Breaking News on Primary Care

Michigan Multipayer 

Primary Care Review March 2023

Michigan Multipayer Initiatives (MMI) convenes payers, practices, and Physician Organizations to lead the transformation of primary care and improve care value, equity, quality, and patient experience in Michigan. To be added to our distribution list, send an email with “Add Me to Newsletter Distribution ” in the subject line to Our website is at To share an idea or ask a question, please contact Diane Marriott ( or 734 740 0511).  

NEW Collaborative Care Multipayer Policy Grid Released

Collaborative care partners primary care practices with expert to integrate the servicing of mental and physical care needs.  To ease the path to understanding requirements and coding related to collaborative care, MMI has produced a new tool to make it easier for practices to partner PCPs with behavioral health professionals.  You will see that the MMI Participating Payers (BCBSM, Priority Health, HAP and MDHSS) have worked to align policies wherever possible to ease practice administrative burden.  All of the payers use the Washington AIMS Model as a basis for policies and requirements.   Collaborative Care (CoCare) implementation has expanded across the state in the last few years and the grid is intended to serve as a helpful tool for those who have already begun implementation and for those interested in learning more.

Social Care Michigan Payer Incentives Comparative Table Update

The primary care community across the state has made great progress in screening patients for Social Determinants of Health (SDoH).    Recognizing that practices need resources to screen patients and connect them with community-based organizations requires resources, BCBSM, Priority Health and HAP have incentivized SDoH screening for several years.    The SDoH Comparative Payer Policy Table has been updated for 2023 and is now available for practices.

There are national drumbeats that will impact SDoH screening measurement in Michigan and other states as well.  Chief among these is the new NCQA HEDIS Social Needs Screening and Intervention (SNS-E) measure.    The Gravity Project has also enabled great advances in developing SDoH data standards and specifications.

As Michigan works to build a better understanding of and approach to meeting social care needs of the population, other states and regions are on a similar journey.   Though select regions have developed some elegant solutions, a statewide data and servicing infrastructure remains elusive.   We will continue to monitor progress in Michigan and across the nation as we learn more together.

CMMI/CMS Universal Foundation Measures

Harmonizing, or making measures more uniform and standardized, has long been a desired goal for reducing collection burden and improving both data and care quality.  CMMI/CMS has taken a big step toward harmonizing measures across their many programs in their recently released preliminary adult and pediatric measures.  The measure sets will create a “universal foundation” that CMS/CMMI Leaders say will be applied to “as many CMS quality-rating and value-based care programs as possible.”  They also acknowledge that it may be necessary to add additional measures depending on population or setting, and to consider the addition of measures for other key areas such as ambulatory patient safety and holistic well-being.

One thing is clear – CMMI/CMS’ announcement means that they understand the challenges from the existing variation in measures across their over twenty programs and have taken constructive action to promote high-quality care.   CMMI/CMS are also hopeful that commercial payers and Medicaid plans adopt the universal foundation over time, amplifying its impact for improved measure reporting.    No time horizon for implementation has been announced yet, as they complete listening sessions and pursue the necessary steps toward proposed rulemaking.  Release of the preliminary Universal Foundation measure sets permits a good sense of what is ahead and the sure knowledge that progress is underway.

The Universal Foundation

Celebrating Family Medicine in Michigan!

This week, March 19-25, is Family Medicine Week nationally.  It is a special time to celebrate the providers and practice team members that work so hard throughout the year to partner with patients and their families and caregivers.  Primary care is a special calling and the cornerstone upon which all other aspects of the healthcare system rests.  We are proud of the hard work done every day in Michigan and celebrate the work that you do!

Community Information Exchange (CIE) Task Force Presents its Interim Report

The Community Information Exchange (CIE) Task Force was chartered by MDHHS to focus on statewide infrastructure to support the collection, exchange, and responsible use of information that can help address the social needs of Michigan’s people and communities.  The Task Force has just released a new report detailing findings of an environmental assessment of the state of social care data in Michigan and proposing recommendations for MDHHS’ consideration.

The goal is for CIE infrastructure to make it easier for people to find and access services by removing obstacles to care, building capacities for service providers to provide holistic care, and informing efforts to address unmet needs.   Here are a few highlights of the report’s contents:

  • CIE infrastructure requires more than funding; it requires trust among stakeholders as well.
  • Interoperability, or clinical and social data among different data systems is the most promising path forward rather than a closed loop referral platform, per se.
  • A CIE Services Agreement template may which should serve as a baseline standard framework for all business agreements associated with a CIE.

Important Change:  MDHHS SDOH Partner Convening Meeting Now on April 18th:  Register Now!

The date and time for the next MDHHS SDOH Partner meeting has been rescheduled for Tuesday, April 18, 2023, from 10:00AM- 11:30AM.  (rather than April 11th).   You can register for the MDHHS SDOH Partner Convening session here.

The MDHHS SDoH Partner Convening sessions are great ways to keep current on the work that the State is leading to better connect and integrate healthcare with social care for more seamless and person-centered servicing.  It will be a chance to celebrate community success with SDoH screening, get the latest on the implementation of Phase II of the SDoH Strategy, and get a glimpse of what is ahead.

2023 Primary Care First (PCF) National to be Held May 16th and 17th

The annual meeting for Primary Care First (PCF) practices will take place virtually on May 16th and 17th from 11 to 3 ET each day.   PCF practices and team members are eligible to attend. The agenda looks very promising and includes sessions on:

  • How the Pandemic Accelerated Improvements in Advance Care Planning
  • The Who and the How of Annual Wellness Visits
  • Advancing Health Equity Engagement and Alignment in PCF
  • Three Unique Strategies to Care Management: Addressing Equity, Leadership Buy-In, and Bottom Line
  • Causal Pathways for Reducing Acute Hospital Utilization (AHU)

Details are available at the PCF 2023 Annual Meeting website where you can also find out how to submit a poster, propose a presentation that uses data to tell your story of performance improvement, or invite patients to share their stories about how working with your practice has made a difference in their lives and their care.

Expiration of the Public Health Emergency Means Changes Ahead

The Biden Administration’s announced COVID-19 Public Health Emergency (PHE) end date of May 11, 2023, is nearing.   MDHHS has been preparing for the PHE expiration through its unwinding process to document changes impacting Medicaid program eligibility, benefits, and policies.  MDHHS has prepared

a  Medicaid Policy Crosswalk as a helpful resource to better understand the upcoming changes and their implications.

Michigan Multipayer Initiatives’ participating commercial payers (BCBSM, Priority Health, and HAP) have also been working to prepare for the PHE’s end.  The focus has been on promoting aligned post-PHE policies to decrease administrative burden, leverage the growing body of telehealth evidence, and prevent fraud and abuse.   Watch for the new, post-PHE version of the Telehealth Policy Alignment table to be distributed in the next few months.  It will be included in an upcoming edition of the Primary Care Review and will be posted on the MMI website (

The Training Corner

To better serve you, we have expanded the array of care management and team-based care training sessions. We are fortunate to have MiCMT, Mi-CCSI, MiCHWA and PTI to provide expert training on important topics in primary care. Here is a summary of their upcoming training sessions.

Michigan Institute for Care Management and Transformation (MiCMT) – 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: For an at a glance view, please find the event calendars and event flyers in the “News” section here.   Questions and concerns can be shared at

Practice Transformation Institute (PTI)

 A list of upcoming trainings can be found in the Events section of the PTI’s website: Current offerings include Introduction to Team Based Care, Foundational Care Management Codes and Billing Opportunities, Patient Engagement, Palliative Care topics, and Unconscious Bias in Health Care.

The Michigan Center for Clinical Systems Improvement (Mi-CCSI) – Training and Webinar Announcement

New at MICCSI for 2023: Palliative Care Training  

For detail, and to register for an upcoming course, visit our website at:

Palliative Care Training Overview:

This training, using evidence-based approaches, will provide the clinical team with knowledge and skills to assist patients who have a diagnosis or condition termed as a serious illness. The training will review and include:

  • Identifying the patient’s understanding of their diagnosis and prognosis.
  • Approaches to broach, identify, and honor the patient’s wishes and values should their condition worsen.
  • Building on skills covered in Engagement Training, to include use of motivational interviewing and creating a self-management and care plan that aligns the patient’s wishes, biomedical and psychosocial status and needs.
  • Review of the link to Team-based Care, to include patient identification, assessment, and care planning, monitoring and follow-up and transitioning to specialist/care coordination and use of the interdisciplinary care team.
  • Review of definitions pertinent to palliative and hospice care services.
  • Review of the billing and benefits available when providing serious illness, palliative care services and hospice care.
  • An opportunity to practice and solidify key components and self-evaluation/awareness of abilities in having the serious illness conversation with a trained standard patient, known as simulation.
  • BCBSM is sponsoring this training. There is no cost to attend.

Highlights on the evaluation results and comments from attendees 

Evaluation ratings reflecting satisfaction and quality of training:

If you have any questions about the training, please contact Sue Vos at


 Community Health Worker Certification Training – 100% Virtual Training

The curriculum is designed to train front line workers to provide culturally responsive services in Michigan communities. The 126 training hours include 25 hours for independent self-study.

For more information contact: Holly Joseph | 231-316-8558

Integrated Health Partners (IHP)

IHP offers an array of trainings throughout the year. Including Introduction to Team Based Care, Patient Engagement, and Foundational Care Management Codes and Billing Opportunities, among others. Each event is listed below along with upcoming dates and the event registration link.

All 2023 training dates are available for registration through the registration link below.

Trainings Upcoming Dates Registration Link
Introduction to Team Based Care 3/13/2023; 4/17/2023; 5/2/2023 Register here
Patient Engagement 4/28/2023; 5/31/2023; 6/22/2023 Register here
Foundational Care Management Codes and Billing Opportunities 3/15/2023; 5/3/2023; 6/19/2023 Register here
Motivational Interviewing and Brief Action Planning 3/8/2023; 7/17/2023; 11/7/2023 Register here
Cultural Competency, Health Literacy, Teach-Back 3/14/2023; 7/18/2023; 11/20/2023 Register here

If you have any questions, please reach out to Allisyn Rainwater at