Stephen Esan is trying to decide if he should go to the emergency department. He’s 40 years old and suffers from congestive heart failure and end-stage renal disease. He has to go to dialysis three times a week until he can get a new kidney.
Today he’s in pain. The phone rings. It’s Maureen Patten, his "accountable care manager" from Montefiore Medical Center’s care management group.
Esan and Patten have never met. He lives in the Bronx; her office is up in Yonkers. Yet she, more than anyone else, is the person who coordinates his care, who knows his medical record, his medications and his hospital stays. They talk once or twice a month by phone.
Today, she asks him probing questions. Did he tell the dialysis nurse he wasn't feeling well? Why doesn't he show up to appointments with his doctor? Patten is part nurse, part advocate, part nagging mom. Every time Esan deals with the healthcare system, she knows, because it goes into his electronic medical record.
Patten's work is part of the Affordable Care Act's best guess for curbing ballooning healthcare costs. The particular program that Stephen Esan is part of is a "Pioneer ACO (Accountable Care Organization)," which attempts to improve how care is delivered to some of the most complex Medicare recipients. Montefiore's is the most successful so far in terms of savings. The Pioneer ACO includes 26,000 patients, and is a sliver of the 265,000 patients, many of whom live in the Bronx, who are managed by almost 800 people — nurses, pharmacists, social workers, therapists and care managers — at a phone bank in Yonkers. They help patients with transportation, rent, food stamps. Basically, anything that affects their health.
The goal is to improve healthcare quality and lower costs. If Montefiore can keep people from getting sicker and from showing up in the emergency room, the hospital system will share the savings with Medicare.
"Patient sees a doctor, three specialists, who's coordinating and talking to each other to make sure that everyone is on the same page?" asked Dr. Henry Chung, who is the chief medical officer for Montefiore's ACO. This is particularly important with Medicare patients who are "fee for service," he said — those whose care is paid for every time they show up in a medical office. Patients like Esan are found through data mining, which identifies Medicare patients with complex problems which are expensive to treat.
ACO's prompt patients to fill prescriptions. To answer the door when a home healthcare practitioner visits. They help them figure out what federal and local aid programs they might qualify for and talk to them about modifying their behavior so that they stay healthy.
Esan couldn't afford food when the program found him. He was $8,000 behind on rent after years of earning $60,000 a year. He kept going to the emergency room. But Patten worked with him to get on the transplant list; she and others at Montefiore helped him get food stamps and find a program that would assist with his rent, so he didn't get evicted. He's not well — but he's doing better.
And Patten keeps calling.
"To this day, Stephen Esan has no idea what we look like... I can be right across the street from him and he would never have known," said his social worker Norma Cruz, "But he knows that there's someone out there helping him."
But there are critics of the new ACO's.
For Dominica Potenza and her husband Dr. Robert Potenza, their small private practice provides care that cannot be replaced by over-the-phone management.
"They don’t understand the dynamics of the family, of what’s going on at home," explains Dominica Potenza. "We see it here. We see when the patient’s family members actually come in with them to an office visit. We know who’s present in the patient’s life."
Their practice in the Throgs Neck neighborhood of the Bronx is staffed by just three people — the Potenzas and their receptionist. The only way they're able to stay afloat now that Medicare is reducing reimbursements, is because Dominica doesn't draw a salary. They have considered joining a hospital network, but fear they couldn't provide the quality care they offer now.
"We love what we do and we want to continue to love what we do. So if we do it the way we want to do it, we know we’re doing it the right way," she said.
Back at Stephen Esan’s parents’ place, Esan is feeling somewhat better. He doesn’t need to go to the emergency department. For now.
Additional reporting by Schuyler Swenson