New York's Montefiore Medical Center, the most financially successful of Medicare's most sophisticated accountable care organizations, may bypass what HHS officials are calling the next generation of the evolving payment model to instead concentrate on expanding its use of full capitation for patients.
HHS Secretary Sylvia Mathews Burwell traveled to New York on Thursday to praise officials at Montefiore, which earned bonuses of $27 million during the first two years of Medicare's Pioneer accountable care program, more than any of its peers.
Burwell, in a press briefing, touted Montefiore's performance and New York's embrace of new healthcare financing models as she promoted rapid federal expansion of accountable care, including the newly announced “next generation” to begin next January. Details of exactly what provider risk the next generation will entail have been sparse.
For Montefiore, however, the next iteration of Medicare accountable care may not be the best option, said Dr. Steven Safyer, the system's CEO.
Safyer said he would review the option, but Montefiore instead is working to aggressively expand its use of full capitation for patients and that will be its priority. Montefiore is seeking to have all Medicare and Medicaid patients under full capitation by 2018, he said.
“We believe that comprehensive coverage, integrated coverage, reinforces integrated care,” he said. “The two go hand in hand. One enables the other.”
Medicare's next generation accountable care will offer nearly full capitation as one option, CMS Chief Medical Officer Dr. Patrick Conway said when he announced the plans this week.
Other details are not yet available. Conway did not say how many other options would be offered or how much risk they would entail. The agency expects that up to 20 ACOs will join the new program in its first two years, Conway said.
Under the model, patients can volunteer to join ACOs and will see changes to copays to encourage certain medical care.
Montefiore's ambitious push to increase its capitation comes as federal and state officials have set targets to increase use of accountable care. But remarks Thursday by Burwell and New York's Medicaid director underscored the uncertainty of those efforts and how many questions remain as the public and private sector seek a working model.
Burwell said Thursday that the new model underscores federal efforts to learn and adapt as organizations test accountable care, including those that have exited the program. Montefiore was among 32 ACOs in the Pioneer program when it started in 2012. Thirteen dropped out, with some exiting the program entirely.
“We're integrating the feedback that we're getting,” she said. “This will be a learning effort. We want to continue to do that. We want to continue to improve.”
Others have exited Medicare's large and growing shared-savings program—a second test of accountable care with roughly 400 ACOs. The largest Medicare ACO operator, Universal American, has pulled out of nine of 32 ACOs in the shared-savings program.
Burwell said efforts would continue to evolve and stressed the necessity for federal, state and private sector insurers to adopt more incentives for quality and efficiency. She also called for more communication across sectors to rapidly promote change. “I think what we are feeling confident about is that moving toward value-based payments away from volume-based payments is what is needed and can work,” she said.
But she acknowledged some efforts will falter. “Some will succeed,” she said. “This is new. So we will have examples of where they don't and we know that.”
Hospitals and medical groups must contend with the financial risks of accountable care, she said. “As one considers who stayed in or out and for different reasons, is it about willingness to take risk and how people want to take risk and how they manage toward that.”
New York Medicaid Director Jason Helgerson on Thursday said the state would use three options as it shifts $50 billion into payment models that use performance on cost and quality to award bonuses and potentially penalties.
The state has set a target for 90% of its Medicaid reimbursement under accountable care and similar models within five years. Of that amount, New York will seek to have 70% paid under models that use penalties and bonuses as incentives, while the remaining 30% offer bonuses without penalties.
HHS in January announced plans to move 50% of Medicare spending outside of managed care into accountable care, bundled payments and or other models that use incentives tied to quality and cost.
Montefiore is eager to accept more risk for managing care and last year revived New York State insurance licenses. Safyer said he does not want to launch an insurance arm, but wants to keep the system's options open.
“My goal is not to be an insurance company,” he said. However, should insurance companies fail to pay enough per patient per month under capitation, he will expand into the market. “If I had to, I'd do it.”
Follow Melanie Evans on Twitter: @MHmevans
