The Michigan Primary Care Transformation (MiPCT) Project Sustainability Update May 14, 2014

Where We Started Together The Vision for a Multi-Payer Model Use the CMS Multi-Payer Advanced Primary Care Practice demo as a catalyst to redesign MI primary care Multiple payers will fund a common clinical model Allows global primary care transformation efforts Support development of evidence-based care models Create a model that can be sustained and expanded Facilitate measurable, significant improvements in population health for our Michigan residents Bend the current (non-sustainable) cost curve Contribute to national models for primary care redesign Form a strong foundation for successful ACO models

Evaluation results available to date Continuing the Journey MiPCT Post Demonstration: A Sustainability Update Evaluation results available to date Factors that influence sustainability and payer updates MiPCT post-demonstration period

Evaluation results available to date

Quarterly Trend Comparison: Medicare PMPM Payments Michigan: quarterly regression difference-in-differences estimates and 90% confidence intervals for total PBPM Medicare payments, comparing performance for Medicare beneficiaries assigned to MAPCP Demonstration PCMHs vs. beneficiaries assigned to comparison PCMHs and non-PCMHs Negative numbers indicate that total Medicare payments increased less for beneficiaries assigned to MAPCP Demonstration practices than for beneficiaries in the comparison group, and suggest that the MAPCP Demonstration is yielding cost savings. RTI presents payment data in multiple categories so that we can better see those cost components on which MiPCT is doing relatively well and those on which we are not. Other cost areas doing well compared to PCMH but not sign: acute hospital, post-acute providers. Mixed or about the same: hospital outpatient Quarter 6 = April – July 2013

Care Manager Survey Results Valid % agree/strongly agree: May: 72% Dec: 79%

Care Manager Survey Results

2. Factors that influence sustainability and payer updates

Factors that Influence Continuity A. Demonstrating Success for Payers Demonstrating to each payer that their patients who would benefit from care management receive timely, effective services. Ability to Demonstrate Return on Investment (ROI) Coordinating transitions in care Value for dollars spent (decreasing spending on unnecessary utilization by at least as much as the MiPCT dollars received by POs and practices Improving quality and patient experience B. CMS decision on demonstration extension C. Fully leveraging MiPCT continuation within: The State Innovation Model (SIM) ACO development and Healthy Michigan Medicaid membership growth The soon-to-be-released refined CMS Chronic Care Code and other care management programs (such as the High Intensity Care Management Program, etc.)

A. Demonstrating Success for Payers: What Has Been Done MiPCT Leadership met with each payer to discuss ongoing participation Available care management funding details have been obtained for sharing with POs in this webinar

Priority Health Priority is committed to ongoing support for in-office care management via G/CPT codes Priority will increase its PCMH incentive payment for 2015 Priority has incorporated some system changes to ensure that their members (even if in HDHP plans with HSAs) will not incur member liability for care management services starting in 2015 Priority will be structuring its self-funded (Administrative Services Only or ASO) accounts with an opt-out structure.  This is intended to increase total membership who is eligible for care management.

BCBSM BCBSM is committed to continuing its support of in-office care management by MiPCT practices via G/CPT codes. BCBSM (and all MiPCT payers) look to PO and practices to continue full engagement and “commitment to the cause”. “Make Whole Payments" will cease after the end of the demonstration period so sustaining the effort will be dependent on adequate service provision and associated billing plus continuation of 5% uplift for eligible practices

BCN Conducting internal evaluation of BCN patients served Expected to be completed in June 2014 BCN will at that point revisit both 2015 MiPCT continuity participation consideration and ongoing payment of care management codes

Medicaid Placeholder in upcoming budget Potential movement to two different support levels to recognize the risk burden differences in: The Aged, Blind and Disabled (ABD) population The Temporary Assistance for Needy Families (TANF) population

Medicare Input into Development of New Monthly Chronic Care Management Code Dr. Malouin on Technical Advisory Panel Steering Committee letter on recommended modifications

B. CMS Decision on Demonstration Extension: What Has Been Done Governor Snyder has sent a formal letter to CMS requesting extension AARP and other state delegations have also sent letters Milbank Fund advocacy MiPCT and partner states have made CMS acutely aware of the need for timely decision

Our Own Governor’s Advocacy for MiPCT Continuity

Milbank and Partner State Advocacy for Continuity Update

C. Fully Leveraging MiPCT Participation in Related Efforts: What Has Been Done MiPCT incorporated in SIM Engaging discussion with payers on potential for consistent approach for other similar care management programs Leveraged communication with CMS on refinement of CMS Chronic Care Management code

CM Sufficiency Requirement Interim Consideration Discussions with payers have been constructive regarding ongoing sustainability as evidenced by the statements obtained thus far from plans. More detailed information (including information on the CMS chronic care code) is expected within the next six week period. Therefore for within the next six week period (from 5/24 -6/24/14), if a Care Manager resigns, the practice or PO will not be responsible for replacing them (in order to meet the 80% level of the 2/5000 care manager sufficiency ratio). However, once we have received clarity regarding ongoing funding for care management services in June, the expectation for MiPCT participation in 2014 and beyond is for the PO/practice to hire to meet the contractually defined ratios.     

ROI Subgroup Modeling The ROI Subgroup of the MiPCT has completed modeling for both practices operating within larger systems and for independent practice models. Key assumptions included: Ongoing funding for Care Management via existing G/CPT codes across all payers (including governmental payers) No incentive or practice transformation payments Assessment of care management activity levels necessary to meet and exceed “break-even” point of Care Manager salary, benefits and some overhead costs (space, PO coordination, etc.) Care Management activity (servicing and billing) levels must meet or exceed the cost of care management for POs and practices

3. MiPCT Post-Demonstration

What Might MiPCT Look Like “Post-Demo”? Essential components to maintain Uninterrupted funding for care management to POs and Practices Multipayer participation Support for key administrative components critical to success (accountability/governance and coordination; data reporting; CM Education; ADT and electronic infrastructure) Continued claims provision Opportunity to build on MiPCT momentum for “Phase Two” (MiPCT “V.2”) and related potential to expand to other practices

Post-Demonstration MiPCT Ongoing “MiPCT V.2” 1/1/12 Original Demonstration Period 1/1/15 Potential CMS Year Extension Components Maintained: Care Management Funding Central Administration, including Data and Reporting Training and Education Accountability and governance Practice Growth Over Time: Manage practice participation growth over time to reach State goals

MiPCT Key Messages Sustainability and Continuity The MiPCT demonstration period will close on 12/31/14 unless extended by CMS The Governor of Michigan has endorsed demonstration extension with CMS Several other Governors have also done so and the Milbank Fund is supporting efforts Regardless of whether CMS extends the demonstration: MiPCT leadership has been in discussions with participating payer regarding continuity CMS will release a revised national approach to monthly care management funding in July’s Federal Register Discussions with payers have been constructive and promising overall for ongoing support from most for: Continued care management funding Continued central operations funding for accountability Final agreements will be announced as soon as possible The MiPCT is a core component of Michigan’s State Innovation Model (SIM) Several POs have already expressed commitment to ongoing care management support post demonstration

MiPCT Key Messages Sustainability and Continuity, cont. It is natural that Care Managers, POs and practice teams are concerned about the opportunity to continue embedded care management after the demonstration period of the project. The MiPCT team understands this and has been working hard with payers for continued multipayer support for care management and ongoing MiPCT operations. We cannot lose focus on using the time left in the demonstration period to produce continued and improved results for each payer on: Increased volume of MiPCT eligible patients receiving Care Management Reduced Avoidable ED and Inpatient Visits Improved Clinical Metrics (especially diabetes) Your continued and focused efforts now on the key metrics above can pave the path to support the case for an ongoing project.

What Can You Expect Next? Updates as available from MiPCT leadership A follow-up sustainability briefing in June 2014