Population Management at Montefiore

Population Management at
Montefiore
Date TBD
Stephen Rosenthal, MSc., MBA
President, Chief Operating Officer
CMO, The Care Management Company of Montefiore
DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.
Conflict of Interest Disclosure
<First Name> <Last Name>, <Degree>
Has no real or apparent conflicts of interest to report.
© 2014 HIMSS
Conflict of Interest Disclosure
<First Name> <Last Name>, <Degree>
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Salary:
Royalty:
Receipt of Intellectual Property Rights/Patent Holder:
Consulting Fees (e.g., advisory boards):
Fees for Non-CME Services Received Directly from a Commercial
Interest or their Agents (e.g., speakers’ bureau):
• Contracted Research:
• Ownership Interest (stocks, stock options or other ownership interest
excluding diversified mutual funds):
• Other:
© 2014 HIMSS
Learning Objectives
3-5 session learning objectives approved by HIMSS are placed
on this slide.
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START PRESENTATION SLIDES HERE
60-Minute Lecture
• Introduction by Moderator – 5 minutes
• The speaker must provide a 45-50 minute (please do not exceed
this time limit) PowerPoint presentation (approx. 25-30 slides).
• 5-10 minutes at the end for Q&A
Who We Are
• Children’s Hospital at Montefiore
• Montefiore Einstein Center for Cancer Care
• Montefiore Einstein Center for Heart and
Vascular Care
• Montefiore Einstein Center for Transplantation
Notable
Centers of
Excellence
Teaching
• ~1,323 Residents & Fellows
• ~420 Allied Health Students
• ~1,552 Graduate &
Undergraduate Nursing
• ~200 Home Health Aides
• ~100 Social Workers
Research
Academic
• Clinical
• Translational
• Health
Services
Health
System
Community
Hospitals
•
•
•
•
8 Campuses
6 Hospitals
1,930 Beds
150 Skilled
Nursing Beds
• 1 Freestanding
ED
Population
Health
• ~21,370 Employees
• ~3,250 Medical Staff
• ~3,450 Integrated Provider
Association Physicians
• ~2,750 Employed MDs
• ~4,270 RN/LPN
• ~3,300 NYSNA RNs
• ~10,280 SEIU/1199
Workforce
•
•
•
•
•
•
•
•
•
Health Education
Community Advocacy
Wellness
Disease Mgmt.
Nutrition
Obesity Prevention
Physical Activity
Reduce Teen Pregnancy
Lead Poisoning Prevention
•
•
•
•
•
•
•
Primary &
Specialty
Care
•
•
•
•
Neuroscience
Orthopedic
Ophthalmology
OB/GYN
Home
Care
• Advanced Primary • Home Health
Care
Programs
• Sub-specialty Care • Primary Care
• Dental
• House Call
• School Based
Program
Health Centers
• Mobile Health
Corporate
Functions
Information
Technology
Finance
Legal
Planning
Purchasing
Compliance
Marketing
Human
Resources
• Clinical
support
• Network
applications
CMO
• Care
Management
(>300K Covered Lives)
• Disease
Management
• Care Coordination
• Telemedicine
• Pharmacy
Education
Integrated Delivery System
Our Locations
1,930 Beds Across 6 Hospitals
– Including 120 beds at CHAM
– 86 NICU/PICU beds
150 Skilled Nursing Beds
154 Sites Including
64 Primary Care Sites
– 21 Montefiore Medical Group Sites
21 School Health Clinics
12 Mental Health/Substance Abuse Treatment
Clinics
65 Specialty Care Sites
– 2 Multi-Specialty Centers
– 6 Pediatric Specialty Centers
– 12 Women’s Health Centers
1 Freestanding Emergency Department
10 Dental Centers
5 Imaging Centers
Montefiore: An Introduction – Revised 1/2014
Evolving Financial
Environment in Healthcare
Historically, Cost Shifting Offered
Approach for Financial Sustainability
Hospital Operating Margins by Payer, 2006*
Medicaid
Medicare
Commercial
25%
20%
15%
23%
10%
Cross-subsidization
5%
0%
-5%
-10%
-14.70%
3.8%
overall
margin
-9.40%
-15%
-20%
*Source: http://publications.milliman.com/research/health-rr/pdfs/hospital-physician-costshift-RR12-01-08.pdf, shows hospital operating margins by payer from 2006, based upon
American Hospital Association survey data
Never the Sole Option in Environments
with Minimal Commercial Base
Bronx:
1.4 M Residents
725 K
Medicaid
70 K
Duals
179 K
Medicare
Current Bronx Total Health Care Spend = $12 B
80% of Medical Expense paid by Medicare and Medicaid
Source: 2013 Greater NY Hospital Association Analysis; 2013 CMB Medicare
Advantage Data; 2010 Milliman Analysis; 2010 NY Dept. of Health
Alternative to Cost Shifting
Medicaid
Medicare
Commercial
25%
20%
15%
23%
10%
5%
0%
-5%
-9.40%
-10%
-14.70%
-15%
-20%
Focus on efficiency and rooting out
waste to improve operating margins
The New Status Quo
Changing dynamics necessitate new cost
efficiency strategies, regardless of payer
mix, population, or geography.
The Montefiore Approach to
Cost Efficiency: Care Guidance
Have developed
care guidance
program based
upon premise that
20% of a
population drives
80% of the costs
and requires more
intensive wraparound services
Evolving Financial Arrangements Support
Care Guidance Approach
14
Care management
infrastructure
Major expansion
development: IT,
of risk
data analytics,
membership
chronic care
programs and
extension of care
Established the
management core
Montefiore IPA and
competencies into
CMO to facilitate
the network
risk contracts
Montefiore
leads
creation of
Bronx RHIO
and
founding of
Bronx
Collaborative
Montefiore
selected as
Pioneer ACO
Formation of
Montefiore led
Medicaid Health
Home Program
Expansion
of
Pioneer ACO
Our Current Portfolio
Source
2013 Population
2013 Est.
Revenue
Risk Contracts
180,000
$1,085 m
Shared Risk
80,000
$685 m
Medicaid Health Home
(Care Coordination)
10,000
$18 m
270,000
$1,788 m
The organization is moving from a transaction-oriented business to a
value-based source of revenue.
Key Components of
Accountable Care:
Defining and Care Managing the
Population Driving Cost
16
Leveraging Data to Identify the “20%”:
High Risk Patients
15
Care Guidance Components to Serve
the Identified Population:
Community Programs Promote
Wrap-around Care
16
Key Components of
Accountable Care: Robust
Post-Acute Care Approach
16
Ongoing/Post Acute Care and
Population Management
• Total Cost of Care
–
The Full Continuum of Care
• Patient Experience
–
Efficiency and Quality
• End of Life Care
–
–
27
Palliative Care
Hospice Care
The Post-Acute Care Environment
• Financial changes
• Diversification in Nursing Home product lines
• Shift to insurer
• Consolidation of organizations
And…
28
Source: The Advisory Board, Next-Generation Partnership Strategy, Strategies for Promoting
Growth through Enhanced Alignment with Acute Care Providers
Montefiore ACO Nursing Facility PostAcute Care Activities
• Training:
– Palliative and Hospice Care Management program helped educate SNF
staff on how to have difficult conversations
– Brought on wound care specialist to inform approaches to deep bone
osteomyelitis among SNF residents
– Leveraged staff to educate the facilities on management of Congestive
Heart Failure
• Launched a comprehensive partnership strategy
with select nursing facilities
30
Accountable
Care in Action:
Pioneer ACO
Pioneer ACO Financing
• 60% of maximum savings are eligible in first year,
gains or losses are capped at 10% of gross spending
• 70% of maximum savings are eligible in 2nd year,
gains or losses are capped at 15% of gross spending
• Third year option to change to a global payment
• Annual Medicare spending per ACO beneficiary
compared to national reference population with
some regional adjustment
25
Pioneer ACO
Savings
• Year One: Generated 24 million in savings against benchmark
– 14 million (60%) retained by Montefiore ACO
• Year Two: Creating sustainable cost reduction
– New Partners
– Patient Population Turnover and Growth
Quality Requirements
• 33 measures of quality performance reported in 4 domains
– Patient/Caregiver Experience
– Care Coordination/Patient Safety
– Preventive Health
– At-Risk Populations
• Performance scoring methodology
– Each domain weighted equally
– Comparison to national performance benchmarks
– Minimum attainment levels: each measure must score over the 30th percentile
– Performance at or above 90th percentile will earn maximum points
• ACO can be placed on corrective action plan if not achieving minimum
level on at least 70% of the measures
• Results will be publicly reported
Pioneer Year 1: Inpatient Admissions
decreased 10.4%
Number of Admissions/ 1000
person years
600
500
518
495
400
477
464
300
200
100
0
Q1
Source: CMMI PY1 Pioneer ACO Data Analysis
Q2
Q3
Q4
Pioneer Year 1: Inpatient Admissions for
Heart Failure decreased 5.6%
Number of Admissions/
1000 beneficiaries
25
20
21.1
19.87
19.88
15
10
5
0
Q1
Source: CMMI PY1 Pioneer ACO Data Analysis
Q2
Q3
Pioneer Year 1: All Cause Readmissions
declined by 35.5%
Number of Readmissions/
1000 beneficiaries
250
200
201.2
198.9
191.1
150
128.3
100
50
0
Q1
Source: CMMI PY1 Pioneer ACO Data Analysis
Q2
Q3
Q4
Pioneer Year 1: Inpatient Admissions for
Diabetes decreased 45.7%
Number of Admissions/
1000 beneficiaries
0.9
0.83
0.8
0.7
0.63
0.6
0.57
0.5
0.45
0.4
0.3
0.2
0.1
0
Q1
Source: CMMI PY1 Pioneer ACO Data Analysis
Q2
Q3
Q4
Accountable
Care in Action:
Other Populations in
Montefiore’s Risk Portfolio
Diabetes Admissions Decline by
13% in 4 Years
(N=5,325)
(N=5,871)
(N=6,102)
(N=5,868)
35
Diabetes 30-Day Readmission
Rates Decline 11%
(N=5,325(N=5,871(N=6,102
(N=5,868
)
)
)
)
Effective Management of Diabetes has
resulted in a 12% Drop in Total Costs
Note: Rx costs not available
Note: Projected Costs Estimated using healthcare inflation trend of 16%
34
Source: CMO Medical Expense Report; Author: H. Shao
Asthma Admissions Decline 25%
in 4 Years
(N=
(N=
(N=
(N=
1,817) 2,135) 2,178) 2,138)
33
Asthma 30-Day Readmissions
Decline 30% in 4 Years
(N=
(N=
(N=
(N=
1,817) 2,135) 2,178) 2,138)
Accountable
Care: Lessons
Learned
Keys to Success in Starting an ACO
• Overarching vision, clear governance structure,
and aligned operations
• Must define and understand the population
• <20% of the population determine the costs,
100% determine the quality of care
• Developing an ongoing care and population
management strategy
The Future:
Reaching One Million Lives
Newly Insured
Individuals
enrolling in
Exchanges/
Medicaid
Individuals in
FFS converting to
managed care
Expanding into
new geographic
areas
Partnerships
with key provider
networks
Marketshare
Growth among
partners
Questions?
Thank You!
Stephen Rosenthal, [email protected]

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