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Ohio’s strategy to enroll primary carepractices in the federal ComprehensivePrimary Care Plus (CPC ) ProgramGreg Moody, DirectorGovernor’s Office of Health TransformationWebinar for Primary Care PracticesJune 10, 2016www.HealthTransformation.Ohio.gov

1. Review core elements of the Ohio PCMH model2. Provide a comparison to CPC 3. Review the CPC practice application

Ohio’s State Innovation Model (SIM) partners

Overview of Ohio’s Patient-Centered Medical Home (PCMH)care delivery and payment model There is one Patient-Centered Medical Home (PCMH) modelin which all practices participate, no matter how close to anideal PCMH they are today. The program is designed toencourage practices to improve how they deliver care to theirpatients over time. The Ohio PCMH model is designed to be inclusive: all Medicaidmembers are attributed or assigned to a provider. In order to join the program, practices will have to submit anapplication and meet enrollment requirements. Model scheduled to launch with an early entry cohort inJanuary 2017 then open to any primary care practice thatmeets model requirements in January 2018 and beyond.

Ohio’s vision for PCMH is to promote high-quality,individualized, continuous and comprehensive care

Ohio’s PCMH Requirements and Payment Streams 1 8 activityRequirements2 5 Efficiencyrequirements PaymentStreams Same-day appointments24/7 access to careRisk stratificationPopulation managementTeam-based caremanagementFollow up after hospitaldischargeTracking of follow up testsand specialist referralsPatient s ED visitsInpatient admissions forambulatory sensitiveconditionsGeneric dispensing rate ofselect classesBehavioral health relatedinpatient admitsEpisodes-linked metricMustpass 30%All requiredSharedSavingsAll requiredTBD for select practices3 20 Clinical Measures4 Total Costof CareClinical measures aligned withCMS/AHIP core standards forPCMHMustpass 50%Enhanced payments wouldbegin January 1, 2018 forany PCP that meets therequirementsBased on selfimprovement &performancerelative to peers

Ohio PCMH Model Practice Eligibility(January 1, 2018 and beyond)Required Eligible provider type and specialty Minimum size: 500 attributed/ assigned Medicaid eligible members within acontracted entity Commitment– To sharing data with payers/ the state1– To participating in learning activitiesNot required– To meeting activity requirements in 6 monthsNot required Accreditation: (e.g., NCQA or URAC) Planning (e.g., develop budget, plan for care delivery improvements, etc.) Tools (e.g., e-prescribing capabilities, EHR, etc.)1 Examples include sharing best practices with other PCMHs, working with existing organizations toimprove operating model, participating in state led PCMH program education at kickoff

Ohio’s Comprehensive Primary Care (CPC) Timeline2015CPC“Classic”CPCStatewideCPC 2016Year 3 2017Year 4Ohio’s SIMsponsoredPCMH modelDesignMedicare-sponsoredPayers apply by regionPractices applywithin regionsEarly Entry into the Ohio CPC Model CPC practices with 500 Medicaid members Practices with 500 Medicaid members withclaims-only attribution AND NCQA III Practices with 5,000 Medicaid members andnational accreditation 201820202019Southwest Ohio’s federally-sponsored,multi-payer PCMH modelYear 1Year 2Year 3 (early entry)(open entry)(open entry)Year 1Year 2Year 3 5(CMS-selected)(CMS-selected)(CMS-selected)Ongoing Enrollment into the Ohio CPC Model Any practice with 500 Medicaid membersthat meets Ohio CPC activity, efficiency andclinical quality requirements

1. Review core elements of the Ohio PCMH model2. Provide a comparison to CPC 3. Review the CPC practice application

Overview of the Federal Comprehensive PrimaryCare Plus (CPC ) Payment ModelCPC is a new payment model that rewards value in primary care forMedicare beneficiaries and encourages multi-payer collaboration Partners sought include: Medicaid FFS, Medicare Advantage,Medicaid managed care, and commercial insurers (ASO and full risk) Practices can apply to one of two tracks dependent on level ofreadiness to assume financial risk (assessed based on EHR readiness) Non-financial benefits include learning program and data sharingCMS intends to select 5,000 practices across 20 regions nationwide

Alignment of CPC model with Ohio PCMH designOhio PCMHCare modelEligible practices Care Model based on key principles of access,coordination, care management, patientengagement, population health management Similar principles Open provider enrollment and inclusive ofmost primary care practice types Application process and excludespediatrics and FQHCsDefinition of practice Group based on tax ID numberPMPMPaymentstreams Risk-adjusted PMPM based on patient status Defined as site rather than group Track 1 vs. 2 have different PMPMsIncentive Shared savings based on quality / efficiency Pay for performance bonusAlt. to FFS Episode-based payment model Track 2 includes partial capitationEHRProgramRequirementsCPC EHR not requiredActivities 8 specific activity requirementsClinicalquality 20 specific clinical quality measuresEfficiency 5 specific efficiency measures EHR required Similar activity requirements 7 of 20 metrics are the same Information not yet released

Application Process for CPC PayerApplicationsCMS SelectsRegionsPracticeApplicationsCMS SelectsPracticesApril 15 – June 8Payers submitapplicationsJune 8 – July 1520 RegionsSelectedJuly 15 – Sept. 1Practices submitapplicationsSept. 1 – Dec. 315,000 practicesselectedPreference given to CPCi and MAPCPparticipants, andMedicaid SIM statesCMS evaluatespayers and selectsregions based onpayer footprint States may need additional waivers/SPAs to apply State created atemplate for payersto apply 20 regions to beselected – intent toaward to the 7current CPCi regionsplus 13 new regionsRegional size andboundaries to bedetermined Practices in selected regions eligible toapplyEvaluation based onpractice diversity(e.g., size, location) Application includes program integritycheck, questionsregarding caremodel, and letters ofsupport includingfrom IT vendorCMS-selectedpractices eligible forCPC Medicarepayments beginningJanuary 1, 2017 State will create atemplate forpractices to apply

All of Ohio’s State Innovation Model (SIM) partnerssubmitted payer applications for CPC

Ohio application of CPC payment streams by line of businessOhio MedicaidFFSOhio MedicaidManaged CareMedicareFFSODMMCP2CMS500 (across allMedicaid members)500 (across allMedicaid members)150 MedicareFFS membersDetermined by planTrack 11 3-5 average 3-5 average 15 averageDetermined by planTrack 21 3-5 average 3-5 average 28 averageDetermined by planTrack 150% gain-sharingrate on TCOC350% gain-sharingrate on TCOC3 2.50 PMPM payfor performanceDetermined by planTrack 265% gain-sharingrate on TCOC65% gain-sharingrate on TCOC 4.00 PMPM payfor performanceDetermined by planTrack 2OnlyEpisodes onlyEpisodes onlyPartial capitationDetermined by planPayerMinimum panel iveto FFS1 Single payment reflects both CPC and PCMH; in no instance would there be double payment2 MCP administers payment in all cases; PMPM payment would be supported through ODM3 Practices would have potential opportunity to earn the higher gain-sharing rate due to highestperformance on TCOC in baseline yearCommercial /Medicare AdvantagePlan

1. Review core elements of the Ohio PCMH model2. Provide a comparison to CPC 3. Review the CPC practice application

Core Elements of the CPC practice applicationA Preliminary questionsB Practice structure and ownershipC Model participationD Practitioner and staff informationE Practice activitiesF Health information technologyG Patient demographicsH Practice revenue and budgetI Care deliveryJ AccessK Quality improvement 43 questions within the 11chapters (detail follows) Accompanying letters of supportalso required from clinicalleadership, owner of parentorganization, and IT vendors

CMS Provider Resources for CPC Model -modeloverviewslides.pdf Frequently asked s-faqs.pdf Program plus-practicecaredlvreqs.pdf Request for plus-rfa.pdf

CPC Model Frequently Asked QuestionsQuestion Would participation in CPC support eligibility for MedicareAccess and CHIP ReauthorizationAct (MACRA) AlternativePayment Model (APM) track?Some indications from CMS forparticipation to support APM, albeiton a long-term timeline Can providers participate in CPC and Medicare Shared SavingsProgram (MSSP)?Confirmation from CMS that MSSPparticipants eligible for CPC model Would dual-eligible Ohioans be included in the CPC model?Yes – dual eligible Ohioans areincluded in the CPC model, with theexception of those in ademonstration project. Dual eligibleOhioans are not included in PCMH What are the core elements ofthe practice application?MACRAMSSPDual eligiblemembersPracticeapplicationResponse Any other questions?Detail follows

Preliminary pre-decisional working draft; subject to changeCPC practice application components (1/4)HIGHLY PRELIMINARY1. For which Track is your practice applying (1 / 2)2. If you are a Track 2 applicant but are not eligible for Track 2, would you like your applicationconsidered for Track 1? (Y/N)APreliminaryQuestions3. Is your practice a concierge practice, a Rural Health Clinic, or a Federally Qualified Health Clinic(Y/N) [Disqualifier]4. Is your practice currently participating in any of the Medicare initiatives that follow? Please check allthat apply– TCPi, Pioneer ACO, Next Generation ACO, MSSP ACO, another Medicare ACO, AccountableHealth Communities, None, participates but plans to withdraw5. Practice identification questions (e.g., name, ownership, belonging to larger system, satellite office)PracticeStructureBandOwnership6. Does practice share a TIN for billing with other practices in the same health system7. Does practice use more than one billing TIN?8. What billing TIN will practice use?9. Who owns the practice [physicians, other practitioners, another physician organization, hospital,health plan, medical school, other]10. Has practice participated in CPCi (Y/N)? If so, what was practice ID?ModelC Participation11. Has practice participated in MPAPCP (Y/N)? If so, what was practice ID?12. Primary contract information13. Secondary contact information14. HIT contactSource: CPC RFAConfidential and Proprietary 19