michigan primary care transformation project...

Michigan Primary Care Transformation Project (MiPCT)Breaking the Mold: The Role of Data and Partnerships in System Transformation

Diane Bechel Marriott, DrPHProject [email protected]

Overview•The Michigan Primary Care Transformation Project: A Brief History of Time

•Translating Data into Information for Action

•Building Partnerships

The Michigan Primary Care Transformation Project: A Brief History of Time

CMS Multi‐Payer Advanced Primary Care Practice (MAPCP) Demonstration

Centers for Medicare &Medicaid Services is exploring the role of the PCMH in improving US health care Participating in state‐based PCMH demonstrations

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 MichiganMichigan start date: January 1, 2012

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The Vision for a Multi‐Payer Model Use the CMS Multi‐Payer Advanced Primary Care Practice demo as a catalyst to redesign MI primary care Multiple payers will fund a common clinical model Allows global primary care transformation efforts Support development of evidence‐based care models

Create a model that can be broadly disseminated Facilitate measurable, significant improvements in population health for our Michigan residents

Bend the current (non‐sustainable) cost curve Contribute to national models for primary care redesign

Form a strong foundation for successful ACO models5

MiPCT Foundation: CMS-Approved Michigan Multi-Payer PCMH Demo Application

= States winning Medicare Multi-Payer Advanced Primary Care Initiative grants to realign payment incentives and build patient-centered medical homes

Source: CMS, March 2011 (http://www.cms.gov/demoprojectsevalrpts/md/itemdetail.asp?itemid=cms1230016) 66

MiPCT Statewide Partners• 377 Practices

• 35 Physician Organizations

• 5 Payers (BCBSM, BCN, Priority Health, Medicare, Medicaid)

• Over 1600 primary care physicians

• Over 400 embedded, trained Care Managers

• Over 1 million patients

PCMH Care Management Components Associated With Positive Outcomes

Care delivery by multidisciplinary teams Care delivery in collaboration with physician’s office Attention to care transitionsMedication reconciliation In‐person visits along with telephonic encounters Patient selection important ‐ risk stratification plusphysician input important to successful interventions

PCMH as the Foundation for ACO Population Management

10Source: Premier Healthcare Alliance

The goal of Accountable Care Organizations should be to reduce, or at least control the growth of, healthcare costs while maintaining or improving the quality of care patients receive (in terms of both clinical quality, patient experience and satisfaction).

- Harold Miller

MiPCT Payment 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

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CMS Complex Care Management Payment Proposal (Post 12/31/2014) The July Federal Register announcement of the 2014 proposed

CMS Physician Fee Schedule included a proposal 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

MiPCT Fast FactsLaunched: January 1, 2012 (three year demonstration

continues through December 31, 2014)

Convener: State of Michigan spurred by CMS (Multipayer Advanced Primary Care Project (MAPCP) opportunity

Project management: University of Michigan

Key players: 5 payers (Medicare, Medicaid, Blue Cross Blue Shield of Michigan, Blue Care Network, Priority Health); Michigan Dept. of Community Health, 35 Physician Organizations,)

Scope: 377 Primary Care Practices, 400 Care Managers, 1700 PCPs, over 1 M patients

Attribution: Via PCP for HMO and POS products and via common attribution algorithm for PPO products

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MiPCT Fast Facts, Cont. Infrastructure: Data Warehouse, Central Care Manager Training,

Leadership Oversight, Medical Director Team, Learning Collaboratives, Website (www.mipctdemo.org)

Payment Model: Population funding model; POs receive 7.50 PMPM for NonMedicare and 9.50 PMPM for Medicare attributed lives

Payment Flow: Practice Transformation paid directly to practices; Care Coordination and Incentives paid to POs and distributed to practices as appropriate

Contractual Relationships: Payers contract with MDCH POs and Practices contract with MDCH MDCH contracts with UMHS for Program Administration UMHS contracts with external and internal vendors

Data Flow via Data Warehouse (common measure set) Receives monthly member list and claims feeds from payers Provides POs monthly member lists, bimonthly dashboards, and

semiannual incentive results2

Translating Data into Information for Action

U.S. Health Care WasteUnnecessary Services $210BInefficiently Delivered Services

$130B

Excess Administrative Costs $190BPrices that are too high $105BMissed Prevention Opportunities

$55B

Fraud $75BTotal Estimated Excess Costs $765B

Source: Institute of Medicine 2011

MiPCT Data Warehouse

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• Summary level and PO-specific

• Delivered to POs POs will distribute to Practices

PO

Multi-Payer Claims Database

datasets

reports

Practice Practice

Practice

Practice

Practice

Practice

Practice

datasets

reports

datasets

reports

PO PO

Retrospective Reports Quality and Utilization performance

metrics chosen for the project Only claims-based metrics for Year 1

• Requires 2-3 month run-out to ensure availability of complete data

Prospective Reports Timely feedback about attributed

population for use in care management• Providers are not being measured/scored

Incentive Payments Reports Incentive scores and payments

MiPCT Measurement Drives Performance and Progress Quarterly Reports Dashboards Compliance with MDCH/PO/Practice Agreement

Requirements Care Management Activity Reporting Care Manager Staffing Sufficiency Ratios Practice Educational Activities Medical Home Meetings

Incentive Measurement Care Coordination Commercial Billing (G and CPT billing)

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Recap: Use and Cost Evaluation Metrics

Total PBPM Costs Medicare Payments Utilization based standardized cost

Utilization Hospitalizations and ED

All-cause Ambulatory care sensitive (“Potentially preventable)

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Recap: Quality and Experience of Care Evaluation Metrics

NationalDiabetes 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)(available: www.mipctdemo.org)

Patient experience (CAHPS) Provider/staff experience

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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 POs8-12%-------4 POs5-8%---------3 POsUnder 5% --11 POs

Overall, from 2012 to 2013, the MiPCT decreased avoidable emergency visits decreased almost 4%.

Admission, Discharge, Transfer MiPCT Data Flow and Progress

Over half of our POs participate in the Spotlight MiPCT partnership• Care managers now receive member lists electronically via a web interface• ADT notifications add where available

MiPCT Web-Based Member List

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MiPCT Web-Based Member List

Building Partnerships

Critical Players, Potential Partners, Helpful Advocates

Who has a dog in the fight? Critical Players

Who has a heart? Helpful Advocates

Who has a vision? Potential Partners

D Bechel Marriott, DrPH, University of Michigan School of Public Health 2013

Conditions that Favor Business Case Acceptance Hard savings (vs. soft savings or cost avoidance) Actuarially‐based ROI (Return on Investment) level that exceeds existing floor for other programs

Empirically proven (vs. theoretical) and already achieved by a benchmark firm

Based on shared risk or a guaranteed minimum result Positively perceived or invisible to employees and retirees (no negative public relations to manage)

Supported by a senior management champion


Hard and Soft Savings Distinguish ”hard” savings from “soft” savings

Hard Savings Changes in the intensity or level of care (alternatives that do not compromise

quality but increase cost savings) Use of midlevel providers Educating patients about palliative care options Avoidance of unnecessary or redundant care (“top ten list”)

Reducing unneeded care through improved primary care coordination Emergency room visits Inpatient admissions

Greater compliance from increased patient engagement and self‐management

Soft Savings Reducing presenteeism and increasing productivity

Assessment of absence patterns (pre/post) for employers who are able to track absence in a meaningful way (a challenge when many timekeeping systems are fairly basic) or via use of presenteeism scales and surveys.

Greater employee satisfaction and loyalty


Building Partnerships: Lessons for Public Hospitals from a Journey in

Self-Insured Group Recruitment

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Characteristics of Self‐Insured Groups Who are they?

Companies (employers), trusts or groups that are large enough to take on the financial risk of providing benefits

How do they pay for coverage? Pay claims as they are incurred (instead of a fixed premium to a carrier)

Also pay an administrative fee to process claims What is important to them?

Pressed for quarter to quarter returns and minimal asset exposure

Value data‐based decision making (balancing cost, quality and access) with ROI


Self-Insured Group RecruitmentUseful Strategies

Find and partner with the employer health business coalitions in your state or area. Develop a “what’s in it for me” business case starter deck to

begin and explore opportunities for partnership focusing on: Patient engagement (the opportunity to demonstrate that the program makes a difference

to the employer’s members) Opportunity for better value in care Productivity gains from a healthier and more engaged workforce Value data-based decision making (balancing cost, quality and access) with ROI

Identify the largest self-insured groups in your participating plans Work with and partner with health plans; Understand the existing benefit design Assesses compatibility of new program with existing benefit design and strategy

Start with a small set; produce deliverables, and use to grow purchaser base

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Leadership

“….the art of getting someone else to do something you want done because he wants to do it.”

Dwight D. Eisenhower

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Summary: Helpful Ideas

Leveraging What You Have

Listen

Let the Data Set You Free

Pleasant Persistence Pays Off Over Time33

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