The Michigan Primary Care Transformation (MiPCT) Project

The Business Case for Care Management

Mary Ellen Benzik, MD Diane Marriott, DrPH

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What Does Sustainability Mean?•To the Practice: Maintaining and growing CM

staffing, processes and roles

•To the PO (and Practice) : Payment reform for CM

•To the State and Patients: Servicing all patients, all payers with effective, efficient services

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Sustainability Variables

• PRACTICE/POs: Success on key metrics; Funding to allow “margin to cover mission”; Change Management

• ENVIRONMENT: Demonstration Extension; Refinement of CMS G Code; Evolving health reform/landscape; “Accountable System” performance

• ROI/PAYER PARTICIPATION: Success on key metrics (by payer); Servicing members of all plans

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The Evolution of Care Management Payment

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Population-Based PMPM

Acuity-Adjusted PMPM

Activity-Based Care Managemen

t G/CPT Codes ?????

Systems Level

Payment

PBPM (For Engaged

Beneficiaries)

All-Payer Billing (Through August 2014)Most and Least Frequently Used Codes

Most Used G9002 98966

99495 99496 98967G9001 98968G9008 G9007

Least Used 99487 99489 98961S0257 98962

MiPCT Resources to Support PO and Practice Business Cases

• All-Payer Billing Collaborative ▫October 30 Morning Half Day In-Person Session

Focus on Care Managers, Billers, Coders, Office Staff Special Webinar for Physicians

▫Follow-up Team Webinars▫Three (3) Practice Learning Credits Granted▫To join, just email mipctdemo@michigan.gov with the subject line:

MiPCT BILLING COLLABORATIVE

• 2015 Revenue Projections to POs Across Payers

• All-Payer Resources on mipctdemo.org

MiPCT Resources to Support PO and Practice Business Cases, cont.

•Payer recruitment

•Policy support on federal and state initiatives

•MiPCT Demo mailbox queries

What Happens After 2016?

•Goal: Transition from demonstration to ongoing payment reform

•Sustaining and growing of the gains

The Work Starts Now……..

One System’s Approach-Mary Ellen Benzik, MD

MiPCT vs. Chronic Care Codes Alone ?

MIPCT Chronic Care Codes

Total revenue /month/ 1000 Medicare lives (PMPM,TOC, AWV) $ 16,888.73 $ 7,042.56

Total expense /month / 1000 Medicare lives $ 12,678 $ 4,554.98

REVENUE - EXPENSE = CONTRIBUTION MARGIN per year $ 50,524 $ 29,850.95

Calculating Revenue Opportunity

• Interactive excel spread sheet• System/practice specific characteristics are entered

into calculator tool • Applicable to Transition of Care (TOC), Annual

Wellness Visit (AWV), and Chronic Care Codes (CCC)• Factors in anticipated investment /expense to

capture revenue • Allows modeling of necessary practice activity to

budget targets

Demonstration of Excel Sheet