1. The Michigan Primary Care Transformation (MiPCT) Project
Sustainability Update
May 14, 2014

2. Where We Started Together The Vision for a Multi-Payer Model
Use the CMS Multi-Payer Advanced Primary Care Practice demo as a catalyst to redesign MI primary care
Multiple payers will fund a common clinical model
Allows global primary care transformation efforts
Support development of evidence-based care models
Create a model that can be sustained and expanded
Facilitate measurable, significant improvements in population health for our Michigan residents
Bend the current (non-sustainable) cost curve
Contribute to national models for primary care redesign
Form a strong foundation for successful ACO models

3. Evaluation results available to date
Continuing the Journey MiPCT Post Demonstration: A Sustainability Update
Evaluation results available to date
Factors that influence sustainability and payer updates
MiPCT post-demonstration period

4. Evaluation results available to date

5. Quarterly Trend Comparison: Medicare PMPM Payments
Michigan: quarterly regression difference-in-differences estimates and 90% confidence intervals for total PBPM Medicare payments, comparing performance for Medicare beneficiaries assigned to MAPCP Demonstration PCMHs vs. beneficiaries assigned to comparison PCMHs and non-PCMHs
Negative numbers indicate that total Medicare payments increased less for beneficiaries assigned to MAPCP Demonstration practices than for beneficiaries in the comparison group, and suggest that the MAPCP Demonstration is yielding cost savings.
RTI presents payment data in multiple categories so that we can better see those cost components on which MiPCT is doing relatively well and those on which we are not.
Other cost areas doing well compared to PCMH but not sign: acute hospital, post-acute providers.
Mixed or about the same: hospital outpatient
Quarter 6 = April – July 2013

6. Care Manager Survey Results
Valid % agree/strongly agree:
May: 72%
Dec: 79%

7. Care Manager Survey Results

8. 2. Factors that influence sustainability and payer updates

9. Factors that Influence Continuity
A. Demonstrating Success for Payers
Demonstrating to each payer that their patients who would benefit from care management receive timely, effective services.
Ability to Demonstrate Return on Investment (ROI)
Coordinating transitions in care
Value for dollars spent (decreasing spending on unnecessary utilization by at least as much as the MiPCT dollars received by POs and practices
Improving quality and patient experience
B. CMS decision on demonstration extension
C. Fully leveraging MiPCT continuation within:
The State Innovation Model (SIM)
ACO development and Healthy Michigan Medicaid membership growth
The soon-to-be-released refined CMS Chronic Care Code and other care management programs (such as the High Intensity Care Management Program, etc.)

10. A. Demonstrating Success for Payers: What Has Been Done
MiPCT Leadership met with each payer to discuss ongoing participation
Available care management funding details have been obtained for sharing with POs in this webinar

11. Priority Health
Priority is committed to ongoing support for in-office care management via G/CPT codes
Priority will increase its PCMH incentive payment for 2015
Priority has incorporated some system changes to ensure that their members (even if in HDHP plans with HSAs) will not incur member liability for care management services starting in 2015
Priority will be structuring its self-funded (Administrative Services Only or ASO) accounts with an opt-out structure.  This is intended to increase total membership who is eligible for care management.

12. BCBSM
BCBSM is committed to continuing its support of in-office care management by MiPCT practices via G/CPT codes.
BCBSM (and all MiPCT payers) look to PO and practices to continue full engagement and “commitment to the cause”.
“Make Whole Payments" will cease after the end of the demonstration period so sustaining the effort will be dependent on adequate service provision and associated billing plus continuation of 5% uplift for eligible practices

13. BCN Conducting internal evaluation of BCN patients served
Expected to be completed in June 2014
BCN will at that point revisit both 2015 MiPCT continuity participation consideration and ongoing payment of care management codes

14. Medicaid Placeholder in upcoming budget
Potential movement to two different support levels to recognize the risk burden differences in:
The Aged, Blind and Disabled (ABD) population
The Temporary Assistance for Needy Families (TANF) population

15. Medicare
Input into Development of New Monthly Chronic Care Management Code
Dr. Malouin on Technical Advisory Panel
Steering Committee letter on recommended modifications

16. B. CMS Decision on Demonstration Extension: What Has Been Done
Governor Snyder has sent a formal letter to CMS requesting extension
AARP and other state delegations have also sent letters
Milbank Fund advocacy
MiPCT and partner states have made CMS acutely aware of the need for timely decision

17. Our Own Governor’s Advocacy for MiPCT Continuity

18. Milbank and Partner State Advocacy for Continuity Update

19. C. Fully Leveraging MiPCT Participation in Related Efforts: What Has Been Done
MiPCT incorporated in SIM
Engaging discussion with payers on potential for consistent approach for other similar care management programs
Leveraged communication with CMS on refinement of CMS Chronic Care Management code

20. CM Sufficiency Requirement Interim Consideration
Discussions with payers have been constructive regarding ongoing sustainability as evidenced by the statements obtained thus far from plans.
More detailed information (including information on the CMS chronic care code) is expected within the next six week period.
Therefore for within the next six week period (from 5/24 -6/24/14), if a Care Manager resigns, the practice or PO will not be responsible for replacing them (in order to meet the 80% level of the 2/5000 care manager sufficiency ratio).
However, once we have received clarity regarding ongoing funding for care management services in June, the expectation for MiPCT participation in 2014 and beyond is for the PO/practice to hire to meet the contractually defined ratios.     

21. ROI Subgroup Modeling
The ROI Subgroup of the MiPCT has completed modeling for both practices operating within larger systems and for independent practice models. Key assumptions included:
Ongoing funding for Care Management via existing G/CPT codes across all payers (including governmental payers)
No incentive or practice transformation payments
Assessment of care management activity levels necessary to meet and exceed “break-even” point of Care Manager salary, benefits and some overhead costs (space, PO coordination, etc.)
Care Management activity (servicing and billing) levels must meet or exceed the cost of care management for POs and practices

22. 3. MiPCT Post-Demonstration

23. What Might MiPCT Look Like “Post-Demo”?
Essential components to maintain
Uninterrupted funding for care management to POs and Practices
Multipayer participation
Support for key administrative components critical to success (accountability/governance and coordination; data reporting; CM Education; ADT and electronic infrastructure)
Continued claims provision
Opportunity to build on MiPCT momentum for “Phase Two” (MiPCT “V.2”) and related potential to expand to other practices

24. Post-Demonstration MiPCT
Ongoing “MiPCT V.2”
1/1/12
Original Demonstration Period
1/1/15
Potential CMS Year Extension
Components Maintained:
Care Management Funding
Central Administration, including
Data and Reporting
Training and Education
Accountability and governance
Practice Growth Over Time: Manage practice participation growth over time to reach State goals

25. MiPCT Key Messages Sustainability and Continuity
The MiPCT demonstration period will close on 12/31/14 unless extended by CMS
The Governor of Michigan has endorsed demonstration extension with CMS
Several other Governors have also done so and the Milbank Fund is supporting efforts
Regardless of whether CMS extends the demonstration:
MiPCT leadership has been in discussions with participating payer regarding continuity
CMS will release a revised national approach to monthly care management funding in July’s Federal Register
Discussions with payers have been constructive and promising overall for ongoing support from most for:
Continued care management funding
Continued central operations funding for accountability
Final agreements will be announced as soon as possible
The MiPCT is a core component of Michigan’s State Innovation Model (SIM)
Several POs have already expressed commitment to ongoing care management support post demonstration

26. MiPCT Key Messages Sustainability and Continuity, cont.
It is natural that Care Managers, POs and practice teams are concerned about the opportunity to continue embedded care management after the demonstration period of the project.
The MiPCT team understands this and has been working hard with payers for continued multipayer support for care management and ongoing MiPCT operations.
We cannot lose focus on using the time left in the demonstration period to produce continued and improved results for each payer on:
Increased volume of MiPCT eligible patients receiving Care Management
Reduced Avoidable ED and Inpatient Visits
Improved Clinical Metrics (especially diabetes)
Your continued and focused efforts now on the key metrics above can pave the path to support the case for an ongoing project.

27. What Can You Expect Next?
Updates as available from MiPCT leadership
A follow-up sustainability briefing in June 2014