SummaryMontefiore Medical Center, the university hospital of the Albert Einstein College of Medicine, established an infrastructure based on the principles of an accountable care organization to allow providers to effectively and efficiently manage the care of patients under capitated contracts with public and private payers. This infrastructure includes The Care Management Company of Montefiore, a wholly owned subsidiary of Montefiore that provides care coordination, chronic care management, provider and customer service, and other administrative functions, and an independent practice association that includes Montefiore's delivery system and community-based and employed providers. Other key aspects of the accountable care organization approach include electronic medical records with links to a regional health information organization, ongoing support based on level of health risk, a physician house call program to provide care to homebound patients, and a care guidance program. Montefiore has achieved improved management of diabetes, asthma, and congestive heart failure and reduced hospital admissions, readmissions, and medical expenses among several key populations.Moderate: The evidence is based on internal reviews of programs that compared the programs' effect on chronic disease management, admission and readmission rates, and medical expenses with comparable patient groups that were not program participants or with data from program participants before enrollment.
Date First Implemented1995
Problem AddressedTraditional models of health care financing and delivery have multiple drawbacks that often lead to ineffective and/or inefficient care, including a reliance on reactive rather than proactive care, coverage denials that may harm patient health, and gaps in care when patients move between settings. Montefiore faced the additional challenge of treating a largely low income population with high rates of chronic illness.
- Reactive rather than proactive care: Individuals generally are responsible for monitoring their own health and deciding when to seek care, even when they suffer from chronic illnesses that would benefit from ongoing care management. As a result, many people wait to seek care until they have serious symptoms, which tend to be more costly and treatment is less effective than if the underlying condition(s) had been diagnosed and addressed earlier. In poor communities, delays in seeking treatment often lead to excessive reliance on costly emergency department (ED) visits that sometimes result in avoidable hospital admissions.1
- Coverage denials that may harm patient health: Private payers, especially those that reimburse under fee-for-service (FFS) payment systems, often put in place utilization review processes that evaluate whether a proposed service (e.g., surgery, hospital stay) is necessary and hence will be reimbursed. In some cases, decisions end up being made by people unfamiliar with a patient's full medical history, leading to denials that negatively affect patient care.2
- Care gaps as patients move between settings: Patients with multiple chronic illnesses who see numerous physicians often face care gaps that negatively affect their health because of inadequate education about how to manage their condition, conflicting advice regarding care, the lack of a single provider responsible for monitoring and coordinating care, and/or ineffective communication across providers.3
- A challenging population: Montefiore serves a largely low-income, minority population: 31 percent of Bronx residents live below the poverty line (making it the nation's poorest urban county) and over three-quarters of the county's residents is Hispanic and/or African American. The Bronx has a higher than average mortality rate, and many residents suffer from one or more chronic illnesses such as asthma, heart disease, obesity, and diabetes. About 12 percent of the population has diabetes.4
Description of the Innovative ActivityMontefiore established an infrastructure based on the principles of an accountable care organization (ACO) to allow providers to manage the care of patients under capitated contracts with public and private payers effectively and efficiently. This infrastructure includes CMO (The Care Management Company of Montefiore), a wholly-owned subsidiary of Montefiore that provides care coordination, chronic care management, provider and customer service, and other administrative functions, and an independent practice association that includes Montefiore's delivery system and community-based and employed providers. Other key aspects of the ACO approach include electronic medical records with links to a regional health information organization, ongoing support based on level of health risk, a physician house calls program to provide care to homebound patients, and a Care Guidance Program. Details on each of these components follow:
- Care management company: CMO, the Care Management Company of Montefiore, is a wholly-owned subsidiary of Montefiore. It currently administers Montefiore's capitated contracts with insurers covering roughly 140,000 individuals, including 100,000 with employer-sponsored insurance and 40,000 enrolled in Medicare and Medicaid managed care programs as well other value-based, shared savings arrangements.
- Montefiore Independent Practice Association (IPA): The Montefiore IPA includes Montefiore’s employed and private practice, community-based, affiliated providers, and represents a broad network of providers, who receive FFS payments plus performance-based incentives. The Montefiore IPA currently has contracts with roughly 2,400 physicians, 1,600 of whom who are Montefiore employees who work at Montefiore’s four hospitals and its approximately 100 primary and specialty outpatient offices, and 800 community-based, private-practice physicians. An example of a performance-based incentive is the Bronx Community Health and Acute Medical Performance Improvement Organizational Network (CHAMPION) Program, a multistakeholder, pay-for-performance program developed with competitive funding from the New York State Department of Health. Montefiore developed this program with significant provider input. Standardized performance measures were selected, primarily those defined by the National Committee for Quality Assurance (NCQA) for comprehensive diabetes care. Montefiore has expanded the program to pediatric providers and populations and is using it to incentivize provider performance in other major initiatives, such as patient-centered medical home reporting, meaningful use of electronic health records, and its Pioneer ACO program.
- Integrated electronic medical record (EMR) with link to community-wide system: Montefiore’s employed providers have access to both inpatient and outpatient EMRs, allowing them to access and share up-to-date information about their patients, communicate among themselves, and submit laboratory and pharmacy orders electronically. They and other Bronx providers also have access to patient data through the Bronx Regional Health Information Organization (Bronx RHIO), a borough-wide system that supports data exchange between Bronx hospitals, health centers, nursing homes, home care agencies and community-based physician practices for patients who have signed data-sharing consent forms.
- House calls program: The Montefiore Medical House Calls Program, launched in 2004 to provide primary care for the vulnerable elderly, addresses patients' need for an independent lifestyle, the comforts of home, and psychosocial support. Program services include physical exams, preventive screenings, in-home medical tests, medication reconciliation, telemonitoring, and limited psychiatric care.
- Ongoing support based on level of health risk: CMO uses software that analyzes clinical and claims data to stratify the patients it manages into three health risk categories, with ongoing support given based on the level of risk, as outlined below:
- The "worried well": These individuals are in generally good health but may have occasional ailments or health concerns. CMO supports them by focusing on education, often delivered through Web-based links, and providing reminders to access preventive health measures (mammograms, flu shots, etc.).
- Functional chronically ill: This group includes patients with one or more chronic illnesses who can perform most daily activities, such as working and exercising. CMO offers them group classes on managing chronic conditions and encourages them to see their primary care physicians (PCPs) regularly and other appropriate professionals (e.g., diabetes educators), as needed. Physicians manage these patients according to care plans (which the patients also receive) and the patients have access to various tools for self-monitoring.
- Frail ill: Patients in this group have multiple chronic conditions and generally need assistance to meet their health care needs. CMO can provide intensive support, including home visits or telemonitoring devices as needed, and frequent phone calls from care managers, with outreach being particularly aggressive after a hospital stay to reduce the risk of readmission.
- Care Guidance Program: The CMO, as the entity supporting the risk-based contracts of the Montefiore IPA, has created a systematic process for care management, evaluation and continuous quality improvement. The process includes standard protocols and processes, individualized care plans and patient data reports.
- Chronic care protocols: Protocols have been established to guide care for those with various chronic diseases, including diabetes, asthma, heart failure, chronic obstructive pulmonary disease, and depression. These protocols help providers offer more consistent care at each stage of illness, thus reducing unwarranted variations that drive up costs and undermine quality.
- Individual care plans: Patients in need of case management services receive a comprehensive baseline assessment which in turns triggers development of a comprehensive, individualized care plan with interventions linked to specific problems. Some of the most commonly identified problems and the linked interventions include: patients taking multiple and sometimes conflicting medications, which can result in a detailed pharmacy review and followup calls to patients, their physicians and pharmacies; patients who are unable to travel to their physician appointments, which can result in referral to Montefiore's physician home visit program; patients with recently diagnosed or poorly controlled diabetes, which can result in an educational mailing and referral to a certified diabetes educator for one-on-one counseling or a group class; and patients with minimal financial resources to address their health care needs, which can result in referral to community-based and government sponsored programs.
- Care variation reports: These reports, generated from the data analysis process described above, are shared with physicians in their offices during patient "rounding" sessions with CMO nurses (e.g., patient rounds). The reports highlight potential need for specific interventions for individual patients and followup reports determine whether the interventions have had the expected impact, thus allowing care plans to be refined as necessary based on individual patient needs.
- Performance reports: The CMO produces periodic reports that compare performance on various metrics across providers. For example, reports compare physician-specific outcomes on key metrics for groups of patients with specific conditions. Allowing physicians to see how their patients fare in comparison to peers creates an incentive to either continue strong performance or to improve.
Context of the InnovationThe largest health care provider in the Bronx, Montefiore Medical Center consists of four hospitals with nearly 1,500 total beds and a network of roughly 100 outpatient facilities, including 21 community-based primary care centers, school-based health centers, and mobile clinics. Montefiore serves as the teaching hospital for Albert Einstein College of Medicine, which offers a residency program to train PCPs to work in medically underserved areas. The medical center serves a largely low-income, minority population, and Medicare and Medicaid cover roughly 80 percent of Bronx residents who have insurance.
The impetus for this program came from growing awareness among Montefiore leaders of three major trends in the early 1990s—rising health care costs, declining Medicaid and Medicare reimbursements, and an increase in the proportion of Bronx residents with multiple chronic diseases. As a result, these leaders began looking for a new business model that would allow the medical center to continue providing high-quality care while maintaining the financial stability of the organization.
ResultsMontefiore has achieved improved management of diabetes, asthma, and congestive heart failure and reduced hospital admissions, readmissions, and medical expenses among several key populations.
Moderate: The evidence is based on internal reviews of programs that compared the programs' effect on chronic disease management, admission and readmission rates, and medical expenses with comparable patient groups that were not program participants or with data from program participants before enrollment.
- Improved diabetes management: By the third year of the Bronx CHAMPION program, the proportion of diabetic patients with blood glucose (HbA1c) levels greater than 9 percent was 14 percent; the comparable national NCQA rate was 45 percent for Medicaid health plans and 28 percent for commercial health plans. The proportion of diabetic patients with low-density lipoprotein (LDL) cholesterol less than 100 was 63 percent at Montefiore, compared to the U.S. Medicaid health plan rate of 34 percent and the commercial health plan rate of 46 percent. In Montefiore's capitated population, the quality improvement and chronic care strategies have yielded similar quality improvements. The following results were achieved for 2,575 Medicare diabetic patients meeting HEDIS® (Healthcare Effectiveness Data and Information Set) qualifications managed by CMO during 2010:
- 8.5 percent of patients had an HbA1c over 9 percent.
- 80 percent of patients had an HbA1c under 8 percent.
- 53.5 percent of patients received microalbumin testing.
- 86 percent of patients had an LDL under 130.
- 62.9 percent of patients had an LDL under 100.
- Improved asthma management: In a population of patients with asthma managed by CMO, there were declines in ED visits between 2008 and 2010 (987.9 per 1000 to 974.3 per 1000), inpatient admissions (254.9 per 1000 to 193.4 per 1000), 30-day readmission rates (13 percent to 8 percent); and total medical costs per year ($3,814 to $3,771).
- Improved congestive heart failure management: For patients with congestive heart failure during the same period, ED visits declined from 550.3 per 1000 to 500.0 per 1000, inpatient admissions declined from 1,426.2 per 1000 to 1,334.2 per thousand, and total annual medical costs declined from $33,847 to $33,697.
- Reductions in admissions, readmissions, and medical expenses among key populations: Positive findings include the following:
- Reduced hospital admissions and medical expenses among diabetes patients: In the capitated population managed by CMO, the findings in an at-risk diabetes cohort (those with an index HbA1c over 7 percent in a calendar year) were as follows between 2007 and 2010:
- Inpatient admissions: Inpatient admissions per 1,000 declined by 25 percent, from 489 to 365 per 1,000. For Medicare patients, inpatient admissions declined 28 percent, from 678.1 to 488.8 per 1,000.
- Medical expenses: Total health care costs declined by 7 percent over the same period. This is a significant achievement, given that aggregate health care cost trends over the same period increased by at least 16 percent. In the Medicare group, total health care costs declined by 10 percent.
- Reduced inpatient admissions and readmissions among Medicare patients: In 2009, Medicare patients covered by CMO experienced a 7.4 percent rate of "potentially preventable readmissions" and a 26.1 percent rate of "potentially preventable admissions." By contrast, the rates for the entire Bronx Medicare Advantage population were 8.6 percent for preventable readmissions and 30 percent for preventable admissions.
- Reduced admissions to hospitals and skilled nursing facilities among house calls program participants: In a sample of 179 patients enrolled in the program (the majority of whom were nonwhite, low-income, and elderly), 38 percent of patients had one or more hospitalizations in the year after enrollments, compared to 61 percent in the year before enrollment. Similarly, 18 percent had least one nursing facility placement after enrollment, compared to 38 percent in the year before. In addition, a patient satisfaction survey of 620 program participants found that 93 percent of the 191 respondents reported that services were "good" or "very good."5
Planning and Development ProcessSelected steps included the following:
- Building on existing services: Before establishing the CMO, Montefiore had spent 30 years building a health care delivery system that included hospitals, ambulatory centers, skilled nursing and rehabilitation facilities, primary care programs reaching into public schools, substance abuse clinics, homeless shelters, and other resources. To address issues of access to care for Bronx residents, in the early 1990s, Montefiore's leadership began to organize the provider community as an IPA that, in combination with the medical center's facilities and program, would form an integrated delivery system centered on the medical center. During this phase, medical center leaders held frequent formal and informal meetings with physicians to discuss how the new model would work and answer their questions.
- Launching the IPA and CMO: In 1995 and 1996, Montefiore formally launched the Montefiore IPA, which includes Montefiore's employed physicians, community-based providers, and Montefiore’s delivery system in its membership and governance structure, as the new provider network along with the CMO to provide care coordination and manage insurance contracts.
- Early and ongoing growth: In subsequent years, the CMO continued to grow, investing in managed care capabilities, chronic care management programs, and information technology to promote the provision of high-quality, coordinated services across the network. By 1999, the Montefiore IPA had 50,000 capitated lives and CMO continued to evolve its Care Guidance Program to meet the needs of the covered population. The CMO continued to expand its infrastructure, resources, and services, especially use of chronic care management programs.
- Strategic plan: In 2008, Montefiore engaged both internal and external stakeholders in the development of a strategic plan to prepare it to adapt to rapidly changing regional and national landscapes while renewing its commitment to its core values of healing, teaching, and advancing the health of the communities it serves.
- ACO planning structure: In 2010, Steven M. Safyer, Montefiore's president, directed the establishment of a high-level ACO planning structure in anticipation of Federal, state, and private payer opportunities focused on population health management. In 2011, Montefiore was 1 of 10 organizations that participated in NCQA's beta testing of its ACO accreditation standards and processes, and in December, the Center for Medicaid and Medicare Innovation designated it as one of 32 "Pioneer ACOs."
Resources Used and Skills Needed
- Staffing: The CMO has over 400 full-time employees involved in care management and other activities delegated through health plan contracts. These include more than 200 clinicians, primarily registered nurses, licensed practical nurses, social workers, and pharmacists involved in care management; more than 100 customer service liaisons in the contact center; 40 analytic professionals to develop scalable population and care management strategies and analytic tools; and provider relations, credentialing, contracting, billing, IT and finance professionals, as well as administrative support personnel.
- Costs: The ongoing costs of maintaining the CMO's infrastructure are approximately 6 percent of the total capitated premium revenue. The early capital investments in IT and other infrastructure costs are in addition to the ongoing costs of the company.
Getting Started with This Innovation
- Emphasize patient benefits and flexibility: Evolving into an ACO structure represents a change for physicians, who may not fully appreciate the consequences of this movement towards performance measurement. To win their support, Montefiore's leadership engaged both the employed medical staff and affiliated community-based physicians in extensive discussions highlighting the model's ability to enhance the focus on patient care and provide physicians with greater freedom and flexibility to develop creative ways to manage the health of their patients.
- Engage "ambassadors" to sell physicians on team approach: Physicians are used to working independently with patients on a one-on-one basis. Yet this new approach requires much more of a team orientation, especially during care episodes and transitions. To convince physicians of its merits, Montefiore first engaged the organization's medical directors and senior leaders in the principles and goals of the new approach, and then let these individuals serve as program ambassadors, selling its merits across the physician community through one-on-one conversations.
- Focus on long-term effects: Early on, Montefiore's leadership highlighted the inefficiencies of traditional health care models and the potential long-term benefits that an accountable care structure can bring. This approach helped to engage professionals and set realistic expectations about the kinds of changes likely to occur.
Sustaining This Innovation
- Appeal to physicians' competitive spirit: Periodic reports help physicians see how they compare to their peers in terms of patient care and outcomes, creating an incentive to maintain strong performance or to improve poor performance.
- Avoid technological complacency: Because EMR technology tends to change quickly, health system leaders need to carefully consider the appropriate time to upgrade. Montefiore has made several significant enhancements to its clinical information and care management systems over the years.
- Customize protocols as necessary: Protocols need to allow for customization and tailoring based on individual needs, thus ensuring effective care and treatment of individuals from different backgrounds and cultures.
Contact the InnovatorStephen Rosenthal
President and Chief Operating Officer
CMO-Montefiore Care Management
200 Corporate Blvd.
South Yonkers, NY 10701
Innovator DisclosuresDr. Rosenthal disclosed that this work was funded in part by small programmatic grants from United Hospital Fund, the New York State Health Foundation and the New York Community Trust. He also reported receiving small grants for other work from the New York State Health Foundation, the New York Community Trust, and the United Hospital Fund.
Dr. Rosenthal serves as a Board Member of HealthFirst, a not-for-profit Medicare/Medicaid insurance company, of which Montefiore is a part owner.
References/Related ArticlesChase D. Montefiore Medical Center: Integrated care delivery for vulnerable populations. The Commonwealth Fund. 2010 Oct;53(1448). Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Oct
/1448_Chase_Montefiore_Med_Ctr_case_study_v2.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Dennard J. Finding the right fit: Montefiore's ACO solutions. Billian's Healthdata. January 19, 2011. Available at: http://www.billianshealthdata.com/news/SiteNews/news_items/2011/January/Montefiore_News.html.
Montefiore Medical Center: On the cutting edge of accountable care. Modern Healthcare Insights. August 29, 2001. Available at: http://www.modernhealthcare.com/article/20110829/RESEARCH/110829981. (Purchase required.)
Wajnberg A, Wang KH, Aniff M, et al. Hospitalizations and skilled nursing facility admissions before and after the implementation of a home-based primary care program. J Am Geriatr Soc. 2010;58(6):1144-7. [PubMed] Available at: http://www.iahnow.com/pdfs/hospitalizationSNadmissionsbeforeandafterhousecall.pdf
Goldberg RJ, Goldberg JH, Pruell S, et al. Delays in seeking medical care in hospitalized patients with decompensated heart failure. Am J Med. 2008 Mar;121(3):212-8. [PubMed]
Moore C, Wisnivesky J, Williams S, et al. Medical errors related to the discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-51. [PubMed]
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Original publication: August 15, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: July 29, 2013.
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