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Michigan’s Proposal CMS Multi-Payer Advanced Primary Care Practice Demonstration. Carol Callaghan Michigan Primary Care Consortium Annual Meeting October 22, 2010. CMS Demonstration Requirements:. Up to 6 States Budget neutrality over 3 years of project

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Michigan’s Proposal CMS Multi-Payer Advanced Primary Care Practice Demonstration

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Michigan’s Proposal CMS Multi-Payer Advanced Primary Care Practice Demonstration

Carol Callaghan

Michigan Primary Care Consortium Annual Meeting October 22, 2010

CMS Demonstration Requirements:

  • Up to 6 States

  • Budget neutrality over 3 years of project

  • Number of Medicare beneficiaries < 150,000 (More allowable if budget neutrality can be assured)

  • Total CMS funding < $10 PMPM

  • Common payment methodology

  • Payers must include

    • Medicaid

    • Private health plans

    • Self-insured employer-sponsored group health plans

Eligible Michigan Practices:

505 PCMH Designation for 2010 (PGIP)

- 28 UMHS practices excluded by overlap___ with UM CMS demo)

477 Eligible for participation*

* 17 of the above are also recognized by NCQA as Level 2/3 PCMH

Clinical Model:

Support for deeper practice transformation will take place through a collaborative network of PO’s and through shared learning facilitated by the Michigan Primary Care Transformation (MiPCT) Administration

Practice Participation Criteria

  • Part of a participating PGIP PO/PHO/IPA

  • Maintain their PCMH designation throughout the 3-year demonstration

  • Agree to work on four specific focus areas:

    • Care Management

    • Self-Management Support

    • Care Coordination

    • Linkage to Community Services

Participating Physician Organizations

  • All 32 Eligible PGIP POs/PHOs/IPAs signed Letters of Intent to participate

  • To participate in the Demo, POs must:

    • Assist practices to advance in all PCMH initiatives, especially the four areas of focus

    • Assist practices with care coordination and community linkages

    • Distribute incentive payments

    • Collect data and submit specified reports

Stakeholders in Application

Payers (public and private): 16

PO/PHO/IPA’s: 32

PCMH Practices: 477


Medicare: 358,000

Medicaid (non-dual): 248,000

Privately insured: 1,153,000

TOTAL Beneficiaries: 1,749,000

Proposed Funding Model

$0.26 PMPM Administrative Expenses

$3.00 PMPMCare Management Support

$1.50 PMPM Practice Transformation Reward

$3.00 PMPM Performance Improvement

$7.76 PMPM Total Payment by Payers*

* Medicare will pay additional $2.00 PMPM to cover additional services for the aging population

Proposed Funding ModelTotal Payments by Payers = $7.76 PMPM

1. Administrative Expenses ($0.26 PMPM)

  • State administration and management of the demo including contracting, reporting, monitoring, funds management, and central administrative hub

  • PO/PHO/practice support (e.g., Learning Collaboratives, other resources)

  • State-level evaluation of the demonstration

Proposed Funding ModelTotal Payments by Payers = $7.76 PMPM

2.Care Management Support ($3 PMPM or T-code equivalent)

  • Payments to practices for non-covered PCMH services, i.e., case mgmt, care coordination, self-mgmt support, community linkages)

  • Expressed as PMPM and administered via each payer’s methodology (e.g., T-codes, PMPM, CMS-specific codes to be identified)

Proposed Funding ModelTotal Payments by Payers = $7.76 PMPM

3.Reward for practice transformation and performance improvement ($4.50 PMPM)

  • 10% increase for E/M fees ($1.50 PMPM)

  • Payers pay practices a bonus for PCMH performance - ($3 PMPM - based on individual payer’s incentive model and distributed as variable PMPM amount)

Payment Delivery Mechanism*

A Central Administrative Hub will be created to collect and disseminate incentive payments from participating payers

  • Participating payers will pay incentive (and admin) payments to the Central Admin Hub

  • The Central Administrative Hub, working closely with MPAC, will distribute incentive payments to POs to share with practices as a PMPM payment, based on performance, quality and use

    * CMS requires a common payment method

Payment Method


  • Multi-payer protected central repository for data analysis and reporting

  • To be used by Medicare, Medicaid FFS, and BCBSM for patient attribution and incentive payment determination

  • Other commercial payers are also welcome to use the repository

Proposed Governance

Steering Committee

  • MDCH – 3

  • PO/PHO/IPA – 6 (elected)

  • Payers – 5 (elected)

  • Expert Consultants – 3 (appointed by MDCH)

    Advisory Committee

  • Other participating Payers

  • Other participating POs/PHOs/IPAs

  • Professional Medical Associations

  • Others

Participating Payers


  • Blue Care Network

  • Blue Cross Blue Shield of Michigan

  • Health Alliance Plan

  • HealthPlus of Michigan

  • McLaren Health Plan

  • Physicians Health Plan of Mid-Michigan

  • Priority Health


    Medicaid Fee For Service

Participating Payers (cont’)

Medicaid Managed Care Plans

  • CareSource

  • Great Lakes Health Plan

  • Health Plan of Michigan

  • HealthPlus Partners

  • McLaren Health Plan

  • Midwest Health Plan

  • Molina Healthcare

  • Physicians Health Plan of Mid-Michigan

  • Priority Health Gov’t Programs

  • Total Health Care

  • Upper Peninsula Health Plan

Planning Committee Members

  • Carol Callaghan, MPH (MI Dept of Community Health)

  • Ann Donnelly, RN, BSN (Genesys PHO)

  • Jean Malouin, MD, MPH (U of M Health System)

  • Susan Moran, MPH (Michigan Medicaid)

  • Paul Ponstein, DO (Lakeshore Health Network)

  • Kevin Taylor, MD (Huron Valley Physicians Association)

  • Trissa Torres, MD, MS (Genesys Health System)

  • Dana Watt, RN, MSN (MI Primary Care Consortium)

Writing Team Members

Caroline Blaum, MD, UMHS

Patrice Eller, CHRT

Jean Malouin, MD, MPH, UM Health Team

Margaret Mason, BCBSM

Tomi Ogundimu, CHRT

Robyn Rontal, BCBSM

Marianne Phillips-Udow, CHRT

Questions from CMS to Michigan

  • Budget Neutrality Assumptions

  • Beneficiary Assignment

  • Payment Methodology

  • Data Needed from CMS

  • Expectations re CMS’ Evaluation

If CMS does NOT select Michigan…Could we do this anyway, without Medicare?Would Michigan payers agree?Would support from employers be useful?Would legislative authority be useful? necessary?


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