Michigan’s Proposal
CMS Multi-Payer Advanced Primary
Care Practice Demonstration
Carol Callaghan
Michigan Primary Care Consortium Annual Meeting
October 22, 2010
CMS Demonstration Requirements:
• Up to 6 States
• Budget neutrality over 3 years of project
• Number of Medicare beneficiaries < 150,000
(More allowable if budget neutrality can be assured)
• Total CMS funding < $10 PMPM
• Common payment methodology
• Payers must include
▫ Medicaid
▫ Private health plans
▫ Self-insured employer-sponsored group health plans
Eligible Michigan Practices:
505
- 28
PCMH Designation for 2010 (PGIP)
___
UMHS practices excluded by overlap
with UM CMS demo)
477
Eligible for participation*
* 17 of the above are also recognized by
NCQA as Level 2/3 PCMH
Clinical Model:
Support for deeper practice transformation will
take place through a collaborative network of
PO’s and through shared learning facilitated by
the Michigan Primary Care Transformation
(MiPCT) Administration
Practice Participation Criteria
• Part of a participating PGIP PO/PHO/IPA
• Maintain their PCMH designation throughout
the 3-year demonstration
• Agree to work on four specific focus areas:
 Care Management
 Self-Management Support
 Care Coordination
 Linkage to Community Services
Participating Physician Organizations
• All 32 Eligible PGIP POs/PHOs/IPAs signed
Letters of Intent to participate
• To participate in the Demo, POs must:
 Assist practices to advance in all PCMH
initiatives, especially the four areas of focus
 Assist practices with care coordination and
community linkages
 Distribute incentive payments
 Collect data and submit specified reports
Stakeholders in Application
Payers (public and private): 16
PO/PHO/IPA’s: 32
PCMH Practices: 477
Beneficiaries:
Medicare:
358,000
Medicaid (non-dual):
248,000
Privately insured:
1,153,000
TOTAL Beneficiaries: 1,749,000
Proposed Funding Model
$0.26 PMPM
$3.00 PMPM
$1.50 PMPM
$3.00 PMPM
Administrative Expenses
Care Management Support
Practice Transformation Reward
Performance Improvement
$7.76 PMPM Total Payment by Payers*
* Medicare will pay additional $2.00 PMPM to cover
additional services for the aging population
Proposed Funding Model
Total Payments by Payers = $7.76 PMPM
1. Administrative Expenses ($0.26 PMPM)
• State administration and management of
the demo including contracting, reporting,
monitoring, funds management, and central
administrative hub
• PO/PHO/practice support (e.g., Learning
Collaboratives, other resources)
• State-level evaluation of the demonstration
Proposed Funding Model
Total Payments by Payers = $7.76 PMPM
2. Care Management Support ($3 PMPM or
T-code equivalent)
• Payments to practices for non-covered PCMH
services, i.e., case mgmt, care coordination,
self-mgmt support, community linkages)
• Expressed as PMPM and administered via
each payer’s methodology (e.g., T-codes,
PMPM, CMS-specific codes to be identified)
Proposed Funding Model
Total Payments by Payers = $7.76 PMPM
3. Reward for practice transformation and
performance improvement ($4.50 PMPM)
• 10% increase for E/M fees ($1.50 PMPM)
• Payers pay practices a bonus for PCMH
performance - ($3 PMPM - based on
individual payer’s incentive model and
distributed as variable PMPM amount)
Payment Delivery Mechanism*
A Central Administrative Hub will be created to
collect and disseminate incentive payments
from participating payers
• Participating payers will pay incentive (and
admin) payments to the Central Admin Hub
• The Central Administrative Hub, working
closely with MPAC, will distribute incentive
payments to POs to share with practices as a
PMPM payment, based on performance,
quality and use
* CMS requires a common payment method
Payment Method
MPAC
• Multi-payer protected central repository for
data analysis and reporting
• To be used by Medicare, Medicaid FFS, and
BCBSM for patient attribution and incentive
payment determination
• Other commercial payers are also welcome to
use the repository
Proposed Governance
Steering Committee
• MDCH – 3
• PO/PHO/IPA – 6 (elected)
• Payers – 5 (elected)
• Expert Consultants – 3 (appointed by MDCH)
Advisory Committee
• Other participating Payers
• Other participating POs/PHOs/IPAs
• Professional Medical Associations
• Others
Participating Payers
Commercial
• Blue Care Network
• Blue Cross Blue Shield of Michigan
• Health Alliance Plan
• HealthPlus of Michigan
• McLaren Health Plan
• Physicians Health Plan of Mid-Michigan
• Priority Health
Medicare
Medicaid Fee For Service
Participating Payers (cont’)
Medicaid Managed Care Plans
• CareSource
• Great Lakes Health Plan
• Health Plan of Michigan
• HealthPlus Partners
• McLaren Health Plan
• Midwest Health Plan
• Molina Healthcare
• Physicians Health Plan of Mid-Michigan
• Priority Health Gov’t Programs
• Total Health Care
• Upper Peninsula Health Plan
Planning Committee Members
•
•
•
•
•
•
•
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Carol Callaghan, MPH (MI Dept of Community Health)
Ann Donnelly, RN, BSN (Genesys PHO)
Jean Malouin, MD, MPH (U of M Health System)
Susan Moran, MPH (Michigan Medicaid)
Paul Ponstein, DO (Lakeshore Health Network)
Kevin Taylor, MD (Huron Valley Physicians Association)
Trissa Torres, MD, MS (Genesys Health System)
Dana Watt, RN, MSN (MI Primary Care Consortium)
Writing Team Members
• Caroline Blaum, MD, UMHS
• Patrice Eller, CHRT
• Jean Malouin, MD, MPH, UM Health Team
• Margaret Mason, BCBSM
• Tomi Ogundimu, CHRT
• Robyn Rontal, BCBSM
• Marianne Phillips-Udow, CHRT
Questions from CMS to Michigan
• Budget Neutrality Assumptions
• Beneficiary Assignment
• Payment Methodology
• Data Needed from CMS
• Expectations re CMS’ Evaluation
If CMS does NOT select Michigan…
Could we do this anyway, without Medicare?
Would Michigan payers agree?
Would support from employers be useful?
Would legislative authority be useful?
necessary?
Questions???