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 ?