Michigan Primary Care Transformation

Demonstration Project

June 13, 2012 Webinar #10

Agenda

Medicaid Payments

Medicare Payments

Care Managers

MiPCT Committee

Metrics

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Doing the Impossible

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Performance

One year look back for quality scores

Ongoing testing for patient registry data dumps

Patient registry data utilized for distribution of

funds

Patient registry submission in time for 12.31.2012

performance payments

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Pay for Performance Data Source

Claims Data: All participating health plans submit

claims data to the Michigan Data Collaborative

which can be used to calculate utilization and cost

metrics.

Claims data will be calculated for each Health Plan

and aggregated across all contracted plans.

Confidence intervals at 95% will be provided.

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Pay for Performance Data Source

MiPCT Quarterly Reports: The report will

document updates to the MiPCT Implementation

Plan and progress to date in developing PCMH

infrastructure capabilities and carrying out MiPCT

clinical initiatives.

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Pay for Performance Data Source

Self-Reported Data (SRD): MNO currently reports

to BCBSM PGIP twice a year on each practice’s

PCMH capabilities

BCBSM applies accuracy, validity and inter-rater

reliability checks and balances to the reports

Financial penalties are imposed for inaccurate

reporting of capabilities and are reflected

proportionally on the distribution of funds

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Pay for Performance: Six Month Metrics - Access

Extended access:

• 30% same day appointment (10 points)

Appointments outside regular hours:

• 8 hours/week (10 points)

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Pay for Performance: Six Month Metrics – eRegistry

1) Practice has electronic registry

2) Registry has interface capability

3) Incorporates evidence-based care guidelines

4) Identifies individual attributed practitioner

5) Information available and used by the practice

unit team at the point of care

6) Used to generate communications to patients

regarding gaps in care

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Pay for Performance: Six Month Metrics - eRegistry

7. Used to flag gaps in care

8. Patient demographics

9. Registry identifies and tracks care for patients

with at least 2 of the following:

diabetes

asthma

cardiovascular disease

pediatric obesity

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Pay for Performance: Six Month Metrics - eRegistry

0 points for entire metric if no eRegistry

1 point each for numbers 1-8

Up to 2 points for number 9

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Role Comparison Review

Moderate Risk Care Manager (MCM)

Complex Care Manager (CCM)

Patient Population

• Moderate risk patients identified by registry, PCP referral for proactive and population management

• High risk patients identified by PCP referral and input, risk stratification, patient MiPCT list

Patient Caseload

• Caseload 500 (approx. 90 - 100 active patients); one MCM per 5,000 patients

• Caseload 150 (approx. 30 - 50 active patients)

• One CCM per 5,000 patients

Focus of Care Management

• Proactive, population management • Work with patients to optimize

control of chronic conditions and prevent/minimize long term complications

• Targeted interventions to avoid hospitalization, ER visits

• Ensure standard of care, coordinate care across settings, help patients understand options

Duration of Care

Management • Typically a series of 1 to 6 visits

• Frequency of visits high at times, duration of months

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Pay for Performance: Six Month Metrics - Care Manager

Number of Moderate Care Managers hired/

contracted by practices and/or PO

• 10 points

Number of Moderate Care Managers within PO

that have completed the required training

• 10 points

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Patient Engagement

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Pay for Performance: Six Month Metrics - Care Manager

Number of Complex Care Managers hired/

contracted by practices and/or PO

• 10 points

Number of Complex Care Managers within PO that

have completed the required training

• 10 points

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Performance Incentive Process

$3.00 PMPM paid into incentive pool*

Performance incentive metrics are assessed and

all funds paid out every 6 months

• 1st period for April starters is 3 months

• Payments will be made about 2 months after performance period ends

• Payment range is 82% to 118 % of mean ($18.00 per member) or $14.76 to $21.24

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Payment Distribution

POs retain approved portion (not to exceed 20%)

POs distribute remaining funds to participating

practices.

• Equally: a fixed dollar amount times the number of beneficiaries or

• Variable amounts: dollar amount is based on additional performance criteria including participation in workshops and collaborative events

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Care Managers

Each practice has a Hybrid Care Manager assigned

and actively engaged

Dietitian, Certified Diabetes Educator, Behavior

Health Specialist, Health Coach, Health Educator,

Certified Asthma Educator, Pharmacist (as

needed)

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PDCM Codes and Fees

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CODE SERVICE

G9001 Initial assessment

G9002 Individual face-to-face visit (per encounter)

98961 Group visit (2-4 patients) 30 minutes

98962 Group visit (5-8 patients) 30 minutes

98966 Telephone discussion 5-10 minutes

98967 Telephone discussion 11-20 minutes

98968 Telephone discussion 21+ minutes

Registration for CCM Workshop

MiPCT moved to an open registration process for

Complex Care Management (CCM) training

CCMs and HCMs that have not previously

registered online for the CCM course to the

section of the MiPCT website entitled “CCM

Online Registration page

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PCMH CAHPS Survey

To be collected on a representative sample of

MiPCT and comparison beneficiaries

Multi-modal (mail with phone follow-up)

Content areas:

• Access

• Communication

• Coordination

• Comprehensiveness

• Shared decision making

• Self-management support

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Adult Clinical Quality Metrics

Diabetes: (ages18-75 years & type 1 or 2

diabetes) HEDIS 1. A1C Test

2. Poor Control A1c>9

3. Control A1c< 8

4. LDL-C Test

5. LDL-C Controlled < 100 mg/dl

6. BP <140/90

7. Retinal Eye Exam

8. Nephropathy Screen or Evidence of Nephropathy* y

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Adult Clinical Quality Metrics

Asthma: Self-Management Plan or Asthma Action

Plan (ages 5-50) Non HEDIS

Hypertension: Controlled BP <140/90 (ages 18-85)

HEDIS

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Adult Clinical Quality Metrics

Cardiovascular Disease (CVD): BP management

<140/90 mmHg (ages 18-75) HEDIS

CVD: LDL-C Management <100 mg/dl (ages 18-85)

HEDIS

Obesity: Adult BMI (Meaningful Use)

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Adult Clinical Quality Metrics

Tobacco: Percent Current Smokers (ages 13 and

older) (non HEDIS)

Breast Cancer Screening: (ages 40-69) HEDIS

Cervical Cancer Screening: (ages 21-64) HEDIS

Colorectal Cancer Screening: (ages 50-75) HEDIS

Chlamydia Screening: (sexually active women

ages 16-24) HEDIS

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Pediatric Clinical Quality Measures

Asthma: Self-Management Plan or Asthma

Action Plan (ages 5-50) Non HEDIS

Obesity: Child BMI (ages 2-17yrs) Meaningful

Use

Lead Screening: (Medicaid only) (Age 2) HEDIS**

Tobacco Use: (ages 13 and older)

Chlamydia Screening: (sexually active women

ages 16–24) HEDIS

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Pediatric Clinical Quality Measures

Chlamydia Screening: (sexually active women

ages 16–24) HEDIS

Childhood Immunizations: Age 2 HEDIS**

Childhood Immunizations: Adolescent Age 13

HEDIS**

Well Child Visits: 15 Months and 3-6 years HEDIS

Well Child Visits: Adolescent (ages12-21) HEDIS

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MNO Expectations

Attendance at webinars

• Share current information

• Brief training moments

• 100% practice representation

• eMail addresses of physicians

• Hold each other accountable and create buddy relationships

• Create inter-professional collaborative care teams

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Questions

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