Maine PCMH Pilot & MAPCP Demonstration Update Lisa M. Letourneau MD, MPH September 2013

Healthy, productive, connected people & families …receiving healthcare from a highly functioning “accountable care organization ” Vision for a Transformed Health Care System … supported by a robust & well-supported primary care base

The Current Primary Care Home 3

The Medical Home: A Start for Change! Providers transform practice, create value with viable & sustainable payment for desired services = Practice Transformation Employers & payers pay for desired services because primary care demonstrates value & saves money = Payment Reform ANDAND 4

Maine PCMH Pilot Leadership Maine Quality Counts DHA’s Maine Quality Forum Maine Health Manageme nt Coalition MaineCare (Medicaid) 5

Maine PCMH Pilot Practice “Core Expectations” 1.Demonstrated physician leadership for improvement 2.Team-based approach 3.Population risk-stratification and management 4.Practice-integrated care management 5.Same-day access to care 6.Behavioral-physical health integration 7.Inclusion of patients & families 8.Connection to community / local HMP 9.Commitment to reducing avoidable spending & waste 10.Integration of health IT 6

Support for Practice Transformation PCMH Learning Collaborative – Institute for Healthcare Improvement (IHI) Breakthrough Series (BTS) model; 3 learning sessions/year Practice Quality Improvement (QI) Coaches – Most from existing physician hospital organizations (PHOs), medical groups – Using microsystems approach to QI Technical Assistance “Experts” – Behavioral health (BH) integration, work with consumers, HIT Ongoing Feedback Reports – Clinical, claims data 7 Lisa Letourneau

Maine PCMH Pilot – Payment Model Major private payers, Medicaid, & Medicare participating (MAPCP demo) PCMH payment model:  Prospective (pmpm) care management payment  Approx $3pmpm commercial payers (Anthem, Aetna, HPHC)  Approx $7pmpm Medicare, $12 Medicaid HHs  Ongoing FFS payments  Performance payment for meeting quality targets (existing P4P programs) 8

Community Care Teams Multi-disciplinary, community-based, practice- integrated care teams Build on successful models (NC, VT, NJ) Support patients & practices in Pilot sites, help most high-needs patients overcome barriers – esp. social needs - to care, improve outcomes Key element of cost-reduction strategy, targeting high-needs, high-cost patients to reduce avoidable costs (ED use, admits) 9

Maine PCMH Pilot - MAPCP Timeline ME PCMH Pilot - Original ME PCMH Pilot - Extended Jan 1, 2010 Dec 31, 2014 Jan 1, 2012 Pilot Expansion, HHs Dec 31, 2014 MAPCP Demo – 3yr 10

Implications of CMS MAPCP Demo Medicare joined as payer in Pilot (Jan 2012) Stronger focus on reducing waste & avoidable costs – particularly readmissions Introduction of Community Care Teams Ability to access Medicare data for reporting, identifying pts at risk Opportunity for 50 additional practices to join “Phase 2” of Pilot (Jan 2013) 11

12 FQHC: federally qualified health center H-O: hospital-owned Original (Phase 1) 26 PCMH Pilot Practices

Maine PCMH Pilot Community Care Teams, Phase 1 and Phase 2 Practice Sites 13

Alignment of Pilot with MaineCare Health Homes Initiative Affordable Care Act (ACA) Sect opportunity to develop Medicaid “Health Homes” initiative MaineCare elected to align HH initiative with current multi-payer Pilot – part of VBP initiative Defined MaineCare “Health Home”(HH): HH = PCMH practice + Community Care Team (CCT) Opportunity to leverage multi-payer PCMH model, practice transformation support infrastructure Maine SIM funding will support QI outreach to HHs 14

Maine’s Medical Home Movement ~ 540 Maine Primary Care Practices 25 Maine PCMH Pilot Practices 50 Pilot Phase 2 Practices 120+ NCQA PCMH Recognized Practices ~150 eligible MaineCare HH-Practices Payers: Medicare Medicaid (HH) Commercial plans (Anthem, Aetna, HPHC) Self-funded employers Payer: Medicaid Payer: Medicare 14 FQHCs CMS APC Demo 15

PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!) Patient Centered Medical Home Primary Care Providers Employers Hospitals/ Hospitalists/ Care Managers Home Health Nursing Homes Specialists Health Mane Parterships Home CarePharmaciesPayers 16 ACO

ACOs in Maine – What’s Happening? Medicare – multiple ACO options – Pioneer ACO – EMHS/Beacon – Shared Savings prgrms – MH, CMMC, ME Comm ACO Medicaid: Value-Based Purchasing strategy – MaineCare -“Accountable Communities” proposals Employer-Provider ACO Pilots – Maine Health Management Coalition leadership – MaineGeneral-SEHC, EMMC, other pilots 17

PCMH & MAPCP Demo: Results to Date Formal evaluation (USM Muskie) underway – Baseline (2008) analysis completed – Yr 1 & Yr 2 results expected fall 2013 – Yr 3 results expected Q AF4Q analysis of claims data shows decreased utilization (hosp’s, ED visits) Results from other Pilots nationally showing positive results 18

PCMH – Lessons Learned Move to PCMH requires transformation (not incremental change) of entire practice, culture, and personal transformation (esp. physicians!) Change starts with effective leadership – organizational, clinician, and administrative Multi-payer approach is essential to create sufficient resources for change Changing practice (and culture) takes time Change fatigue is serious concern Transforming primary care is essential to wider efforts! 19

A Compelling Case for Action 20

Summing Up: Primary Care Transformation… Is difficult, requires true culture change Needs sufficient time & resource Essential to wider payment reform efforts! 21

Contact Info / Questions Maine PCMH Pilot: (See “Major Programs”  “PCMH Pilot”) – Lisa Letourneau MD, MPH : – Practice Transformation Lead: Nancy Grenier – Project Management Lead: Lisa Tuttle MaineCare Health Homes – Kitty Purington: