The Michigan Primary Care Transformation (MiPCT) Project

Annual SummitOctober 2013

MiPCT Overview and Updates

1

Objectives•Recap MiPCT Overview and 2013/14 Focus

Areas

•Review MiPCT Project Evaluator Findings to Date

•Discuss Project Sustainability

MiPCT OverviewJean Malouin

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

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Participants

•380 practices•35 POs•1,500 physicians•1 million patients•5 Payers

▫Medicare▫Medicaid managed care

plans▫BCBSM▫BCN▫Priority Health (7/13)

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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4

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

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Multi-Payer Claims Database

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• 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

Multi-Payer Claims Database

Medicare

Medicaid BCN

BCBSM

MiPCT

MDC: MiPCT Dashboards

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PopulationMembership• Attributed members by PayerRisk Information• # of members by Risk LevelPopulation Information• # patients by Chronic Condition

(Asthma, CKD, CHF, etc)

Quality MeasuresScreening and Test Rates • Diabetes tests, Cancer Screens, etcPrevention• Immunization Rates, Wellness Visits, etc.Comparison to Benchmarks

Utilization MeasuresRates • ED Use, Admissions, Re-admissions, etcComparison to Benchmarks

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!

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

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How will CMS define success?

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The tie to budget neutrality and ROI

Successes• 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

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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

MiPCT Brief Review: Balancing Successes and Challenges

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www.mipctdemo.org

MiPCT Evaluation UpdateClare Tanner

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

MiPCT Practices

Financial Investment, 2012“New” Money1 Total2

Care Coordination $35,577,697 $35,577,697

Practice Transformation

$8,739,951 $28,287,509

1. New money includes: Medicaid, Medicare, BCN g-code payments, BCBSM g-code + make whole payments

2. Total adds in: BCBSM Practice transformation (E&M uplift) of $19 million, but does not include incentive payments

Hybrid59%

(248)

Mod-erate26%

(109)

Complex15% (63)

Care Manager RolesN=420

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70% have 1 practice 23% have 2-4

practices 7% have 5 or more

practices

Care Manager Volume Quarter 2, 2013

EncountersUnique PatientsFace to

Face Phone

Total 15,250 32,709 22,237

Per CM FTE 63 112 82

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Care Manager Survey•Conducted in May 2013•434 care managers asked to complete

survey•53% completed the survey (n=228)

Care Manager Survey Results

•Care Managers reported working with an average of 8.4 physicians

•On average, 83% of these physicians referred patients

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Physician Interaction

Care Manager Survey Results

OtherOther discharge list

Other staffFax discharge summaries

Patient self-referralsRegistry

ED visit summariesElectronic admit discharge notifications

Daily practice visit scheduleMiPCT list

Physician referrals

4%1%2%

24%25%

39%57%61%61%

79%91%

How Care Managers Build Caseloads

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Care Manager Survey Results

Number of maintenance drug prescriptions

BCBSM high deductable plan

Emergency department utilization

Risk score

Chronic condition diagnosis

11%

22%

36%

57%

57%

Utilization of MiPCT List In-formation

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Care Manager Survey Results

Daily Weekly Every 2 weeks

> Every 2 weeks

Never0%

20%

40%

60%

42%35%

6% 8%3%

How Often Care Managers Converse with PCP Regarding MiPCT-Eligible

Patients

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Care Manager Survey Results

Weekly Every 2 weeks

Monthly >Monthly Never0%

20%

40%

22%

8%

28%

7%

29%

How Often Care Team Meets to Discuss Delivery of Care Management and/or

Specific Patient Cases

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Care Manager Survey Results

•The physician(s) I work with support the concepts of the MiPCT care management team.

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Strongly

Disagree

Disagree

Neither Agree

nor Disagre

e

Agree Strongly Agree

Care Manager Survey Results

•Physicians are available on a daily basis to address questions related to management of MiPCT patients.

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Never Rarely

Sometimes

Frequently

Always

Care Manager Survey Results•Physicians understand and are actively

involved in population management

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Never Rarely

Sometimes

Frequently

Always

Care Manager Survey Results

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•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

Care Manager Survey Results

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•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

Cost, Quality and Utilization

National and State Metrics

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

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Quality and Experience of Care Metrics:MI and National Evaluations are Different,

But Share Common Elements

NationalDiabetes 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)

Michigan• Diabetes• Asthma• Hypertension• Cardiovascular• Obesity• Adult preventive care• Child preventive care• Childhood lead screening

(Medicaid)

• Patient experience (CAHPS)• Provider/staff experience

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Cost, Quality and Utilization

Initial Results (Year One)

MiPCT Number of POs with Quality Rate Changes>= +10%

Positive<10%

Negative>-10% <= -10%

Number of POs with Positive Change in All

Group MeasuresBreast Cancer Screening 1 22 12 0

Cervical Cancer Screening 30 5 0 0

Chlamydia Screening 8 8 7 12

Adult Preventive 7

Adolescent Well-Care 9 10 10 6

15-Month Well-Child 14 5 5 8

3-6 Year Well-Child 8 9 10 7

Well-Child Care 8

Diabetic Eye Exam 2 12 21 0

Diabetic HbA1c Testing 0 15 20 0

Diabetic LDL-C Testing 0 4 31 0

Diabetic Nephropathy Screening 3 10 19 3

Diabetes Care 2

MiPCT Number of POs with Quality Rate Changes

MiPCT Number of POs with Quality Rate ChangesStatistically Significant Increases (p<=.1)

Increases(Not

Statistically Significant)

Decreases (Not

Statistically Significant)

Statistically Significant Decreases

(p<=.1)

Overall MiPCT Change

Significant (p<=.1)

Breast Cancer Screening 5 18 11 1 Positive Yes

Cervical Cancer Screening

31 4 0 0 Positive Yes

Chlamydia Screening 1 15 10 9 Negative Yes

Adolescent Well-Care 8 11 8 8 Negative Yes

15-Month Well-Child 8 11 7 6 Positive No

3-6 Year Well-Child 5 12 6 11 Negative Yes

Diabetic Eye Exam 4 10 15 6 Negative Yes

Diabetic HbA1c Testing 3 13 16 3 None No

Diabetic LDL-C Testing 0 4 26 5 Negative Yes

Diabetic Nephropathy Screening

4 9 14 8 Negative Yes

MiPCT Number of POs with Quality Rate Changes

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

-20.00%

-15.00%

-10.00%

-5.00%

0.00%

5.00%

POs/PHOs

MiPCT Overall

MiPCT Post-Demonstration Funding and SustainabilityDiane Marriott

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

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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.

• MiPCT submitted 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.

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."

Sustainability Progress▫Addition of Priority Health

▫State Innovation Model (SIM)

▫Medicaid

▫Milbank Fund Advocacy

▫ROI PO Subgroup financial modeling

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PO Primary Care Sensitive Emergency Department Use (Change from 1/1/12 to 12/31/12)

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11

4Improved (stat sig.)

For POs with Stat. Sig. Better Performance, Amt. of Change

Over 12%---2 POs8-12%-------4 POs5-8%---------3 POsUnder 5% --11 POs

Overall, from 2012 to 2013, the MiPCT decreased avoidable emergency visits decreased almost 4%.

No Improvement

Improved (not stat. sig.)

We ARE the MiPCT!

We can do this together!

We can make care better!

Questions?