Will Groneman Executive Vice President System Development TriHealth Innovation Grant: CMMI Comprehensive Primary Care Initiative (CPCi) presented to HFMA Southwestern Ohio Chapter Will Groneman Executive Vice President System Development TriHealth

Comprehensive Primary Care Initiative (CPCi) What is it? 4-year pilot program from CMS Innovation Center – CMMI Authorized under the Accountable Care Act Funding for 330,750 Medicare and Medicaid beneficiaries

Comprehensive Primary Care Initiative (CPCi) What is it? 4-year pilot program from CMS Innovation Center – CMMI Authorized under the Accountable Care Act Funding for 330,750 Medicare and Medicaid beneficiaries Designed to accomplish the “triple aim” at the community level Aligns multiple payers in a community around common goals

Comprehensive Primary Care Initiative (CPCi) What is it? 4-year pilot program from CMS Innovation Center – CMMI Authorized under the Accountable Care Act Funding for 330,750 Medicare and Medicaid beneficiaries Designed to accomplish the “triple aim” at the community level Aligns multiple payers in a community around common goals Aimed at Primary Care Physicians Builds on the “Medical Home” concept Holds PCP practices accountable for the total cost of care Solicitation issued in late September 2011

Comprehensive Primary Care Initiative (CPCi) CMS’ Framework for Comprehensive Primary Care Risk stratified care management Access and continuity Planned care for chronic conditions and preventive care Patient and caregiver engagement Coordination of care across the medical neighborhood

Four Basic Steps in the Process Select communities to participate Number of commercial plans willing to participate Support of state Medicaid Community infrastructure and history of collaboration Seven Communities were selected Arkansas Colorado New Jersey Oregon New York Capital District-Hudson Valley Region Greater Tulsa Region Cincinnati-Dayton-Northern Kentucky Region Community selection completed April 2012

Four Basic Steps in the Process Select Communities to participate (April 2012) Align payers who are willing to commit to: Payment above normal Fee-for-Service (e.g. pmpm) CMS pmt will be risk adjusted and will average $20 pmpm Provide gainsharing opportunities in years 2-3-4 Common set of metrics for cost, quality, service Using 18 of the 33 ACO measures as a starting point Providing aggregate member level cost/utilization data Signing a Letter of Intent with CMS Cincinnati had 10 payers commit to participate Includes Aetna, Anthem, Humana, Medicaid, MMO, United Payers signed non-binding LOIs in June 2012

Four Basic Steps in the Process Select Communities to participate Align payers Select PCP Practice Locations Practice = physical office location 75 practices per market to be selected Screening Criteria: 150 FFS Medicare patients Physicians have attested to Meaningful Use Qualitative Criteria: >60% of patients are covered by participating payer Demonstration of readiness to transform PCMH Recognized Commitment to transformational activities Practices to be selected August 2012

Year 1 Commitments Required by CMS Complete an annual budget Implement risk stratification methodology for all patients Attest to 24/7 patient access to a nurse or practitioner with access to the patient’s EHR Establish baseline for patient satisfaction using CG-CAHPs Demonstrate care coordination for the medical neighborhood and c omply with at least one of the following: Notification of ED visit in a timely fashion Med reconciliation completed with 72 hours of hospital discharge Exchange of clinical information at the time of admission and at discharge Exchange of clinical information between PCP-specialists Participate in quarterly market based learning collaborative

Four Basic Steps in the Process Select Communities to participate Align payers Select PCP Practice Locations “Negotiate” with practices and start program No negotiations with CMS Expect limited negotiation with plans Will need to conform with their LOI commitments Will plans cover TriHealth PCMH sites not selected? Not clear if “ASO” employers will participate Go-live November 1, 2012 13 months from solicitation to go-live

CPCi v. Accountable Care Organization Focus is on Patient Centered Medical Home (PCMH) as the foundation for managing care ACO not as prescriptive as to care management strategy Provides new funding for infrastructure Focused on adult PCP sites For systems: only funds part of the PCP base For independents: provides funding to sustain independence Requires participating competitors to cooperate in sharing best practices Goal is to demonstrate impact at the community level Monthly meetings of practices

CPCi v. Accountable Care Organization Requires commercial plans/Medicaid support Must provide additional pmpm funding Patient attribution updated quarterly Must commit to a common “menu” of cost/quality measures to be used for gainsharing program Must provide monthly claims/utilization data Still defining level of detail Monthly multi-stakeholder meetings ASO customers must agree to participate Does not require gainsharing/full risk on day 1 Year 1 used to build capabilities and establish data baselines Gainsharing in years 2-3-4 still undefined

CPCi Challenges Attribution requires 24 months of claims experience What happens when a commercial enrollee switches plans Many “Key Success Factors” still undefined Attribution methodology Cost/utilization data specificity Gainsharing methodology Severity adjustment methodology CMS’ agenda does not always support community existing initiatives Public Reporting through the Health Collaborative

CPCi Challenges Self Insured Employers must agree to participate ASO provider cannot commit without their consent Threats to health system goal of creating a system brand for their PCP network TH has 34 PCP practice locations 30 NCQA Recognized Level 3 PCMH sites 19 Sites have been selected by CMS to participate Funding only applies to 19 sites How to fund remaining 15 sites? Can we get performance data for non CPCi sites even if we are not part of a payer’s P4P program?

CPCi Challenges Common community agenda still a challenge 19 Common Quality/Measures Selected CMS priorities Medicare Advantage “star” program measures Medicaid plans’ payment incentives Commercial payers’ national quality/cost agendas

. Questions?