1. The Michigan Primary Care Transformation (MiPCT) Project Leadership Briefing 2015 Northern Summit

2. Overview Overview and Synergy of MiPCT with State Initiatives MiPCT Evaluation Results MiPCT Clinical Update Preparing for Sustainability Best Practice Awards! 2

3. Overview and MiPCT Synergy with State Initiatives 3

4. MiPCT Payers, Patients and Providers As of March 2015: 1814 providers ▫1,577 physicians ▫237 mid-level providers Over 500 care managers 346 PCMH practices 1,158,650 members # Patients% Patients Medicare186,99716.1% Medicaid214,74518.5% BCBSM361,80231.2% BCN275,31623.8% Priority119,99010.4% Total1,158,850100.0%

5. MiPCT Synergy with Blueprint Pillars 5 Vision: MC system that maximized health status through evidence and value-based care delivery MiPCT Population Health Management -Registry skill- building -Role of panel managers -Training specific to each role as well as team-wide sessions MiPCT Pay for Value -Competitive Incentives to Drive Behavior -Commercial G and CPT Code Care Management Billing MiPCT Integration of Care -Patient identification and Engagement -Team-based care focus -Transition coordination MiPCT Structural Transformation -Dashboards; Incorporation of Registry Data -Support for Health IT and Analytics -ADT alerting

6. Michigan State Innovation Model Proposal Overview Michigan Blueprint for Health Innovation developed with broad stakeholder engagement in 2013 Model Test proposal submitted July 2014 ▫Closely follows Blueprint Proposal presentation at Center for Medicare and Medicaid Innovation: October 2014 $70 Million award announcement: December 2014 Project begin date: February 1, 2015 6

7. Phased Model Test Wave I Regions  Have all model components and capabilities  Prior experience with pay for value  May include Level I and II Accountable Systems of Care Wave II Regions  Have some, but not all, model components and capabilities  Could benefit from additional planning, investment, community convening, before implementation  May include Level I and II Accountable Systems of Care 7

8. Michigan’s Model Test Timeline Pre- Implementation Model Test: Wave I Model Test: Waves I and II Model Test and spread State-wide dissemination 8 2015 2016 2017 2018 2019 - 2020

9. Michigan’s Blueprint Raises the Bar 9 Patient Centered Medical Home + Systems of Care Patient Centered Medical Home + Accountable Systems of Care + Population health capacity + Payment reform Infrastructure for a Learning Health System Policy

10. Accountable Systems of Care ▫Physician organizations  Cover all of Michigan: both provider and health system led  Contracting and credentialing support  Practice coaching and quality improvement  Support for patient centered medical home transformation ▫Medicaid managed care ▫Emphasize whole-system transformation, anchored by strong primary care and effective care management ▫Create systems that coordinate care within and beyond health care system (e.g., improved transitions in care) ▫Better leverage health information technology and health information exchange ▫Link with Community Health Innovation Regions for better outcomes ▫Emphasize whole-system transformation, anchored by strong primary care and effective care management ▫Create systems that coordinate care within and beyond health care system (e.g., improved transitions in care) ▫Better leverage health information technology and health information exchange ▫Link with Community Health Innovation Regions for better outcomes 10

11. State Innovation Model Performance Measures ▫Drive adoption of a core set of measures ▫Align payment and core set of measures across payers to reduce administrative complexity and provider burden  Michigan State Medical Society has developed a common clinical measure list across several Michigan payers  State Innovation Model Performance Measurement and Recognition Committee will establish additional process and population health measures 11

12. Payment Reform Align with trend toward payment for population level performance, moving away from fee-for-service ▫Level I: Shared savings (upside risk) ▫Level II: Capitation models Designed to drive: ▫Consistent delivery of high-quality, person/family-centered care ▫Reductions in low-value care ▫Reductions in avoidable acute care utilization Provide for investments in community health 12

13. Community Health Innovation Regions ▫Multipurpose collaborative bodies ▫Chartered Value Exchanges ▫Health Improvement Organizations ▫Community Benefit ▫Work together for collective impact on population health: ▫Assess community need ▫Define common priorities ▫Adopt shared measures of success ▫Pursue mutually reinforcing strategies towards common priorities ▫Implement systems to coordinate health care, community services, and public health ▫Invest in prevention ▫Work together for collective impact on population health: ▫Assess community need ▫Define common priorities ▫Adopt shared measures of success ▫Pursue mutually reinforcing strategies towards common priorities ▫Implement systems to coordinate health care, community services, and public health ▫Invest in prevention 13

14. Health Information Exchange/ Health Information Technology Key functions of Health Information Exchange in State Innovation Model: ▫Support care coordination within Accountable Systems of Care and across the health care system ▫Support community linkages to better address social determinants ▫Allow real-time performance monitoring, rapid-cycle improvement processes ▫Infrastructure components ▫Electronic Medical Record functionality ▫Connection to sub-state Health Information Exchange ▫Data aggregator 14

15. State Innovation Model Target Populations Healthy babies Emergency Department super-utilization (8+ visits/year) Multiple chronic conditions 15

16. Medicaid Managed Care Rebid Managed Care Rebid ▫Plans and Regions announced 10/14/15 ▫Requires health plan participation in the State Innovation Model ▫Specifically promotes key components of delivery system transformation:  Patient-centered medical homes  Support for care management  Community health workers 16

17. Pre-Implementation Update Complete ▫Accountable System of Care and Community Health Innovation Region capacity assessments reviewed To Do ▫Region and site selection ▫Develop key program materials for feedback Looking ahead ▫Finalize programs ▫Develop operational plans with Model Test participants ▫Execute agreements with Model Test participants ▫Launch Model Test learning system ▫Implement payment reform 17

18. 18 Quarter 1 (Feb - April) Hiring and orientation Tool and model development Stakeholder engagement plan Quarter 2 (May - July) ASC capacity assessment CHIR capacity assessment Continued model development Timeline development MDHHS workgroups launched Quarter 3 (Aug - Oct) Develop CMS Operational Plan Convening: Performance Measurement and Recognition Committee Quarter 4 (Nov - Jan) Regional selection announced Program policy public comment period CMS Operational Plan submitted Quarter 1 (Feb - April) ASCs and CHIRs submit operational plans and requests for funding Participation agreements signed Collaborative learning networks launch Quarter 2 (May - July) CHIRs undertake strategic planning for population health ASCs, MHPs, and MDHHS test administrative information systems Quarter 3 (Aug - Oct) ASCs and MHPs sign contracts to begin October 1, including: Shared savings Pregnancy bundle Partial and global capitation options Quarter 4 (Nov - Jan) Michigan completes Population Health Improvement Plan Implementation Year 1: February 2016 – January 2017 Pre-Implementation: February 2015 – January 2016

19. MiPCT Evaluation Results 19

20. Overall evaluation results to date Patient experience (2015) ▫MiPCT Adults generally more positive than non-MiPCT ▫MiPCT parents about the same as non-MiPCT All-payer utilization, 2011 - 2013 ▫Increase in ED rates ▫Moderate decline in hospitalizations Cost savings for Medicare beneficiaries ▫Caveat: quarter to quarter variation 20

21. Overall evaluation results to date Provider/staff survey reveals satisfaction with Care Management model Care Management survey and PO data collection reveal progress on embedment Care Manager activity leveling off: 25,000 – 30,000 unique patients per quarter 21

22. 22

23. 23 Adult survey results: MiPCT

24. 24 Adult survey results: MiPCT

25. 25 Child survey results: MiPCT

26. 26 Reported occurrence Child survey results: MiPCT

27. * * * * 27 Adult survey results * Statistically significant difference

28. 28 Adult survey results * Statistically significant difference * * * * * *

29. Child survey results: MiPCT versus comparison groups MiPCT patients were not significantly different than other PCMH patients across domains MiPCT patients were not significantly different than non-PCMH patients across most domains ▫Exception: MiPCT patient ratings of provider attention to growth and development 11.6% higher 29 *

30. 30

31. 31 Average Total Patients in Caseload (at the time of survey) :

32. Protocols 32

33. Team members understand which patients might benefit from care management 33

34. Practice Support 34

35. 35

36. PO Quarterly Reporting 36

37. 2011, 2012, & 2013 37

38. Estimated Average MiPCT ED and Inpatient Rates (#/1,000 member years) NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color. 38

39. Estimated Average MiPCT Diabetes Rates NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color. 39

40. Estimated Average MiPCT Adult Preventive Rates NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color. 40

41. Estimated Average MiPCT Peds Preventive Rates NOTE: Changes from baseline are significant at 0.05 level, unless the rates are in red color. 41

42. MiPCT Clinical Update 42

43. 43 The Care Management Resource Center: Helping our Practices to Help Our Patients Year# CM Trained 2012273 2013165 201470 2015 to date73 TOTAL581 Almost 600 CMs have been trained and supported with continuing education since the MiPCT began As health plans (Priority, BCBSM) have expanded the care management benefit beyond MiPCT practices, the CMRC has expanded training sessions (link at: http://mipct.org/care- management-resource- center/ccm-online-registration- page/ http://mipct.org/care- management-resource- center/ccm-online-registration- page/ CMRC Care Manager Training Growth Over Time

44. The Higher the Risk, the More Likely Patients are to Receive CM 44

45. Progress Recap 2015-16 Clinical Focus Areas Addressing social determinants of health and overcoming barriers ▫Mary Ellen Benzik, Tiger Team Lead ▫Toolkit and white paper in development Integrating behavioral health ▫Kevin Taylor, Tiger Team Lead ▫Tiger Team tookit and white paper in development ▫Advocacy: proposed CMS collaborative care model ▫Coordinating with BCBSM/Priority Health work 45

46. Progress Recap 2015-16 Clinical Focus Areas Patient registry and data support for population health ▫Registry and EHR User groups being formed for systems most-used by MiPCT practices ▫CMRC site visits to better understand and spread processes highly linked to HEDIS and STAR improvement Integrating palliative and end-of-life care ▫Advocacy for CMS proposed advance care planning codes ▫Ongoing work with Palliative Care subject matter experts Addressing appropriateness of care (e.g., Choosing Wisely program, etc.) ▫To launch in 2016 46

47. Preparing for Sustainability: Never Too Early! 47

48. Strategy Avenue 1: CMS and State Policy CMS Policy ▫Potential 2017 Expansion of Comprehensive Primary Care Program (CPC) (our “sister” program) ▫CPC milestones are very similar to the MiPCT  Enhanced patient access and continuity of care,  Planned chronic and preventive care,  Risk-stratified care management,  Patient and caregiver engagement, and  Coordination of care across a “medical neighborhood” State Policy ▫SIM synergy ▫Medicaid Managed Care Plan Rebid and Care Management 48

49. Strategy Avenue 2: Meeting Each Payer’s Goals  Payer Leadership Meetings to understand what is important to each payer group so that we can better service their members – and deliver value that can help to sustain the program in the longer term  HEDIS and STAR Measure Improvement  Cost Savings  Improved Coordination with Proactive Outreach  Admission, Discharge, Transfer alert follow-up  Servicing patients from all payers -- Medicaid, Medicare, BCBSM, Priority Health and BCN – who are likely to benefit from Care Management 49

50. Strategy Avenue 3: Leveraging Care Management Billing Codes Billing and Coding Collaborative offers support to practices and POs (in Resources tab of mipctdemo.org) G and CPT Codes - Billing for commercial members with proactive eligibility checking Some Codes are Payable by Medicare (e.g.,) ▫Complex Care Management Code (99490) ▫Transition of Care Codes (99495, 99496) 50

51. Best Practice Awards! 51

52. Celebrating Success in MiPCT Practices!

53. Practice Awards-Categories Most Improved – Adult and Family Medicine Most Improved – Pediatrics Diabetic Metric Improvement Best Overall - Diabetes Best Overall – Adult and Family Medicine Practices Best Overall – Pediatric Practices

54. Best Overall – Adult and Family Practices – Risk Adjusted* Composite score based on practices’ rankings in the following MDC Measures, risk adjusted by MPHI: ▫Inpatient Admissions ▫ED Visits per 1000 Patients ▫PCS ED Visits ▫Acute ACSC Admission Rate ▫Chronic ACSC Admission Rate ▫Diabetes Overall

55. Best Overall – Adult and Family Medicine Practices Marquette Internal Medicine Pediatric Associates Fenton Medical Center, P.C. Jane Castillo, MD Dhiraj Bedi, DO Lifetime Family Care, PLLC /A Division of Michigan Healthcare Professionals PC

56. Winning Category: Best Overall Adult and Family Practice Name: Marquette Internal Medicine and Pediatric Assoc. Independent primary care office founded in the 1960s and incorporated since 1992 WHAT MADE A DIFFERENCE (Process Change, etc.): ▫Culture has always been patient centered ▫Physicians meet every week as a group for an hour ▫The providers spend an hour with every physical, paying close attention to each chronic medical condition as well as preventative maintenance. ▫The Physicians have always covered their own practice most days and nights and have a team approach. ▫Early adaptation of Electronic Medical Records-2006 ▫Additional of physician extenders- Physician Assistants and Nurse Practitioners ▫Strong patient-provider relationships

57. Winning Category: Best Overall Adult and Family Practice Name: Marquette Internal Medicine and Pediatric Assoc. HINTS FOR OTHER PRACTICES ▫Access to care  Culture in place  Letter to patients in their physical exam packets that the providers would rather see them for acute visits rather than them going to the Emergency Department or Walk-in Clinic.  Reminding patients at the end of each physical when they will be seen again and our desire to see them for all acute visits  Utilizing Physician Assistants and Nurse Practitioners ▫Coordination of Care  Automatic notice of any inpatient admissions  Discharge summary reviewed upon discharge and appointment scheduled within the week to go over the summary, medications, etc.  Meetings with the Hospitalist group  Availability of our Electronic Medical Records to the Hospitalist.

58. Questions? 58