Editors’ Note

An accomplished physician leader and highly respected health care executive, Dr. Steven Safyer has been at Montefiore since 1982, previously serving as Senior Vice President and Chief Medical Officer. Safyer received his Bachelor of Science degree from Cornell University and his medical degree from Albert Einstein College of Medicine. He completed his internship and residency in Social Medicine at Montefiore. He is board certified in Internal Medicine, and is a Professor of Medicine and Professor of Epidemiology and Population Health at Einstein. He is a fellow of the New York Academy of Medicine, founding member of The Health Management Academy, and a member of the Healthcare Institute. Safyer currently serves as Chair of the League of Voluntary Hospitals and Homes and is the immediate past Chairman of the Board of Governors for the Greater New York Hospital Association. He is a board member of the Hospital Association of New York State; Association of American Medical Colleges’ Council of Teaching Hospitals Administrative Board; Coalition to Protect America’s Health Care; Josiah Macy Jr. Foundation; New York eHealth Collaborative; and University HealthSystem Consortium. Safyer has authored and co-authored numerous articles in peer-reviewed journals.

Institution Brief

Montefiore (montefiore.org) is a premier academic health system and the University Hospital for Albert Einstein College of Medicine. Combining clinical excellence with a population health perspective, Montefiore delivers coordinated care where, when, and how patients need it most.

How has Montefiore evolved over the years?

Montefiore was founded in 1884 in Manhattan and moved to the Bronx in 1913.

Its mission at inception was not that different from its mission now, which was to create a best-in-class acute care hospital focused on research and education that serves the community, and manages and cares for those with chronic illness. In 1913, that chronic illness was tuberculosis; in 2014, it’s obesity and diabetes.

Along the way, we have taken on every challenge. Montefiore was an early sentinel site for HIV and tuberculosis in the ’80s. Then, as now, the emerging challenges in our region reflected what was going on in other challenged communities.

How we address chronic illness has changed. In the beginning, we worked toward developing treatments, but most chronic illness was not treatable and the majority of care was palliative. We now have many more treatment options available and can offer patients access to clinical trials to take advantage of the latest science.

What is unique about Montefiore is our public health approach to care – an understanding that health promotion and disease prevention, in combination with science and innovation, improve a population’s health.

Is there an appropriate awareness today of the need to focus as much on prevention and wellness as on care?

There is at Montefiore, and at some of the more innovative health-care systems with similar missions.

Even if we were pitch perfect on public health, there is still a great deal of disease burden in our community. There will continue to be the need for things like heart transplants, liver transplants, and complicated cancer surgery.

But our focus has shifted, and there is a recognition here that how we pay for and deliver care needs to change. We believe that everyone should have access to affordable insurance and be able to participate in the health-care system – we think of health care as a human right, not a privilege.

We have 24,000 employees and six hospitals. We have close to 5 million patient encounters a year and approximately 125,000 hospital discharges with a very high case mix index. As an academic medical center, and University Hospital for the Albert Einstein College of Medicine, we have one of the largest graduate medical education training programs in the country – 87 programs with 1,400 interns, residents, and fellows. We’re a more than $3-billion enterprise.

We’re very large, and we do what our sister institutions do in Manhattan, but in a different way. We’re migrating away from what is a fee-for-service system. Most of the way care is paid for in this country is piece work – the more you do, the more you make. We have been advancing the pre-payment or capitation model.

When you change that dynamic, the way you pay, you have to change the way you deliver care.

Any kind of payment system is susceptible to overuse or underutilization of services, so you always have to aim for the highest quality. But if you’re being paid to keep people well or you manage their care, you shift the paradigm. It demands that you have a more integrated delivery system. Montefiore’s hospitals are only one component of our integrated delivery system – we have more than 60 primary care sites, home care, long-term care, specialty care, and rehabilitation – all working together seamlessly to best serve the patient. We also have a care management organization with 1,000 employees who manage the care of nearly 300,000 people in a capitated or pre-paid structure – this is approximately 50 percent of our inpatient revenue.

But we’re not an insurance company. We’re a nonprofit that seeks to be paid upfront and gets rewarded to keep people healthy. The 1,000 people working for us in care management are social workers, nurses, pharmacists, and psychiatrists, as well as people we have trained to follow up with patients by phone and home visits; reconcile medications; and make sure people keep their appointments.

We are changing both how we’re paid and how we deliver care, and I predict the whole country will need to move in this direction at some point.

Are you concerned that with all the pressures, the doctor/patient relationship is being lost today?

Yes. I went to medical school because of what I perceived to be the mission of keeping people well, and understood it would be a rewarding career. When I began, I didn’t think about how I would deliver care or be paid. But I grew up professionally in the Montefiore environment, where we’re unique with respect to how we think about our community.

Our best recruits still come from within our system. Many of our finest students choose to stay. About 20 percent of our physicians are in private practice, but they are still very committed and involved in the programs I’m talking about. For the doctors who are employed by us, they’re not making their salary based on the services they provide; they’re making their salary based on how well the patients and the health system do. This is a different way of operating.

In an environment based on physician reimbursements, it would be hard to make a living in New York. But when we operate under a pre-payment approach and are compensated to keep people healthy, physicians are excited to participate. They’re not spending time and energy trying to figure out if they are going to make payroll for their practice; they’re thinking about how best to care for their patients, and they’re more gratified.

We reward our clinicians with the ability to practice at the top of their licenses. It’s not our goal to have a bunch of expert billers; we want expert doctors who are thinking about the patient and how the team can manage their patients’ care.

Is it critical that your employee base mirrors the diversity of your patient base?

Our employees reflect the community because so many of them live in our community. We think this is very important for several reasons. We use our workforce to affect change in the community – it’s the best lever we have. So we emphasize healthy eating, exercise, smoking cessation, and wellness among our employees because the workforce becomes more productive and engaged as a result, and they bring this knowledge home to their families and neighbors.

You’ve invested a lot in technology. How critical is it to be at the forefront of these changes while making sure it doesn’t take away the human touch?

We embraced electronic medical records in the early 1990s. We’re very proud because we had 100 percent physician order entry in 1998 at a time when this was the case at probably only 1 percent of hospitals.

Like all things that are electronic, there are tremendous advantages, but I recognize that parts of it can dehumanize things. We have worked very hard to have portable records so when the nurses walk the floor they can bring the record with them. In our ambulatory world, we configure the desks so patients can see what we’re doing; it’s alienating to just watch someone type. The medical record is owned by the patient – it should not be something the patient thinks you’re hiding.

But you struggle with this at every step because information systems are not perfect. They are proprietary and don’t all speak to each other. Sometimes you have to trade the best of breed for integration.

We have about 500 people in our IT department and they are led by clinicians, and clinically focused people. We’re changing over our electronic medical record system and moving toward the comprehensive and integrated Epic platform. As we design our Epic system over the next year and implement it over the following two years, we’re mindful of being patient-centric, focusing on clinical work flow and patient outcomes, and using its efficiencies while not getting bogged down in the aspects of it that don’t add value. Our systems are designed and built by caregivers who utilize our IT team’s vast technological expertise.

How important is it to get the employees to buy into community engagement?

I like to think of our employees as ambassadors in the communities in which they live. Serving our community is our primary purpose. We’re in 65 schools in the borough providing health care, and we focus on keeping kids in school and helping them stay in shape. Wherever we are, we are advocating for green markets and farm stands, and changing the food that is being offered in grocery stores or bodegas. All of our campuses are smoke-free. The food we serve here on a daily basis is healthy, labeled, and proportioned. Health education is extremely important and we practice what we preach.

Some say that going forward there will be a small number of large health systems. How critical is scale to remaining competitive in the future?

Scale is critical for competition and is important for the quality of care you provide.

Most people think of scale in terms of the number of beds. Our definition of scale relates to the treatment and care management we provide.

To execute care management, which is critical to keeping people well, we have 1,000 employees caring for nearly 300,000 covered lives. Our goal is to have one million lives under care management because that level provides significant economies of scale.

I also think scale relates to where you deliver care, and I believe that regional delivery systems will be sustainable in the future.

Is it difficult to remain optimistic long-term on the health and well-being of people?

I can’t help but be an optimist. My strengths are best suited to Montefiore’s mission and model. I’m certain that changing the paradigm is critical for long-term success. What we need to do in this country to have an impact is to make public health a societal priority again. The big public health advances of the past 150 years – such as the control of infectious diseases through clean water and sanitation, immunizations, and family planning, to name a few – were possible because there was widespread commitment to their importance. We need to see this commitment again. One of the key public health issues today is making sure that everyone has access to health insurance and enrolls in a plan. The success of the Affordable Care Act is vital for this effort.

We also need to change from the current compensation model to a pre-payment model, and change from the current fragmented system of delivering care to one that is seamless and integrated.

Montefiore has long been innovating in these areas. As one of 32 Pioneer Accountable Care Organizations nationally, Montefiore’s ACO generated substantial savings for the Medicare program, representing the highest financial performance with improved outcomes in the first year. 

I am definitely optimistic, but we must embrace change and continually push for new approaches to care that can form the basis of an improved health care system for all Americans.•