1. Michigan’s Multi-Payer Advanced Primary Care Practice Demonstration – Application to CMS
Carol Callaghan
Michigan Department of Community Health and
Michigan Primary Care Consortium

2. Priorities of the Michigan Primary Care Consortium
Transform Primary Care Practices to routinely provide evidence-based, coordinated, whole-person care
Reform Payment System for primary care
Engage Consumers in their own health management
Rebuild the Primary Care Workforce
Most Promising Solution to ALL of the above:
Patient-Centered Medical Home (PCMH)

3. CMS Requirements for Multi-Payer PCMH Demo
Up to 6 states to be selected
Number of Medicare beneficiaries < 150,000 (More might be allowed if case is compelling)
Total Medicare funding < $10 PMPM
Common payment methodology
Budget neutral over 3 years of project
Multi-payers, including Medicaid, commercial plans, self-insured employer-sponsored group health plans
CMS GOAL:
Determine the impact of PCMH on cost and quality of health care

4. Stakeholders in MI Application for PCMH Demo
Payers, public and private 16
PO/PHO/IPA’s 32
PGIP-PCMH/NCQA Practices
477
Beneficiaries
Medicare
358,000
Medicaid (non-dual)
248,000
Privately insured
1,153,000
Total Beneficiaries
1,749,000

5. Proposed Governance Steering Committee MDCH – 3
PO/PHO/IPA – 6 (elected)
Payers – 5 (elected)
Advisory Committee
Professional medical associations
Other participating payers
Other participating POs/PHOs/IPAs
Others

6. Clinical Model
Support for deeper practice transformation will take place through networks of PO’s plus learning collaboratives, with special focus on:
Care Management
Self-Management Support
Care Coordination
Linkage to Community Services

7. Proposed Funding Model
$ .26 PMPM Administrative Expenses
$3.00 PMPM Care Management Support
$1.50 PMPM Practice Transformation Reward
$3.00 PMPM Performance Improvement
$7.76 PMPM Total Payment by Payers*
* Medicare will pay additional $2.00 PMPM to cover additional services for the aging population

8. Participating Payers Commercial Medicare Medicaid Fee For Service
Blue Care Network
Blue Cross Blue Shield of Michigan
Health Alliance Plan
HealthPlus of Michigan
McLaren Health Plan
Physicians Health Plan of Mid-Michigan
Priority Health
Medicare
Medicaid Fee For Service

9. Participating Payers (continued)
Medicaid Managed Care Plans
CareSource
Great Lakes Health Plan
Health Plan of Michigan
HealthPlus Partners
McLaren Health Plan
Midwest Health Plan
Molina Healthcare
Physicians Health Plan of Mid-Michigan
Priority Health, Gov’t Programs, Inc.
Total Health Care
Upper Peninsula Health Plan

10. If Michigan is NOT selected by CMS . . .
Could we do this anyway, without Medicare?
Would Michigan payers agree?
Would support from employers be useful?
Would legislative authority be useful? or necessary?