The Multi-payer Advanced Primary Care Practice

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Transcript The Multi-payer Advanced Primary Care Practice

The Multi-payer Advanced
Primary Care Practice (MAPCP)
Demonstration
Jody Blatt
Senior Research Analyst
Project Officer, MAPCP Demonstration
Medicare Demonstrations Program Group
Our charge: Identify, Test, Evaluate, Scale
“The purpose of the Center is to test innovative
payment and service delivery models to reduce
program expenditures under Medicare, Medicaid, and
CHIP…while preserving or enhancing the quality of
care furnished.”
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Resources: $10 billion funding for FY2011 through 2019
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Opportunity to “scale up”: The HHS Secretary has the authority
to expand successful models to the national level
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More flexibility: Budget neutrality requirements more flexible
Innovation Center Initiatives
http://innovations.cms.gov
ACO Suite:
 Shared Savings Program
 Pioneer ACO Model
 Advance Payment ACO Model
 Accelerated and Learning Development
Sessions
Primary Care Suite
 Comprehensive Primary Care Initiative
(CPCI)
 Federally Qualified Health Center Advanced
Primary Care Practice Demonstration
 Multi-Payer Advanced Primary Care Practice
(MAPCP) Demonstration
 Independence at Home
 Medicaid Health Home State Plan Option
Bundled Payment Suite
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Bundled Payment for Care Improvement
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State Demonstration to Integrate care for
Dual Eligible Individuals
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Financial Alignment to Support State Efforts to
Integrate Care
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Demonstration to Reduce Avoidable
Hospitalizations of Nursing Facility Residents
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Medicaid Health Home State Plan Option
Diffusion and Scale Suite:
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Partnership for Patients
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Million Hearts Campaign
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Innovation Advisors Program
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Care Innovations Summit
Healthcare Innovation Challenge
Rapid Cycle Evaluation and Research
Learning and Diffusion
Dual Eligible Suite:
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MAPCP Demonstration Overview
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Medicare joining Medicaid and private insurers in state
health reform initiatives aimed at improving delivery of
primary care
A multi-payer effort
◦ Private payers covering a majority of commercial market
◦ Medicaid (managed care and/or FFS)
◦ Medicare
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State designed program:
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Definition of medical home
Payment methodology and rates (subject to CMS ceiling)
Selection of practices
Beneficiary assignment methodology
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Practice Demonstration
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MAPCP Demonstration Overview
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Three year demonstration
◦ 8 states: ME,VT, RI, NY, PA, NC, MI & MN
◦ Start dates from July 2011-January 2012; each project will run
36 months
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Most projects involve monthly payment to the practice
for beneficiaries “assigned” using a state-specific
algorithm
◦ Total monthly payments generally <= $10 pbpm
◦ Some projects involve community health teams (which may or
may not receive separate payments up to $10 max
◦ Some projects include payment (within $10 max) to state for
administrative/evaluation services
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Practice Demonstration
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MAPCP Demonstration Overview
(continued)
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States required to conduct evaluation of state
project
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CMS will conduct an independent evaluation
across all states focusing on Medicare &
Medicaid
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Practice Demonstration
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Projected Enrollment by Year
(based on original state proposals)
# MEDICAL HOMES
# BENEFICIARIES COVERED
Year 1 Year 2
Year 3
Year 1
Year 2
Year 3
Maine
26
42
42
40,000
80,000
80,000
Vermont
110
176
220
56,914
92,519
117,499
Rhode Island
13
13
13
9,600
9,600
9,600
New York
35
35
35
30,976
30,976
30,976
Pennsylvania
78
78
78
71,846
71,846
71,846
North Carolina
61
61
61
40,928
42,529
44,729
Michigan
477
477
477
358,402
358,402
358,402
Minnesota
159
250
340
95,856
150,631
205,406
TOTAL
959
1,132
1,266
704,522
836,503
918,458
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Practice Demonstration
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MAPCP & the Michigan Primary Care
Transformation Project (MiPCT)
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Medicare beneficiary eligibility
Medicare Payments
◦ How much will Medicare pay?
◦ How will payments be processed?
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Feedback & Evaluation
Questions
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Beneficiary Eligibility
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Covered under the traditional FFS Medicare Program
◦ Not in a Medicare Advantage or other Medicare Health Plan
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Must have BOTH Medicare Part A & Part B
Medicare must be the primary payer
◦ Not working and covered under an employer’s plan
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Michigan resident
May include any of the following groups of beneficiaries:
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“Dual” eligibles (Medicare & Medicaid)
ESRD
Disabled
Hospice
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Beneficiary Assignment
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Beneficiary assignment algorithm run quarterly
using a common 5-step assignment algorithm:
 12-24 month (2 stages) look back
 Primary care office and home visits (inc. FQHC visits)
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Beneficiary assigned to the practice where he/she
had the greatest # visits during the look-back
period
Accurate and timely information on providers in the
practice (Tax ID #, NPI, P-TAN) critical to accurate and
complete assignment and timely payment
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Beneficiary Assignment
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Newer patients may take several quarters to show up
on your lists.
CMS will provide quarterly beneficiary assignment lists
with beneficiary names and key identifying information.
 List will show who is new/dropped off each quarter
 DUA must be signed to receive this information
 Starting spring 2012 beneficiary assignment lists will be
available through a web portal
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Remember:
◦ Beneficiary retains full FFS rights to go to any provider.
Beneficiary is NOT locked in.
◦ No enrollment is requires but CMS would like beneficiary
notification (newsletter, notice in waiting room, etc.)
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Monthly Medicare Payments
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Payments directly to practice (G9008): $2.00 pbpm
Support for team coordination and other traditionally
non-reimbursed medical home expenses paid to central
entity for distribution by PO/PHO (G9152): $4.50 pbpm
Incentive Pool Contribution (paid to central entity)
(G9153):
$3.00 pbpm
Payment to state for administrative services/evaluation
support (G9151):
$0.26 pbpm
Total Medicare payment: $9.76 pbpm
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Claims Payment Process
Practices do not have to submit claims for demonstration
payments but payments will be processed like a claim
 On a monthly basis, CMS’ contractor (Actuarial Research
Corporation) will create a claim record for each beneficiary on
your list and submit it to the “MAC” or carrier for payment.
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◦ “Date of service” will be 1st of the month
◦ Payment will likely be received mid-month
◦ Practice payment ($2.00) is processed under one rendering NPI to
facilitate payment
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Individual monthly claims will be processed for each
beneficiary in the same manner as any other electronic claim.
◦ Due to claims volume, claims may be spread out over course of the
month.
Remittance advice will be sent to the practice
 Medicare Summary Notice (MSN) will NOT show
demonstration claims
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Claims Payment Process
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Monthly claim will reject if beneficiary is no longer
eligible for demonstration:
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Deceased
No longer has Part A or Part B
Joined an MA plan
Medicare no longer primary
Practices can NOT balance bill the patient if the service
is rejected
Payment may be recouped if retroactive information
indicates payment should not have been made
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Reports and Feedback
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Quarterly Feedback Reports
◦ Practice specific summary reports
◦ Benchmark comparisons
◦ Actionable information specific to practice’s patients
(e.g. ER visits, hospital admissions)
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MAPCP Evaluation
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Each state required to conduct an evaluation of its
program
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CMS has contracted for an independent evaluation
of all 8 programs
MAPCP Evaluation Contractor: RTI International
(subcontracts with The Urban Institute & the National
Academy for State Health Policy (NASHP)
 Project Director: Nancy McCall, ScD
 MI State Team Lead: Josh Wiener, PhD
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MAPCP Evaluation
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Assess the effects of the PCMH model when
supported by Medicare, Medicaid, and private
health plans
Mix of qualitative and quantitative analyses
Populations of interest
◦ Medicare FFS beneficiaries (not Medicare Advantage)
◦ Medicaid beneficiaries (duals and non-duals)
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Evaluation design
o Pre/post analyses w. comparison group
MAPCP Evaluation
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Data sources
◦ CMS: Medicare claims
◦ State: Medicaid claims, practice/PHO surveys,
patient surveys, PCMH scores
◦ Primary data collection
 Site visits, interviews, focus groups, observation of TA
activities
 Minimize burden on participants
MAPCP Evaluation
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Quantitative outcomes
◦ Expenditures and budget neutrality
◦ Utilization (e.g., hospitalizations, readmissions, ED visit
rates)
◦ Quality of care
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Qualitative research
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Structure and features of state initiatives
Practices’ transformational process
Effort involved in Medicare joining state initiatives
How PCMH payments are used
MAPCP Information Links
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Web site
http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=
CMS1230016
 Solicitation
 Fact Sheets
 Qs & As
 Sign up for automatic notification of all updates
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Questions about demonstration:
First contact your regional representative
CMS:
[email protected]
Jody Blatt, Project Officer - (410) 786-6921
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