The Michigan Primary Care Transformation (MiPCT) Project

PGIP Meeting UpdateMarch 8, 2013

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Agenda• Reminder: 2013 Priorities• Updates

▫State and National Evaluation Highlights (C Tanner) ▫Quarterly Reporting (C Tanner)▫Learning Activities (M Benzik)▫Membership update (J Malouin)▫Billing codes (J Malouin) ▫12 Month Incentives (D Bechel Marriott) ▫Care Management (M Beisel)

• Upcoming Town Hall Dinner Schedule• Questions

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2013 Priorities

•Care managers fully integrated into practices•Target PCMH interventions to patients from all

participating payers▫Distribute multi-payer lists and dashboards▫Bill G-codes/CPT codes on BCBSM/BCN patients▫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

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Health IT- Registry / EHR registry functionality * - Care management documentation *- E-prescribing (optional)- Patient portal (advanced/optional)- Community portal/HIE (adv/optional)- Home monitoring (advanced/optional)

Patient Access- 24/7 access to decision-maker * - 30% open access slots *- Extended hours *- Group visits (advanced/optional)- Electronic visits (advanced/optional)

Infrastructure Support- PO/PHO and practice determine

optimal balance of shared support - Patient risk assessment - Population stratification - Clinical metrics reporting

*denotes requirement by end of year 1

PCMH Services PCMH Infrastructure

Complex CareManagementFunctional Tier 4

All Tier 1-2-3 services plus: Home care team Comprehensive care plan Palliative and end-of life care

Care Management

Functional Tier 3

All Tier 1-2 services plus: Planned visits to optimize

chronic conditions Self-management support Patient education Advance directives

Transition Care

Functional Tier 2

All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation

Navigating the Medical Neighborhood

Functional Tier 1

Optimize relationships withspecialists and hospitals

Coordinate referrals and tests Link to community resources

Prepared Proactive Healthcare TeamEngaging, Informing and Activating Patients

Michigan Primary Care Transformation Project Advancing Population Management

P O P U L A T I O N M A N A G E M E N T

Michigan Public Health Institute (MPHI)=Michigan evaluatorResearch Triangle Institute (RTI) = National evaluator

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Utilization and Cost Metrics: MI and National Evaluations are Consistent

•Total PBPM 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

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Quality and Experience of Care 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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How will we (and CMS) know if we are making progress?• Monitor trends in outcomes over time

▫ All beneficiaries▫ High risk beneficiaries: changes with this group are

expected to be more dramatic▫ By payer (in Michigan)

• Utilize comparison groups ▫ Include beneficiaries from both PCMH and non-PCMH

practices

• Statistical adjustments will be made▫ Beneficiary characteristics (including risk score)▫ Practice characteristics

• Beneficiary outcomes should be associated with practice transformation in MiPCT functional tiers

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NarrativeFinancialCare Manager Activity

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Quarterly Report Status•Narrative Templates

▫Draft under review – estimated release end of March

▫Topics mirror contractual requirements for 2013

•Financial Reporting▫Reviewing expense and Care Manager FTE data▫Obtaining additional revenue data for 2012 to

enable final profit/loss calculations•New for Quarter 1, 2013: Care Manager

Activity Reporting

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Care Manager Activity Reporting Method 1

Data entry into a new screen on the Financial Reporting application (Practice and Care Manager names pre-populated based on already entered data)

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PracticeCare

ManagerBCBSM BCN

Medicare

Medicaid

Face to Face EncountersPractice 1 Mary Smith        Practice 1 John Tanner        Practice 2 Kathy Miller        Practice 3 Kathy Miller        Phone EncountersPractice 1 Mary Smith        Practice 1 John Tanner        Practice 2 Kathy Miller        Practice 3 Kathy Miller        Number of PatientsPractice 1 Mary Smith        Practice 1 John Tanner        Practice 2 Kathy Miller        Practice 3 Kathy Miller        

Care Manager Activity Reporting Method 2

Upload a standardized file

• PO creates a report in a tab-delimited text file• Must ensure the following fields match our records exactly:

▫ Practice ID▫ Care Manager Name and DOB (mm/dd) 

• Error message if upload fails• Validation check at the time of report submission looks for

complete activity data for all active care managers• Data entry screen displayed for user to verify their data,

and to make edits or additions if needed.

• Contact us to test this process: ctanner@mphi.org or jmoore@mphi.org

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MiPCT Learning Activity Update

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Educational Activities Requirements

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•Learning and Educational Activities – A Guide to Satisfying 2013 Practice Requirements (on www.mipctdemo.org website)

▫Care Manager Educational Requirement (one hour per month)

▫Practice Learning Activity Requirement (eight hours per year)

Which one do you see?

Learning Collaboratives--Two Sides to the Picture Smaller waves

Data was difficult to assess

Every wave has been unique

Allowed more dialogue and tailoring of the experience

Use of process measures that assessed change in team

A lot of rapid cycle changes in curriculum

Learning Collaboratives- Learning to Date

▫Transition of care Emergency rooms transitions most challenging

▫Medication Reconciliation Still a challenge across all teams

▫Time commitment Valued cross team collaboration and problem

solving Even with 3 full day sessions – time was tight Timing was more critical than location

▫Growing interest Wave 4 largest to date – teams added up to the last

week

Learning Collaboratives- By the Numbers•25 teams •10 PHO/PO represented •All care delivery settings represented •Minimal attrition •Positive evaluations •Cohort Two

▫Anticipate Fall 2013 ▫Working with community partners around

the state to collaborate on roll out to reach previous unengaged POs and practices

MiPCT Membership Update

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Membership update

•Ongoing and very positive discussions with Priority Health regarding their participation▫Care coordination payments => G/CPT codes

•Potential expansion of BCBSM member lists to include most attributed patients▫Details being worked out

•Benefits of potential expansion of member lists▫Allow more population-based management▫Easier to operationalize with PCP team

•More details will be provided soon

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MiPCT Care Coordination Funding

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Financial Update:BCBSM Care Coordination Payments•BCBSM committed to providing “make

whole” payments to POs to cover their $3 PMPM commitment

•Payments semi-annually, likely April/October▫Make also include July reconciliation

payment•Payment amount will reflect difference

between $3 PMPM and G/CPT code billing

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G/CPT Code Billing:Your required commitment

•BCBSM “make whole” payments will go to POs making a good faith effort to bill G/CPT codes

•Activity requirement:▫PO must have hired and trained care managers

to the level specified in the MiPCT/PO contract 2/5000 members, with 20% allowance

▫Every practice in the PO must have submitted G/CPT code claims

▫Overall claims should be reflective of managing chronic conditions within the population

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G/CPT Code Billing:How MiPCT can help

•We will begin distributing new monthly reports▫G/CPT claims totals for each practice in your PO▫Summary report of all POs

Percent of practices billing codes Percent of members engaged in care management

▫Initial reports will be BCBSM only, once BCN claims data available will include BCN reporting

•Deep-dive analysis for POs not meeting criteria▫Explore root causes

•More to come – webinars, care manager mentoring

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G/CPT Code Billing:How YOU can help

•Work with your practices to education on billing, team development, etc.

•Help your practices identify patients needing care management▫Use practice registry and MDC claims

database▫Focus on both moderate and complex patients▫Patients with diabetes, COPD, asthma,

hypertension are all candidates for self-management support and chronic condition management

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Twelve Month Incentive Update

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Twelve Month Metric Update27

• Twelve Month Metrics

1. 30% same day appointments2. Access outside regular hours: 12 hrs/week3. Electronic patient registry functionality: Tracking chronic illness care

and preventive services4. Moderate care managers (MCMs) trained and working 5. Complex care managers (CCMs) trained and working6. Notification of hospital admissions and discharges for at least 50% of

MiPCT beneficiaries *7. Primary care sensitive ED visits (NYU algorithm) *

* New Measure

• Process and Timing

▫ Follow up with POs where data are missing or incomplete

▫ QA check on data elements and metric results

▫ One-week PO metric result review period (target: by late April)

▫ Receipt of financial amounts to POs

▫ Processing of payments (target: distribution by early May)

MiPCT Care Management

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MiPCT Complex Care Management (CCM)Course

•MiPCT CCM course▫required for Complex and Hybrid Care

Managers▫face to face 4 consecutive days

•MiPCT CCM Course – 2013 Future Dates Location - Lansing

• April 15-18• May 20-23• May 20-23• June 17-20• July 15-18• August 12-15

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MiPCT Complex Care Management (CCM)Course –Self Paced Course•Self Paced course:

▫consists of remote course work and one day face to face

▫recorded webinars▫ reading/homework▫ pilot pre and post tests

•Pilot April 2013, small number of CCM/HCM in class ▫Plan to pilot monthly X 3 - revise as needed

•Goal – Standardized CCM training

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Care Management Activity

Care Manager Caseload Development: •Care Manager role HCM, CCM, MCM•MiPCT Model = Population Health•MiPCT List – identify patients

▫Risk score and PCP recommendation•Patient Caseload

▫Hybrid Care manager caseload - must include both Moderate and Complex patients

▫Impact patients within all MiPCT Payers BCBSM, BCN, BCBSM Medicare Advantage,

Medicare, Medicaid

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IV. Most complex

(e.g., Homeless,Schizophrenia)

III. ComplexComplex illness

Multiple Chronic DiseaseOther issues (cognitive, frail

elderly, social, financial)

II. Mild-moderate illnessWell-compensated multiple diseases

Single disease

I. Healthy Population

<1% of population Caseload 15-40

3-5% of population Caseload 50-200

50% of populationCaseload~1000

Managing Populations: Stratified approach to patient care and

care management*Care management for moderate patients will prevent or slow progression to complex

MiPCT Patient List• MiPCT Patients

▫ patients that have a health plan participating in the MiPCT demonstration project

▫ patient is attributed to the PCP at the practice and is on the MDC Member list

• MiPCT participating Health Plans:▫ BCBSM Commercial▫ BCN▫ Medicare FFS▫ Medicaid Managed Care▫ BCBSM MA – care management only

Recorded webinar “MiPCT Member List 2.15.13”posted on mipctdemo.org

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Planned patient care i.e. huddles, processes, work flow, policies

Care Manager and PCP

partnership

Office staff – defined roles

and responsibilities

Information technology,

support

Patient

Care Management Delivery by the Practice

PO and Practice Leadership

PCMH meetings monthly,

action plan,

follow up

Care Management - Building a Patient Case loadTarget moderate and complex patients who will benefit from care▫Care manager and PCP review MiPCT list sorted by risk and payer▫Referrals are from PCP, practice staff, and patient self referral▫Recent hospital discharges and other high risk transitions▫Office visits▫Current patient’s already enrolled in Care manager’s caseload

MiPCT Team and PO Leaders Work together to Define Care Management Activity •Define standard work

▫Gather and share examples of standard work developed by POs and practices

▫New Tool: CCM Responsibilities with detailed description of processes and action step, available end of March

•Conduct “go sees” – ongoing by Master Trainers, Clinical Leads▫Gather and share best practice processes,

resources, tools, staff job descriptions▫Continue to identify gaps – assist with developing

solutions

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MiPCT Benchmark for Care Manager Caseload

• Increasing Care manager’s patient caseload▫Enroll minimum:

3-4 new patients per week -full time Complex CM 4-6 new patients per week - full time HCM 6 or more new patients per week - full time MCM

▫For Hybrid care managers Caseload = 40% moderate, 60% complex patients Adjust number of moderate and complex patients in

caseload based on the practice’s MiPCT patient population acuity

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MiPCT Benchmark for Care Manager Caseload

MiPCT Dashboard Data and MiPCT Patient list: ensure patients in caseload match the MiPCT payer mix at the practice

MiPCT dashboard data – practice level▫% patients for each MiPCT payer▫Risk scores/acuity

Monthly and periodic review the MiPCT patient list to ▫identify potential patients - gain understanding of chronic

conditions, risk scores, ▫ER visit data available 3/13 , hospitalization available 5/13,▫ data regarding enrolled patients

Ideas for improving the MiPCT Patient List? Suggestions Welcome!

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Town Hall Remaining Meetings

Dates and Regions Agenda• 6-6:30pm – appetizers• 6:30pm – dinner begins

with welcome, introductions and shared conversation

• 7:30-8pm - dessert and closing remarks

Day of Week

Date Region

Tuesday 3/19 MuskegonThursday 3/21 Grand RapidsTuesday 4/23 Novi

Wednesday 4/24 TroyThursday 6/06 Lansing

Advance registration required via www.mipctdemo.org website

Questions?