Health Plans
Health Plans interested in making value-based payments to clinics that have achieved PCPCH recognition may access the file below.
The password for this file was updated on 12/31/2021. Please contact us at PCPCH@oha.oregon.gov with your name, title, and organization to request access.
Aligning Payment with Quality
Primary care is the front line of Oregon’s health system, and the Oregon Health Authority (OHA) is working with public and commercial payers across the state on payment reform initiatives that move from volume to value and away from fee-for-service. In 2015 the Oregon legislature signaled its commitment to primary care payment reform by enacting Senate Bill 231. This legislation mandated the following:
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Primary Care Spending Report: OHA and the Department of Consumer and Business Services (DCBS) report the percent of health care expenditures allocated to primary care by prominent carriers, Coordinated Care Organizations and PEBB/OEBB.
- Primary Care Payment Reform Collaborative: The objective of the collaborative is to allow participants to share best practices that support innovation and improvement in primary care and to work together to seek alignment and agreement around primary care reimbursement to help improve population health, patient care, and control health care costs across Oregon. This collaborative is building on previous consensus-based strategies agreed to by payers and other key partners convened by OHA and the Oregon Health Leadership Council in 2013.
Value-Based Payments to PCPCH Clinics
The following payers are making value based payments to recognized PCPCH clinics in Oregon. If your Health Plan would like to be included on this list please email PCPCH@oha.oregon.gov
Public Employees' Benefit Board
The Public Employee's Benefit Board (PEBB) provides an age-adjusted, per-member-per-month incentive payment to recognized primary care homes in the PEBB Statewide plan, administered by Providence Health Plan. In addition, PEBB members in the PEBB Statewide plan have lower cost share for primary care services when they access care through a recognized primary care home - from 15 to 10 percent.
Coordinated Care Organizations
Many Coordinated Care Organizations (CCO) across Oregon are offering innovative payment incentives to recognized Patient-Centered Primary Care Homes.
Beginning in 2020, CCOs have been required to provide per-member-per-month (PMPM) payments to their PCPCH clinics as a supplement to any other payments made to PCPCHs, such as fee-for-service or VBPs. PMPMs will vary by PCPCH tier level and increase each year over a five-year contract.
Aetna
Aetna's Patient Centered Medical Home (PCMH) recognition program offers per-member-per-month payment incentives using the PCPCH tiers, and is available to physician practices in Oregon that meet certain criteria: Directly contracted with Aetna; Received recognition by the NCQA or by the State of Oregon Patient-Centered Primary Care Home program as a PCPCH; Have 10 or more attributed Aetna members; and be reimbursed at 100% of the Aetna Market Fee Schedule (AMFS)