Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. PDCM and PDCM-O Phase III Overview Billing Road Shows Fall 2015

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. PDCM for PCPs Effective July 1, 2015, all 1,551 PCMH-designated practices are eligible to bill the 12 Provider Delivered Care Management codes –MiPCT continues until 12/31/16 –New criteria applicable to non-MiPCT practices only PCMH-designated practices that meet additional criteria may qualify for the 5 percent PDCM uplift effective July 1, 2016 –It may take time for POs to engage all of their PCMH-designated practices in PDCM –It is not expected that all practices will be ready to qualify for uplift by July 1, 2016 –Practices that do not qualify in 2016 will have future opportunities As part of the 5% uplift, an annual attestation process will take place for non-MiPCT PCMH-designated practices only –Part of PCMH nomination process

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. PCP Attestation Process Physician organizations will attest that each practice has: –Physician champion who is a proponent of care management, understands PDCM, and will refer patients for care management –Access to a trained care manager who will close gaps in care for engaged patients when appropriate –Practice panel managers or PO clinical leads who will actively work to close gaps in care across the patient population –Appropriate staff participation in BCBSM billing webinars

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Training Requirements PDCM training requirements are similar to those of MiPCT, and include: –Self-management support training through a Care Management Resource Center-approved program List of approved trainings available on CMRC website: –CMRC complex care management training, completed prior to 7/1/16 –Participation in at least 75 percent of the ongoing CMRC webinars

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Claims Requirement Practices that have participated in PDCM/MiPCT for at least one year must have submitted claims for at least 2 percent of their Blue Cross Commercial PDCM-eligible patients –Based on claims data for the prior calendar year –Using BCBSM PCP attribution process For practices at the end of their first year of participation, only 6 months of claims data will be available, so claims must have been submitted for at least 1 percent of PDCM-eligible patients.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. PDCM for Oncologists Eligibility for the 5 percent PDCM-O uplift will be assessed annually and uplifts will be started, stopped, or continued at the same time as non- oncology specialist fee uplifts –Starting in 2016, this will be in March (previously Feb.) To qualify for the PDCM-O fee uplift, oncology practices must meet the following criteria: –Claims have been submitted for at least 2 percent of practices’ Blue Cross Commercial attributed members, based on the most recent 12 months –Practice has core PCMH capabilities in place, as developed by the PDCM-O Workgroup in Practices that have been receiving the uplift for one or more years must also have Advanced PCMH capabilities in place.

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Attestation for PDCM-O Oncology practice attests to having: –At least one oncologist who is a proponent/supporter of care management, understands and intends to actively engage in the PDCM-O program, and has participated in at least one CMRC educational webinar –At least one care manager who has participated in the CMRC oncology care management training Additional training dates will be available in late 2015/early Stay tuned!

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Appendix: PDCM-O Core Capabilities 2.0 Patient registry Capability 2.1 Patient registry for all chemotherapy patients Capability 2.5Attributed practitioner Capability 2.8Patient demographics and clinical parameters 3.0 Performance reporting Capability 3.4Data validated 4.0 Individual care management Capability 4.1PCMH training Capability 4.2Integrated team of multi-disciplinary providers Capability 4.3Evidence-based care guidelines in use at point of care Capability 4.5Action plan and self-management goal-setting Capability 4.6Appointment tracking and reminders – one chronic condition Capability 4.7Follow-up for needed services – one chronic condition Capability 4.8Planned visits – one chronic condition Capability 4.10Medication review and management Capability 4.16Advance care planning Capability 4.18Palliative care

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Core Capabilities cont’d. Required capability for all oncology PUs to participate in PDCM 5.0 Extended access Capability hour access to a clinical decision-maker by phone with feedback loop within 24 hours Capability 5.4All patients fully informed about after-hours care availability Capability 5.9 Practice unit has telephonic or other access to interpreters for all languages common to practice's established patients 13.0 Coordination of care Capability 13.1Notified of each patient admission and discharge Capability 13.2 Process for coordinating information exchange with other providers Capability 13.3Systematically track patients across all care settings Capability 13.4Flags for time-sensitive health issues Capability 13.5Transition plans Capability 13.6Coordination of care for patients with complex/catastrophic conditions Capability 13.7Coordination care process 14.0 Specialist referral process Capability 14.1Defined parameters for referral process from PCPs Capability 14.2Documented procedures for referral process Capability 14.3Specialist directory Capability 14.5Makes specialist appointments on behalf of patients Capability 14.7Completion of referral by patient Capability 14.8Staff training on referral process Capability 14.10Physician to physician pre-consultation

Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Advanced Capabilities 2.0 Patient registry Capability 2.3Evidence-based care guidelines 3.0 Performance reporting Capability 3.1Performance reports and comparison of results Capability 3.2PO/sub-PO, practice unit, and individual provider level Capability 3.3Registry for all cancer patients Capability 3.5Trend reports Capability 3.6Performance reports for populations of patients Capability 3.7Performance reports including well patients 4.0 Individual care management Capability 4.4One chronic condition Capability 4.17Survivorship plan 5.0 Extended access Capability 5.3Access to non-ED after-hours provider for urgent care needs during at least 8 after-hours per week, with feedback loop