Maine PCMH Pilot & Community Care Teams (CCTs)

Lisa M. Letourneau MD, MPH

October 2013

Maine PCMH Pilot Leadership

Maine Quality Counts

Dirigo HealthAgency’s (DHA’s)

Maine QualityForum

Maine Health Management

Coalition

MaineCare (Medicaid) 2

Maine PCMH Pilot Practice “Core Expectations”

1. Demonstrated physician leadership2. Team-based approach3. Population risk-stratification and management4. Practice-integrated care management5. Same-day access6. Behavioral-physical health integration7. Inclusion of patients & families8. Connection to community / local HMP9. Commitment to waste reduction10. Patient-centered HIT

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Implications of CMS MAPCP Demo• Projected to achieve budget-neutrality (i.e. to

reach $10 pmpm savings) via reductions in avoidable ED use, hospitalizations

• Stronger focus on reducing waste & avoidable costs• Introduced CCTs as targeted strategy to support

high-needs patients & reduce avoidable costs• Access to Medicare data to identify high patients• Opportunity to add 50 additional practices to join

“Phase 2” of Pilot (Jan 2013)

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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,

Medicaid HHs

2011 2012 2013 Dec 31, 2014

MAPCP Demo – 3yr

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CCTs

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)

Lisa Letourneau 6

High-need Individual

Maine PCMH Pilot Community Care Teams

Transportation

Workplace

Environment

Food Systems

Shopping

Income

HeatFaith

Community

Literacy

Coaching

Physical Therapy

Hospital Services

Specialists

Outpatient Services

Med Mgt

HousingCare Mgt

Behav. Health & Sub

Abuse

Family

Schools

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CCT Selection• Used structured application, selection process• CCTs committed to PCMH Core Expectations• Had to get agreement from PCMH/HH

practices• Had to meet minimum practice population

size ~15,000

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ME PCMH Pilot CCTs• AMHC• Androscoggin Home Health• Coastal Care Team (Blue Hill FP, Community Health

Center/MDI, Seaport FP)• CHANS (MidCoast area)• Community Health Partners (Newport FP, Dexter

FP)• DFD Russell (FQHC)• Eastern Maine Homecare• Kennebec Valley (MaineGeneral Health)• Maine Medical Center PHO• Penobscot Community Health Care (FQHC)

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

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 + CCT

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

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Health Homes Beneficiary

Coaching

Med Mgt

Care Mgt

Behav. Health & Sub Abuse

MaineCare Health HomesStage A: Help Individuals with Chronic Conditions

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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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CCT Populations ServedCCTs review data from available sources (Medicare RTI reports, MaineCare Utilization reports, other payers, HIN) to identify •Hospital Admissions

o 3 or more admissions in past 6 monthso 5 or more admissions in past 12 months

•Emergency Department Utilizationo 3 or more E.D. visits in past 6 monthso 5 or more E.D. visits in past 12 months

•Payer identification of high-risk or high-cost patients

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CCT Staffing

Minimum expectations:•Medical Director (part-time)•CCT Manager•Nurse Care Manager•LCSW / Care Coordinators•Access to BH, SA expertise

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Financing CCTs: Maine Approach• Linked CCT model, payment to multi-payer

PCMH model• Leveraged public, private payers agreement to

provide pmpm payment• Participation in CMS MAPCP demo brought in

Medicare as payer• Alignment of ACA Health Homes with multi-

payer Pilot provided opportunity to leverage federal 90:10 match for CCT services

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CCT Payments

• Practice population-based capitated payments– Medicare: $2.95 pmpm – Commercial payers: $0.30 pmpm

• Per-person capitated payments– Medicaid / Health Homes: $129.50 pmpm

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CCT Goals & Performance Measurement

• Improve care, reduce costs for most high-cost, high- needs individuals of PCMH/HH practices– Reduce hospitalizations, readmissions– Reduce ED visits

• Performance tracked through quarterly reporting– Number CCT contacts– Number ED visits, hospitalizations pre/post CCT

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CCT Reporting

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Unique Features of Maine Approach• Defining “Health Home” as PCMH + CCT• Adding CCT services to specifically support high-

needs, high-cost members (recognizing these mbrs can often outstrip capacity of most primary care practices – even PCMHs!)

• Recognizes differences between “routine”/chronic disease care management & CCT multi-disciplinary team approach for most high-needs mbrs

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Maine CCTs: Successes• Have developed functional CCT infrastructure• CCT structure, support highly welcomed by practices,

patients• Most PCMH/HH practices report high levels of

satisfaction with CCT services• Have demonstrated numerous examples of high-

needs individuals positively impacted by CCTs

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Maine CCTs: Challenges & Lessons Learned

• Need to focus on most high-cost individuals, particularly those with frequent hospitalizations, who are open to intervention

• Be cautious of focusing on high-needs individuals who are highly resistant to changing behaviors

• Value of trauma-informed approach

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Maine CCTs: Challenges & Lessons Learned

• Building CCT structure & relationships takes time (up to 2-6 mos)

• Data critical to identifying potential patients; current data sources are siloed, time-lagged

• Successful interventions depend on strong relationships, with individuals & with practices

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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

Primary Care & CCT Payment in ACOs: So What Will Change?

• Despite PCMH, ACO pilots, FFS remains most predominant payment model for providers

• Relying on FFS payments continues to emphasize volume & threatens meaningful practice change

• Little meaningful change yet to concept of “productivity”

*Payment Reform for Primary Care within ACOs, A. Goroll & S. Schoenbaum, JAMA, Aug 2012

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Contact Info / QuestionsMaine Quality Counts

• www.mainequalitycounts.org Maine PCMH Pilot

• www.mainequalitycounts.org(See “Programs” PCMH)

Lisa Letourneau MD, MPH• LLetourneau@mainequalitycounts.org, 207.415.4043• Hpeterson@mainequalitycounts.org, 207.266.7211

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