Will Groneman Executive Vice President System Development TriHealth

1. Innovation Grant:CMMI Comprehensive Primary Care Initiative (CPCi)presented toHFMA Southwestern Ohio Chapter Will Groneman Executive Vice President System Development TriHealth

2. Comprehensive Primary Care Initiative (CPCi) • What is it? • 4-year pilot program from CMS Innovation Center – CMMI • Authorized under the Accountable Care Act • Funding for 330,750 Medicare and Medicaid beneficiaries

3. Comprehensive Primary Care Initiative (CPCi) • What is it? • 4-year pilot program from CMS Innovation Center – CMMI • Authorized under the Accountable Care Act • Funding for 330,750 Medicare and Medicaid beneficiaries • Designed to accomplish the “triple aim” at the community level • Aligns multiple payers in a community around common goals

4. Comprehensive Primary Care Initiative (CPCi) • What is it? • 4-year pilot program from CMS Innovation Center – CMMI • Authorized under the Accountable Care Act • Funding for 330,750 Medicare and Medicaid beneficiaries • Designed to accomplish the “triple aim” at the community level • Aligns multiple payers in a community around common goals • Aimed at Primary Care Physicians • Builds on the “Medical Home” concept • Holds PCP practices accountable for the total cost of care • Solicitation issued in late September 2011

5. Comprehensive Primary Care Initiative (CPCi) • CMS’ Framework for Comprehensive Primary Care • Risk stratified care management • Access and continuity • Planned care for chronic conditions and preventive care • Patient and caregiver engagement • Coordination of care across the medical neighborhood

6. Four Basic Steps in the Process • Select communities to participate • Number of commercial plans willing to participate • Support of state Medicaid • Community infrastructure and history of collaboration • Seven Communities were selected • Arkansas • Colorado • New Jersey • Oregon • New York Capital District-Hudson Valley Region • Greater Tulsa Region • Cincinnati-Dayton-Northern Kentucky Region • Community selection completed April 2012

7. Four Basic Steps in the Process • Select Communities to participate (April 2012) • Align payers who are willing to commit to: • Payment above normal Fee-for-Service (e.g. pmpm) • CMS pmt will be risk adjusted and will average $20 pmpm • Provide gainsharing opportunities in years 2-3-4 • Common set of metrics for cost, quality, service • Using 18 of the 33 ACO measures as a starting point • Providing aggregate member level cost/utilization data • Signing a Letter of Intent with CMS • Cincinnati had 10 payers commit to participate • Includes Aetna, Anthem, Humana, Medicaid, MMO, United • Payers signed non-binding LOIs in June 2012

8. Four Basic Steps in the Process • Select Communities to participate • Align payers • Select PCP Practice Locations • Practice = physical office location • 75 practices per market to be selected • Screening Criteria: • 150 FFS Medicare patients • Physicians have attested to Meaningful Use • Qualitative Criteria: • >60% of patients are covered by participating payer • Demonstration of readiness to transform • PCMH Recognized • Commitment to transformational activities • Practices to be selected August 2012

9. Year 1 Commitments Required by CMS • Complete an annual budget • Implement risk stratification methodology for all patients • Attest to 24/7 patient access to a nurse or practitioner with access to the patient’s EHR • Establish baseline for patient satisfaction using CG-CAHPs • Demonstrate care coordination for the medical neighborhood and c omply with at least one of the following: • Notification of ED visit in a timely fashion • Med reconciliation completed with 72 hours of hospital discharge • Exchange of clinical information at the time of admission and at discharge • Exchange of clinical information between PCP-specialists • Participate in quarterly market based learning collaborative

10. Four Basic Steps in the Process • Select Communities to participate • Align payers • Select PCP Practice Locations • “Negotiate” with practices and start program • No negotiations with CMS • Expect limited negotiation with plans • Will need to conform with their LOI commitments • Will plans cover TriHealth PCMH sites not selected? • Not clear if “ASO” employers will participate • Go-live November 1, 2012 • 13 months from solicitation to go-live

11. CPCi v. Accountable Care Organization • Focus is on Patient Centered Medical Home (PCMH) as the foundation for managing care • ACO not as prescriptive as to care management strategy • Provides new funding for infrastructure • Focused on adult PCP sites • For systems: only funds part of the PCP base • For independents: provides funding to sustain independence • Requires participating competitors to cooperate in sharing best practices • Goal is to demonstrate impact at the community level • Monthly meetings of practices

12. CPCi v. Accountable Care Organization • Requires commercial plans/Medicaid support • Must provide additional pmpm funding • Patient attribution updated quarterly • Must commit to a common “menu” of cost/quality measures to be used for gainsharing program • Must provide monthly claims/utilization data • Still defining level of detail • Monthly multi-stakeholder meetings • ASO customers must agree to participate • Does not require gainsharing/full risk on day 1 • Year 1 used to build capabilities and establish data baselines • Gainsharing in years 2-3-4 still undefined

13. CPCi Challenges • Attribution requires 24 months of claims experience • What happens when a commercial enrollee switches plans • Many “Key Success Factors” still undefined • Attribution methodology • Cost/utilization data specificity • Gainsharing methodology • Severity adjustment methodology • CMS’ agenda does not always support community existing initiatives • Public Reporting through the Health Collaborative

14. CPCi Challenges • Self Insured Employers must agree to participate • ASO provider cannot commit without their consent • Threats to health system goal of creating a system brand for their PCP network • TH has 34 PCP practice locations • 30 NCQA Recognized Level 3 PCMH sites • 19 Sites have been selected by CMS to participate • Funding only applies to 19 sites • How to fund remaining 15 sites? • Can we get performance data for non CPCi sites even if we are not part of a payer’s P4P program?

15. CPCi Challenges Common community agenda still a challenge 19 Common Quality/Measures Selected CMS priorities Medicare Advantage “star” program measures Medicaid plans’ payment incentives Commercial payers’ national quality/cost agendas

16. . Questions?