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

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. 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. 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. 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. Four Basic Steps in the Process
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. Four Basic Steps in the Process
Select Communities to participate (April 2012)
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 2-3-4
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. Four Basic Steps in the Process
Select Communities to participate
Align payers
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. 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. Four Basic Steps in the Process
Select Communities to participate
Align payers
Select PCP Practice Locations
“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. 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. 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. 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. 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. 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. .
Questions?