The Michigan Primary Care Transformation ( MiPCT ) Project

1. The Michigan Primary Care Transformation (MiPCT) Project Annual Summit October 2013 MiPCT Overview and Updates

2. Objectives • Recap MiPCT Overview and 2013/14 Focus Areas • Review MiPCT Project Evaluator Findings to Date • Discuss Project Sustainability

3. MiPCT Overview Jean Malouin

4. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • Centers for Medicare & Medicaid Services is participating in state-based PCMH demonstrations • Assessing effect of different payment models • CMS Demo Stipulations • Must include Commercial, Medicaid, Medicare patients • Must be budget neutral over 3 years of project • Must improve cost, quality, and patient experience • 8 states selected for participation, including Michigan • Michigan start date: January 1, 2012

5. Participants • 380 practices • 35 POs • 1,500 physicians • 1 million patients • 5 Payers • Medicare • Medicaid managed care plans • BCBSM • BCN • Priority Health (7/13)

6. MiPCT Funding Model $0.26 pmpm Administrative Expenses $3.00 pmpm*, **Care Management Support $1.50 pmpm*, **Practice Transformation Reward $3.00 pmpm*, **Performance Improvement $7.76 pmpm Total Payment by non-Medicare Payers*** * Or equivalent ** Plans with existing payments toward MiPCT components may apply for and receive credits through review process *** Medicare will pay additional $2.00 PMPM to cover additional services for the aging population

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8. MiPCT Mid-Point: Statewide Care Management Progress to Date • Over 300 Care Managers hired and trained • Building infrastructure in partnership with POs • CM Documentation tools • Ongoing Care Manager training, coaching, mentoring • Patient education materials • Communication- PCP, CM, staff members • Interface with community resources • Building volume of G code and CPT codes submitted • Building caseloads of targeted high-risk patients

9. Multi-Payer Claims Database • Collect data from multiple Payers and aggregate it together in one database • Creates a more complete picture of a patient’s information when they: • Receive benefits from multiple insurance carriers • Visit physicians from different Practices, Physician Organizations or Hospitals • Phase 1 – claims data • Phase 2 - claims and clinical data MiPCT BCN Medicaid BCBSM Medicare Multi-Payer Claims Database

10. MDC: MiPCT Dashboards • Population • Membership • Attributed members by Payer • Risk Information • # of members by Risk Level • Population Information • # patients by Chronic Condition (Asthma, CKD, CHF, etc) • Quality Measures • Screening and Test Rates • Diabetes tests, Cancer Screens, etc • Prevention • Immunization Rates, Wellness Visits, etc. • Comparison to Benchmarks • Utilization Measures • Rates • ED Use, Admissions, Re-admissions, etc • Comparison to Benchmarks

11. Admission, Discharge, Transfer MiPCT Data Flow and Progress • 17 POs participate in the “Spotlight” MiPCT offering (at no cost to PO) with opportunity for additional POs to join (by October 30, 2014) • Allows care managers direct access to member lists via web interface • ADT notifications adding for Trinity, Henry Ford, and Beaumont!

12. 2013-2014 Priorities • Care managers fully integrated into practices • Target PCMH interventions to patients from all participating payers • Distribute multi-payer lists and dashboards • Ensure care management for at risk members • Use registry for proactive population management • Focus on efficient and effective health care • Avoid unnecessary services/hospitalizations • Assess practice utilization patterns • Ensure adequate clinic access to meet demands

13. How will CMS define success? The tie to budget neutrality and ROI 13

14. MiPCT Brief Review: Balancing Successes and Challenges Successes Challenges • Success on cost, quality and utilization measures is key to sustainability • Member lists vs. the population • G and CPT code billing and “throughput” • PO and practice infrastructure varies • Many competing priorities • Champions abound; We have gained traction! • Michigan is well-poised compared to other states despite its broad scale • Hard-working, dedicated people • Multi-payer Database • Strong PCMH foundation

15. www.mipctdemo.org

16. MiPCT Evaluation Update Clare Tanner

17. Objectives • MiPCT Investment in PCMH • Care Management Implementation • Quality/Utilization

18. MiPCT Practices

20. Financial Investment, 2012 • New money includes: Medicaid, Medicare, BCN g-code payments, BCBSM g-code + make whole payments • Total adds in: BCBSM Practice transformation (E&M uplift) of $19 million, but does not include incentive payments

22. 70% have 1 practice • 23% have 2-4 practices • 7% have 5 or more practices

23. Care Manager Volume Quarter 2, 2013

24. Care Manager Survey • Conducted in May 2013 • 434 care managers asked to complete survey • 53% completed the survey (n=228)

25. Care Manager Survey Results Physician Interaction • Care Managers reported working with an average of 8.4 physicians • On average, 83% of these physicians referred patients

26. Care Manager Survey Results

27. Care Manager Survey Results

28. Care Manager Survey Results

29. Care Manager Survey Results

30. Care Manager Survey Results • The physician(s) I work with support the concepts of the MiPCT care management team.

31. Care Manager Survey Results • Physicians are available on a daily basis to address questions related to management of MiPCT patients.

32. Care Manager Survey Results • Physicians understand and are actively involved in population management

33. Care Manager Survey Results • Top 3 broad areas of challenge • Care Manager Challenges • Need for work flow processes • Need for practice team support/understanding of CM role • Time management • Care Management Embedment • Need for practice staff education on CM role and process workflows • CMs serving multiple practices or working as a CM part time • Physician Engagement

34. Care Manager Survey Results • Top 3 broad areas of success • Development of Process Improvement • Transition of Care • Using the MiPCT List • Reviewing the practice schedule regularly • Culture Change within the Practice • Physician engagement • Reviewing potential patients with the provider/use of huddles • Practice staff understanding of the CM role • Advanced/Improved IT Capabilities

35. Cost, Quality and UtilizationNational and State Metrics

36. Utilization and Cost Metrics: MI and National Evaluations are Consistent • Total PMPM Costs • Medicare Payments (National) • Utilization based standardized cost calculations across all participating payers (Michigan) • Additional analysis of cost categories • Utilization • All-cause hospitalizations • Ambulatory care sensitive hospitalizations • All-cause ED visits • ‘Potentially preventable’ ED visits

37. Michigan Diabetes Asthma Hypertension Cardiovascular Obesity Adult preventive care Child preventive care Childhood lead screening (Medicaid) Patient experience (CAHPS) Provider/staff experience Quality and Experience of Care Metrics:MI and National Evaluations are Different, But Share Common Elements National Diabetes care: • LDL-C screening • HbA1c testing • Retinal eye examination • Medical attention for nephropathy • All 4 diabetes tests • None of the 4 diabetes tests Ischemic Vascular Disease: • Total lipid panel test Patient experience (CAHPS)

38. Cost, Quality and UtilizationInitial Results (Year One)

39. MiPCT Number of POs with Quality Rate Changes MiPCT Number of POs with Quality Rate Changes

40. MiPCT Number of POs with Quality Rate Changes MiPCT Number of POs with Quality Rate Changes

41. MiPCT 2012 PCS ED Rate per 1000 ED VisitsPercent Change from 2011 Baseline Rate by PO MiPCT Overall

42. MiPCT Post-Demonstration Funding and Sustainability Diane Marriott

43. What Does Sustainability Mean? • To the Health Plan: Added value for their customers • To the Practice: Maintaining and growing CM staffing, processes and roles • To the PO: Payment reform for CM

44. CMS Complex Care Management Post-Demo Payment Proposal • Good News! CMS Physician Fee Schedule included proposed codes for Complex Care Management quarterly payment beginning 1/1/2015. • MiPCTsubmitted comments on this constructive development, focusing on: • Discouraging CMS from imposing patient financial responsibility for care management services • Recognizing alternative designations (e.g., PGIP PCMH) for medical home definition • Removing the requirement that the practice employ an advanced care nurse or PA (NP or PA) and streamlining requirements for electronic all-provider communication, annual patient consent, etc.

45. Payer Sustainability "As participating Michigan Primary Care Transformation Project (MiPCT) payers, we recognize the value of care management embedded in primary care practices.  We applaud CMS' recent payment proposal to continue funding for complex care coordination after the December 31, 2014 ending period of the demonstration project.  We support continuation of this model of care to produce improvements in patient experience, quality and the value of care. We look forward to working together with the partnership of the MiPCT, the plans and the health care providers in improving Michigan's primary care system."

46. Sustainability Progress • Addition of Priority Health • State Innovation Model (SIM) • Medicaid • Milbank Fund Advocacy • ROI PO Subgroup financial modeling

47. PO Primary Care Sensitive Emergency Department Use (Change from 1/1/12 to 12/31/12) No Improvement • For POs with Stat. Sig. Better Performance, Amt. of Change • Over 12%---2 POs • 8-12%-------4 POs • 5-8%---------3 POs • Under 5% --11 POs Improved (not stat. sig.) Overall, from 2012 to 2013, the MiPCT decreased avoidable emergency visits decreased almost 4%.

48. We ARE the MiPCT! We can do this together! We can make care better!

49. Questions?