When I served as executive director of the Berger Commission, many of New York State’s hospitals were in shaky condition.
The Commission was charged with evaluating and reforming the State’s health care delivery and financing systems, and we made sweeping recommendations affecting one-quarter of the State’s hospitals, including many restructurings and even a few closures, recognizing the need to shift away from bricks and mortar based inpatient services and toward primary care to better meet communities’ needs.
More than a decade later, New York State’s hospitals still face many of the same issues we grappled with back then: How can hospitals best serve their communities and patients? What should we do about hospitals that seem to have permanent financial struggles? How do we measure, improve, and sustain high-quality care? How can our health care system meet the growing need for primary care and address the non-clinical factors that affect health?
Just last week, I participated in two public discussions of hospitals in New York State. The first was a conversation with Dr. Mitchell Katz, the new president and CEO of NYC Health + Hospitals (H+H), the nation’s largest public health care system. The second was a discussion hosted by the Empire Center, sparked by a new report on hospital ownership laws and whether for-profit hospitals should be permitted in New York State. And while H+H faces unique challenges as a large public hospital system, some common themes emerged across the conversations:
1. Patients should be at the center of care. But that doesn’t always happen. I’ve written previously about my personal experience with a hospital that treated one of my family members more as an inconvenience than as its most important customer. But sometimes it’s simply that systems aren’t designed to meet patients’ needs and preferences.
As just one example, Dr. Katz noted that H+H’s scheduling system would default to offer a patient the next available appointment. That sounds good, right? Getting a patient in as quickly as possible makes sense. But it turned out that the system wasn’t searching for the next available appointment with a patient’s regular or preferred provider. So if Dr. Smith, who knows me and who I’m comfortable with, doesn’t have availability until Thursday, I could be assigned to Dr. Jones on Wednesday, even though that would disrupt my continuity of care. It was an easy fix, and a small issue, but a good example of how everyday operations can be altered to think holistically about patients and put them first.
2. It’s really tough to measure quality of care, but New York has lots of room to improve. Everyone agrees we need to care about and attend to hospital quality. The challenge is identifying, reporting, and being accountable for an agreed-upon set of quality measures that are meaningful and accurate. According to a 2015 report by the Institute of Medicine, literally thousands of quality measures are in use, leading to what some have described as “measurement madness.”
Even with so many measures, few of them are responsive and attuned to what matters to patients. And as many measures as we have, there are an equal number of opinions about which ones are good and which ones are fair and which ones matter and why none of them is perfect.
The skeptics have a point; there is no such thing as a perfect quality measurement system, and New York’s hospitals do perform well on selected measures. But it’s also true that, regardless of the quibbles anyone has with any number of performance measures, New York State is at or near the bottom on a wide range of measures from a variety of sources. The pattern is undeniable. New York ranks 50th among states in the Centers for Medicare & Medicaid Services Hospital Compare Star Rating; 47th on the Consumer Reports Safety Score; 48th for the Leapfrog Group’s “A” rating; and 50th for 30-day readmission rates. I could go on, but you get the idea. New York is usually a leader when it comes to health care: in the number of residents with health insurance, in our consumer protections, in our innovative and comprehensive approaches to care. But we are lagging behind on some important measures of quality.
3. Consolidation is the new normal, but it also raises concerns.Consolidations, mergers, and acquisitions are taking place at a lightning-quick pace. New York’s 12 largest systems now control half of all acute care hospitals and 70% of patient acute care beds across the State. Consolidation offers many benefits: larger organizations can manage population health, manage care across the spectrum, facilitate electronic information exchange, accept risk in value-based purchasing arrangements, and realize economies of scale. Consolidation can also offer a lifeline for struggling hospitals. Many smaller hospitals operate at a loss and only remain open because of financial subsidies from the State. Twenty-six hospitals are on a New York State financial watch list and have less than 15 days cash on hand; perhaps a dozen more are close to joining that list. Consolidation is one way to preserve these hospitals without permanent financial support from the State.
At the same time, consolidation raises concerns about reduced competition, higher prices, reduced access, and restricted consumer choices. Striking a careful balance between competition and consolidation is crucial. And it’s important that consumers have input here, too. A new report from MergerWatch shows that patients have little input into health care mergers, downsizing, or hospital closures in their communities. There’s more room for patient voices at every level of decision-making, and policy-makers should make it a priority to ensure that health care consumers are at the table when consolidations are being considered.
4. Hospitals increasingly need to address primary care, social determinants of health, and health equity. We have long known that decreasing excess hospital capacity in New York State needs to be balanced with increased availability of primary and community-based care; that was the genesis of the Berger Commission. And hospitals are increasingly looking at how to beef up their ability to provide primary care and outpatient services, sometimes by reconfiguring space to transform inpatient units into outpatient clinics, for example. But in the days of the Berger Commission, it was less widely accepted that hospitals need to address not only primary care but also broader determinants of health. Today, there is wider recognition that hospitals have a role to play in addressing the factors outside of health care that affect how healthy their patients are. Many hospitals host Medical-Legal Partnerships that help patients out with housing, insurance coverage, immigration, transportation, and other issues that can help or hinder their health.
Partnerships between hospitals and community-based organizations are meant to be a key part of New York’s DSRIP (Delivery System Reform Incentive Payment) program. There’s still work to be done; despite recognizing the need, many of New York’s hospitals have been slow to tackle population health issues and hospitals and community-based organizations often find it challenging to work together given their different cultures and work styles.
The events I participated in last week invoked a mix of nostalgia, frustration, and inspiration. Some of the problems remain the same, while clear progress has been made on others. The hard work continues. I was encouraged by the range of energetic leaders throughout the State — hospital executives, policymakers, consumer advocates, analysts, and civic leaders — who are committed to changing and strengthening our hospital system.
By David Sandman, President and CEO, New York State Health Foundation
Published in Medium on May 24, 2018