Innovation Grant:
CMMI
Comprehensive Primary
Care Initiative (CPCi)
presented to
HFMA Southwestern Ohio Chapter
Will Groneman
Executive Vice President System Development
TriHealth
Comprehensive Primary Care Initiative (CPCi)
 What is it?
 4-year pilot program from CMS Innovation Center – CMMI
 Authorized under the Accountable Care Act
 Funding for 330,750 Medicare and Medicaid beneficiaries
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Comprehensive Primary Care Initiative (CPCi)
 What is it?
 4-year pilot program from CMS Innovation Center – CMMI
 Authorized under the Accountable Care Act
 Funding for 330,750 Medicare and Medicaid beneficiaries
 Designed to accomplish the “triple aim” at the community level
 Aligns multiple payers in a community around common goals
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Comprehensive Primary Care Initiative (CPCi)
 What is it?
 4-year pilot program from CMS Innovation Center – CMMI
 Authorized under the Accountable Care Act
 Funding for 330,750 Medicare and Medicaid beneficiaries
 Designed to accomplish the “triple aim” at the community level
 Aligns multiple payers in a community around common goals
 Aimed at Primary Care Physicians
 Builds on the “Medical Home” concept
 Holds PCP practices accountable for the total cost of care
 Solicitation issued in late September 2011
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Comprehensive Primary Care Initiative (CPCi)
 CMS’ Framework for Comprehensive Primary Care
 Risk stratified care management
 Access and continuity
 Planned care for chronic conditions and preventive care
 Patient and caregiver engagement
 Coordination of care across the medical neighborhood
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Four Basic Steps in the Process
1. Select communities to participate
 Number of commercial plans willing to participate
 Support of state Medicaid
 Community infrastructure and history of collaboration
 Seven Communities were selected
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Arkansas
Colorado
New Jersey
Oregon
New York Capital District-Hudson Valley Region
Greater Tulsa Region
Cincinnati-Dayton-Northern Kentucky Region
 Community selection completed April 2012
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Four Basic Steps in the Process
1. Select Communities to participate (April 2012)
2. Align payers who are willing to commit to:
 Payment above normal Fee-for-Service (e.g. pmpm)
 CMS pmt will be risk adjusted and will average $20 pmpm
 Provide gainsharing opportunities in years 2-3-4
 Common set of metrics for cost, quality, service
 Using 18 of the 33 ACO measures as a starting point
 Providing aggregate member level cost/utilization data
 Signing a Letter of Intent with CMS
 Cincinnati had 10 payers commit to participate
 Includes Aetna, Anthem, Humana, Medicaid, MMO, United
 Payers signed non-binding LOIs in June 2012
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Four Basic Steps in the Process
1. Select Communities to participate
2. Align payers
3. Select PCP Practice Locations
 Practice = physical office location
 75 practices per market to be selected
 Screening Criteria:
 150 FFS Medicare patients
 Physicians have attested to Meaningful Use
 Qualitative Criteria:
 >60% of patients are covered by participating payer
 Demonstration of readiness to transform
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PCMH Recognized
 Commitment to transformational activities
 Practices to be selected August 2012
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Year 1 Commitments Required by CMS
 Complete an annual budget
 Implement risk stratification methodology for all patients
 Attest to 24/7 patient access to a nurse or practitioner with
access to the patient’s EHR
 Establish baseline for patient satisfaction using CG-CAHPs
 Demonstrate care coordination for the medical neighborhood
and c omply with at least one of the following:
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Notification of ED visit in a timely fashion
Med reconciliation completed with 72 hours of hospital discharge
Exchange of clinical information at the time of admission and at discharge
Exchange of clinical information between PCP-specialists
 Participate in quarterly market based learning collaborative
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Four Basic Steps in the Process
1. Select Communities to participate
2. Align payers
3. Select PCP Practice Locations
4. “Negotiate” with practices and start program
 No negotiations with CMS
 Expect limited negotiation with plans
 Will need to conform with their LOI commitments
 Will plans cover TriHealth PCMH sites not selected?
 Not clear if “ASO” employers will participate
 Go-live November 1, 2012
 13 months from solicitation to go-live
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CPCi v. Accountable Care Organization
 Focus is on Patient Centered Medical Home (PCMH) as
the foundation for managing care
 ACO not as prescriptive as to care management strategy
 Provides new funding for infrastructure
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Focused on adult PCP sites
For systems: only funds part of the PCP base
For independents: provides funding to sustain independence
 Requires participating competitors to cooperate in
sharing best practices
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Goal is to demonstrate impact at the community level
Monthly meetings of practices
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CPCi v. Accountable Care Organization
 Requires commercial plans/Medicaid support
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Must provide additional pmpm funding
Patient attribution updated quarterly
Must commit to a common “menu” of cost/quality measures to be
used for gainsharing program
 Must provide monthly claims/utilization data
 Still defining level of detail
 Monthly multi-stakeholder meetings
 ASO customers must agree to participate
 Does not require gainsharing/full risk on day 1
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Year 1 used to build capabilities and establish data baselines
Gainsharing in years 2-3-4 still undefined
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CPCi Challenges
 Attribution requires 24 months of claims experience
 What happens when a commercial enrollee switches plans
 Many “Key Success Factors” still undefined
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Attribution methodology
Cost/utilization data specificity
Gainsharing methodology
Severity adjustment methodology
 CMS’ agenda does not always support community
existing initiatives
 Public Reporting through the Health Collaborative
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CPCi Challenges
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Self Insured Employers must agree to participate
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ASO provider cannot commit without their consent
Threats to health system goal of creating a system
brand for their PCP network
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TH has 34 PCP practice locations
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30 NCQA Recognized Level 3 PCMH sites
19 Sites have been selected by CMS to participate
Funding only applies to 19 sites
How to fund remaining 15 sites?
Can we get performance data for non CPCi sites even if we are
not part of a payer’s P4P program?
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CPCi Challenges
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Common community agenda still a challenge
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19 Common Quality/Measures Selected
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CMS priorities
Medicare Advantage “star” program measures
Medicaid plans’ payment incentives
Commercial payers’ national quality/cost agendas
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Questions?
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