Changes in Payment Structure

Prior to January 1, 2009 OHCA paid each SoonerCare Choice PCP a fixed monthly capitated payment for case management and a limited set of primary care services. 

According to the Patient Centered Primary Care Collaborative (PCPCC) the key to implementing the Patient Centered Medical Home (PCMH) model is aligning incentives through an enhanced reimbursement system that is structured to recognize the cost of performing the functions of a medical home. Ideally, compensation to the practice takes the shape of the following:

  • A monthly care coordination payment (bundled care coordination fee) for the physician work that falls outside of a face-to-face visit and for the health information technologies needed to achieve better outcomes. Bundling of services into a monthly fee removes volume-based incentives and promotes efficiency. The prospective nature of the payment recognizes the up-front costs to maintain the required level of care. Care coordination payments should be risk-adjusted to ensure that there are no inherent incentives to avoid the treatment of the more complex, costly patients.
  • A visit-based fee-for-service component that recognizes visit-based services that are currently paid under the present fee-for-service payment system and maintains an incentive for the physician to see the patient in an office-visit when appropriate.
  • A performance-based component that recognizes achievement of quality and efficiency goals.

As of January 1, 2009, all of these components were implemented under the new system. Transition payments were available to assist some providers with the shift from capitation payments to fee-for-service.