1. Michigan Primary Care
Transformation
Demonstration Project
June 13, 2012
Webinar #10

2. Agenda
 Medicaid Payments
 Medicare Payments
 Care Managers
 MiPCT Committee
 Metrics
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3. Doing the Impossible
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4. Performance
 One year look back for quality scores
 Ongoing testing for patient registry data dumps
 Patient registry data utilized for distribution of
funds
 Patient registry submission in time for 12.31.2012
performance payments
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5. Pay for Performance Data Source
 Claims Data: All participating health plans submit
claims data to the Michigan Data Collaborative
which can be used to calculate utilization and cost
metrics.
 Claims data will be calculated for each Health Plan
and aggregated across all contracted plans.
 Confidence intervals at 95% will be provided.
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6. Pay for Performance Data Source
 MiPCT Quarterly Reports: The report will
document updates to the MiPCT Implementation
Plan and progress to date in developing PCMH
infrastructure capabilities and carrying out MiPCT
clinical initiatives.
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7. Pay for Performance Data Source
 Self-Reported Data (SRD): MNO currently reports
to BCBSM PGIP twice a year on each practice’s
PCMH capabilities
 BCBSM applies accuracy, validity and inter-rater
reliability checks and balances to the reports
 Financial penalties are imposed for inaccurate
reporting of capabilities and are reflected
proportionally on the distribution of funds
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9. Pay for Performance:
Six Month Metrics - Access
 Extended access:
• 30% same day appointment (10 points)
 Appointments outside regular hours:
• 8 hours/week (10 points)
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10. Pay for Performance:
Six Month Metrics – eRegistry
1) Practice has electronic registry
2) Registry has interface capability
3) Incorporates evidence-based care guidelines
4) Identifies individual attributed practitioner
5) Information available and used by the practice
unit team at the point of care
6) Used to generate communications to patients
regarding gaps in care
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11. Pay for Performance:
Six Month Metrics - eRegistry
7. Used to flag gaps in care
8. Patient demographics
9. Registry identifies and tracks care for patients
with at least 2 of the following:
diabetes
asthma
cardiovascular disease
pediatric obesity
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12. Pay for Performance:
Six Month Metrics - eRegistry
 0 points for entire metric if no eRegistry
 1 point each for numbers 1-8
 Up to 2 points for number 9
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13. Role Comparison Review
Moderate Risk Care Manager Complex Care Manager
(MCM) (CCM)
• Moderate risk patients identified by • High risk patients identified by PCP
Patient
registry, PCP referral for proactive referral and input, risk stratification,
Population and population management patient MiPCT list
• Caseload 500 (approx. 90 - 100 active • Caseload 150 (approx. 30 - 50 active
Patient
patients); one MCM per 5,000 patients)
Caseload patients • One CCM per 5,000 patients
• Proactive, population management • Targeted interventions to avoid
• Work with patients to optimize hospitalization, ER visits
Focus of Care
control of chronic conditions and • Ensure standard of care, coordinate
Management prevent/minimize long term care across settings, help patients
complications understand options
Duration of
• Frequency of visits high at times,
Care • Typically a series of 1 to 6 visits
duration of months
Management
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14. Pay for Performance:
Six Month Metrics - Care Manager
 Number of Moderate Care Managers hired/
contracted by practices and/or PO
• 10 points
 Number of Moderate Care Managers within PO
that have completed the required training
• 10 points
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15. Patient Engagement
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17. Pay for Performance:
Six Month Metrics - Care Manager
 Number of Complex Care Managers hired/
contracted by practices and/or PO
• 10 points
 Number of Complex Care Managers within PO that
have completed the required training
• 10 points
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18. Performance Incentive Process
 $3.00 PMPM paid into incentive pool*
 Performance incentive metrics are assessed and
all funds paid out every 6 months
• 1st period for April starters is 3 months
• Payments will be made about 2 months after
performance period ends
• Payment range is 82% to 118 % of mean ($18.00 per
member) or $14.76 to $21.24
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19. Payment Distribution
 POs retain approved portion (not to exceed 20%)
 POs distribute remaining funds to participating
practices.
• Equally: a fixed dollar amount times the number of
beneficiaries
or
• Variable amounts: dollar amount is based on
additional performance criteria including participation
in workshops and collaborative events
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20. Care Managers
 Each practice has a Hybrid Care Manager assigned
and actively engaged
 Dietitian, Certified Diabetes Educator, Behavior
Health Specialist, Health Coach, Health Educator,
Certified Asthma Educator, Pharmacist (as
needed)
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21. PDCM Codes and Fees
CODE SERVICE
G9001 Initial assessment
G9002 Individual face-to-face visit (per encounter)
98961 Group visit (2-4 patients) 30 minutes
98962 Group visit (5-8 patients) 30 minutes
98966 Telephone discussion 5-10 minutes
98967 Telephone discussion 11-20 minutes
98968 Telephone discussion 21+ minutes
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22. Registration for CCM Workshop
 MiPCT moved to an open registration process for
Complex Care Management (CCM) training
 CCMs and HCMs that have not previously
registered online for the CCM course to the
section of the MiPCT website entitled “CCM
Online Registration page
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24. PCMH CAHPS Survey
 To be collected on a representative sample of
MiPCT and comparison beneficiaries
 Multi-modal (mail with phone follow-up)
 Content areas:
• Access
• Communication
• Coordination
• Comprehensiveness
• Shared decision making
• Self-management support
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25. Adult Clinical Quality Metrics
 Diabetes: (ages18-75 years & type 1 or 2
diabetes) HEDIS
1. A1C Test
2. Poor Control A1c>9
3. Control A1c< 8
4. LDL-C Test
5. LDL-C Controlled < 100 mg/dl
6. BP <140/90
7. Retinal Eye Exam
8. Nephropathy Screen or Evidence of Nephropathy*
y
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26. Adult Clinical Quality Metrics
 Asthma: Self-Management Plan or Asthma Action
Plan (ages 5-50) Non HEDIS
 Hypertension: Controlled BP <140/90 (ages 18-85)
HEDIS
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27. Adult Clinical Quality Metrics
 Cardiovascular Disease (CVD): BP management
<140/90 mmHg (ages 18-75) HEDIS
 CVD: LDL-C Management <100 mg/dl (ages 18-85)
HEDIS
 Obesity: Adult BMI (Meaningful Use)
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28. Adult Clinical Quality Metrics
 Tobacco: Percent Current Smokers (ages 13 and
older) (non HEDIS)
 Breast Cancer Screening: (ages 40-69) HEDIS
 Cervical Cancer Screening: (ages 21-64) HEDIS
 Colorectal Cancer Screening: (ages 50-75) HEDIS
 Chlamydia Screening: (sexually active women
ages 16-24) HEDIS
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29. Pediatric Clinical Quality
Measures
 Asthma: Self-Management Plan or Asthma
Action Plan (ages 5-50) Non HEDIS
 Obesity: Child BMI (ages 2-17yrs) Meaningful
Use
 Lead Screening: (Medicaid only) (Age 2) HEDIS**
 Tobacco Use: (ages 13 and older)
 Chlamydia Screening: (sexually active women
ages 16–24) HEDIS
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30. Pediatric Clinical Quality
Measures
 Chlamydia Screening: (sexually active women
ages 16–24) HEDIS
 Childhood Immunizations: Age 2 HEDIS**
 Childhood Immunizations: Adolescent Age 13
HEDIS**
 Well Child Visits: 15 Months and 3-6 years HEDIS
 Well Child Visits: Adolescent (ages12-21) HEDIS
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32. MNO Expectations
 Attendance at webinars
• Share current information
• Brief training moments
• 100% practice representation
• eMail addresses of physicians
• Hold each other accountable and create buddy
relationships
• Create inter-professional collaborative care
teams
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33. Questions
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