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 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

Care Management

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

The Bronx: Poor, Minority, Young, Heavy Disease Burden

Highest Overall Morbidity* in NYS Sample Population Health Status Measures Bronx vs. other NYC, NY State and US Averages - 2010 Percent of Residents *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

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)

The Montefiore Model “Systemness” Academic Medical Center Employed physicians Quality Improvement Accept financial risk Population-based strategy Information Technology

Clinical Information Systems 2 million patients Master Patient Index Lifetime Medical Record Doctor’s Office and Home 100% MD Order Entry 100% MD Order Entry >600 Expert rules and Decision Support >600 Expert rules and Decision Support Scheduling Scheduling Ambulatory Care Problem List Problem List Rx Pad Rx Pad Care Plans Care Plans Medical Group Clinical Looking Glass Data Warehouse Clinical Research Hospitals

Over 85% of the Bronx Providers participating the Bronx RHIO

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

Montefiore Integrated 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

The Montefiore Network

Experience with Pre-payment or Capitation

Risk Transfer Arrangements Capitation Savings

care management operations Montefiore IPA and CMO CMO care management operations 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 Established in 1996 Wholly-owned subsidiary of Montefiore Medical Center Performs care management delegated by health plans Licensed UR agent and certified claims adjustors

Managing Care MMC’s Capitation Contracts Serve Our Community

Network Cross-Cutting Functions CMO Care Management Operations Acute Care Responsibilities Care Management Activities for payers Network Care Support 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 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)

CMO

Next Step Toward Accountable Care Coordination Incentives CMS Medicare High Cost Beneficiary Demonstration The Bronx Collaborative Patient Centered Medical Homes 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

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

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