC to be a Beacon
Community. The HIE will provide point of care medical information as well as the necessary analytics needed to create the
attribution for modeling the payment model for an ACO, the analysis and reporting for coordination and improving care, and the
data set for education and health services research central to a Health Innovation Zone.
Further Advancing the Quality and Efficiency of Health Care in the Tulsa Region: The Tulsa Health Innovation Zone (THIZ)
Responding to Oklahoma’s poor health status, health system performance, overall cost of care, access to care, health inequity
and very low physician per capita ratio, a coalition of healthcare providers and payers in northeast Oklahoma has built the first three
installments of a model health care delivery system to improve quality and access as well as improve the value and efficiency of care.
In further advancing the quality and efficiency of the Tulsa region’s health system, this coalition is committed to create a unique Health
Innovation Zone (HIZ) with a central Accountable Care Organization (ACO) and the incorporation of health professions education. Our
HIZ will comprise the northeast Oklahoma (the Tulsa Beacon Community) teaching hospitals, physicians, and other providers. The
proposed payors include the Oklahoma SoonerCare program, Medicare and area commercial insurance vendors. The proposed
denominator population for measuring the effectiveness of the THIZ’s innovations would be about 50,000 persons from north, east and
west Tulsa. 25,000 would be Medicaid, 10,000 Medicare, 8,000 BC&BS, and 7,000 uninsured. We estimate approximately 2,200
individuals within this population would be dually eligible for Medicare and Medicaid coverage. The distinguishing parts of the THIZ is
that it incorporates community driven planning, innovative methods for the recruitment and training of future and current
health care professionals, and proposes to use gain-sharing savings for public good to expand medical education programs.
The Tulsa Health Innovation Zone (THIZ) has 5 Goals:
Oklahoma Proposal
Page 1 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
Accountable Care Organization
Create a pilot ACO that brings together patient care, payment and health information innovations into an organized system of
care for the most vulnerable and costly patients - the dually eligible.
2. Demonstrate the Center for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation and Center for
Medicare and Medicaid Integration leadership’s “triple aim” for better care, better outcomes and lower costs.
3. Create the platform for integrating several initiatives within the Health Resources and Services Administration, Center for
Medicare and Medicaid Integration, Center for Medicare and Medicaid Innovation, and the Oklahoma Health Care Authority to
improve care, lower costs and expand the health workforce.
4. Train a new generation of clinician leaders prepared to thrive in the patient-centered Accountable Care Model of care.
5. Create a value-added and efficient health system that can care for 100,000 newly insured Tulsa area citizens with great attention
to the new insurance exchange, Medicaid and Medicare populations.
The THIZ will use 6 Strategies to meet these goals:
1. Develop the policies and procedures for delivering and teaching care in Patient Centered Medical Home primary care and disease
specific interdisciplinary teams which are then seamlessly connected to the vast array of specialists, hospitals, community
agencies, home health, durable medical equipment, and long term care services.
2. Incorporate health information technology (Health Information Exchange, EMRs, referral tracking systems, and clinical decision
analytics) to provide proactive outreach services, care coordination and access to the most appropriate level of care.
3. Use performance metrics and lean production quality improvement techniques to improve the quality of care for high risk
patients particularly the dually eligible.
4. Incorporate care teams, proactive prevention care and early interventions, care coordination and health information exchange to
assure more appropriate utilization of health services and control the costs of care.
5. Use community-based participatory research methods to plan the THIZ’s ACO which will include patients receiving care,
providers, and physician assistant students, nurse practitioner students, medical students and resident physicians in the
planning, design, implementation and measurement of outcomes of these efforts.
6. Simplify and integrate the payment system of Medicare and Medicaid to stimulate seamless, coordinated, and value-added care
for the dually eligible patients.
Health Innovation Zone
1.
Patient Centered
Medical Home Teams
Advanced Outpatient, Urgent
Subspecialist Care
Direct Care Level
Hemophilia
Multiple Chronic Disease
Special Populations
Team Care- Duals
Sickle Cell
Hospital
Care
Severe Mental Illness
Dementia
Care Coordination Level- Health Access Network-, Patient Navigation, Case Management, e-based, tele-health
Health Information Exchange Level- Beacon Community- Reduce Duplications, Adverse Drug Events, Outcomes
Payment Innovations Level- Capitation, Case Rates, Bundles, ACE, Gain-sharing  Reinvestment in medical education and
expansion of outreach clinical services.
Health Professions Education Level- Incorporation of medical students and resident physicians in design and implementation of
programs, model teaching environment is the model clinical environment, Teaching Health Centers, Gain-sharing funds are
re-invested to expand medical education and outreach care services.
Health Services Research Level- Community Based Participatory Research, quality improvement/ systems efficiency
Learning Network of Urban Serving Medical Schools- OU, Univ Chicago, UCLA/ Drew, Tulane, Wayne State, FIU
As depicted in the above diagram, our long term plan for health system and medical education redesign involves the development
of several levels of programs working in concert (systems within systems) including a spectrum of primary and specialty care, high
risk care teams, care coordination programs, health information exchange, medical education and research programs and a “co-op”
of urban and rural serving medical schools that have pledged to share and replicate their clinical, research and education innovations.
Tulsa Health Innovation Zone High Coordinated Care for (Dually Eligible)
Oklahoma Proposal
Page 2 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
This planning grant proposal focuses on developing a pilot ACO that specifically manages the care of the 2,200 dually eligible
patients. Conservatively, using Federal estimates, the cost of care for these 2,200 patients may be as much as $88,000,000 per year.
From our clinical experience, we anticipate that these patients fall into several groupings including i) elderly, living at home, with
multiple medical diagnoses including dementia, ii) elderly, living in care facilities, with multiple medical diagnoses including dementia,
iii) middle-aged adults, living at home, with multiple medical or severe mental illnesses and iv) middle-aged adults, living in care
facilities with multiple medical diagnoses or severe mental illness.
We anticipate these patients’ multiple medical problems to be i) chronic severe mental illnesses – e.g. Dementia, Schizophrenia,
Bipolar Affective and Schizoaffective Disorders, ii) chronic pediatric disease – e.g. Type I Diabetes, Cystic Fibrosis, Sickle Cell Disease
and iii) multiple chronic adult diseases – e.g. Congestive Heart Disease, Chronic Obstructive Pulmonary Disease, End-Stage Renal
Disease, End-stage Cancer, Degenerative Neurological Disorders
We believe the highest cost components of the care of these patients include i) recurrent acute hospitalizations due to
inadequate primary care and coordination of home provider and multiple specialty care, ii) multiple medications and iii) redundancy
and duplication of care across providers and facilities
OU School of Community Medicine has experience with several models for providing coordinated care for high risk patients. For
example, our IMPACT interdisciplinary team provides comprehensive community-based psychiatric and rehabilitative care to
individuals with severe mental illness. After one year in the IMPACT program, patients symptoms are much improved, scores on
independent living skills are higher, patient and family satisfaction is dramatically improved, hospitalization and incarceration rates
are reduced by as much as 80% with a net reduction in annual cost of health care of $ 15,000 per patient has been seen. A similar set
of results has been produced by our palliative care team which has reduced hospital length of stay by an average of 2 days and has
significantly improved patient, family and hospital staff satisfaction. We have additional teams in place for high risk obstetrics, Type I
Diabetes Mellitus and Child Abuse. Additionally, Hillcrest Medical Center has a certified ambulatory aqua-pheresis program for heart
failure patients that has dramatically reduced the need for hospitalizations.
Tulsa Health Innovation Zone Reimbursement – Reinvestment Model
As we have already experienced with those with severe mental illness within our IMPACT program, we anticipate that providing
these high cost patients with diagnostic specific outreach teams will lower the cost of their care through reduced hospitalization and
care facility placement while improving their quality of life and satisfaction with the services they have received. We support the
concept of “Gain-sharing” where reductions in cost of care for these patients are shared with the Tulsa Health Innovation Zone. What
makes this proposal unique is our willingness to re-invest those saving into further strengthening the health care delivery system in
the Tulsa area by expanding medical education programs and supporting new outreach specialty services that in turn should further
reduce the overall cost of care in the region.
Measurement of Effectiveness of THIZ’s ACO for Dually Eligible
Within the Tulsa Health Innovation Zone, we have proposed the following balanced score card of outcomes. For the dually eligible
patients we would track the same outcomes. These are the measures that are going to be collected and reported in compliance with
the ONC’s contract for the Tulsa Beacon Community.
Tulsa Health Innovation Zone Balanced Score Card Measurements
Health of Population
-Prevention Measures- retinal and foot exams, mammograms, PAP, colonoscopies, EPSDT, vaccinations
-Chronic Disease Measures- lipids, HgbA1C, blood pressure, aspirin utilization, stroke and MI rates, early cancer detection rates
Satisfaction Rates
-Patients, family members
-Clinicians
-Students, Resident physicians
Utilization
-Emergency room utilization
-Hospital length of stay
- Overall cost of care per patient per year
Workforce
-School loan debt
-Specialty Choice
-Job placement
-Hospitalization rates
-Nursing Home Utilization
Planning Schedule
Phase 1: (Months 0-3) Data Gathering and Analysis
 Identify the Dually Eligible population of patients for the ACO
 Aggregate the Medicaid and Medicare data for this population to determine the historical cost, service use pattern,
morbidity,
Oklahoma Proposal
Page 3 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011

Conduct Community-Based Participatory focus groups to understand the needs and suggestions for improving care from a
representative sample of the various groups that comprise the population for the ACO.
 Conduct focus groups with providers, service agencies, pharmacists, and social services that currently provide care for the
population, and identify successful models existing in the community.
 Perform a literature review of the health services research regarding the care of dually eligible, particularly looking for
reports of successful care coordination models.
 Engage RAND Corporation to assist in the data analysis
Phase 2: (Months 4-6) Value-Stream Mapping and Design
 Draw maps of the current care system from the patient’s perspective identifying opportunities for immediate improvement
in the System.
 Develop new care management, coordination of care, decision support tools to implement the improvements in the care
delivery process for the population
 Develop the payment model for the ACO integrating Medicaid and Medicare payment and eligibility policies and developing the
waivers needed to implement the payment aspect of the pilot.
Phase 3: (Months 7-10) Rapid Cycle Tests of Change
 Perform rapid cycle tests of the policies and procedures, including the training of the providers and teams in the
implementation of the processes and use of the technology that will be used in the ACO pilot.
 Collect data on the impact of the changes in the processes of care.
 Continually innovate based on the results of the multiple rapid cycle tests of change.
Phase 4 (Month 11-12) Report and Dissemination Strategy
 Analyze the results of the rapid cycle tests of change and write the document that describes the training and
implementation of the new care process.
 Write the policies and procedures for reporting provider performance to payers and demonstrating continuous quality
improvement.
 Write the dissemination plan for implementing the plan across the THIZ and across all providers for dually eligible patients in
Oklahoma.
In developing a more in-depth plan for dually eligible patients, we would need a more detailed analysis of the demographics,
location and needs of these patients. We would require the assistance of SoonerCare and Medicare to accomplish this. We also
propose that the Tulsa Health Innovation Zone be a community driven ACO. This would require a process that allows for community
input into design and implementation as well as board representation for on-going operations. In addition, we would hope for
additional assistance from thought leaders in planning, design and implementation of these complex plans such as RAND Corporation
and the Commonwealth Fund. If successful, the Tulsa Health Innovation Zone would serve as the state-wide training site for replication
of successful components of this proposal.
Concept #2- New Benefit Plan for Dual-Eligibles, Patterned After a Shared-Savings Model
Oklahoma would like to begin exploring the feasibility of establishing a benefit plan and network, administered and operated
by the state, in a somewhat similar fashion to models in operation in South Carolina and accountable care organizations being
developed across the nation. We propose combining the funding streams from Medicare and the Oklahoma Health Care Authority
(OHCA) and using these funds to purchase coverage through a plan and network developed and administered by OHCA. This product
would be similar to the Individual Plan (IP) offered through the Insure Oklahoma Program. Insure Oklahoma (IO) is the state’s premium
assistance program helping businesses and their modest and low-income employees, as well as those self-employed and unemployed
Oklahoma families, gain and keep health insurance coverage. Beginning enrollment in November 2005, the IO program is funded by the
state’s tobacco tax (approved by voters in 2004) and uses state and federal funds. A safety-net part of the program, Insure Oklahoma
Individual Plan (IP) helps self-employed, unemployed individuals seeking work or employees working for small businesses that do not
have access to group coverage. The IP provides a state-sponsored benefit plan and provider network (which differs significantly from
traditional SoonerCare coverage) to qualifying Oklahomans.
Advantages
Oklahoma Proposal
Page 4 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
Purchasing one product at a local level should allow for a greater efficiency and responsiveness of the coverage. It’s recognized
that for a state like Oklahoma, in which the delivery system ranges from sparse (such as in the Panhandle area) to metropolitan (such
as Oklahoma City and Tulsa), financial coverage needs to be flexible to meet the needs of the members. In addition to geographical
variability, over 100,000 Oklahoma dual eligibles are on a continuum of health status ranging from good to poor. We would envision the
insurance product functioning as a standard payer for the more healthy population and in more rural areas of the state. For
populations requiring more extensive chronic health care services, the existing managed care support functions of the agency, such
as case management, would be used. Additionally, targeted programs such as home and community-based waivers or end stage renal
disease programs could be used with the chronic health needs populations.
Implementation
The agency’s history with the Insure Oklahoma program and SoonerCare Choice program allows a depth of current experience,
capabilities, knowledge, and expertise such that a program focused on the duals should be successful. A separate administrative
function, either in-house or privately contracted, could be employed. Appropriate monitoring of operating results and outcomes
should be planned from the beginning with accountability achieved through on-going reporting. The timeline and activities for this
demonstration are as follows:
Month
1
2
3–5
6–9
10 – 12
Activity
Recruit and hire project staff; including coordinator, support staff and consultants.
Identify key internal (governmental) stakeholders that will be responsible for program development and
implementation.
Identify key external (public) stakeholders who will provide input from the perspective of the citizens, medical
community, etc.
Begin planning meetings for project design. This phase will include a study of utilizations patterns and an
actuarial analysis.
Develop final project design and report for submission to grant monitors.
Key Product Feature
In addition to serving the general dual eligible population, a key feature to this product design could be the emphasis placed on
our citizens with behavioral health needs. Dual eligible adults currently can obtain BH services that are allowable under the Medicare
(MCR) plan, but these are limited to psychotherapy which does not meet the special needs of this population.
This product could place greater emphasis on behavioral health care coordination which is limited by the barriers from the current
dual systems among Medicare and Medicaid. Care Coordination is proven to increase the member’s satisfaction with services and
overall health, and to decrease the overall healthcare costs over time, OHCA has a good starting point from which to build an
infrastructure for improving continuum of care for dual eligibles.
Current System Limitations for Adult BH Duals:
1) Two separate systems for providers to deal with creating administrative burden for prior authorization and claims filing.
2) Medicare only covers psychologists and social workers and not the full array of licensed behavioral health providers.
3) Medicare only covers psychotherapies and not the broader array of BH services that we provide under Title XIX, such as
psychological evaluations which are necessary for adequate diagnosis and treatment planning.
4) Medicaid does not cover:
a. Licensed Behavioral Health Professionals (LBHPs) for Adults 21 and over
5) Medicare and Medicaid do not cover:
a. Residential Substance Abuse/Co-Occurring Treatment for Adults
6) No coordination of care between Medicare and Medicaid.
7) Lack of Psychologists. Social Workers could serve the dual populations in the state whether they live in the home, Residential
Care Facilities, or Nursing Homes.
8) Income guidelines sometimes de-incentivize getting and succeeding in employment.
Changes To Be Integrated Into Our System Of Care For Dual Eligibles:
1) Medicaid and Medicare need to allow full data sharing.
2) Develop an integrated eligibility, prior authorization, claims payment, and clinical outcomes electronic data system.
3) A full Continuum of Care array of BH services for duals
Oklahoma Proposal
Page 5 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
4) Integrated Treatment Plans between MCR/MCD so that there is fully integrated and coordinated care between the plans.
5) Allowance of duals to be covered partially under Insure Oklahoma as a secondary insurance.
Current Strengths of the existing Oklahoma SoonerCare system for Dual Eligibles:
1) Care Coordination for Duals as requested
2) Strong MMIS system that is provider friendly
3) Strong Prior Authorization system that is provider friendly
4) Strong Collaboration with Stakeholders who hold positions on the OHCA BH Advisory Council, Medical Advisory Committee, and
Statewide BH Collaborative Workgroups. Stakeholders include: consumers, consumer advocacy groups, public and private
providers, state agencies, and private entities.
5) Strong Network of BH Agencies and LBHPs available to serve dual eligibles if coverage was allowable for these provider types.
6) Insure Oklahoma plan is an excellent resource for those who get a job and need affordable insurance.
Concept #3-Oklahoma PACE Program Statewide Expansion
The Program of All-inclusive Care for the Elderly (PACE) model is centered on the belief that it is better for the well-being of
seniors with chronic care needs and their families to be served in the community whenever possible. PACE is a federal program
designed to keep elders living in their homes, connected with their communities and out of nursing home facilities. It combines the
services of an adult day health center, primary care office, and rehabilitation facility into a single location. PACE provides an allinclusive and comprehensive continuum of care designed to maintain and ideally to improve the quality of life for the elderly.
Cherokee Elder Care is the first PACE program in the state of Oklahoma and the first PACE program to be sponsored by a Native
American Tribe. Cherokee Elder Care PACE is one of fifteen (15) rural PACE sites in the nation. Cherokee Elder Care is available to
eligible individuals living within the five surrounding counties of Tahlequah, Oklahoma. Cherokee Elder Care began in August of 2008
with the goal of using a team effort to increase the availability and quality of services, facilitate timely delivery and enhance the lives
of elderly persons by assisting them to remain in their homes and community as long as possible.
Within a year of the program starting, the Cherokee Elder Care program grew from 2 participants to 50 participants. There are
currently 77 participants in the Cherokee Elder PACE program. Approximately 96% of Cherokee Elder Care PACE participants are
considered dual eligible.
Cherokee Elder Care serves individuals who are 55 or older, certified by the state of Oklahoma to need nursing home level of
care, are able to live safely in the community at the time of enrollment, and who live in the Cherokee Elder Care service area. Although
PACE participants must be certified to need nursing home level of care to enroll in Cherokee Elder Care, less than 1% of Cherokee
Elder Care participants permanently reside in a nursing home. Cherokee Elder Care participants have demonstrated improvement in
health as a result of being frequently monitored, having input in their managed care plan, and living with as much independence as
possible within the community.
Services Provided Through Cherokee Elder Care PACE
The services provided by Cherokee Elder Care are all-inclusive. Services include all benefits provided through both Medicare and
Medicaid in addition to what is deemed necessary by the inter-disciplinary team as a part of a participants care plan. Services include
but are not limited to:
 Outpatient Health Services (i.e. nursing care, physical therapy, occupational therapy, home health, personal care, prescribed
medications and pharmacy services etc…)
 Adult Day Health Services (includes nursing, recreational therapy, meals, nutritional counseling etc…)
 Inpatient Health Services (i.e. medical and surgical care, psychiatric care, ambulance services, emergency treatment etc…)
 Nursing Home Care (i.e. semi private room and board, doctor and skilled nursing services, custodial care etc…)
 Other Health Related and Community Based Services (i.e. prosthetics, oral surgery, transportation, meals etc…)
Financial Benefits of Cherokee Elder Care PACE
The Cherokee Elder Care (CEC) PACE program is a unique model that utilizes capitated payments. This unique model allows for
cost effectiveness and cost savings that benefit the state of Oklahoma. The capitated payment method allows for great budget
predictability and cost control. The Cherokee Elder Care PACE program is paid through Medicare, Medicaid, and private pay dollars
(for those who do not qualify for either Medicare or Medicaid). The Medicare rate is composed of the average per capita cost (all Part
A and B expenditures for all Medicare eligible individuals in each county) multiplied by a frailty factor. The Medicaid rate is composed
of a blended rate of nursing home and home and community based waiver costs. The current rate paid for participants classified as
Oklahoma Proposal
Page 6 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
Medicaid only is $3444.39 per person, per month. The current rate paid for participants classified as Dual eligible is $2736.63
per person, per month.
The average monthly Medicaid nursing facility rate is $3772.50 per person, per month. The difference between the average
Medicaid nursing facility rate and the PACE dual eligible rate is $1035.87 per person, per month. With 77 members currently in
the CEC PACE program the monthly savings to the state is approximately $79,772 or $957,264 per year. As the PACE program grows,
so will the savings for the state of Oklahoma.
Strategies for using PACE with Dual Eligible Grant (including timeline)
PACE demonstrates an effective model to integrate care for individuals who are dual eligible. The PACE model is a cost effective
way to ensure enhanced quality of care. As part of the proposed dual eligible demonstration grant, Opportunities for Living Life (OLL)
would conduct the following activities as a strategy for serving this population. Grant funds as described in the budget below would be
used to accomplish these tasks.
Month
Activity
1
1. Recruit and hire project assistant
2 - 5 2. Identify, utilizing focus groups, workgroups, community organizations and available data areas statewide that could
benefit from a PACE project.
6 – 11 3. Identify and recruit organizations or entities statewide who express interest in the PACE program. This would include
marketing to potential partners by giving the organization/entity information about what PACE is in an effort to find if
PACE is the appropriate program for their group. Additionally, this would include identifying target populations and
developing “mini” proposals for future consideration.
12
4. Evaluation of findings and develop a final report for submission to the grant monitors.
Once the initial demonstration was complete and OHCA has been awarded a subsequent implementation grant, the following
activities would be initiated. The following activities are contingent upon successful completion of activities 1 – 4 and continued
implementation funding.
5. Provide greater levels of support to interested groups by providing technical assistance with completing letters of intent,
applications and proposals.
a. Assistance with letters of intent.
b. Face-to-face meetings to aid in the process.
c. Technical assistance in completing the application. OLL staff will regularly check with PACE applicants to assist in
completing the application.
d. Training (initial and ongoing) to assist PACE projects in improving quality.
e. Fast-track agency processes including the green sheet (the green sheet is the initial approval needed to begin the
policy work to add additional providers), the PACE application (from the CMS website) and submission of request to CMS.
6. Potentially develop a program lending model that provides upfront funds for organizations that need funding for infrastructure
development. These funds would be repaid to the authority once the program was operational.
Overview of state capacity and infrastructure
Recognizing the need for specific expertise in the administration of Oklahoma’s Medicaid programs, and as a result of
recommendations from broad-based citizens’ committees, the State Legislature established OHCA in 1993 through authorizing state
legislation. The OHCA authorizing law can be found in Oklahoma Statutes Title 63, Sec. 5004. OHCA leads the effort to oversee the
supplementation of state dollars with available and appropriate federal dollars. OHCA staff performs an array of critical functions
necessary for program administration. These functions include member and provider relations and education; developing SoonerCare
payment policies; managing programs to fight waste, fraud and abuse; etc. OHCA has numerous oversight boards, advisory
committees, and task forces, which all ensure that decisions are made to best serve members’ needs while maintaining the fiscal
integrity of the agency.
OHCA is capable of operating a multi-billion dollar agency with a total budget exceeding $4 billion dollars. In state fiscal year
2010, over 885,000 Oklahomans (1 in 4 Oklahomans) were served by Oklahoma Medicaid (namely SoonerCare) programs. OHCA is
among the top Medicaid agencies in terms of members served and total operating budget. OHCA is seen as a leader among other state
Oklahoma Proposal
Page 7 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
Medicaid agencies and is often asked to share best-practices in terms of policy, process, and systems with other states across the
nation.
OHCA has gained national recognition as a leader in the design and development of new, innovative programs. Most recently, two
projects have been successfully implemented which required creation of new programs and processes to better serve members:
Patient-Centered Medical Home and PACE (Program of All-inclusive Care for the Elderly). These two OHCA projects have had
significant visibility and impact upon the Oklahoma Medicaid program, and demonstrate the capacity and infrastructure already in
place to move forward with the development of an Oklahoma model.
The key program personnel for this project include the following OHCA staff:
Cassell Lawson, Director, Opportunities for Living Life
Aimee Moore, Quality Compliance Supervisor
Lynn Puckett, Information Services Contract Director
Debbie Spaeth, Behavioral Health Services Director
Melody Anthony, Director, Provider Services
Nancy Nesser, Pharmacy Director
Buffy Heater, Planning & Development Manager
Essential Partners/Stakeholders (listed within this proposal)
OHCA expects to utilize consultant contractor(s) to assist with data analysis, budget impact, and determination of feasibility. At
this time the actual contractor is not known for this project. The contractor will be sought and awarded via a state request for
proposal (RFP). The scope of work for the RFP will be determined through the early planning process and as the project progresses.
Anticipated work activities of the contractor may include: gap analysis of Medicare data and recommendations how to improve the
data linkages with Medicaid; actuarially sound analysis of estimated potential savings of Medicare and Medicaid costs; and identified
efficiencies gained through specific integration efforts i.e. duplicative and/or unnecessary services.
Description of current analytic capacity
Currently OHCA has access to Medicare crossover data, Bendex and MMA files. With access to Part D (Drug) and full Medicare
claims history, Oklahoma will be able to link and analyze claim data streamlining and speeding the identification of dual eligibles in need
of care coordination and outreach. Dual eligible members will be included in predictive modeling, grouping patients by disease state
and chronic illnesses to direct care through OHCA’s Care Management or contractor Health Management teams. This brings early
intervention to the forefront and insures best possible outcomes for the patient. Analysis of medication claim history data along with
disease state information can be used by our SoonerCare pharmacy team to yield the most cost effective and appropriate drugs.
The SoonerCare MMIS can support multiple enrollment, benefit and payment methodologies producing innovative and cost
effective patient centered care delivery models. Fully capitated managed care, partially capitated managed care and patient centered
medical home care delivery models can all be supported by the MMIS. Oklahoma’s MMIS is HP’s Interchange claims processing system,
which currently processes approximately 4 million claims per month for Medicaid and other Health and Human Services agencies in
the state. Using Initiate, OHCA will rapidly match Medicare and Medicaid files, ensuring proper payment and preventing fraud. With one
of the best Payment Error Rate Measurement (PERM) records in the nation, Oklahoma has a proven track record of ensuring that
Medicaid funds are properly utilized for patient care.
In addition to cost savings identified by care coordination and health management, financial analysis of all claim data can identify
savings and innovative care delivery payment methods.
Summary of Stakeholder Environment
The OHCA, in all areas of expertise, provides input into the strategic plan of the agency. OHCA, its health partners, advocacy
groups, legislators and other stakeholders meet annually to discuss the agency’s upcoming enhancements, goals and challenges.
These meetings help guide and set the strategic plan for that specific year. Leading up to the annual strategic planning event, OHCA
staff conducts numerous formal and informal discussions with stakeholders across the state. These interactions allow OHCA to
maintain and create relationships with stakeholders, gaining their valuable input as to the design and implementation of projects and
programs serving the citizens of our state.
The planning and development unit of the agency, on a daily basis, conducts large and small workgroups, ad hoc meetings, task
oriented small groups, open meetings, etc all for the purpose of seeing the planning process through to implementation. The planning
Oklahoma Proposal
Page 8 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
and development unit is comprised of project managers tasked with gathering experts both inside and outside the agency to design
and oversee implementation of high priority projects. This effort requires substantial buy-in and involvement of many stakeholders. In
Oklahoma the key state health agencies playing a key role in the health care system include but are not limited to the OKDHS,
ODMHSAS, OSDH, and Oklahoma medical schools including the University of Oklahoma (OU) and Oklahoma State University (OSU). Many
other for-profit and non-profit health centers are partnering with the OHCA’s efforts some of which include the OKPCA, Tribal/Indian
Health Centers, Indian Health Services, OHA, Oklahoma Chapters of the American Medical Association, OID and numerous private health
carriers for the IO program. Engagement of partner agencies occurs at many levels through the executive staff, management, and
solicited involvement for specific projects where efforts can be streamlined and maximized. It is anticipated that this project will seek
out involvement of partners by invitation to an initial meeting to discuss the opportunity, then following the processes already set forth
by OHCA, convening a large working group, smaller sub-groups tasked with specific solution gathering, and ad hoc discussions. All
workgroups agree to meet monthly, and more frequently if needed. OHCA’s planning and development unit staff of project managers
will develop agenda’s for each meeting (with input from key personnel) and update task lists / action plans accordingly. A website for
distribution of meeting information (i.e. agendas, minutes, action plans, outstanding questions, etc) will be created to ensure
transparency in the design and development process.
Timeframe
The planning phase of each of the three concepts will be developed concurrently. Each of the proposals presented above has its
own timeline tied to the needs of the project. By the end of the planning period the feasibility and cost effectiveness of each proposal
will be identified and ready to begin implementation. The OHCA does not anticipate this project being dependent upon state legislative
action or authority. The development of a model program to integrate care for dual eligible individuals is operational in nature and
considered within the scope of the OHCA. At the time the program is fully developed and implemented, should additional state funds be
necessary, a budget request will be submitted to the state legislature for review, approval and appropriations.
Budget and use of funds
Concept #1- Initial Budget Estimates – Note: OHCA will enter into a sub-recipient relationship with OU/Tulsa for these efforts. The
total $339,120.00 will be reflected as a contractual cost to OHCA. This detail of OU/Tulsa activities is provided for the reviewer’s
information.
1. Project Manager – 1.0 FTE, dedicated to facilitation of the entire planning process over a 12 month period. Salary and fringe at $
90,000.
2. Medical Director Oversight -0.25 FTE physician to provide medical oversight of the planning process. Salary and fringe at $
50,000.
3. Data management, aggregation, analysis – 1.0 FTE dedicated to working with Medicare, SoonerCare and area providers to identify
high risk patients, utilization and quantify baseline data and systems for tracking changes in utilization and quality indicators.
Salary and fringe at $ 90,000.
4. Travel and Consultation – Fund to travel to CMS - Center for Medicare and Medicaid Innovation and Center for Medicare and
Medicaid Integration 4 to 7 times over the 12 month period. $ 14,000.
5. Focus Groups – Fund to advertise and provide support for community-based focus groups for design of THIZ / ACO. $ 20,000
6. Design meetings, planning, and documentation - $50,000
7. Direct and indirect costs for data management and analysis $25,120
Estimate of Funding Total - $ 339,120
Concept #2- Initial Budget Estimates –
1. Project Coordinator – 1.0 FTE, dedicated to implementing project goals over the life of this demonstration. Salary and fringe at
$90,000.
2. Behavioral Health Specialist – 1.0 FTE, dedicated to addressing the special needs of our target population with mental health
issues. Salary and fringe at $55,000.
3. Health Insurance Specialist – 1.0 FTE, dedicated to the development of an IP product to meet the needs of our dual eligible
product. Salary and fringe at $55,000.
4. Consultant Contract for data analysis- $263,480.
5. Travel and Consultation – Funds to travel to CMS meetings 4 to 7 times over the 12 month period. $14,000
Oklahoma Proposal
Page 9 of 10
State Demonstration to Integrate Care for Dual Eligible Individuals
Oklahoma Proposal
February 1, 2011
6.
Planning meetings – Funds to advertise, rent space and provide support for community-based focus and work groups. $ 50,000
Estimate of Funding Total - $ 527,480.
Concept #3-Initial Budget Estimates –
7. Project Assistant – 1.0 FTE, dedicated to assisting the Project Coordinator in implementing project goals over the life of this
demonstration. Salary and fringe at $45,000.
8. Travel and Consultation – Funds to travel to CMS meetings and statewide recruitment and informational meetings. $32,000.
9. Focus/Work Groups – Funds to advertise, rent space and provide support for community-based focus/work groups. $ 50,000
Estimate of Funding Total - $ 127,000.
Category
$50,400.00
1 FTE - behavioral health specialist @ $30,800.00
$30,800.00
1 FTE - health insurance specialist @ $30,800.00
$30,800.00
Concept #3
1 FTE - project assistant @ $25,200.00
$25,200.00
Fringe Benefits
Total Personnel
Costs
44% per position
Concept #1
Sub-recipient Contract with OU/Tulsa
Concept #2
Travel
$107,800.00
$245,000.00
1 FTE - project manager @ $50,400.00
$50,400.00
.25 FTE - medical director @ $112,000.00
$28,000.00
1 FTE- data management analyst @ $50,400.00
$50,400.00
Fringe Benefits estimated @ 44%
$101,200.00
Personnel Costs for OU/Tulsa
$2,000 - $3,500 person x 4 trips for consultation
meetings.
$230,000.00
$14,000.00
Focus groups
$20,000.00
Design meetings, planning, and documentation
$50,000.00
Direct and indirect costs calculated @ 8%
$25,120.00
Total Contract Amount
$339,120.00
Consultant Contract for Data Analysis
$263,480.00
Total Contracts
$602,600.00
Concept #2
$3,500 per person x 4 trips for consultation meetings.
$14,000.00
Concept #3
$3,500 per person x 4 trips for consultation meetings.
$14,000.00
Additional Travel
For in state recruitment and research
$18,000.00
Total Travel Costs
Focus
Groups and
Planning
Meetings
Total
1 FTE - project coordinator @ $50,400.00
Contracts
Personnel
Concept #2
Explanation
$46,000.00
Concept #2
Focus groups and planning meetings
$50,000.00
Concept #3
Focus groups and planning meetings
$50,000.00
Total Focus Groups and Planning Meetings
Total Funding Requested
Oklahoma Proposal
$100,000.00
$993,600.00
Page 10 of 10