CMO, in fact, is one of the key reasons Montefiore was chosen as one of 32 Pioneer ACOs by CMS' Center for Medicare & Medicaid Innovation: Montefiore can already do much of the risk management that the Pioneer standards demand, but at the beginning, it's no exaggeration to say that Montefiore bet its future on it.
The Montefiore Integrated Provider Association is the risk-bearing entity. It's made up of providers of all stripes who have a relationship with Montefiore that includes community representatives. Each entity, Montefiore and the providers, has one vote on the board "so we would always have to build consensus for our activities," Rosenthal says.
The IPA can assume financial risk for patients assigned to it, which, says Rosenthal, "is the beginning of managing a population." The care management operation, owned by Montefiore, provides all the infrastructure support that an integrated delivery system needs to manage a population.
"We do all the data analytics and the contracting between insurance companies, the government, and providers, and establish network opportunities," Rosenthal says. Additionally, CMO educates providers, whether employed by Montefiore or not, and develops all care management strategies so the sickest patients get truly managed care, he says. CMO employees, often nurses, make sure each of these patients has a clear individual care plan that works for the patient, their family, and their physician, he says.
"What this means is we offer a tremendous amount of support for the physician," he says. "We're available to the patient all the time. Our goal is to be proactive ... to prevent costly services to the patient and the system."
He stresses that hospitals can be disadvantaged in such a program, where much of the savings shared among participants comes from preventing admissions there, adding that Montefiore itself is fortunate because physicians in the community have come together in the IPA, under which transparency of information is critical, he says.
"That's critical because you have to join together in real cultural and behavioral changes that need to occur with a provider population. When managing a population, you're looking holistically, and that fosters creativity," he says, adding that the exchange of clinical data and claims data from insurance companies and the ability to manipulate it makes it possible to proactively identify the individuals to apply the right interventions at the right time.
As part of the Pioneer ACO, CMO now manages about 23,000 Medicare fee-for-service beneficiaries, of which less than 10% account for more than 50% of medical costs.
"You can drill down into those individuals and be very proactive," says Rosenthal. "Of the individuals with the most needs, more than 900 people are being actively case-managed with the goal of improving their health and the quality of their care while also lowering costs."