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

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.