The accountable care model is front and center on the national stage as healthcare providers, payers and policy makers look for ways to improve health outcomes while lowering costs.
One hospital has managed to do just that. Montefiore Medical Center, the university hospital of the Albert Einstein College of Medicine in the Bronx, N.Y., is using an infrastructure based on the principles of an accountable care organization that enables providers to effectively and efficiently manage the care of patients under capitated contracts with public and private payers.
Montefiore Medical Center is profiled in a report published in August on The Agency for Healthcare Research and Quality Innovations website. The report, entitled "Medical Center Establishes Infrastructure to Manage Care under Capitated Contracts, Leading to Better Chronic Care Management and Lower Utilization and Costs," explores Montefiore's care management program, consistent with the principles of an accountable care organization (ACOs), and highlights the hospital’s success in improving outcomes for patients with chronic disease.
In December 2011, the Centers for Medicare & Medicaid Innovation selected Montefiore to participate in its Pioneer Accountable Care Organization Program. The Montefiore Pioneer Accountable Care Organization is one of only 32 Pioneer ACOs in the nation and the only Pioneer ACO in New York State.
The Pioneer Program is a new federal initiative meant to improve the quality of care for Medicare beneficiaries and reduce expenditures through enhanced care coordination. Montefiore has offered advance models of care coordination and innovative payment methodologies since 1996.
Montefiore's ACO model has been successful in achieving improved management of diabetes, asthma, and congestive heart failure and reduced hospital admissions, readmissions, and medical expenses among several key populations.
Data from 2007 to 2010 cited in the report indicate Montefiore’s success in managing chronic diseases and lowering readmissions.
Between 2008 and 2010, emergency department visits among the asthma population declined from 987.9 per 1,000 patients to 974.3 per 1,000 patients, and inpatient admissions dropped from 254.9 per 1,000 to 193.4. In addition, 30-day readmission rates for this population fell from 13 percent to 8 percent, and total medical costs per year decreased from $3,814 to $3,771.
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.
Among diabetes patients, inpatient admissions per 1,000 declined by 25 percent, from 489 to 365 per 1,000 between 2007 and 2010. For high-risk diabetes Medicare patients, inpatient admissions declined 28 percent, from 678.1 to 488.8 per 1,000 over the same period.
Total healthcare costs for the at-risk diabetes populations declined by 7 percent over the same period. In the Medicare group, total health care costs declined by 10 percent. At the same time, aggregate healthcare cost trends over the same period increased by at least 16 percent.
Montefiore attributes its success to its many comprehensive care management programs and its integrated network of four hospitals, 21 community-based primary care centers, school-based health centers, and mobile clinics, which are all interconnected through an electronic medical records system.
The AHRQ report describes various initiatives launched by Montefiore to comprehensively manage care through individualized care plans for patients with chronic or complex conditions. Among these initiatives is the House Calls Program, which provides primary care services for the homebound elderly, enabling them to maintain an independent lifestyle. Services include physical exams, preventive screenings, in-home medical tests, medication reconciliation, telemonitoring, and psychosocial support.
In a sample of 179 patients enrolled in the House Calls 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 at least one nursing facility placement after enrollment, compared to 38 percent in the year before.
Other initiatives include chronic care protocols 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.
Montefiore also uses individual care plans, care variation reports, and provider performance reports to help improve the quality of care for patients.
In addition, the AHRQ report addresses the benefits of Montefiore's value-based capitation programs – an alternative method of paying providers – compared to the traditional fee-for-service payment models which can result in ineffective, fragmented care.