Help the Uninsured (Without Going Broke)

The medical center decided the best way to embrace the community was to keep the doctors from fleeing to other boroughs with more commercial customers, and the only definite way to keep those physicians was to employ them. And to employ them, there had to be a way to pay them.

Montefiore owns three hospitals with 1,228 licensed beds, taking in more than 70,000 inpatient stays a year. As Safyer says, "Medicaid in New York state is a decent payer to the hospitals and a very poor payer to the doctors." Those patients who are uninsured are put on a state program for emergency Medicaid eligibility. To collect those funds, Safyer says Montefiore employs more than 600 finance staffers. "That is an expense and a bureaucracy. It is backward. But I hire those people because in the end their expense is lower than the revenue I can reclaim by getting them on Medicaid."

The revenue from the inpatient side allows Montefiore to supplement an extensive, ambulatory care network that includes a 350-member primary-care group and sees 2.5 million outpatients a year. Follow-up care is provided by a hospital-based home health agency that sees more than 400,000 annual visits.

To manage the patient population, Montefiore also takes capitated risk in government and commercial payers. "We have about one third of our revenue coming in through an IPA, which is the doctors and all the ancillaries and the hospitals. It is about $650 million a year. We make that work not in the way traditional managed care companies have. We don't deny the care or prevent access to care. We manage the care. So it is a prepayment system. That has been very good for growth and good for the economics," Safyer says.

"We are really a large ambulatory care system with some big hospitals. The economics are simple: To make whole the employed physician community—which includes that ambulatory care network—we have to move about $90 million into that system a year. It is not exactly apples to apples, but $90 million would triple our bottom line. It is money a lot of systems would target for profit, which we are plowing back into the care system."

Not all hospitals—even large urban academic medical centers—have the funding levels that New York state provides, but Safyer says the key that allows Montefiore to provide care for the uninsured and underinsured without threatening the system's financial health is its level of overall integration, especially employing physicians. Those tools have allowed Montefiore to stay viable in the Bronx.

"We provide complex care to a huge population," Safyer says. "We do heart transplants, kidney transplants; we do sophisticated and innovative surgery of all sorts. We provide them to a borough that is 80% governmental payers and has 350,000 uninsured patients. Some academic medical centers would simply either move, which we could not do, or just attract patients from another borough."

Being so integrated also allows the physicians at Montefiore to overcome any headaches over treatment and payment. "There is no financial stigma associated with the patient status," says Stephen Rosenthal, vice president of network care management and president and COO of Montefiore's subsidiary care management organization. "There are rules and regulations and guidelines, but we try to make the patient's experience consistent so we don't have physicians looking at patients differently because of reimbursement issues."

—Jim Molpus, Kathryn Mackenzie, John Commins

Creative in Memphis

Methodist Le Bonheur Healthcare in Memphis, TN, faces a daunting uninsured burden in a city plagued by significant poverty. For senior leaders at the seven-hospital system, traditional solutions are simply not enough—they have been forced to find innovative ways to address the community's tremendous need.

Gary Shorb, president and CEO of the faith-based system, points to two significant strategies at Methodist:

1. Last year the system launched a program to link nonurgent emergency department patients with a community-based medical home. The program, which is a partnership between Methodist University Hospital, the University of Tennessee Health Science Center's Preventive Medicine Department, and a number of local community clinics, was born in part from a university-initiated survey of patients in EDs across Memphis that showed that 64% of those patients were unaware of other healthcare resources that were available to them.

2. More than half of the uninsured patients who come into Methodist emergency rooms are also regular visitors to the city's hundreds of churches—so it was a logical next step to tap work with local congregations to help church members find the best avenue to receive the care they need, Shorb says ("Faith in the Hospital" April 2008). Methodist's Congregational Health Network Partnership creates a tangible connection between the church and the health system. "We saw the potential to improve not only the care we deliver to our patients, but also to improve the quality of life for our community," Shorb says.

The partnership places a so-called "navigator" in each of the more than 100 affiliated congregations that have agreed to a covenant with the hospital system; the navigators help direct church members to the best avenue for their particular health needs, which may or may not include referrals to Methodist. "The idea is that the navigators become more than just a healthcare worker telling the congregation where to go or what to do. They become trusted members of the congregation who really care about the community's healthcare needs," says Shorb.

—Kathryn Mackenzie