Episode-Based Payment Model
The Ohio SIM project plans to use an episode-based payment model in combination with PCMH implementation to strengthen the foundation for total cost of care and accountability. This payment model, outlined in the state's Episode-Based Payment Charter, encourages coordinated and cost effective care by holding a single provider or entity accountable for all services provided over a certain episode of care rather than specific visits or procedures.
In March 2016 the state reported on 13 episodes including a perinatal episode and asthma acute exacerbation. Ohio will design episodes for both behavioral and physical health in 2016 that will be launched in 2017. The goal is to have up to 50 episodes in a multi-payer environment by the end of the SIM grant.
Ohio's Office of Health Transformation has also standardized quality measures across multiple payers for PCMH and episode-based payment models. The list of measures addresses preventive care, appropriate care, and behavioral health and encompasses both pediatric and adult populations. Examples of pediatric-related measures include the following:
- Well-child visits in the first 15 months as well as 3, 4, 5, and 6 years of age
- Adolescent well-care visits
- Weight assessment and counseling for nutrition and physical activity for children and adolescents
- Medication management for asthma
- Follow up after hospitalization for mental illness
- Preventive care and screening for tobacco use; screening and cessation intervention
Only metrics that can be measured through claims data will be used in the initial rollout of PCMH. Over time, as the PCMH matures, hybrid measures will be required. The goal of creating core quality measures is to define, measure, track and pay for quality in ways that create value for all stakeholders and to reduce the reporting burden for providers.