The Michigan Primary Care Transformation (MiPCT) Project

Succeeding in 2014: What it Will Take

MiPCT Team-Based Care Recap

16

MiPCT Team-Based Care Evergreen” Themes•Care managers work in close proximity to PCP team

▫In PCP office as much as possible▫Work with PCP team to meet their needs▫Regular communication via huddles, medical meetings,

etc.•Ensure Care Management coverage

▫Focus on MiPCT patients (across participating payers)▫Manage high-complexity, high-cost patients▫Patients selected based on risk score plus PCP input

•Focus on evidence-based interventions▫Medication reconciliation▫Care transitions▫In-person contact with patients whenever possible▫Comprehensive care plan for complex patients

16

Success = Improvements in Population Health + Cost + Patient Experience

4

Reduction in Unnecessary and Non-Value-Added Costs

5

5

How do we make a dent in cost?

-Preventing unnecessary ED and inpatient visits by providing care upstream before a crisis - Making sure your patients know about your extended access and how to reach you after hours - Using resources more wisely

2014 Priorities•Target the Right Patients

▫ Combine data with clinical judgment

• Introduce palliative care opportunities when appropriate

•Diabetes Management

•Expanded Access▫Make sure patients know how to contact the practice’s

24/7 access

6

MiPCT: Beyond 2014…

7

Preparing for Sustainability

•Physician Organizations have made a significant investment in care management

•Working hard for payers to support the model financially

•We need your help!

8

CMS – Looking for Solutions(desperately)•Areas of promise – what we’re doing!•Good directional signs

▫CMS Quarterly Payment Proposal (for 2015)▫Commercial Payer Sustainability Statement▫Potential for Demo Extension

•Question on the table - Can primary care redefine care delivery?▫This is our best (last?) chance to provide the

answer▫If successful, can lead to new funding models

9

How can YOU help shape the future?

10

It’s Time to Put on Your Cape!

11

Thank You!