Comprehensive Primary Care Plus (CPC+)

Comprehensive Primary Care Plus (CPC+) What is CPC+? Comprehensive Primary Care Plus (CPC+) is a national advanced primary care medical home model that strengthens primary care through regionally-based multipayer payment reform and care delivery transformation. CPC+ includes two tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the U.S. Model Design Practices participate in either Track 1 or Track 2 of CPC+ depending on their care delivery and health IT capabilities. Participating in either Track of CPC+ requires the use of Certified Electronic Health Record Technology (CEHRT). In Track 1, practices build the capabilities to deliver comprehensive primary care and better meet the needs of patients. Track 2 practices have already built these capabilities and will increase the comprehensiveness of care they deliver, focusing on the assessment and management of patients with complex needs. Payment redesign offers the ability for greater cash flow and flexibility for primary care practices to deliver high quality, whole-person, patientcentered care and lower the use of unnecessary services. CPC+ provides practices with an innovative learning system, as well as patient-level cost and utilization data. Practices in both tracks are expected to make care delivery changes based on key Comprehensive Primary Care Functions: Access and Continuity Care Management Comprehensiveness and Coordination Patient and Caregiver Engagement Planned Care and Population Health Payment Design Differences between the 3 CPC+ payment elements: 1) Care Management Fee (CMF): Both tracks provide a non-visit based CMF paid per beneficiary per month (PBPM). The amount is risk-adjusted for each practice to account for the intensity of care management services required for the practice s specific population. The CMFs will be paid to the CPC+ practice on a quarterly basis. 2) Performance-based incentive payment: CPC+ will prospectively pay and retrospectively reconcile a performance-based incentive payment based on how well the practice performs on patient experience measures, clinical quality measures, and utilization measures that drive total cost of care. The performancebased incentive payment will be paid to the CPC+ practice on an annual basis. 3) Payment under the Medicare Physician Fee Schedule: a. Track 1 continues to bill and receive payment from Medicare FFS as usual. b. Track 2 practices also continue to bill as usual, but the FFS payment for evaluation and management services will be reduced to account for CMS shifting a portion of Medicare FFS payments into Comprehensive Primary Care Payments (CPCPs), which will be paid in a lump sum on a quarterly basis. Objective Care Management Fee (PBPM*) Support staffing and training for delivering comprehensive primary care Performance-based Incentive Payment (PBPM) Reward practice performance on utilization and quality of care Payment Structure Redesign Reduce dependence on visit-based FFS to offer flexibility in care setting Track 1 $15 average $2.50 opportunity N/A (Standard FFS) Track 2 $28 average; including $100 to support patients with complex needs * PBPM = Per Beneficiary Per Month $4.00 opportunity Reduced FFS with prospective Comprehensive Primary Care Payment (CPCP) May 2017

Comprehensive Primary Care Plus (CPC+) CPC+ and the Quality Payment Program Tracks 1 and 2 of CPC+ are included on the list of Advanced Alternative Payment Models (APMs) under the Quality Payment Program (QPP). This determination was based on medical home model-specific requirements. For payment years 2019 through 2024, clinicians who meet the threshold for sufficient participation in Advanced APMs and who meet requirements regarding parent organization size (as applicable for 2018 onward), are excluded from the Merit-based Incentive Payment System (MIPS) reporting requirements and payment adjustments and may qualify for a 5% APM incentive payment. More information about the QPP and Advanced APMs can be found on the CMS QPP website: https://qpp.cms.gov CPC+ Care Delivery Transformation Activities Track 1 Track 2 Access and Continuity 24/7 patient access Assigned care teams E-visits Expanded office hours Care Management Comprehensive and Coordinated Care Risk stratified patient population Short and long-term care management Identifying high volume/cost specialists serving population Follow-up on patient hospitalizations Care plans for high-risk chronic disease patients Behavioral health integration Psychosocial needs assessment and inventory resources and supports Patient and Caregiver Engagement Convening a Patient and Family Advisory Council Supporting patients selfmanagement of high-risk conditions Data-Driven Population Health Management Analysis of payer reports to inform improvement strategy At least weekly care team review of all population health data www.mipcc.org 517-908-8241

MACRA and the Quality Payment Program What is MACRA? The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is bipartisan federal legislation signed into law on April 16, 2015. MACRA does many things, but most importantly it makes significant reforms to the Medicare physician payment system, transitioning from volumebased to value-based care by repealing the Sustainable Growth Rate (SGR) formula and creating the Quality Payment Program (QPP). What is the Quality Payment Program? Various Centers for Medicare and Medicaid Services (CMS) quality programs were streamlined into the QPP. This allows eligible clinicians (ECs) to participate in a way that best suits their practice by choosing one of two paths: the Merit-based Incentive Payment System (MIPS) or an Advanced Alternate Payment Model (APM). ECs include: Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists. Exclusions include: new Medicare-enrolled ECs, clinicians who fall under the low-volume threshold (less than $30,000 in Medicare Part B claims or 100 Medicare patients), or are a Qualifying Participant (QP) in an Advanced APM. The Merit-based Incentive Payment System (MIPS) MIPS is a new program that streamlines the existing Medicare Meaningful Use, PQRS, and Value Modifier programs to work as one, and eases the clinician reporting burden. It adds a fourth component to promote ongoing improvement and innovation to clinical activities. Quality Resource Use Clinical Practice Improvement Advancing Care Information MIPS provides clinicians the flexibility to choose the activities and measures that are most meaningful to their practice to demonstrate performance. Clinicians scores in the MIPS performance categories (Final Score) will be used to compute positive or negative adjustments to Medicare Part B payments, or determine that no change in payments is warranted. There are 3 types of Alternative Payment Models (APMs) One type of APM is the Advanced APM, clinicians who significantly participate in Advanced APMs: Are exempt from MIPS payment adjustments Qualify for a 5% Medicare Part B incentive payment for 2019-2024 Are eligible for higher fee schedule updates beginning in 2026 To qualify, ECs would have to receive enough of their payments or see enough of their patients (Qualifying Participant threshold) through Advanced APMs. Certain Advanced APM participants who fall short of this threshold but meet a lower threshold of participation (partial QPs) would be able to choose whether they want to participate in MIPS and be subject to a MIPS payment adjustment. Criteria for Advanced APMs 50% of participants must use certified EHR Technology (CEHRT) Must report and at least partially base clinician payments on quality measures comparable to MIPS Bear more than nominal risk for monetary losses Defined as the lesser of 8% of total Medicare revenues or 3% of total Medicare expenditures Primary Care Medical Home models with < 50 clinicians have different standards (2.5%-5% total Medicare revenues) May 2017

MACRA and the Quality Payment Program Quality Payment Program timeline: First performance period: Jan. 1 - Dec. 31, 2017. During 2017, record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can join and provide care during the year through that model. To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to CMS by March 31, 2018. In order to earn the 5% incentive payment by significantly participating in an Advanced APM, submit quality data through your Advanced APM. Medicare will give feedback about your performance after you send your data. You may earn a positive MIPS payment adjustment for 2019 if you submit 2017 data by March 31, 2018. If you participate in an Advanced APM in 2017, then you may earn a 5% incentive payment in 2019, based on 2018 charges. Pick Your Pace available only for Program Year 2017: Participate in an Advanced Alternative Payment Model + MIPS Test Pace Partial Year Full Year Some practices may choose to participate in an Advanced Alternative Payment Model in 2017 Submit some data collected after Jan. 1, 2017 Neutral or small payment adjustment. Report for 90-day period after Jan. 1, 2017 Small positive payment adjustment Fully participate starting Jan. 1, 2017 Modest positive payment adjustment Not participating in the Quality Payment Program for the transition year will result in a negative 4% payment adjustment in Calendar Year 2019. www.mipcc.org 517-908-8241

Physician Group Incentive Program (PGIP) Physician Group Incentive Program PGIP is a performance improvement program established by Blue Cross Blue Shield of Michigan in 2005. The program is comprised of a collection of clinical and quality-based initiatives with the goal of transforming clinical practice and improving patient care in Michigan. Currently, more than 40 physician organizations (POs), representing nearly 20,000 primary and specialty care physicians participate in PGIP. How does PGIP work? Participation in PGIP requires providers to partner with a participating physician organization (PO) and to be affiliated with a PGIP recognized PO. Physician organizations play a vital leadership role by providing the infrastructure and support to guide their physician members in health care transformation efforts. Part of the support offered includes the following: Facilitating engagement of PCP and specialists practice transformational efforts Integrating information systems and care management approaches across member practices Conducting population management and performance reporting at both the PO and practice level PGIP uses a combination of reward payments to POs and value-based reimbursement (VBR) for individual physicians to ensure providers have the financial support needed to fully adopt the Patient-Centered Medical Home (PCP) or Patient-Centered Medical Home-Neighbor (specialist) model and to deliver optimal care. What makes PGIP successful? Providers lead the way Blue Cross Blue Shield of Michigan s PGIP program is recognized as being a national leader in practice transformation with demonstrated higher quality and preventive care services for PCMH designated practices. Through provider collaboration, PGIP promotes teamwork among POs and practitioners to transform how care is delivered for all patient populations. Practitioners collaborate directly with PGIP leadership to develop and structure initiatives (programs) based upon their clinical experience and knowledge, increasing credibility and ownership among participants. Through this process, program goals are clearly defined, encouraging participant engagement and performance improvement. The overall culture of sharing information and best practices allows for continuous improvement and fosters clinical guideline development, and improving the overall Michigan health care system. Focused on patient outcome, not patient payer PGIP initiatives encourage improved care processes across all payers. Systems of care which are used for all patients help assure providers do not have to alter care processes based on the type of patient coverage, encouraging them to follow best practices and apply care processes equally to all patients, all of the time. This all-payer approach benefits patients and physicians alike, while furthering the Blue Cross mission to improve the future health of all Michigan residents. Value-based reimbursement redirects funds that in the past were used for across-the-board fee increases to providers who are delivering patient-centered, high value care, by increasing common fees by up to 13 percent for specialists, and by as much as 40 percent for primary care physicians under the PGIP VBR fee schedule. PGIP has moved Michigan from a fee-for-service to a feefor-value health care reimbursement model. May 2017

Physician Group Incentive Program (PGIP) 2017 PGIP Initiatives Core Clinical Process-focused Initiatives PGIP Clinical Quality - encourages PO implementation of evidence-based medical guidelines Coordination of Care* - coordinates care across the whole spectrum, including specialist collaboration and patient/ caregiver communication Extended Access* - encourages operational changes that offer patient access to the physician practice outside of standard business hours Individual Care Management* - helps practices manage patient care through development of care teams, visit plans, and follow-up services Integrating Behavioral Health in General Medicine - increases coordination of care between physicians and behavioral health specialists Linking to Community Services* - assists in creating systematic processes for referral to and tracking of community service offerings Patient Provider Partnership* - establishes mutual roles and responsibilities between a physician and the patient Performance Reporting* - creates reporting methods to track care processes and outcomes Preventative Services* - requires offering of preventative measures counseling to aid patients in managing their health Self-Management Support* - expands physician education techniques for better patient selfmanagement of chronic conditions Specialist Referral Process* - improves efficiency of referral processes and ensures timely sharing of patient care information Test Tracking and Follow-up* - implementation of effective processes for tracking patient test results and patient follow-up Clinical Information Technology-focused Initiatives Health Information Exchange - supports PO participation in daily admit/discharge/transfer and ER notifications Patient Portal* - development of web-based applications that allow for improved physician-patient communications and information sharing Patient Registry* - establish a comprehensive patient registry for managing population health statuses Electronic Prescribing of Controlled Substances - encourages the use of electronic prescribing mechanisms for enhanced safety of controlled substances Service-focused Initiatives Resource Stewardship - encourages the reduction in use of certain services, procedures, and tests that are overused or of questionable value Other Initiatives Organized Systems of Care - three initiatives to catalyze the implementation of OSC-level integrated patient registries, integrated performance measurement, and integrated processes of care Patient Experience of Care - supports POs to develop common methodology for assessment and reporting patient care experiences To learn more about PGIP and value partnerships please visit www.valuepartnerships.com. If you are a physician interested in learning how to become engaged in PGIP please send an email to valuepartnerships@bcbsm.com or visit bcbsm.com/providers, then click on Value Partnerships in the blue bar, for more information. *PCMH initiatives Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. www.mipcc.org 517-908-8241

Physician-Payer Quality Collaborative (PPQC) What is PPQC? The Physician-Payer Quality Collaborative (PPQC) is a multi-stakeholder initiative of physicians, commercial payers, state Medicaid and the statewide health information network to simplify, align and standardize the components and processes of quality reporting programs in the state. It is led by the Michigan State Medical Society (MSMS) with support from the Michigan Health Information Network Shared Services (MiHIN). The Need for Incentive Program Alignment Health care providers today face a multitude of quality improvement incentive programs. Learning and complying with each set of unique requirements for various reporting programs is complex and burdensome. Similar to how the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) law established the new Merit-Based Incentive Payment System (MIPS) for Medicare to consolidate and streamline disparate CMS reporting programs, the PPQC initiative looks to reduce complexity and reporting burden at an all-payer, allpatient level in Michigan. Surveys among stakeholders identified quality measure alignment as a top priority, providing strong support for the PPQC initiative. The Vision The PPQC will serve to bring stakeholders together to focus quality improvement efforts around a core set of measures, and standardize performance reporting and feedback with health plans. There are three components that form the PPQC vision: Report Once Measure Superset Incentive Alignment Quality measures only need to be reported one time to one location for all payers and all patients. A data file containing all the information necessary to calculate all measures from established measure sets. All payers agree to channel new incentives to a core set of measures, with common performance thresholds, evaluated on an allpayer and all-patient basis. Three Action Teams were created to champion these goals, with representatives from various physician organizations and health plans across Michigan. The Action Teams and their responsibilities are: Data Capture and Collection Quality Measures Harmonize Financial Incentives Review physician organizations practices and make recommendations for a seamless process to capture and transport quality data from providers to payers, and to facilitate feedback from payers to providers. Analyze quality measures to develop consistent definitions for numerators, denominators, or exclusion statements between national level measure sets to streamline reporting for all patients and all payers. Analyze ways to introduce aligned incentives that can facilitate improvement across a subset of quality measures, while accounting for disparate levels currently achieved by providers across payers and regions of Michigan. Core Quality Measures The PPQC Quality Measures Action Team has identified a subset of 27 measures which will be the focus of initial work. This initial measure subset has significant overlap with national and local quality reporting programs, including the State of Michigan s State Innovation Model (SIM) initiative. Implementation Technical Pilot The first phase of a technical pilot began in 2016 to test the all-payer, all-patient report once concept. The second phase of the pilot will work to implement the Quality Reporting Document Architecture (QRDA), a national standard for quality measure submission, and to standardize feedback reports such as gaps in care. Existing health information network infrastructure operating in the state will be utilized for quality measure submission from providers to payers, and delivering feedback from payers to providers. May 2017

Physician-Payer Quality Collaborative (PPQC) Core Quality Measures List* Measure # Measure Title 1 Childhood Immunization Status 2 Cervical Cancer Screenings 3 Chlamydia Screening in Women 4 Comprehensive Diabetes Care 5 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing (HA1C) 6 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) 7 Comprehensive Diabetes Care: Eye Exam (retinal) performed 8 Comprehensive Diabetes Care: Medical Attention for Nephropathy 9 Adult BMI Assessment 10 Controlling High Blood Pressure 11 Breast Cancer Screening 12 Colorectal Cancer Screening 13 Immunizations for Adolescents 14 Appropriate Testing for Children with Pharyngitis 15 Lead Screening in Children 16 Use of Imaging Studies for Low Back Pain 17 Depression Screening 18 Antidepressant Medication Management 19 Tobacco Use and Cessation 20 Well-Child Visits in the First 15 Months of Life 21 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life 22 Prenatal & Postpartum Care: Timeliness of Prenatal Care (PPC) 23 Adolescent Well-Care Visits 24 Follow-Up Care for Children Prescribed ADHD Medication 25 Appropriate Treatment for Children with Upper Respiratory Infection (URI) 26 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents 27 Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis * List of PPQC Core Quality Measures with full descriptions available here: https://www.msms.org/portals/0/documents/msms/membership/ppqc Core Measures FINAL.pdf www.mipcc.org 517-908-8241

SIM and Michigan s Blueprint for Health Innovation What is SIM? The State Innovation Models (SIM) is a Centers for Medicare and Medicaid Services initiative that partners with states to advance multi-payer health care payment and delivery system reform models. Each state-led model aims to achieve better quality of care, lower costs, and improved health for the population of the participating states. The initiative is testing the ability of state governments to utilize policy and regulatory controls to accelerate health system transformation to meet these aims. Under this CMS initiative, The State of Michigan has received approval and grant funding to develop and test it s SIM, the Blueprint for Health Innovation. Blueprint for Health Innovation Michigan s Blueprint for Health Innovation provides a health system transformation plan that brings together the people and resources needed to enhance care coordination, strengthen Michigan s primary care infrastructure, and reduce healthcare costs while improving health outcomes for all Michiganders. It is designed to move the State away from fee-for-service payment structures by focusing on the development and implementation of innovative, multi-payer service delivery and payment models that are supported by the Blueprint s five core components: 1. Community Health Innovation Regions (CHIR) Building on existing community coalition efforts, CHIRs will assess community needs, define and support regional health priority planning, and increase awareness and use of community-based services among healthcare providers and systems. 2. Accountable Systems of Care (ASC) and Patient- Centered Medical Homes (PCMH) The Blueprint ASC initiative will focus on creating PCMH programs with the Medicaid Managed Care Organizations to increase care coordination and accountability in the medical neighborhood. Supported by CHIRs, it will also encourage integration of behavioral health services, longterm care planning, and community resources. 3. Alternative Payment Models (APM) Implementation of APM funding mechanisms that are linked to provider participation and performance metrics will encourage provider accountability in care quality, coordination, utilization, and the patient experience. The Blueprint includes APM plans for PCMH payments, care coordination activity reimbursement, shared savings/ shared risk models and population-based payment models through Medicaid, Medicare, and commercial payors. 4. Health Information Technology (HIT) and Exchange A statewide foundation of HIT infrastructure will be leveraged to enable information sharing that supports care coordination as well as greater interoperability between healthcare and community entities. Statewide HIT will also be vital in population health monitoring and enabling SIM program performance evaluation. 5. Stakeholder Engagement, Measurement, Evaluation and Improvement A stakeholder commission will be created and tasked with analyzing SIM program performance, leading data-driven discussions for model improvements, and evaluating the future implications of SIM policy changes. Blueprint for Health Innovation Timeline Beginning in the fall of 2016, MDHHS began work with community partners and stakeholders to further develop and test the Blueprint model in five pilot regions in Michigan: Jackson County, Muskegon County, Genesee County, Northern Region, and the Washtenaw and Livingston counties area. Testing in multiple geographies will provide the opportunity to refine the model before it is expanded to additional payers and regions, proposed to begin in Fall 2018. May 2017

List of Acronyms Acronym Acronym Definition AHRQ Agency for Healthcare Research and Quality APM Alternative Payment Model C-CDA Consolidated Clinical Document Architecture CME Continuing Medical Education CMMI Center for Medicare & Medicaid Innovation CMS Centers for Medicare & Medicaid Services CPC Comprehensive Primary Care Initiative EHR Electronic Health Record ELR Electronic Lab Reporting GLPTN Great Lakes Practice Transformation Network HCIA Health Care Innovation Award HIE Health Information Exchange HIT Health Information Technology HITA Health Innovation and Technical Assistance HRSA Health Resources & Services Administration MACRA Medicare Access and CHIP Reauthorization Act of 2015 MCEITA Michigan Center for Effective IT Adoption MDHHS Michigan Department of Health & Human Services MCIR Michigan Care Improvement Registry MiHIN Michigan Health Information Network Shared Services MIPS Merit-based Incentive Payment System MOC Maintenance of Certification MU Meaningful Use ONC Office of the National Coordinator for Health Information Technology PCMH Patient-Centered Medical Home PGIP Physician Group Incentive Program PPQC Physician-Payer Quality Collaborative PQRS Physician Quality Reporting System QPP Quality Payment Program REC Regional Extension Center for Health Information Technology SIM State Innovation Model SRA Security Risk Assessment TA Technical Assistance VBR Value-Based Reimbursement www.mipcc.org 517-908-8241

Michigan s Vision for Health Information Technology and Exchange Secure Health Information Exchange (HIE) facilitates safe, timely, efficient, patient-centered care by delivering the right health information to the right place at the right time; while improving quality, cost, safety and efficiency across the care continuum. The state and federal government have been and will continue promoting the creation of HIEs in a movement toward national standards for secure electronic exchange of health information. Fewer early deaths, chronic disease, and obesity Improved mental health and reduced substance abuse Healthy child development Adequate nutrition and exercise Reduce health disparities associated with race, ethnicity, income, geography, or source of insurance Access to Patient Centered Medical Home Coordinated care Fewer hospitalizations and emergency department visits Reduce administrative complexity Reduced expenditures by payer due to a healthier population and reduced administrative complexity Slow the rate of spending through better utilization and efficiency, thus reducing insurance premiums Health Information Technology (HIT) and HIE in Michigan is Driven by its Blueprint for Health Innovation Michigan s Blueprint for Health Innovation provides a health system transformation plan that brings together the people and resources needed to enhance care coordination, strengthen Michigan s primary care infrastructure, and reduce healthcare costs while improving health outcomes for all Michiganders. It is designed to move the State away from fee-for-service payment structures by focusing on the development and implementation of innovative, multi-payer service delivery and payment models that are supported by the Blueprint s five core components: 1. Community Health Innovation Regions (CHIR) - Building on existing community coalition efforts, CHIRs will assess community needs, define and support regional health priority planning, and increase awareness and use of community-based services among healthcare providers and systems. 2. Accountable Systems of Care (ASC) and Patient- Centered Medical Homes (PCMH) - Creating PCMH programs with the Medicaid Managed Care Organizations to increase care coordination and accountability in the medical neighborhood, and encourage integration of behavioral health services, long-term care planning, and community resources. 3. Alternative Payment Models (APM) - Implementation of APM funding mechanisms that are linked to provider participation and performance metrics will encourage provider accountability in care quality, coordination, utilization, and the patient experience. 4. Health Information Technology and Exchange - A statewide foundation of HIT infrastructure will be leveraged to enable information sharing that supports care coordination as well as greater interoperability between healthcare and community entities. May 2017

Statewide HIT will also be vital in population health monitoring and enabling State Innovation Model (SIM) program performance evaluation. 5. Stakeholder Engagement, Measurement, Evaluation and Improvement - A stakeholder commission will be created and tasked with analyzing SIM program performance, leading data-driven discussions for model improvements, and evaluating the future implications of policy changes with SIM Centers for Medicare and Medicaid Services (CMS) initiative that partners with states to advance multipayer health care payment and delivery system reform models. Participation in the statewide Michigan Health Information Network (MiHIN) use case Admit Discharge Transfer (ADT) service provides foundational support to number 2 on the previous page, the Patient Centered Medical Home model of care, and helps practitioners receive timely notification when an ADT or emergency room event occurs. This is expected to result in better care transitions, improved health outcomes, and reduced hospital readmissions. The focus of the incentive structure continues to shift from the sending and receiving of Active Care Relationship Service (ACRS)/ADT data to the use of ADTs in improving patient transitions of care, expanding use of the state s shared infrastructure, and implementing the processes required to build a sustainable statewide model for data sharing. Michigan s Blueprint for Health is supported by SIM. Under this CMS initiative, The State of Michigan has received approval and grant funding to develop and test its SIM. Each state-led model aims to achieve better quality of care, lower costs, and improved health for the population of the participating states. Since Michigan began their SIM activities, following their February 2015 to April 2016 Strategic Approach, CMS has taken action that triggered meaningful consideration and an opportunity to update our SIM payment reform strategy. As a result, Michigan s SIM approach has recently been updated to implement broad-based pursuit of advanced alternative payment models (APMs) that align with provider-facing Medicare incentives, while allowing for market-based innovation between payers and providers, including providing directional goals for the percentages of healthcare payment made through APMs over the course of the next several years. This updated approach leverages existing and future clinical integration, and maximizes provider opportunity for participating in Medicare incentives. Collaborative Governance Leads to HIT-HIE Success The success of HIE and HIT in Michigan can be largely attributed to the governance model featuring a collaboration between the Michigan Department of Health and Human Service (MDHHS) HIT Commission (HITC) and the MiHIN Shared Services Governance Board, with representation by private health care organizations and the State of Michigan. Figure 1. Michigan s Coordinated Governance Model MiHIN is a public and private non-profit collaboration developed by and for physicians, hospital systems, health insurers and privacy officers throughout Michigan. Its governance structure is intended to be broad and inclusive, and relies on input from stakeholders from more than 20 organizations. MiHIN has been formally designated as Michigan s statewide health information exchange by a cooperative agreement between the Michigan State Health Information Exchange program and the Office of the National Coordinator for Health Information Technology. Therefore, MiHIN is a network for sharing health information statewide for Michigan. The HITC serves in an advisory capacity to the MDHHS. The HITC s objective is to recommend and advise MDHHS on policy decisions, business and technical needs, and general oversight for the HIT activities essential Michigan s HIT and HIE landscape. HIT and HIE Efficiency Improvements Achieved The vision of MiHIN was to improve Michigan s existing HIE by mitigating the duplicative infrastructure and processes of multiple HIE organizations and other data providers across the state. The existing HIE structure in Michigan was not replaced, instead, MiHIN leverages relationships with Michigan s sub-hie organizations to receive information from participating hospitals and skilled nursing facilities, identify patient care relationships, and transmit notifications to the State of Michigan and attributed physician organizations. This allows for an efficient, single access point to obtain daily emergency room and inpatient admission, discharge and transfer

Figure 2. MiHIN Shared Services High Level Organization alerts, as well as medication information for their entire patient population regardless of hospital affiliation or payer membership. A snapshot of the MiHIN shared service organizational efficiency can be seen in Figure 2. MiHIN created this statewide ecosystem to realize a statewide legal trust fabric; connect MDHHS and all health plans, HIEs, Pharmacies, appropriate Federal agencies, and others; maintain statewide master data sharing infrastructure; convene groups to identify data sharing barriers, reduce provider burdens, engage consumers, and enable population health; and align incentives and/or regulations to fairly share data and promote data standardization (via use cases). Through the collaborative governance and implementation of the shared services for health information exchange, Michigan continues to make progress towards a fully interoperable HIE infrastructure. Health care providers across the state have adopted and are using Electronic Health Records (EHR) to coordinate and improve the delivery of supports and services. The MDHHS, MiHIN, and other health care organizations have successfully established a shared infrastructure to support health information sharing across the Michigan health care system. Figure 3 (on the next page), provides a snapshot of the progress made to date in statewide use cases and scenarios made possible with the shared services infrastructure, as well as what is yet to come (conceptual and planning & development). The Forward Momentum of HIT and HIE in Michigan Again, Michigan s Blueprint for Health Innovation provides a health system transformation plan that brings together the people and resources needed to enhance care coordination, strengthen Michigan s primary care infrastructure, and reduce healthcare costs while improving health outcomes for all Michiganders. It is designed to move the State away from fee-for-service payment structures by focusing on the development and implementation of innovative, multi-payer service delivery and payment models that are supported by the Blueprint s five core components outlined earlier. Beginning in the fall of 2016, MDHHS began work with community partners and stakeholders to further develop and test the Blueprint model in five pilot regions in Michigan: Jackson County, Muskegon County, Genesee County, Northern Region, and the Washtenaw and Livingston counties area. Testing in multiple geographies will provide the opportunity to refine the model before it is expanded to additional payers and regions, proposed to begin in fall 2018. Michigan continues to be on the leading edge of HIE and HIT adoption under the policy guidance by the HITC and evidenced by the innovation of MiHIN. The forward momentum of HIT and HIE in Michigan will focus on improving public health, provider engagement and coordination of physical and behavioral patient health care. To facilitate this, electronic exchange will expand, as will sharing of health information resources.

Figure 3. Statewide Shared Services Practically Applied through Valuable Use Cases and Scenarios Now that the technical infrastructure for health information sharing has been built, the Michigan HIT Commission has been exploring how the infrastructure can be leveraged to support critical statewide health care efforts. Three topics of particular focus by the Commission are: 1. Using Health Information Sharing to Improve the Management of Prescription Drugs 2. Using Health information Sharing to Advance Business Integration and Strategic Alignment within MDHHS 3. Using Health Information Sharing to Support Health Care System Transformation One example of the practical application would be to address the alarming rise in prescription drug and opioid over-prescribing and misuse 200% rise, on average, across the nation between 2005 and 2014 by proposing needed legislation, such as statewide adoption and use of Electronic Prescribing Controlled Substance (EPCS), by helping physical and behavioral health providers access critical information to prevent dependency and misuse, and by supporting the Prescription Drug and Opioid Abuse Task Force recommendations for Prevention, Treatment, Regulation, Policy & Outcomes, and Enforcement. Another practical example would be continued efforts and improvement in support of meaningful use reporting requirements for state public health and Medicaid systems, MDHHS, in partnership with Michigan Department of Technology, Management and Budget (MDTMB) in connecting all the state systems that are part of the meaningful use requirements to a State mini HIE, the MDHHS Data Hub. By bringing all the state meaningful use health systems into an HIE environment, all of the systems can leverage the same HIE technology, and

providers will have a single gateway to access or report to these systems. The MDHHS Data Hub will allow complete interoperability based on national standards, easily share information within the state in a secure way and leverage technology investments made by other programs and departments. In addition to the two main Medicaid systems, CHAMPS and the Data Warehouse, all of the other state government health related systems would be connected to the MDHHS Data Hub. To accomplish these examples, and many other critical use cases and scenarios, MDHHS and MiHIN will be driving to: Align new use cases with network participant readiness: Incentives; Policy levers Focus on revenue-generating opportunities to drive participation: Death Notifications; Immunization History-Forecast Focus on use cases that simplify workflow: Newborn screening bundle w/ birth notifications, common key assignment; Birthing hospitals can report once for five use cases Leverage existing infrastructure: Tobacco free e-referrals Interstate sharing of public health data starting with: Immunizations; Blood lead results Now that the technical infrastructure for health information sharing has been built, the Michigan HIT Commission has been exploring how the infrastructure can be leveraged to support critical statewide health care efforts. MDHHS and MiHIN, along with the many HIE stakeholders, will be driving to make this happen. Measuring Success An important take-away as you consider the current forward movement of HIT and HIE in Michigan is the accumulated successes. There are many more that could be listed, but below are some noteworthy stats: Participating Provider Organizations (PO) are receiving daily ADT and ER visit notifications for more than 7 Million Michigan patients, and 85% of Patient-Centered Medical Home practices in participating POs are currently engaged in the HIE Initiative Medication reconciliation data going through MiHIN represents over 70% of discharges in Michigan As of December 2016, notifications sent to the statewide service by participating hospitals represented almost 91% of the total volume of admissions statewide As of December 2016, notifications sent to the statewide service by participating hospitals represented almost 91% of the total volume of admissions statewide As of April 30, 2017, MiHIN reported a cumulative use case transactional total of 1,220,945,629 messages, which is up from 431,446,911 since Q3 2015 The combined efforts of MDHHS, MiHIN, and the many stakeholders in Michigan s HIT and HIE movement will continue to prove and improve secure HIE which facilitates safe, timely, efficient, patient-centered care by delivering the right health information to the right place at the right time; while improving quality, cost, safety and efficiency across the care continuum. Source List: Value Partnerships-BCBS of MI 2017 PGIP Fact Sheet: Health Information Exchange Initiative Michigan Health IT Commission 2016 Annual Report MiHIN.org Frequently Asked Questions (FAQ s) MiHIN Strategic Plan Michigan Health Information Technology Commission presentation, February 16, 2017 MDHHS Michigan State Innovation Model Kick-Off Summit, 8/10-11/2016, Accountable Care Breakout Session www.mipcc.org 517-908-8241