1. The Michigan Primary Care Transformation (MiPCT) Project Update MiPCT Overview

2. MiPCT Origin and Partners 2

3. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Centers for Medicare & Medicaid Services interested in PCMH improving US health care and value ▫ Participating in state-based PCMH demonstrations CMS Demo Stipulations ▫ Must include Commercial, Medicaid, Medicare patients ▫ Must be budget neutral over 3 year (2012-14) period ▫ Must improve cost, quality, and patient experience 8 states selected to participate, including Michigan Michigan and five other states granted a two year extension (through 12/31/16) by CMS Michigan’s other participating payer partners also extend their participation until 12/31/16 3

4. MAPCP Demo: Participating States Maine 70 practices 122,420 patients Michigan 358 practices 1,109,926 patients Minnesota **282 practices 1,013,545 patients New York 41 practices 99,019 patients North Carolina 47 practices 83,553 patients Pennsylvania ** 51 practices 163,670 patients Rhode Island 16 practices 57,676 patients Vermont123 practices 272,324 patients ____________________________________________ TOTAL 988 practices 2,922,151 patients ** no 2015-16 extension granted

5. 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 broadly disseminated ▫ 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 5

6. Practice Participation Criteria Criteria: Continuous PGIP or NCQA designation Part of a participating PO/PHO/IPA Maintain key PCMH capabilities (e.g., extended access; 30% same-day scheduling; registry, etc.) Agree to work on the four selected focus initiatives: o Care Management o Self-Management Support o Care Coordination o Linkage to Community Services 6

7. MiPCT Participants 355 practices 35 POs 1,815 physicians 1.1 million patients – Medicare – Medicaid managed care plans – BCBSM – BCN – Priority Health (7/13)

8. Two Primary Interventions 8 Clinical (care managers embedded in primary care office) Financial (payment for care management services)

9. MiPCT Financial Model 9

10. MiPCT Funding Model $0.26 pmpm Administrative Component $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*** *Commercial payers fund via care management G and CPT billing and amounts paid are based on services provided (may exceed or be less than $3 pmpm) ** 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 10

11. MiPCT Clinical Model: Optimizing Patient Engagement, Improving Population Health 11

12. PCMH as the Foundation for ACO Population Management 12 Source: Premier Healthcare Alliance The goal of Accountable Care Organizations should be to reduce, or at least control the growth of, healthcare costs while maintaining or improving the quality of care patients receive (in terms of both clinical quality, patient experience and satisfaction). - Harold Miller

13. IV. Most complex (e.g., Homeless, Schizophrenia) III. Complex Complex illness Multiple Chronic Disease Other issues (cognitive, frail elderly, social, financial) II. Mild-moderate illness Well-compensated multiple diseases Single disease I. Healthy Population <1% of population Caseload 15-40 3-5% of population Caseload 50-200 50% of population Caseload~1000 Managing Populations: Stratified approach to patient care and care management

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15. MiPCT Care Management Principles Care managers work in close proximity to PCP team ▫ In PCP office as much as possible ▫ Work with PCP team to meet their needs ▫ Evidence supports this model as superior to vendor- based Focus on Chronic Disease and Complex Care ▫ Manage high-complexity, high-cost patients and those who are likely to benefit from care management ▫ 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 and coordinated care plan 16

16. MiPCT PO/Practice Expectations Care management ▫ Performed for appropriate high and moderate risk individuals ▫ Transitions of care promptly coordinated Population management ▫ Registry functionality ▫ Proactive patient outreach ▫ Point of care alerts for services due Access improvement ▫ 24/7 access to clinician ▫ 30% same-day access ▫ Extended hours 16

17. Resources To POs, Practices 17

18. Care Management Resources For launch, partnered with Geisinger for Care Management training ▫ How to identify patients for care management ▫ Tools for care management deliver that draw from best practices ▫ How to integrate within your practice Over 400 care managers trained! ▫ National and local evidence-based models ▫ Also allow credit for existing PO/PHO training models

19. Multipayer Data Warehouse 19 Summary level and PO-specific Delivered to PO (and practices for whom PO approves access) PO Multi-Payer Claims Database datasets reports Practice datasets reports datasets reports PO Retrospective Reports  Quality and Utilization performance metrics chosen for the project (recent incorporation of registry data) Requires 2-3 month run-out to ensure availability of complete data Prospective Reports  Timely feedback about attributed population for use in care management Incentive Payments Reports  Incentive scores and payments Member List Reports

20. MDC: MiPCT Dashboards 20 Population 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

21. MiPCT/MiHIN/CareBridge Admission, Discharge, Transfer (ADT) Electronic Alerting Provided via project (at no cost to PO) Allows Care Managers near-real-time web-based ADT alerting for timely initiation of transition care (Trinity, HFHS, UM, Beaumont, Oakwood, McLaren, etc.

22. Incorporating the Voice of Patients Statewide Patient Advisory Council with representatives from across the state ▫ Real patients and families served by the program ▫ Advise on program design and operation Launch of patient and family advisors within primary care practices (in partnership with the Institute for Patient and Family-Centered Care and the Greater Detroit Area Health Council)

23. Team Development Resources Goal: Build on PCMH team-based capabilities ▫ Using team members to the maximum capability of their roles and licenses ▫ Clearly define roles for physicians, nurses, medical assistants, front office staff, and all other team members (social workers, pharmacists, dieticians, etc.) Updates and Dialogue with Physician Organizations as key partners and supporters of practice teams Facilitated learning opportunities for practice teams ▫ Examples: Practice Collaboratives (e.g., team-based care, billing and coding, etc.), Practice Coaching, webinars, etc.

24. 24 www.mipctdemo.org

25. Cost, Quality and Utilization National and State Metrics 25

26. How Will We Define Success? 26

27. 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 27

28. 2012-14 Quality and Experience of Care Metrics: MI and National Evaluations are Different, But Share Common Elements (Discussion in process re: 2015/16) 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) Michigan Diabetes Asthma Hypertension Cardiovascular Obesity Adult preventive care Child preventive care Childhood lead screening (Medicaid) Patient experience (CAHPS) Provider/staff experience 28

29. Success = Improvements in Population Health + Cost + Patient Experience 29

30. Reduction in Unnecessary and Non- Value-Added Costs 30 The tie to budget neutrality and ROI

31. Cost, Quality and Utilization Results to Date 31

32. MiPCT Statewide Progress to Date Over 400 Care Managers hired and trained ▫ Building caseloads of targeted high-risk patients Building infrastructure in partnership with participating Physician Organizations and practices ▫ Ongoing Care Manager training, coaching, mentoring ▫ Learning collaboratives (team-based care, billing) ▫ 2014 - developing Palliative Care expertise ▫ Best-practice sharing Multi-payer claims database ▫ Dashboards, member lists, activity reports ▫ Now incorporating clinical (registry) data 32

33. State Evaluation Conducted by: Michigan Public Health Association (MPHI)

34. 34 Care Manager Survey Results

35. Physicians Support MiPCT 35

36. Staff Support MiPCT 36

37. “I would like to see care management in my practice continue”

38. Good News! The report found that the in its first year, the demonstration produced an estimated $4.2 million in savings for Medicare. Importantly, the rate of growth in Medicare FFS health care expenditures was reduced in Vermont and Michigan, driven largely by reduced growth in inpatient expenditures. For Michigan, this was estimated at about $148 per full-year eligible Medicare beneficiary.

39. First Annual MAPCP Report MiPCT’s year 1 estimated savings = $27.8 million ▫$148 per full-year eligible Medicare FFS beneficiary Results are preliminary ▫Future years of evaluation are required to confirm whether results persist over time Future reports will address quality 39

40. Sustainability and Funding For the Long Term (post 2016) 40

41. 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; Improved value, quality and experience of care 41

42. Our Own Governor’s Advocacy for MiPCT Continuity

43. Pre-Extension Payer Sustainability Statement "As participating Michigan Primary Care Transformation Project (MiPCT) payers, we recognize the value of care management embedded in primary care practices. We applaud CMS' recent payment proposal to continue funding for complex care coordination after the December 31, 2014 ending period of the demonstration project. We support continuation of this model of care to produce improvements in patient experience, quality and the value of care. We look forward to working together with the partnership of the MiPCT, the plans and the health care providers in improving Michigan's primary care system."

44. 2015 Physician Fee Schedule includes revised Medicare monthly 99490 code for non-face-to-face chronic care management language ▫ Effective January 1, 2015 at rate of ~$41/month (expectation of at least 20 min of clinical services per month) for:  Medicare Beneficiaries with 2+ chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and  For whom care coordination services would be expected to last at least 12 months or until the death of the patient ▫ MiPCT submitted comments on potential improvements and enhancements in future years  Discouraging CMS from imposing patient financial responsibility for care management services  Enhance payment rate; Existing rate is not sufficient level of contact with patient and to provide for care management 44 Medicare 2015 Care Management Code

45. Relationship to Other Key Initiatives  The Michigan Primary Care Transformation Project (MiPCT) is an underpinning and foundation of the State Innovation Model (SIM) recently awarded to the State.  The MiPCT is also a basis for primary care transformation in the Michigan Blueprint and Healthy Michigan programs.  The MiPCT has enabled a state-wide voluntary data base, standardized care management training model that is evidence-based, and served to assist providers in the movement to reimbursement based on value.

46. Michigan: Post-Demonstration MiPCT 46 1/1/12 12/31/14 Post-Demo MiPCT Original Demonstration Period Two Year CMS Extension 12/31/16 GOAL: To sustain our gains (effective, efficient team- based care with embedded Care Managers) post- demonstration period

47. What We’ve Learned Care manager integration is not plug-and-play, and requires all of the following for optimal success: ▫ Fully functioning team, including physician buy-in ▫ IT that allows information sharing among team ▫ Effective population risk stratification ▫ Notification of transitions in care, ideally electronic “Sticking to the knitting” with effective interventions pays off (execute, execute, execute) POs, practice teams, patients, purchasers and payers really do have common goals Multi-payer support for a common model and a platform for effective scaling are key This window of opportunity will not come again. We must fully leverage it to maximize returns on investment for all stakeholders

48. MiPCT Contacts Diane Bechel Marriott, DrPH (Project Manager) dbechel@umich.edu dbechel@umich.edu Sue Moran (CoDirector) morans@michigan.gov Jean Malouin, MD MPH (CoDirector, Medical Director) jskratek@med.umich.edu jskratek@med.umich.edu Theresa Landfair (CoDirector) landfairt@michigan.gov 48

49. Questions and Discussion