Michigan Primary Care Transformation Project...
Transcript of 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
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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
D Bechel Marriott, DrPH, University of Michigan School of Public Health 2013
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
D Bechel Marriott, DrPH, University of Michigan School of Public Health 2013
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
D Bechel Marriott, DrPH, University of Michigan School of Public Health 2013
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