Pioneer ACO
Overview to NYSDOH ACO
Workgroup
March 6, 2014
Montefiore Overview
Our Locations
1,930 Beds Across 6 Hospitals
– Including 120 beds at CHAM
– 86 NICU/PICU beds
150 Skilled Nursing Beds
154 Sites Including
64 Primary Care Sites
– 21 Montefiore Medical Group Sites
21 School Health Clinics
12 Mental Health/Substance Abuse Treatment Clinics
65 Specialty Care Sites
– 2 Multi-Specialty Centers
– 6 Pediatric Specialty Centers
– 12 Women’s Health Centers
1 Freestanding Emergency Department
10 Dental Centers
5 Imaging Centers
Montefiore IPA and CMO
Montefiore IPA (MIPA)
• Formed in 1995
• MD/ Hospital Partnership
• Supplies network of par
providers committed to
cooperation in care
improvements
• Accepts some full risk
capitation from health plans
CMO
Montefiore Care
Management
• Established in 1996
• Wholly-owned subsidiary of
Montefiore Medical Center
• Performs care management
delegated by health plans
• CMO performs most functions
for MIPA
• 900+ staff
The Montefiore ACO
• Bronx Accountable Healthcare Network IPA, Inc.
(BAHN), does business as the Montefiore ACO
• BAHN is an IPA, separate from MIPA
• BAHN contracts with CMS for Medicare Pioneer
ACO program
– BAHN subcontracts with MIPA to supply most of the
network of clinical participating providers
– BAHN sub-contracts with CMO to supply all care
management and all administrative services
Montefiore Pioneer ACO
Participating Network
(Clinical services)
Non-Montefiore
Par Providers:
Bronx Accountable
HealthCare
Network IPA
(BAHN)
Subcontracts
with:
Pioneer
Agreement
St. Barnabas
Acacia Health
Morris Heights
Hudson River HC
NS-LIJ (partial)
(Most also
participate in health
home governance)
Montefiore
Medical Center
Includes BAHN
Health Home
Montefiore IPA
Community MDs
(600)
+
Ancillary
providers/labs
Montefiore
Care
Management Org
(CMO)
Montefiore
Employed MDs
(1700)
Montefiore ACO Big Picture
• Many health plans are switching from FFS to care
management arrangements with shared savings
opportunities/quality metrics
• Montefiore ACO has history of such
arrangements with Government and nonGovernment Payers
• Montefiore ACO encompasses other providers:
– Bronx Community-based providers
– Provider groups within other entities such as NS-LIJ, St. Barnabas,
Hudson River Health Care, FQHCs
– ACO will include new Montefiore affiliates (Sound Shore 750)
Care Guidance Program Supporting
Innovation
6
Our Current Portfolio
Source
2014 Population
Health plan fully delegates UR/care
coordination to us
(payment - capitation)
185,000*
Play a lead role in care coordination
(payment – FFS with shared savings
opportunity)
100,000 (end of year)
Our Medicaid Health Home
(payment – care management fee)
4,000
~300,000
Montefiore CMO tailors administrative requirements and care
management intensity to the needs of the population being served
* Including Pioneer ACO members
Care Guidance Example: Behavioral Care
Synergy Program
•
•
•
•
•
Goal is to augment behavioral health services in
patient centered medical home (PCMH) context
Implement evidence-based models for treatment
of patients with poorly controlled depression and
at-risk drinking with chronic medical conditions
(diabetes, CAD, CHF)
Develop a joint care management “synergy” team
approach to support and manage these complex
patients
Uses RN care manager, LCSW, psychiatrist in a
“virtual” mode as standard approach
Evaluate clinical outcomes, patient and provider
satisfaction and cost
Chung et al, Gen Hospital Psych 2013
Detail: Pioneer ACO Program
• Serves Medicare Part A & B beneficiaries
• Care coordination program designed for organizations with
prior experience with population-based care management
• Includes comprehensive patient satisfaction and quality
metrics
• Brings care coordination to the fee-for-service coverage
population, without restrictions such as gatekeepers or
limitations on out of network benefits
• Montefiore ACO is the only Pioneer ACO in New York State
• 3 Year demonstration started in 2012
– May be extended to 5 years
– Just started Performance Year 3 (2014)
Quality Evaluation
• 33 quality metrics in 4 domains:
–
–
–
–
Patient/Caregiver Experience
Care Coordination/Patient Safety
Preventive Health
At-Risk Populations
• Data from patient satisfaction surveys,
claims and administrative data and
medical record reviews based on mix of
reporting and performance relative to
U.S. benchmarks
2013: Pioneer ACO Beneficiary Characteristics
• 23,250 attributed Part A & B beneficiaries
• “Attributed” because majority of primary care has been
delivered to those patients by providers in the ACO
• 2,500 SNF Residents
• Age ranges from 5 – 112
–
–
–
–
Average age of 72
175 beneficiaries (0.8%) are age ≥100
4,238 beneficiaries (18.2%) are < 65
Of those, 215 are age ≤ 30
• Approximately 1/3 of population are duals (8,000)
– Interested in opportunities to more comprehensively manage Medicaid
benefit through a single care manager for each patient
– Montefiore is already managing the Medicare benefit
Pioneer ACO Success
• 2012-Year One: Reduced Medicare spending by 7%
against “benchmark” CMS projected it would spend in
2012 on these particular patients
• 2013-Year Two:
– Created sustainable cost reduction
– Added new provider partners: NSLIJ, St. Barnabas, etc.
• 2014: Just starting Year 3
2012: Inpatient Admissions
decreased 10.4%
Number of Admissions/ 1000
person years
600
500
518
495
400
477
464
300
200
100
0
Q1
Source: CMMI PY1 Pioneer ACO Data Analysis
Q2
Q3
Q4
2012: 30-day All Cause Readmissions declined
by 35.5%
Number of Readmissions/
1000 beneficiaries
250
200
201.2
198.9
191.1
150
128.3
100
50
0
Q1
Source: CMMI PY1 Pioneer ACO Data Analysis
Q2
Q3
Q4
2012: Inpatient Admissions for Diabetes
decreased 45.7%
Number of Admissions/ 1000
beneficiaries
0.9
0.83
0.8
0.7
0.63
0.6
0.57
0.5
0.45
0.4
0.3
0.2
0.1
0
Q1
Source: CMMI PY1 Pioneer ACO Data Analysis
Q2
Q3
Q4
Questions?
202602114