The Michigan Primary Care Transformation (MiPCT) Project Annual Summit October 2013 MiPCT Overview and Updates

Objectives Recap MiPCT Overview and 2013/14 Focus Areas Review MiPCT Project Evaluator Findings to Date Discuss Project Sustainability

MiPCT Overview Jean 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

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

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

Multi-Payer Claims Database 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 Population Quality Measures Utilization Measures Membership Attributed members by Payer Risk Information # of members by Risk Level Population Information # patients by Chronic Condition (Asthma, CKD, CHF, etc) Quality Measures Screening and Test Rates Diabetes tests, Cancer Screens, etc Prevention Immunization Rates, Wellness Visits, etc. Comparison to Benchmarks Utilization Measures Rates ED Use, Admissions, Re-admissions, etc Comparison to Benchmarks

Admission, Discharge, Transfer MiPCT Data Flow and Progress 17 POs participate in the Care Team Connect (CTC)/MiPCT partnership (at no cost to PO) Care managers access member lists directly via a web interface ADT notifications adding for Trinity, Spectrum, 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

How will CMS define success? The tie to budget neutrality and ROI 13

MiPCT Brief Review: Balancing Successes and 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 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

www.mipctdemo.org

MiPCT Evaluation Update Clare Tanner

Objectives MiPCT Investment in PCMH Care Management Implementation Quality/Utilization

MiPCT Practices

Financial Investment, 2012 Care Coordination $35,577,697 “New” Money1 Total2 Care Coordination $35,577,697 Practice Transformation $8,739,951 $28,287,509 New money includes: Medicaid, Medicare, BCN g-code payments, BCBSM g-code + make whole payments Total adds in: BCBSM Practice transformation (E&M uplift) of $19 million, but does not include incentive payments

70% have 1 practice 23% have 2-4 practices 7% have 5 or more practices

MiPCT Benchmark* for Care Manager Caseload Care manager’s patient caseload – 2nd Quarter PO Data Care Manager Role 90th Percentile Qtr 2 face to face/FTE 90th Percentile QTR 2 Phone encounters/FTE Encounters per day = Benchmark* Complex 84 260 6 encounters per day Hybrid 160 321 8 encounters per day Moderate 193 238 7 encounters per day Keep as is – per team.

Care Manager Volume Quarter 2, 2013 Encounters Unique Patients Face to Face Phone Total 15,250 32,709 22,237 Per CM FTE 63 112 82 35 POs 5 POs are under the 80% minimum for care manager sufficiency 86% (n=30) have at least 80% care manager sufficiency 54% (n=19) of the 35 POs have 100% or better

2013 PO Report – 1st & 2nd Quarter Care Manager Activities Part time CMs are included. The metrics are normalized by FTE – this essentially inflates the number of visits/patients for part-time CMs to the level they would be at if they were full time. The Mean increases are statistically significant. The 75th percentile equals 5 encounters per day (quarter 2). We know the data may not be 100% accurate, but it is what we have today.

Care Manager Survey Conducted in May 2013 434 care managers asked to complete survey 53% completed the survey (n=228)

Care Manager Survey Results Physician Interaction Care Managers reported working with an average of 8.4 physicians On average, 83% of these physicians referred patients With respect to physician interaction, care managers reported working an average of 8.4 physicans 83% of these physicians referred patients. Number of physicians worked with ranged from 0 to 97. Proportion of physicians that referred patients ranged from 0% to 100%.

Care Manager Survey Results

Care Manager Survey Results How CMS used the MiPCT List Accuracy

Care Manager Survey Results 6% did not respond

Care Manager Survey Results 6.6% did not respond

Care Manager Survey Results The physician(s) I work with support the concepts of the MiPCT care management team. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree

Care Manager Survey Results Physicians are available on a daily basis to address questions related to management of MiPCT patients. Never Rarely Sometimes Frequently Always

Care Manager Survey Results Physicians understand and are actively involved in population management Never Rarely Sometimes Frequently Always

Care Manager Survey Results 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 Select all that apply

Care Manager Survey Results 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 Select all that apply

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

Quality and Experience of Care Metrics: MI and National Evaluations are Different, But Share Common Elements Michigan Diabetes Asthma Hypertension Cardiovascular Obesity Adult preventive care Child preventive care Childhood lead screening (Medicaid) Patient experience (CAHPS) Provider/staff experience National Diabetes 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)

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 Measures Breast Cancer Screening 1 22 12 Cervical Cancer Screening 30 5 Chlamydia Screening 8 7 Adult Preventive Adolescent Well-Care 9 10 6 15-Month Well-Child 14 3-6 Year Well-Child Well-Child Care Diabetic Eye Exam 2 21 Diabetic HbA1c Testing 15 20 Diabetic LDL-C Testing 4 31 Diabetic Nephropathy Screening 3 19 Diabetes Care MiPCT Number of POs with Quality Rate Changes The care management programs were put into place in 2012

MiPCT Number of POs with Quality Rate Changes Statistically 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 Chlamydia Screening 15 10 9 Negative Adolescent Well-Care 8 15-Month Well-Child 7 6 No 3-6 Year Well-Child 12 Diabetic Eye Exam Diabetic HbA1c Testing 3 13 16 None Diabetic LDL-C Testing 26 Diabetic Nephropathy Screening 14 MiPCT Number of POs with Quality Rate Changes The care management programs were put into place in 2012

MiPCT 2012 PCS ED Rate per 1000 ED Visits Percent Change from 2011 Baseline Rate by PO The care management programs were put into place in 2012 The percent change from baseline ranged from 4 to -16% with an overall change of -4%.

MiPCT Post-Demonstration Funding and Sustainability Diane 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 To the State and Patients: Servicing all patients, all payers What is the “Return on Investment”? To each payer? To each PO? How does the MiPCT fit in with other changes and projects? How effective are practices at providing patients who can benefit from care management receive timely, effective services?

Sustainability Progress Reduction of 4% in number of emergency room visits for MiPCT patients for ambulatory care-sensitive conditions from 2012 to 2013 Addition of Priority Health brings payer participation from the largest plans in Michigan CMS Complex Care Management proposal Patient Advisory Council launched that offers the patient voices and input in program design and operations ROI PO Subgroup financial modeling ADT messaging and direct Care Manager member list distribution at no cost to POs PCMH incorporation in SIM proposal

PO Primary Care Sensitive Emergency Department Use (Change from 1/1/12 to 12/31/12) No Improvement For POs with Stat. Sig. Better Performance, Amt. of Change Over 12%---2 POs 8-12%-------4 POs 5-8%---------3 POs Under 5% --11 POs Improved (not stat. sig.) Overall, from 2012 to 2013, the MiPCT decreased avoidable emergency visits decreased almost 4%.

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: Encouraging consideration of quarterly payments for moderate care management as well 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. Offering to share our experience and input on payment rates

We ARE the MiPCT! We can do this! We can make care better!

Questions?