Way back in the 1930s the original Jewish Italian settlers started leaving
the Bronx they were escaping prohibition gangs for calmer suburbs into the vacuum
came Hispanic and African Americans fleeing grinding poverty in Costa Rica
or discrimination in the deep south the remaining middle-class families upped
sticks in the 70s when heroin, opioids, HIV, took possession of the Bronx
people described a synergy of plague so you know disruption of housing
homelessness economic decline as well as as well as profound health problems you
know a good ten percent of people have diabetes 15% of people of asthma eight
to ten percent of people how in the south of the Bronx report severe
psychological distress that's two to three times higher than the national
average Montefiore is fundamentally it's a it's a hospital based system at its
heart it's an academic metal centre a training college for doctors and a
teaching hospital but from the very start it committed itself to serving
this deeply deprived population its purpose was to use medicine and the
resources of health care to fight the battle and tackle social injustice
Montefiore I think did something remarkable from the 1980s onwards
they built two primary care brick-by-brick
from the bottom up from the 80s they started hiring primary care doctors and
training primary care doctors by the end of the 1980s they had established three
clinics in the poorest neighborhoods in in in the Bronx by the end of the 1990s
they developed pretty much the biggest primary care network in the US at the
time you know 200 doctors 21 sites carrying out almost a million
appointments every year and this really was a start of a
tradition of a hospital reaching beyond the hospital's boundaries it's a month
of your set up children's mobile clinics to go into the poorest neighborhoods
where they could get directly to children and homeless children they set
up clinics and homeless shelters they started building rehabilitation
facilities home care facilities residential care facilities wherever
there was a need Montefiore attempted to find the solution even though for the
most part it wasn't the hospital's responsibility and there was indeed
somebody else to blame Montefiore was one of the first hospital systems in the
US to start considering the social and environmental conditions that were
driving the epidemic in chronic conditions in their populations. Montefiore's
current chief operating officer focuses on the the relationship between
housing and asthma what is the point in handing out inhale as if we're going to
send these children back to the the damp and rat-infested conditions that are
fundamentally the the cause of their conditions Montefiore had an answer to
that question the 80s had established a not-for-profit subsidiary and over a
course of two decades it pretty much renovated all of the derelict blocks in
a large neighborhood around the Medical Center by now you're probably wondering
what enormous resources Montefiore had to be able to do all of this stuff
in the local community and the honest truth is that by the late 1990s Montefiore
was almost bankrupt you know this is a safety net system it deals with
largely Medicare and Medicaid patients and who don't pay very well in the US
almost all hospitals in the US rely on their commercial customers to subsidise
the costs of their Medicare and Medicaid customer
way way ahead of anybody else before any of us had heard about the joys of
value-based purchasing and risk based contracts it was working with its
insurers to move to decapitated arrangements took on its first early
based early risk contracts for a few tens of thousands of people in in the
mid 1990s now in 2018 it holds risk based contracts for around 400,000
patients are still a tiny proportion of the people it serves maybe 10 or 11%
their plan is to grow fast they want to get to a good million and a half this
really is the jewel in the crown of Montefiore system
it doesn't look like much it's a you know it's a single-story building on a
trading estate in the outskirts of the Bronx but this is the place that
crunches the numbers works out which of the patient groups that Montefiore is
dealing with have the greatest opportunities for improvements in care
and reduce reductions in cost improvements in coordination and this is
the place that takes charge of those those high-risk patients and really
improves how their care is being delivered every week the analytics team
is crunching the numbers looking through Montefiore's claims data and
utilisation data for health services to identify the next group of patients to
bring in to case management there's a team of experienced nurses who run 90
minute telephone interviews to get to the bottom of people's problems identify
you know the fundamental drivers causing them to turn up at A&E regularly causing
their their high utilisation and then there's a good team of 200 nurse case
managers and social workers who are developing care plans and I think
underpinning all of this is you know a real commitment to understanding what
works you know they don't just put in place an intervention you know they know
how many people who received peer-to-peer support
for their diabetes management saw an improvement in their diabetes A1C
hemoglobin A1C levels it's hard nosed and absolutely focused on results
Montefiore became the poster child for Obamacare in around 2014 when it was
clear that it was by far the strongest performer of the 32 accountable care
pioneers in the first two years five years into that programme it was
delivering a and ninety six percent performance score and 30 metrics ranging
from access to population health to patient satisfaction delivered that
pretty dramatic improvement in performance in comparison to other US
health systems while cutting the cost of care for this group by a good 75 million
dollars seventy five million dollars for a small group twenty-three thousand
Medicare patients in the beginning.