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Moving Toward an Accountable Care Organization


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Moving Toward an Accountable Care Organization

  1. 1. Moving Toward an Accountable Care Organization Montefiore Medical Center Donald Ashkenase, MHA Special Advisor to the President National Academy for State Health Policy 23 rd Annual State Health Policy Conference October 4-6, 2010
  2. 2. Moving Toward an Accountable Care Organization <ul><li>The Broad Concepts of an ACO </li></ul><ul><ul><li>Provider Partnerships </li></ul></ul><ul><ul><ul><li>Structure drives population </li></ul></ul></ul><ul><ul><li>Manage Chronic Disease </li></ul></ul><ul><ul><ul><li>Drives most of Medicare & Medicaid’s costs </li></ul></ul></ul><ul><ul><li>Digitize Care Delivery </li></ul></ul><ul><ul><ul><li>Quality measurement and clinical integration </li></ul></ul></ul><ul><ul><li>Maximize cost efficiencies </li></ul></ul><ul><ul><ul><li>The end game remove waste from the system </li></ul></ul></ul>
  3. 3. Care Management
  4. 4. Today’s Presentation <ul><li>Overview of the Bronx and Montefiore Medical Center </li></ul><ul><li>Experience with capitation and care management </li></ul><ul><li>Chronic Care and Readmission Initiatives </li></ul><ul><li>Pay for Performance </li></ul><ul><li>Lessons Learned </li></ul>
  5. 5. The Bronx: Poor, Minority, Young, Heavy Disease Burden
  6. 6. Highest Overall Morbidity * in NYS Percent of Residents Sources: 2010 County Health Rankings, Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute; *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. Sample Population Health Status Measures Bronx vs. other NYC, NY State and US Averages - 2010
  7. 7. Montefiore: “The Public Option” <ul><li>More than 75% of revenue is Medicare and Medicaid </li></ul><ul><ul><li>Medicaid population increasing </li></ul></ul><ul><li>Under 25% Commercial insurance </li></ul><ul><ul><li>Blue collar </li></ul></ul><ul><ul><li>Commercial population decreasing </li></ul></ul><ul><li>Bad Debt and Charity Care on the rise </li></ul><ul><ul><li>$126M (2007) to $188M (2009) </li></ul></ul>
  8. 8. The Montefiore Model <ul><li>“ Systemness” </li></ul><ul><li>Academic Medical Center </li></ul><ul><li>Employed physicians </li></ul><ul><li>Quality Improvement </li></ul><ul><li>Accept financial risk </li></ul><ul><li>Population-based strategy </li></ul><ul><li>Information Technology </li></ul>
  9. 9. Clinical Information Systems 100% MD Order Entry Scheduling Care Plans >600 Expert rules and Decision Support Problem List Rx Pad Doctor’s Office and Home Ambulatory Care Medical Group Hospitals 2 million patients Master Patient Index Lifetime Medical Record 100% MD Order Entry Scheduling Care Plans >600 Expert rules and Decision Support Problem List Rx Pad <ul><li>Clinical Looking Glass </li></ul><ul><li>Data Warehouse </li></ul><ul><li>Clinical Research </li></ul>
  10. 10. Over 85% of the Bronx Providers participating the Bronx RHIO
  11. 11. Montefiore-Albert Einstein College of Medicine An Academic Medical Center *All clinical faculty and MMG physicians are salaried by Montefiore ** Includes residents/medical students from New York Medical College
  12. 12. Montefiore Integrated Delivery System <ul><li>Inpatient Care – Over 93,000 admissions including 7,000 births </li></ul><ul><ul><li>Three general hospitals </li></ul></ul><ul><ul><li>Children’s hospital </li></ul></ul><ul><ul><li>1,500 beds </li></ul></ul><ul><li>Ambulatory Care – 2.5 million visits/year </li></ul><ul><ul><li>23 community primary care centers (>1 million visits) </li></ul></ul><ul><ul><li>16 school health centers (52,000 visits) </li></ul></ul><ul><ul><li>7 mobile healthcare units (11,000 visits) </li></ul></ul><ul><ul><li>3 major specialty care centers (> 1 million visits) </li></ul></ul><ul><ul><li>2 special care units (Child Advocacy Center; Lead Poisoning Prevention) </li></ul></ul><ul><ul><li>4 emergency departments (301,000 emergency visits ) </li></ul></ul><ul><li>Post-acute care </li></ul><ul><ul><li>Home care agency- 500,000 visits </li></ul></ul><ul><ul><li>Rehabilitation </li></ul></ul><ul><li>Geographic concentration </li></ul><ul><ul><li>90% of Montefiore’s patients from Bronx or Westchester </li></ul></ul>
  13. 13. The Montefiore Network
  14. 14. Experience with Pre-payment or Capitation
  15. 15. Risk Transfer Arrangements Savings Capitation
  16. 16. Montefiore IPA and CMO <ul><li>Formed in 1995 </li></ul><ul><li>MD/ Hospital Partnership </li></ul><ul><li>Contracts with managed care organizations to accept and manage risk </li></ul><ul><li>Over 1,900 physician members </li></ul><ul><ul><li>500 PCPs </li></ul></ul><ul><ul><li>1,400 Specialists </li></ul></ul><ul><li>Established in 1996 </li></ul><ul><li>Wholly-owned subsidiary of Montefiore Medical Center </li></ul><ul><li>Performs care management delegated by health plans </li></ul><ul><li>Licensed UR agent and certified claims adjustors </li></ul>Montefiore IPA CMO care management operations
  17. 17. Managing Care MMC’s Capitation Contracts Serve Our Community
  18. 18. Network Cross-Cutting Functions Care Management Activities for payers Acute Care Responsibilities <ul><li>Network Care Management </li></ul><ul><ul><li>Social Work/discharge planning </li></ul></ul><ul><ul><li>Utilization Review </li></ul></ul><ul><ul><li>Complex Case Action Team </li></ul></ul><ul><ul><li>Documentation Improvement </li></ul></ul><ul><ul><li>Patient Navigation </li></ul></ul><ul><li>Contact Center support to hospitalists </li></ul><ul><li>Patient Education </li></ul><ul><li>Data Analysis and Reporting </li></ul><ul><li>Medical staff and insurance credentialing </li></ul>Network Care Support <ul><li>Care Guidance </li></ul><ul><li>Chronic Care Management </li></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Respiratory </li></ul></ul><ul><li>High Cost/Risk </li></ul><ul><li>Telemonitoring </li></ul><ul><li>Palliative care </li></ul><ul><li>Post-Discharge Calls </li></ul><ul><li>Ambulatory EMR </li></ul><ul><li>Urgent care access </li></ul><ul><li>Medical home model </li></ul><ul><li>Call center support </li></ul><ul><li>On-site MMG case managers </li></ul><ul><li>Patient Education </li></ul><ul><li>House Calls </li></ul><ul><li>Online Patient Communication (MyMontefiore) </li></ul>CMO Care Management Operations
  19. 19. CMO
  20. 20. Next Step Toward Accountable Care Coordination Incentives CMS Medicare High Cost Beneficiary Demonstration The Bronx Collaborative <ul><li>Joint Venture with Bosch Healthcare </li></ul><ul><li>Over 6,000 Bronx Medicare FFS members </li></ul><ul><li>Not-for-profit NYS Corporation </li></ul><ul><li>Includes Montefiore; 2 other Bronx Hospitals;2 Health Plans </li></ul><ul><li>Managing care transitions </li></ul><ul><li>NYS Health Foundation funding for care transitions </li></ul><ul><li>Interdisciplinary care teams </li></ul><ul><li>2 pilot sites- 40k pts </li></ul><ul><li>Teaching/ nonteaching practices </li></ul><ul><li>Seeking NCQA certification </li></ul>Patient Centered Medical Homes
  21. 21. Future Opportunities <ul><li>Accountable Care Organization </li></ul><ul><ul><li>Health Care Reform </li></ul></ul><ul><ul><li>The Bronx Collaborative </li></ul></ul><ul><ul><li>The Bronx RHIO </li></ul></ul><ul><li>Improving medical cost savings initiatives </li></ul><ul><ul><li>Care Guidance Program: Population-based focus on managing the chronically ill </li></ul></ul><ul><ul><li>Proving the value of the CMS demonstration effect </li></ul></ul><ul><ul><li>Expanding House Calls, the physician home visit program </li></ul></ul><ul><li>CMO new business opportunities </li></ul><ul><ul><li>Care Management </li></ul></ul><ul><ul><li>Customer Service </li></ul></ul><ul><li>Expand Network Manager Role </li></ul>
  22. 22. Lessons Learned <ul><li>The Importance of commitment to: </li></ul><ul><ul><li>Integrated system of care </li></ul></ul><ul><ul><li>Quality, Safety and Service </li></ul></ul><ul><ul><li>Employed physician model </li></ul></ul><ul><ul><li>Information Technology </li></ul></ul><ul><ul><li>Alignment of financial incentives </li></ul></ul><ul><ul><li>Partnerships </li></ul></ul><ul><ul><li>Care Coordination </li></ul></ul>