The Multi-payer Advanced Primary Care Practice (MAPCP) Demonstration Jody Blatt Senior Research Analyst Project Officer, MAPCP Demonstration Medicare Demonstrations Program Group

Our charge: Identify, Test, Evaluate, Scale “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.” Resources: $10 billion funding for FY2011 through 2019 Opportunity to “scale up”: The HHS Secretary has the authority to expand successful models to the national level More flexibility: Budget neutrality requirements more flexible

Innovation Center Initiatives ACO Suite:  Shared Savings Program  Pioneer ACO Model  Advance Payment ACO Model  Accelerated and Learning Development Sessions Primary Care Suite  Comprehensive Primary Care Initiative (CPCI)  Federally Qualified Health Center Advanced Primary Care Practice Demonstration  Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration  Independence at Home  Medicaid Health Home State Plan Option Bundled Payment Suite Bundled Payment for Care Improvement Dual Eligible Suite: State Demonstration to Integrate care for Dual Eligible Individuals Financial Alignment to Support State Efforts to Integrate Care Demonstration to Reduce Avoidable Hospitalizations of Nursing Facility Residents Medicaid Health Home State Plan Option Diffusion and Scale Suite: Partnership for Patients Million Hearts Campaign Innovation Advisors Program Care Innovations Summit Healthcare Innovation Challenge Rapid Cycle Evaluation and Research Learning and Diffusion 3

MAPCP Demonstration Overview Medicare joining Medicaid and private insurers in state health reform initiatives aimed at improving delivery of primary care A multi-payer effort ◦ Private payers covering a majority of commercial market ◦ Medicaid (managed care and/or FFS) ◦ Medicare State designed program : ◦ Definition of medical home ◦ Payment methodology and rates (subject to CMS ceiling) ◦ Selection of practices ◦ Beneficiary assignment methodology Multi-payer Advanced Primary Care Practice Demonstration4

MAPCP Demonstration Overview Three year demonstration ◦ 8 states: ME, VT, RI, NY, PA, NC, MI & MN ◦ Start dates from July 2011-January 2012; each project will run 36 months Most projects involve monthly payment to the practice for beneficiaries “assigned” using a state-specific algorithm ◦ Total monthly payments generally <= $10 pbpm ◦ Some projects involve community health teams (which may or may not receive separate payments up to $10 max ◦ Some projects include payment (within $10 max) to state for administrative/evaluation services Multi-payer Advanced Primary Care Practice Demonstration5

MAPCP Demonstration Overview (continued) States required to conduct evaluation of state project CMS will conduct an independent evaluation across all states focusing on Medicare & Medicaid Multi-payer Advanced Primary Care Practice Demonstration6

Projected Enrollment by Year (based on original state proposals) Multi-payer Advanced Primary Care Practice Demonstration7

MAPCP & the Michigan Primary Care Transformation Project (MiPCT) Medicare beneficiary eligibility Medicare Payments ◦ How much will Medicare pay? ◦ How will payments be processed? Feedback & Evaluation Questions MAPCP Demonstration - March 20128

Beneficiary Eligibility Covered under the traditional FFS Medicare Program ◦ Not in a Medicare Advantage or other Medicare Health Plan Must have BOTH Medicare Part A & Part B Medicare must be the primary payer ◦ Not working and covered under an employer’s plan Michigan resident May include any of the following groups of beneficiaries:  “Dual” eligibles (Medicare & Medicaid)  ESRD  Disabled  Hospice MAPCP Demonstration - March 20129

Beneficiary Assignment Beneficiary assignment algorithm run quarterly using a common 5-step assignment algorithm:  month (2 stages) look back  Primary care office and home visits (inc. FQHC visits) Beneficiary assigned to the practice where he/she had the greatest # visits during the look-back period Accurate and timely information on providers in the practice (Tax ID #, NPI, P-TAN) critical to accurate and complete assignment and timely payment MAPCP Demonstration - March

Beneficiary Assignment Newer patients may take several quarters to show up on your lists. CMS will provide quarterly beneficiary assignment lists with beneficiary names and key identifying information.  List will show who is new/dropped off each quarter  DUA must be signed to receive this information  Starting spring 2012 beneficiary assignment lists will be available through a web portal Remember: ◦ Beneficiary retains full FFS rights to go to any provider. Beneficiary is NOT locked in. ◦ No enrollment is requires but CMS would like beneficiary notification (newsletter, notice in waiting room, etc.) MAPCP Demonstration - March

Monthly Medicare Payments Payments directly to practice (G9008) : $2.00 pbpm Support for team coordination and other traditionally non-reimbursed medical home expenses paid to central entity for distribution by PO/PHO (G9152): $4.50 pbpm Incentive Pool Contribution (paid to central entity) (G9153): $3.00 pbpm Payment to state for administrative services/evaluation support (G9151):$0.26 pbpm Total Medicare payment: $9.76 pbpm MAPCP Demonstration - March

Claims Payment Process Practices do not have to submit claims for demonstration payments but payments will be processed like a claim On a monthly basis, CMS’ contractor (Actuarial Research Corporation) will create a claim record for each beneficiary on your list and submit it to the “MAC” or carrier for payment. ◦ “Date of service” will be 1 st of the month ◦ Payment will likely be received mid-month ◦ Practice payment ($2.00) is processed under one rendering NPI to facilitate payment Individual monthly claims will be processed for each beneficiary in the same manner as any other electronic claim. ◦ Due to claims volume, claims may be spread out over course of the month. Remittance advice will be sent to the practice Medicare Summary Notice (MSN) will NOT show demonstration claims MAPCP Demonstration - March

Claims Payment Process Monthly claim will reject if beneficiary is no longer eligible for demonstration:  Deceased  No longer has Part A or Part B  Joined an MA plan  Medicare no longer primary Practices can NOT balance bill the patient if the service is rejected Payment may be recouped if retroactive information indicates payment should not have been made MAPCP Demonstration - March

Reports and Feedback Quarterly Feedback Reports ◦ Practice specific summary reports ◦ Benchmark comparisons ◦ Actionable information specific to practice’s patients (e.g. ER visits, hospital admissions) MAPCP Demonstration - March

MAPCP Evaluation Each state required to conduct an evaluation of its program CMS has contracted for an independent evaluation of all 8 programs MAPCP Evaluation Contractor: RTI International (subcontracts with The Urban Institute & the National Academy for State Health Policy (NASHP)  Project Director: Nancy McCall, ScD  MI State Team Lead: Josh Wiener, PhD

MAPCP Evaluation Assess the effects of the PCMH model when supported by Medicare, Medicaid, and private health plans Mix of qualitative and quantitative analyses Populations of interest ◦ Medicare FFS beneficiaries (not Medicare Advantage) ◦ Medicaid beneficiaries (duals and non-duals) Evaluation design o Pre/post analyses w. comparison group

MAPCP Evaluation Data sources ◦ CMS: Medicare claims ◦ State: Medicaid claims, practice/PHO surveys, patient surveys, PCMH scores ◦ Primary data collection  Site visits, interviews, focus groups, observation of TA activities  Minimize burden on participants

MAPCP Evaluation Quantitative outcomes ◦ Expenditures and budget neutrality ◦ Utilization (e.g., hospitalizations, readmissions, ED visit rates) ◦ Quality of care Qualitative research ◦ Structure and features of state initiatives ◦ Practices’ transformational process ◦ Effort involved in Medicare joining state initiatives ◦ How PCMH payments are used

MAPCP Information Links Web site CMS  Solicitation  Fact Sheets  Qs & As  Sign up for automatic notification of all updates Questions about demonstration: First contact your regional representative CMS: Jody Blatt, Project Officer - (410) MAPCP Demonstration - March