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Innovation Grant: CMMI Comprehensive Primary Care Initiative (CPCi) presented to HFMA Southwestern Ohio Chapter Will Groneman Executive Vice President.

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Presentation on theme: "Innovation Grant: CMMI Comprehensive Primary Care Initiative (CPCi) presented to HFMA Southwestern Ohio Chapter Will Groneman Executive Vice President."— Presentation transcript:

1 Innovation Grant: CMMI Comprehensive Primary Care Initiative (CPCi) presented to HFMA Southwestern Ohio Chapter Will Groneman Executive Vice President System Development TriHealth

2 2 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

3 3 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

4 4 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

5 5 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

6 6 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  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

7 7 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  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

8 8 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  PCMH Recognized  Commitment to transformational activities  Practices to be selected August 2012

9 9 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 :  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

10 10 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

11 11 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  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  Goal is to demonstrate impact at the community level  Monthly meetings of practices

12 12 CPCi v. Accountable Care Organization  Requires commercial plans/Medicaid support  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  Year 1 used to build capabilities and establish data baselines  Gainsharing in years still undefined

13 13 CPCi Challenges  Attribution requires 24 months of claims experience  What happens when a commercial enrollee switches plans  Many “Key Success Factors” still undefined  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

14 14 CPCi Challenges  Self Insured Employers must agree to participate  ASO provider cannot commit without their consent  Threats to health system goal of creating a system brand for their PCP network  TH has 34 PCP practice locations  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?

15 15 CPCi Challenges  Common community agenda still a challenge  19 Common Quality/Measures Selected  CMS priorities  Medicare Advantage “star” program measures  Medicaid plans’ payment incentives  Commercial payers’ national quality/cost agendas

16 16. Questions?


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