1. The Michigan Primary Care Transformation (MiPCT) Project Annual Summit October 2013 MiPCT Overview and Updates 1

2. Objectives Recap MiPCT Overview and 2013/14 Focus Areas Review MiPCT Project Evaluator Findings to Date Discuss Project Sustainability

3. MiPCT Overview Jean Malouin

4. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration Centers for Medicare & Medicaid Services is participating in state-based PCMH demonstrations ▫ Assessing effect of different payment models CMS Demo Stipulations ▫ Must include Commercial, Medicaid, Medicare patients ▫ Must be budget neutral over 3 years of project ▫ Must improve cost, quality, and patient experience 8 states selected for participation, including Michigan Michigan start date: January 1, 2012 4

5. Participants 380 practices 35 POs 1,500 physicians 1 million patients 5 Payers ▫ Medicare ▫ Medicaid managed care plans ▫ BCBSM ▫ BCN ▫ Priority Health (7/13)

6. MiPCT Funding Model $0.26 pmpm Administrative Expenses $3.00 pmpm*, ** Care Management Support $1.50 pmpm*, ** Practice Transformation Reward $3.00 pmpm*, ** Performance Improvement $7.76 pmpm Total Payment by non-Medicare Payers*** * Or equivalent ** Plans with existing payments toward MiPCT components may apply for and receive credits through review process *** Medicare will pay additional $2.00 PMPM to cover additional services for the aging population 6

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8. MiPCT Mid-Point: Statewide Care Management Progress to Date Over 300 Care Managers hired and trained Building infrastructure in partnership with POs ▫ CM Documentation tools ▫ Ongoing Care Manager training, coaching, mentoring ▫ Patient education materials ▫ Communication- PCP, CM, staff members ▫ Interface with community resources Building volume of G code and CPT codes submitted Building caseloads of targeted high-risk patients 8

9. Multi-Payer Claims Database 9 Collect data from multiple Payers and aggregate it together in one database  Creates a more complete picture of a patient’s information when they: Receive benefits from multiple insurance carriers Visit physicians from different Practices, Physician Organizations or Hospitals  Phase 1 – claims data  Phase 2 - claims and clinical data Multi-Payer MiPCT Claims and Clinical Database CLAIMS Medicare Medicaid BCBSM BCN Priority Health CLINICAL 35 participating POs

10. MDC: MiPCT Dashboards 10 Population Membership Attributed members by Payer Risk Information # of members by Risk Level Population Information # patients by Chronic Condition (Asthma, CKD, CHF, etc) Quality Measures Screening and Test Rates Diabetes tests, Cancer Screens, etc Prevention Immunization Rates, Wellness Visits, etc. Comparison to Benchmarks Utilization Measures Rates ED Use, Admissions, Re-admissions, etc Comparison to Benchmarks

11. Admission, Discharge, Transfer MiPCT Data Flow and Progress 17 POs participate in the Care Team Connect (CTC)/MiPCT partnership (at no cost to PO) Care managers access member lists directly via a web interface ADT notifications adding for Trinity, Spectrum, Beaumont!

12. 2013-2014 Priorities Care managers fully integrated into practices Target PCMH interventions to patients from all participating payers ▫ Distribute multi-payer lists and dashboards ▫ Ensure care management for at risk members ▫ Use registry for proactive population management Focus on efficient and effective health care ▫ Avoid unnecessary services/hospitalizations ▫ Assess practice utilization patterns Ensure adequate clinic access to meet demands 12

13. How will CMS define success? 13 The tie to budget neutrality and ROI

14. Successes Champions abound; We have gained traction! Michigan is well-poised compared to other states despite its broad scale Hard-working, dedicated people Multi-payer Database Strong PCMH foundation 14 Challenges Success on cost, quality and utilization measures is key to sustainability Member lists vs. the population G and CPT code billing and “throughput” PO and practice infrastructure varies Many competing priorities MiPCT Brief Review: Balancing Successes and Challenges

15. 15 www.mipctdemo.org

16. MiPCT Evaluation Update Clare Tanner

17. Objectives MiPCT Investment in PCMH Care Management Implementation Quality/Utilization

18. MiPCT Practices

20. Financial Investment, 2012 “New” Money 1 Total 2 Care Coordination $35,577,697 Practice Transformation $8,739,951$28,287,509 1.New money includes: Medicaid, Medicare, BCN g-code payments, BCBSM g-code + make whole payments 2.Total adds in: BCBSM Practice transformation (E&M uplift) of $19 million, but does not include incentive payments

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22. 22  70% have 1 practice  23% have 2-4 practices  7% have 5 or more practices

23. MiPCT Benchmark* for Care Manager Caseload Care manager’s patient caseload – 2 nd Quarter PO Data 23 Care Manager Role 90 th Percentile Qtr 2 face to face/FTE 90 th Percentile QTR 2 Phone encounters/FTE Encounters per day = Benchmark* Complex842606 encounters per day Hybrid1603218 encounters per day Moderate1932387 encounters per day

24. Care Manager Volume Quarter 2, 2013 Encounters Unique Patients Face to Face Phone Total15,25032,70922,237 Per CM FTE 6311282 24

25. 2013 PO Report – 1 st & 2 nd Quarter Care Manager Activities 25

26. Care Manager Survey Conducted in May 2013 434 care managers asked to complete survey 53% completed the survey (n=228)

27. Care Manager Survey Results Care Managers reported working with an average of 8.4 physicians On average, 83% of these physicians referred patients 27 Physician Interaction

28. Care Manager Survey Results 28

29. Care Manager Survey Results 29

30. Care Manager Survey Results 30

31. Care Manager Survey Results 31

32. Care Manager Survey Results The physician(s) I work with support the concepts of the MiPCT care management team. 32 Strongly Disagree DisagreeNeither Agree nor Disagree AgreeStrongly Agree

33. Care Manager Survey Results Physicians are available on a daily basis to address questions related to management of MiPCT patients. 33 NeverRarelySometimesFrequentlyAlways

34. Care Manager Survey Results Physicians understand and are actively involved in population management 34 NeverRarelySometimesFrequentlyAlways

35. Care Manager Survey Results 35 Top 3 broad areas of challenge ▫Care Manager Challenges  Need for work flow processes  Need for practice team support/understanding of CM role  Time management ▫Care Management Embedment  Need for practice staff education on CM role and process workflows  CMs serving multiple practices or working as a CM part time ▫Physician Engagement

36. Care Manager Survey Results 36 Top 3 broad areas of success ▫Development of Process Improvement  Transition of Care  Using the MiPCT List  Reviewing the practice schedule regularly ▫Culture Change within the Practice  Physician engagement  Reviewing potential patients with the provider/use of huddles  Practice staff understanding of the CM role ▫Advanced/Improved IT Capabilities

38. Utilization and Cost Metrics: MI and National Evaluations are Consistent Total PMPM Costs ▫Medicare Payments (National) ▫Utilization based standardized cost calculations across all participating payers (Michigan) ▫Additional analysis of cost categories Utilization ▫All-cause hospitalizations ▫Ambulatory care sensitive hospitalizations ▫All-cause ED visits ▫‘Potentially preventable’ ED visits 38

39. Quality and Experience of Care Metrics: MI and National Evaluations are Different, But Share Common Elements National Diabetes care: LDL-C screening HbA1c testing Retinal eye examination Medical attention for nephropathy All 4 diabetes tests None of the 4 diabetes tests Ischemic Vascular Disease: Total lipid panel test Patient experience (CAHPS) Michigan Diabetes Asthma Hypertension Cardiovascular Obesity Adult preventive care Child preventive care Childhood lead screening (Medicaid) Patient experience (CAHPS) Provider/staff experience 39

41. MiPCT Number of POs with Quality Rate Changes >= +10% Positive <10% Negative >-10%<= -10% Number of POs with Positive Change in All Group Measures Breast Cancer Screening122120 Cervical Cancer Screening30500 Chlamydia Screening88712 Adult Preventive7 Adolescent Well-Care910 6 15-Month Well-Child14558 3-6 Year Well-Child89107 Well-Child Care8 Diabetic Eye Exam212210 Diabetic HbA1c Testing015200 Diabetic LDL-C Testing04310 Diabetic Nephropathy Screening310193 Diabetes Care2 MiPCT Number of POs with Quality Rate Changes

42. Statistically Significant Increases (p<=.1) Increases (Not Statistically Significant) Decreases (Not Statistically Significant) Statistically Significant Decreases (p<=.1) Overall MiPCT Change Significant (p<=.1) Breast Cancer Screening518111PositiveYes Cervical Cancer Screening 31400PositiveYes Chlamydia Screening115109NegativeYes Adolescent Well-Care81188NegativeYes 15-Month Well-Child81176PositiveNo 3-6 Year Well-Child512611NegativeYes Diabetic Eye Exam410156NegativeYes Diabetic HbA1c Testing313163NoneNo Diabetic LDL-C Testing04265NegativeYes Diabetic Nephropathy Screening 49148NegativeYes MiPCT Number of POs with Quality Rate Changes

43. MiPCT 2012 PCS ED Rate per 1000 ED Visits Percent Change from 2011 Baseline Rate by PO

44. MiPCT Post-Demonstration Funding and Sustainability Diane Marriott

45. What Does Sustainability Mean? To the Health Plan: Added value for their customers To the Practice: Maintaining and growing CM staffing, processes and roles To the PO: Payment reform for CM To the State and Patients: Servicing all patients, all payers 45

46. Sustainability Progress ▫Reduction of 4% in number of emergency room visits for MiPCT patients for ambulatory care-sensitive conditions from 2012 to 2013 ▫Addition of Priority Health brings payer participation from the largest plans in Michigan ▫CMS Complex Care Management proposal ▫Patient Advisory Council launched that offers the patient voices and input in program design and operations ▫ROI PO Subgroup financial modeling ▫ADT messaging and direct Care Manager member list distribution at no cost to POs ▫PCMH incorporation in SIM proposal 46

47. PO Primary Care Sensitive Emergency Department Use (Change from 1/1/12 to 12/31/12) For POs with Stat. Sig. Better Performance, Amt. of Change Over 12%---2 POs 8-12%-------4 POs 5-8%---------3 POs Under 5% --11 POs Overall, from 2012 to 2013, the MiPCT decreased avoidable emergency visits decreased almost 4%. No Improvement Improved (not stat. sig.)

48. CMS Complex Care Management Post-Demo Payment Proposal Good News! CMS Physician Fee Schedule included proposed codes for Complex Care Management quarterly payment beginning 1/1/2015. MiPCT submitted comments on this constructive development, focusing on: ▫Encouraging consideration of quarterly payments for moderate care management as well ▫Discouraging CMS from imposing patient financial responsibility for care management services ▫Recognizing alternative designations (e.g., PGIP PCMH) for medical home definition ▫Removing the requirement that the practice employ an advanced care nurse or PA (NP or PA) and streamlining requirements for electronic all-provider communication, annual patient consent, etc. ▫Offering to share our experience and input on payment rates

49. Payer Sustainability Statement "As participating Michigan Primary Care Transformation Project (MiPCT) payers, we recognize the value of care management embedded in primary care practices. We applaud CMS' recent payment proposal to continue funding for complex care coordination after the December 31, 2014 ending period of the demonstration project. We support continuation of this model of care to produce improvements in patient experience, quality and the value of care. We look forward to working together with the partnership of the MiPCT, the plans and the health care providers in improving Michigan's primary care system."

50. We ARE the MiPCT! We can do this! We can make care better!

51. Questions?