1. The Michigan Primary Care Transformation (MiPCT) Project November 2015 PO Quarterly Webinar

2. Agenda 1.Final 2016 CMS Physician Fee Schedule and the MiPCT (10 min)- Diane Marriott 2.PO/Practice/MDHHS 2016 Agreement Overview/Status (20 min)- Theresa Landfair 3.Tiger Team Update (15 min)- Mary Ellen Benzik 4.MPHI Evaluation Update (10 min)- Jason Forney, Clare Tanner 5.MDC Update (15 min) – Cindy Adams, Susan Stephans 6.Summit 2016 Dates (5 min) – Jean Malouin 7.Announcements and Open Q&A – Amanda First and Jean Malouin 2

3. 1. Final 2016 CMS Physician Fee Schedule and the MiPCT 3

4. 1) New Advance Care Planning Codes ▫Purpose: To pay for a provider's time discussing patient choices for advance directives and completing necessary forms. ▫Code Detail:  Coverage of first 30 minutes  Additional 30-minute blocks ▫Beginning 1/1/16, CMS will reimburse CPT codes 99497 and 99498. 4 The Final PFS (Issued 10/30/15)- Implications for the MiPCT

5. 1) New Advance Care Planning Codes, cont. ▫Does NOT waive beneficiary copay for discussions (except for discussions at annual wellness visits) ▫Also billable for FQHCs and RHCs ▫Payment estimated at $86 for 99497 (initial 30-minutes) and $75 for 99498 (subsequent 30 minutes). 5 The Final PFS (Issued 10/30/15)- Implications for the MiPCT

6. 2) Transitional Care Management (99495 and 99496) ▫Now allows submission of claim when the face-to- face visit is completed 3) Still Waiting……..New Collaborative Care Model Code for Beneficiaries with Common Behavioral Conditions…Potentially in 2017 6 The Final PFS (Issued 10/30/15)- Implications for the MiPCT

7. 4) The Bigger Issue for Us – Potential Comprehensive Primary Care Expansion Our “sister program” that parallels the Multipayer Advanced Primary Care Demonstration (MAPCP) approach. ▫CPCI focus areas (milestones) largely similar to MiPCT programming  Enhanced patient access and continuity of care,  Planned chronic and preventive care,  Risk-stratified care management,  Patient and caregiver engagement, and  Coordination of care across a “medical neighborhood” CMS staff acknowledge that (if expanded), an announcement early in 2016 is key to continuity of staffing and servicing 7 The Final PFS (Issued 10/30/15)- Implications for the MiPCT, cont.

8. 2. PO/Practice/MDHHS 2016 Agreement Overview/Status 8

9. See MS Word document labeled: “Substantive Changes in the MiPCT 2016 Paricipation Agreement” and Draft 2016 Agreement Redline 9

10. 3. Tiger Team Update 10

11. 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

13. Where do we go from Demonstration? Key areas to be addressed ▫Social determinants of health ▫Integration of Behavioral health

14. Creating the Model – Engaging with the POs Created Tiger Teams to address each area Representatives from PO, practices, payers, and state wide Expertise on these topics Met monthly – every other in person Created model and tool kits for the addressing social determinants and integrating behavioral health

15. MiPCT INTEGRATION and INTER RELATEDNESS OF MENTAL HEALTH AND SOCIAL DETERMINANTS OF HEALTH

16. Planning steps for integration of at the PO level Mental Health integration Addressing Social Determinants Financial analysis and business plan 1.Business case for behavioral integration monograph PDF 2.Business case proforma 3.AIMS Center U of W, implementation guide step 2 4.http://www.integration.sam hsa.gov/financing/Sustainabi lity_Checklist_revised_2.pdfhttp://www.integration.sam hsa.gov/financing/Sustainabi lity_Checklist_revised_2.pdf 5.http://www.integration.sam hsa.gov/financing/billing- tools\http://www.integration.sam hsa.gov/financing/billing- tools\ 6.http://www.integration.sam hsa.gov/financing/Michigan. pdfhttp://www.integration.sam hsa.gov/financing/Michigan. pdf Addressing Patient’s Social Needs: Business Case ADDRESSING PATIENTS’ SOCIAL NEEDS: An Emerging Business Case for Provider Investment. Reasons to invest in social determinants, examples and strategies of various projects/programs payment models. http://www.commonwealthfund.org/~/media/files/pu blications/fund- report/2014/may/1749_bachrach_addressing_patients _social_needs_v2.pdf http://www.commonwealthfund.org/~/media/files/pu blications/fund- report/2014/may/1749_bachrach_addressing_patients _social_needs_v2.pdf Assessmen t of current state of integration Integrated tool #1 Compass self-assessment OATI #4 Collaborative care principles and components - AIMS center Assessmen t of resources at practice, PO and community CMS funding brief DBM reference Identification of the relationships with psychiatric partners for developing care collaborative model Practical Playbook; Primary Care and Public Health Together Community Commons Interactive Maps: Poverty levels, education and more by census tract.(Log in is required). See Maps and Data Tab http://assessment.communitycommons.org/Footprint/ http://assessment.communitycommons.org/Footprint/ Current state assessment of community partnerships and joint planning of intervention Partnership checklist OATI tool 1 Frieden: Health Impact Pyramid Linking with your community health team works Current state assessment for readiness for change OATI tool 3 administrative readiness tool or AIMS Center Organizational readiness worksheet GROW Pathway Planning Worksheet BUILDING INTEGRATION ON A FRAMEWORK OF ADVANCED MEDICAL HOME CAPABILITY PRESENT IN MIPCT PHYSICIAN ORGANIZATIONS AND PRACTICES

17. Planning steps for integration of at the practice level Behavioral Health integration Addressing Social Determinants Financial analysis and business plan SBIRT basics utilization and financial aspects Assessment of current state of integration MeHAF Integrated practice assessment tool (IPAT) CHIS framework American Academy of Pediatrics integration tool Bright Future Assessing Chronic Illness Care (ACIC) particularly sections 2, 7 Assessing Chronic Illness Care (ACIC) Assessment of resources at practice, PO and community CHIS quick start decision tree section workforce and clinical practice Current state assessment of community partnerships and joint planning of intervention Same as PO *assessment of health literacy, cultural competency – see SD tool kit Current state assessment for readiness for change AIMS center organizational readiness GROW Pathway Planning Worksheet AAP MH Practice Readiness Inventory http://pediatrics.aappublications.org/ /125/Supplement_3/S129.full.pdf BUILDING INTEGRATION ON A FRAMEWORK OF ADVANCED MEDICAL HOME CAPABILITY PRESENT IN MIPCT PHYSICIAN ORGANIZATIONS AND PRACTICES

18. Doing the work at the Practice Level – Defining new Workflow

19. Toolkit for the Practices to Change Workflow Social determinants of health Practice level steps – operationalizing the change Tools to support (more in website – these starting documents ) Poverty Behavioral factors (smoking, at risk substance use ) Adverse childhood events Integration of behavioral health Overview document Community Commons Interactive Maps The Childhood Adversity Narratives CAN. http://www.improvingprimaryca re.org/work/behavioral-health- integration Measurement strategy GROW tool Capturing Social and Behavioral Domains and Measures in EHRs: Phase 2. Measuring Vital Signs http://integrationacademy.ahrq. gov/atlas/overviewofmeasures#r eviewmeasures Implementation plan Strengthening Families- A Protective Factors Framework https://aims.uw.edu/collaborativ e-care/implementation-guide Guidebook for professional practices for implementation Suicide prevention tool kit Screening tools HealthBegins Social screening tool V6 Resiliency and ACES Assessment Tool.(pdf) Depression tool kit Community care North Carolina SAMSA screening tools

20. Toolkit for the Practices to Change Workflow Social determinants of health Practice level steps – operationalizin g the change Tools to support (more in website – these starting documents ) Poverty Behavioral factors (smoking, at risk substance use ) Adverse childhood events Integration of behavioral health Registry utilization http://aims.uw.edu/sites/default /files/ClinicalWorkflowPlan.pdfhttp://aims.uw.edu/sites/default /files/ClinicalWorkflowPlan.pdf http://aims.uw.edu/collaborative -care/implementation- guide/plan-clinical-practice- change/identify-population- basedhttp://aims.uw.edu/collaborative -care/implementation- guide/plan-clinical-practice- change/identify-population- based Treatment intensification AIMS Center – commonly prescribed psychotropic meds Primary Care Psychiatry –Pocket Guide V. 1.5 Feb 2014 Panel management and follow up http://aims.uw.edu/collaborative- care/implementation-guide/plan- clinical-practice-change/create- clinical-workflow Referral partnerships for advanced services MiICCSI Community Resources Directory Click on Community Resources link at http://www.miccsi.org /CareManagement.ht ml http://www.miccsi.org /CareManagement.ht ml

21. Addressing Team Factors: Health Literacy and Cultural Competency Team based factors impacting integration Framework / toolkits Assessment of PO/ practice capabilities PO/practice care team process/ tools and training Patient Tools / educational materials Health literacy AHRQ Health Literacy Universal Precautions Toolkit The Health Literacy Environment of Hospitals & Health Centers: Making Your Healthcare Facility Literacy-Friendly Ten Attributes of Health Literate Health Care Organizations The Health Literacy Environment Activity Packet: First Impressions and A Walking Interview Measures to Assess a Health-literate Organization In Plain Words In Plain Words - Tr Effective Communication Tools for Healthcare Professionals Effective Communication Tools for Healthcare Professionals (Tr video) National Network of Libraries of Medicine: Health literacyNational Network of Libraries of Medicine: Health literacy (Tr – info to include in training) Ask Me 3Ask Me 3- Partnership for Clear Health Communication— Ask Me 3 - http://www.npsf.org /?page=askme3 http://www.npsf.org /?page=askme3 Ethnicity/Cultur al Competency Effective Communication Tools for Healthcare Professionals Effective Communication Tools for Healthcare Professionals (tr video) Guide to Providing Effective Communication and Language Assistance Services ? National Standards for Culturally and Linguistically Appropriate Services http://minorityhealth.hhs.gov/omh /browse.aspx?lvl=2&lvlid=53 https://www.thinkculturalhealth.h hs.gov/Content/clas.asp

22. Thank You Mary Ellen Benzik mebenzik@gmail.com Mipctdemo.org Resources tab Clinical areas Social Determinants

23. 4. MPHI Evaluation Update 23

24. 24

25. 5. MDC Update 25

26. MDC Agenda Where do I get information? What’s New? ▫ Coming soon – new MDC web page ▫ All Payer Patient Lists ▫ Report Writer ▫ Standard Cost Enhancement 26

27. Dashboard 27 Accessing Dashboard and Support Documentation ▫ Michigan Data Collaborative Website www.MichiganDataCollaborative.org Support page includes the following materials: ▫ Dashboard general reference and user guides ▫ Dashboard release notes ▫ Information about the data included in the Dashboard ▫ All Payer Patient List reference document

28. 28 New MDC Web Page

29. Page 29 Support Page 29

30. Page 30 Dashboard Reference Materials General info, user guides Provides more detail about each report 30

31. Page 31 Release Notes 31

32. Page 32 Data Reference Material 32

33. Page 33 Data Timeline 33

34. All-Payer Patient List Changes - 2015 34 Addition of High Risk Flag (April) Healthy MI Flag (coming soon) ▫ Identifies members who have signed up for coverage in the Affordable Care Act ▫ Only set in the Medicaid population (not traditional Medicaid recipients)

35. Page 35 All-Payer Patient List - Helpful Documentation 35

36. Page 36 All-Payer Patient List Information Document 36

37. Page 37 All-Payer Patient List - Details 37

38. Dashboard – What’s New? 38 Report Writer Enhancements (August 2015) ▫ Added Totals ▫ Added Overall measures  Quality  Adult Preventive  Diabetes  Pediatric Preventive ▫ Trends – Diabetes Overall Note: The enhancements are documented in the Report Writer August 2015 Enhancement Release NotesReport Writer August 2015 Enhancement Release Notes

39. 39 Dashboard – Accessing Report Writer

40. 40 Report Writer – Totals & Overall checkboxes

41. 41 Report Writer – Selecting What You Want

42. 42 Report Writer – Viewing Results

43. 43 Standard Cost Background Truven Health provides standard cost valuation utilizing their MarketScan database that includes large state and national Employer/Commercial data for over 180 million patients MarketScan provides the mean unit price based on: ▫ DRG for inpatient claims ▫ ICD, CPT, and HCPCS Procedure and Revenue Codes for facility claims ▫ CPT and HCPCS Procedure Codes for professional claims ▫ NDC for pharmacy claims As new codes are implemented, they flow into the Truven system; however, unit prices are not published until all data has been submitted and analyzed MarketScan data is currently based on 2012 data When claims are processed on the dashboard, some procedures and revenue codes do not have standard costs associated with them

44. 44 Standard Cost Enhancement Released with Enhancement 14.01 on 11/10/15 When MarketScan standard costs are updated with new codes, MDC re-evaluates previously received claims with no standard cost and applies the new rate(s) Increased claims and members are included in standard cost rates adding over 50,000 members in the current measurement period

45. 45 Standard Cost Enhancement High and Very High Risk groups show the largest rate increases since they are higher utilizers Medicare populations show a larger rate increase because they contain more patients in the High and Very High risk groups Because the updates from Truven are based on claims through 2012, earlier trend periods are enhanced the most by updating standard costs for previously-blank codes

46. 6. 2016 Summit Dates 46

47. 2016 Summits – Save the Date! October 13, 2016 – Thompsonville Summit (North) October 18, 2016 – Grand Rapids Summit (West) October 26, 2016 – Ann Arbor Summit (Southeast) 47

48. Announcements and Open Q and A 48