Maine PCMH Pilot & MAPCP Demonstration Update

1. Maine PCMH Pilot & MAPCP DemonstrationUpdate Lisa M. Letourneau MD, MPH September 2013

2. Vision for a Transformed Health Care System Healthy, productive, connected people & families …receiving healthcare from a highly functioning “accountable care organization” … supported by a robust & well-supported primary care base

3. The Current Primary Care Home 3

4. The Medical Home: A Start for Change! Providers transform practice, create value with viable & sustainable payment for desired services = Practice Transformation Employers & payers pay for desired services because primary care demonstrates value & saves money = Payment Reform AND

5. Maine PCMH Pilot Leadership DHA’s Maine Quality Forum Maine Health Management Coalition Maine Quality Counts MaineCare (Medicaid) 5

6. Maine PCMH Pilot Practice “Core Expectations” • Demonstrated physician leadership for improvement • Team-based approach • Population risk-stratification and management • Practice-integrated care management • Same-day access to care • Behavioral-physical health integration • Inclusion of patients & families • Connection to community / local HMP • Commitment to reducing avoidable spending & waste • Integration of health IT

7. Support for Practice Transformation • PCMH Learning Collaborative • Institute for Healthcare Improvement (IHI) Breakthrough Series (BTS) model; 3 learning sessions/year • Practice Quality Improvement (QI) Coaches • Most from existing physician hospital organizations (PHOs), medical groups • Using microsystems approach to QI • Technical Assistance “Experts” • Behavioral health (BH) integration, work with consumers, HIT • Ongoing Feedback Reports • Clinical, claims data 7 Lisa Letourneau

8. Maine PCMH Pilot – Payment Model • Major private payers, Medicaid, & Medicare participating (MAPCP demo) • PCMH payment model: • Prospective (pmpm) care management payment • Approx $3pmpm commercial payers (Anthem, Aetna, HPHC) • Approx $7pmpm Medicare, $12 Medicaid HHs • Ongoing FFS payments • Performance payment for meeting quality targets (existing P4P programs) 8

9. Community Care Teams • Multi-disciplinary, community-based, practice-integrated care teams • Build on successful models (NC, VT, NJ) • Support patients & practices in Pilot sites, help most high-needs patients overcome barriers – esp. social needs - to care, improve outcomes • Key element of cost-reduction strategy, targeting high-needs, high-cost patients to reduce avoidable costs (ED use, admits) 9

10. Maine PCMH Pilot - MAPCP Timeline Jan 1, 2010 2011 2012 2013 Dec 31, 2014 ME PCMH Pilot - Original Jan 1, 2012 MAPCP Demo – 3yr ME PCMH Pilot - Extended Dec 31, 2014 Pilot Expansion, HHs 10

11. Implications of CMS MAPCP Demo • Medicare joined as payer in Pilot (Jan 2012) • Stronger focus on reducing waste & avoidable costs – particularly readmissions • Introduction of Community Care Teams • Ability to access Medicare data for reporting, identifying pts at risk • Opportunity for 50 additional practices to join “Phase 2” of Pilot (Jan 2013) 11

12. Original (Phase 1) 26 PCMH Pilot Practices FQHC: federally qualifiedhealth center H-O: hospital-owned 12

13. Maine PCMH Pilot Community Care Teams, Phase 1 and Phase 2 Practice Sites 13

14. Alignment of Pilot with MaineCare Health Homes Initiative • Affordable Care Act (ACA) Sect 2703 - opportunity to develop Medicaid “Health Homes” initiative • MaineCare elected to align HH initiative with current multi-payer Pilot – part of VBP initiative • Defined MaineCare “Health Home”(HH): HH = PCMH practice + Community Care Team (CCT) • Opportunity to leverage multi-payer PCMH model, practice transformation support infrastructure • Maine SIM funding will support QI outreach to HHs 14

15. Maine’s Medical Home Movement ~ 540 Maine Primary Care Practices Payer: Medicaid ~150 eligible MaineCare HH-Practices 120+ NCQA PCMH Recognized Practices • Payers: • Medicare • Medicaid (HH) • Commercial plans (Anthem, Aetna, HPHC) • Self-funded employers 50 Pilot Phase 2 Practices 14 FQHCs CMS APC Demo 25 Maine PCMH Pilot Practices Payer: Medicare 15

16. PCMH: Hub of Wider Delivery & Payment Reform Models (ACOs!) ACO

17. ACOs in Maine – What’s Happening? • Medicare – multiple ACO options • Pioneer ACO – EMHS/Beacon • Shared Savings prgrms – MH, CMMC, ME Comm ACO • Medicaid: Value-Based Purchasing strategy • MaineCare -“Accountable Communities” proposals • Employer-Provider ACO Pilots • Maine Health Management Coalition leadership • MaineGeneral-SEHC, EMMC, other pilots 17 17

18. PCMH & MAPCP Demo: Results to Date • Formal evaluation (USM Muskie) underway • Baseline (2008) analysis completed • Yr 1 & Yr 2 results expected fall 2013 • Yr 3 results expected Q1 2014 • AF4Q analysis of claims data shows decreased utilization (hosp’s, ED visits) • Results from other Pilots nationally showing positive results 18

19. PCMH – Lessons Learned • Move to PCMH requires transformation (not incremental change) of entire practice, culture, and personal transformation (esp. physicians!) • Change starts with effective leadership – organizational, clinician, and administrative • Multi-payer approach is essential to create sufficient resources for change • Changing practice (and culture)takes time • Change fatigue is serious concern • Transforming primary care is essential to wider efforts! 19

20. A Compelling Case for Action

21. Summing Up: Primary Care Transformation… 21 Is difficult, requires true culture change Needs sufficient time & resource Essential to wider payment reform efforts!

22. Contact Info / Questions • Maine PCMH Pilot: www.mainequalitycounts.org (See “Major Programs”  “PCMH Pilot”) • Lisa Letourneau MD, MPH: LLetourneau@mainequalitycounts.org • Practice Transformation Lead: Nancy Grenier ngrenier@mainequalitycounts.org • Project Management Lead: Lisa Tuttle ltuttle@mainequalitycounts.org • MaineCare Health Homes • Kitty Purington: kitty.purington@maine.gov