A single mother in her 30s from the Bronx was not able to take care of her diabetes. In 2011, she entered a hospital 20 times, twice out of state.
Although the young woman knew about her disease and understood the importance of taking care of herself, she was "basically noncompliant with her care," which is why she ended up in the hospital frequently, said Sandra Mitchell, manager of case management for Montefiore Medical Center's The Care Management Co.
The constant in-and-out of the hospital had to stop. So when she was admitted in July 2011 to Montefiore's Weiler Hospital in the Bronx, the management company's medical director got in her car and went to visit the woman. She agreed to work with a diabetes educator and an endocrinologist.
"This is what you have to do," said Kathleen Byrne, the company's director of medical management. "People have complicated lives. She put everybody before herself. We said, 'We care about you and there's an answer. Under the care of the right doctor, you can spend that time with family rather than in the hospital.' "
The Care Management Co. is called an accountable care organization, or ACO, one of several approaches that the federal government is promoting as part of the Affordable Care Act to try to give patients better care and save money.
ACO generally signifies a network of local health care providers, including primary care doctors, specialists and hospitals, who together are responsible for the cost and quality of care for a group of patients.
Different ways of paying doctors and hospitals are being tested, but generally hospitals and doctors are paid based on keeping patients healthy, not on the volume of tests or procedures. The goal of ACOs is to reward them for value, that is, for providing quality care cost-efficiently.
"The term [accountable care organization] didn't exist 15 years ago when we started," said Dr. Steven Safyer, chief executive of Montefiore. "This is an evolution."
The government's goal is to figure out how to better coordinate Medicare patients' care and use federal dollars more effectively. ACOs like Montefiore's are the vanguard of the health care overhaul and a way for the government to test what works best. When U.S. Health and Human Services Secretary Kathleen Sebelius announced the initiative in December 2011 she said it could save up to $1.1 billion over five years.
Some worry that the approach may not deliver the savings or quality of care promised, but Montefiore said it has improved the health of its ACO patients and saved money, especially in treatment of usually high-cost diseases such as diabetes, congestive heart failure and asthma.
The difference, hospital officials say, is in the team approach to monitoring patients.
"Somebody is in charge of the patient's care," said Stephen Rosenthal, president of The Care Management Co. That contrasts with most health care today, he said, "which is highly fragmented and nobody is in charge."
In a nondescript office park in Yonkers, Byrne, Mitchell and more than 400 company nurses, social workers, pharmacists, nutritionists, educators and care managers form the hub of a team. They coordinate care for about 225,000 patients in the Bronx -- a county whose 1.4 million population for the past four years has been deemed the least healthy in the state by the Robert Wood Johnson Foundation and University of Wisconsin Population Health Institute.
Their goal is to keep their group as healthy as possible by flooding the zone with preventive care, monitoring and education and to make sure a patient, when sick, gets the care he needs every step of the way.
If someone with congestive heart failure reports -- via a device in his home -- a sudden weight gain, which can be associated with a decline in heart function, a nurse calls that day to see if he's taken his medication or might need to see a doctor. When a patient is diagnosed with cancer, a care manager and team immediately step in to coordinate care.
Montefiore, where the management company has been operating for more than 15 years, was one of 32 health care organizations nationwide -- and the only one in New York State -- designated in 2011 by the federal government as a "pioneer accountable care organization," or pioneer ACO, for people 65 and older on Medicare. Of its 225,000 patients, about 25,600 Medicare recipients are part of the pioneer ACO.
Montefiore's approach is one of the reasons that the North Shore-Long Island Jewish Health System said it decided to ally with the Bronx medical center in May 2011, sharing information and best practices on about a dozen projects. This January, doctors within two North Shore-LIJ-affiliated practices also joined with Montefiore's ACO.
"When I look around for people thinking innovatively over the long haul I consider Montefiore one of the best," said Michael Dowling, North Shore-LIJ's chief executive.
The federal Centers for Medicare & Medicaid Services have expanded the number of ACOs beyond the 32 pioneer ACOs to a total of 252, including at least three on Long Island. Healthcare analyst Leavitt Partners has identified an additional 153 non-federally associated ACOs in at least 45 states.
Patients in a Medicare ACO still can visit any doctor they choose, do not need a referral and receive their traditional Medicare benefits.
For the first two years, Medicare pioneer ACOs are still paid on a fee-for-service basis, that is, for each procedure or test. But the government will share with the ACO a percentage of any savings the organization makes compared with the previous year. In the third year, the pioneer ACO is to get money upfront to manage the care of a large group of patients. The other 220 Medicare ACOs, part of what is called the Medicare shared savings program, continue to be paid on a fee-for-service basis.
Even those who embrace the ACO concept acknowledge that making it work -- and making money -- is fraught with challenges.
Peyton Howell, president of AmerisourceBergen Consulting Services, part of the giant drug distributor, said she believes Medicare ACOs will need more flexibility to both save money and meet quality standards. "I'm not sure ACOs will be the ultimate destination 20 years out," she said. "They may not be the ultimate tool; they may be a way station."
Dr. Norman Chenven, chief executive of Austin Regional Clinic in Austin, Texas, and vice chair of the Council of Accountable Physician Practices, a group dedicated to improving health care delivery, agreed. "It's a bridge model," he said. That's because it mixes traditional fee-for-service payments with rewarding doctors for quality care.
"The ACO concept is not fully formed; there's not clear visibility toward a profitable outcome," he said.
Chenven said he believes ACOs "will evolve towards more defined networks, with patients making a commitment to a provider that has proven itself."
A new financial modelMontefiore has managed to make money from all of its ACO care management programs and improve the health of its patients, according to executives. But it's unclear whether it will make money from its participation in the pioneer ACO -- that will be based on its ability to reduce costs to Medicare.
The financial model that The Care Management Co. has evolved is not like the government's. Instead of fee-for-service or the hybrid Medicare ACO model, insurers pay an upfront fee to take care of those patients. Called capitation, that money is then used to pay for all the health care for those patients. Money left over has been plowed back into upgrading services, Rosenthal said.
"Looking at the total cost of care can allow us to be very proactive and creative," he said.
About half of all of Montefiore's 400,000-500,000 patients are paid for through capitation, Rosenthal said. His goal is to have about 75 percent paid for this way by year's end.
They have seen results. According to company figures:
Hospital admissions for diabetics declined from 339 per 1,000 in 2008 to 292 in 2011. The cost per member per year increased slightly, from $9,195 in 2008 to $9,631 -- below the national trend.
Emergency room visits for asthma dropped from 987.9 per 1,000 in 2008 to 953.7 per 1,000 in 2011. Hospital admissions dropped from 254.9 per 1,000 to 191.1 per 1,000. Annual medical costs for asthma fell from $3,814 to $3,538 per patient in that time period.
Emergency room visits for congestive heart failure dropped from 682.5 per 1,000 in 2008 to 381.0 per 1,000 in 2011. Medical costs declined from $31,733 per patient in 2008 to $26,842 in 2011.
"Reallocating our resources allowed us to be successful," Rosenthal said.
Ethel Blount of Co-op City in the Bronx believes her mother, Mary Sanders, is one of those success stories. The 92-year-old has had two strokes, a knee replacement, a hip replacement, cervical neck surgery and has suffered from insomnia and depression.
When her mother first came to live with her in 2002, Blount, who used to work the night shift at St. Luke's-Roosevelt Hospital Center in Manhattan before retiring in 2011, said getting her to the doctor was close to impossible.
"I wasn't even sure if she could stand for me," she said.
Then in 2005, she signed up for the Montefiore ACO's house call program. Now a nurse practitioner and social worker regularly come to the apartment and, when needed, her mother's primary care doctor, a psychiatrist, therapists and lab technicians. She has a night aide and her medications and equipment needs are taken care of.
"They took care of every little thing," she said. Since then, her mother has been in the hospital for short stays only three times "and we didn't have to go to the ED [emergency department]."
For Blount, it has meant "I have a life now. I can go out and do things," she said.