SoonerCare 1115 Waiver Evaluation: Final Report Part 1

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
A. PURPOSE ………………………………………………………………………………………………….1
B. METHODS ………………………………………………………………………………………………..2 
 II SOONERCARE PROGRAM STRUCTURE AND HISTORY ……………………………….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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