Click to edit Master title style Moving Toward an Accountable Care Organization Montefiore Medical Center Donald Ashkenase, MHA Special Advisor to the

Click to edit Master title style

Moving Toward an Accountable Care Organization

Montefiore Medical CenterDonald Ashkenase, MHA

Special Advisor to the President

National Academy for State Health Policy23rd Annual State Health Policy Conference

October 4-6, 2010


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Moving Toward an Accountable Care 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

Click to edit Master title styleClick to edit Master title style

Care Management


4

Today’s 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:Poor, Minority, Young, Heavy Disease Burden

0%

5%

10%

15%

20%

25%

30%

Bronx New York City New York State

Population < Poverty Bronx vs NYC and NYS

Age

20-44 years

65+ years 0-19

years45-64 years

Race / Ethnicity

Hisp.48%

Black31%

Other3%White

15%

Asian3%

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

ACS

Adm

its/K

Ambulatory Care Sensitive Hospital Admits

ACS Admits/K 9.95 13.98 10.98 8.26 7.85 8.60

New York City Bronx Brooklyn Manhattan Queens Staten Island


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Highest Overall Morbidity* in NYS

0

10

20

30

Fair or poor health Low Birth Weight Diabetes Asthma

Bronx

NYC

NY State

US 90th percentile

Perc

ent

of R

esi

den

ts

Sources: 2010 County Health Rankings, Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute; www.counthealthrankings.org/new-york.com

*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 MeasuresBronx vs. other NYC, NY State and US Averages - 2010


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Montefiore: “The Public Option”

• 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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The Montefiore Model

• “Systemness”• Academic Medical

Center• Employed physicians• Quality Improvement• Accept financial risk • Population-based

strategy• Information

Technology


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Clinical Information Systems

100% MD Order Entry

Scheduling

Care Plans

>600 Expert rules and Decision

Support Problem ListRx 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 ListRx Pad

Clinical Looking Glass•Data Warehouse•Clinical Research


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Over 85% of the Bronx Providers participating the Bronx RHIOOver 85% of the Bronx Providers participating the Bronx RHIO


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Montefiore-Albert Einstein College of MedicineAn Academic Medical Center

*All clinical faculty and MMG physicians are salaried by Montefiore** Includes residents/medical students from New York Medical College

NY Medical College Montefiore AECOM

ResearchTeachingPatient Care

2500 Medical Staff - 900 Voluntaries - 1600 F/T Faculty* - 427 PCPs* - 37 Hospitalists3200 RN/ LPN (F/T, P/T, PD)600 Allied Staff

1,100 Housestaff **- 120 Medical Students**- Health Professional Ed. - CME

- Basic- Clinical- Translational- Health Services


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MontefioreIntegrated 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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The Montefiore Network


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Experience with Pre-payment or Capitation


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Risk Transfer Arrangements

Savings

Capitation Premium

Insurance Company

Provider-Sponsored IPA(Risk Bearing)

MSO

Primary Care HospitalSpecialty Care

▪ Capitation Payments to IPA▪ Savings Delivery System


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Montefiore IPA and CMO

• 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

• Established in 1996• Wholly-owned subsidiary of

Montefiore Medical Center• Performs care

management delegated by health plans

• Licensed UR agent and certified claims adjustors

Montefiore IPA CMO care management operations


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Managing CareMMC’s Capitation Contracts Serve Our Community

MMC Capitated EnrolleesN=150,000

($750m in premium revenue)

Medicaid58,000

Medicare27,000

Commercial65,000

IPA/CMON=20,000

HealthfirstN=38,000

IPA/CMON=20,000

HealthfirstN=7,000


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Care ManagementActivities for payers

Network Cross-Cutting Functions

Acute CareResponsibilities

• 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 CareSupport

• 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)

CMOCare Management Operations


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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 Coordination Incentives

CMS Medicare High Cost Beneficiary

Demonstration

The BronxCollaborative

•Joint Venture with Bosch Healthcare

•Over 6,000 Bronx Medicare FFS members

•Not-for-profit NYS Corporation

•Includes Montefiore; 2 other Bronx Hospitals;2 Health Plans

•Managing care transitions

•NYS Health Foundation funding for care transitions

•Interdisciplinary care teams

•2 pilot sites- 40k pts

•Teaching/ nonteaching practices

•Seeking NCQA certification

Patient Centered Medical Homes


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Future 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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Lessons Learned

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

Documents

Click to edit Master title style Moving Toward an Accountable Care Organization Montefiore Medical Center Donald Ashkenase, MHA Special Advisor to the