Innovation Grant:CMMI

Comprehensive Primary Care Initiative (CPCi)

presented toHFMA Southwestern Ohio Chapter

Will GronemanExecutive Vice President System DevelopmentTriHealth

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Comprehensive Primary Care Initiative (CPCi)

What is it?

4-year pilot program from CMS Innovation Center – CMMI

Authorized under the Accountable Care Act

Funding for 330,750 Medicare and Medicaid beneficiaries

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Comprehensive Primary Care Initiative (CPCi)

What is it?

4-year pilot program from CMS Innovation Center – CMMI

Authorized under the Accountable Care Act

Funding for 330,750 Medicare and Medicaid beneficiaries

Designed to accomplish the “triple aim” at the community level

Aligns multiple payers in a community around common goals

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Comprehensive Primary Care Initiative (CPCi)

What is it?

4-year pilot program from CMS Innovation Center – CMMI

Authorized under the Accountable Care Act

Funding for 330,750 Medicare and Medicaid beneficiaries

Designed to accomplish the “triple aim” at the community level

Aligns multiple payers in a community around common goals

Aimed at Primary Care Physicians

Builds on the “Medical Home” concept

Holds PCP practices accountable for the total cost of care

Solicitation issued in late September 2011

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Comprehensive Primary Care Initiative (CPCi)

CMS’ Framework for Comprehensive Primary Care

Risk stratified care management

Access and continuity

Planned care for chronic conditions and preventive care

Patient and caregiver engagement

Coordination of care across the medical neighborhood

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Four Basic Steps in the Process

1. Select communities to participate Number of commercial plans willing to participate

Support of state Medicaid

Community infrastructure and history of collaboration

Seven Communities were selected Arkansas Colorado New Jersey Oregon New York Capital District-Hudson Valley Region Greater Tulsa Region Cincinnati-Dayton-Northern Kentucky Region

Community selection completed April 2012

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Four Basic Steps in the Process

1. Select Communities to participate (April 2012)

2. Align payers who are willing to commit to: Payment above normal Fee-for-Service (e.g. pmpm)

CMS pmt will be risk adjusted and will average $20 pmpm

Provide gainsharing opportunities in years 2-3-4

Common set of metrics for cost, quality, service Using 18 of the 33 ACO measures as a starting point

Providing aggregate member level cost/utilization data

Signing a Letter of Intent with CMS

Cincinnati had 10 payers commit to participate Includes Aetna, Anthem, Humana, Medicaid, MMO, United

Payers signed non-binding LOIs in June 2012

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Four Basic Steps in the Process

1. Select Communities to participate

2. Align payers

3. Select PCP Practice Locations Practice = physical office location 75 practices per market to be selected Screening Criteria:

150 FFS Medicare patients Physicians have attested to Meaningful Use

Qualitative Criteria: >60% of patients are covered by participating payer Demonstration of readiness to transform

PCMH Recognized

Commitment to transformational activities

Practices to be selected August 2012

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Year 1 Commitments Required by CMS

Complete an annual budget

Implement risk stratification methodology for all patients

Attest to 24/7 patient access to a nurse or practitioner with access to the patient’s EHR

Establish baseline for patient satisfaction using CG-CAHPs

Demonstrate care coordination for the medical neighborhood and c omply with at least one of the following: Notification of ED visit in a timely fashion Med reconciliation completed with 72 hours of hospital discharge Exchange of clinical information at the time of admission and at discharge Exchange of clinical information between PCP-specialists

Participate in quarterly market based learning collaborative

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Four Basic Steps in the Process

1. Select Communities to participate

2. Align payers

3. Select PCP Practice Locations

4. “Negotiate” with practices and start program

No negotiations with CMS

Expect limited negotiation with plans Will need to conform with their LOI commitments Will plans cover TriHealth PCMH sites not selected? Not clear if “ASO” employers will participate

Go-live November 1, 2012 13 months from solicitation to go-live

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CPCi v. Accountable Care Organization

Focus is on Patient Centered Medical Home (PCMH) as the foundation for managing care ACO not as prescriptive as to care management strategy

Provides new funding for infrastructure Focused on adult PCP sites For systems: only funds part of the PCP base For independents: provides funding to sustain independence

Requires participating competitors to cooperate in sharing best practices Goal is to demonstrate impact at the community level Monthly meetings of practices

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CPCi v. Accountable Care Organization

Requires commercial plans/Medicaid support Must provide additional pmpm funding Patient attribution updated quarterly Must commit to a common “menu” of cost/quality measures to be

used for gainsharing program Must provide monthly claims/utilization data

Still defining level of detail

Monthly multi-stakeholder meetings ASO customers must agree to participate

Does not require gainsharing/full risk on day 1 Year 1 used to build capabilities and establish data baselines Gainsharing in years 2-3-4 still undefined

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CPCi Challenges

Attribution requires 24 months of claims experience What happens when a commercial enrollee switches plans

Many “Key Success Factors” still undefined Attribution methodology Cost/utilization data specificity Gainsharing methodology Severity adjustment methodology

CMS’ agenda does not always support community existing initiatives Public Reporting through the Health Collaborative

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CPCi Challenges

Self Insured Employers must agree to participate ASO provider cannot commit without their consent

Threats to health system goal of creating a system brand for their PCP network

TH has 34 PCP practice locations 30 NCQA Recognized Level 3 PCMH sites 19 Sites have been selected by CMS to participate Funding only applies to 19 sites How to fund remaining 15 sites? Can we get performance data for non CPCi sites even if we are

not part of a payer’s P4P program?

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CPCi Challenges

Common community agenda still a challenge 19 Common Quality/Measures Selected

CMS priorities Medicare Advantage “star” program measures Medicaid plans’ payment incentives Commercial payers’ national quality/cost agendas

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Questions?