SoonerCare 1115
Waiver Evaluation:
Final Report
January 2009
James Verdier, JD
Margaret Colby, MPP
Debra Lipson, MHSA
Samuel Simon, PhD
Christal Stone, MPH
Thomas Bell, MBA
Vivian Byrd, MPP
Mindy Lipson
Victoria Pérez
Submitted to:
Oklahoma Health Care Authority
4545 N. Lincoln Blvd., Suite 124
Oklahoma City, OK 73105
Project Officer:
Beth Van Horn
Submitted by:
Mathematica Policy Research, Inc.
600 Maryland Ave. S.W., Suite 550
Washington, DC 20024-2512
Telephone: (202) 484-9220
Facsimile: (202) 863-1763
Project Director:
Jim Verdier
CONTENTS
Chapter Page
FINAL EVALUATION SUMMARY ……………………………………………………………… xiii
I INTRODUCTION …………………………………………………………………………………………….1
I INTRODUCTION …………………………………………………………………………………………….1
A. PURPOSE ………………………………………………………………………………………………….1
B. METHODS ………………………………………………………………………………………………..2
II SOONERCARE PROGRAM STRUCTURE AND HISTORY ……………………………….5
A. INTRODUCTION ………………………………………………………………………………………5
A. INTRODUCTION ………………………………………………………………………………………5
B. THE ORIGIN AND EARLY YEARS OF SOONERCARE: 1992 TO 1996 ………6
1. Search for a Solution to Burgeoning Medicaid Costs, 1992 and 1993 …………6
2. No Expansion of Medicaid Eligibility in Original SoonerCare Waivers………8
3. The Oklahoma Health Care Authority …………………………………………………….8
4. The SoonerCare Managed Care Program ………………………………………………..9
5. 1997 Evaluation of Initial Implementation of SoonerCare ……………………….14
6. Coverage of the Aged, Blind, and Disabled (ABD) Populations ………………14
C. DEVELOPMENT AND EXPANSION OF MANAGED CARE:
1997 TO 2003 …………………………………………………………………………………………..15
1. Continued Development of SoonerCare Plus …………………………………………15
2. Continued Development of SoonerCare Choice ……………………………………..17
3. Expansion of Medicaid Eligibility in 1997 …………………………………………….18
4. Transition of ABD Populations to SoonerCare ………………………………………18
5. Capitated Rate-Setting for the ABD Populations in SoonerCare Plus………..19
6. Increasing Medicaid Budget Pressures in 2002 and 2003 ………………………..20
7. Rising Costs in SoonerCare Plus ………………………………………………………….21
8. Positive Results in SoonerCare Choice ………………………………………………….23
9. End of SoonerCare Plus ………………………………………………………………………23
D. ENHANCING THE PCCM MODEL AND EXPANDING COVERAGE:
2004 TO 2008 …………………………………………………………………………………………..25
1. A New Era for SoonerCare Choice ……………………………………………………….25
2. Comparison with Enhanced PCCM Programs in Other States ………………….27
II (continued)
3. Health Management Program ………………………………………………………………27
4. SoonerCare Choice Next Steps?Toward a ?Medical Home? Model ………….28
5. Expanding Coverage for Uninsured Children and Adults ………………………..30
6. American Indians and SoonerCare ……………………………………………………….33
E. OHCA STRUCTURE, MANAGEMENT, AND COMMUNICATIONS …………37
1. OHCA Structure and Governance ………………………………………………………..37
2. OHCA Organization and Management ………………………………………………….37
3. Advances in Information Technology……………………………………………………37
4. OHCA Communications ……………………………………………………………………..38
III OUTCOMES AND TRENDS WITHIN OKLAHOMA?S SOONERCARE
PLUS AND CHOICE PROGRAMS ………………………………………………………………….41
A. SOONERCARE WAIVER MEMBERS? ACCESS TO PRIMARY CARE ………41
1. Provider Participation …………………………………………………………………………42
2. Hospitalizations for Ambulatory Care Sensitive Conditions (Preventable
Hospitalizations) ………………………………………………………………………………..50
3. Emergency Room Utilization Trends ……………………………………………………64
B. EFFECTS OF MEDICAID ELIGIBILITY EXPANSIONS ON
SOONERCARE ENROLLMENT, PARTICIPATION RATES, AND
INSURANCE COVERAGE ……………………………………………………………………….66
1. Data and Methods ………………………………………………………………………………67
2. Results ………………………………………………………………………………………………69
C. SOONERCARE CHOICE: QUALITY MEASURES AND MEMBER
SATISFACTION ………………………………………………………………………………………77
1. Data Sources and Methods …………………………………………………………………..78
2. Results ………………………………………………………………………………………………79
D. SOONERCARE FINANCIAL OUTCOMES ……………………………………………….83
1. Per-Member Costs ……………………………………………………………………………..85
2. State Expenditures and Revenue …………………………………………………………..88
E. TRENDS IN PRIMARY CARE UTILIZATION AND HEALTH CARE
STATUS AMONG LOW-INCOME OKLAHOMANS ………………………………….9
IV MAJOR FINDINGS ………………………………………………………………………………………103
A. ACCESS ………………………………………………………………………………………………..103
1. Health Insurance Coverage ………………………………………………………………..103
2. Physician Participation ………………………………………………………………………104
3. Emergency Room (ER) Visits ……………………………………………………………105
4. Preventable Hospitalizations ………………………………………………………………106
5. Primary Care Utilization Among Low-Income Oklahomans ………………….106
B. QUALITY ………………………………………………………………………………………………107
1. HEDIS …………………………………………………………………………………………….107
2. CAHPS ……………………………………………………………………………………………108
3. ECHO ……………………………………………………………………………………………..108
4. Health Care Status Among Low-Income Oklahomans …………………………..108
C. COST …………………………………………………………………………………………………….108
D. OHCA PERFORMANCE …………………………………………………………………………109
V LESSONS AND IMPLICATIONS FOR OTHER STATES ………………………………..113
A. PROGRAM DESIGN AND MANAGEMENT……………………………………………113
1. Managed Care Organizations (MCOs) vs. In-House Care Management …..113
2. General Program Design ……………………………………………………………………113
3. Ongoing Performance Measurement …………………………………………………..114
4. Approach to Client Service ………………………………………………………………..115
B. AGENCY MANAGEMENT …………………………………………………………………….116
C. RELATIONSHIPS WITH EXTERNAL STAKEHOLDERS ………………………..117
APPENDIX A: COMPLETED INTERVIEWS
APPENDIX B: ADDITIONAL QUANTITATIVE ANALYSES
II.1 OKLAHOMA POLITICAL CONTEXT, 1992 TO 2009 ………………………………………. 7
II.2 STATES WITH MEDICAID PCCM AND/OR MCO PROGRAMS IN 1992-1996 .. 10
II.3 OKLAHOMA SOONERCARE PLUS MCO REGIONS AND YEARS OF
SERVICE ……………………………………………………………………………………………………… 13
II.4 OKLAHOMA SOONERCARE PLUS MCO CHARACTERISTICS ……………………. 16
II.5 OKLAHOMA MEDICAID ELIGIBILITY INCOME LEVELS RELATIVE TO
FEDERAL POVERTY STANDARDS AND OTHER STATES ………………………….. 34
III.1 SOONERCARE PLUS AND CHOICE PRIMARY CARE PROVIDER (PCP)
CONTRACTS BY TYPE AND REGION, 1997-2007 ………………………………………… 45
III.2 SOONERCARE PLUS AND CHOICE PCP CONTRACTS TURNOVER RATE,
1997-2007 ……………………………………………………………………………………………………… 46
III.3 TOTAL PANEL ASSIGNMENTS BY PCP CONTRACT TYPE AND REGION,
1997-2007 ……………………………………………………………………………………………………… 47
III.4 SERVICES COVERED BY THE SOONERCARE CHOICE PARTIAL
CAPITATION RATE: DISTRIBUTION OF ENCOUNTERS PROVIDED
TO MEMBERS BY CONTRACT BY REGION, 1997-2007 ………………………………. 48
III.5 SOONERCARE CHOICE PCPS BY TYPE AND REGION, 2004-2007 ……………… 50
III.6 SOONERCARE CHOICE PCP PARTICIPATION RATES AMONG PRIMARY
CARE SPECIALISTS, 2004-2006 ……………………………………………………………………. 51
III.7 SOONERCARE CHOICE PARTICIPATION RATES AMONG ALL MDS,
2004-2006 ……………………………………………………………………………………………………… 52
III.8 MATCHED INPATIENT HOSPITALIZATIONS AMONG SOONERCARE
PLUS AND CHOICE MEMBERS, 2002-2006 ………………………………………………….. 53
III.9 STANDARDIZED RATES OF PREVENTABLE HOSPITALIZATIONS PER
100,000 AMONG ADULT (AGES 20 TO 64) SOONERCARE MEMBERS WITH
AT LEAST THREE MONTHS CONTINUOUS ENROLLMENT IN THE
CALENDAR YEAR, 2002-2006 ……………………………………………………………………… 54
III.10 STANDARDIZED RATES OF PREVENTABLE HOSPITALIZATIONS PER
100,000 AMONG SOONERCARE MEMBERS AGES 20 TO 44 WITH AT
LEAST THREE MONTHS CONTINUOUS ENROLLMENT IN THE
CALENDAR YEAR, 2002-2006 ……………………………………………………………………… 56
III.11 STANDARDIZED RATES OF PREVENTABLE HOSPITALIZATIONS PER
100,000 AMONG SOONERCARE MEMBERS AGES 45 TO 64 WITH AT
LEAST THREE MONTHS CONTINUOUS ENROLLMENT IN THE
CALENDAR YEAR, 2002-2006 ……………………………………………………………………… 57
III.12 STANDARDIZED RATES OF PREVENTABLE HOSPITALIZATIONS PER
100,000 AMONG ADULT (AGES 20 TO 64) FEMALE SOONERCARE
MEMBERS WITH AT LEAST THREE MONTHS CONTINUOUS
ENROLLMENT IN THE CALENDAR YEAR, 2002-2006 ………………………………… 58
III.13 STANDARDIZED RATES OF PREVENTABLE HOSPITALIZATIONS PER
100,000 AMONG ADULT (AGES 20 TO 64) MALE SOONERCARE
MEMBERS WITH AT LEAST THREE MONTHS CONTINUOUS
ENROLLMENT IN THE CALENDAR YEAR, 2002-2006 ………………………………… 59
III.14 STANDARDIZED RATES OF PREVENTABLE HOSPITALIZATIONS PER
100,000 AMONG SOONERCARE MEMBERS AGES 0 TO 19 WITH AT
LEAST THREE MONTHS CONTINUOUS ENROLLMENT IN THE
CALENDAR YEAR, 2002-2006 ……………………………………………………………………… 60
III.15 STANDARDIZED RATES OF PREVENTABLE HOSPITALIZATIONS PER
100,000 AMONG MALE SOONERCARE MEMBERS AGES 0 TO 19 WITH AT
LEAST THREE MONTHS CONTINUOUS ENROLLMENT IN THE
CALENDAR YEAR, 2002-2006 ……………………………………………………………………… 60
III.16 STANDARDIZED RATES OF PREVENTABLE HOSPITALIZATIONS PER
100,000 AMONG FEMALE SOONERCARE MEMBERS AGED 0-19 WITH
AT LEAST THREE MONTHS CONTINUOUS ENROLLMENT IN THE
CALENDAR YEAR, 2002-2006 ……………………………………………………………………… 61
III.17 TRENDS IN PREVENTABLE HOSPITALIZATION RATES IN OKLAHOMA
VS. OVERALL U.S. POPULATION ……………………………………………………………….. 62
III.18 SOONERCARE AVERAGE MONTHLY ENROLLMENT BY MEDICAID
ELIGIBILITY GROUP, 1997-2007 ………………………………………………………………….. 70
III.19 ESTIMATED MEDICAID PARTICIPATION RATES IN OKLAHOMA, 2000
AND 2006 …………………………………………………………………………………………………….. 73
III.20 SOURCE OF INSURANCE FOR NON-ELDERLY INDIVIDUALS IN
FAMILIES EARNING UP TO 200 PERCENT OF FPL: OKLAHOMA
AND U.S., 1995-2007 …………………………………………………………………………………….. 75
III. 21 CHANGE IN SOURCE OF INSURANCE COVERAGE FOR
NON-ELDERLY INDIVIDUALS IN FAMILIES EARNING UP TO 200
PERCENT OF FPL, OKLAHOMA AND U.S., 1995-2007 …………………………………. 76
III.22 OHCA HEDIS MEASURE PERFORMANCE OVER TIME (2001 ? 2007) AND
IN COMPARISON TO NATIONAL MEDICAID MEANS ………………………………… 80
III.23 SOONERCARE CHOICE CAHPS ADULT SURVEYS AND COMPARISON
WITH NATIONAL MEDICAID BENCHMARKS ……………………………………………. 82
III.24 SOONERCARE CHOICE CAHPS CHILD SURVEYS AND COMPARISON
WITH NATIONAL MEDICAID BENCHMARKS ……………………………………………. 83
III.25 2003 ? 2005 SOONERCARE CHOICE ECHO RATINGS (CHILDREN) ……………. 84
III.26 2004 ? 2007 SOONERCARE CHOICE ECHO RATINGS (ADULTS) ………………… 84
III.27 PER-ENROLLEE MEDICAID EXPENDITURES AND AVERAGE
ANNUAL GROWTH RATE BY ELIGIBILITY GROUP, FISCAL
YEAR 1999-2005. ………………………………………………………………………………………….. 89
III.28 CHARACTERISTICS OF LOW-INCOME ADULTS IN OKLAHOMA,
1995-2007 ……………………………………………………………………………………………………… 93
III.29 PERCENTAGE OF LOW-INCOME OKLAHOMAN ADULTS IN
HOUSEHOLDS WITH CHILDREN RECEIVING ROUTINE CHECKUPS,
BY HEALTH CARE COVERAGE STATUS AND PRIMARY CARE
PROVIDER ACCESS, BRFSS 2007 ………………………………………………………………… 95
II.1 BASIC PCCM TO MEDICAL HOMES TRENDS FROM 1990 TO 2008 ……………. 29
III.1 RATIO OF EMERGENCY ROOM TO OFFICE VISITS, BY YEAR …………………… 67
III.2 95TH PERCENTILE: ER TO OFFICE VISIT RATIO, BY YEAR ……………………… 68
III.3 SOONERCARE ENROLLMENT TRENDS, 1997-2007 ……………………………………. 71
III.4 MEDICAID PAYMENTS PER ENROLLEE (ADULTS AND CHILDREN),
FISCAL YEARS 1996-2005 ……………………………………………………………………………. 86
III.5 MEDICAID PAYMENTS PER ENROLLEE (AGED AND DISABLED),
FISCAL YEARS 1996-2005 ……………………………………………………………………………. 87
III.6 PERCENTAGE GROWTH IN STATE REVENUES AND EXPENDITURES
ON MEDICAID, OKLAHOMA VS. NATIONAL AVERAGE, 1996-2006 ………….. 90
III.7 PERCENTAGE OF TOTAL STATE EXPENDITURES ON MEDICAID,
1995-2006 ……………………………………………………………………………………………………… 91
III.8 PERCENTAGE OF LOW-INCOME ADULTS IN OKLAHOMA REPORTING
THAT THEY HAVE A PERSONAL HEALTH CARE PROVIDER, BRFSS
2001-2007 ……………………………………………………………………………………………………… 94
III.9 PERCENTAGE OF LOW-INCOME ADULTS IN OKLAHOMA WHO DID
NOT SEE A DOCTOR BECAUSE OF COST, BRFSS 1995-2007 ……………………… 94
III.10 PERCENTAGE OF LOW-INCOME ADULTS IN OKLAHOMA RECEIVING
A RECENT CHECKUP, BRFSS 1995-2007 ……………………………………………………… 96
III.11 PERCENTAGE OF LOW-INCOME ADULTS IN OKLAHOMA RECEIVING
A FLU SHOT WITHIN THE PAST YEAR, BRFSS 1995-2007 ………………………….. 98
III.12 PERCENTAGE OF LOW-INCOME ADULTS IN OKLAHOMA REPORTING
EXCELLENT, VERY GOOD, OR GOOD OVERALL HEALTH STATUS,
BRFSS 1995-2007 ………………………………………………………………………………………….. 99
III.13 PERCENTAGE OF LOW-INCOME ADULTS IN OKLAHOMA REPORTING
ZERO POOR MENTAL HEALTH DAYS AND THE MEAN NUMBER OF
POOR DAYS REPORTED AMONG THOSE WITH SOME POOR DAYS,
BRFSS 1995-2007 ………………………………………………………………………………………… 100
III.14 PERCENTAGE OF LOW-INCOME ADULTS IN OKLAHOMA REPORTING
ZERO POOR PHYSICAL HEALTH DAYS AND THE MEAN NUMBER OF
POOR DAYS REPORTED AMONG THOSE WITH SOME POOR DAYS,
BRFSS 1995-2007 ………………………………………………………………………………………… 101
FINAL EVALUATION SUMMARY
In 1993, the Oklahoma Health Care Authority (OHCA) was created by statute and charged
with reforming Oklahoma?s Medicaid program. OHCA?s charter was to implement a statewide
managed care model that would control costs and improve care for Medicaid enrollees. During
the subsequent 15 years, OHCA substantially modified the Medicaid program, called
SoonerCare, through a Section 1115 waiver that uses managed care approaches to serve most
non-elderly enrollees. Through the waiver, OHCA first implemented fully capitated services in
urban areas (SoonerCare Plus) and then a partially capitated primary care case management
(PCCM) program (SoonerCare Choice) in rural areas, before extending SoonerCare Choice
throughout the state in 2004.1 Over time t
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