Two decades ago, Montefiore Medical Center started investing millions of dollars in technology and staff to help it deliver better clinical outcomes at lower costs.

Now that long-ago investment is helping the Bronx health system add a new line of business: medical insurance. In 2015, the Montefiore Insurance Co. will offer a health coverage plan to small businesses, as well as insurance services in other niches, including long-term care."It's a business decision based on the opportunities," said Dr. Steven Safyer, Montefiore's president and chief executive.

Montefiore isn't alone in that assessment. The North Shore-LIJ Health System launched an insurer, CareConnect, last year. Crystal Run Healthcare, a multispecialty practice with some 300 providers in the Hudson Valley and lower Catskill region, also is getting into the insurance business.

Most hospitals get paid for the tests and procedures they perform. Taking on the risk of a patient's health, as insurers do, offers a potentially rich revenue stream because federal and state health reforms have put a premium on paying medical providers for the quality rather than the quantity of care. It's new territory for New York hospitals. Most have not yet adapted their clinical model of care to be financially accountable for a patient's health.Montefiore and North Shore-LIJ are the exceptions. The former already has an infrastructure in place to manage the financial risk and other aspects of delivering health care. Montefiore's footprint in the Bronx and northward gives it the size it needs to compete for employers looking to offer insurance to their workers. One out of every three residents in the Bronx gets care from Montefiore. The system recently added hospitals in Westchester County and may swoop up another in Rockland.The operations that support how Montefiore manages risk—data experts, care managers, social workers and other staff—cost about $100 million annually but help the system generate $2 billion in revenue from shared- or full-risk initiatives. That infrastructure will serve the insurance company well.