Pub­lic health just as essen­tial as po­lice, fire­fight­ers, clean wa­ter. Let’s value it equally

Modern Healthcare - - COMMENT - By Dr. Ram Raju

De­spite pol­icy and tech­no­log­i­cal in­no­va­tion oc­cur­ring na­tion­wide, what I like to call “Health­care Nir­vana”—bet­ter out­comes, cost ef­fec­tive­ness and health eq­uity—re­mains un­re­al­ized. It is time to in­vest in a bet­ter health­care fu­ture for all.

NYC Health & Hos­pi­tals is a key tool for mak­ing that in­vest­ment in New York. We are proud to part­ner with Mayor Bill de Bla­sio on a com­pre­hen­sive trans­for­ma­tion plan to se­cure fi­nan­cial sta­bil­ity. NYC Health & Hos­pi­tals, like other pub­lic health­care de­liv­ery sys­tems across the na­tion, safe­guards health, a ben­e­fit as essen­tial as pub­lic safety, fire­fight­ing and clean wa­ter, and one that should be val­ued the same way.

A re­port re­cently pub­lished by New York’s In­de­pen­dent Bud­get Of­fice reached two con­clu­sions about our trans­for­ma­tion plan: Re­viv­ing our fis­cal health will re­quire co­op­er­a­tion from fed­eral and state gov­ern­ment and la­bor; but suc­cess is un­cer­tain. With all due re­spect, those of us work­ing in the trenches to strengthen the pub­lic health­care sys­tem al­ready knew this.

The IBO’s re­port em­pha­sizes our deficit, but is flawed by omis­sion, of­fer­ing no con­text for the rea­sons be­hind short­falls, and no al­ter­na­tive to the trans­for­ma­tion we have em­barked on. They seem to be say­ing: Your plan will be hard to ac­com­plish, bet­ter not at­tempt it. It’s a good thing they weren’t ad­vis­ing Gen. Eisen­hower be­fore D-Day.

Let’s be clear: Pub­lic health­care in New York and else­where de­liv­ers much care with­out get­ting paid for it. Crit­ics sug­gest­ing the New York sys­tem is los­ing money are wrong. De­spite our grat­i­tude for in­creased city fund­ing, we are like a fam­ily sta­tion wagon that ev­ery­one uses, but no one gases up.

One in six New York­ers ac­cesses our com­pre­hen­sive ser­vices. We pro­vide 1.1 mil­lion ER vis­its, 4.2 mil­lion clinic vis­its, and 45% of be­hav­ioral health­care oc­cur­ring an­nu­ally.

Our deficit is due to ba­sic economics: low Med­i­caid re­im­burse­ment, un­fair method­ol­ogy for dis­tri­bu­tion of state char­ity care, and evis­cer­a­tion of pay­ments to com­pen­sate us for care pro­vided to pa­tients who can­not pay.

This last point is sig­nif­i­cant. Mod­ern Health­care re­cently shined a spot­light on dis­ap­pear­ing dis­pro­por­tion­ate-share dol­lars—huge re­duc­tions baked into the Af­ford­able Care Act on the as­sump­tion that wider in­sur­ance cov­er­age would lessen the need for fed­eral fund­ing. It hasn’t yet worked out that way. Un­cer­tainty in new mar­ket­places, ex­clu­sion of the un­doc­u­mented, and re­fusal of many states to ex­pand Med­i­caid, means the un­com­pen­sated care bur­den for pub­lic sys­tems across the coun­try hasn’t de­clined. Adding in­sult to in­jury, the CMS has pro­posed a new DSH for­mula rule that will fur­ther dis­ad­van­tage us. Of course the im­pact of changes in fed­eral pol­icy isn’t ex­clu­sive to New York. They pose fis­cal chal­lenges to pub­lic hos­pi­tal sys­tems na­tion­wide.

Our deficit didn’t re­sult from un­nec­es­sary spend­ing. We don’t have celebrity wings, valet park­ing or atrium grand pi­anos. Nor is it a re­sult of mis­man­age­ment. We are reg­u­larly cited by lead­ing jour­nal­ism/ad­vo­cacy or­ga­ni­za­tions for qual­ity and safety ex­cel­lence. We’re at the fore­front of re­forms to im­prove care and save health­care dol­lars.

The IBO’s re­port does a dis­ser­vice by of­fer­ing no al­ter­na­tive to our aim to avoid elim­i­nat­ing ser­vices, or our re­liance on ef­fi­cien­cies, growth and gov­ern­ment sup­port. Sure, gen­er­at­ing rev­enue is harder than cut­ting, but if pub­lic hos­pi­tals cut, where will peo­ple go for care? What would a day with­out us look like? How many trou­bled in­di­vid­u­als would wan­der the streets? How many would per­ish from hy­pother­mia in win­ter? How many wouldn’t make it through traf­fic to dis­tant ERs?

Whether it’s vic­tims of gun vi­o­lence in our trauma de­part­ments, pa­tients made ill from street drugs pre­sent­ing in our ERs, or pa­tients who’ve vis­ited coun­tries grap­pling with epi­demics like Zika or Ebola be­ing screened by our in­fec­tious­dis­ease spe­cial­ists, if there’s a health emer­gency, pub­lic hos­pi­tals across the coun­try step up. And we do so de­spite the lack of re­im­burse­ment streams for such care.

With­out a ro­bust pub­lic sys­tem here in New York, achiev­ing health eq­uity is less likely. We will move closer to a Tale of Two Cities, one rich and healthy, the other poor and sick. New York has al­ways re­jected that path, stand­ing in­stead for the idea that health is a hu­man right. Th­ese are times to deepen—rather than doubt— that com­mit­ment.

Dr. Ram Raju is pres­i­dent and CEO of NYC Health & Hos­pi­tals.

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