1
The Michigan Primary Care
Transformation (MiPCT) Project
Annual Summit
October 2013
MiPCT Overview and Updates
Objectives
• Recap MiPCT Overview and 2013/14 Focus Areas
• Review MiPCT Project Evaluator Findings to Date
• Discuss Project Sustainability
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
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
$3.00 pmpm*, **
$1.50 pmpm*, **
$3.00 pmpm*, **
$7.76 pmpm
Administrative Expenses
Care Management Support
Practice Transformation Reward
Performance Improvement
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
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
MiPCT
Medicaid
Medicare
BCN
BCBSM
 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
10
MDC: MiPCT
Dashboards
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
Admission, Discharge, Transfer MiPCT Data
Flow and Progress
• 17 POs participate in the “Spotlight” MiPCT offering (at no cost to PO)
with opportunity for additional POs to join (by October 30, 2014)
• Allows care managers direct access to member lists via web interface
• ADT notifications adding for Trinity, Henry Ford, and 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
Successes
Challenges
• Champions abound; We have
gained traction!
• Success on cost, quality and
utilization measures is key to
sustainability
• Michigan is well-poised
compared to other states
despite its broad scale
• Member lists vs. the population
• Hard-working, dedicated people
• Multi-payer Database
• Strong PCMH foundation
• G and CPT code billing and
“throughput”
• PO and practice infrastructure
varies
• Many competing priorities
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www.mipctdemo.org
MiPCT Evaluation Update
Clare Tanner
Objectives
• MiPCT Investment in PCMH
• Care Management Implementation
• Quality/Utilization
MiPCT Practices
Financial Investment, 2012
“New” Money1
Care
Coordination
Practice
Transformation
1.
2.
Total2
$35,577,697
$35,577,697
$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
21
Care Manager Roles
N=420
Complex
15% (63)
Moderate
26% (109)
Hybrid
59% (248)
22
 70% have 1 practice
 23% have 2-4 practices
 7% have 5 or more
practices
23
Care Manager Volume
Quarter 2, 2013
Encounters
Face to
Face
Phone
Unique
Patients
Total
15,250
32,709
22,237
Per CM
FTE
63
112
82
Care Manager Survey
• Conducted in May 2013
• 434 care managers asked to complete survey
• 53% completed the survey (n=228)
25
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
26
Care Manager Survey Results
How Care Managers Build Caseloads
Physician referrals
91%
MiPCT list
79%
Daily practice visit schedule
61%
Electronic admit discharge…
61%
ED visit summaries
57%
Registry
39%
Patient self-referrals
25%
Fax discharge summaries
24%
Other staff
Other discharge list
Other
2%
1%
4%
27
Care Manager Survey Results
Utilization of MiPCT List
Information
Chronic condition
diagnosis
57%
Risk score
57%
Emergency department
utilization
36%
BCBSM high deductable
plan
Number of maintenance
drug prescriptions
22%
11%
28
Care Manager Survey Results
How Often Care Managers Converse with
PCP Regarding MiPCT-Eligible Patients
60%
40%
42%
35%
20%
6%
8%
Every 2
weeks
> Every 2
weeks
3%
0%
Daily
Weekly
Never
29
Care Manager Survey Results
How Often Care Team Meets to Discuss
Delivery of Care Management and/or Specific
Patient Cases
40%
29%
28%
22%
20%
8%
7%
0%
Weekly
Every 2
weeks
Monthly
>Monthly
Never
30
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
31
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
32
Care Manager Survey Results
• Physicians understand and are actively involved
in population management
Never
Rarely Sometimes Frequently Always
33
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
34
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
36
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
37
Quality and Experience of Care Metrics:
MI and National Evaluations are Different,
But Share Common Elements
National
Michigan
• Diabetes
Diabetes care:
• Asthma
• LDL-C screening
• Hypertension
• HbA1c testing
• Retinal eye examination
• Cardiovascular
• Medical attention for nephropathy
• Obesity
• All 4 diabetes tests
• Adult preventive care
• None of the 4 diabetes tests
• Child preventive care
Ischemic Vascular Disease:
• Total lipid panel test
Patient experience (CAHPS)
• Childhood lead screening
(Medicaid)
• Patient experience (CAHPS)
• Provider/staff experience
MiPCT Number of POs with Quality Rate Changes
Number of POs
with Positive
Change in All
Group Measures
MiPCT Number of POs withPositive
Quality
Rate Changes
Negative
>= +10%
<10%
>-10%
<= -10%
Breast Cancer Screening
1
22
12
0
Cervical Cancer Screening
30
5
0
0
Chlamydia Screening
8
8
7
12
Adult Preventive
7
Adolescent Well-Care
9
10
10
6
15-Month Well-Child
14
5
5
8
3-6 Year Well-Child
8
9
10
7
Well-Child Care
8
Diabetic Eye Exam
2
12
21
0
Diabetic HbA1c Testing
0
15
20
0
Diabetic LDL-C Testing
0
4
31
0
Diabetic Nephropathy Screening
3
10
19
3
Diabetes Care
2
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)
Change
Significant
(p<=.1)
Breast Cancer Screening
5
18
11
1
Positive
Yes
Cervical Cancer
Screening
31
4
0
0
Positive
Yes
Chlamydia Screening
1
15
10
9
Negative
Yes
Adolescent Well-Care
8
11
8
8
Negative
Yes
15-Month Well-Child
8
11
7
6
Positive
No
3-6 Year Well-Child
5
12
6
11
Negative
Yes
Diabetic Eye Exam
4
10
15
6
Negative
Yes
Diabetic HbA1c Testing
3
13
16
3
None
No
Diabetic LDL-C Testing
0
4
26
5
Negative
Yes
Diabetic Nephropathy
Screening
4
9
14
8
Negative
Yes
MiPCT Number of POs with Quality Rate ChangesOverall
MiPCT
MiPCT 2012 PCS ED Rate per 1000 ED Visits
Percent Change from 2011 Baseline Rate by PO
5.00%
0.00%
-5.00%
MiPCT
Overall
-10.00%
-15.00%
-20.00%
POs/PHOs
MiPCT Post-Demonstration
Funding and Sustainability
Diane Marriott
43
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
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:
▫ 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.
Payer Sustainability
"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."
46
Sustainability Progress
▫ Addition of Priority Health
▫ State Innovation Model (SIM)
▫ Medicaid
▫ Milbank Fund Advocacy
▫ ROI PO Subgroup financial modeling
PO Primary Care Sensitive Emergency
Department Use (Change from 1/1/12 to 12/31/12)
No Improvement
Improved (stat
sig.)
4
11
20
For POs with Stat. Sig. Better
Performance, Amt. of Change
Over 12%---2 POs
8-12%-------4 POs
5-8%---------3 POs
Under 5% --11 POs
Improved
(not stat. sig.)
Overall, from 2012 to 2013, the MiPCT decreased
avoidable emergency visits decreased almost 4%.
We ARE the MiPCT!
We can do this together!
We can make care better!
Questions?