Transcript Document

Michigan Primary Care
Transformation Project
WEBINAR #1:
FUNDING MODEL,
CARE MANAGEMENT MODELS
AND
IMPLEMENTATION PLAN
NOVEMBER 3, 2011
Agenda
2
 MiPCT funding
 Payment amounts
 Timing of distribution
 BCBSM/BCN care coordination payments
 MiPCT Care Managers
 Overview of roles, job descriptions and training
 Staffing models for your PO/PHO
 Part C Implementation Plan
 Section 1: Care management contacts and staffing
 Section 2: Activities for MiPCT functional tiers
 Section 3: Care coordination and incentive payments
MiPCT Funding
Payment Amounts
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Payer
Care
Coordination
Payment
Practice
Transformation
Payment
Performance
Incentive
Payment
Medicare
$4.50 PMPM
$2.00 PMPM
$3.00 PMPM
(variable)
Medicaid Managed $3.00 PMPM
Care
$1.50 PMPM
$3.00 PMPM
(variable)
BCBSM
Encounter based
G-codes
10% E/M uplift
(not new money)
Existing PGIP
incentives (not
new money)
BCN
Encounter based
G-codes
$1.50 PMPM for
FFS contracts only
Difference
between $3.00
and current pool
Funding/Distribution by Payer
5
 Medicare

Care coordination payment ($4.50 PMPM)
Paid monthly
 Flows to PO/PHO
 First payment expected January 2012
 One month’s payment held for complex care manager training yr 1


Practice transformation payment ($2.00 PMPM)
Paid monthly
 Flows to practice
 First payment expected January 2012


Performance incentive payment ($3.00 PMPM average)
Paid semi-annually
 Flows to PO/PHO
 First payment expected July 2012

Funding/Distribution by Payer
6
 Medicaid

Care coordination payment ($3.00 PMPM)
Paid quarterly
 Flows to PO/PHO
 First payment expected March 2012
 One month’s payment held for complex care manager training year 1


Practice transformation payment ($1.50 PMPM)
Paid quarterly
 Flows to practice
 First payment expected March 2012


Performance incentive payment ($3.00 PMPM average)
Paid semi-annually
 Flows to PO/PHO
 First payment expected July 2012

Funding/Distribution by Payer
7
 BCBSM
 Care coordination payment (G-codes, CPT codes)
Encounter-based payments
 Flows to entity who files the claim
 First G-code payments expected April 2012
 First quarter’s payments will be paid PMPM in late Nov 2011


Practice transformation payment
Existing 10% E/M uplift
 No changes in amount/flow – NOT NEW MONEY


Performance incentive payment (Existing PGIP payment)
Paid semi-annually
 No changes in amount/flow – NOT NEW MONEY

Funding/Distribution by Payer
8
 BCN

Care coordination payment (G-codes, CPT codes)
Encounter-based payments
 Flows to entity who files the claim
 First G-code payments expected January 2012 (still TBD)


Practice transformation payment ($1.50 PMPM)
Paid monthly (tentative) ONLY TO FFS CONTRACTS
 Flows to practice
 First payment expected January 2012


Performance incentive payment ($1.20 PMPM average)
Paid semi-annually (tentative)
 $1.20 amount incremental to existing PRP/PAYG payments
 Flows to PO/PHO (tentative)
 First payment expected July 2012

Care Management Funding Sources
9
 Two sources of care management funding:
 PMPM payments – “guaranteed” funding
 G codes and CPT codes – payment for services provided
Depends on appropriate staffing
 Funding model based on $3 PMPM equivalent in payments
 How much activity is needed to equate to $3 PMPM??
 Assumptions:

• Hire one care manager for 2,500 patients
• Average G-code reimbursement is $60-$65 (fee schedule TDB)

Activity level:
• One full time care manager would need to bill 6-7 encounters per
work day (48 week year) to equate to $3 PMPM – very feasible
BCBSM/BCN Care Coordination Payments
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 G codes
 G9001: Coordinated care fee – initiation rate (all inclusive)
 G9002: Coordinated care fee – maintenance rate
 CPT codes
 98961: Group education (2-4 patients)
 98962: Group education (5-8 patients)
 98966: Telephone assessment/medical discussion (5-10 min)
 98967: Telephone assessment/medical discussion (11-20 min)
 98968: Telephone assessment/medical discussion (21+ min)
 More details to be provided on next webinar
MiPCT Funding Spreadsheets
11
 Distributed to each PO/PHO
 Contents
 Sheet 1: Information tab
 Sheet 2: PO/PHO funding summary
 Sheet 3: Funding detail by practice
Includes number of care managers funded by practice
 Moderate risk care managers
 Complex care managers
 Allows customization of care manager salary/benefits

MiPCT Care Managers
OVERVIEW OF ROLES, JOB DESCRIPTIONS,
TRAINING
Role Comparison: Moderate Risk Care Manager,
Complex Care Manager
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Moderate Risk Care Manager (MCM)
Complex Care Manager (CCM)
Patient Population
Moderate risk patients identified by registry, PCP referral
for proactive and population management.
High risk patients identified by PCP referral and input,
risk stratification, patient MiPCT list.
Patient Caseload
Caseload 500 (approx. 90 - 100 active patients); one
MCM per 5,000 patients.
Caseload 150 (approx. 30 - 50 active patients); one CCM
per 5,000 patients.
Focus of Care
Management
Duration of Care
Management
Proactive, population management. Work with patients to Targeted interventions to avoid hospitalization, ER visits.
optimize control of chronic conditions and
Ensure standard of care, coordinate care across settings,
prevent/minimize long term complications.
help patients understand options.
Typically a series of 1 to 6 visits
Frequency of visits high at times, duration of months
Hybrid Care Manager Model
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Definition of hybrid model: one individual who fills both Complex Care Manager
(CCM) and Moderate Risk Care Manager (MCM) role

Considered only for special circumstances
 practices with significantly fewer that 5,000 MiPCT attributed patients
 Practice that serve primarily pediatric patients and have fewer complex
patients

Individual filling both roles must complete the MCM and CCM training
requirements

Hybrid model will be evaluated during first year of intervention; continued if
successful
Complex Care Manager Role
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 Partners with practice leadership team to integrate care management into practice
 Completes comprehensive patient assessments – ex. functionality, depression

initial and periodically, over time
 Provides self management support

focus on building capacity of patient/family for self care
 Provides patient/family education

with teach back, sustain over time
 Implements evidence-based care, chronic disease protocols and guidelines
 intervene early during acute exacerbations
 analyze complex data sets
 monitor patient/family response
 Creates/maintains individualized plan of care
Complex Care Manager Role cont.
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 Coordination of care

Specialists, hospitals, community resources, etc.
 Transitions of care
 Assists with advance directives, palliative care, hospice and other end of life
coordination
Complex Care Manager Job Description
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Sample of key required qualifications*
 Current MI License: RN, MSW, NP, PA
 3 years experience
 adult medicine and pediatric patients (as applicable to practice)
 setting: home health agency, primary care practice, skilled nursing facility,
hospital medical-surgical unit
 Ability to manage complex chronic conditions
 utilize evidence-based guidelines
 critical thinking skills
 excellent assessment and triage skills
 ability to analyze complex data sets
 ability to implement evidence-based interventions and protocols for chronic
conditions
 Excellent communication and facilitation skills
*note:
see CCM job description for complete details
Complex Care Manager Training
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 MiPCT and Care Management Resource Center will provide training - required
standardized interventions and tools
 evidence based
 if practice currently has a complex care program in place, MiPCT team will
review
 MiPCT to partner with Geisinger for CCM training (potential)
 train the trainer model
 Self Management Support training – required
 More details on CCM training will be provided in the next webinar

Moderate Risk Care Manager Role
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 Partners with practice leadership team to integrate care management
 Assesses healthcare, educational, and psychosocial needs of patient/family
 Provides self management support
 focus is typically on lifestyle and behavior change
 Provides patient/family education
 with teach back
 Implements evidence-based care

chronic disease protocols and guidelines
 Assists with transitions between settings
 includes medication reconciliation
 Assists with advance directives
Moderate Risk Care Manager Job Description
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Sample of key required qualifications*
 Current MI License: RN, MSW, NP, PA, LPN, RD, Pharmacist
 2 years experience


adult medicine and pediatric patients (as applicable to practice)
setting: home health agency, primary care practice, skilled nursing facility,
hospital medical-surgical unit
 Knowledge of chronic conditions

evidence-based guidelines, prevention. . .
 Excellent assessment, triage skills
 Excellent communication and facilitation skills
*note: see MCM job description for complete details
Moderate Risk Care Manager Training
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 Core Curriculum: three areas of focus



Self Management Support training - required
General training topics - suggested
 Important for building MCM’s knowledge base and skills
 Topics may be refined based on individualized needs of the practice
MiPCT training – required
 MCM Training responsibility shared

MiPCT and Care Management Resource Center + POs/PHOs/IPAs, practices
Moderate Risk Care Manager Training: Who
arranges/provides training?
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MCM Training topic
Shared by
MiPCT and
PO/PHO/IPA/
practice
MiPCT
team
PO/PHO/
IPA,
Practice
Self management support training –
required, arranged by the PO/PHO/IPA,
practice
x
General, suggested topics
x
- subset of the general topics
MiPCT training topics - required
x
x
Moderate Risk Care Manager Training
General Topics - sample
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Chronic Care Model
Basic care management tools, concepts
PCMH overview
Developing competence in managing
chronic conditions (DM, Asthma, CAD,
HF, COPD, HTN, Depression)
Role of the Moderate Risk Care Manager
Transition of care, coordination of care,
medication reconciliation, health
literacy, cultural competency, advance
directives * (MiPCT team and
PO/PHO/IPA, practices - provide
training)
Identifying psychosocial issues and barriers
Criteria to identify/refer to CCM
Moderate Risk Care Manager Training
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MiPCT Topics - sample
Orientation to PCMH and MiPCT
G code billing
Participation in Michigan Care
Management Consortium
Measurement and reporting
Integration into PCMH designated
practices
Care management documentation
Transition of care, coordination of care,
medication reconciliation, health
literacy, cultural competency, advance
directives * (MiPCT team and
PO/PHO/IPA, practices - provide
training)
MiPCT Care Managers
HOW MANY DO YOU NEED?
WHERE WILL YOU PUT THEM?
Care Management Priorities
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 Care managers work in close proximity to PCP team
 In PCP office as much as possible
 When designing model, work with PCP team to meet their needs
 Ensure Complex Care Management coverage
 1:5000 for adult population
 1:2500 if using hybrid model
 Focus on evidence-based interventions
 Medication reconciliation
 Care transitions
 In-person contact with patients whenever possible
 Comprehensive care plan for complex patients
Designing a Model for your PO/PHO
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 Consider on-site care managers (CCM and MCM) for
sites with 5,000 or more beneficiaries
 Sites with 2,500-5,000 beneficiaries

Options (examples, other scenarios possible)
on-site CCM, “travel team” for moderate risk patients
 On-site MCM, CCM shared among 2-3 practices
 On-site “hybrid” care manager, plus non-licensed care coordinator

 Sites with < 2,500 beneficiaries

Both CCM and MCM roles shared among 2-3 sites
 Case studies and implementation guide on the way
 Contact MIPCTDEMO.michigan.gov for free consultation
Contact Information: Care Management
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Marie Beisel MSN, RN, CPHQ
UMHS Project Manager, Care Management Resource Center
e mail: [email protected]
office phone: 734 998 8519
Jean Malouin MD, MPH
Medical Director, Michigan Primary Care Transformation Project
e mail: [email protected]
Office phone: 734 232 6222
Implementation Plan
Part C
OVERVIEW
AND
GENERAL
INSTRUCTIONS
Instructions for completing form
30
 Work with participating practices to develop
responses for each section on the form
 Return completed form to Amanda First at
[email protected] by December 1, 2011
 Completed forms will be reviewed and feedback
provided by December 15, 2011
 POs/PHOs needing assistance should contact MiPCT
at [email protected]
Section 1: Care Management Contacts/Staffing
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 Identify lead MiPCT care management contact for
each practice
 Care management staffing


Describe how care management will be staffed for each
participating practice
Describe tools/processes to integrate care managers into
practice
 Describe plans for training care managers
 Complex care managers (MiPCT program)
 Hybrid care managers (use MiPCT complex care training)
 Moderate risk care managers (menu of options)
 Specify if consultation desired
Section 2: Activities for MiPCT Functional Tiers
32
 Describe current and planned activities for each of
the MiPCT functional tiers:




Navigating the medical neighborhood
Care Transitions
Care Management
Complex Care Management
Section 3: Care Coordination and Incentive
Payments
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 Describe how care coordination funding will be
distributed between PO/PHO and practice
 Describe how incentive payments will be distributed
between the PO/PHO and practice (Information
required by CMS)


Percentage of incentive payments to be retained by PO/PHO
Services provided by PO/PHO
Questions ?
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