Multipayer CPC+ Updates!

Try Them Out!  Michigan’s High-Performing Practice Action Tools

The Care Interventions Subcommittee, chaired by Dr. Jerome Finkel, has produced a paper summarizing the results of their study of the CPC+ practices in Michigan with top twentieth-percentile performance on ED and inpatient utilization, as well as systems recognized as national leaders in primary care transformation.  Six behaviors were found to be common characteristics of all the high-performing practices.  The Subcommittee developed Action Tools as resources to assist CPC+ practices in bringing each of the high-performing characteristics to life in all CPC+ practices in our state.  This month, we are rolling out Action Tools for the first three high-performing practice characteristics:    

  1. Physician engagement drives patient and practice team engagement and promotes a practice culture that embraces adapting innovations to improve care regardless of setting (large or small practice; part of a health system or independent). Download action tool here.
  1. Co-located, engaged teams with care management at the core are key. The size of the team does not matter but co-location does.  Download action tool here.
  1. Offloading routine tasks (e.g., medication refills, gap closures) from the PCP workstream frees physicians to focus on patient needs and championing team-based care.  Download action tool here.

Here are some ideas for putting the Action Tools  to use in your practice:

  • Introduce one per week in your staff meetings and discuss it as a team.  How could the Action Tool improve patient care?  Is there a tweak you can make to your existing processes and policies that might improve performance? 
  • Use the MDC Dashboard to look at your level of ED visit and acute admissions utilization at the practice level and the PO level.   These can be found in the dashboard under the “Comparisons MO (Managing Organization)” and “Comparisons Practice” tabs.  How does your ED and inpatient utilization compare to other CPC+ Michigan practices?   Think about how the Action Tool might assist in improving your performance compared to your peers.
  • Ask for a volunteer or assign one team member to compare the suggestions in each Action Tool to existing processes and policies at your practice and report back to the team on their findings and recommendations.
  • Let us know if the Action Tool(s) were helpful to you, or if you have suggestions to share with other practices.  We are happy to include your ideas in the February edition of the NewsBriefing. 

Next month, we will be releasing the Action Tools for the last three characteristics of the High-Performing Practice series.  

2021 Social Determinants of Health (SDoH) Commercial Payer Incentive Program Update

The CPC+ commercial payers (Priority and BCBSM) understand that social determinants of health (SDoH) needs are an important to understand and work to address to allow for optimal patient care and health status.  Both payers have offered incentive programs in 2021 to support the collection and utilization of SDoH information.  We thank the POs, practices and providers in CPC+ who have been working with us over the last year and generously providing their time on this important topic.  This work will continue over the coming year. 

  • Priority Health: Practices with PCMH designation will be eligible for a PMPM incentive providing that they:  1) attest to the use of a recognized screening tool and identify the tool used; and 2) screen members and submit one or more z-codes for a minimum of 5% of the Medicare Advantage and Medicaid Priority patients serviced by the practice.
  •  BCBSM:  The incentive is in development and will be announced when finalized.

We are working in partnership with the plans, CMS, community-based organization SDoH platforms, MiHIN and other state stakeholders the longer-term strategy and are appreciative of your thoughts and guidance as we pursue the next steps together on SDoH.

Primary Care First (PCF) 2021 Practices and PCF in 2022

The Primary Care First (PCF) multipayer CMS demonstration began on 1/1/21 for accepted non-CPC+ practices in 26 regions including Michigan.  In our state, there are 52 practices who have been accepted by CMS for 2021.  CMS and Humana are the participating PCF 2021 payers. The listing of 2021 Michigan PCF participating practices, payers and partners is now available here.

Existing CPC+ Tracks 1 and 2 practices will have an opportunity to apply for the second round of Primary Care First which will begin in January 2022.  CMS anticipates 2022 PCF practice applications being available in spring of 2021.  This is a tentative date and as we learn more, we will share it in upcoming updates.

Behavioral Health, Patient Engagement, and Telemedicine Resources for CPC+ Practices

The following free, accessible resources may be of interest to you as they are topics that you have let us know are important to you.  If there are additional resources or topic areas that you would like us to explore, please email or and we would be happy to research them for you.

Enhancing patient engagement during virtual care: A conceptual model and rapid implementation at an academic medical center

This piece provides lessons for enhancing patient engagement in virtual visits and is from a national leader in primary care, Stanford:

Enhancing patient engagement during virtual care: A conceptual model and rapid implementation at an academic medical center

MiHIN Offers “The Download” Series for Health Data Fans

For data analysts and other team members in your practice or PO who are interested in learning the latest news about health information exchange in Michigan, MiHIN, has a monthly feature called “The Download” that can join online each month where they feature new information about use cases and data-sharing tools.  You can learn more about the sessions and download material from earlier months at MiHIN Monthly Download Sessions.  

Michigan Data Collaborative CPC+ Dashboard  

CPC+ Dashboard Schedule Update

The Michigan Data Collaborative (MDC) released the release 3.0 of the CPC+ Dashboard on December 28th!   This newest release contains integration of Priority Health data and a new Measure Trends tab.

Two reporting periods are included in Release 3.0.

  • April 2019 – March 2020 reporting period will include Medicare Fee-for-Service (FFS) and Blue Cross Blue Shield data
  • July 2019 – June 2020 will include data from all three payers, BCBSM, CMS Medicare, and Priority Health

A major enhancement to be included in the Dashboards this year is the inclusion of risk-adjusted expenditure measures.

If you would like access and have not yet completed the Data Use Agreement(DUA) or the User Account Request to allow access to the CPC+ Dashboards for your organization, please contact the Michigan Data Collaborative and we will work with you to complete.

Additional information, such as an Online Tutorial, Release Announcements, Release Notes, User Guide, and CPC+ Measures Technical Guide can all be found on both the CPC+ Support page of the MDC Website and the User Guide & Technical Guide tabs of the Dashboard itself.

If you have any questions or suggestions regarding the dashboard, please contact MDC at

If you have any questions or suggestions regarding the dashboard, please contact MDC at

Michigan Institute for Care Management and Transformation – Training and Webinar Announcement

A  list of upcoming training sessions, including live webinars, can be found in the News and Events section of MICMT’s website:  For an at a glance view, please find the event calendars and event flyers in the “News” section here.        

Please do not hesitate to reach out with any questions or concerns:

Contact Us! How Can We Help? Supporting CPC+ POs and Practices in Michigan

The joint commercial CPC+ payers in Michigan are working together to support multipayer alignment with the University of Michigan. We advocate with CMS to emphasize the important role that POs play in supporting CPC+ and work with them as partners in the Michigan CPC+ community, work with all participating payers in Michigan to create consistency in payer policy and approach wherever possible, and work to remove roadblocks that practices and POs face in CPC+ implementation and operations. We are interested in learning about your successes, challenges and questions.  Please contact the CPC+ Michigan Regional Convener, Diane Marriott ( or 734 740 0511) at any time to share your ideas and experiences.