By Mike McPhate
Conspiracy theories were running wild in East Harlem the other night.
Residents had gathered in an auditorium to discuss the fate of their local hospital, the Metropolitan. Speakers told the largely black and Spanish-speaking crowd that white businessmen are meeting in clandestine boardrooms to decide whether to shut the hospital down. They described a nefarious plan by Governor Pataki to close the state’s most needed medical facilities. Hollering and swaying like a gospel congregation, the crowd vowed to fight.
With a state commission finalizing recommendations to axe one-third of the state’s hospital beds, the residents fear that the financially-strapped Metropolitan soon may be forced to shut down. Commission members say it’s not racism but economics driving the hospital closures.
But for many public health advocates the reassurances have provided little comfort. At the East Harlem meeting, City Councilwoman Melissa Mark Viverito rose to declare that the commission is going to target communities where they feel people can be stepped on. “We need to demonstrate that we will not allow that to happen,” she said. “That’s right! That’s right!” someone shouted. In an emotional crescendo, Viverito cried out, “We need to take it to the streets!” The crowd went wild.
Such passion has been echoed in recent weeks throughout New York City where people worry that the city’s sharp health disparities between rich and poor will be worsened by decisions to shut down hospitals. Officials say that while plans to trim the state’s health care facilities may be painful to some constituencies, the money-losing system is in dire need of reform.
Governor Pataki convened the 18-member Commission on Health Care Facilities in the 21st Century, also known as the “hospital closings commission”, last year to recommend closures, consolidations and streamlining of the state’s hospitals and nursing homes. As the December 1 deadline for the commission’s recommendations nears, speculation about which hospitals will get pegged for the scrap heap has become feverish. Hospital administrators have quietly retained lobbying firms and lawyers should their facilities make the list.
New York’s hospitals have been losing money since the late 1990’s. They are plagued by rising hospital costs, heavy debts, underpayment for care, and the growing number of uninsured patients—now 25 percent of the city’s population.
Most health experts and community leaders agree that reform is necessary and that hospital closures should be part of the solution. The state hopes that by shuttering health care facilities it will strengthen those left open. By some estimates, 19,000 of the state’s 62,000 beds are unnecessary. Money saved with the reforms will be reinvested into health care.
Board members aren’t saying which hospitals will be selected for closure, but they say some painful decisions are unavoidable.
“One of the basic premises that many people hold is that New York health care is not sustainable into the future. What bigger risk is there than a system that is in the process of collapse?” said commission member Neil Roberts, former head of the New York Association of Homes and Services for the Aging.
No Tinkering
The commission’s proposals will likely become law. The legislature will have only the month of December to reject or tinker with them; if no action is taken they pass automatically into law by Dec. 31. And last month, the Bush administration promised $1.5 billion over five years to help pay for the health facilities reform with a key stipulation: the legislature must accept the commission’s recommendations wholesale.
Activists have good reason to fear the worst. In the last 40 years, 66 hospitals have closed in New York City, the majority in high-poverty, medically underserved areas, say health experts. Many now fear that sorely needed hospitals will get shut down and further strain service to low-income New Yorkers.
Alan Sager, professor at the Boston University School of Public Health, conducted a 52-city study of hospital closures over several decades in which he found that America’s poorest neighborhoods are usually the first to be targeted for hospital closures. He said he sees no evidence that the commission will depart from that trend. “If your hospital is located in a black or Latino neighborhood you’re probably at greater risk, especially if you’re not a major teaching hospital,” he said.
Sager found that when hospitals close patients are often slow to transition to a new facility, possibly endangering their health.
Enough Input?
Many community leaders have complained that the commission has failed to gather enough input from locals.
Gary Fitzgerald, president of the Iroquois Healthcare Alliance, which represents 56 upstate hospitals, has called for the commission’s proposals to be rejected. He noted that several appointments to regional boards set up to advise the commission were simply not filled. “Someone suggested, ‘Well, you know, you can’t criticize what you haven’t seen,’” he said. “Well, by the time we see [the recommendations] they’ll be very little time to analyze it and get back to the legislative people and get them to act on it.”
He added, “We know we need to make changes obviously in health care and we’re looking for improved access and improved quality. It’s just that we believe there needed to be discussion about the solution.”
Board members though say that local considerations factored highly in their deliberations. From rural upstate New York to the inner city, the commission ranked hospitals and nursing homes with a scoring system that included six criteria: vulnerable populations, availability of services, quality of care, utilization, viability, and economic impact.
“Financial considerations were part of it, quality was part of it, access was part of it, disadvantaged populations was part of it,” said commission member Roberts. “Did one of them override the others? I don’t think so. I think they were all considered.”
Roberts added, “[The regional advisory committees] may have been undermanned but they were manned with very highly qualified people that worked tremendously hard...And while the commission reports varied significantly, I was deeply impressed by the knowledge that some of these folks had of the marketplace. If we had worked with the data in the absence of the [the regional advisory committees] we wouldn’t have gotten it right I don’t think.”
How To Save Money
Rather than bolstering primary care, which advocates call the best cost-saving measure, the commission has focused too heavily on reducing beds and closing facilities, said a report released last month by the Primary Care Development Corporation, a public-private partnership that advocates for medically underserved communities. One of the main reasons for hospitals’ poor economic performance said Ronda Kotelchuck, director of PCDC, is the overuse of costly emergency rooms rather than early treatment.
More than half of New York City has a shortage of primary care physicians, the report found. As a result, patients with minor conditions like a sore throat or fever are likely to allow their conditions to worsen until a visit to the emergency room is required, said Kotelchuck.
“What we’re saying is that the commission is trying to address excess capacity in the hospital and the nursing home sectors. And we know underneath that there’s concern about rising cost. And so the reason they’re doing it is to save money,” said Kotelchuck. “But just like when you have an ill patient if you don’t intervene until things have gone way down the road you have very few options open to you.”
Sager also said there were many better ways to save money without shutting down hospitals, including the reduction of poor medical care, bureaucratic paper waste, overpriced prescriptions, and theft. “The hospital closings commission imagines that having extra hospitals and beds is what engenders high cost,” said Sager. “That doesn’t seem to be the case.”
Board members will meet once more to iron out details before submitting the final set of recommendations. Roberts said critics should wait to see what the commission says before passing judgment. “I think when they see the results they’re gonna, I don’t know if pleased is the right word, but I don’t think they’re gonna feel like anybody was singled out to be disadvantaged. I think that the process wasn’t to disadvantage anyone. The process was to advantage New York.”
“The proof will be in the pudding,” he said.
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Commission Members Draw Mixed Reviews
By Mike McPhate
Some observers have criticized the hospitals commission for being unrepresentative of New York’s diversity and for lacking public health expertise. Two-thirds of the members were appointed by the governor and the rest by the state Senate and Assembly. Leading the commission is Stephen Berger, a cigar-smoking investment banker.
The board consists of ten members with some background in health, several policy wonks and bankers, a university president, a lawyer and a Bishop. Four of them are women.
Judy Wessler, director of the nonprofit Commission on the Public’s Health System, said the board is dominated by “upstate, white businessmen” with little understanding of low-income communities that might be hurt by a hospital closure. “There are two kind of decent people on the commission,” she said. “But I don’t want to out them in any way.”
Gary Fitzergerald, president of the Iroquois Healthcare Alliance, disagreed. “They’re a good cross section of professionals,” he said. “I know many of them. I’ve worked with some of them. And I think that they really have a good knowledge of health care.”
Ronda Kotelchuck, director of the Primary Care Development Corporation, praised the commissioners for trying to reach out to the community. “[The commission members] have been extremely conscientious about getting out to every group they could possibly get out to. And I think they’re very responsive about sharing any kind of input that they’re getting,” she said.
“I’m sure it could be a better process,” she added. “I’m sure it could be different. But from where I sit I think they’ve done a good job.”
Commission member Neil Roberts said a lot of misconceptions are swirling about the commissioners’ motives. “I think people perceive that the process was probably more political than it really was. It was a very academic discussion,” he said.
Roberts praised Berger’s leadership, as well as the research skills of the commission staff. “I can only tell you that Stephen Berger’s a very impressive man and did a tremendous job drawing these people together and to direct the staff. I don’t think that’s understood.”
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Why Hospitals Are Losing Money
New York's hospitals have been losing money since 1998. They lost a combined $127 million in 2004, as hospitals in other parts of the country made profits. Here are four major reasons why, according to health experts:
1. Hospital labor and equipment costs rising faster than local government tax dollars
2. Low government and insurance reimbursement rates
3. Heavy debts
4. Cost of covering the growing number of uninsured patients—more than 3 million New Yorkers are uninsured.
