Complex coordination

Medicare Pioneer ACOs that saved money on patient care—and will share Medicare's $140 million in total savings for 2012—credit their success to an intense focus on improving coordination and care for the most complex and costly patients.

One Pioneer success story is New York City-based Montefiore Medical Center, which operates one of the 32 Pioneer ACOs launched last year by the Center for Medicare and Medicaid Innovation, which was created by the Patient Protection and Affordable Care Act. Montefiore, with 23,000 enrollees, will receive $14 million from Medicare.

Boston-based Partners HealthCare, with 52,000 patients, will receive $14.4 million in shared savings. Phoenix-based Banner Health Network will get $13 million for its management of about 50,500 patients. Also in Boston, Beth Israel Deaconess Care Organization claimed a payout of nearly $7.8 million after bringing spending under budget for 30,000 Medicare patients. And Indianapolis-based Franciscan Alliance ACO, with 20,000 enrollees, will pocket $6.6 million.

In total, 13 Pioneer ACOs will receive a combined $76.1 million because of their cost-saving success in the first year of the Pioneer effort. Another five Pioneers also saved Medicare money, but not enough to earn bonus payouts.

Steve Rosenthal, vice president and chief operating officer for Montefiore's case management operations, said his organization's ACO was able to “zero in very quickly” on the roughly 2,000 patients who accounted for nearly half the group's medical costs.

Care managers were paired with Montefiore's high-risk patients to identify their needs and how to fix them, he said. For patients with congestive heart failure, Montefiore used high-tech scales in patients' homes to detect weight gain, which can signal a worsening condition. Educators were assigned to diabetes patients to help them learn more about their disease. Hospital stays dropped, accounting for most of the savings the ACO achieved.

At the Franciscan Alliance, Jay Brehm, senior vice president of strategic planning and business development, also credited savings to investments in care coordination, chronic disease case management and improved communication. He described the Pioneer effort as integral to redesigning its delivery system.

“This is particularly critical as we move away from fee-for-service medicine toward a system focused on creating greater value for patients and bettering population health,” he said in a written statement.

Dr. Richard Parker, chief medical officer for Beth Israel Deaconess, which came in 4.2% below its budget target, said “we use a sophisticated computer algorithm and see who's at risk for hospitalization. Then we run that data past the primary-care doctors and develop care-management resources as appropriate.”

His ACO also focused its efforts on high-risk patients. Nurse practitioners make monthly house calls to sick, homebound patients who had emergency department visits. Less acutely ill patients receive phone calls or visits from registered nurses, he said.

His system's primary-care physician structure also contributed to the ACO's success, he said. Physician leaders communicate about care management and use of services to doctors in 21 primary-care groups across northern Massachusetts, Cape Cod and suburban Boston, he said.

“It's necessary to have a primary-care structure in order to communicate with all primary-care physicians … to understand how to continually improve quality and decrease unnecessary utilization,” he said.

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