Steven M. Safyer, M.D., Montefiore Medicine

Steven M. Safyer, M.D.

Agents of Change

Editors’ Note

Prior to being appointed to his current post in 2008, Dr. Steven Safyer held a variety of senior leadership roles at Montefiore, including Senior Vice President and Chief Medical Officer from 1998 until 2008. He was an early champion of clinical information systems and launched physician order entry (electronic entry of medical practitioner instructions for the treatment of patients) in the 1990s that supported his focus on creating nationally recognized quality and safety programs. In addition, he galvanized a broad effort to stem the burgeoning epidemics of HIV and TB that were taking their greatest toll on the poor during the 1990s in New York City. Dr. Safyer led the way for Montefiore to set a new standard for equitable healthcare systems. He earned his medical degree from Albert Einstein College of Medicine and completed his internship and residency in Social Medicine at Montefiore. He is board certified in internal medicine, and is a Professor of Medicine and a Professor of Epidemiology and Population Health at Einstein. He received his Bachelor of Science degree from Cornell University.

Institution Brief

As the academic health system and University Hospital for Albert Einstein College of Medicine, Montefiore (montefiore.org) is nationally recognized for clinical excellence – breaking new ground in research, training the next generation of healthcare leaders, and delivering science-driven, patient-centered care. Montefiore is ranked among the top hospitals nationally and regionally by U.S. News & World Report. For more than 100 years, Montefiore has been innovating new treatments, procedures and approaches to patient care, producing stellar outcomes and raising the bar for health systems in the region and around the world.

What is your view on the current state of healthcare?

The question has to be answered from three points of view: nationwide, statewide and local. Montefiore has a huge local footprint stretching from the Bronx into the Hudson Valley.

On the national level, there is still a strong desire to repeal the Affordable Care Act, although both Republicans and Democrats have really underestimated each other in this debate. People fought back in both the red states and the blue states. Communities didn’t realize that the ACA included Medicaid expansion, which provides so many important protections, including great benefits for kids.

The threat against the ACA is not over: it’s a very uncertain time for healthcare, but repeal would not be a step in the right direction. From a statewide perspective, ACA repeal would be damaging for a place like Montefiore. New York is a progressive state and works closely with Montefiore as we try to raise quality and what people get for their money while lowering costs.

We serve as an economic anchor in our communities and are the largest employer in the regions where we are located, providing stability to employees and their families.

Our goal is always to change incentives from putting people in beds to keeping them healthy within the community. We’ve made real progress on this front, but if the state funds are affected by regressive healthcare policies, this will hurt us as well. We have been able to do quite well with a heavy dose of government insurance through Medicare and Medicaid, even though they don’t pay as much as commercial insurance.

Locally, these are very challenging times. Our communities in the Bronx and lower Westchester comprise four million people. This includes communities that are often under-resourced, with food deserts and which are blanketed with ads for unhealthy food and drinks by large corporations.

Many of our patients are struggling and living through tough times, so they’re dependent upon a social network that believes that healthcare is a right, not a privilege. That is our fundamental belief despite the uncertain political landscape – we need to keep well and maintain access to top quality healthcare.

As you focus on keeping patients out of the hospital, how does this change the role of the hospital in the future?

Ideally, better outpatient care should result in fewer and fewer beds. That’s a good thing. If we keep people out of beds and we keep them well, that means we are doing our jobs, saving money, and we should get rewarded for that. Montefiore has always been on the cutting edge of what we call value based care. We want to get paid for keeping people well, not keeping them sick. We participated in the Pioneer ACO model which was designed to support value based care and save the government money. We were one of the original 32 hospitals in this program and only about six stayed in it until the end. We performed well, delivering excellent patient care and generating more than $73 million in savings to Medicare. In the past year of the model, our doctors’ average performance rate was higher than all other ACOs in providing immunizations and conducting preventive health screenings. This proves that keeping people well is cost efficient and where we all need to be moving as a country.

From 2012 until a year ago, healthcare spending throughout the country was growing at a slower rate. That is not the result of a policy, at least at the federal level, but from encouraging people to participate in models like the Pioneer ACO.

In addition, we built a 280,000-square-foot hospital without beds, Montefiore Hutchinson Campus, and we are doing remarkable things there. We are doing far more complicated surgeries and procedures than I ever imagined when we set out to test the concept of a “bed-less hospital.” People like going there because it is convenient, and they don’t have to sleep in a hospital bed. People, however, are still able to benefit from a range of services like cardiac care for pregnant women and their families, to advanced imaging. There is also a Spine Center and Pain Management for children with special needs.

Montefiore now has 11 owned and operated hospitals with about 35,000 employees taking care of two million people; with our five or six affiliates, we’re even larger.

If someone needs to be in a hospital bed, they want to be in the very best, and we can of course accommodate that. However, if they don’t absolutely need to be in a bed, people generally prefer not to stay because hospitals have a lot of risk attached to them, which is hard to completely mitigate.

My message is that the signals are unclear and the U.S. is a country that spends $3 trillion per year on healthcare. The entire world only spends $7 trillion. Europe is getting better outcomes at lower costs than us. They’ve done it by being progressive and trying new ways to keep people healthy, as we have done at Montefiore. The purpose of a hospital should evolve and grow as we understand the costs associated and can find innovative ways to take care of people that are simply less expensive.

As we add more debt and spending starts to rise again in healthcare, there is going to be an appetite to not grant Medicaid and to cut back Medicare. This will make things very challenging for us.

Is there a unified voice among industry leaders in regard to how to address these challenges?

I am part of a bipartisan effort called the United States of Care, and Andy Slavitt, who directed the Centers for Medicare and Medicaid Services during the Obama Administration, is leading it. There are several other health system presidents and CEOs who are working to change how we provide care.

The program doesn’t specify that we need a single payer system, but we firmly believe there must be healthcare for all. It also advocates pushing forward with innovations in value-based care and bedless facilities that enhance outpatient services like those I mentioned earlier.

Medicare and Medicaid have a lot of power as they cover 130 million people. The number of Medicare recipients is growing rapidly so addressing this in a bipartisan forum will be an important initiative.

For the people who run systems like me, it has more to do with where they are and how vocal they are. This is an effort to bring together people who are on different sides of the aisle.

Frankly, it will be difficult to create the right model, especially if we are working in a vacuum. In the past five years, pharmaceutical prices went up 12 percent at least twice. The price we pay for equipment has also gone up 7 percent per year. There are also only three large national insurance companies now; that gives them a lot of leverage. Reforming healthcare in this country has to be a team effort in order to succeed. System leaders can’t do it alone.

People can be very concerned about change. In leading Montefiore, how critical has it been to communicate internally about Montefiore’s role as a change agent and have your people understood this effort?

I’ve seen resistance to change in the past, but in the last 10 years, our people have come together strongly around the values that we hold dear.

The Montefiore mission is alive and well among our staff: we are fortunate to attract talented people who are motivated to take care of everyone who is in need. This is why they go into healthcare and why they come to Montefiore.

Our employees are proud that they are on the cutting edge of transformation in healthcare. They also understand that we have support in some high places. We have a great partnership with Albany, and Governor Cuomo has been a terrific ally, as was the previous administration. Our medical students are some of the best in the world. We admit about 4 percent of all the applicants to fill the class of almost 900 students in all four years. Many of our students go on to become interns, residents and fellows within the 80 different programs we have in the Montefiore Health System. They are highly motivated and love working here and taking care of patients that need their care: they understand that we are agents of change.

We were also granted $174 million of NIH research funding in fiscal year 2017. An analysis by Blue Ridge Institute for Medical Research recently showed that Einstein ranked 7th in award dollars per investigator among the nation’s top medical schools.

Change at Montefiore also includes medical and surgical advances. We perform highly specialized procedures like lung transplants, even bloodless lung transplants. We also do liver, heart, kidneys and bone marrow transplants. For heart and liver, we have some of the best outcomes in the country. We’re very proud of that. Last year, we were among the first medical teams to successfully transplant a Hepatitis C infected liver into a young man who was desperately in need and waiting for an organ. Now, we know how to treat the Hep C, so we have access to more life-saving organs.

We also offer sophisticated primary care: five million ambulatory visits in the community at 250 sites. We work hard to integrate behavioral health into our primary care setting so we can better address patients’ comprehensive needs all in one place to try and make sure nobody slips through the cracks.

People who work here appreciate change and transformation: they understand that Montefiore is providing a continuum of care – it’s not just complicated hospital care. People love this because we follow our patients and stay with them and know their families.

When you’re dealing in different markets within Montefiore’s 11 hospitals, how important is providing consistent care and seamless services while addressing very different needs?

Challenges tend to be much more similar than people realize. St. Luke’s Cornwall in Newburgh, New York, is a rural hospital and it has many of the same patient challenges as an urban hospital: poverty and joblessness amidst gentrifying neighborhoods.

The value of developing one Montefiore culture throughout the system is the goal, but it does take time to curate – it doesn’t happen overnight. We want the power of one voice in purchasing and dealing with insurance companies, as well as the shared services that bring value to an organization. That’s where size has impact if we use it correctly. It brings about quality and safety.

The commitment to the community is at the core of Montefiore’s values and mission. What role do you foresee Montefiore playing as a part of its communities?

There are communities within communities so, in the more urban areas we’re in, the doctors are employed by the hospital. This has been a transition from having more private doctors.

As we expand and move into other areas, there are many doctor groups we work with. Crystal Run is a system of about 500 primary care doctors and subspecialists in the Hudson Valley. We have a new partnership with them that will enable us to learn from their ambulatory care expertise, while their patients can have access to our specialty services. The important thing about coming together with institutions that are thriving is we can also learn from them.

What has kept you with Montefiore for all these years?

The remarkable thing is that Montefiore has always nurtured me and challenged me at the same time. I had no idea years ago that I would be doing what I am doing now. I did know that I would not only be practicing medicine: I saw bigger opportunities to be creative within healthcare and really change the system. Early on, I was influenced by situations we found ourselves in: the AIDS epidemic, followed by a tuberculosis problem. Today, Meth is back. If you are a clinician long enough, you start to see cycles. The opioid epidemic is so frustrating for us because it never really left the Bronx and now it’s back. Sometimes progress is measured, but when I look around and see all we have accomplished and the progress we have made in community health and cancer care, transplant and pediatrics, I feel incredibly grateful that I have been able to build such a fulfilling career here. I’m proud that Montefiore never dodged the difficult issues and that we’ve been able to anticipate changes that need to be made to provide the best care for our patients.

Do you worry whether the best and brightest will continue to enter medicine?

No, medicine is a great profession. Remarkably, young people are still entering healthcare, despite the fact that these kids have a lot of debt and the training takes years. It’s more expensive if one adjusts it for inflation than it was when I went to medical school. These kids are taking on loans that equal what people used to take on for a house, so something needs to give – yet, they keep applying. I’m pleased about that.