Systems of Care Access to high quality primary care Healthy Environments Improved Social Determinants Healthy Lifestyle
Better Care Better Health Lower Costs
Figure B*. Simplified Driver Diagram
Figure B*. Simplified Driver Diagram
PAYMENT MODEL
Better Care through Delivery System Change
Primary Care Improvements
Michigan Primary Care Transformation Program
The Michigan Primary Care Transformation program is a three-year multi-payer project aimed at improving health in the state, making care more affordable, and strengthening the patient-care team relationship. The program grew out of the Patient Centered Medical Home initiative led by Blue Cross Blue Shield of Michigan, and is now the largest Patient Centered Medical Home demonstration project in the country.
Assistance and support for practice transformation takes place through a collaborative network of physician/physician hospital organizations and shared learning opportunities facilitated by the Michigan Primary Care Practice Transformation program administrative staff and the Care Management Resource Center, based at the University of Michigan. The Michigan Department of Community Health provides oversight and leadership for this program.
The Michigan Primary Care Transformation program model requires primary care practices to be affiliated with provider organizations to become designated as Patient Centered Medical Homes. The model requires designation through Blue Cross Blue Shield of Michigan or the National Committee for Quality Assurance (level 2/3). See appendix 2.4 for a crosswalk of the Blue Cross Blue Shield of Michigan and National Committee for Quality Assurance’s designation criteria. A recent peer-reviewed article validates the Blue Cross Blue Shield of Michigan designation criteria,126 and additional research demonstrates that this Patient Centered Medical Home model contributes to improved health outcomes and cost savings. 127
This model emphasizes population management through practice infrastructure investment and coordinated care, as described in greater detail in chapter E. Focus areas for transformation under the demonstration include care management, self-management support, care coordination and linkages to community services. The project is working toward a common incentive model across health plans, and provides clinical models, resources and supports aimed at avoiding emergency department and inpatient use for ambulatory care sensitive conditions, reducing fragmentation of care among providers, and involving the patient in decision-making.
The Michigan Primary Care Transformation program has made substantial progress in developing and implementing the necessary support infrastructure and services for primary care practices and provider organizations:128
As of October 2013, 362 Michigan Patient Centered Medical Homes were participating in the multi-payer demonstration, covering 1,175,288 beneficiaries, 1,844 providers, and 35 physician organizations
Five payers participate in the multi-payer project: Blue Cross Blue Shield of Michigan (461,577 beneficiaries, 39%) Blue Care Network (224,629, 19%), Medicare (197,554, 17%), Medicaid (185,499, 16%), and Priority Health (106,029, 9%)
Four hundred and twenty-four Care Managers and Complex Care Managers have been hired, trained, and embedded in primary care medical home practice teams
Three-hundred-sixty-two (362) practices have electronic health records in place with demonstrated all-patient electronic registry functionality to manage population health Nearly all practices have a clinical decision-maker available 24 hours / 7 days per week
Two-hundred-eighty-four (284) practices receive daily electronic notifications of patient hospital admissions, discharges, and transfers – and all utilize Care Managers to provide transition care Project leadership has created a compendium of best practices in the following areas: advanced care planning, palliative care, and utilizing the recommendations of the American Board of Internal Medicine’s ‘Choosing Wisely’ campaign that are spread through learning collaboratives, meetings, and webinars
The Michigan Data Collaborative has been established at the University of Michigan to accept and standardize claims/encounters and eligibility history data for all participating beneficiaries Data are utilized to disseminate and monitor key quality, utilization, and standardized cost information
Michigan Primary Care Transformation coverage is depicted in Figure B.11 below, which shows that Patient Centered Medical Homes participating in the demonstration are spread across the state, but do not cover all populations equally. There are many areas in which populations do not have ready access to a Patient Centered Medical Home. However, Blue Cross Blue Shield of Michigan – a key participant in Michigan’s multi-payer demonstration program – continues to expand its Patient Centered Medical Home program. To date, Blue Cross Blue Shield of Michigan has designated 1,240 Patient Centered Medical Home practices according to its validated designation criteria that it has developed internally.
Michigan Quality Improvement Network
The Michigan Quality Improvement Network utilizes quality improvement and system redesign methodology to improve community health centers’ performance outcomes in quality of care delivery, patient experience, and cost containment. The Network utilizes the Michigan Primary Care Association’s data repository to aggregate practice management, electronic health record, registry, and other data, which are translated into meaningful information that can be used by providers and quality improvement staff to drive improvements in the health centers. Several of the Michigan Primary Care Association’s 35
members are working on the National Committee for Quality Assurance’s Medical Home designation.129 In addition, Michigan’s Federally Qualified Health Centers participating in the Quality Improvement Network are utilizing electronic health record systems.130
Support for Patient Centered Medical Homes
In addition to Blue Cross Blue Shield of Michigan’s support for Patient Centered Medical Homes, other payers also support practice transformation. For instance, Priority Health has supported Patient Centered Medical Home development for 15 years. It recognizes the National Committee for Quality Assurance accreditation, and also participates in the Michigan Primary Care Transformation program.
Systems of Care
A system of care, or an organized delivery system, is a network of organizations that provides or arranges to provide a coordinated continuum of services to a defined population and is willing to be held clinically and fiscally accountable for the outcomes and health status of the population served.131
In recent years, significant hospital and health system consolidation has occurred both nationally132 and within Michigan.133 Although consolidation of hospitals and ambulatory practices is occurring, Michigan health care is not currently dominated by large health systems. Michigan has 134 community hospitals – facilities that provide both inpatient and outpatient care and operate an emergency department – of which, 35 are critical access hospitals, 14 are public hospitals, 47 are teaching hospitals, and 18 are long-term acute care hospitals. The most recently available data indicates that of the estimated 3,500 primary care practices in the state as of 2005, about 85% were solo or small practices with one to three physicians, and 15% were larger group practices with four or more physicians.134 There is some evidence that physician consolidation has also been increasing since then.135
Physician Organizations
The predominance of independent practices in Michigan is one reason that Blue Cross Blue Shield of Michigan requires physician organization participation for providers who want to participate in its Physician Group Incentive Program. This program includes 40 physician organizations representing 15,500 primary care and specialty physicians. Blue Cross Blue Shield of Michigan encourages physician organizations to work on initiatives that may include: practice transformation, standardization of treatment for specific conditions, implementing processes to track needed services and follow-up, or accelerating the adoption of health information technology. As depicted in figure B.12, physician
organizations cover most of the state. In a 2011
survey, physician organizations participating in the Michigan Primary Care Transformation program reported providing the following functions:
Administrative support o Contracting o Reporting o Credentialing Training Quality improvement Utilization management Data management
Information technology implementation & support o Registry
o Electronic prescribing o Electronic health records o Health information exchange
As part of the Michigan Primary Care Transformation program, physician organizations are hiring Care Managers and embedding them in Patient Centered Medical Homes. Physician organizations are also creating relationships with specialists.
Organized Systems of Care
Blue Cross Blue Shield of Michigan is working with physician organizations and hospitals across the state to develop Organized Systems of Care. Similar to an Accountable Care Organization, an Organized System of Care is a community of caregivers that is responsible for a specific patient population, which Blue Cross Blue Shield of Michigan is developing. The Organized Systems of Care are responsible for the care and treatment provided to a patient population attributed to the community's primary care physicians. They are expanding Blue Cross Blue Shield of Michigan’s Patient Centered Medical Home model to include hospitals, specialists, and other providers within the community of caregivers.
Accountable Care Organizations
Accountable Care Organizations are groups of doctors, hospitals, and other health care providers who come together in a formal arrangement to give coordinated high quality care to the patients they serve and share accountability for outcomes.
The Centers for Medicare and Medicaid Services established the Medicare Shared Savings Programto facilitate coordination and cooperation among providers to improve the quality of care for Medicare fee- for-service beneficiaries and reduce unnecessary costs. Michigan has seven Accountable Care
Organizations participating in the Medicare Shared Savings Program including: Accountable Healthcare Alliance, Oakwood Accountable Care Organization, Partners in Care, Physician Organization of
Michigan, ProMedica Physician Group Inc., Southeast Michigan Accountable Care Inc., and the University of Michigan Health System.
The Pioneer Accountable Care Organization model is designed for health care organizations and
providers that are already experienced in coordinating care for patients across care settings. It allows these provider groups to move more rapidly from a shared savings payment model to a population-based
payment model on a track consistent with, but separate from, the Medicare Shared Savings Program. Two Pioneer Accountable Care Organizations cover urban populations in Genesee County and Detroit.
Genesys Physician Hospital Organization includes the Genesys Health System, 160 primary care physicians, and 400 specialist physicians. Michigan Pioneer Accountable Care Organization is a partnership of the Detroit Medical Center and its physicians, serving 13,000 Medicare beneficiaries. Michigan Surgical Quality Collaborative
The Michigan Surgical Quality Collaborative was founded in 2005 with support from Blue Cross Blue Shield of Michigan and Blue Care Network to organize systems of care around surgical services, and has 52 member hospitals. Each member hospital collects and reports surgical outcomes data to a data
coordinating center at the University of Michigan. Hospitals and surgeons receive quality reports and participate in quality improvement meetings. To date, collected data has been analyzed to identify best practices. Additional uses currently being tested include an application to provide personalized surgical risk assessment for decision-making, and identify patients who would benefit from pre-operative health improvement services.
Care Coordination
Care coordination is defined as the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.136
It is particularly important for those with complex social or medical needs, such as those with behavioral health care needs, those with comorbid chronic conditions, and the frail elderly.137 Moderate and complex care management is a central feature of the Michigan Primary Care Transformation program.
Until recently, care coordination was an uncompensated activity in fee-for-service payment systems, and therefore was an activity performed by managed care organizations or available to certain populations only. For example, Medicaid mental health and developmental disability services are required to be coordinated with other community agencies (including Medicaid health plans, family courts, local health departments, MiChoice waiver providers, school-based services providers, and the county Department of Human Services). They are provided according to an individual, person-centered written plan of service. Similarly, the MiChoice Home and Community Based Waiver program provides supports coordination; a service designed to inform, assist, and coordinate a variety of home care and other community-based services needed by elderly and other adults with disabilities aged 18 years and older who meet nursing facility levels of care criteria and who are enrolled in MiChoice.
There are many efforts to improve transition care when a person moves from one care setting to another, such as from hospital to home. In order to improve care and reduce costs, the Michigan State Action on Avoidable Rehospitalizations project, which concluded in June, aimed to reduce the number of patients who experience unplanned, related readmissions within 30 days of discharge, and to increase patient and family satisfaction with transitions and coordination of care. The project is transitioning to a statewide collaborative. The Michigan Health and Hospital Association’s Keystone Center has convened the Michigan Care Transitions Coordinating Team, a group of key stakeholders tasked with providing strategic direction for care transitions work in the state.
Individuals dually eligible for Medicare and Medicaid are a particularly vulnerable population, for whom the health care delivery system has been largely uncoordinated. Michigan was selected as one of fifteen states to design new approaches to better coordinate care for individuals who are dually eligible for Medicare and Medicaid. In the demonstration, services and supports for persons who are dually eligible will be delivered by newly created Integrated Care Organizations and currently existing Prepaid Inpatient Health Plans. Integrated Care Organizations will be responsible for the provision of all physical health, long term care, and pharmacy services, while Prepaid Inpatient Health Plans will be expected to cover behavioral health and habilitative services for people with developmental disabilities, mental illness, or substance abuse issues. The Integrated Care Team will be connected through the Care Bridge, a care coordination model developed to integrate long term care, physical and behavioral health care services and establish communication linkages. The Care Bridge includes an electronic platform that supports individualized patient-centered care plans. The Integrated Care Team works collaboratively with the person to ensure the care plan is carried out according to the person’s preferences.
In addition, Michigan is developing a pilot Medicaid Health Homes under the Affordable Care Act Section 2703 designation to provide “a comprehensive system of care coordination”138
for beneficiaries with a serious and persistent mental health condition who also have co-occurring chronic medical conditions and high rates of hospital and emergency department utilization.139 The program will focus on integrating behavioral health, medical care, and care coordination services for this population.
The Pathways Community Hub model – operating in three Michigan cities – has received a Healthcare Innovation Award from the Center for Medicare and Medicaid Innovation to integrate between health care settings and community services. The Michigan Pathways to Better Health project connects at risk individuals to community health workers who work with the Hub’s registered nurse and clinical social workerto coordinate access to health care and social services. These at-risk individuals have multiple chronic conditions and complex social and medical needs. The Pathways Community Hub is described in more detail in appendix 2.1.