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A Pioneer ACO success story: Planning, infrastructure and compassion

October 1st, 2013

by Stephen Rosenthal

It is widely recognized in the healthcare field that a small percentage of complex patients drive the majority of expenses. This is true nationally as well as in the Bronx, New York, one of the nation's poorest and sickest counties, where Montefiore Medical Center is located.

With more than 15 years of experience taking accountability for the health of patients through targeted, customized care, Montefiore was an accountable care organization before there were ACOs. We have spent years implementing and fine-tuning a system that addresses the complex and challenging needs of a population facing severe poverty, a high disease burden and lack of access to healthy foods and housing.

Because of Montefiore's experience managing those challenges, the academic medical center was selected in 2011 as one of 32 Pioneer ACO models in the United States by the Centers for Medicare & Medicaid Services' Innovation Center.


In the first year, Montefiore was able to achieve the triple aim of improved quality, patient outcomes and a significant lowering of costs. Montefiore also achieved the highest financial performance of all Pioneer ACOs, which equaled a 7 percent reduction in the cost of care or a savings of $23 million to Medicare. Based on those results, Montefiore received $14 million of the savings.

So what made Montefiore's first-year efforts a success? We have found, and healthcare experts agree, the following attributes are needed:

  • A strong primary care network supported by access to specialty, ancillary and hospital care;
  • Administrative, management and analytic acumen to plan budgets and resource needs and support reliable performance measurement;
  • A clear organizational mission and commitment to achieve quality and cost efficiencies; and
  • Robust health information technology to manage patients across the continuum of care and across institutional settings.

Based on Montefiore's strong foundation in those attributes, the first-year results were good news for Montefiore, but the broader implications are even more compelling. Montefiore's results show the Pioneer ACO model works and can be replicable beyond urban communities like the Bronx. They also reflect how targeted interventions can be effectively implemented to manage healthcare costs.

Patients enrolled in Montefiore's Pioneer ACO Chronic Care Management Program need and get more attention than most, and our care managers are known to go the extra mile to keep a patient healthy. Over the years, we have found simple solutions often have the biggest impact. Recently, a phone call from a care manager resolved a pharmacy billing error that had stopped an ACO patient from getting her prescriptions filled. Another care manager scheduled transportation and arranged for dental and eye care, enabling an ACO patient to get to his needed weekly medical treatments and treat the serious side effects of his disease.

In both instances, providing these simple supports prevented patients' health from deteriorating and requiring hospitalization or other more expensive treatment.

Our Pioneer ACO success is possible not only because of our dedicated and compassionate associates but also because of investments made in our integrated care delivery system, which includes employed and community-based physicians, and long-term care partners in the community. Our population health experience allowed us to organize human and technical resources to ensure the sickest among our Pioneer population were quickly identified and connected to the right care at the right time. We leveraged our existing EMR technology and providers' experience to understand our beneficiaries' medical, mental health and social needs, and determine appropriate interventions.

Overall, Montefiore's well-established disease and care management programs proved easily adaptable to the Pioneer population, and in year one, 10 percent of the 23,000 Pioneer beneficiaries received intensive care management. Our ED care navigator, post-discharge transitional care programs and house call program for homebound patients also proved to be important assets.

We also have learned lessons along the way. There is no single magic bullet to address the needs of patients. We must meet them where they are in life and health and offer numerous tools to address their needs successfully. We also recognize tremendous opportunity for continued improvement. Every provider, academic medical center and hospital can do better.

Montefiore's Pioneer ACO year one success demonstrates real change can happen with a vision, commitment and aligned financial incentives. We can make a positive impact on the quality, outcomes and value of care provided through Medicare, and must continue to push our system to do even better for the most vulnerable populations who deserve high-quality, effective and compassionate care.

Stephen Rosenthal, M.Sc., M.B.A., is vice president, care management at Montefiore Medical Center in the Bronx, N.Y.


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