1. The Michigan Primary Care Transformation (MiPCT) Project Succeeding in 2014: What it Will Take

2. MiPCT Team-Based Care Recap 16

3. MiPCT Team-Based Care Evergreen” Themes Care managers work in close proximity to PCP team ▫ In PCP office as much as possible ▫ Work with PCP team to meet their needs ▫ Regular communication via huddles, medical meetings, etc. Ensure Care Management coverage ▫ Focus on MiPCT patients (across participating payers) ▫ Manage high-complexity, high-cost patients ▫ Patients selected based on risk score plus PCP input Focus on evidence-based interventions ▫ Medication reconciliation ▫ Care transitions ▫ In-person contact with patients whenever possible ▫ Comprehensive care plan for complex patients 16

4. Success = Improvements in Population Health + Cost + Patient Experience 4

5. Reduction in Unnecessary and Non- Value-Added Costs 5 5 How do we make a dent in cost? -Preventing unnecessary ED and inpatient visits by providing care upstream before a crisis - Making sure your patients know about your extended access and how to reach you after hours - Using resources more wisely

6. 2014 Priorities Target the Right Patients ▫ Combine data with clinical judgment Introduce palliative care opportunities when appropriate Diabetes Management Expanded Access ▫ Make sure patients know how to contact the practice’s 24/7 access 6

7. MiPCT: Beyond 2014… 7

8. Preparing for Sustainability Physician Organizations have made a significant investment in care management Working hard for payers to support the model financially We need your help! 8

9. CMS – Looking for Solutions (desperately) Areas of promise – what we’re doing! Good directional signs ▫ CMS Quarterly Payment Proposal (for 2015) ▫ Commercial Payer Sustainability Statement ▫ Potential for Demo Extension Question on the table - Can primary care redefine care delivery? ▫ This is our best (last?) chance to provide the answer ▫ If successful, can lead to new funding models 9

10. How can YOU help shape the future? 10

11. It’s Time to Put on Your Cape! 11

12. Thank You!