Getting Ready for the Maryland Primary Care Program May 17, 2018 Maryland Health Care Commission
Agenda • Overview • Care Delivery Redesign • Payment Redesign • Supports for Practices • Eligibility and Restrictions • Timeline 2
Overview Total Cost of Care Model Improving health, enhancing patient experience, and reducing per capita costs . 2029 2017 Maryland Primary HSCRC Models HSCRC Care Redesign All Payer – 2014-18 Care Program Programs Total Cost of Care – 2019-29 2019-2026 2017 - TBD 2014 - 2029 Improve efficiency of care in hospital Increase preventive care to lower the Total Cost of Care Reduce unnecessary readmissions/ Increase communication between Decrease avoidable utilization hospital and community providers hospitalizations Decrease unnecessary ED Reduce hospital-based Increase complex care coordination for visits infections high and rising risk Increase care coordination Increase appropriate care Reduce unnecessary lab tests Increase community outside of hospital supports
Overview Population Health Transformation Advanced Primary Care Practice Reduce PAU + Lower TCOC Care Transformation Organization Improved Health Outcomes + A System of Coordinated Care State And Community Population Health Policy and Programs 4
Overview How is MDPCP Different from CPC+? CPC+ MDPCP Integration with other State Independent model Component of MD TCOC Model efforts No limit – practices must meet program Enrollment Limit Cap of 5,000 practices nationally qualifications Enrollment Period One-time application period for 5-year program Annual application period starting in 2018 Track 1 v Track 2 Designated upon program entry Migration to track 2 by end of Year 3 Supports to transform Payment redesign Payment redesign and CTOs primary care Payers 61 payers are partnering with CMS including BCBS Medicare FFS, Duals, (Other payers plans; Commercial payers including Aetna and encouraged for future years) UHC; FFS Medicaid, Medicaid MCOs such as Amerigroup and Molina; and Medicare Advantage Plans 5
Care Delivery Redesign Requirements: Primary Care Functions Two tracks encompassing five primary care functions: 5. Planned Care for Health 1. Access & Continuity Outcomes 2. Care Management 4. Patient & Caregiver Experience 3. Comprehensiveness & Coordination 6
Care Delivery Redesign 1. Access and Continuity Track One • Empanel patients to care teams • 24/7 patient access Track Two (all of the above, plus) • Alternatives to traditional office visits 7
Care Delivery Redesign 2. Care Management Track One • Integrate care manager into operations • Risk stratify patient population • Short-and long-term care management • Follow-up on patient hospitalizations Track Two (all of the above, plus) • Care plans & medication management for high risk chronic disease patients 8
Care Delivery Redesign 3. Comprehensiveness and Coordination Track One • Coordinate referrals with high volume/cost specialists serving population • Behavioral health integration Track Two (all of the above, plus) • Facilitate access to community resources and supports for social needs 9
Care Delivery Redesign 4. Patient and Caregiver Engagement Track One • Convene Patient Family Advisory Council (PFAC) and integrate recommendations into care, as appropriate Track Two (all of the above, plus) • Advance care planning 10
Care Delivery Redesign 5. Planned Care for Health Outcomes Track One & Two • Continuously improve performance on key outcomes 11
Care Delivery Redesign Quality Metrics electronic Clinical Quality Measures (eCQM) (75%) • Group 1: Outcome Measures (2) – Report both outcome measures • Group 2: Other Measures (7) – Report at least 7 of 17 process Measures • Measures overlap closely with MSSP ACO measures Patient Satisfaction (25%) • Consumer Assessment of Healthcare Providers and Systems (CAHPS) • CMS will survey a representative population of each practice’s patients, including non - Medicare FFS patients Current metrics as of 2018 – TBD for 2019 12
Care Delivery Redesign Quality - eCQM Metrics – Group 1 Report both outcome measures CMS ID# Measure Title CMS165v6 Controlling High Blood Pressure CMS122v6 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) Current metrics as of 2018 – TBD for 2019 13
Care Delivery Redesign Quality - eCQM Metrics – Group 2 Report at least 7 Other process Measures: Measure Type CMS ID# Measure Title CMS125v6 Breast Cancer Screening Cancer CMS130v6 Colorectal Cancer Screening CMS124v6 Cervical Cancer Screening CMS131v6* Diabetes: Eye Exam Diabetes CMS134v6 Diabetes: Medical Attention for Nephropathy Care Coordination CMS50v6 Closing the Referral Loop: Receipt of Specialist Report Medication Management CMS156v6 Use of High Risk Medications in the Elderly CMS2v7 Preventive Care and Screening: Screening for Depression and Follow- Up Plan Mental Illness/Behavioral CMS160v6 Depression Utilization of the PHQ-9 Tool Health CMS149v6 Dementia: Cognitive Assessment CMS138v6 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention Substance Abuse CMS137v6 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Safety CMS139v6 Falls: Screening for Future Fall Risk CMS147v7 Preventive Care and Screening: Influenza Immunization Infectious Disease CMS127v6 Pneumococcal Vaccination Status for Older Adults CMS164v6 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet Cardiovascular Disease CMS347v1 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease 14
Care Delivery Redesign Utilization Metrics ED Visits • Emergency department utilization (EDU) per 1,000 attributed beneficiaries Hospitalizations • Inpatient hospitalization utilization (IHU) per 1,000 attributed beneficiaries Utilization measures require no reporting on the part of practices Calculated by CMS and its contractor at the end of each program year 15
Payment Redesign Payment Incentives for Better Primary Care Practices – Track 1 Care Management Fee (PBPM) Performance-Based Incentive Underlying Payment Payment (PBPM) Structure • $15 average payment • Up to a $2.50 PBPM • Standard FFS • $6-$50 PBPM payment opportunity • Timing: Regular Tiered payments based on • Must meet quality and Medicare FFS claims acuity/risk tier of patients in utilization metrics to keep payment practice including $50 to support patients with complex needs incentive payment • Timing: Paid prospectively on a • Timing: Paid prospectively quarterly basis, not subject to on an annual basis, subject repayment to repayment if measures are not met AAPM Status under MACRA Law to be determined – potential for additional bonuses 16
Payment Redesign Payment Incentives for Better Primary Care Practices – Track 2 Care Management Fee (PBPM) Performance-Based Underlying Payment Structure Incentive Payment (PBPM) • $28 average payment • “Comprehensive Primary Care Payment” (CPCP) • Up to a $4.00 PBPM payment • $9-$100 PBPM opportunity • Partial pre-payment of historical Tiered payments based on • Must meet quality and E&M volume acuity/risk tier of patients in practice including $100 to support utilization metrics to keep • 10% bonus on CPCP percentage patients with complex needs incentive payment selected • Timing : Paid prospectively on a • Timing: Paid prospectively on • Timing: CPCP paid prospectively quarterly basis, not subject to repayment an annual basis, subject to on a quarterly basis, Medicare FFS repayment claim submitted normally but paid at reduced rate AAPM Status under MACRA Law to be determined – potential for additional bonuses 17
Supports for Practices Care Transformation Organization Designed to assist the practice in meeting care transformation requirements Services Provided to Practice: Provision of Services By: Care Coordination Services Care Managers Support for Care Transitions Pharmacists CTO Data Analytics and Informatics LCSWs Standardized Screening Community Health Workers Practice Practice Transformation TA 18
Supports for Practices Payment Incentives for Better Primary Care CTOs Care Management Fee (PBPM) Performance-Based Incentive Payment (PBPM) Receives a parallel payment for Track 1 Up to 50% of a practice’s care and Track 2 practices engaged with management fee; depends on option CTO chosen by practice Timing: Paid prospectively on an annual Timing: Paid prospectively on a basis; CTO will be required to repay quarterly basis funds if they do not meet annual performance thresholds 19
Supports for Practices Support You Can Expect Information Technology ● CRISP CMMI Practice Portal CMMI Learning System Vendors – educate practices on how to transform ● Additional State supports on practice transformation ● 20
Supports for Practices MDPCP Data Tools CRISP Portal CMMI CMMI Quality Practice’s CRISP Social Claims Practice Learning Reporting EHRs Services Needs Reports Portal Site Solution 21
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