learnings from the michigan clinically integrated network · 2019. 10. 2. · commercial products...

Michigan Community Health Network

Learnings from the Michigan Clinically Integrated Network

For the Maine Primary Care Association

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Presented by Russ Kolski RNMCHN Executive Director / Clinical Quality Director

Russ Kolski RN, MSA

• Paramedic for 25 years• RN for 25+ years• Ambulatory Care Supervisor for 25+ years• Worked for FQHC’s for 17+ years▫ Quality / Safety Director ▫ Health Center Executive Director▫ CIN Quality Director / Executive Director▫ Misc. duties – Strategic Planning,

Construction, Grant Writing and Grant Management

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Presentation Goals

• Understand the importance of managing PCP Rosters and Membership Lists as related to transitioning accountability from patients seen in the past year to assigned patients.

• The importance of clinical care standardization and the setting of Network level expectations

• The role of data and transparency in network operations and improvement

• The crucial role of aligned strategic planning and alignment of resources with Health Center partners

• Basic understanding of the financial drivers of value-based contracting

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Change in Thought

In today’s model you are paid for the amount of healthcare services you deliver and we are moving to a model in which you are paid based on the value of the care provided as measured by comparing outcomes against the cost of delivering the outcomes

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Change in Actions (Significant Change)

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MCHN - Who are we?

• Clinically Integrated Network• Group of independent Primary

Care Providers• Also happen to be all FQHC’s• Currently focus on Michigan

Medicaid Plans

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Organizations Involved

• Michigan Primary Care Association• 38 FQHC’s• 3 FQHC Look Alike• 3 Indian Health Service Providers

• Michigan Quality Improvement Network• Michigan HCCN

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MI Community Health Network

• Ownership• 33 Health Centers• Michigan Primary Care Assoc

• Operations• MCHN Health Centers operate

239 sites in 59 counties • MCHN Health Centers provide

care to approx. 500,000 lives, of which 300,000 are Medicaid

• 11 Medicaid Health Plans• 30 Health Centers are part of 1 of

2 Value Based Contracts

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Clinically Integrated Network

• Compliance Requirements to obtain safe harbor from antitrust scrutiny• Physician Leadership and Commitment• Development and implementation of clinical practice

guidelines to improve performance• Development of infrastructure and technology• Financial incentives for achieving goals

• An opportunity to work as part of a group without giving up independence

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Formation Path / Collaboration• Started with MPCA Clinical Quality Committee• Expanded to HCCN (MQIN) – December 2012• Round 1 – focus on EHR Implementation, Meaningful Use• Round 2 – focus on PCMH, HIE, Health Data Integration – 39 Health Centers• Round 3 – focus on Interoperability, QI, Data Integration – 41 Health Centers

• Value Based Care Readiness• PCMH Recognition (32/34 Health Centers in HCCN)• Health Center Readiness Assessment • CMS Demo Projects (MiPCT 1/2012, MiCare Team 7/2016, SIM 8/2016)

• Integrated Data System selection • May 2016 – Committee Startup• March 2017 – Contract Complete with Azara• December 2017 – 11 Health Centers live• December 2018 – 22 Health Centers live• Today – 28 Centers live (23 MCHN) - 5 more before end of 2019 (4 MCHN)

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CIN Formation• Initial Discussions – 2011 (Did not result in any action)• Network Formation Steering Committee (Starling Advisors) – May 13, 2014• MOU for 33 Health Centers Early 2015• MCHN capitalized and incorporated – May 1, 2105• CEO Hired – October 2016• First Contract – October 1, 2017• Second Contract – January 1, 2019 • Current Staff• Contracted CEO (20%)• Contracted Quality Director / Executive Director (Full Time)• Executive Assistant / Membership Coordinator (Full Time)• Contracted CMO

• PCA Purchased Services• Financial Services• IT / Data Analytics• Compliance / HR

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MCHN Commitments1. Improving the quality and efficiency of all the MCHN member organizations through standardization

of quality measures, care coordination and efficiency practices.2. Utilizing one Integrated Data System for measuring quality and cost efficiency performance.3. Creating a Value Proposition with Partner Health Plans to develop innovative reimbursement

arrangements that reward MCHN members with incentive and gain sharing payments for meeting agreed upon clinical quality and efficiency measures.

4. Negotiating contracts for members that reflect the intent of the Value Proposition between MCHN and respective Health Plan partners.

5. MCHN over time will selectively move toward risk/reward contracts as the MCHN members achieve the level of integration necessary to manage risk.

6. MCHN will develop shared services arrangements that benefit MCHN members to reduce their operating costs.

7. MCHN will continue to grow its members and operations capacity to meet the needs of the communities served.

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Structure

• For Profit LLC (Moving to Partnership)• Governance• Board of Managers• 11 Health Center CEO’s Selected by Regions• 1 Clinician Manager – Clinical Quality Committee Chair

• Executive Committee – 4 Board Officers• Committees – 13 members• Finance• Operations • Clinical Quality

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Current Contracts

• Meridian Health Plan – October 2017 • 55,000 lives for January 2018• 80,000 lives for January 2019

• Molina Health Plan – January 2019• 50,000 lives for January 2019

• Anticipated for 2020• Aetna• Blue Cross Complete• McLaren Health Plan

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VBC Contracting – Finance 101

• Sustainability / Generating Revenue• Group Compliance• Total Cost of Care vs. Cost of Primary Care• Current Cost vs. Future Cost• Funding MCHN

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Why Value Based Contracting?

• Payers / Funders are pushing for improved outcomes• Lower Costs• Increase Access to Care• Improved Population Health

• Improved Financial Opportunities• The greater the assumed risk, the greater the reward

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Shared Savings Bundles Shared

RiskGlobal

CapitationIncreasing

Risk

Value Based Models

MCHN Value Based Contracting

• Utilize model that replaces Quality Incentive Payments and sits on top of Health Center Base Agreement

• Applies to the performance / incentive portions of the business• On top of payment for services and cost based

reimbursement

• Payments are PMPM• Paid on all members, not just compliant members

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What Changes?

• All incentive measures are based upon assigned members rather than members (patients) with a visit during the calendar year• Responsible for clean membership rosters• All Membership and PCP changes must include network

• MCHN is the contact for questions related to membership, Primary Care Provider lists and member attribution, quality payments• Accountability!• Responsible for Outreach

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What Doesn’t Change?

• Fee for Service contract stays in place and Health Plans pay visit related billings directly to you as previous.

• Value based contracts only include Primary Care Providers – no change for Specialists, BH, Other LIP’s

• Currently does not include Medicare Advantage or Commercial products for any VBC plans.

• Billing issues are handled directly with plan• MCHN works as a facilitator to address other problems

with the Health Plans in areas where normal communications are not working.

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Our Value Based Contract Parts

• Quality Improvement • Access to Care • Clinical Quality (HEDIS) • Cost of Care (Shared Savings)

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Quality Improvement

• Meridian Focused Opportunity Initiative• $$ PMPM for priority activities• PCP / Membership Accuracy• Post Hospital Discharge Follow Up• Frequency of visit for patients with HTN

• Per Meridian – Preparing for future success• Started as means of transitioning payment structure

from quarterly to 6 months after year end - claims runout

• Part of all contract negotiations to this point

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Access to Care

• Meridian – Gateway to Surplus (GTS)• Annual Primary Care Visit• Twice Annual Chronic Care Visit with Qualifying Provider

(Diabetes, HTN, CHF, COPD, Asthma, Obesity)• Molina – Quality Gate• Measure Access to Care - 6 HEDIS age groups (Age 1 to 64 yrs.)• Must meet 4 of 6 including either 12-24 Months or 20 to 44 years• Goal is 10% improvement over 2018 or 90th Percentile

• Internal Expectation - Outreach• 2 attempts per year for non-compliant members (patients)

• Compliance based upon paid claim

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Shared Savings

• Reduce overall cost of care• Monitor Utilization Rates• Monthly Summary / Detail (Molina)• Quarterly Summary (Meridian)• Twice Weekly ADT / Census (Meridian)• Transition of Care Reporting – Data Registry

• Reduce inappropriate ER Utilization• Reduce Inpatient readmission rates• Internal Expectations• 100% follow up on Hospitalized Patients• Perform a Transition in Care assessment• Act on results of assessment

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Shared Savings

• Meridian• Total Cost of Care model• Member Benefit Ration (Medical Loss Ratio) target is 88%• Eligible for % of savings if Gateway to Surplus is met.

• Molina• Utilization Model• Reduction in use of ER / Inpatient Admit / Readmits• Compared to 2018 base year• Visit Values – ER $175, Inpatient $6,000, Readmit $9,000• Eligible for % of savings if MCHN meets the Access to Care

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Activities to Reduce TCOC

• Embrace Data Registry• Risk Stratification• Real time data aggregation• Point of Care use

• Outreach – Access to Care (Increase Visits)• Post Hospital Discharge Follow Up• Identify and engage High Risk Patients• Education• Clinical Standardization• ED Utilization Reduction

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HEDIS – Clinical Quality

• Meridian Quality Bonus Program (QBP)• Replaces historical Pay for Performance Program (P4P). • Measures HEDIS compliance at the 75th and 90th percentiles• Consists of 30 HEDIS Quality Measures • Currently 12 Priority Measures Selected by MCHN• Measures Change Annually

• Molina Clinical Quality• 10 Measures• 75th and 90th with one-time payment (2019) for 10% improvement

• Shared Expectations• Sharing of supplemental data• Follow MQIC (Michigan Payer Aligned Evidence Based Care)• Expect Alignment with internal Health Center QI Efforts

• Supplemental data plays a key role

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Key Clinical Activities

• Annual Clinical Quality Plan• Agreed upon areas of focus• Staff Education• Health Center Engagement• Alignment of goals of Health Centers and CIN

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Current Health Plan Data

• Membership Report• PCP Report• Clinical Quality Report (HEDIS)• Access to Care Information• Paid Claims • All Claims• Utilization (ER / Inpatient Visits)• Pharmacy Claims

• Admission / Discharge / Transfer Data (Meridian Only)

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Utilizing Technology

• Shared Data Repository• Azara for Michigan

• Advanced Data Analytics• Currently using Contract IT Programming• Exploring additional Azara functionality

• Outreach• Exploring addition of single text messaging vendor

• Local Connectivity / HIE’s• Michigan Care Improvement Registry (Immunizations)• Michigan Health Improvement Network (HIE)

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Accountability• Required to avoid Anti-trust concerns when forming a clinically integrated network.• Routine monitoring of key network activities• Health Centers that are performing significantly below the MCHN network average

are provided Clinical Assistance• Health Centers are recommended for assistance by the MCHN Clinical Quality

Director and approved by the Clinical Quality Committee and Board of Managers

Step 1: MCHN Clinical Quality Director will ask the organizations designated Quality Improvement staff member for an informal plan of action to obtain the minimum expected level of performance for the measure.

Step 2: MCHN Clinical Quality Director to facilitate formal meeting with Health Center CEO designated representative(s) to discuss methods to improve performance. Summary of meeting will be provided to Health Center and MCHN CMO

Step 3: Meeting with MCHN CMO, MCHN Clinical Quality Director and Health Center CEO designated C-Suite members to review performance and discuss potential solutions. Health Center will develop an action plan to exceed the minimum threshold that will be reviewed and approved by the MCHN Quality Committee upon recommendation of the MCHN CMO.

• Could eventually result in a Health Center being asked to leave network

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Communications• MCHN Communication E-mail list• MCHN-QI@“youre-mail.com” for Clinical Messages• MCHN-PCP@“youre-mail.com” for Membership• Maintained by your IT staff – must be added to distribution list by

your Health Center

• Monthly Clinical Staff / MCHN Call• Share new information• Review performance / share best practices

• Clinical Quality Committee Meetings – Open to all to listen• 2nd Wed. of Odd months at 1:00 PM (Jan, Mar, May, Jul, Sep, Nov)• Via Webinar

• Face to Face Meeting Opportunities with MCHN staff• Most MPCA Clinical Trainings

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Pearls

• Standardization• Clinical Care• Approach to Health Plan Negotiation

• Alignment• Priorities (HRSA / PCA / HCCN / CIN)• Measures with plans

• Integration• Integration of CIN staff into PCA and HCCN Culture• Shared Staff• PCA is non voting owner in organization

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Pearls

• Full Transparency – peer support / peer pressure• Accountability• Health Centers musts• Share the workload across multiple people• Participate in Calls / Education Sessions• Review data / Compare Reports

• Communication• Overcommunicate!• Friendly Reminders• Value of Face to Face contact

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Challenges• Health Plans• New Contracts• Data (delays, accuracy, standardization)• Long Cycle Time for correcting reports / incorporating HC data

• Data• Sharing Health Center specific data (splitting reports)• Identification of hospitalized patients• Cost of information distribution• Need for rapid turn around• Actionable reporting

• Health Centers• Staff Turnover• CMO / C-Suite Involvement• “We treat all patients the same.”• Consensus vs. significant change

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Challenges

• Network Issues• Integration of PCA / HCCN / CIN staff• Legal Documents / Legal Structure (taxability)• Payments (high performers vs. low performers)• Cost of operations / sustainability (maximum return vs.

build infrastructure)• Standardization / Quality Improvement• One size fits all vs. customize activity plans• Time required to make significant change• Reporting burden vs. Accountability

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Russ Kolski – rkolski@mi-chn.com616-460-5210

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Questions