1. The Michigan Primary Care Transformation (MiPCT) Project
Annual Summit
October 2013
MiPCT Overview and Updates

2. Objectives Recap MiPCT Overview and 2013/14 Focus Areas
Review MiPCT Project Evaluator Findings to Date
Discuss Project Sustainability

3. MiPCT Overview
Jean Malouin

4. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration
Centers for Medicare & Medicaid Services is participating in state-based PCMH demonstrations
Assessing effect of different payment models
CMS Demo Stipulations
Must include Commercial, Medicaid, Medicare patients
Must be budget neutral over 3 years of project
Must improve cost, quality, and patient experience
8 states selected for participation, including Michigan
Michigan start date: January 1, 2012

5. Participants 380 practices 35 POs 1,500 physicians 1 million patients
5 Payers
Medicare
Medicaid managed care plans
BCBSM
BCN
Priority Health (7/13)

6. MiPCT Funding Model $0.26 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 non-Medicare Payers***
* Or equivalent
** Plans with existing payments toward MiPCT components may
apply for and receive credits through review process
*** Medicare will pay additional $2.00 PMPM to cover additional
services for the aging population

7. 4

8. MiPCT Mid-Point: Statewide Care Management Progress to Date
Over 300 Care Managers hired and trained
Building infrastructure in partnership with POs
CM Documentation tools
Ongoing Care Manager training, coaching, mentoring
Patient education materials
Communication- PCP, CM, staff members
Interface with community resources
Building volume of G code and CPT codes submitted
Building caseloads of targeted high-risk patients

9. Multi-Payer Claims Database
Collect data from multiple Payers and aggregate it together in one database
Creates a more complete picture of a patient’s information when they:
Receive benefits from multiple insurance carriers
Visit physicians from different Practices, Physician Organizations or Hospitals
Phase 1 – claims data
Phase 2 - claims and clinical data
Multi-Payer Claims Database
Medicare
Medicaid
BCN
BCBSM
MiPCT

10. MDC: MiPCT Dashboards Population Quality Measures Utilization Measures
Membership
Attributed members by Payer
Risk Information
# of members by Risk Level
Population Information
# patients by Chronic Condition (Asthma, CKD, CHF, etc)
Quality Measures
Screening and Test Rates
Diabetes tests, Cancer Screens, etc
Prevention
Immunization Rates, Wellness Visits, etc.
Comparison to Benchmarks
Utilization Measures
Rates
ED Use, Admissions, Re-admissions, etc
Comparison to Benchmarks

11. Admission, Discharge, Transfer MiPCT Data Flow and Progress
17 POs participate in the Care Team Connect (CTC)/MiPCT partnership (at no cost to PO)
Care managers access member lists directly via a web interface
ADT notifications adding for Trinity, Spectrum, Beaumont!

12. 2013-2014 Priorities Care managers fully integrated into practices
Target PCMH interventions to patients from all participating payers
Distribute multi-payer lists and dashboards
Ensure care management for at risk members
Use registry for proactive population management
Focus on efficient and effective health care
Avoid unnecessary services/hospitalizations
Assess practice utilization patterns
Ensure adequate clinic access to meet demands

13. How will CMS define success?
The tie to budget neutrality and ROI 13

14. MiPCT Brief Review: Balancing Successes and Challenges
Success on cost, quality and utilization measures is key to sustainability
Member lists vs. the population
G and CPT code billing and “throughput”
PO and practice infrastructure varies
Many competing priorities
Champions abound; We have gained traction!
Michigan is well-poised compared to other states despite its broad scale
Hard-working, dedicated people
Multi-payer Database
Strong PCMH foundation

16. MiPCT Evaluation Update
Clare Tanner

17. Objectives MiPCT Investment in PCMH Care Management Implementation
Quality/Utilization

18. MiPCT Practices

20. Financial Investment, 2012 Care Coordination $35,577,697
“New” Money1
Total2
Care Coordination
$35,577,697
Practice Transformation
$8,739,951
$28,287,509
New money includes: Medicaid, Medicare, BCN g-code payments, BCBSM g-code + make whole payments
Total adds in: BCBSM Practice transformation (E&M uplift) of $19 million, but does not include incentive payments

22. 70% have 1 practice
23% have 2-4 practices
7% have 5 or more practices

23. MiPCT Benchmark* for Care Manager Caseload
Care manager’s patient caseload – 2nd Quarter PO Data
Care Manager Role
90th Percentile Qtr 2
face to face/FTE
90th Percentile QTR 2
Phone encounters/FTE
Encounters per day = Benchmark*
Complex 84
260
6 encounters per day
Hybrid
160
321
8 encounters per day
Moderate
193
238
7 encounters per day
Keep as is – per team.

24. Care Manager Volume Quarter 2, 2013
Encounters
Unique Patients
Face to Face
Phone
Total
15,250
32,709
22,237
Per CM FTE 63
112 82
35 POs
5 POs are under the 80% minimum for care manager sufficiency
86% (n=30) have at least 80% care manager sufficiency
54% (n=19) of the 35 POs have 100% or better

25. 2013 PO Report – 1st & 2nd Quarter Care Manager Activities
Part time CMs are included. The metrics are normalized by FTE – this essentially inflates the number of visits/patients for part-time CMs to the level they would be at if they were full time.
The Mean increases are statistically significant.
The 75th percentile equals 5 encounters per day (quarter 2). We know the data may not be 100% accurate, but it is what we have today.

26. Care Manager Survey Conducted in May 2013
434 care managers asked to complete survey
53% completed the survey (n=228)

27. Care Manager Survey Results
Physician Interaction
Care Managers reported working with an average of 8.4 physicians
On average, 83% of these physicians referred patients
With respect to physician interaction, care managers reported working an average of 8.4 physicans
83% of these physicians referred patients.
Number of physicians worked with ranged from 0 to 97.
Proportion of physicians that referred patients ranged from 0% to 100%.

28. Care Manager Survey Results

29. Care Manager Survey Results
How CMS used the MiPCT List
Accuracy

30. Care Manager Survey Results
6% did not respond

31. Care Manager Survey Results
6.6% did not respond

32. Care Manager Survey Results
The physician(s) I work with support the concepts of the MiPCT care management team.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree

33. Care Manager Survey Results
Physicians are available on a daily basis to address questions related to management of MiPCT patients.
Never
Rarely
Sometimes
Frequently
Always

34. Care Manager Survey Results
Physicians understand and are actively involved in population management
Never
Rarely
Sometimes
Frequently
Always

35. Care Manager Survey Results
Top 3 broad areas of challenge
Care Manager Challenges
Need for work flow processes
Need for practice team support/understanding of CM role
Time management
Care Management Embedment
Need for practice staff education on CM role and process workflows
CMs serving multiple practices or working as a CM part time
Physician Engagement
Select all that apply

36. Care Manager Survey Results
Top 3 broad areas of success
Development of Process Improvement
Transition of Care
Using the MiPCT List
Reviewing the practice schedule regularly
Culture Change within the Practice
Physician engagement
Reviewing potential patients with the provider/use of huddles
Practice staff understanding of the CM role
Advanced/Improved IT Capabilities
Select all that apply

37. Cost, Quality and Utilization National and State Metrics

38. Utilization and Cost Metrics: MI and National Evaluations are Consistent
Total PMPM Costs
Medicare Payments (National)
Utilization based standardized cost calculations across all participating payers (Michigan)
Additional analysis of cost categories
Utilization
All-cause hospitalizations
Ambulatory care sensitive hospitalizations
All-cause ED visits
‘Potentially preventable’ ED visits

39. Quality and Experience of Care Metrics: MI and National Evaluations are Different, But Share Common Elements
Michigan
Diabetes
Asthma
Hypertension
Cardiovascular
Obesity
Adult preventive care
Child preventive care
Childhood lead screening (Medicaid)
Patient experience (CAHPS)
Provider/staff experience
National
Diabetes care:
LDL-C screening
HbA1c testing
Retinal eye examination
Medical attention for nephropathy
All 4 diabetes tests
None of the 4 diabetes tests
Ischemic Vascular Disease:
Total lipid panel test
Patient experience (CAHPS)

40. Cost, Quality and Utilization Initial Results (Year One)

41. MiPCT Number of POs with Quality Rate Changes
>= +10%
Positive
<10%
Negative
>-10%
<= -10%
Number of POs with Positive Change in All Group Measures
Breast Cancer Screening 1 22 12
Cervical Cancer Screening 30 5
Chlamydia Screening 8 7
Adult Preventive
Adolescent Well-Care 9 10 6
15-Month Well-Child 14
3-6 Year Well-Child
Well-Child Care
Diabetic Eye Exam 2 21
Diabetic HbA1c Testing 15 20
Diabetic LDL-C Testing 4 31
Diabetic Nephropathy Screening 3 19
Diabetes Care
MiPCT Number of POs with Quality Rate Changes
The care management programs were put into place in 2012

42. MiPCT Number of POs with Quality Rate Changes
Statistically Significant Increases (p<=.1)
Increases
(Not Statistically Significant)
Decreases (Not Statistically Significant)
Statistically Significant Decreases (p<=.1)
Overall MiPCT Change
Significant (p<=.1)
Breast Cancer Screening 5 18 11 1
Positive
Yes
Cervical Cancer Screening 31 4
Chlamydia Screening 15 10 9
Negative
Adolescent Well-Care 8
15-Month Well-Child 7 6 No
3-6 Year Well-Child 12
Diabetic Eye Exam
Diabetic HbA1c Testing 3 13 16
None
Diabetic LDL-C Testing 26
Diabetic Nephropathy Screening 14
MiPCT Number of POs with Quality Rate Changes
The care management programs were put into place in 2012

43. MiPCT 2012 PCS ED Rate per 1000 ED Visits Percent Change from 2011 Baseline Rate by PO
The care management programs were put into place in 2012
The percent change from baseline ranged from 4 to -16% with an overall change of -4%.

44. MiPCT Post-Demonstration Funding and Sustainability
Diane Marriott

45. What Does Sustainability Mean?
To the Health Plan: Added value for their customers
To the Practice: Maintaining and growing CM staffing, processes and roles
To the PO: Payment reform for CM
To the State and Patients: Servicing all patients, all payers
What is the “Return on Investment”?
To each payer?
To each PO?
How does the MiPCT fit in with other changes and projects?
How effective are practices at providing patients who can benefit from care management receive timely, effective services?

46. Sustainability Progress
Reduction of 4% in number of emergency room visits for MiPCT patients for ambulatory care-sensitive conditions from 2012 to 2013
Addition of Priority Health brings payer participation from the largest plans in Michigan
CMS Complex Care Management proposal
Patient Advisory Council launched that offers the patient voices and input in program design and operations
ROI PO Subgroup financial modeling
ADT messaging and direct Care Manager member list distribution at no cost to POs
PCMH incorporation in SIM proposal

47. PO Primary Care Sensitive Emergency Department Use (Change from 1/1/12 to 12/31/12)
No Improvement
For POs with Stat. Sig. Better Performance, Amt. of Change
Over 12%---2 POs
8-12% POs
5-8% POs
Under 5% --11 POs
Improved (not stat. sig.)
Overall, from 2012 to 2013, the MiPCT decreased avoidable emergency visits decreased almost 4%.

48. CMS Complex Care Management Post-Demo Payment Proposal
Good News! CMS Physician Fee Schedule included proposed codes for Complex Care Management quarterly payment beginning 1/1/2015.
MiPCT submitted comments on this constructive development, focusing on:
Encouraging consideration of quarterly payments for moderate care management as well
Discouraging CMS from imposing patient financial responsibility for care management services
Recognizing alternative designations (e.g., PGIP PCMH) for medical home definition
Removing the requirement that the practice employ an advanced care nurse or PA (NP or PA) and streamlining requirements for electronic all-provider communication, annual patient consent, etc.
Offering to share our experience and input on payment rates

49. We ARE the MiPCT! We can do this! We can make care better!

50. Questions?