This briefing is authored by the Michigan Multipayer CPC+ Team (and not by CMS or a CMS contractor) and is made possible through support from BCBSM and Priority Health (our CPC+ commercial payer partners) to support CPC+ success in our state.
To be added to the distribution list, email MichiganMultipayerCPCPlus@med.umich.edu with “Add Me to the MI CPC+ Newsletter Distribution” in the subject line. You can find additional information and past briefings at https://cpcplusmichigan.org/
Included in November‘s Issue
- Michigan’s High-Performing Practices: What They Do That Makes Them Different
- “Silver Linings” Innovation Challenge Awards: The Winners and Their Innovations
- The MIHIN SDoH Use Case
- 2021 Social Determinants of Health (SDoH) Commercial Payer Incentive Program Update
- Resources for CPC+ Practices
- Updates from the Michigan Data Collaborative
- Michigan Institute for Care Management and Transformation Training and Webinar Announcements
Michigan’s High-Performing Practices: What They Do That Makes Them Different
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 use. Site visits or in-depth phone interviews were conducted with each practice and with leading health systems across the nation. The following six themes were common to all the groups studied:
- 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).
- Co-located, engaged teams with care management at the core are key. The size of the team does not matter but co-location does.
- 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.
- Availability and responsiveness to patient needs as well as patient awareness of the availability mattered more than extended hours. Though hours outside traditional 8am-5pm practice operations can be very helpful for those whose schedules cannot accommodate standard workweek hours, they are not useful to patients if they are consistently filled or cannot accommodate an urgent need. More important is the patient’s ability to have clinical expertise that responds to patient questions quickly. In the high-performing practices, patient calls were returned and the loop closed the same day, and in some practices, within the hour.
- Performance reporting integrated in regular team huddles or communication drives attention to and accountability for performance. Sharing provider-level performance regularly similarly motivated improvement among individual providers.
- High performing practices had a method for identifying patients that would benefit from interventions (e.g., care management, self-management programs; remote patient monitoring; etc.) All high-performers studied readily recited their “triggers” for intervention and care management.
The paper contains examples of how the high-performing practices put the themes above into action. We are grateful for their willingness to take time out of their busy schedules to meet with us to explore their work processes and cultures. We also acknowledge Brian Allison from the Michigan Data Collaborative who served as an analytical consultant to the work. We hope you take a moment to read it and to see if it is useful to the transformation work that each of you is leading at your organizations.
“Silver Linings” Innovation Challenge Awards: The Winners and Their Innovations
Thanks to all for the robust participation in the “Silver Linings” Innovation Challenge. Congratulations to the five award winning entrants:
- Ascension Providence Medical Center – South Lyon
- David M. Byrens, M.D., P.C.
- Day One Family Health Care P.C.
- Hastings Internal and Family Medicine
- PRISM Medical Group
You can find the details for their innovations here. From Coumadin patient management to care management scheduling, the array of topics the innovations span is impressive. In addition, we recognize two additional practices as runners’ up:
- Eastside Internal Medicine
- Huron Family Practice Center
These CPC+ practices sought to deliver care in new ways and to address and quickly respond to pressing patient needs. These innovations are illustrative of the hard work done in practices and POs to improve the effectiveness and efficiency of population health. We are glad to share the best practice learnings with the CPC+ Michigan community.
The MIHIN SDoH Use Case
For those who may not have heard, MiHIN, our state-designated health information network has been hard at work on a project that will facilitate interoperability of social determinant of health information. The first deliverables of their SDoH use case work are anticipated to be completed by the end of the year.
MiHIN is inviting organizations (POs, practices, etc.) that can benefit from the SDoH Use Case and are interested to reach out to them to set up a time to explore its applicability to your organizations by contacting Katrina.Gagne@mihin.org.
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. A comprehensive life cycle approach to meeting SDoH needs requires both short and long term strategies and these must be informed with guidance from practices and POs. The thoughts and input that you have provided over the past few months in our CPC+ multipayer work has been so valuable. 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 later this year and in 2021.
Resources for CPC+ Practices
- Holland Hospital Primary Care (HHPC) is offering patients comprehensive medication management through an embedded Pharmacist. HHPC has found Pharmacist involvement and lead in the process of comprehensive medication management to be a very beneficial addition. The article “Practice Spotlight: Holland Hospital Primary Care, Holland Michigan – Comprehensive Medication Management” tells their story.
- Building a behavioral health integration program requires new process designs, new staff roles and responsibilities, and organization-wide collaboration. This resource on “Applying quality improvement principles” can support and guide teams on their journey.
- Hear from Care Transformation Collaborative-Rhode Island (CTC-RI) about how adult and pediatric primary care practices have created the new normal for integrated behavioral health (IBH) in their state; how data comparing pre-COVID to post-COVID for IBH and Social Determinants of Health had impacted decision-making; and how staffing and burnout had impacted Rhode Island primary care practices with IBH. Access the webinar recording and slide deck here.
- Milbank released a new issue brief about telebehavioral health programs, which appear to be a cost-effective alternative to in-person care. As we work together to better understand and discern the best uses of telehealth and telemedicine, it is wonderful to see the evidence on its usefulness being rigorously studied and evaluated.
Michigan Data Collaborative CPC+ Dashboard Update
The Michigan Data Collaborative (MDC) is excited to announce we are in the process of validating, aggregating, and running measures for a 3-Payer Dashboard release in December. There will be two simultaneous reporting periods included.
- 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
In addition to multiple enhancements (many based on user requests) already incorporated into the CPC+ Dashboards, we are also in process of planning more functionality, and utility for the upcoming year, including:
- Procuring the ACG algorithm to include risk-adjusted measures
- Plotting trend data for all payers
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 MichiganDataCollaborative@med.umich.edu.
Michigan Institute for Care Management and Transformation – Training and Webinar Announcement
A list of upcoming trainings, including live webinars, can be found in the News and Events section of MICMT’s website: https://micmt-cares.org/events. 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: email@example.com
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 (firstname.lastname@example.org or 734 740 0511) at any time to share your ideas and experiences.