Michigan’s Proposal CMS Multi-Payer Advanced Primary Care Practice Demonstration

1. Michigan’s Proposal CMS Multi-Payer Advanced Primary Care Practice Demonstration Carol Callaghan Michigan Primary Care Consortium Annual Meeting October 22, 2010

2. CMS Demonstration Requirements: • Up to 6 States • Budget neutrality over 3 years of project • Number of Medicare beneficiaries < 150,000 (More allowable if budget neutrality can be assured) • Total CMS funding < $10 PMPM • Common payment methodology • Payers must include • Medicaid • Private health plans • Self-insured employer-sponsored group health plans

3. Eligible Michigan Practices: 505 PCMH Designation for 2010 (PGIP) - 28 UMHS practices excluded by overlap___ with UM CMS demo) 477 Eligible for participation* * 17 of the above are also recognized by NCQA as Level 2/3 PCMH

4. Clinical Model: Support for deeper practice transformation will take place through a collaborative network of PO’s and through shared learning facilitated by the Michigan Primary Care Transformation (MiPCT) Administration

5. Practice Participation Criteria • Part of a participating PGIP PO/PHO/IPA • Maintain their PCMH designation throughout the 3-year demonstration • Agree to work on four specific focus areas: • Care Management • Self-Management Support • Care Coordination • Linkage to Community Services

6. Participating Physician Organizations • All 32 Eligible PGIP POs/PHOs/IPAs signed Letters of Intent to participate • To participate in the Demo, POs must: • Assist practices to advance in all PCMH initiatives, especially the four areas of focus • Assist practices with care coordination and community linkages • Distribute incentive payments • Collect data and submit specified reports

7. Stakeholders in Application Payers (public and private): 16 PO/PHO/IPA’s: 32 PCMH Practices: 477 Beneficiaries: Medicare: 358,000 Medicaid (non-dual): 248,000 Privately insured: 1,153,000 TOTAL Beneficiaries: 1,749,000

8. Proposed Funding Model $0.26 PMPM Administrative Expenses $3.00 PMPMCare Management Support $1.50 PMPM Practice Transformation Reward $3.00 PMPM Performance Improvement $7.76 PMPM Total Payment by Payers* * Medicare will pay additional $2.00 PMPM to cover additional services for the aging population

9. Proposed Funding ModelTotal Payments by Payers = $7.76 PMPM 1. Administrative Expenses ($0.26 PMPM) • State administration and management of the demo including contracting, reporting, monitoring, funds management, and central administrative hub • PO/PHO/practice support (e.g., Learning Collaboratives, other resources) • State-level evaluation of the demonstration

10. Proposed Funding ModelTotal Payments by Payers = $7.76 PMPM 2.Care Management Support ($3 PMPM or T-code equivalent) • Payments to practices for non-covered PCMH services, i.e., case mgmt, care coordination, self-mgmt support, community linkages) • Expressed as PMPM and administered via each payer’s methodology (e.g., T-codes, PMPM, CMS-specific codes to be identified)

11. Proposed Funding ModelTotal Payments by Payers = $7.76 PMPM 3.Reward for practice transformation and performance improvement ($4.50 PMPM) • 10% increase for E/M fees ($1.50 PMPM) • Payers pay practices a bonus for PCMH performance - ($3 PMPM - based on individual payer’s incentive model and distributed as variable PMPM amount)

12. Payment Delivery Mechanism* A Central Administrative Hub will be created to collect and disseminate incentive payments from participating payers • Participating payers will pay incentive (and admin) payments to the Central Admin Hub • The Central Administrative Hub, working closely with MPAC, will distribute incentive payments to POs to share with practices as a PMPM payment, based on performance, quality and use * CMS requires a common payment method

13. Payment Method

14. MPAC • Multi-payer protected central repository for data analysis and reporting • To be used by Medicare, Medicaid FFS, and BCBSM for patient attribution and incentive payment determination • Other commercial payers are also welcome to use the repository

15. Proposed Governance Steering Committee • MDCH – 3 • PO/PHO/IPA – 6 (elected) • Payers – 5 (elected) • Expert Consultants – 3 (appointed by MDCH) Advisory Committee • Other participating Payers • Other participating POs/PHOs/IPAs • Professional Medical Associations • Others

16. Participating Payers Commercial • Blue Care Network • Blue Cross Blue Shield of Michigan • Health Alliance Plan • HealthPlus of Michigan • McLaren Health Plan • Physicians Health Plan of Mid-Michigan • Priority Health Medicare Medicaid Fee For Service

17. Participating Payers (cont’) Medicaid Managed Care Plans • CareSource • Great Lakes Health Plan • Health Plan of Michigan • HealthPlus Partners • McLaren Health Plan • Midwest Health Plan • Molina Healthcare • Physicians Health Plan of Mid-Michigan • Priority Health Gov’t Programs • Total Health Care • Upper Peninsula Health Plan

18. Planning Committee Members • Carol Callaghan, MPH (MI Dept of Community Health) • Ann Donnelly, RN, BSN (Genesys PHO) • Jean Malouin, MD, MPH (U of M Health System) • Susan Moran, MPH (Michigan Medicaid) • Paul Ponstein, DO (Lakeshore Health Network) • Kevin Taylor, MD (Huron Valley Physicians Association) • Trissa Torres, MD, MS (Genesys Health System) • Dana Watt, RN, MSN (MI Primary Care Consortium)

19. Writing Team Members Caroline Blaum, MD, UMHS Patrice Eller, CHRT Jean Malouin, MD, MPH, UM Health Team Margaret Mason, BCBSM Tomi Ogundimu, CHRT Robyn Rontal, BCBSM Marianne Phillips-Udow, CHRT

20. Questions from CMS to Michigan • Budget Neutrality Assumptions • Beneficiary Assignment • Payment Methodology • Data Needed from CMS • Expectations re CMS’ Evaluation

21. If CMS does NOT select Michigan…Could we do this anyway, without Medicare? Would Michigan payers agree? Would support from employers be useful? Would legislative authority be useful? necessary?

22. Questions???