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Moving Toward an
Accountable Care Organization
Montefiore Medical Center
Donald Ashkenase, MHA
Special Advisor to the President
National Academy for State Health Policy
23rd Annual State Health Policy Conference
October 4-6, 2010
Moving Toward an Accountable Care
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Organization
• The Broad Concepts of an ACO
– Provider Partnerships
• Structure drives population
– Manage Chronic Disease
• Drives most of Medicare & Medicaid’s costs
– Digitize Care Delivery
• Quality measurement and clinical integration
– Maximize cost efficiencies
• The end game remove waste from the
system
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Care Management
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Presentation
• Overview of the Bronx and Montefiore
Medical Center
• Experience with capitation and care
management
• Chronic Care and Readmission Initiatives
• Pay for Performance
• Lessons Learned
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The Bronx:
ClickMinority,
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Poor,
Young, Heavy
Disease Burden
Race / Ethnicity
Population < Poverty
Bronx vs NYC and NYS
AsianOther
White 3% 3%
15%
30%
25%
20%
Hisp.
48%
15%
10%
Black
31%
5%
0%
45-64
years
New York City
65+
years
New York State
Ambulatory Care Sensitive
Hospital Admits
Age
20-44
years
14.0
0-19
years
12.0
ACS Admits/K
Bronx
10.0
8.0
6.0
4.0
2.0
0.0
ACS Admits/K
New York City
Bronx
Brooklyn
Manhattan
Queens
Staten Island
9.95
13.98
10.98
8.26
7.85
8.60
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Highest Overall Morbidity*
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in NYS
Percent of Residents
Sample Population Health Status Measures
Bronx vs. other NYC, NY State and US Averages - 2010
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Bronx
NYC
NY State
20
US 90th percentile
10
0
Fair or poor health
Low Birth Weight
Diabetes
Asthma
*Morbidity defined as: Poor or fair health, low birth weight, poor physical and mental health days.
Low birth weight is defined as <2,500 grams (5.5 pounds). Target is 90% percentile of U.S. Counties.
Sources: 2010 County Health Rankings, Robert Wood Johnson Foundation and University of Wisconsin
Population Health Institute; www.counthealthrankings.org/new-york.com
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styleOption”
Montefiore:
“Thetitle
Public
• More than 75% of revenue is
Medicare and Medicaid
– Medicaid population increasing
• Under 25% Commercial
insurance
– Blue collar
– Commercial population
decreasing
• Bad Debt and Charity Care on
the rise
– $126M (2007) to $188M
(2009)
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Model
• “Systemness”
• Academic Medical
Center
• Employed physicians
• Quality Improvement
• Accept financial risk
• Population-based
strategy
• Information
Technology
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Clinical
Systems
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2 million patients
Master Patient Index
Lifetime Medical Record
Doctor’s Office and
Home
100%
100%
MDMD
Order
Order
Entry
Entry
Ambulatory Care
>600 Expert
Expert rules
rules and
and Scheduling
>600
Scheduling
Decision Support
Support
Decision
Problem
Problem
ListList
Rx Rx
PadPad
Care Plans
Care Plans
Medical Group
Clinical Looking
Glass
•Data Warehouse
•Clinical Research
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Hospitals
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Over 85% of the Bronx Providers participating the Bronx RHIO
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Montefiore-Albert Einstein College of Medicine
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MasterMedical
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An Academic
Center
Montefiore
NY Medical College
Patient Care
2500 Medical Staff
- 900 Voluntaries
- 1600 F/T Faculty*
- 427 PCPs*
- 37 Hospitalists
AECOM
Teaching
1,100 Housestaff **
- 120 Medical Students**
- Health Professional Ed.
- CME
Research
-
Basic
Clinical
Translational
Health Services
3200 RN/ LPN (F/T, P/T, PD)
600 Allied Staff
*All clinical faculty and MMG physicians are salaried by Montefiore
** Includes residents/medical students from New York Medical College
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Montefiore
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Delivery
System
• Inpatient Care – Over 93,000 admissions including 7,000 births
– Three general hospitals
– Children’s hospital
– 1,500 beds
• Ambulatory Care – 2.5 million visits/year
–
–
–
–
–
23 community primary care centers (>1 million visits)
16 school health centers (52,000 visits)
7 mobile healthcare units (11,000 visits)
3 major specialty care centers (> 1 million visits)
2 special care units (Child Advocacy Center; Lead Poisoning
Prevention)
– 4 emergency departments (301,000 emergency visits)
• Post-acute care
– Home care agency- 500,000 visits
– Rehabilitation
• Geographic concentration
– 90% of Montefiore’s patients from Bronx or Westchester
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Master titleNetwork
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The
Montefiore
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Experience with Pre-payment or
Capitation
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Master Arrangements
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Risk
Transfer
Capitation
Premium
Insurance Company
Savings
Provider-Sponsored IPA
(Risk Bearing)
MSO
Primary Care
Specialty Care
Hospital
▪ Capitation Payments to IPA
Delivery System
▪ Savings
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titleand
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CMO
Montefiore IPA
• Formed in 1995
• MD/ Hospital Partnership
• Contracts with managed
care organizations to
accept and manage risk
• Over 1,900 physician
members
– 500 PCPs
– 1,400 Specialists
CMO
care management operations
• Established in 1996
• Wholly-owned subsidiary
of Montefiore Medical
Center
• Performs care
management delegated by
health plans
• Licensed UR agent and
certified claims adjustors
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Managing Care
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MMC’s
Contracts
Serve
Our Community
MMC Capitated Enrollees
N=150,000
($750m in premium revenue)
Medicaid
58,000
Medicare
27,000
IPA/CMO
N=20,000
IPA/CMO
N=20,000
Healthfirst
N=38,000
Healthfirst
N=7,000
Commercial
65,000
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Network
Cross-Cutting
Functions
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CMO
Care Management Operations
Acute Care
Responsibilities
• Network Care Management
 Social Work/discharge
planning
 Utilization Review
 Complex Case Action
Team
 Documentation
Improvement
 Patient Navigation
• Contact Center support to
hospitalists
• Patient Education
• Data Analysis and Reporting
• Medical staff and insurance
credentialing
Network Care
Support
Care Management
Activities for payers
• Care Guidance
• Chronic Care
Management
 CHF
 Diabetes
 Respiratory
 High Cost/Risk
• Telemonitoring
• Palliative care
• Post-Discharge Calls
•
•
•
•
•
Ambulatory EMR
Urgent care access
Medical home model
Call center support
On-site MMG case
managers
• Patient Education
• House Calls
• Online Patient
Communication
(MyMontefiore)
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CMO
Delivery System Innovation and Support
Care Management/
Care Coordination
Quality/ Data
Outcomes
Best Practice
Modeling and
Implementation
Financial
Modeling Support
IT Support and
Functionality
Integrated Delivery System
Centers of Excellence
Specialty Services
PCMH
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Next Step Toward Accountable Care
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Coordination
Incentives
CMS Medicare
High Cost Beneficiary
Demonstration
The Bronx
Collaborative
Patient Centered
Medical Homes
•Joint Venture with Bosch
Healthcare
•Not-for-profit NYS
Corporation
•Interdisciplinary care
teams
•Over 6,000 Bronx Medicare
FFS members
•Includes Montefiore; 2
other Bronx Hospitals;2
Health Plans
•2 pilot sites- 40k pts
•Managing care transitions
•NYS Health Foundation
funding for care transitions
•Teaching/ nonteaching
practices
•Seeking NCQA
certification
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Opportunities
• Accountable Care Organization
− Health Care Reform
− The Bronx Collaborative
− The Bronx RHIO
• Improving medical cost savings initiatives
− Care Guidance Program: Population-based focus on managing the
chronically ill
− Proving the value of the CMS demonstration effect
− Expanding House Calls, the physician home visit program
• CMO new business opportunities
− Care Management
− Customer Service
• Expand Network Manager Role
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Master Learned
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Lessons
The Importance of commitment to:
• Integrated system of care
• Quality, Safety and Service
• Employed physician model
• Information Technology
• Alignment of financial incentives
• Partnerships
• Care Coordination
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