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Michigan Primary Care Transformation Project. Webinar #1: Funding model, Care management models And Implementation plan November 3, 2011. Agenda. MiPCT funding Payment amounts Timing of distribution BCBSM/BCN care coordination payments MiPCT Care Managers
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Michigan Primary Care Transformation Project Webinar #1: Funding model, Care management models And Implementation plan November 3, 2011
Agenda • MiPCT funding • Payment amounts • Timing of distribution • BCBSM/BCN care coordination payments • MiPCT Care Managers • Overview of roles, job descriptions and training • Staffing models for your PO/PHO • Part C Implementation Plan • Section 1: Care management contacts and staffing • Section 2: Activities for MiPCT functional tiers • Section 3: Care coordination and incentive payments
Funding/Distribution by Payer • Medicare • Care coordination payment ($4.50 PMPM) • Paid monthly • Flows to PO/PHO • First payment expected January 2012 • One month’s payment held for complex care manager training yr 1 • Practice transformation payment ($2.00 PMPM) • Paid monthly • Flows to practice • First payment expected January 2012 • Performance incentive payment ($3.00 PMPM average) • Paid semi-annually • Flows to PO/PHO • First payment expected July 2012
Funding/Distribution by Payer • Medicaid • Care coordination payment ($3.00 PMPM) • Paid quarterly • Flows to PO/PHO • First payment expected March 2012 • One month’s payment held for complex care manager training year 1 • Practice transformation payment ($1.50 PMPM) • Paid quarterly • Flows to practice • First payment expected March 2012 • Performance incentive payment ($3.00 PMPM average) • Paid semi-annually • Flows to PO/PHO • First payment expected July 2012
Funding/Distribution by Payer • BCBSM • Care coordination payment (G-codes, CPT codes) • Encounter-based payments • Flows to entity who files the claim • First G-code payments expected April 2012 • First quarter’s payments will be paid PMPM in late Nov 2011 • Practice transformation payment • Existing 10% E/M uplift • No changes in amount/flow – NOT NEW MONEY • Performance incentive payment (Existing PGIP payment) • Paid semi-annually • No changes in amount/flow – NOT NEW MONEY
Funding/Distribution by Payer • BCN • Care coordination payment (G-codes, CPT codes) • Encounter-based payments • Flows to entity who files the claim • First G-code payments expected January 2012 (still TBD) • Practice transformation payment ($1.50 PMPM) • Paid monthly (tentative) ONLY TO FFS CONTRACTS • Flows to practice • First payment expected January 2012 • Performance incentive payment ($1.20 PMPM average) • Paid semi-annually (tentative) • $1.20 amount incremental to existing PRP/PAYG payments • Flows to PO/PHO (tentative) • First payment expected July 2012
Care Management Funding Sources • Two sources of care management funding: • PMPM payments – “guaranteed” funding • G codes and CPT codes – payment for services provided • Depends on appropriate staffing • Funding model based on $3 PMPM equivalent in payments • How much activity is needed to equate to $3 PMPM?? • Assumptions: • Hire one care manager for 2,500 patients • Average G-code reimbursement is $60-$65 (fee schedule TDB) • Activity level: • One full time care manager would need to bill 6-7 encounters per work day (48 week year) to equate to $3 PMPM – very feasible
BCBSM/BCN Care Coordination Payments • G codes • G9001: Coordinated care fee – initiation rate (all inclusive) • G9002: Coordinated care fee – maintenance rate • CPT codes • 98961: Group education (2-4 patients) • 98962: Group education (5-8 patients) • 98966: Telephone assessment/medical discussion (5-10 min) • 98967: Telephone assessment/medical discussion (11-20 min) • 98968: Telephone assessment/medical discussion (21+ min) • More details to be provided on next webinar
MiPCT Funding Spreadsheets • Distributed to each PO/PHO • Contents • Sheet 1: Information tab • Sheet 2: PO/PHO funding summary • Sheet 3: Funding detail by practice • Includes number of care managers funded by practice • Moderate risk care managers • Complex care managers • Allows customization of care manager salary/benefits
MiPCT Care Managers Overview of Roles, Job Descriptions, Training
Role Comparison: Moderate Risk Care Manager, Complex Care Manager
Hybrid Care Manager Model Definition of hybrid model: one individual who fills both Complex Care Manager (CCM) and Moderate Risk Care Manager (MCM) role • Considered only for special circumstances • practices with significantly fewer that 5,000 MiPCT attributed patients • Practice that serve primarily pediatric patients and have fewer complex patients • Individual filling both roles must complete the MCM and CCM training requirements • Hybrid model will be evaluated during first year of intervention; continued if successful
Complex Care Manager Role • Partners with practice leadership team to integrate care management into practice • Completes comprehensive patient assessments – ex. functionality, depression • initial and periodically, over time • Provides self management support • focus on building capacity of patient/family for self care • Provides patient/family education • with teach back, sustain over time • Implements evidence-based care, chronic disease protocols and guidelines • intervene early during acute exacerbations • analyze complex data sets • monitor patient/family response • Creates/maintains individualized plan of care
Complex Care Manager Role cont. • Coordination of care • Specialists, hospitals, community resources, etc. • Transitions of care • Assists with advance directives, palliative care, hospice and other end of life coordination
Complex Care Manager Job Description Sample of key required qualifications* • Current MI License: RN, MSW, NP, PA • 3 years experience • adult medicine and pediatric patients (as applicable to practice) • setting: home health agency, primary care practice, skilled nursing facility, hospital medical-surgical unit • Ability to manage complex chronic conditions • utilize evidence-based guidelines • critical thinking skills • excellent assessment and triage skills • ability to analyze complex data sets • ability to implement evidence-based interventions and protocols for chronic conditions • Excellent communication and facilitation skills *note: see CCM job description for complete details
Complex Care Manager Training • MiPCT and Care Management Resource Center will provide training - required • standardized interventions and tools • evidence based • if practice currently has a complex care program in place, MiPCT team will review • MiPCT to partner with Geisinger for CCM training (potential) • train the trainer model • Self Management Support training – required • More details on CCM training will be provided in the next webinar
Moderate Risk Care Manager Role • Partners with practice leadership team to integrate care management • Assesses healthcare, educational, and psychosocial needs of patient/family • Provides self management support • focus is typically on lifestyle and behavior change • Provides patient/family education • with teach back • Implements evidence-based care • chronic disease protocols and guidelines • Assists with transitions between settings • includes medication reconciliation • Assists with advance directives
Moderate Risk Care Manager Job Description Sample of key required qualifications* • Current MI License: RN, MSW, NP, PA, LPN, RD, Pharmacist • 2 years experience • adult medicine and pediatric patients (as applicable to practice) • setting: home health agency, primary care practice, skilled nursing facility, hospital medical-surgical unit • Knowledge of chronic conditions • evidence-based guidelines, prevention. . . • Excellent assessment, triage skills • Excellent communication and facilitation skills *note: see MCM job description for complete details
Moderate Risk Care Manager Training • Core Curriculum: three areas of focus • Self Management Support training - required • General training topics - suggested • Important for building MCM’s knowledge base and skills • Topics may be refined based on individualized needs of the practice • MiPCT training – required • MCM Training responsibility shared • MiPCT and Care Management Resource Center + POs/PHOs/IPAs, practices
Moderate Risk Care Manager Training: Who arranges/provides training?
MiPCT Care Managers How many do you need? Where will you put them?
Care Management Priorities • Care managers work in close proximity to PCP team • In PCP office as much as possible • When designing model, work with PCP team to meet their needs • Ensure Complex Care Management coverage • 1:5000 for adult population • 1:2500 if using hybrid model • Focus on evidence-based interventions • Medication reconciliation • Care transitions • In-person contact with patients whenever possible • Comprehensive care plan for complex patients
Designing a Model for your PO/PHO • Consider on-site care managers (CCM and MCM) for sites with 5,000 or more beneficiaries • Sites with 2,500-5,000 beneficiaries • Options (examples, other scenarios possible) • on-site CCM, “travel team” for moderate risk patients • On-site MCM, CCM shared among 2-3 practices • On-site “hybrid” care manager, plus non-licensed care coordinator • Sites with < 2,500 beneficiaries • Both CCM and MCM roles shared among 2-3 sites • Case studies and implementation guide on the way • Contact MIPCTDEMO.michigan.gov for free consultation
Contact Information: Care Management Marie Beisel MSN, RN, CPHQ UMHS Project Manager, Care Management Resource Center e mail: mbeisel@umich.edu office phone: 734 998 8519 Jean Malouin MD, MPH Medical Director, Michigan Primary Care Transformation Project e mail: jskratek@umich.edu Office phone: 734 232 6222
Implementation PlanPart C Overview And General Instructions
Instructions for completing form Work with participating practices to develop responses for each section on the form Return completed form to Amanda First at afirst@umich.edu by December 1, 2011 Completed forms will be reviewed and feedback provided by December 15, 2011 POs/PHOs needing assistance should contact MiPCT at MIPCTDEMO@michigan.gov
Section 1: Care Management Contacts/Staffing • Identify lead MiPCT care management contact for each practice • Care management staffing • Describe how care management will be staffed for each participating practice • Describe tools/processes to integrate care managers into practice • Describe plans for training care managers • Complex care managers (MiPCT program) • Hybrid care managers (use MiPCT complex care training) • Moderate risk care managers (menu of options) • Specify if consultation desired
Section 2: Activities for MiPCT Functional Tiers • Describe current and planned activities for each of the MiPCT functional tiers: • Navigating the medical neighborhood • Care Transitions • Care Management • Complex Care Management
Section 3: Care Coordination and Incentive Payments • Describe how care coordination funding will be distributed between PO/PHO and practice • Describe how incentive payments will be distributed between the PO/PHO and practice (Information required by CMS) • Percentage of incentive payments to be retained by PO/PHO • Services provided by PO/PHO