the multi-payer advanced primary care practice (mapcp) demonstration jody blatt senior research...

The Multi-payer Advanced The Multi-payer Advanced Primary Care Practice Primary Care Practice

(MAPCP) Demonstration(MAPCP) Demonstration

Jody BlattSenior Research AnalystProject Officer, MAPCP DemonstrationMedicare 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 levelMore flexibility: Budget neutrality requirements more flexible

Innovation Center InitiativesInnovation Center Initiativeshttp://innovations.cms.govhttp://innovations.cms.gov

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MAPCP Demonstration MAPCP Demonstration OverviewOverview

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 Demonstration 4


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 monthsMost 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



(continued)(continued)

States required to conduct evaluation of state project

CMS will conduct an independent evaluation across all states focusing on Medicare & Medicaid


Projected Enrollment by YearProjected Enrollment by Year(based on original state proposals)(based on original state proposals)


Year 1 Year 2 Year 3 Year 1 Year 2 Year 3Maine 26 42 42 40,000 80,000 80,000 Vermont 110 176 220 56,914 92,519 117,499 Rhode Island 13 13 13 9,600 9,600 9,600 New York 35 35 35 30,976 30,976 30,976 Pennsylvania 78 78 78 71,846 71,846 71,846 North Carolina 61 61 61 40,928 42,529 44,729 Michigan 477 477 477 358,402 358,402 358,402 Minnesota 159 250 340 95,856 150,631 205,406

TOTAL 959 1,132 1,266 704,522 836,503 918,458

# MEDICAL HOMES # BENEFICIARIES COVERED

MAPCP & the Michigan Primary Care MAPCP & the Michigan Primary Care Transformation Project (MiPCT)Transformation Project (MiPCT)

Medicare beneficiary eligibility Medicare Payments

◦ How much will Medicare pay?◦ How will payments be processed?

Feedback & EvaluationQuestions

MAPCP Demonstration - March 2012 8

Beneficiary EligibilityBeneficiary EligibilityCovered under the traditional FFS Medicare

Program◦ Not in a Medicare Advantage or other Medicare

Health PlanMust have BOTH Medicare Part A & Part BMedicare must be the primary payer

◦ Not working and covered under an employer’s planMichigan residentMay include any of the following groups of

beneficiaries: “Dual” eligibles (Medicare & Medicaid) ESRD Disabled Hospice


Beneficiary AssignmentBeneficiary AssignmentBeneficiary assignment algorithm run

quarterly using a common 5-step assignment algorithm:

12-24 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


Beneficiary AssignmentBeneficiary AssignmentNewer 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 portalRemember:

◦ 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.)


Monthly Medicare Monthly Medicare PaymentsPaymentsPayments directly to practice (G9008): $2.00

pbpmSupport 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 pbpmMAPCP Demonstration - March 2012 12

Claims Payment ProcessClaims 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 1st 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 claimsMAPCP Demonstration - March 2012 13

Claims Payment ProcessClaims Payment ProcessMonthly 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


Reports and FeedbackReports 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 2012

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MAPCP EvaluationMAPCP Evaluation

MAPCP EvaluationMAPCP EvaluationAssess 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 designo Pre/post analyses w. comparison group

MAPCP EvaluationMAPCP 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 EvaluationMAPCP EvaluationQuantitative 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 LinksMAPCP Information LinksWeb site

http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1230016

Solicitation Fact Sheets Qs & As Sign up for automatic notification of all updates

Questions about demonstration:First contact your regional representative

CMS:[email protected] Blatt, Project Officer - (410) 786-6921


the multi-payer advanced primary care practice (mapcp) demonstration jody blatt senior research...

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