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A Systems-Based Approach Powers Montefiore ACO

Michael B. Prystowsky, MD, PhD, FCAP

Montefiore MedicalCenter (Montefiore) in the Bronx, New York, serves one of the poorest and most diverse urban communities in the United States. Each year, Montefiore logs 93,000 admissions and 2.6 million ambulatory visits in nearly 100 networked locations. Medicaid and Medicare accounted for 80% of patient revenue in 2011.1

Montefiore is the university hospital for the Albert Einstein College of Medicine (Einstein), which hosts the second largest residency program in the United States. Montefiore and Einstein are among 60 medical research institutions nationwide that have been selected for a Clinical and Translational Science Award from the National Institutes of Health (NIH).

The Department of Pathology at Montefiore/Einstein is home to more than 75 faculty and more than 700 associates and trainees who provide 10 million laboratory tests, interpretations, and diagnostic consultations at Montefiore each year and conduct NIH-funded research at Einstein.


Systems-oriented innovations
Long before anyone had heard the term accountable care organization (ACO), Montefiore was functioning as an integrated, comprehensive health care system. After 15 years in coordinated care, says Michael B. Prystowsky, MD, PhD, FCAP, chairman of the Department of Pathology at Montefiore/Einstein and a member of the CAP Board of Governors, the Montefiore Integrated Provider Organization (MIPA) takes full risk from insurance companies for about 50% of their patients. In another 10 years, he predicts, "The MIPA will assume risk for most, if not all, patients at Montefiore."

Montefiore is one of 32 ACOs invited to participate in the federal Centers for Medicare & Medicaid Services (CMS) Pioneer ACO Model project. As proven coordinated care organizations, the Pioneer ACOs were challenged to innovate in ways that would improve outcomes and efficiency while lowering costs. In July, Montefiore reported that initial data from the CMS Innovation Center showed that it had achieved the highest financial performance in the group and will receive $14 million of the savings it has generated for Medicare. Those dollars, it said, will be reinvested in the medical center and also shared with participating physicians.

The pathology service line, says Dr. Prystowsky, is paid a set amount for each inpatient test. Outpatient fee-for-service contracts also contribute to departmental revenue as they continue to transition to 100% coordinated care. At the end of each fiscal year, net revenue is split between the pathology department and the hospital; the departmental portion funds its research and academic missions. Montefiore ensures that the pathology service line is resourced properly to support clinical programs. Like everything else, Dr. Prystowsky says, compensation is approached in a bigpicture, systems-oriented way. Everyone is salaried at levels commensurate with the local market so that talented people are readily recruited and retained.

Systems-based thinking
Systems-based thinking, says Dr. Prystowsky, who is also associate director for shared resources of the Albert Einstein Cancer Center, enables departments at Montefiore to innovate in ways that benefit the system as a whole. For example, he says, the pathology department is committed to bringing point-of-care (POC) testing closer to those who need it. When clinicians at the Montefiore Einstein Center for Cancer Care asked if the laboratory could conduct fineneedle aspiration (FNA) as a POC test at the outpatient site to limit cancer patients' need to travel for testing, the laboratory staff worked with them to design a space and coordinate schedules.

Montefiore inculcates a cultural commitment to systems-based planning to support population health. Its staff employs sophisticated data programs to track on quality outcomes and efficiencies that produce economies that are reinvested where they are needed.

The Department of Pathology at Montefiore is among the many beneficiaries of Clinical Looking Glass (CLG), a proprietary, userfriendly software query system developed by Eran Bellin, MD, a vice president for clinical information technology research and development at Montefiore and professor of clinical epidemiology and population health and medicine at Albert Einstein College of Medicine/Montefiore Medical Center.

CLG is a radically powerful and flexible tool for epidemiologic and longitudinal clinical research.2 Physicians, nurses, administrators, and medical residents use CLG to extract data about patients with specific symptoms, signs, diseases, and disorders, which they use to track progress and outcomes over time.

The CLG data repository incorporates information from the clinical laboratory. This enlightens patient care planning, raises awareness of the many uses for laboratory information, and encourages multidisciplinary collaboration. Research with CLG has facilitated papers on such topics as (1) whether or not it is useful to employ low molecular weight heparin as a bridge to cardioembolic prevention in patients with atrial fibrillation, and (2) evidence that reference limits for TSH differ between races and with age.


Dr. Prystowsky and Ira I. Sussman,MD, his vice chair, wrote an article for Human Pathology that describes their department's experience with coordinated care and captures a key prerequisite for the success of the current national experiment. It's a good sentence; sticks in your mind.

"Instead of having insurance companies manage cost," they write, "health care organizations will have to manage health."

1. Sussman I, Prystowsky MB. Pathology service line: a model for accountable care organizations at an academic medical center. Hum Pathol. 2012;43(5):5;629—631. doi: 10.1016/j. humpath.2011.12.017

2. Bellin E, Fletcher DD, Geberer N, Islam S, Srivastava N. Democratizing information creation from health care data for quality improvement, research, and education — the Montefiore Medical Center experience. Acad Med. 2010;85(8):1362—1368. doi: 10.1097/ACM.0b013e3181df0f3b

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