Dr. Steven M. Safyer, Class of '82, assumed his position as the new president and chief executive officer of Montefiore Medical Center, the University Hospital for the Albert Einstein College of Medicine, in January 2008. His appointment culminates a 25-year career at Montefiore, during which he held increasingly senior leadership positions, including that of senior vice president and chief medical officer. He is professor of medicine and professor of epidemiology and population health at Einstein. Dr. Safyer recently spoke with Gordon Earle, the new associate dean for public affairs & communications at the College of Medicine, about his vision for Montefiore, for the relationship between Einstein and Montefiore, and for the future of healthcare.

What do you see as Montefiore's mission?

My goal is to take Montefiore into the top tier of academic medical centers nationwide and to demonstrate, using our innovative healthcare delivery network, that it is possible to transform the health of an entire population. Montefiore's mission of patient care, teaching, research and community service is unwavering. To realize our full potential and fulfill our stated vision, we will seek to advance our partnership with Einstein. A top-tier academic medical center needs to demonstrate excellence in all spheres, from bench research to patient care and community service.

I think we're in a unique position because of our long-standing investment and focus on our community's health. We're located in the Bronx, the 10th largest 'city' in the country, so if we want to show how to transform the health of a population, this is a great place to do it. I'm talking about providing community services, public health services, primary and preventative care, tertiary care and end-of-life care in a coordinated, managed fashion, for all persons, whether insured or uninsured.

I want my work at Montefiore to be measured by how well our team actually makes a difference in the overall health and quality of life in the population we serve.

What's going to be different about the execution of your vision and what has gone before?

I have a historical perspective based on three decades of working at Montefiore. The history of Montefiore has been one of growth and evolution, and I believe it is time for Montefiore to evolve yet again. What began in 1884 as a Home for Chronic Invalids later became a community teaching hospital. In the mid 1980s, the borough was distressed. We focused on building a primary-care network connected to the hospital and integrating that healthcare delivery system in a way that was unique for an academic medical center. We began to look at the health of the whole patient, not just when he or she needed a specialist or hospitalization, but at how we could help them stay healthier over time. We built a major care-managing capacity at the same time 'managed care' was becoming an unpopular concept. We embraced the ideal and actually managed our patients' care. No other academic medical center pursued this path to the extent we did.

Currently, our academic strengths are in pediatric subspecialties, heart disease and organ transplantation, and we are positioned to expand our transplantation expertise with our new liver transplantation program. But that alone won't make us a top-tier academic medical center. I believe the next evolution of Montefiore must include an evolution of its relationship with Einstein. We cannot take Montefiore to the next level without the ability to recruit the caliber of physicians and researchers who will make new treatments possible. Just as Einstein's role will be critical to Montefiore's success, I contend that a positive, synergistic relationship with Montefiore is critical to the College's success. Together, we are greater than the sum of our parts. I like to say that 1+1=5. This is a significant break from the past.

What kind of impact will the affiliation between Einstein and Montefiore have on healthcare and biomedical research in the years ahead?

The relationship between Einstein and Montefiore should represent synergy between biomedical advancement and its application to patient care. Together, we can work to push both bench science and translational research. What happens in the future will depend on how innovative we are. In my mind, we need to constantly recalibrate what we identify as state-of-the-art and innovative. I expect that future innovations will come from those areas in which we have a strong joint focus.

For example, Einstein has several major research programs in cancer, liver disease, and diabetes that we could expand more into the areas of clinical innovation, prevention and community health. Montefiore has several clinical and community-based interventions, the efficacies of which have not been rigorously studied. Our location in the Bronx, which has the highest rates of obesity and diabetes in the nation, provides a perfect opportunity for harnessing the power of Einstein's science and Montefiore's medicine. Working together, we can aspire to advance important fields such as diabetes, cancer, liver disease, heart disease, and child health.

You have been quoted as saying that you 'look forward to working with Einstein and other local healthcare partners to transform the health of the region and to create a national model for healthcare reform.' What transformation would you like to see in the healthcare that is available in the region?

Everybody talks about healthcare reform, but when you look closely at the proposals, you're only talking about insuring the uninsured. There are 47 million people in the United States who are uninsured and 350,000 of them live in the Bronx. I'd be happy if these people were insured, but I'm not naïve enough to think that this alone is a model for national healthcare reform.

Our current system is plagued with serious public health problems. For example, the average life expectancy over the next five years is expected to decrease because so many of our kids are obese and in danger of developing heart disease and diabetes. Even if you are insured, access to care is often difficult. Medical care is fragmented. Medical records are fragmented. Every time you see a different doctor, he or she doesn't know what your previous doctor did or the medications prescribed. And only your pharmacy knows if you filled the prescriptions. I think that communities, and the country as a whole, have ignored dealing with these big issues. Healthcare reform has been reduced to only insuring more people and not changing the system.

The financial incentives in the system support this fragmentation and inefficiency. The greatest financial value is gained by hospitalization. But if you are talking about maximizing health, you want to prevent disease or at least minimize its impact. You want to keep people healthier, at home and in their communities. To accomplish this, you need to reprioritize the incentives.

We have led an effort in the Bronx to link up the information technology systems of the major healthcare providers in the borough. This is crucial in urban areas where patients walk into any of several emergency rooms for episodic care. The program we are working on, we believe, not only will improve care and reduce the risk of adverse events from duplicative invasive procedures, but will reduce costs as well. This is the kind of transformation that I think we need in the healthcare system.

How would you go about reforming the system?

I suggest that Medicare, Medicaid and healthcare providers in the Bronx create a large-scale demonstration project that would bring in the uninsured. About 1,000,000 people in the Bronx are either covered by Medicaid or Medicare or are uninsured. Society is already paying for the care they receive when hospitalized in the form of emergency Medicaid. The Bronx provides a unique opportunity to show how to insure all and change the care system at the same time.

There is an opportunity here to take collective responsibility for most of the healthcare needs of the 1.5 million residents of the Bronx. We already assume the insurance risk for 10 percent of that population. In the model I propose, we would, in partnership with other providers in the borough, take the risk for an additional 80 percent. We would be compelled to manage the care of that population, to invest in prevention, to invest in primary care and to do all the other things I have been talking about. It would be good for Montefiore and Einstein because it would create a new model of a top-tier academic medical center providing a spectrum of innovative care from preventive to tertiary care. It would be good for Einstein because there would be tremendous opportunities for clinical research in all the medical conditions that are highly prevalent in the community. It would be good for the borough because the care would remain here.

What was it like when you were at Einstein?

I chose to come to Einstein in 1978 because of my passion for academics and clinical excellence, civil rights and social justice. It was a good fit. At the time, it ranked number 11 among all the medical schools in the country. It was an 'Ivy League' medical college with a heart. It had a commitment to education, the community and community health that resonated strongly with me.

How did your Einstein experience prepare you for your career?

My Einstein experience taught me what good medicine is and what a powerful tool it can be for affecting positive social change. It was my entry point to Montefiore, where I have had the privilege of advancing my career. It also taught me that scientific rigor, clinical excellence, and human compassion are inextricable components of being a good doctor. Through my career, I have held myself to these high standards and used them to set the bar for care provided at Montefiore. Lastly, Einstein prepared me to seize opportunities and challenges as they presented themselves. I believe we are at a crucial moment now to seize the opportunity to strengthen the alliance between Montefiore and Einstein and bring Montefiore into the top tier of academic medical centers providing innovative care.

Note: Dr. Safyer met his wife, Paula Marcus, MD '82, on the first day of medical school. She is a psychiatrist on faculty at Einstein.

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