Developing a Multi-Payer Patient-Centered Medical Home Model for Michigan

1. Developing a Multi-Payer Patient-Centered Medical Home Model for Michigan Jean Malouin, MD, MPH University of Michigan Health System December 2, 2010

2. Agenda • U.S. Health Care: A National Crisis • Patient-Centered Medical Home: The Silver Lining? • CMS Demonstration Project background • The Michigan Primary Care Transformation model • Vision and goals • Participants • Clinical model • Next steps

3. U.S. Health Care: A National Crisis

4. Average Health Spending Per Capita ($US) K. Davis et al. Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data Page 4

5. Number of U.S. Citizens Over 65

6. Procedure Rates for Heart Disease (2006):More is NOT better

7. Life Expectancy at Birth (2010)

8. Infant MortalityRates Per 1,000 Live Births (1970-2004) United States Median Canada France Japan United States Canada Median France Japan Note: The median includes all OECD countries. The decrease from 1960-2004 is in percentage points. Source: OECD Health Data 2006.

9. “…in much of the country, no one is in charge. And the result is the most wasteful and the least sustainable health-care system in the world.” -Atul Gawande MD MPH Source: “The Cost Conundrum: What a Texas town can teach us about health care”. The New Yorker, June 1, 2009

10. Patient-Centered Medical Home:The Silver Lining?

11. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • Original specifications – June 2010 • CMS will join existing multi-payer state PCMH initiatives • Up to 6 States to be selected • Max. number of Medicare beneficiaries = 150,000/state • Total CMS funding < $10 PMPM • Common payment methodology • Budget neutral over 3 years of project • Payers must include: • Medicaid • Private health plans (at least 50% of commercial market) • Self-insured employer-sponsored group health plans

12. CMS Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration • Award notification - November 2010 • State selections announced November 16, 2010 • 8 states selected for participation, including Michigan • Did not limit Medicare beneficiaries to 150,000/state • Some flexibility on common payment methodology • May stop a state’s participation if not budget neutral • Many details still need to be worked out with CMS • First conference call on December 7, 2010

13. MAPCP Demo: Participating States • Maine 22 practices  42 (year 3) • Michigan 477 practices • Minnesota 159 practices  340 (year 3) • New York 35 practices • North Carolina 54 practices • Pennsylvania 78 practices • Rhode Island 13 practices • Vermont 110 practices  220 (year 3) _____________________________________________ • TOTAL 948 practices  1,259 (year 3)

14. The Michigan Primary Care Transformation (MiPCT) Model

15. Michigan: Some interesting facts • Total population (July 2009): 9,969,727 • 11th largest state of the United States and the 26th state to become part of the United States • Home to more than 11,000 lakes and the largest State Forest system in the nation • Has the longest freshwater shoreline in the world • Sault Ste. Marie (est. 1668) is the oldest town between the Alleghenies and the Rockies

16. And… • Although Michigan is called the "Wolverine State" there are no longer any wolverines in Michigan

17. Michigan: Some sobering statistics • 45th (of 50 states) in coronary heart disease deaths • 43rd in percent of obese adults • 40th in breast cancer death rate • 38th in infant mortality rate • 37th in percent of adults who smoke • 35th in overall cancer death rate • 30th in colorectal cancer death rate • 28th in stroke-related deaths

18. Michigan Primary Care Transformation (MiPCT) Model • Basic Premise: • Better primary care delivery  better health outcomes • Support for primary care practice transformation will take place through a collaborative network of POs/payers • Shared learning will be facilitated by Michigan Primary Care Transformation (MiPCT) administration • Infrastructure: • Built on a foundation of the BCBSM Physician Group Incentive Program (PGIP) PCMH designation process • Incorporate principles and features of other payer models

19. Our Vision for a Multi-Payer Model • Use the CMS Multi-Payer Advanced Primary Care Practice demo as a catalyst to redesign MI primary care • Multiple payers will fund a common clinical model, allowing global primary care transformation efforts • Support development of evidence-based care models • Create a model that can be broadly disseminated • Facilitate measurable, significant improvements in population health for our Michigan residents • Contribute to national models for primary care redesign • Form a strong foundation for successful ACO models

20. MiPCT: Hypotheses to Test • Building a robust PCMH primary care network can reduce healthcare costs and improve health outcomes • It is possible to disseminate relatively uniform clinical and operational models over a large number of autonomous practices with • multiple geographic areas • varying health information technology capabilities • differing organizational structures • Multiple Payers and Physician Organizations can come together and agree on common models

21. MiPCT: Current Stakeholders • Payers (public and private): 17 • PO/PHO/IPAs: 32 • PCMH Designated Practices: 477 • Beneficiaries (our patients!): • Medicare 358,000 • Medicaid (state FFS) 150,000 • Medicaid (managed care) 248,000 • Privately insured 1,153,000 • TOTAL Beneficiaries 1,909,000

22. 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

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

24. Practice Participation Criteria • Currently PCMH-designated, and maintain their designation throughout the 3-year demonstration • Part of a participating PGIP PO/PHO/IPA • Agree to work on the four selected focus initiatives: • Care Management • Self-Management Support • Care Coordination • Linkage to Community Services

25. Care Management: Better Outcomes

26. Self-Management Support: EFFECTIVE interventions

27. Care Coordination: Right care, right place

28. Health System Organization of Health Care Linkage to Community Services: The “umbrella” Community Resources & Policies ClinicalInformationSystems Decision Support DeliverySystem Design Self-Management Support Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Improved Outcomes E. Wagner, MD Group Health Cooperative Supported by the RWJF

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

30. Proposed MiPCT Governance Steering Committee • MDCH – 3 (appointed) • PO/PHO/IPA – 6 (4 elected, 2 appointed) • Payers – 5 (3 elected, 2 appointed) • Subject matter experts – 3-4 (appointed) Advisory Committee • Professional medical associations • Other participating payers • Other participating POs/PHOs/IPAs • Others

31. Next Steps for Michigan • Establish MiPCT governance structure • Steering committee elections are underway • First steering committee meeting December 16, 2010 • Determine data repository needs and components of multi-payer database • Develop clinical model for MiPCT focus areas • Develop a widespread communication strategy • Physician organizations/practices/physicians • Patients/communities • Payers

32. MiPCT Planning Committee Carol Callaghan* (MI Dept of Community Health) Ann Donnelly (Genesys PHO) Jean Malouin* (U of M Health System) Susan Moran (Michigan Medicaid) Paul Ponstein (Lakeshore Health Network) Kevin Taylor (Huron Valley Physicians Association) Trissa Torres (Genesys Health System) Dana Watt (MI Primary Care Consortium) * MiPCT project co-leads

33. MiPCT Development Team Caroline Blaum (U of M Health System) Patrice Eller (CHRT*) Jean Malouin (U of M Health System) Margaret Mason (Blue Cross Blue Shield of MI) TomiOgundimu (CHRT*) Robyn Rontal (Blue Cross Blue Shield of MI) Marianne Udow-Phillips (CHRT*) * Center for Healthcare Research & Transformation

34. Questions?jskratek@umich.edu