Presentation on theme: "CMS and Primary Care: A New World"— Presentation transcript:
1 CMS and Primary Care: A New World Betsy Walton, MSW, MPHSenior AdvisorSeamless Care Models DivisionInnovation CenterCenters for Medicare & Medicaid ServicesBHCAG WorkshopComprehensive Primary Care InitiativeMay 24th, 2012
2 Thank You For supporting the health and wellness of your work force. For your interest in Patient Centered Medical HomesFor your willingness to engage in making health care better.
3 The Affordable Care Act: New tools in the CMS toolbox Medical HomesHealth HomesBonus Payments – For Good ResultsReducing Fraud, Waste & AbuseMedicare Shared Saving ProgramOffer Medicare patient’s free annual physicals and free preventive care services.Federal Coordinated Health Care OfficeInnovation Center
4 The Innovation Center“The purpose of the Center is to test innovative payment and service delivery models to reduce program expenditures under Medicare, Medicaid and CHIP…while preserving or enhancing the quality of care furnished…”“Preference to models that improve coordination, quality and efficiency of health care services.”Resources - $10 Billion in funding for FY2011 through 2019Opportunity to “scale up”: HHS Secretary authority to expand successful models to the national level
5 The Innovation Center Mission Statement Help transform the Medicare, Medicaid and CHIP programs to deliver better healthcare, better health and reduced costs through improvement for CMS beneficiaries and in so doing, help to transform the healthcare system for all Americans. The Center carries out this mission by being a constructive and trustworthy partner in identifying, testing and spreading new models of care and payment.
6 Measures of SuccessBetter healthcare - Improve individual patient experiences of care along the IOM 6 domains of quality: Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity Better health - Focus on the overall health outcomes of populations by addressing underlying causes of poor health, such as: physical inactivity, behavioral risk factors, lack of preventive care, and poor nutrition Reduced costs - Lower the total cost of care resulting in reduced monthly expenditures for Medicare, Medicaid or CHIP beneficiaries by improving care
7 Our WorkPatient Care Models - The right care at the right time, in the right setting – every time.Seamless Coordinated Care Models - Coordinating care to improve health outcomes for patientsCommunity and Population Health Models - Keeping families and communities healthy
8 Primary CarePrimary care is critical to achieving the three part aim of promoting health, improving care, and reducing overall system costs.Current visit-based fee-for-service system may not provide resources for comprehensive primary care.CMS is exploring new care delivery and payment models.
9 CMS Initiatives for Primary Care Medicare and Medicaid enhanced payments to primary care physicians (Affordable Care Act)FQHC Advanced Primary Care Practice DemonstrationMedicaid Health HomeMulti-payer Advanced Primary Care Practice Initiative (8 states, Title 18 funded)Comprehensive Primary Care Initiative (7 markets , ACA funded)
11 Evidence Supporting Comprehensive Primary Care Community Care of North CarolinaDecreased preventable hospitalizations for asthma by 40 %Lowered visits to the Emergency Room by 16%Group Health Cooperative of Puget SoundReduced emergent and urgent care visits by 29%Lowered hospital admissions by 6%
12 Evidence Supporting Comprehensive Primary Care: Employers Wisconsin-based QuadMedOperates five employee clinics on-site or nearbyHealth care expenditures are 17–31% lower compared to other employers in the communityIncreased quality indicators, including patient satisfactionLower rates of emergency department visits and hospital admissionsGeisinger Health PlanReduced admission rates by 18%Lowered hospital readmissions by 36% per year
13 Practice and Payment Redesign through the CPC initiative
14 Realizing the Vision of the CPC Initiative Through the leadership of public and private payers working together, we believe we will establish a new national standard for the purchase and delivery of comprehensive primary care that will improve health and reduce costs across our country.
15 Practice and Payment Redesign through the CPC initiative A major barrier to transformation in practice is transformation in paymentWill test two models simultaneously:Practice RedesignProvision of core primary care functionsBetter use of dataPayment RedesignPBPM care management feeShared Savings opportunity
16 Comprehensive Primary Care Functions: What is CMS trying to support? Risk-stratified care managementAccess and continuityPlanned care for chronic conditions and preventive carePatient and caregiver engagementCoordination of care across the medical neighborhood
17 1. Risk-stratified care management Participating practices will deliver intensive care management for the sickest patients with highest needsBy engaging patients, providers can create a plan of care that uniquely fits each patient’s individual circumstances and valuesMarkers of Success:Policies and procedures that describe routine risk assessmentPresence of appropriate care plans informed by the risk assessment
18 2. Access and continuityPatient care team must be accessible to patients 24/7Use patient data tools to provide real-time, personal health care informationProvide care from the same provider or health team to build trusted relationshipsMarkers of Success:Continuity of visits with same providerAvailability of EHR when office is closed
19 3. Planned care for chronic conditions & preventive care Primary care practices will proactively assess patients to determine needProvide appropriate and timely preventive careUse disease registries to track and appropriately treat chronically ill patientsMarkers of Success:Provision of Medicare’s Annual Wellness VisitDocumentation of medication reconciliation
20 4. Patient & caregiver engagement Primary care practices will engage patients and their families in active participation in goal setting and decision making.Patients will be full partners in truly patient-centered careMarkers of Success:Policies and procedures designed to ensure that patient preferences are sought and incorporated into treatment decisions
21 5. Coordination of care across the medical neighborhood Primary care as first point of contact will take the lead in coordinating carePrimary care team will work together with broader health team and the patient to make decisionsAccess to and meaningful use of electronic health records will be used to support these effortsMarkers of Success:Use of processes and documents for communicating key information during care transitions or upon referral to other providers
22 Three Components of Medicare Payment in the CPC initiative Medicare fee-for-service remains in placeAverage $20 PBPM fee (risk-adjusted) to support increased infrastructure to provide CPC for first 2 yearsReduced to an average of $15 PBPM in years 3 and 4Opportunity for Shared Savings in years 2, 3, and 4Calculated at the market levelPractice share determined by size, acuity and quality metrics
23 Additional Support for Primary Care Practices Commitment to share data with practices on utilization and the cost of care for aligned beneficiariesShared learning to help practices effectively share their experiences, track their progress and rapidly adopt new ways of achieving improvements in quality, efficiency and population health
24 Collaboration with Payers and Purchasers Individual health plans, covering only their members, cannot provide enough resources to transform primary care deliveryRequires investment across multiple payersCMS invited public and private insurers to collaborate in purchasing high value primary care in communities they serve
25 Participating Payers and Purchasers Commercial InsurersMedicare Advantage plansStatesMedicaid Managed Care plansState/federal high risk poolsSelf-insured businessesAdministrators of self-insured group (TPA/ASO)
26 CMS invites Payers and Purchasers to align support strategies in a community Interested payers described in their application how they would propose to align with CMS:What they are already doing to support CPC functions through enhanced, non-visit based supportWhat they would be prepared to do to support CPC functionsThe geographic area in which they would be prepared to test this model with CMSAligned strategies were scored as is a continuum, not a binary variable. CMS is not requiring a specific payment methodology.
27 Evaluating Payer Applications Innovation Center assessed alignment of payer proposals:Method of enhanced, non-visit-based support for comprehensive primary care functionsOpportunity for practices to qualify for shared savingsAttribution methodology for how a payer’s members will be identified as being served by a participating practiceSharing data on cost and utilization with participating practicesWillingness to align quality, practice improvement and patient experience measures
28 CPC Initiative Selected Markets These markets are multi-payer and may include private health plans, state Medicaid agencies, and employers:Arkansas: StatewideColorado: StatewideNew Jersey: StatewideNew York: Capital District-Hudson Valley RegionOhio: Cincinnati-Dayton RegionOklahoma: Greater Tulsa RegionOregon: Statewide
29 Result of Market Discussions Each payer will enter into a Memorandum of Understanding (MOU) with CMS:The content of the MOU will be the same for all payers in a marketThrough the MOU, payers will commit to the common approach to data sharing, implementation milestones and quality metrics, care coordination fee payment not connected to ffs and shared savings with practicesThe MOU will reference the payer’s proposal to CMS of their support for comprehensive primary care
30 Practice SelectionThe goal is for CMS to select and enroll ~75 practices per marketWe expect to attract high-performing practicesCMS and participating payers will enroll primary care practices who agree to provide comprehensive primary care and achieve the milestone requirements and adhere to Terms and Conditions of programTerms and Conditions will become an addendum to the Medicare Provider AgreementPayers will sign separate agreements with practices
31 ResourcesMore information can be found on the website,