Montefiore Health System in New York is a pioneering accountable care organisation which has been able to improve the quality of patient care while reducing expenditure through enhanced care coordination. In this session from our 2018 accountable care summit, Ben Collins talks about the findings from our report focusing on Montefiore’s improvement journey and the key components of the model that could provide lessons for the NHS.
Way back in the 1930s the original prohibition Italian settlers started leaving the Bronx, they were escaping prohibition gangs for calmer suburbs. Into the vacuum came Hispanic and African-Americans fleeing grinding poverty in Costa Rica or discrimination in the deep south. The remaining middle class families upped sticks in the 70s when heroin, opioids, HIV took possession of the Bronx. People described a synergy of plagues, so you know, destruction of housing, homelessness, economic decline as well as profound health problems; a good 10% of people have diabetes, 15% of people have asthma, 8-10% of people in the south of the Bronx report severe psychological distress. That’s 2-3 times higher than the national average.
Montefiore is fundamentally, it’s a hospital-based system. At its heart is an academic medical centre, a training college for doctors and a teaching hospital. But from the very start it committed itself to serving this deeply deprived population. Its purpose was to use medicine and the resources of healthcare to fight the battle and tackle social injustice.
Montefiore I think did something remarkable from the 1980s onwards, they built primary care brick by brick from the bottom up. From the 80s they started hiring primary care doctors and training primary care doctors. By the end of the 1980s they had established three clinics in the poorest neighbourhoods in the Bronx. By the end of the 1990s they had developed pretty much the biggest primary care network in the US at the time, you know 200 doctors, 21 sites carrying out almost a million appointments every year, and this really was a start of a tradition of a hospital reaching beyond the hospital’s boundaries.
So Montefiore set up children’s mobile clinics to go into the poorest neighbourhoods where they could get directly to children and homeless children. They set up clinics in homeless shelters. They started building rehabilitation facilities, homecare facilities, residential care facilities. Wherever there was a need, Montefiore attempted to find the solution and even though for the most part it wasn’t the hospital’s responsibility and there was indeed somebody else to blame.
Montefiore was one of the first hospital systems in the US to start considering the social and environmental conditions that were driving the epidemic in chronic conditions in their populations. Montefiore’s current Chief Operating Officer focuses on the relationship between housing and asthma. What is the point in handing out inhalers if we’re going to send these children back to the damp and rat infested conditions that are fundamentally the cause of their conditions? Montefiore had an answer to that question. In the 80s they’d established a not-for-profit subsidiary and over the course of two decades, it pretty much renovated all of the derelict blocks in a large neighbourhood around the medical centre.
By now you’re probably wondering what enormous resources Montefiore had to be able to do all of this stuff in the local community, and the honest truth is that by the late 1990s Montefiore was almost bankrupt. You know, this is a safety net system. It deals with largely Medicare and Medicaid patients who you don’t pay very well in the US. Almost all hospitals in the US rely on their commercial customers to subsidise the costs of their Medicare and Medicaid customers way. Way ahead of anybody else before any of us had heard about the joys of value-based purchasing and risk based contracts it was working with its insurers to move to decapitated arrangements. Took on its first early risk contracts for a few tens of thousands of people in the mid-1990s, now in 2018 it holds risk based contracts for around 400,000 patients. That’s still a tiny proportion of the people it serves, maybe 10 or 11%. Their plan is to grow fast. They want to get to a good million and a half.
This really is the jewel in the crown of Montefiore system. It doesn’t look like much, it’s a single storey building on a trading estate in the outskirts of the Bronx, but this is the place that crunches the numbers, works out which of the patient groups that Montefiore is dealing with have the greatest opportunities for improvements in care and reduce productions in cost, improvements in coordination and this is the place that takes charge of those high risk patients and really improves how their care is being delivered.
Every week the analytics team is crunching the numbers, looking through Montefiore’s claims data and utilisation data for how services to identify the next group of patients to bring into case management. There’s a team of experienced nurses who run 90 minute telephone interviews to get to the bottom of people’s problems, identify you know, the fundamental drivers causing them to turn up at A&E regularly causing their high utilisation and then there’s a good team of 200 nurse case managers and social workers who are developing care plans, and I think underpinning all of this is a real commitment to understanding what works. You know, they don’t just put in place an intervention, you know they know how many people who received peer to peer support for their diabetes management, saw an improvement in their diabetes A1C, haemoglobin A1C levels. It’s hard-nosed and absolutely focused on results.
Montefiore became the poster child for Obama care in around 2014 when it was clear that it was by far the stronger performer of the 32 accountable care pioneers in the first two years. Five years into that programme it was delivering a 96% performance score on 30 metrics ranging from access to population health to patient satisfaction, delivered that pretty dramatic improvement in performance in comparison to other US health systems while cutting the costs of care for this group by a good $75 million. $75 million dollars for a small group, 23,000 Medicare patients in the beginning.