In the movement toward integrated, patient-centered care, the accountable care organization (ACO) might be regarded as the ultimate player, a multidisciplinary system built around the principles of collaborative care, financial rewards based on cost savings, and performance against quality measures.
As a “Pioneer” ACO—one of 32 participating in the Centers for Medicare and Medicaid Innovation (CMMI) Pioneer ACO model—Montefiore Medical Center in New York appears to be a trailblazer. This year Montefiore achieved the highest financial performance among the 32 pioneer ACOs, according to initial data reported by CMMI; the savings represent a 7 percent reduction in the cost of care when compared against the benchmark CMMI established for more than 23,000 patients attributed to physicians in the Montefiore ACO.
The chief medical officer at Montefiore’s Care Management Organization and medical director of its ACO, psychiatrist Henry Chung, M.D., told Psychiatric News that his institution was chosen as a pioneer because its long history of collaborative care management and managing financial risk made it a ready start-up. He explained that a unique facet of the pioneer model is that physician reimbursement is based on fee for service, and patients retain their free choice of physicians (unlike Medicare Advantage, in which patients are assigned a primary care physician and are confined to a network).
Psychiatrist Henry Chung, M.D., believes the accountable care model encourages novel ways of thinking about how to improve care. For instance, Montefiore has embarked on a pilot program to have a psychiatrist embedded in the evaluation of patients admitted to the medical inpatient unit.
Henry Chung, M.D., Montefiore Medical Center
That means that a principal task for Montefiore is physician engagement. “If you think about it, since these patients don’t have an assigned provider, we needed to figure out, based on their history, who were the likeliest doctors they would be seeing and try to foster and improve the relationship in the context of an accountable care program,” he said. “For the physician, that means really engaging the patient, communicating with patients, and letting them know that they are part of an ACO.
“And it also means letting the providers know that we have an infrastructure at Montefiore to support their patients’ complex needs. We know that many of our Medicare patients are also on Medicaid, and we know that that is a proxy for being poorer and more disabled. So we have really worked hard to let doctors know that when they see such patients, we can support them with care-management programs. And we can use claims data to stratify patients and reach out to the highest utilizers and most complex cases.”
Last month Chung received the 2012 Lewis and Jack Rudin New York Prize for Medicine and Health from the New York Academy of Medicine (NYAM) and the Greater New York Hospital Association (GNYHA) Foundation. The award was established in 2003 by the NYAM and GNYHA, together with the Rudin Family Foundation, to honor medical professionals from New York City institutions working toward integrated care to address prevention, community health, and health policy issues.
Chung said Montefiore has found what many physician practices and health systems entering the integrated care arena have found: that the highest utilizers are often patients with comorbid general medical and psychiatric conditions. “We have found that a third of our patients have had some form of diagnosed behavioral disorder in the past three years,” he said. “That one-third has 50 percent to 60 percent higher costs in utilization than patients who don’t have those disorders.”
He said Montefiore has been especially aggressive in having primary care physicians use the PHQ-2 and PHQ-9 to screen for depression. “Even before I came to Montefiore three years ago, the institution’s Care Management Organization and the Department of Psychiatry embarked on an educational campaign, with help from the Robert Wood Johnson Foundation, directed toward our primary care physicians around depression screening using the PHQ-9,” Chung said. “So when I came here three years ago, depression screening was already embedded in a large number of our primary care practices.”
Chung explained that in the ACO model as envisioned in the Affordable Care Act, any cost savings achieved are prorated according to how well the organization performs on 33 quality measures (one of which includes screening for depression and documentation of follow-up).
“Traditionally, so much of health care has been driven by the convenience of the health care system, rather than what’s good for the patient,” he said. “If you want to get that patient out of the hospital as quickly as possible, you aren’t going to spend a lot of time investing in aftercare.”
But under “bundled payment” arrangements in the ACO model, specialists take on a fixed payment for a procedure and all follow-up care for up to 90 days after the procedure. That incentivizes collaboration across disciplines toward achieving optimal patient outcomes.
And it is an arrangement in which psychiatry can add enormous value. “At Montefiore, our Cardiology Department on its own has invested in a half-time psychiatrist to manage psychiatric conditions associated with cardiovascular disease,” he said.
It is also a system that encourages novel ways of thinking about how to improve care. Chung said Montefiore has embarked on a pilot program to have a geriatric psychiatrist embedded in the evaluation of patients admitted to the medical inpatient unit. “Typically, consultation-liaison [C-L] psychiatrists are called in too late,” he said. “Historically, the C-L psychiatrist is often called the day before discharge. Especially as lengths of stay have gotten shorter, that is too short a period to help the patient or make a dent in decreasing the possibility of re-admission.
“Geriatric psychiatrists are comfortable in medical settings, and they get a lot of exposure to community-based settings,” he said. “So they are thinking from day one about diagnosis, treatment, and aftercare, about where this patient can get home care and community-based mental health and social services after discharge.”
So how can APA members working in other kinds of settings and other parts of the country use the lessons of Montefiore’s success in their own “medical neighborhoods”?
“Our friends in primary care and specialty medicine are actually very aware of the need for behavioral health and are actively seeking partnerships,” Chung said. “I would like to see APA members cultivate those relationships. And they should not stop there but should ask their primary care and specialty colleagues how they can be helpful in improving outcomes for their patients. At the structural level, I would be out trying to find the ACOs in my area and how I can be at the table with them. Many of these changes are being driven by primary care, so that’s where our members need to go. We can’t be in our office just waiting for referrals.” ■