Maine PCMH Pilot & MAPCP Demonstration

UpdateLisa M. Letourneau MD, MPH

September 2013

Healthy, productive, connected people &

families

…receiving healthcare

from a highly functioning

“accountable care

organization”

Vision for a Transformed Health Care System

… supported by a robust & well-supported primary care base

The Current Primary Care Home

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The Medical Home: A Start for Change!

Providers transform practice, create value with viable &

sustainable payment for desired services

= Practice Transformation

Employers & payers pay for desired services because

primary care demonstrates value & saves money

= Payment Reform

AND

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Maine PCMH Pilot Leadership

Maine Quality Counts

DHA’s Maine Quality Forum

Maine Health

Management Coalition

MaineCare (Medicaid) 5

Maine PCMH Pilot Practice “Core Expectations”

1. Demonstrated physician leadership for improvement2. Team-based approach3. Population risk-stratification and management4. Practice-integrated care management5. Same-day access to care6. Behavioral-physical health integration7. Inclusion of patients & families8. Connection to community / local HMP9. Commitment to reducing avoidable spending & waste10. Integration of health IT

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Support for Practice Transformation

• PCMH Learning Collaborative– Institute for Healthcare Improvement (IHI) Breakthrough Series

(BTS) model; 3 learning sessions/year• Practice Quality Improvement (QI) Coaches

– Most from existing physician hospital organizations (PHOs), medical groups

– Using microsystems approach to QI• Technical Assistance “Experts”

– Behavioral health (BH) integration, work with consumers, HIT• Ongoing Feedback Reports

– Clinical, claims data

7Lisa Letourneau

Maine PCMH Pilot – Payment Model• Major private payers, Medicaid, & Medicare

participating (MAPCP demo)• PCMH payment model:

Prospective (pmpm) care management payment Approx $3pmpm commercial payers (Anthem, Aetna,

HPHC) Approx $7pmpm Medicare, $12 Medicaid HHs

Ongoing FFS payments Performance payment for meeting quality

targets (existing P4P programs)

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Community Care Teams• Multi-disciplinary, community-based, practice-

integrated care teams• Build on successful models (NC, VT, NJ)• Support patients & practices in Pilot sites, help

most high-needs patients overcome barriers – esp. social needs - to care, improve outcomes

• Key element of cost-reduction strategy, targeting high-needs, high-cost patients to reduce avoidable costs (ED use, admits)

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Maine PCMH Pilot - MAPCP Timeline

ME PCMH Pilot - Original

ME PCMH Pilot - Extended

Jan 1, 2010

Dec 31, 2014

Jan 1, 2012

Pilot Expansion, HHs

2011 2012 2013 Dec 31, 2014

MAPCP Demo – 3yr

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Implications of CMS MAPCP Demo

• Medicare joined as payer in Pilot (Jan 2012)• Stronger focus on reducing waste & avoidable

costs – particularly readmissions• Introduction of Community Care Teams• Ability to access Medicare data for reporting,

identifying pts at risk• Opportunity for 50 additional practices to join

“Phase 2” of Pilot (Jan 2013)

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FQHC: federally qualifiedhealth center

H-O: hospital-owned

Original (Phase 1) 26 PCMH Pilot Practices

Maine PCMH Pilot Community Care Teams, Phase 1 and Phase 2 Practice Sites

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Alignment of Pilot with MaineCare Health Homes Initiative

• Affordable Care Act (ACA) Sect 2703 - opportunity to develop Medicaid “Health Homes” initiative

• MaineCare elected to align HH initiative with current multi-payer Pilot – part of VBP initiative

• Defined MaineCare “Health Home”(HH):HH = PCMH practice + Community Care Team (CCT)

• Opportunity to leverage multi-payer PCMH model, practice transformation support infrastructure

• Maine SIM funding will support QI outreach to HHs

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Maine’s Medical Home Movement

~ 540 Maine Primary Care Practices

25 Maine PCMH Pilot Practices

50 Pilot Phase 2

Practices

120+ NCQA PCMH Recognized Practices

~150 eligible MaineCare HH-Practices

Payers: • Medicare• Medicaid (HH)•Commercial plans (Anthem, Aetna, HPHC)•Self-funded employers

Payer: Medicaid

Payer: Medicare

14 FQHCs CMS APC

Demo

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PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!)

Payers

Pharmacies

Home Care

HealthMane

PartershipsSpecialists

NursingHomes

Home Health

Hospitals/Hospitalists/

CareManagers

Employers

Primary Care Providers

PatientCenteredMedical Home

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ACO

ACOs in Maine – What’s Happening?• Medicare – multiple ACO options

– Pioneer ACO – EMHS/Beacon– Shared Savings prgrms – MH, CMMC, ME Comm ACO

• Medicaid: Value-Based Purchasing strategy– MaineCare -“Accountable Communities” proposals

• Employer-Provider ACO Pilots– Maine Health Management Coalition leadership– MaineGeneral-SEHC, EMMC, other pilots

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PCMH & MAPCP Demo: Results to Date

• Formal evaluation (USM Muskie) underway– Baseline (2008) analysis completed– Yr 1 & Yr 2 results expected fall 2013– Yr 3 results expected Q1 2014

• AF4Q analysis of claims data shows decreased utilization (hosp’s, ED visits)

• Results from other Pilots nationally showing positive results

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PCMH – Lessons Learned• Move to PCMH requires transformation (not

incremental change) of entire practice, culture, and personal transformation (esp. physicians!)

• Change starts with effective leadership – organizational, clinician, and administrative

• Multi-payer approach is essential to create sufficient resources for change

• Changing practice (and culture) takes time • Change fatigue is serious concern• Transforming primary care is essential to wider efforts!

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A Compelling Case for Action

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Summing Up: Primary Care Transformation…

• Is difficult, requires true culture change

• Needs sufficient time & resource

• Essential to wider payment reform efforts!

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Contact Info / Questions

• Maine PCMH Pilot: www.mainequalitycounts.org(See “Major Programs” “PCMH Pilot”)

– Lisa Letourneau MD, MPH: LLetourneau@mainequalitycounts.org

– Practice Transformation Lead: Nancy Grenier ngrenier@mainequalitycounts.org

– Project Management Lead: Lisa Tuttle ltuttle@mainequalitycounts.org

• MaineCare Health Homes– Kitty Purington: kitty.purington@maine.gov