Brooklyn Boro

Brooklyn health care Town Hall emphasizes transition to outpatient care, collaboration, and funding

But ignores LICH

November 22, 2013 By Mary Frost Brooklyn Daily Eagle
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At Tuesday’s town hall meeting “Transforming Health Care in Brooklyn,” held at Brooklyn Law School, the five-member panel of hospital and policy administrators was asked, “What would health care in Brooklyn look like if you could start from scratch?”

The consensus: There’s no simple answer — but a transformed system would include a greater emphasis on primary care, outpatient centers integrated with hospitals, and more collaboration between hospitals.

Panelists sounded the alarm, however, about finding sufficient interim funding to transform from the old model to an outpatient centered system, and said things were going to get worse for Brooklyn under the Affordable Care Act.

They also expressed hope that several billion dollars potentially coming New York City’s way, generated by Medicaid Redesign Team reforms, could act as “bridge” money while moving to a new emphasis on outpatient care.

While in general consensus, panelists disagreed on at least one issue: whether Brooklyn is “overbedded.” They also ignored the elephant in the room — the plight of Long Island College Hospital (LICH) — until a member of the audience brought the issue to the fore. The bankruptcy of Interfaith Medical Center also received scant attention.

The town hall was sponsored by The Brooklyn Hospital Center and its Young Leadership Council; Lutheran HealthCare; and Brooklyn Law School and its Center for Health Science and Public Policy.

Hospital administrators included Dr. Richard Becker, president and CEO of The Brooklyn Hospital Center, and Wendy Goldstein, president and CEO of Lutheran HealthCare System. SUNY Downstate was represented by Dr. Miriam Vincent, professor and Chair of the Department of Family Medicine at SUNY Downstate.

Salvatore Russo, Senior VP & General Counsel at the New York City Health & Hospitals Corporation and Adjunct Professor of Law at Brooklyn Law School; and Karen Heller, Executive VP, Greater New York Hospital Association rounded out the panel.

Moderator Michael Cahill, Vice Dean and Professor of Law, asked participants to lay out their vision of Brooklyn hospitals’ “uncertain future and uncertain present.”

Brooklyn has a “fragmented” health care system, said Brooklyn Hospital Center’s Dr. Becker, with “a large number of sites working in an uncoordinated manner.” Adding to Brooklyn’s problems, Brooklyn hospitals are reimbursed less than hospitals in Manhattan, he said.

While the vision of the Affordable Health Care Act (Obamacare) is good, Becker said, the resulting funding cuts in New York State and New York City will be “nothing short of devastating.” New York has been liberal in its enrollment of Medicaid patients, but “Obamacare shifts the funding in a manner that damages New York City. Brooklyn and private safety net hospitals get hurt.”

Becker said that cultural differences affect the way Brooklynites access health care. “They rely on emergency rooms and the hospital. ERs get a high number of visits, but half are low acuity. In other places people go to urgent care centers or their primary physician’s office for dealing with their chronic diabetes, asthma” and other problems.

“We want to get to hospitals providing high acuity care, and shift low acuity to other sites. That takes investment and changes in thinking,” he said. “And that takes time.”

Lutheran’s Wendy Goldstein said that Lutheran HealthCare System, as a Federally qualified health center (FQHC), is in better shape than other providers in Brooklyn. FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits.

“We get paid for what it costs us to provide health care,” she said. In one example, when other hospitals were getting paid $64, “at Lutheran, we received $185, what it cost to provide the service.”

Across Brooklyn, however, hospitals are financially fragile, Goldstein said, with a profit margin of just .26 percent. “That’s more of a rounding error than a surplus.”

Goldstein warned about being too quick to close hospitals, as closing institutions could affect Lutheran’s ability to provide charity care. “Our determination is to provide care to everybody, as a ministry of the Lutheran Church. The Affordable Care Act is reducing the care that underwrites charity care.”

Even with a large number of ambulatory care clinics in place, low acuity patients are still visiting Lutheran’s ER, she said. “Medicaid pays for a lot of things, but not for the strips test. Patients get into a crisis, then go running into the ER. It’s a complicated situation; we need an integrated approach to health care delivery.

“The ER is key,” she said. Part of Lutheran’s ER is set up to take care of primary care visits, where a Quick Care area provides treatment for less urgent conditions. “Twenty-five percent of patients never get to the back [the standard ER].”

NYC Health & Hospitals Corporation’s Salvatore Russo said that Brooklyn hospitals are “overbedded.”

“Occupancy is at the 70 percent level, according to the [Stephen] Berger report.” He said that Brooklyn is “underserved by 250-450 primary care physicians,” and needs to realign to the new ambulatory care environment.

“I disagree that we’re overbedded in Brooklyn,” said Lutheran’s Goldstein. “That’s a fallacy,” based on an incorrect number of operational beds described in the report.

Preventative care is the right goal, she said, “but the payback is long term. Sixty-two percent of school children are obese in Sunset Park right now.” Hospitals need money to cope now, she said, “with, not instead of, ambulatory care. It’s a fallacy that we can teach people to eat vegetables and won’t have to pay for the nursing staff of the ICU.”

Greater New York Hospital Association’s Karen Heller said that new programs are emerging that will drive reimbursement based on the quality and efficiency of hospital care. “We need to follow the patient to all stops on the way to get home,” she said. “You don’t just say goodbye; you have linkages every step of the way.”

In the past, she said, the care focus — and the funds — were focused around inpatient stays. “The outpatient component is grotesquely underfunded.”

The Affordable Care Act has another “critical flaw,” she said. “In performance-based payment, the federal and state government withhold money and redistribute it based on rank in various performance indexes. This discriminates against hospitals that care for the underinsured and Medicaid patients.”

In one example, Heller said some funding would depend on patient satisfaction surveys. “If a hospital is short of capital, overcrowded, and not able to invest in pristine infrastructure, you’re going to be punished for that.”

She said she was hopeful about “getting an infusion of funds, reinvestment of the savings we have generated for the government.” The savings were generated by Medicaid Redesign Team reforms, and the funds are “vital for the transformation.”

SUNY’s Dr. Miriam Vincent said that in her lifetime “an entire need for medical care has shifted.” There are no more TB hospitals, she said, but “rather, diabetes and hypertension disproportionately affect Brooklyn. Our folks need primary care.”

She agreed that changes in funding rules would work against Brooklyn. There’s a “vicious form of diabetes known as ‘Flatbush Avenue Diabetes,’” she said. “It will be looked at as a failure by us,” resulting in a negative bottom line.

Maribel Agosto, a medical surgical nurse at LICH, commented to the panel during the question and answer session, “With all due respect, you are disconnected from the community. Voters have voted overwhelmingly for a mayor based on the hospital crisis. LICH has been remarkably mismanaged by its operator, SUNY Downstate.”

Agusto said that SUNY had “failed to maintain excellent doctors, failed to collect our fees, paying Continuum millions, and has not followed through on seven recent court orders to keep LICH open.” She pointed out the  recent overcrowding at local ERs caused by SUNY’s diversion of ambulance from LICH, “putting patients’ lives at risk.”

“No preparation or monitoring was done” before effecting the diversion, she said. “SUNY has received Heal money and the LICH endowment, yet is operating LICH with no business plan. They did not add one bed. Is SUNY above the law?”

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