‘You can­not have two vi­sions. You can­not have two mis­sions’

Modern Healthcare - - Q & A -

Dr. Steven Safyer be­came CEO of Mon­te­fiore Med­i­cal Cen­ter in the Bronx in 2008 af­ter three decades in the sys­tem, where he made his name treat­ing in­mates at Rik­ers Is­land and tack­ling

New York City’s HIV and tu­ber­cu­lo­sis epi­demics. To­day, Mon­te­fiore Health Sys­tem’s four hos­pi­tals, 1,200 em­ployed physi­cians and 125 health clin­ics have won plau­dits for their ef­forts to tackle the obe­sity, di­a­betes and asthma epi­demics af­fect­ing the bor­ough’s mostly His­panic pop­u­la­tion. Mod­ern Health­care edi­tor Mer­rill Goozner re­cently in­ter­viewed Dr. Safyer in his Bronx head­quar­ters. The fol­low­ing is an edited tran­script.

Mod­ern Health­care: How do you de­fine pop­u­la­tion health man­age­ment?

Dr. Steven Safyer: Pop­u­la­tion health has be­come a com­mon phrase, and if you quiz peo­ple, it will have dif­fer­ent mean­ings. Most peo­ple will go to the Triple Aim, and I think that that’s a rea­son­able ap­proach. The re­cent his­tory of health­care over the last 40, 50, 60 years was very fo­cused on the in­di­vid­ual and on spe­cific dis­eases.

But it was out of con­text some­times with the fam­ily, the com­mu­nity, and other so­cial ser­vices that com­ple­ment and make a per­son’s well-be­ing eas­ier to man­age. Pen­sions, the abil­ity to re­tire, ac­tu­ally hav­ing in­sur­ance for your health­care, jobs, ed­u­ca­tion, an in­tact fam­ily, a com­mu­nity that works—all th­ese things max­i­mize the out­comes.

We don’t do so well on out­comes com­pared to Europe. It’s my con­tention it’s not be­cause of the care that’s given in a hos­pi­tal or in a med­i­cal cen­ter. It has much more to do with the so­cial ser­vices and the fam­ily con­text, which tend to be weaker in this coun­try. So pop­u­la­tion health to me is, in the most gen­eral of terms, re­cal­i­brat­ing and re­tar­get­ing what we’re fo­cused on for peo­ple’s well-be­ing.

MH: What is your strat­egy to ad­dress those is­sues?

Safyer: It’s my job to first and fore­most walk the walk. I can’t boil the ocean. But we try to in­flu­ence the boil­ing of the ocean.

I have to work with the state pub­lic health depart­ment or the city health depart­ment or with agen­cies in the com­mu­nity or with churches. We’re in one-third of the schools in the Bronx with com­pre­hen­sive health­care try­ing to pre­vent young girls from be­com­ing preg­nant. Or, if they do be­come preg­nant, learn­ing how to take care of that baby.

Most im­por­tantly, walk­ing the walk to me means mov­ing the care from be­ing frag­mented to fo­cus on … pri­mary care, com­mu­nity care, home health, and even care man­age­ment. The best way to do that is to in­te­grate the pay­ments, which is cap­i­ta­tion with an­other name, be­cause then it en­ables and con­trib­utes to com­pre­hen­sive care.

MH: But how can you af­ford to de­liver com­mu­nity health ser­vices if you’re not be­ing re­im­bursed for it?

Safyer: You man­age it with strength and with vi­sion, and you man­age it with the best peo­ple pos­si­ble. We live in two worlds. The econ­omy of Mon­te­fiore is just over $6 bil­lion. At the same time, we’re tak­ing full, or al­most full, cap­i­tated fi­nan­cial re­spon­si­bil­ity for 450,000 in­di­vid­u­als who, in one way or an­other, are in val­ue­based pur­chas­ing. That’s half of your rev­enue.

So we’re in two worlds. But you can­not have two vi­sions. You can­not have two mis­sions. An or­ga­ni­za­tion couldn’t un­der­stand. It would be con­fused. So our en­tire fo­cus is on mov­ing to­ward 100% pre­paid, which will take time, but that’s how we run the or­ga­ni­za­tion.

MH: Can you give an ex­am­ple of of­fer­ing a ser­vice for which you re­ceive no re­im­burse­ment?

Safyer: If you went to our emer­gency rooms, which col­lec­tively see 650,000 vis­its a year, all of them have a nurse prac­ti­tioner whose sole job is to iden­tify peo­ple who we can di­vert their ad­mis­sion and not have them ad­mit­ted to the hos­pi­tal. Maybe they need a catheter­i­za­tion the next day;

“Walk­ing the walk to me means mov­ing the care from be­ing frag­mented to fo­cus on … pri­mary care, com­mu­nity care, home health and even care man­age­ment.”

maybe they need a shel­ter to live in; maybe they need their medicines re­newed. In a lot of other places, they would get ad­mit­ted.

The nurse prac­ti­tioner walks around with an iPad that’s con­nected to the in­for­ma­tion sys­tem that red flags in­di­vid­u­als who are at risk of be­ing ad­mit­ted and can be pro­vided with ser­vices to pre­vent that ad­mis­sion. We do that be­cause our beds are full any­way. But, more im­por­tantly, we’re driv­ing to­ward one out­come, one cul­ture.

MH: New York state is in the sec­ond year of a ma­jor over­haul of its Med­i­caid pro­gram. How has it af­fected your abil­ity to do the kinds of things you’re try­ing to do in pop­u­la­tion health?

Safyer: It’s a ter­rific pro­gram. The state made very large sav­ings over the past six years in Med­i­caid. So we got a 1115 waiver from the fed­eral gov­ern­ment that took about half the sav­ings and gave them back to us to in­vest in trans­form­ing the health­care sys­tem … to move in this di­rec­tion of pop­u­la­tion health. To a large ex­tent, that’s hap­pen­ing.

MH: Mon­te­fiore has ex­panded into Westch­ester County and the Hud­son Val­ley. What’s the strat­egy?

Safyer: At its very essence it’s to build a health­care de­liv­ery sys­tem in a re­gion that that has 3 mil­lion in­di­vid­u­als. We be­lieve that if we build that out, 1 mil­lion of them will be in one way or an­other in a pop­u­la­tion health in­sured model. We be­lieve that we have the scale to ramp up.

MH: Do you see net­work com­pe­ti­tion com­ing to New York?

Safyer: This is New York, so there will be com­pe­ti­tion. Com­pe­ti­tion is healthy.

MH: Where will it hap­pen? You’re not go­ing to see ma­jor com­pe­ti­tion in the Bronx. Mon­te­fiore is so dom­i­nant.

Safyer: Man­hat­tan is go­ing to be a very com­pet­i­tive mar­ket­place. You’re see­ing that.

That has a lot to do with the high amount of com­mer­cial in­sur­ance there, and this is not news to any­body.

There’s go­ing to be a lot of com­pe­ti­tion on Long Is­land and in Westch­ester, there’s no ques­tion about it. Pretty much ev­ery­body has got some turf and is build­ing scale.

All of us have slightly dif­fer­ent mod­els or rad­i­cally dif­fer­ent mod­els. We’re all af­fil­i­ated with med­i­cal schools.

MH: Turn­ing back to pop­u­la­tion health, was the gov­ern­ment’s ac­count­able care or­ga­ni­za­tion pro­gram flawed?

Safyer: That’s a good ques­tion. The Pi­o­neer ACO was called pi­o­neer be­cause it was in in­sti­tu­tions and or­ga­ni­za­tions that were most ready to take risk. We were one of 32 and we re­main in the pro­gram. We have led the sav­ings and have led the qual­ity out­comes through­out that whole pe­riod of time. We’re in our fifth year now. It will bridge into some­thing new called Next Gen.

I think the ul­ti­mate des­ti­na­tion is true cap­i­ta­tion. They should con­tinue, and they should do it ag­gres­sively. MACRA (the new physi­cian re­im­burse­ment pro­gram) and some other things are mov­ing in that same di­rec­tion.

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