It’s im­por­tant to sta­bi­lize New York City Health and Hos­pi­tals Corp.

NYC safety net hos­pi­tals can lead the way on re­form but need some help

Modern Healthcare - - Front Page - Alan Aviles Alan Aviles is pres­i­dent and CEO of the New York City Health and Hos­pi­tals Corp.

Nearly 15 years ago the New York City Health and Hos­pi­tals Corp., the city’s vast pub­lic hos­pi­tal sys­tem, was rou­tinely crit­i­cized as grossly in­ef­fi­cient and on the verge of be­ing dis­man­tled for de­liv­er­ing what many con­sid­ered sub­stan­dard care. Much of the crit­i­cism was jus­ti­fied.

While the ef­fort to “break up” and pri­va­tize the sys­tem was ul­ti­mately thwarted, it served as a much-needed wake-up call for the nation’s largest pub­lic hos­pi­tal sys­tem to fo­cus on greater ef­fi­ciency and far-reach­ing qual­ity im­prove­ments.

HHC has made re­mark­able strides since those dif­fi­cult days. Qual­ity and op­er­a­tional im­prove­ments made since that nadir have trans­formed the sys­tem into a na­tion­ally renowned or­ga­ni­za­tion de­liv­er­ing ef­fec­tive, ef­fi­cient and pa­tient-cen­tered care. In­deed, our pub­lic hos­pi­tals now outscore the ma­jor­ity of New York City’s pri­vate hos­pi­tals on a host of pub­licly re­ported qual­ity and pa­tient-sat­is­fac­tion mea­sures. In 2008, HHC re­ceived the Na­tional Qual­ity Fo­rum and the Joint Com­mis­sion’s John M. Eisen­berg Award for In­no­va­tion in Pa­tient Safety and Qual­ity—an honor that would have been highly un­likely just a few years ear­lier.

But de­spite how far we’ve come, the road ahead is fraught with peril, and the tim­ing could not be more ironic. Even with na­tional health­care re­form a re­al­ity, and its po­ten­tial to vastly re­duce the num­ber of unin­sured Amer­i­cans on the hori­zon, HHC is in se­ri­ous jeop­ardy once again. The sys­tem faces a pro­jected $1 bil­lion bud­get deficit that could se­verely desta­bi­lize our in­fra­struc­ture and com­pro­mise ac­cess to care.

How did we again ar­rive at the door of fis­cal cri­sis? Like many hos­pi­tal sys­tems, HHC strug­gled with soar­ing costs for pro­vid­ing care, shrink­ing re­im­burse­ments and the swelling ranks of the unin­sured long be­fore the re­ces­sion took hold. Specif­i­cally, over the past three years, the sys­tem’s an­nu­al­ized state Med­i­caid re­im­burse­ment has been slashed by $250 mil­lion, with an­other $50 mil­lion in cuts ap­proved this year. Fur­ther, fed­eral sup­ple­men­tal Med­i­caid fund­ing for pub­lic hos­pi­tals is ex­pected to de­cline by hun­dreds of mil­lions of dol­lars, and the num­ber of unin­sured that HHC treats has sky­rock­eted by an ad­di­tional 60,000 pa­tients. And low Med­i­caid re­im­burse­ment rates for com­pre­hen­sive pri­mary-care ser­vices—a sta­ple of the sys­tem’s safety net—gen­er­ate enor­mous losses.

The im­por­tance of a fis­cally sta­ble HHC

Were HHC to floun­der, there would be no way to fill the gap, and not just for poor pa­tients.

can­not be over­stated. Were it to floun­der and fail, there would be no way to fill the health­care gap left be­hind, and the poor would not be the only group to suf­fer. New York City’s re­main­ing pri­vate, not-for-profit hos­pi­tals, many of whose emer­gency de­part­ments are al­ready strained, would sim­ply be over­whelmed.

Con­sider the breadth and scope of HHC’s reach. We serve 1.3 mil­lion pa­tients an­nu­ally, in­clud­ing 450,000 with­out health in­surance. The sys­tem ac­counts for 5 mil­lion out­pa­tient vis­its, 225,000 hos­pi­tal ad­mis­sions, 25% of all New York City births, 70% of its in­vol­un­tary psy­chi­atric ad­mis­sions, 30% of its trauma ser­vices and 1 mil­lion emer­gency vis­its.

To pro­tect and strengthen HHC over the long term, we must se­cure a re­im­burse­ment method­ol­ogy that sup­ports our fo­cus and core mis­sion of keep­ing pa­tients and com­mu­ni­ties healthy through ro­bust pri­mary and pre­ven­tive care. For­tu­nately, the new fed­eral health re­form law of­fers hope.

The Pa­tient Pro­tec­tion and Af­ford­able Care Act em­pow­ers the CMS to sup­port global cap­i­ta­tion re­im­burse­ment pi­lot pro­grams un­der which an in­te­grated health­care de­liv­ery sys­tem such as HHC could re­ceive a sin­gle monthly pay­ment to cover all health­care ser­vices needed by Med­i­caid pa­tients, and per­haps by resid­ual unin­sured pa­tients. Un­like tra­di­tional Med­i­caid fee-for-ser­vice pay­ments, global cap­i­ta­tion en­cour­ages in­vest­ment in pri­mary and pre­ven­tive care and leads to more cost-ef­fec­tive care that im­proves the long-term health of pa­tients, in­clud­ing those with chronic dis­eases, who ac­count for a large por­tion of most states’ Med­i­caid ex­penses and are at higher risk of hos­pi­tal­iza­tion.

This promis­ing pay­ment model would build on the ex­ten­sive in­vest­ments in pri­mary and pre­ven­tive care HHC has al­ready made— in­vest­ments that are re­duc­ing for­merly per­sis­tent health dis­par­i­ties among New York­ers. How­ever, ini­tial global cap­i­ta­tion rates must be set at a level that will also sup­port the in­vest­ment nec­es­sary for a more ro­bust care man­age­ment and care co­or­di­na­tion in­fra­struc­ture, an in­fra­struc­ture that can ul­ti­mately pay for it­self un­der the cap­i­tated re­im­burse­ment model by re­duc­ing emer­gency depart­ment vis­its and hos­pi­tal­iza­tions.

As the next best thing to truly uni­ver­sal health cov­er­age—there will al­ways be unin­sured pa­tients in need of a safety net, in­clud­ing large num­bers of un­doc­u­mented im­mi­grants—the sys­tem is now uniquely po­si­tioned to ben­e­fit from fed­eral health­care re­form by serv­ing as a prov­ing ground for pay­ment re­form that aligns with long-term value for our health­care dol­lar.

Af­ter a long and un­par­al­leled pe­riod of sta­ble se­nior man­age­ment, along with con­sis­tently strong sup­port from Mayor Michael Bloomberg, New York City’s crit­i­cally im­por­tant pub­lic hos­pi­tals are ready to help de­fine how health­care is de­liv­ered more ef­fec­tively and ef­fi­ciently in the post-health­care re­form world. As the largest health­care safety net in Amer­ica’s largest city, we ask only that govern­ment at all lev­els give us the op­por­tu­nity and re­sources to show that it can be done.<<

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