michigan primary care transformation project
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WEBINAR #1:
FUNDING MODEL,CARE MANAGEMENT MODELS
ANDIMPLEMENTATION PLAN
NOVEMBER 3 , 2011
Michigan Primary Care Transformation Project
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Agenda
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 Amounts4
Payer Care Coordination Payment
Practice Transformation Payment
Performance Incentive Payment
Medicare $4.50 PMPM $2.00 PMPM $3.00 PMPM (variable)
Medicaid Managed Care
$3.00 PMPM $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
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Funding/Distribution by Payer
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
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Funding/Distribution by Payer
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
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Funding/Distribution by Payer
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
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Funding/Distribution by Payer
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
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Care Management Funding Sources
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
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BCBSM/BCN Care Coordination Payments
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
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MiPCT Funding Spreadsheets
Distributed to each PO/PHOContents
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
OVERVIEW OF ROLES, JOB DESCRIPTIONS, TRAINING
MiPCT Care Managers
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Role Comparison: Moderate Risk Care Manager, Complex Care Manager
Moderate Risk Care Manager (MCM)
Complex Care Manager (CCM)
Patient PopulationModerate 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 CaseloadCaseload 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
Proactive, population management. Work with patients to optimize control of chronic conditions and prevent/minimize long term complications.
Targeted interventions to avoid hospitalization, ER visits. Ensure standard of care, coordinate care across settings, help patients understand
options.
Duration of Care Management
Typically a series of 1 to 6 visitsFrequency of visits high at times, duration of
months
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Hybrid Care Manager Model
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
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Complex Care Manager Role
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
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Complex Care Manager Role cont.
Coordination of care Specialists, hospitals, community resources, etc.
Transitions of care
Assists with advance directives, palliative care, hospice and other end of life coordination
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Complex Care Manager Job Description
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
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Complex Care Manager Training
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
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Moderate Risk Care Manager Role
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
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Moderate Risk Care Manager Job Description
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
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Moderate Risk Care Manager Training
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
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Moderate Risk Care Manager Training: Who arranges/provides training?
MCM Training topic Shared by MiPCT and PO/PHO/IPA/practice
MiPCTteam
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 x
MiPCT training topics - required x
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Moderate Risk Care Manager TrainingGeneral Topics - sample
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
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Moderate Risk Care Manager Training
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
Transition of care, coordination of care, medication reconciliation, health literacy, cultural competency, advance directives * (MiPCT team and PO/PHO/IPA, practices - provide training)
Care management documentation
HOW MANY DO YOU NEED?
WHERE WILL YOU PUT THEM?
MiPCT Care Managers
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Care Management Priorities
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
needsEnsure 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
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Designing a Model for your PO/PHO
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 wayContact MIPCTDEMO.michigan.gov for free
consultation
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Contact Information: Care Management
Marie Beisel MSN, RN, CPHQUMHS Project Manager, Care Management Resource Center
e mail: mbeisel@umich.eduoffice phone: 734 998 8519
Jean Malouin MD, MPHMedical Director, Michigan Primary Care Transformation Project
e mail: jskratek@umich.eduOffice phone: 734 232 6222
OVERVIEWAND
GENERAL INSTRUCTIONS
Implementation PlanPart C
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Instructions for completing form
Work with participating practices to develop responses for each section on the form
Return completed form to Amanda First at afirst@umich.edu by December 1, 2011
Completed forms will be reviewed and feedback provided by December 15, 2011
POs/PHOs needing assistance should contact MiPCT at MIPCTDEMO@michigan.gov
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Section 1: Care Management Contacts/Staffing
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
practiceDescribe 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
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Section 2: Activities for MiPCT Functional Tiers
Describe current and planned activities for each of the MiPCT functional tiers: Navigating the medical neighborhood Care Transitions Care Management Complex Care Management
33Section 3: Care Coordination and Incentive Payments
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
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Questions ?
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