buffy l. heater, mph director of planning & development oklahoma health care authority
DESCRIPTION
COORDINATING CARE FOR MEMBERS DUALLY ELIGIBLE FOR MEDICARE AND SOONERCARE: EXPLORING A NEW FRONTIER. Buffy L. Heater, MPH Director of Planning & Development Oklahoma Health Care Authority. 1. Oklahoma Dual Eligible Population. 2. SoonerCare 727,369. Medicare 607,465. Duals 104,538. - PowerPoint PPT PresentationTRANSCRIPT
COORDINATING CARE FOR MEMBERS DUALLY ELIGIBLE FOR MEDICARE AND SOONERCARE:EXPLORING A NEW FRONTIER
Buffy L. Heater, MPHDirector of Planning & Development
Oklahoma Health Care Authority
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Oklahoma Dual Eligible Population
DualsDuals104,538104,538
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Source: SoonerCare data as of June 2011
MedicareMedicare607,465607,465
SoonerCareSoonerCare727,369727,369
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Dual Eligibles by Race
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Dual Eligible Population by Gender
•66,308 Females•39,224 Males
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Dual Eligibles by Region
Source: SoonerCare data as of June 2011Heater 5
Dual Eligible Reimbursement by Quarter
Source: OHCA Fast Facts March 2011Heater
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Per Member Per Month Cost (monthly average per quarter)
Heater 7Source: OHCA Fast Facts March 2011
Reasonable Conclusions
• Services for the Duals are expensive as they require extensive care.
• Care being rendered between two programs results in fragmented and uncoordinated care.
• Care coordination would be a valuable added service.– Improved quality of care – Positive budget impact
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Original Proposal• OHCA envisioned establishing a state-operated
benefit plan for duals, in lieu of Medicare• OHCA would have been responsible for ALL CARE of
duals, demonstrating outcomes• Would have required CMS and OHCA to agree upon
a cap rate for dual services• Savings shared between OHCA and CMSBUT…CMS financing models require 3-way contracts
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SoonerCare SilverSoonerCare Silver
Proposal #1Proposal #1
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OHCA Care Management
• Why OHCA should be the solution:– The agency already applies care coordination to
its SoonerCare members.– Adding Care Management to the Duals doesn’t
overwhelm the SoonerCare program.– Spreading our fixed cost over a larger population
should result in lower PMPM costs. (economies of scale)
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Modified Proposal
• OHCA “sells” our proven and effective managed care services for the Dual population to CMS.
• Enhance existing care coordination efforts– 7 Regional Nurse Care Management Teams– 1 Health Management Team• Intensive care management for top 5,000
utilizers• Covers wide range of diagnosis
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PACE - Interdisciplinary Care Team
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Proposal #3 - THIZ• University of Oklahoma – Tulsa• School of Community Medicine• Tulsa’s Health Innovation Zone (THIZ)• Create an ACO in Tulsa area serving high cost,
dual eligible patients– Focused on providing payment models that
promote improved patient outcomes and an overall lower cost of care.
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No time like the present…• Data, data, data• Stakeholders• Develop the plan• Stakeholders• Finalize the plan• Stakeholders
And did I mention…stakeholders?
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Oklahoma Resources• Oklahoma Medicaid Program Fast Facts– Opportunities for Living Life Document– http://www.okhca.org/research.aspx?id=87&parts=7447
• Evaluation of Oklahoma’s Medicaid Service Delivery System– Mathematica Evaluation of SoonerCare Choice– http://www.okhca.org/research.aspx?id=10087&parts=7447
• Annual, Performance, and Quality Reports; Strategic Plan – http://www.okhca.org/research.aspx?id=84&parts=7447
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Contact Information
Buffy Heater, MPHDirector of Planning & Development, OHCA(405) [email protected]
Marva WilliamsonProject Manager, Dual Eligible Initiative, OHCA(405) [email protected]
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