Transcript Maine Quality Counts presents… August Provider Lunch

Maine PCMH Pilot &
Community Care Teams (CCTs)
Lisa M. Letourneau MD, MPH
October 2013
Maine PCMH Pilot Leadership
Dirigo Health
Agency’s (DHA’s)
Maine Quality
Forum
Maine
Quality
Counts
Maine
Health
Management
Coalition
MaineCare (Medicaid)
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Maine PCMH Pilot
Practice “Core Expectations”
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Demonstrated physician leadership
Team-based approach
Population risk-stratification and management
Practice-integrated care management
Same-day access
Behavioral-physical health integration
Inclusion of patients & families
Connection to community / local HMP
Commitment to waste reduction
Patient-centered HIT
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Implications of CMS MAPCP Demo
• Projected to achieve budget-neutrality (i.e. to reach
$10 pmpm savings) via reductions in avoidable ED
use, hospitalizations
• Stronger focus on reducing waste & avoidable costs
• Introduced CCTs as targeted strategy to support
high-needs patients & reduce avoidable costs
• Access to Medicare data to identify high patients
• Opportunity to add 50 additional practices to join
“Phase 2” of Pilot (Jan 2013)
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Maine PCMH Pilot - MAPCP Timeline
Jan 1, 2010
2011
2012
2013
Dec 31, 2014
ME PCMH Pilot - Original
Jan 1, 2012
MAPCP Demo – 3yr
CCTs
ME PCMH Pilot - Extended
Pilot
Expansion,
Medicaid HHs
Dec 31, 2014
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Community Care Teams
• Multi-disciplinary, community-based, practiceintegrated 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)
Lisa Letourneau
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Maine PCMH Pilot Community Care Teams
Environment
Schools
Transportation
Housing
Workplace
Outpatient
Services
Care Mgt
Family
Food Systems
High-need
Individual
Shopping
PCMH Med Mgt
Practice
Specialists
Coaching
Behav. Health
& Sub Abuse
Income
Hospital
Services
Physical
Therapy
Heat
Faith
Community
Literacy
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CCT Selection
• Used structured application, selection process
• CCTs committed to PCMH Core Expectations
• Had to get agreement from PCMH/HH
practices
• Had to meet minimum practice population
size ~15,000
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ME PCMH Pilot CCTs
• AMHC
• Androscoggin Home Health
• Coastal Care Team (Blue Hill FP, Community Health
Center/MDI, Seaport FP)
• CHANS (MidCoast area)
• Community Health Partners (Newport FP, Dexter FP)
• DFD Russell (FQHC)
• Eastern Maine Homecare
• Kennebec Valley (MaineGeneral Health)
• Maine Medical Center PHO
• Penobscot Community Health Care (FQHC)
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Maine PCMH Pilot Community Care Teams, Phase 1 and Phase 2 Practice
Sites
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 + CCT
• Provided opportunity to leverage multi-payer PCMH
model, practice transformation support infrastructure
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MaineCare Health Homes
Stage A: Help Individuals
with Chronic Conditions
Health Homes
Beneficiary
Care Mgt
Med Mgt
PCMH Practice
Coaching
Behav. Health
& Sub Abuse
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Maine’s Medical Home Movement
~ 540 Maine Primary Care
Practices
~150 eligible MaineCare HH-Practices
Payer:
Medicaid
120+ NCQA PCMH
Recognized Practices
Payers:
• Medicare
• Medicaid (HH)
•Commercial
plans (Anthem,
Aetna, HPHC)
•Self-funded
employers
25 Maine
PCMH Pilot
Practices
50 Pilot
Phase 2
Practices
14 FQHCs
CMS APC
Demo
Payer:
Medicare
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CCT Populations Served
CCTs review data from available sources (Medicare RTI
reports, MaineCare Utilization reports, other payers,
HIN) to identify
• Hospital Admissions
o 3 or more admissions in past 6 months
o 5 or more admissions in past 12 months
• Emergency Department Utilization
o 3 or more E.D. visits in past 6 months
o 5 or more E.D. visits in past 12 months
• Payer identification of high-risk or high-cost patients
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CCT Staffing
Minimum expectations:
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Medical Director (part-time)
CCT Manager
Nurse Care Manager
LCSW / Care Coordinators
Access to BH, SA expertise
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Financing CCTs: Maine Approach
• Linked CCT model, payment to multi-payer
PCMH model
• Leveraged public, private payers agreement to
provide pmpm payment
• Participation in CMS MAPCP demo brought in
Medicare as payer
• Alignment of ACA Health Homes with multipayer Pilot provided opportunity to leverage
federal 90:10 match for CCT services
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CCT Payments
• Practice population-based capitated payments
– Medicare: $2.95 pmpm
– Commercial payers: $0.30 pmpm
• Per-person capitated payments
– Medicaid / Health Homes: $129.50 pmpm
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CCT Goals &
Performance Measurement
• Improve care, reduce costs for most high-cost,
high- needs individuals of PCMH/HH practices
– Reduce hospitalizations, readmissions
– Reduce ED visits
• Performance tracked through quarterly
reporting
– Number CCT contacts
– Number ED visits, hospitalizations pre/post CCT
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CCT Reporting
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Unique Features of Maine Approach
• Defining “Health Home” as PCMH + CCT
• Adding CCT services to specifically support highneeds, high-cost members (recognizing these
mbrs can often outstrip capacity of most primary
care practices – even PCMHs!)
• Recognizes differences between
“routine”/chronic disease care management &
CCT multi-disciplinary team approach for most
high-needs mbrs
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Maine CCTs: Successes
• Have developed functional CCT infrastructure
• CCT structure, support highly welcomed by
practices, patients
• Most PCMH/HH practices report high levels of
satisfaction with CCT services
• Have demonstrated numerous examples of
high-needs individuals positively impacted by
CCTs
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Maine CCTs: Challenges &
Lessons Learned
• Need to focus on most high-cost individuals,
particularly those with frequent hospitalizations,
who are open to intervention
• Be cautious of focusing on high-needs
individuals who are highly resistant to changing
behaviors
• Value of trauma-informed approach
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Maine CCTs: Challenges &
Lessons Learned
• Building CCT structure & relationships takes time
(up to 2-6 mos)
• Data critical to identifying potential patients;
current data sources are siloed, time-lagged
• Successful interventions depend on strong
relationships, with individuals & with practices
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PCMH: Hub of Wider Delivery &
Payment Reform Models (ACOs!)
Primary Care
Providers
Employers
Payers
Hospitals/
Hospitalists/
Care
Managers
Pharmacies
Patient
Centered
Medical
Home
Home
Health
Home Care
Health
Mane
Parterships
Nursing
Homes
Specialists
ACO
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Primary Care & CCT Payment in ACOs:
So What Will Change?
• Despite PCMH, ACO pilots, FFS
remains most predominant
payment model for providers
• Relying on FFS payments continues
to emphasize volume & threatens
meaningful practice change
• Little meaningful change yet to
concept of “productivity”
*Payment Reform for Primary Care within ACOs,
A. Goroll & S. Schoenbaum, JAMA, Aug 2012
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Contact Info / Questions
Maine Quality Counts
• www.mainequalitycounts.org
Maine PCMH Pilot
• www.mainequalitycounts.org
(See “Programs”  PCMH)
 Lisa Letourneau MD, MPH
• [email protected], 207.415.4043
• [email protected], 207.266.7211
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