Michigan Primary Care Transformation (MiPCT) Project Frequently Asked Questions

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1 Michigan Primary Care Transformation (MiPCT) Project Frequently Asked Questions Demonstration Design 1. What is the Michigan Primary Care Transformation (MiPCT) Project? The Centers for Medicare and Medicaid (CMS) is joining Michigan (MiPCT) and pilots in seven other states in a 3 year demonstration of the value of the Patient-Centered Medical Home (PCMH) model of care. Participating payers (Medicare Fee-for Service, Medicaid Managed Care and Blue Cross Blue Shield of Michigan PPO to date) will provide financial support to a network of physician organizations, physician hospital organizations and independent practice associations (POs) and a group of affiliated primary care practices with patient centered medical home designation to support the additional services offered in a PCMH. Rigorous evaluations will be conducted by CMS and the State of Michigan. 2. What is the purpose of the Demonstration? CMS is interested in evaluating whether PCMH practices that receive additional financial support from Medicare, Medicaid, and Commercial health plans, will (1) reduce unjustified variation in utilization and expenditures; (2) improve the safety, effectiveness, timeliness, and efficiency of health care; (3) increase the ability of beneficiaries to participate in decisions concerning their care; (4) increase the availability and delivery of care that is consistent with evidence-based guidelines in historically underserved areas; and (5) reduce unjustified variation in utilization and expenditures under the Medicare program. CMS expects the Demonstration to be budget neutral by Year 3 and reserves the right to withdraw their participation at any time if this seems unlikely. Michigan is interested in evaluating whether multi-payer support of a net work of POs and affiliated primary care physicians striving to implement the PCMH model of care will demonstrate improvement in the quality of healthcare, reduction or at least stabilization of the cost of healthcare and increased patient satisfaction with healthcare experiences. 3. Which other states are participating? Maine, Minnesota, New York, North Carolina, Pennsylvania, Rhode Island and Vermont. 4. What are the dates of the Demonstration? The Demonstration will begin January 1, 2012 and run through December 31, What is unique about the MiPCT? Unique features of the MiPCT project are: Large size. Michigan s 484 eligible practices represent half of the practices identified for participation during Year One in all eight states combined. Supportive Network of Physician Organizations. Participating physician organizations will assist with practice recruitment and reporting and provide infrastructure support to assist practices in their transformation. PCMH Transformation Process. The eligible practices are well along in the process of transforming their practice to a PCMH, a process which often requires several years for a practice to complete. Since 2009, the eligible PCMH designated practices have been the 1

2 top performers on measure of PCMH capabilities in place, cost and utilization in a participating commercial health plan s incentive program. 6. Who is eligible to participate? Thirty- seven POs and 484 primary care practices with patient centered medical home status. PCMH designation by BCBSM Provider Group Incentive Program in 2010 and 2011 and/or Level 2 or 3 PCMH recognition by NCQA before July 1, To maintain eligibility, practices must Maintain PCMH designation/recognition throughout the three years of the project. Sign the annual participation contract. Meet MiPCT practice transformation requirements (see below). 7. Can a practice participate even though its PO opts not to participate? No. MiPCT is a joint PO/Practice endeavor and both must participate. 8. Will practices that receive PCMH recognition or designation after the demonstration begins be allowed to join in Years 2 or 3? There are currently no plans to add additional practices once the project is underway. The application identified the cohort of practices to be included in the Demonstration as those meeting PCMH designation criteria as of July This cohort is expected to meet the cap placed by some plans on the maximum number of beneficiaries for inclusion in the Demonstration. CMS even granted Michigan permission to exceed its original cap in order to allow all the practices with PCMH designation in 2010 to participate. The addition of practices may be reviewed at some future time, however, if circumstances warrant. 8. What financial supports will be provided? In addition to normal payments/reimbursements for services, participating payers will provide funds to participating PCMH practices and physician organizations to build and strengthen advanced capabilities for delivering patient-centered care. Beginning January 1, 2011 enrolled practices may be authorized to receive the following three types of payment. Payment schedules may differ between payers. Practice transformation payment - $1.50 per member per month (PMPM) or equivalent as an E&M uplift ($2.00 PMPM for Medicare) paid directly to the practice on a monthly or quarterly basis. Care coordination payment - $3.00 PMPM or equivalent payment based on the submission of G codes ($4.50 PMPM for Medicare) to be paid monthly or quarterly to the physician organization or practice to support care manager and complex care manager services. Performance incentives - $3.00 PMPM paid twice yearly in variable amounts to physician organizations and practices based on performance on incentive metrics. Payers will also contribute $.26 PMPM to MiPCT for administrative costs. 9. What is the role of Physician Organizations in the Demonstration? The PO is responsible for assisting with implementation of the MiPCT Project and for supporting affiliated Practices in their development of PCMH capabilities and attainment of the MiPCT goals of 2

3 reducing preventable costs and improving patients health status and their healthcare experience. Specific responsibilities include Assist with the initial recruitment and enrollment of eligible Practices for participation in the MiPCT Demonstration Project. (see Enrollment section below) Inform MiPCT of significant practice changes and changes in participating physicians throughout the Demonstration. Arrange Care Coordination services for those Practices that choose not to hire their own Care Manager or Complex Care Manager. Distribute MiPCT payments to participating Practices as specified in the approved PO implementation plan. Provide supportive services, in accordance with agreements in place, to enable Practices to continue developing their PCMH capabilities and to achieve or exceed the Year One PCMH Infrastructure Thresholds. Enter into a Business Associate and Data Use Agreement with MDCH, CMS, and UMHS Submit quarterly narrative and financial reports to MDCH on practice progress and receipt, distribution, and use of funds. As needed, assist in providing requested registry/emr data for Demonstration purposes. Support the State and the National Demonstration Project evaluation by assisting with the dissemination of physician/staff surveys to Practices and encouraging Practices to respond and by responding directly to PO surveys within the requested timeframe. Both surveys will be conducted twice during the project, at baseline and year What are the terms and conditions of PCMH practice participation? Practices must Sign the demonstration application and collaborate with the PO in development of the MiPCT PO/Practice Implementation plan (see Enrollment Process below). Plan to remain in the Demonstration throughout the 3 years of the project Participate in education/training programs such as learning collaboratives, Lean workshops, practice-based coaching, webinars, and seminars. Enter into a Business Associate and Data Use Agreement with MDCH, CMS, and UMHS Cooperate with the MiPCT evaluation vendor, Michigan Public Health Institute, and provide information or data as needed. 10. What are practices expected to do during the demonstration? Practices are expected to continue to develop PCMH capabilities throughout the demonstration and to focus on care coordination and care management (see Figure 1 page 6). Engage patients through the provision of patient-centered, evidence-based chronic illness and preventive care. Develop/Improve care coordination capabilities o Patient navigation and linking to community resources o Transitions of care Integrate one or more care managers into the care team to provide moderate to complex care management services Assure PCMH Infrastructure components (registry functionality, care management tools, and advanced access) are in place during Year 1 to support the clinical processes/services. 3

4 11. How will the Care Management component work? Health care is delivered locally, so there may be considerable variation in how care management services will be provided in different settings. The care management payment is estimated to be sufficient to cover the cost of employing one care manager and one complex care manager to provide services for approximately every 5000 beneficiaries enrolled in participating health plans. Care Managers and Complex Care Managers may be employed by the practice, or if more practical, by the Physician Organization or other entity. The PO and practice will jointly develop an Implementation Plan, using a MiPCT template, detailing how and when the care management component will be executed. MiPCT must review and ultimately approve the plan before the payment of care management funds will be initiated. Regardless of who employs the Care Manager or the Complex Care Manager, these individuals are expected to function as an integral part of the Practice s care team to enable frequent communication with the team and have direct access to patient records. All Care Managers receiving financial support under the MiPCT demonstration must meet MiPCT Education and Training requirements. All Care Managers will use an appropriate EHR, patient registry and/or care management product to document care plans and encounters for patients enrolled in care management services. The Practice (or the PO) will submit MiPCT-specified G codes and modifiers with a zero dollar charge to document and/or bill for care management encounters. Enrollment Process 1. What are the steps for a PO and practice to enroll in the MiPCT Demonstration? The steps are: 1) PO and each participating PCMH practice sign the MiPCT PO/Practice Agreement, the business associate agreement and data use agreement. PO mails the signed signature pages to MiPCT. 2) POs/Practices are informed of dates for webinars/teleconferences on completing the MiPCT PO/Practice implementation plan (optional, but recommended). 3) The PO and participating practices collaborate to complete the PO/PCMH Practice Implementation Plan. 4) Proposed Implementation Plans are reviewed by MiPCT and feedback is provided. Final plans are signed by the PO/Practice and MDCH. 5) MDCH notifies payers to begin payments, in accordance with the timeline in the Implementation Plan. 2. When should the PO/Practice Agreement and Implementation Plans be submitted to assure participation and payments begin January 1, 2012? Payers require 6-8 weeks to process payments. To begin the Demonstration January 1 and assure payment are received for the first quarter, POs and participating Practices should sign and submit the MiPCT Agreement and the approved PO/Practice Implementation plan by November 8, Since the November 8 date may be impossible for some, applications and Implementation Plans will be accepted through February 3, 2012 with payments commencing in April of

5 MONITORING 1. How will the Demonstration be monitored? The Michigan Department of Community Health is responsible for overall direction and control of the Demonstration Project and will assure that programmatic standards are met, provisions in agreements are adhered to, and program objectives are achieved. Monitoring will be accomplished through Quarterly narrative and financial reports submitted by each Physician Organization on practice/po progress in achieving MiPCT goals. Semi-annual payer reports. Financial reports Standard audit procedures TECHNICAL ASSISTANCE 1. What types of technical support will be provided? MiPCT will provide various types of support to help practices be successful Educational opportunities: Learning collaboratives, lean training, webinars and other facilitated practice transformation assistance will be offered to Practices and/or POs. The Care Management Resource Center: o Development of a Care Management Consortium - open to all POs/PHOs o Personalized consultation services for all Consortium members o Online Web-based resource for Consortium members The Michigan Data Collaborative: This robust, multi-payer claims data base will o Calculate member attribution, risk stratification, and performance incentives. o Generate feedback reports on MiPCT metrics. EVALUATION 1. Who will evaluate MiPCT? CMS has contracted with RTI to do the multistate evaluation. MiPCT has contracted with Michigan Public Health Institute to do the state evaluation. 2. What will Michigan s evaluation entail? Michigan s evaluation will be based on the IHI Triple Aim: a. Cost/efficiency - Overall costs, hospitalizations, 30 day all cause re-admissions, emergency department visits and others. b. Experience of care Patients (CAHPS PCMH Survey) and staff (survey) c. Population health Clinical quality measures, Patient s assessment of health. CONTACTS 1. How can I learn more? Check the website at questions to mipctdemo@michigan.gov 5

6 Michigan Primary Care Transformation Project Advancing Population Management PCMH Services PCMH Infrastructure Complex Care Management Functional Tier 4 Care Management Functional Tier 3 Transition Care Functional Tier 2 Navigating the Medical Neighborhood Functional Tier 1 All Tier services plus: Home care team Comprehensive care plan Palliative and end-of life care All Tier 1-2 services plus: Planned visits to optimize chronic conditions Self-management support Patient education Advance directives All Tier 1 services plus: Notification of admit/discharge PCP and/or specialist follow-up Medication reconciliation Optimize relationships with specialists and hospitals Coordinate referrals and tests Link to community resources Health IT - Registry / EHR registry functionality * - Care management documentation * - E-prescribing * - 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 Prepared Proactive Healthcare Team Engaging, Informing and Activating Patients *denotes requirement by end of year 1 P O P U L A T I O N M A N A G E M E N T Draft