On December 15, 2015, Ohio Department of Medicaid Director John McCarthy provided a number of health care organizations, including the Ohio Academy of Family Physicians, with an update on Ohio’s approach to pay for value instead of volume. OAFP Executive Vice President Ann Spicer and Deputy EVP Kate Mahler, CAE, attended the update.
- Provide access to medical homes for most Ohioans
- Use episode-based payments for acute events
- Coordinate health information infrastructure
- Coordinate health sector workforce programs
- Report and measure system performance.
With regard to episode-based payments, 2014’s six episodes were asthma acute exacerbation, chronic obstructive pulmonary disease exacerbation, perinatal, acute and non-acute percutaneous coronary intervention, and joint replacement. In 2015, seven new episodes; upper respiratory infection, urinary tract infection, cholecystectomy, appendectomy, gastrointestinal hemorrhage, esophagogastroduodenoscopy, and colonoscopy were added. In 2016, plans call for the addition of 20 additional episodes, including behavioral health.
Under the episodic-based payment system, physicians will continue to deliver care as they do now. Claims will be submitted the same way and payers will reimburse for all services as they do now. Incentive payments will be calculated based on outcomes after the close of a 12 month performance period. Payers will calculate average risk-adjusted reimbursement per episode and compare to predetermined “commendable” and “acceptable” levels. Physicians can share in savings if average costs are below commendable levels and quality targets are met. If average costs are above “acceptable” level, the physician may owe money back. And those who have average costs between “commendable” and “acceptable” levels will see no impact. Payments for shared savings episodes will be made retrospectively.