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BCBSM Vision for Team-Based CareTitleKarolina Skrzypek MDMedicalDirectorSubtitleBCBSM

- Measurable outcomes- Patient experience- Support for physicians to manage growing patientpanelsLOWERBETTERWhat is the goal of team-based care? 2019- Cost- Unnecessary utilization of ED- In-patient admissions resulting from unmanagedchronic conditionsBlue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

PCPs are being pulled in every direction Physicians are constantly pulled in every direction An average PCP’s panel size is 2,300, makingdelivering high-quality care very difficult Estimates suggest that patients receive only 55% ofrecommended chronic and preventive services Care teams are vital to supporting physicians andtheir patients.– The team-based model can help distributepatient care among the interdisciplinary teamto allow for high quality care and bettermanagement of the entire patient panel Ensuring care managers are functioning at the topof their licensure and fully utilized, such asmanaging schedules as supported by the BCBSMscheduling initiative and the scorecard 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Offices utilizing care teams significantly impact cost and qualityThe Department of Health and Human Services (HHS) states that “by 2030, 25 percent of the U.S.population will be 60 and older, and 19 percent of the population will be 65 years of age and older. Atleast 90 percent of those 65 and older now have one or more chronic conditions.”Care management delivers benefits to the aging population and those patients with chronic conditionsby: Reducing treatment costs Reducing the rate of hospitalizations Eliminating unnecessary and redundant testing Managing medications to prevent adverse interactions Involving the patient’s family and community to boost emotional well-being Ensuring the primary care physician maintains a complete picture of the patient’s overall health Enabling the provider to properly manage all care, improving outcomes for the patient 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

National outcomes of team-based care vs traditionalpractice managementStudy conclusion and results: Receipt ofprimary care at team-based care practicescompared with traditional practice modelpractices was associated with higher ratesof some measures of quality of care, lowerrates for some measures of acute careutilization, and lower actual paymentsreceived by the delivery etwork.com/journals/jama/fullarticle/2545685 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

2020 Performance, for PCMH designated practicescompared to non-PCMH designated PGIP practices26.6%Lower rate of emergencydepartment visits35.5%PatientCenteredMedical HomeLower rate of ambulatorycare- sensitive inpatientdischargesAdults (18-64)9.6%Lower rate of high-techradiology usage 201929.4%Lower rate ofreadmissions33.1%Lower rate of primary caresensitive emergencydepartment visits5.4%Lower rate of low-techradiology usageBlue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.6

2020 Performance, for PCMH-designated practicescompared to non-PCMH designated PGIP practices29.0%Lower rate of emergencydepartment visitsPatientCenteredMedical Home39.1%Lower rate of primary caresensitive emergencydepartment visitsChildren (0-17)7.4%Lower rate of low-techradiology usage 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.7

PCMH is foundational to PDCM Patient-Centered Medical Home model is the foundation of Provider-Delivered CareManagement– PCMH specifically addresses implementation of care managementtools/resources/ capabilities Multi-disciplinary care team; coordination between specialists and PCPs; selfmanagement support for chronic condition patients; individual caremanagement– Providers must be PCMH designated or CPC recognized to deliver PDCM (or aspecialist who meets training and capability requirements) 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.8

Efforts to grow PDCM services are paying off!The number of members engaged in PDCM has steadily increased year over year 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.9

PCMH supports PDCM which enables better care in many areasCollaborative CareMedication AssistedTreatmentPatient Centered MedicalHome as the foundation forbetter management ofpopulation healthTeamBasedCarePalliative CareHealth DisparitiesSpecialist TeamBased Care 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Cost and utilization savings attributed to PDCMPCMH practices utilizing PDCM as compared to PCMH only practices have demonstrated7.2% lower primary care sensitive ED utilization and 5.8% lower for pediatric population11.5% lower ambulatory care sensitive inpatient utilization2.1% lower rate of high-tech radiology services2.5% lower rate of low-tech radiology services1.9% lower rate of low-tech radiology services in the pediatric population 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Social determinants of health It’s estimated that as much as 80% of aperson's health can be attributed to factorsother than heath care Care teams bridge the gaps of disparitieswhich affect health and health care by– creating vital linkages to communityresources– support the appropriate sharing ofinformation to identify needs and buildresources to address them 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

PDCM flexibility to accommodate COVID-19In response to the COVID-19 pandemic, Blue Cross Blue Shield of Michigan has extended the following changesfor PDCM:The following professional provider fee increases have been extended through November 30, 2020 :- G9001- G9002- G9008Open Q & AUpdated amounts for all services listed above may be found in web-DENIS under the "Fee Changes" page.7/8/2020Care coordination services that typically must be delivered in a face-to-face setting can be deliveredvia telemedicine (audiovisual or telephone). PDCM procedure codes *98961, *98962, G9001 andG9002 are affected by this temporary change. 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Guidelines for telehealth services CMS expanded telemedicine services under the 1135 waiver authority and forCoronavirus Preparedness and Response Supplemental Appropriations Act for theduration of the public health emergency for COVID-19 Allowed the use any audio-visual functionality including mobile phones using videochat applications including FaceTime, Zoom for Healthcare and Skype. Facebook Live, Twitch, or TikTok not allowed. Documentation requirements have also been temporarily relaxed during the COVID19 public health emergency.Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 2019 Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

PGIP is making it easier to delivercare management servicesEnhanced Provider-Delivered CareManagement (PDCM) fees bytemporarily increasing the feeschedule on PDCM codes by 20%Encouraged providers to conductoutreach and engage chronically illpatients in virtual caremanagementMany of these members wouldtypically be completing in-personvisits to address their chronicconditions 2019Relaxed criteria to allow all PDCMservices to be delivered virtually,through video-audio or telephoneonly delivery methodsConnected hospitalized patients,in isolation, with their families topromote care coordination andassessed the need connectingmembers to behavioral healthresourcesBlue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

2020 Metric scoring results by measureTotal PracticesPDCM PracticesPDCM / PCMH scriptionIP Discharges (perPractices% EligibleEarnedEarning VBR Practices Earning onersEarningVBR Count53849992.8%4943871872members per year)54131758.6%1762811091High Blood Pressure541541100%54101954ComprehensiveDiabetes Control:HbA1c 8%54051395.0%49326318971000 members per year)ED Visits (per 1000 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.16

2020 Metric scoring results by VBR earned% VBR EarnedPractice Unit CountPractitioner Count271945192617176183121082Total5411954 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Changes for 2021 Adult Category High Blood Pressure Measure will be scored on Performance andImprovement Addition of 3 Pediatric Category Measures- ED Visits- IP Visits- Pediatric Composite including: Medication Management for People with Asthma age 5-11 Medication Management for People with Asthma age12-18 Follow-Up After Emergency Department Visit for Mental Illness Follow-Up Care for Children Prescribed ADHD Medication - Initiation Performance Thresholds are based on internal modeling rather than industrybenchmarks Measures will be both age category and practice type specific 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

PDCM outcomes VBR for 2022 To allow practices to focus on their performance and improvement on the currentmeasures in the PDCM Outcomes program, Value Partnerships will NOT be makingany changes to the metrics or analytic methods for the 2022 payment cycle (basedon CY 2021 claims).MetricED Encounters(per 1000 members per year)ED EncountersAgePerformance ThresholdLowest/Highest PotentialRateImprovementAdult175 encounters5510%5510%158%19%Pediatric(per 1000 members per year)IP EncountersAdult(per 1000 members per year)IP EncountersPediatric(per 1000 members per year)(per 1000 members per year)164 encounters(per 1000 members per year)45 encounters(per 1000 members per year)13.5 encounters(per 1000 members per year)HbA1c Control 8%Adult70%0.9810%High Blood PressureAdult70%0.9810%PediatricTo Be DeterminedTo Be DeterminedN/AMMA; ED for MH; ADHDC&M 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Questions 2019Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Updated amounts for all services listed above may be found in web-DENIS under the "Fee Changes" page. Care coordination services that typically must be delivered in a face-to-face setting can be delivered via telemedicine (audiovisual or telephone). PDCM procedure codes *98961, *98962, G9001 and G9002 are affected by this temporary change. Open .