Multi-Payer Participation

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1 State Innovation Model Multi-Payer Participation healthier and more productive lives, no matter their stage in life.

2 SIM Multi-Payer Participation The Patient Centered Medical Home Initiative was designed as a multipayer effort, recognizing the importance of participating payer scale for PCMH practices MDHHS will take a lead role in Patient Centered Medical Home implementation working in partnership with Medicaid managed care organizations, Medicare, and participating commercial payers Medicare participation in advanced primary care activities in Michigan can be attained through multiple approaches including the Comprehensive Primary Care Plus program and the custom Medicare participation in SIM demonstration option The purpose of today s webinar is to discuss Medicare participation options in Michigan and gain feedback from practices to help shape our path forward healthier and more productive lives, no matter their stage in life. 2

3 1. Forego CPC+ participation and instead move forward with a customized statewide approach for Medicare participation through SIM 2. Coordinate an application for CPC+ participation with Michigan payers and primary care practices, treating CPC+ as the vehicle for Medicare engagement in SIM 3. A combination of options one and two, wherein CPC+ is used as a mechanism for Medicare participation for a specific group of practices over the next five years and additional practices are addressed/added through simultaneously pursuing a customized Medicare approach in SIM healthier and more productive lives, no matter their stage in life. 3

4 Option One: Forego CPC+ participation and instead move forward with a customized statewide approach for Medicare participation through SIM Set of principles put forward by CMS to design a proposal for Medicare participation in a SIM model Patient centered Accountable for the total cost of care Transformative Broad-based Feasible to implement Feasible to evaluate Would involve a set of negotiations between MDHHS/SIM and CMS to develop an agreement with Medicare Requires specific new waiver authority to align Medicare with a state model healthier and more productive lives, no matter their stage in life. 4

5 Option One: Forego CPC+ participation and instead move forward with a customized statewide approach for Medicare participation through SIM Positive Aspects- Flexibility The custom approach provides the greatest amount of flexibility in designing how payment reform and delivery system transformation are pursued in Michigan We believe we will have the opportunity to continue to grow the size of our PCMH program, allowing for practice expansion (within a negotiated framework) in Michigan over time Potential Challenges- Time Horizon CMS considers the custom approach a new demonstration which will take an estimated 18 months to complete negotiations and implement Custom Medicare participation needs to have one or more new/unique components, we cannot use it to implement models which have been previously demonstrated Stakeholder engagement/input surrounding the custom Medicare approach would need to be substantial and would likely be time-intensive healthier and more productive lives, no matter their stage in life. 5

6 Option 2: Coordinate an application for CPC+ participation with Michigan payers and primary care practices, treating CPC+ as the vehicle for Medicare engagement in SIM Five-year advanced primary care medical home model that begins in January 2017 Centered on Comprehensive Primary Care Functions: (1) Access and Continuity (2) Care Management (3) Comprehensiveness and Coordination (4) Patient and Caregiver Engagement (5) Planned Care and Population Health Prospective care management fees to Track 1 and 2 practices based on beneficiary risk tiers in addition to a performance-based incentive payment Track 2 introduces a hybrid of Medicare fee-for-service payments called the Comprehensive Primary Care Payment (a percentage of practice s expected Medicare reimbursement for E&M claims upfront) healthier and more productive lives, no matter their stage in life. 6

7 Option 2: Coordinate an application for CPC+ participation with Michigan payers and primary care practices, treating CPC+ as the vehicle for Medicare engagement in SIM Positive Aspects- Immediacy CPC+ would offer an immediate path to Medicare participation for some practices, coming online January 1, 2017 with no break in alternative payment model funding to practices currently involved in MiPCT Potential Challenges- Exclusions and Limited Scale CPC+ excludes all practices currently participating in the Medicare Shared Savings Program (i.e. Medicare ACOs) in addition to Federally Qualified Health Centers and Rural Health Clinics CPC+ would be limited to a fixed number of approved participating practices in Michigan with no currently identified path for expansion The CPC+ program has garnered significant interest and the selection process will be competitive- no guarantee the whole state will be selected as one of CMS CPC+ regions or that all eligible practices will be chosen healthier and more productive lives, no matter their stage in life. 7

8 Option Three: A combination of options one and two, wherein CPC+ is used as a mechanism for Medicare participation for a specific group of practices over the next five years and additional practices are addressed/added through simultaneously pursuing a customized Medicare approach in SIM The SIM PCMH Initiative application process would be pulled forward to identify expansion practices in SIM s five test locations and combine those with existing MiPCT practices to apply as a group for CPC+ Those approximately 500 practices would remain in CPC+ (if selected) for five years, beginning January 2017 At the same time, MDHHS would pursue negotiation of a custom Medicare participation option in SIM Practices that join the SIM PCMH Initiative during expansion in the second and third SIM implementation years would participate with Medicare through the negotiated custom approach healthier and more productive lives, no matter their stage in life. 8

9 Option Three: A combination of options one and two, wherein CPC+ is used as a mechanism for Medicare participation for a specific group of practices over the next five years and additional practices are addressed/added through simultaneously pursuing a customized Medicare approach in SIM Positive Aspects- Potential Balance of Needs Blending the CPC+ and custom Medicare participation approaches balances need for a near term path to Medicare participation with development of a custom participation approach that will likely be a better fit for Michigan long term Potential Challenges- Complexity CPC+ and the custom Medicare approach will likely have different program requirements and payment model variations which could be complicated Michigan will have to navigate and manage an additional layer of programmatic complexity for several years while two PCMH programs are underway CPC+ exclusion of some practices would remain an issue in the near term (i.e. before the custom Medicare approach is in place) healthier and more productive lives, no matter their stage in life. 9

10 Our Questions For You The amount of time it will take to negotiate and implement a custom Medicare approach presents possible challenges, namely to current PCMH infrastructure Could your practice maintain its current PCMH infrastructure (including care management) with Medicare FFS reimbursement of chronic and transitional care management as the Medicare payment component of SIM during 2017? Medicaid managed care and participating commercial payer payments would continue as we have previously discussed for SIM The 2016 Physician Fee Schedule hinted at a potential increase to the Chronic Care Management (99490) code for 2017 Affirmative feedback would allow us to pursue the custom Medicare participation approach without CPC+ participation, which many consider our best option healthier and more productive lives, no matter their stage in life. 10

11 What We Ask of You: Visit the Weblink by 10am Thursday, May 5- Your Opinion Counts! An evaluation link is available to collect feedback to these questions at: Please submit your response (one per PO) by 10am Thursday, May 5. The link will also be sent in a followup later today to you. 1. Based on what you have learned about the SIM PCMH Initiative Medicare participation options, do you feel the custom Medicare participation approach or the CPC+ program would be best suited to your practice needs? 2. Why? (Please provide your comments and rationale) 3. Could your practice maintain its current PCMH infrastructure (including care management) with Medicare FFS reimbursement of chronic care management (99490 code) and transitional care management codes (99495, 99496) as the Medicare payment component of SIM during 2017 as a bridge for Medicare payment until such time that approval for a custom approach can be obtained? 4. Are you in an ACO currently? If so, how likely do you think that your practices would be to withdraw from their ACO arrangement to apply for CPC+? Please register one response per organization healthier and more productive lives, no matter their stage in life. 11 The web link will be open until 10 am on Thursday, May 5 for your responses

12 State Innovation Model Questions and Discussion healthier and more productive lives, no matter their stage in life.

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