The Michigan Primary Care Transformation (MiPCT) Project

PGIP Meeting UpdateSeptember 12, 2014

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Agenda1. Welcome and Overview

2. Evaluation Update

3. Diabetes Performance and Practice Coaching Update

4. Billing Collaborative, Payer Updates and CMS Response Letter

5. Best Practice Workgroup Update

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Evaluation Update

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Topics•National Evaluation Update▫Most recent cost and utilization analysis▫Patient experience

•Michigan Evaluation Update▫Cost and utilization analysis▫Key survey findings to date: multiple perspectives

on Care Management

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National EvaluationResults from Research Triangle Institute

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Quarterly Trend Comparison: Medicare PMPM Payments

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Quarterly Trend Comparison: Payments to PC and Specialty Physicians

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Quarterly Trend Comparison: Hospital Admissions

Patient Survey – PCMH CAHPS

• Medicare Beneficiaries

• Analysis adjusted for demographic and other factors for purposes of comparison

State Response Rate (%) # Completed

ME 46.2 643

MI 42.6 599

MN 43.3 602

NC 45.3 634

NY 44.6 630

PA 41.6 584

RI 46.1 544

VT 44.3 627

Access to Care Composite

Communication with Providers Composite

Shared Decision-Making Composite

Self-Management Support Composite

Comprehensive Orientation Composite

Michigan EvaluationMichigan Public Health Institute

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Status

Activity Status

Cost, quality and utilization analysis

• MiPCT practice level analysis underway• Comparison data supplied by all payers

through December 2013• Being processed – expected Delivery to MPHI:

October

PO Survey Complete

Care Manager Survey Three time points available, additional survey planned

Practice/Staff Survey Still open for response

Patient Survey • Mail/phone follow-up• Using claims data to randomly select

respondents• We could use your help to encourage response

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Survey DataMultiple Perspectives on Care Management

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Care Manager Survey18

Survey 1: Survey 2: Survey 3:

May 2013 Dec. 2013 June 2014

Data Collected via Survey Monkey ®

May 20th - June 12th, 2013

Dec. 16th, 2013 - Jan. 5th, 2014

June 9th - June 26th, 2014

Number of Care Managers emailed invitations to participate 434 424 421

Care Managers who completed the survey #(%) 228 (53%) 213 (50%) 209 (50%)

New respondents # (%) 228 (100%) 83 (39%) 58 (28%)

Repeat respondents N/A 130 (61%) 151 (72%)

Data cleaning and analysis performed using SPSS v19

Average Percent of Time Spent at the Following Locations:

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Min: 0%Max: 100%

Min: 0%Max: 100%

Min: 0%Max: 25%

Min: 0%Max: 90%

Physicians’ Availability20

Physicians Support for Care Management21

Staff Support for Care Management22

Provider/Staff Survey Preliminary Results, n=1,032

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Provider/Staff Survey Preliminary Results(questions not asked of Care Managers)

Percent Agree/Strongly Disagree (5 point scale, remaining responses largely neutral)

Please help us encourage response to the Provider/Staff SurveyDeadline extended to end of next week

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PO Feedback:MiPCT should do differently next time• Clear and consistent expectations (n=13)▫ In general▫ Related to performance incentives▫ Consistency across payers▫ Consistency over time, fewer program changes▫ Better and more timely communication

• More help (n=10)▫ Better data sooner▫More access to data▫ Assistance with physician engagement▫ Assistance with care management implementation

• More responsiveness to local variation and capacity(n=2)• Different model (n=2)▫ Over-reliance on Geisinger and/or nursing model

PO Lessons Learned:PO should do differently next time• Care Management Embedment (almost everyone!)▫ Better define practice roles from the beginning, better

planning▫ Physician engagement, incentives, requirements▫ Pair practice coaches with Care Managers▫More oversight of Care Managers by POs, more meetings with

practices, PO hire CMs not practices▫ Software investment▫ Develop alternatives to the MiPCT patient list

• Be more selective, include fewer practices, assess practice readiness earlier (n=6)

• Collaborate with other POs, contract for CM services (n=3)• We did it right! (n=1)

Diabetes Performance and Practice Coaching Update

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MiPCT 2014 Annual Summits

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2014 Summit Overview

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Morning Session – Open to All

The morning session is an all-stakeholder meeting that is open to all. The theme for the morning is: “The Future of Primary Care: MiPCT in 2015 and Beyond”.

Practice teams attending with a physician are eligible to earn 4 Practice Learning Credits

Afternoon Session – Care Manager Training

•Designed for MiPCT Care Managers though other interested team partners are welcome to attend as well

•Topics include a Palliative Care RN Expert Presentation and Update on the MiPCT Care Management Best Practice Work Group Update.

The MiPCT 2014 Summit Care Manager Session has been submitted to the Michigan Nurses Association for approval to award contact hours. The Michigan Nurses Association is an approver of

continuing nursing education is the State of Michigan Board of Nursing.

2014 Summit Logistics36

Morning Summits – Two in-person locations:

Ann Arbor – University of Michigan North Campus Research Center (NCRC), October 7, 2014 – 8:00 AM to Noon; and Grand Rapids – Frederik Meijer Gardens, October 9, 2014 – 8:00 AM to Noon (this location will also have a live webinar link allowing those who cannot travel to participate).

Afternoon Care Manager Education – Three in-person locations:

Ann Arbor – University of Michigan North Campus Research Center (NCRC), October 7, 2014 – 1:00 pm-4:30pmGrand Rapids – Frederik Meijer Gardens, October 9, 2014 – 1:00 pm-4:30pmGaylord –Ostego Conference Center October 1, 2014 – 11:30am – 4:30 pm

Note: The Gaylord morning Summit session will not take place this year. Instead, Gaylord afternoon Care manager training will begin with a special hour-long briefing session with MiPCT Leadership on MiPCT evaluation and 2015 sustainability/continuity. The Grand Rapids morning summit on October 9 th will also be available via webinar link and will be recorded and available on the mipctdemo.org site soon afterward.

2014 Summit Registration

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• Register by visiting the mipctdemo.org website and clicking on the “2014 MiPCT Annual Summits” tab.

• Registration is key to practices receiving Practice Learning Credits

• Tab contains detailed information on locations, hotel block codes for travelers, parking information

• Meeting material will also be posted here in advance of the summits

• To allow for processing time for materials registration will close on September 30th so register now!

• Registration is at no cost to attendees; lunch is provided

Billing Collaborative, Payer Updates and CMS Response Letter

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MiPCT Multipayer Billing and Coding Collaborative

• Led by Mary Ellen Benzik

• Practice Learning Credits Awarded: Four credits

• Focus: Accelerated support to POs and practices for robust billing and coding infrastructures and processes

• Structure – Each PO is invited to join with one to three practices for:▫ A half day in-person session ▫ Monthly Webinars

• Sign up by emailing micptdemo@michigan.gov by 9/17 with: PO name, practice participants and roles (practice manager; billers and coders; Care Managers, etc.)

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MiPCT Multipayer Billing and Coding Collaborative

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• Payer-led briefings• The business case for care management• Learning from the leaders: Best processes and practices

PO: Sample PO

Indicates that estimate is in process

PayerPayment Approach PMPM

% Patients with Two or More Chronic Cond.

2013 G/CPT Code Revenue**

Member Count Revenue Payer

Payment Approach PMPM

% Patients with Two or More Chronic Cond.

2013 G/CPT Code Revenue**

Member Count Revenue

Medicare

PMPM for Attributed Patients $9.50 15000 $ 1,710,000 Medicare

PMPM for Attributed Patients N/A 15000 N/A

Medicare

Monthly G Code for nonattributed engaged patients (PEPM)* $42.00 56% 424 $ 213,457 Medicare*

Monthly G Code for engaged patients w/ 2+ chronic conditions (PEPM) $ 41.92 56% 3388 $1,704,400

Medicaid Managed Care MiPCT PMPM $7.50 20000 $ 1,800,000

Medicaid Managed Care MiPCT PMPM 7.5 20,000 $1,800,000

Priority Commercial MiPCT G/CPT Codes 10000

Priority Commercial MiPCT**

G/CPT Codes 10000

Priority Commercial MiPCT

Incentive for PCMH and Embedded Care Manager $3.25 10000

Priority Commercial MiPCT

Incentive for PCMH and Embedded Care Manager 3.25 70000

BCBSM Commercial - MiPCT*** G/CPT Codes 10000

BCBSM Commercial - MiPCT**

G/CPT Codes 10000

BCBSM Commercial - MiPCT*** E&M Uplift 10000 $ 360,000

BCBSM Commercial - MiPCT*** E&M Uplift 10000 $360,000

BCBSM Medicare Advantage** G/CPT Codes 5000

BCBSM Medicare Advantage**

G/CPT Codes 5000

TOTAL $ 4,083,457 TOTAL $ 3,864,400

PHYSICIAN TRANSITION OF CARE REVENUE from 99495 and 99496 (to be added) PHYSICIAN TRANSITION OF CARE REVENUE from 99495 and 99496 (to be added)

2015 PO Projections - MiPCT Care Management Revenue Modeling with and w/o CMS Demo Period ExtensionEstimates Based on June 2014 MiPCT Member Counts

ADDITIONAL PRACTICE VISIT REVENUE FROM CLOSING GAPS IN CARE (to be added) including increase in office visits due to decreased ED use; etc.

Stage Two Additional Modeling Components: Stage Two Additional Modeling Components:

CARE MANAGEMENT REVENUE

ADDITIONAL PRACTICE VISIT REVENUE FROM CLOSING GAPS IN CARE (to be added) including increase in office visits due to decreased ED use; etc.

Scenario One: With Demonstration Period Extension

CARE MANAGEMENT REVENUE

Scenario Two: Transition from Demonstration to Ongoing Program

This describes revenue estimation with Medicare continuing to pay on a PMPM basis should they extend the period of the demonstration

This describes revenue estimation with Medicare's G code for engaged patients with two or more chronic conditions

Indicates that estimate is in process

MiPCT 2015 Plan Care Management Funding Recap (regardless of CMS demonstration

period extension decision)

• Medicaid: $7.50 PMPM continues

• BCBSM: E&M Uplift and G/CPT Codes

• Priority Health: $3.25 PMPM Care Management Incentive and G/CPT Codes

• BCBSM Medicare Advantage: G/CPT Codes

• BCN evaluation in process

Medicare FFS payment will continue as $9.50 PMPM (with demo period extension) or at the $41.92 PBPM for engaged chronic patients)

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CMS Chronic Care Management Monthly G Code:

The MiPCT Response

• Submitted on September 2, 2014

• Main themes:

▫ Insufficiency of payment rate proposed to fund effective care management

▫ Non-Face-to-Face Care Management not included

▫ Patient financial liability may pose barrier to patient engagement

▫ EHR certification level

▫ Clarification needed regarding definition of clinical staff

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Best Practice Workgroup Update

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MiPCT Care Management Best Practice Work Group – Background•Care management activity across the state is

varied.

•Statewide the volume of care management encounters are lower than expected.

•Care management best practices do exist and it

will be beneficial to gather and analyze these best practice activities via a MiPCT work group to identify models and improvement processes.

MiPCT Care Management Best Practice Work Group – SOW DeliverablesHigh Level Deliverable: Create a Generic Framework

which can be individualized to meet the needs of the practice /PO

• Identify best practice for Care Manager time management, caseload, patient encounters, positive patient outcomes

 • Care Management delivery best practice model for

complex and moderate risk patients

• Preliminary findings, best practice infrastructure to support care management

A Unique Opportunity • To recognize and highlight collective workgroup

expertise

• To create an evidence based toolkit for MiPCT Care Management delivery based on best practice

• To share this work with ▫MiPCT Leadership▫MiPCT POs/practices/care managers ▫Participating MiPCT payers▫Potentially other health care leaders

MiPCT Care Management (CM) Best Practice Work Group Participants• MiPCT Statewide Representation

• Invitation based on performance criteria of CM encounter data, MiPCT quality and utilization metrics for Adult population PO Leaders

Care Managers

Clinical Leads

Physician(s)

CM Best Practice ParticipantsMiPCT PO Leaders and MiPCT Clinical Leads•Anne Levandoski- UPHP•Susan Viviano- Advantage Health•Margaret Jacobs- UMHS•Maureen Braun- IHA•Karen Bennett- Sparrow Health Medical Group•Chris Rusin- United Physicians•Ruth Clark- Integrated Health Partners•Lynn King- Lakeshore Health Network, MiPCT Clinical Lead

CM Best Practice Participants cont.

MiPCT PO Leaders, Care Managers, and MiPCT Clinical Leads•Belinda Fish- UMHS•Mary Kramer- UPHP•Victoria Lee- Advantage Health Physicians•Diane McLeod- Sparrow Medical Group•Lindsay Schohl- Lakeshore Health Network•Robin Schreur- Spectrum Health Medical Group, MiPCT Clinical Lead•Della Slavsky- UPHP, MiPCT Clinical Lead•Tammy Starks- IHP•Heidi Steinhebel- IHA•Juliann Testy- Henry Ford Medical Group, MiPCT Clinical Lead•Loretta Warda- CIPA/MAG, MiPCT Clinical Lead

MiPCT Clinical Leadership:Dr. Kevin Taylor, Dr. Jean Malouin, Marie Beisel, Paula Amormino

Individual Care Manager (CM): How does the care manager complete daily work?

System Factors: Leadership, Infrastructure & Practice embedment

Four Focus Areas• Care Management Fundamentals ▫ 5 Step CM process for moderate and complex patients

• Sharing Innovative Best Practices ▫ Identify what is working

• “New work” development ▫ Focus on topics with high level of impact to contribute to efficient

and effective care management delivery▫ CM best practice participants form a sub group – develop

guidelines

• CM activity – what does effective and efficient care management look like?▫ Non direct patient care such as care coordination

Potential Outcomes of this Work Group

•Shared learning of CM Best practice innovative work▫Document “what works” to achieve increased

Care Management encounters / benchmark goals and quality outcomes

•Document “what has been tried and does not work”

Potential Outcomes of this Work Group cont.

•Evidence based best practice model utilizing patient acuity as the driver for care interventions. ▫ Address Complex and moderate risk patients and improved

patient outcomes

•Toolkit▫Resources, tools, workflows developed by MiPCT

participants ▫Crosswalk key elements required by MiPCT participating

health plans, CMS Chronic Care codes which will be effective Jan 2015

•Reference list ▫ Evidence based resources, articles and websites

Timeline •7/17/14 Kick off webinar•8/5/14 In person meeting •8/12/14 Webinar•8/26/14 In person meeting•9/18/14 Webinar •9/26/14 In person meeting•Plan one additional in person meeting

•Nov/Dec 2014 Share statewide ▫ Toolkit and Best Practice materials

Progress to date cont.

•Care Management Fundamentals – group work, report out, documentation ▫ 5 Step Care Management process – patient

identification, screening, assessment, intervention/management, case closure Moderate care management Complex care management

• Identification of 7 Innovative topics:▫Chart audit, coaching and mentoring CMs, social

determinants of health, care giver action plan, case closure criteria, advance directives and inpatient/out patient Care Manager Care Coordination.

Progress to date cont.

CM Best Practice Participants- survey distributed 9.8.14 ▫7 Innovative topics current state

assess each participants level of implementation goal – report out Best Practice sharing, gather

documentation▫Prioritize potential “New topics”

•Gathering: resources, work flow, tools

Questions?