Gotham Gazette https://www.gothamgazette.com/component/tags/tag/2532 Thu, 09 Apr 2020 11:50:05 +0000 Joomla! - Open Source Content Management en-gb webmaster@gothamgazette.com (Webmaster) Max & Murphy Podcast: City Council Member Carlina Rivera on Hospital Oversight Amid Coronavirus https://www.gothamgazette.com/city/9293-max-murphy-podcast-city-council-member-carlina-rivera-on-hospital-oversight-amid-coronavirus-oubreak https://www.gothamgazette.com/city/9293-max-murphy-podcast-city-council-member-carlina-rivera-on-hospital-oversight-amid-coronavirus-oubreak 2 city council ant carwbai

Council Member Rivera visits a hospital (photo: John McCarten/City Council)


April 08, 2020 - Max & Murphy Podcast: City Council Member Carlina Rivera on Hospital Oversight Amid Coronavirus

carlina rivera 150wbaiCity Council Member Carlina Rivera, chair of the Council's hospitals committee, joined the show to discuss her oversight of the city's response to the coronavirus outbreak and what needs improvement.

Listen to the conversation and let us know what you think -- we're on Twitter @TweetBenMax and @JarrettMurphy. You can listen to the show through the embedded audio below or download the episode wherever you get your podcasts, under "Max & Murphy," and listen to Max & Murphy live on Wednesdays at 5 p.m. on WBAI radio, 99.5FM or wbai.org.

***
by Ben Max, Gotham Gazette
     

Read more by this writer.

]]>
Max & Murphy Podcast: City Council Member Carlina Rivera on Hospital Oversight Amid Coronavirus Wed, 08 Apr 2020 04:00:00 +0000
A 'Human Rights Tragedy' Unfolding - Part I: Racial Bias and Life-Saving Care During the Coronavirus Pandemic https://www.gothamgazette.com/city/9289-human-rights-tragedy-unfolding-racial-bias-life-saving-health-care-during-coronavirus-pandemic-new-york https://www.gothamgazette.com/city/9289-human-rights-tragedy-unfolding-racial-bias-life-saving-health-care-during-coronavirus-pandemic-new-york 5 mbdb management

Mayor de Blasio, a ventilator, and two doctors (photo: Ed Reed/Mayor's Office)


As government officials anticipate a wave of coronavirus patients overwhelming the New York City hospital system within days or weeks, the question of how racial disparities in health care will impact who dies of COVID-19 and the disaster's long-term public health fallout loom large and, as yet, unaddressed.

Differences in access to quality care for African-Americans and other people of color are well-documented in virtually all aspects of the health-care system. With the apex of the COVID-19 outbreak approaching, experts fear structural inequality and implicit racial bias are impacting who receives critical treatment in a hospital, a chilling prospect in a scenario where survival will likely depend on the allocation of scarce medical resources.

Beleaguered emergency rooms -- serving both as the first site of care for many underserved communities and, now, as the epicenter of coronavirus management -- are a particular vector for differential treatment.

"I don't think we fully yet have a grasp as to the nature of the human rights tragedy that is about to unfold, particularly in spaces like New York City," said Lurie Daniel Favors, executive director of the Center for Law and Social Justice at Medgar Evers College in Brooklyn.

The extent to which the city's communities of color bear the weight of the coronavirus death toll and collateral health consequences will be influenced by two now-magnified factors directly related to hospital capacity. One is how doctors' and nurses' implicit biases manifest in decisions to allocate limited hospital space and other resources (explored in part one of this two-part series). The other is the disproportionate number of people of color, particularly black and Latino New Yorkers, who rely on emergency rooms as their primary source of medical treatment and whose access to sufficient care during the health crisis is severely limited (discussed in part two).

"This is going to be a long day and it's going to be a hard day, and it's going to be an ugly day, and it's going to be a sad day," Governor Andrew Cuomo said at a March 27 press briefing from the Javits Convention Center in Hell's Kitchen, which has been turned into a temporary hospital by the Army Corp of Engineers.

"The rescue mission is to save lives and, as hard as we work, we're not going to be able to save everyone," he said. Last week, the governor cited a projection from the Institute for Health Metrics and Evaluation predicting 16,000 people would die in New York State (as of April 6 it projected roughly 15,600 deaths in New York).

There have already been reports of city hospitals being overrun and turning people away. EMS workers, fielding record-high call volume, are being forced to make decisions about who to leave behind. As the outbreak rages, experts say biases are likely to factor into decisions, not only about who receives a life-saving ventilator in an Intensive Care Unit (ICU), but who is even admitted to the hospital.

“We just need to be very aware of the fact that biasing is going to happen right at the door," said Dr. Alison Bateman-House, a professor in the Division of Medical Ethics at NYU School of Medicine, which is part of the NYU Langone Health hospital network.

In numerous studies of differential treatment, black patients waited longer to be seen in the ER than white patients, and were less likely to be admitted. There is already evidence to suggest the coronavirus outbreak is having a disproportionate impact on communities of color, though city and state officials have not released racial or ethnic demographic data on positive cases, hospitalizations, intubations, or deaths.

There is "a striking overlap of where this virus is doing the most damage and where we've had historic health care disparities – a very, very strong overlap," Mayor Bill de Blasio said Sunday in response to a reporter's question about when the city would release a racial breakdown of cases and fatalities. "That overlaps also with where our public hospitals are in particular."

The neighborhoods with the highest rates of positive coronavirus tests largely coincide with zip codes with greater black and Latino populations, particularly in the Bronx, Queens, and Brooklyn.

In response to Gotham Gazette inquiries, officials at the state Department of Health, city Department of Health and Mental Hygiene, and New York City Health + Hospitals -- the city's network of public hospitals and other health care facilities -- each said "equity" was part of their mission to provide care, but did not answer specific questions on hospital safeguards against differential treatment based on race.

As of Monday, 16,837 people were hospitalized for COVID-19 and 4,758 had died statewide; with 2,738 of those fatalities in New York City. Over 4,500 people were in Intensive Care Unit (ICU) beds across the state, usually attached to scarce ventilators to breathe. Gaps in city and state reporting make it impossible to know the racial and ethnic breakdown of those patients, including those who have died.

In Michigan, which has released racial demographic data, at least 40 percent of the people killed by the new coronavirus have been black, despite making up only 14 percent of the population and 35 percent of positive cases.

Cuomo is attempting to rapidly expand hospital capacity to accommodate up to 140,000 patients, expected by mid-April, and 40,000 ICU beds, based on the most cautious estimates. The city and state are desperately trying to acquire 30,000 to 40,000 ventilators, the most essential piece of life-saving equipment, as the state moves toward an imminent shortfall. At a March 26 press briefing, de Blasio said the need for medical supplies "is going to be a day-to-day, hour-to-hour reality," as the city attempts to triple its hospital capacity and add the reserve workforce to staff it.

But officials have not yet given an answer to how they will save the most lives now of people whose health needs have never been adequately served, in a crisis where the reality of mass loss of life has already been acknowledged and begun to take place.

Implicit Bias in Medical Care
The problem of racism, both interpersonal and systemic, in United States health care long predates the new coronavirus. Falsehoods, dating to slavery and the Middle Passage, about the physiology of black bodies -- that black people experience less pain than white people, for example, or that they have lower lung-capacities -- and racial stereotypes -- that white people make "better," more cooperative patients, or that black people are less equipped to make decisions about their care or less prone to telling the truth about their conditions -- are pervasive. While explicit racial discrimination is now condemned in mainstream medicine, studies show a huge number of dangerous misconceptions and prejudices persist in the implicit biases held by health care professionals.

Those biases can lead to lower quality care and have the potential to be pushed to extremes in an overwhelmed medical system like New York City's is now. During a crisis compounded by scarcity, lower quality care could mean no care at all.

"When you're talking about access to medical resources, particularly when you're in a situation of scarcity there are always fears that there is going to be preferential allocation given to certain groups [over] other groups," said Bateman-House of NYU School of Medicine. "You're going to see a lot of judgments of relative value made."

Bateman-House said the way a patient looks or speaks, their perceived communicativeness and satisfaction, all impact clinical assessments. Studies have shown that assumptions that black patients may abuse care or squander treatment options impact doctors' decisions.

Much public attention has been focused on the difficult life-and-death decisions that doctors or government officials will have to make as hospitals begin running out of ventilators. But the impact of racial bias may be most acute at the front door as crowded emergency rooms become increasingly inundated with the sick and dying.

"I think...it feels more sort of poignant to think about two patients in the ICU ward and you have one ventilator...but you don't even get to that point until you get into the hospital," Bateman-House said. "Biasing has happened long before that choice about a ventilator happens."

Black patients are already less likely to be admitted as inpatients in the ER. One 2015 study published in the journal Medical Care found that black patients with severe abdominal pain were admitted 11 percent of the time, while white people expressing the same symptoms were admitted 17 percent of the time. Hispanic people were admitted in only 10 percent of such cases. The study also found the same black and Hispanic patients waited longer in the ER before being seen: 31 percent had a "prolonged" ER visit, defined as over six hours, compared with 23 percent of white patients who waited that long.

Unlike explicit racial bias, implicit bias is often unconscious and unintentional. In clinical studies, it is measured through an Implicit Association Test, in which doctors and nurses are asked to do word association pairings with black and white faces in a matter of milliseconds. Studies show doctors with higher implicit bias spend less time and are less communicative with black patients than white ones. Others show that racial biases can influence diagnoses and treatments in even the most serious circumstances, like for patients at risk of contracting HIV or people with heart disease in need of anti-clotting drugs.

Bateman-House said assessments of relative human value, inhumane as they are, have already played out publicly during the early stages of the current crisis. When people ignore guidelines out of a belief that only the elderly and people with pre-existing conditions are susceptible to the virus, "and hence [that it is] sort of more permissible for it to be a potentially deadly disease, you can see the sort of bias right there," she said.

In The Emergency Room
Under normal circumstances in the ER, patients are typically first seen by a triage nurse who assesses their condition and what level of care may be appropriate, according to Bateman-House. Right now, with hospitals overflowing, triage in many ERs may be limited to assessing who is likely to need intubation or to rapidly decline.

New York City Health + Hospitals, the city's network of 11 public hospitals, did not respond to requests for information about how triage procedures have changed during the outbreak.

While the profession requires adept practitioners of life-saving judgement, Bateman-House says, racial bias may be a persistent problem among triage personnel who are already in the position of turning people away.

According to the U.S. Department of Health and Human Services, black patients receive lower quality care than white patients in 40 percent of over 250 measures (the greatest disparity of any of the racial/ethnic groups analyzed). Hundreds of other studies over the last two decades show similar inequities in every setting from routine visits to palliative care.

Differential treatment finds a fertile home in the emergency room, where doctors and nurses are trained to make snap judgements and where continuity of care is by definition truncated. 

The 2015 study also showed race was a factor in whether patients would be given pain medication. Another study from 2008 found ER doctors had a lower probability of ordering lab tests for acute coronary syndrome when black patients presented with chest pain than when white patients did.

Often treatments are rationed or withheld from black patients that are routinely given to white patients. Disparities like this exist even when factors like structural differences in access to care are controlled.

Research suggests implicit bias is heightened when doctors are under pressure, stress, or fatigue, or lack contextual information -- conditions found in abundance in ERs across the city today. (An executive order recently signed by the governor removed limits on working hours for physicians and trainees.)

"Both on the level of trying to decide who is in enough of a crisis to be admitted into the emergency room and then in terms of monitoring how a patient is doing, only so much of that is done on the interpretation of clinical signs," Bateman-House, the medical ethicist, said.

The ER at Elmhurst Hospital in Queens is already seeing thousands of people seeking care for flu-like symptoms every week, many times what it sees typically this time of year, as The City recently reported. Citywide, doctors, nurses, and paramedics are now working around the clock to see patients, and the state and city are seeking more surge personnel to support them. Last week, the city took steps to relieve Elmhurst, part of Health + Hospitals, with a "surge" of medical supplies and personnel.

The magnitude and urgency of life-saving decisions is astronomical. Mayor de Blasio said Sunday that citywide between 200 and 300 new patients are being intubated daily. He said the city has 135 ventilators remaining in reserves and needs to secure another 1,000-1,500 ventilators by next Sunday in order to meet the projected demand. The situation is most dire in public hospitals, where resources have always been spread more thin and which serve especially at-risk populations who do not have other access to healthcare.

"That level of discretion about who is owed care is being rolled out under these types of stressful circumstances, when the healthcare system is already going to be overburdened," said Daniel Favors of the Center for Law and Social Justice, referring to the life-and-death consequences of denying or limiting care for coronavirus. "We know that black and brown people are going to be the ones that bear the brunt of that."

The Official Response
Public officials have been silent on the issue of implicit bias and have barely acknowledged the potential for disproportionate mortality rates because of unequal medical attention or access.

City and state officials did not respond directly to questions about protections against bias and discrimination in coronavirus treatment, or to how city and state governments plan to mitigate the impact of historically disparate access to care. As Gotham Gazette first reported, neither the city nor state has adopted official policies for ventilator triage, and there is no indication that officials plan to.

In an emailed statement, a spokesperson from the New York State Department of Health said its primary focus was expanding hospital capacity statewide by ending elective procedures, reducing the current inpatient population, and building more bed space. "This will allow for all populations to be cared for eqitably [sic], irrespective of economic, social or demographic characteristics," the statement read.

“At NYC Health + Hospitals our patients will receive the care necessary to their diagnosis,” an Health + Hospitals representative wrote in a statement. “We are committed to our mission to care for all New Yorkers regardless of immigration status and ability to pay, and are focused on keeping all our patients and staff safe.”

"Equity is a foundational principle at the NYC Health Department and it is embedded in every guidance, strategy and decision we make as an agency," wrote Michael Lanza, spokesperson for the city's Department of Health and Mental Hygiene. "We are in the midst of an unprecedented health crisis and remain committed to treating every New Yorker equally."

NYU Langone Health has given ER doctors sole discretion around ventilator allocation in its emergency departments, the Wall Street Journal reported last week. But it is not clear there is an official city- or state-wide policy about who will have the authority to make decisions about life-saving care, either in terms of hospital admission or ventilator allocation. Officials did not answer questions about whether and how those decisions would be monitored.

Suspended Regulations
The mandate to expand New York's hospital bed space comes with a need to staff tens or even hundreds of thousands of new positions. As of Saturday, April 4, Cuomo reported the state had a volunteer hospital surge force of 85,000, including many recent med school graduates and retirees. To help get there, Cuomo signed a series of executive orders suspending dozens of laws and regulations around who is legally able to provide medical care and in what settings.

The orders relax a host of requirements related to licensure and registration for doctors, nurses, nurse practitioners, physician assistants, radiologists, respiratory therapists, pharmacy technicians, and medical students. They allow students who graduated from foreign medical schools to practice in New York hospitals without licensure. They also allow for "abbreviated medication administration training" in state-licensed facilities for people with developmental disabilities. The latest order, signed Saturday, allows medical students to practice medicine if they are set to graduate.

Meanwhile, the state has moved from regulating to underwriting the decisions of medical professionals.

Apparently anticipating a deluge at hospitals, one order removes important oversight and record-keeping requirements to allow more flexibility in providing rapid treatment, and eliminates certain civil and criminal liabilities for healthcare providers.

Registered nurses and physician assistants can now perform certain new functions without a supervising physician. As the death toll inevitably rises, doctors, nurses, and physician assistants will be immune from civil liability for any injury or death "sustained directly as a result of an act or omission" in the course of providing COVID treatment. This was largely codified in the Emergency Disaster Treatment Protection Act, which was passed Thursday in the state budget. The law extends liability protections to administrators and leaders of medical facilities.

To what extent safeguards against bias and differential treatment have been suspended under the lax regulations is not yet known.

The same order that loosens oversight also removes civil liabilities if a provider fails to comply with medical record-keeping requirements. Quality record-keeping is essential for maintaining adequate care and helps hold physicians accountable. The Department of Health's Office of Professional Medical Conduct, which oversees physician misconduct and discipline in New York State, publishes the outcomes of all adjudicated misconduct charges on its website including a boiler-plate description of the infraction. Clicking through the first 100 profiles shows a majority of doctors who were disciplined for misconduct that included failing "to maintain accurate medical records."

A state Department of Health spokesperson said they could only comment on fully adjudicated matters, not general complaints, and did not respond to a request for information on adjudicated charges related to racial bias.

The U.S.N.S Comfort
In many ways, the possibility of a disproportionate death toll in communities of color is a question of how ongoing inequities in medical care are reregistered at each joint of the enormous web of hospital infrastructure that has begun to solidify in recent days.

With city and state governments desperately trying to manage the growing demand for medical attention, Cuomo announced on March 30 an unprecedented new network of resource-sharing among all hospitals, public and private, throughout the entire state. The plan, coordinated by the state Department of Health, involves transferring patients, as well as supplies and personnel, from one hospital to another as facilities reach capacity.

The statewide distribution system mirrors a strategy that New York's public health officials have been pursuing for weeks: Cuomo, with the help of the federal government and local partners, is trying to rapidly find, build, and import space for additional hospital beds to serve as a release valve on the city's swelling system.

A key component of Cuomo's "rescue mission" is the U.S.N.S. Comfort, a 1,000-bed Navy hospital ship with a dozen operating rooms, which has been deployed to war zones and the sites of natural disasters. The Comfort arrived in New York Harbor on Monday and docked off of Manhattan's West Side. Along with the Javits Center, it makes up a bulk of the city's 2,500 new hospital beds.

The Comfort, until Monday, had not been authorized to receive COVID-19 patients. But even among non-COVID patients, federal officials had set up broad restrictions on who it will accept for treatment and had only admitted 20 patients as of last Thursday, according to a New York Times report.

The ship's promise has been squandered in the past, due in large part to the tangle of bureaucracy that can arise when multiple levels of government must respond to a disaster. In that scenario implicit and explicit bias were part of its failures.

During the 53 days that the Comfort was deployed to Puerto Rico in the aftermath of Hurricane Maria, which decimated the island's health system in 2017, it admitted only 290 patients (an average of six per day), the New York Times reported at the time -- due largely to the hurdles involved in transferring patients from the island's hospitals. In a discussion of the vessel's limitations, the Times reported one ship doctor was heard complaining about "social cases," which typically refers to patients who have no home or caregiver to be discharged to.

While the island's conditions posed different challenges, the episode gives a clue about how people can be denied care when a crisis obliterates health care infrastructure. And it speaks to the human element involved in that process, especially when the health care system can no longer attempt to provide the secondary supports, like locally-based discharge workers, that usually accompany hospital treatment in the United States.

In January 2010, the U.S.N.S. Comfort arrived in Port-au-Prince, Haiti, after an earthquake killed hundreds of thousands of people and crumbled the nation's roads and hospitals. Admission to the ship was coordinated largely by the American military, including the 82nd Airborne Division of the U.S. Army, first from the lawn of the National Palace and later from a site further inland. Images captured at the time show humvees and helicopters full of people on stretchers with head wounds and badly damaged limbs filing toward the ship.

One photograph taken by Getty Images photographer Joe Raedle in the ship's staging area near the Palace shows a young girl, not more than ten, in a hospital gown, lying on a stretcher, with braided hair and a laceration around one eye. Stuck onto her forehead is a piece of transparent tape with the word "Ship" written on it.

Christina Sharpe, a scholar of Black Diaspora Studies at York University, in her 2016 book In the Wake: On Blackness and Being notes that the tape could signal "medical necessity." It is hard to ignore the “imperative” of the piece of tape, and what she calls its "expedien[cy]." But the tape is also dehumanizing, which seems antithetical to the concept of a rescue mission, and Sharpe questions "the violence of someone placing the word Ship on the forehead of a young Black girl."

***This was part one of a two-part series. Part two will be published soon.***

***
by Ethan Geringer-Sameth, reporter, Gotham Gazette
     

Read more by this writer.

]]>
A 'Human Rights Tragedy' Unfolding - Part I: Racial Bias and Life-Saving Care During the Coronavirus Pandemic Tue, 07 Apr 2020 04:00:00 +0000
As They Issue Dire Shortage Warnings, Neither State Nor City Has Plan for Ventilator Triage https://www.gothamgazette.com/state/9235-as-they-issue-dire-shortage-warnings-neither-state-nor-city-has-plan-for-ventilator-triage https://www.gothamgazette.com/state/9235-as-they-issue-dire-shortage-warnings-neither-state-nor-city-has-plan-for-ventilator-triage gov cuomoo 3way

Gov. Cuomo gives dire warnings about hospital capacity (photo: Darren McGee/Governor's Office)


City and state officials have been saying for over a week that as the spread of coronavirus continues New York's hospitals will not be able to provide life-saving treatment for everyone who needs it. One of the most immediate needs is ventilators, which are required to save the most critical COVID-19 patients and are already in short supply in New York City hospitals. With the note of alarm reaching a fever pitch in recent days, public health officials have not made available an official policy regarding ventilator triage, and have not said that any exist.

The pace of urgent developments and the overwhelming set of challenges posed by the unprecedented coronavirus crisis have left the state's highest officials themselves triaging the most pressing life-or-death matters. Governor Andrew Cuomo and Mayor Bill de Blasio have been calling on the federal government to provide more medical supplies -- most importantly ventilators -- while also pursuing them themselves.

Saying on Sunday that he had actually been able to secure an additional 6,000 ventilators, Cuomo said, "Ventilators are the most important piece of equipment and the piece of equipment that is most scarce.”

De Blasio is now saying New York City will need more ventilators very soon to avoid additional loss of life. The mayor said on CNN Monday morning that on Sunday evening he told President Trump and Vice President Pence, “if we don't get a supply of ventilators quickly, our public hospital system, literally after about a week or so, we will not have enough ventilators to keep people alive who could live through this crisis and could be saved.”

As of Monday afternoon, 1,500 of the city's 3,500 ventilators were in use, according to the mayor's office, and the administration is seeking 15,000 from the federal government by April. In the afternoon, the mayor announced the federal government was sending the city an initial 400 ventilators to help.

Calling ventilators “the number one precious commodity” during a Monday briefing from Albany, Cuomo said that there are 3,000 ICU beds across the state, but that “we may need between 18,000 to 37,000. That's my greatest concern because that's where we need ventilators to turn those ICU beds into beds for people suffering from the virus."

But as they predict dire situations and scramble to secure more ventilators, New York government and public health officials do not yet appear to be creating any ventilator allocation policies. 

And the likely shortfall and short timeline are worrisome for medical ethicists who say any government policy that may ultimately dictate who lives and who dies should be thoroughly communicated and publicly vetted.

Asked about ventilator triage guidelines and policy-making, a spokesperson for the city's Department of Health and Mental Hygiene told Gotham Gazette that such guidelines fall into the state Department of Health’s jurisdiction.

In response to a Gotham Gazette inquiry about how difficult decisions will be made by doctors when there are not enough ventilators to save every patient, a spokesperson for the state Department of Health (DOH) wrote: "Under Governor Cuomo’s direction, hospitals in New York State continue to rapidly modify their current operating function to accommodate increasing support for patients with COVID-19 as well as the rest of the hospital population. Specific tactics include stopping elective procedures, reducing current inpatient population and expanding bed capacity. Commissioner of Health Dr. Howard Zucker has discussed this with senior hospital leadership from throughout New York State, and this is being enacted throughout the state."

A council led by Ken Raske, president of the Greater New York Hospital Association, and Michael Dowling, president of Northwell Health, has been tasked by the governor with developing hospital surge capacity. That body would be responsible for making decisions about ventilator allocation, according to another DOH spokesperson.

At this point in the state's response, the council is discussing every aspect of managing hospital surge, that spokesperson said, with the focus now on ensuring that the required equipment and processes are in place. Cuomo has already made several announcements about how the state is increasing hospital capacity, including with federal help.

In 2015, the DOH's New York State Task Force on Life and the Law developed guidelines for ventilators in a influenza pandemic, which Zucker described as "a foreseeable threat" in the report's introduction. While the task force's guidelines were designed with a "severe pandemic" in mind, the DOH spokesperson said that it is not a binding policy document steering the state's response, though it has been well circulated and read recently within the Department.

Notably, an FAQ accompanying the report specifically mentioned that the state would not be able to stockpile enough ventilators for such a scenario. The stated question was, "Can the State stockpile as many ventilators as would be needed in a severe pandemic?" The answer reads, "Even if New York State purchases additional ventilators, the demand would quickly outpace supply in a severe pandemic. No matter how many ventilators are available, in a severe pandemic there will be shortages because so many people will be sick at the same time. In addition, even with enough ventilators, a sufficient number of trained staff may not be available to operate them, particularly because health care workers will be among the ill."      

The guidelines are broken into three different categories for triaging ventilators (adult, pediatric, and neonatal guidelines) and consider a set of exclusion criteria and mortality risk with treatment. Exclusion criteria include medical conditions connected with "immediate or near-immediate mortality even with aggressive therapy," according to a fact sheet accompanying the document.

Advanced age, disability, “social worth,” are not exclusion criteria under the guidelines. Healthcare providers assessing adult mortality risk use a scoring system called SOFA (Sequential Organ Failure Assessment). For pediatric and neonatal, determinations should be made through "physician clinical judgment, a structured decision-making process that carefully considers only specific clinical factors based on available medical evidence," the sheet said.

Ethicists have been thinking about this at least since the SARS outbreak in 2003, according to Dr. Alison Bateman-House, assistant professor in the Division of Medical Ethics at NYU School of Medicine attached to NYU Langone Health. "When we saw the SARS epidemic and there were more people critically ill than we had the machines to provide for, people actually did the hard work of sitting down and saying, 'Well, if we're going to have to make difficult choices, how do we make them?'"

"Obviously no one was planning per se for COVID-19, because it is new and novel, but the basic principles were there of, there is some sort of respiratory disease that is widely infectious and we don't have enough equipment, how do we prioritize?" she said of the 2015 task force guidelines.

The task force estimated that in a severe pandemic the state could see a shortfall of as many as 15,783 ventilators. President Trump, citing claims made in an op-ed published by former New York State Lieutenant Governor Betsy McCaughey, said Tuesday that New York's current projected shortfall is Cuomo's failure for not purchasing more ventilators in 2015.

The report briefly addresses the idea of stockpiling ventilators and illuminates the state's thinking in 2015. "The State’s current approach to stockpiling a limited number of ventilators balances the need to prepare for a potential pandemic against the need to maintain adequate funding for current and ongoing health care expenses," the report reads. At the time, the state had 1,750 ventilators in reserve.

A footnote later states: "There are significant financial burdens associated with obtaining, storing, and maintaining equipment and supplies. In addition, stockpiling results in significant opportunity costs when choosing stockpiling over another priority."

In terms of hospital capacity, Governor Cuomo has been focused on three things: reducing the rate of the outbreak's spread to help distribute the burden on hospitals over a longer period of time; building new hospital space with the help of the U.S. Army Corp of Engineers, the Federal Emergency Management Agency (FEMA), and local stakeholders; and securing necessary medical equipment, from masks to gowns to ventilators. The state DOH says there are also plans to redistribute resources from hospitals in areas that have not been hit hardest.

With more than 60% of the confirmed coronavirus cases statewide, New York City's hospitals may experience the most imminent shortages. As of 6 p.m. Sunday, the Mayor’s Office reported 10,764 positive cases of COVID-19 and 99 related fatalities, with at least 1,800 people hospitalized due to the virus, and of those individuals, at least 450 in the ICU, where ventilators are typically used.

“I made clear to them what I need right now is action, not words, and every day counts because we're literally in that very tight window now that if we don't get the ventilators in particular we will actually start to lose lives who could have been saved,” de Blasio said on CNN Monday of his conversation with Trump and Pence.

The mayor is imploring the federal government to deliver ventilators, surgical masks, gloves and gowns using its emergency production powers, which have in previous times of crisis been used to mandate factories produce necessary supplies. Even as he also asks Trump to produce more ventilators and other essential supplies and deliver them to New York, Cuomo has been purchasing and otherwise securing such equipment. The governor made the Sunday announcement that the state has purchased an additional 6,000 ventilators and is redistributing existing ones to the areas with the highest needs throughout the state, he said.

As with the state, the city's public health officials have not formalized a plan for ventilator allocation and in some ways appear to be ignoring the issue.

A spokesperson for New York City Health + Hospitals, the city's system of 16 public hospitals and other health care facilities, told Gotham Gazette by email Friday that there were no plans to implement ventilator triage and that every patient who needs a ventilator would receive one. The spokesperson noted that Health + Hospitals is a single health system that could shift resources from one facility to another as needed, and that it is coordinating closely with city, state, and federal agencies to ensure the most clinically appropriate care is provided.

In response to an inquiry Friday seeking clarity on the apparently contradictory information coming from the Mayor and Health + Hospitals, a spokesperson wrote, "We expect to meet our patient’s [sic] needs."

In terms of the city's private hospitals and coordination with City Hall and the public system, mayoral spokesperson Freddi Goldstein said that "There is a daily call” among Deputy Mayor for Health and Human Services Dr. Raul Perea-Henze, Health + Hospitals CEO Dr. Mitchell Katz, and Ken Raske, the president and CEO of the Greater New York Hospital Association, which represents 250 not-for-profit hospitals in New York, New Jersey, Connecticut, and Rhode Island.

During an appearance this past week on the New York Times podcast The Daily, host Michael Barbaro asked Governor Cuomo about how the apparently imminent choices of which critical patients get ventilators and which do not will be made. "Well, I pray we don’t get there,” Cuomo said. “But if we get there, it should be a medical decision. Unless God intervenes and God makes the determination first."

***
by Ethan Geringer-Sameth, reporter, Gotham Gazette
     

Read more by this writer.

Note: This article has been updated with the latest ventilator information from the mayor's office on Monday afternoon and Cuomo's Monday comments about ventilators and ICU beds, as well as additional information on ventilator stockpiles from the 2015 DOH Task Force report. 

]]>
As They Issue Dire Shortage Warnings, Neither State Nor City Has Plan for Ventilator Triage Mon, 23 Mar 2020 04:00:00 +0000
State Health Department Must Reject Unneeded, Burdensome Luxury Hospital Expansion https://www.gothamgazette.com/130-opinion/8863-health-department-must-reject-luxury-lenox-hill-hospital-expansion https://www.gothamgazette.com/130-opinion/8863-health-department-must-reject-luxury-lenox-hill-hospital-expansion northwell lenox hill expansion plan 2

rendering of proposed Leonx Hill Hospital expansion


Northwell Health is proposing an unprecedented, $2.5 billion expansion of Lenox Hill Hospital that includes construction and sale of a 490-foot condo tower to help finance a new 520-foot hospital tower and other massive new structures. This pitch has already generated much controversy, as residents of the Lenox Hill neighborhood and surrounding communities are speaking out forcefully against Northwell’s plan.

While it is widely understood that this development plan must go through the city’s land use approval process (known as ULURP) because of zoning changes Northwell is seeking, many New Yorkers are unaware that Northwell also needs approval from the State Department of Health before it can proceed with any expansion of Lenox Hill Hospital.

The crucial point here is that Northwell must apply to the State DOH to receive a “certificate of need” for its expansion plan. But the facts show that there truly is no need for this proposed expansion on the Upper East Side – and that is why the State DOH must reject the plan and send Northwell back to the drawing board.

This is a matter of common sense. In order to be granted a certificate of need, an institution should be able to demonstrate that its proposal promises to deliver something that is actually needed by the community. When it comes to Northwell’s plan for Lenox Hill Hospital, that is not the case.

We can all agree that Lenox Hill Hospital must offer high-quality, state-of-the-art medical care in a well-maintained facility. And if a straightforward modernization plan were all that Northwell were proposing, it would be worthy of support. In fact, it appears that Northwell has already begun financing its own upgrades at Lenox Hill Hospital, with a recent news story noting that officials have “hired a Michelin Star Chef” and made numerous other cosmetic improvements to provide a “luxury hotel experience.”

But the idea of building a monstrous luxury condo tower in the midst of a historic residential district to finance single-occupancy hospital rooms and destination medical facilities in one of the city’s most affluent and well-served areas is grandiose and insulting to community residents. Simply put, we do not need more hospital beds and significantly larger hospital facilities on the Upper East Side – and our community is not asking for them.

Let’s be clear: there are already more than 10,000 hospital beds in Manhattan, at least 3,000 of which are located throughout the Upper East Side. Our communities have access to healthcare facilities and specialty medical care that are the envy of our other-borough neighbors, many of whom have demanded better access to quality medical care.

Want to talk about healthcare needs? Look at the South Bronx, where low-income residents suffer from the state’s highest asthma rates. Look at Central Brooklyn, where national experts have called that community’s hospitals some of the worst in the entire nation.

If Northwell were truly interested in developing an expansion plan worthy of a “certificate of need,” it would seek out ways to bring more of its high-quality healthcare resources to communities like these. Instead, it is advancing a lucrative real estate development pitch that will create the tallest hospital in New York City and serve primarily to reap profits for its grandiose vision and satisfy the egos of its senior executives. All of this will take place at the expense of the local neighborhood, which will be forced to endure 10 years of hazardous construction and a massive condo tower that will destroy the fabric of a historic community.

The bottom line here is that if the State Department of Health follows its mandate to serve the healthcare needs of all New Yorkers and takes a thoughtful approach to evaluating these types of proposals, it has no choice but to reject Northwell’s plan and compel the institution to rethink its approach.

***
Andy Soussloff is a Lenox Hill resident and a member of the non-profit Committee to Protect Our Lenox Hill Neighborhood, Inc.

***
Have an op-ed idea or submission for Gotham Gazette? Email opinion@gothamgazette.com

]]>
State Health Department Must Reject Unneeded, Burdensome Luxury Hospital Expansion Sun, 20 Oct 2019 04:00:00 +0000
What's The [Data] Point? 1,112,975, with Dr. Mitchell Katz, President of NYC Health + Hospitals https://www.gothamgazette.com/city/8430-what-s-the-data-point-1-112-975-with-dr-mitchell-katz https://www.gothamgazette.com/city/8430-what-s-the-data-point-1-112-975-with-dr-mitchell-katz whats the data point


What's The [Data] Point? Episode 71 -- 1,112,975, with Dr. Mitchell Katz, president of NYC Health + Hospitals [You can download What's The [Data] Point? wherever you get your podcasts, including on iTunes]

artworks 000515225592 2py301 t500x500Dr. Mitchell Katz is in charge of the city's public hospital system, which includes 11 hospitals and dozens of other facilities and clinics. Katz came to New York City Health + Hospitals to help turn around the struggling system, especially in terms of its finances, but also in its delivery of care. He recently spoke at Citizens Budget Commission breakfast, after which he joined the podcast to take a few questions -- this episode consists of that Q&A followed by Katz's remarks at the breakfast about what he's doing to change H+H, what progress has been made and what challenges persist.

Listen to the conversation and let us know what you think: Ben Max of GG (@TweetBenMax), Maria Doulis of CBC (@MariaDoulis). Listen below or download wherever you get your podcasts!

***
by Ben Max, Gotham Gazette
     

Read more by this writer.

]]>
What's The [Data] Point? 1,112,975, with Dr. Mitchell Katz, President of NYC Health + Hospitals Thu, 04 Apr 2019 04:00:00 +0000
New York Nurses Threaten Major Strike Over ‘Understaffing’ https://www.gothamgazette.com/state/8351-new-york-nurses-threaten-major-strike-over-understaffing https://www.gothamgazette.com/state/8351-new-york-nurses-threaten-major-strike-over-understaffing  nynurses

(photo: @nynurses)


During one night shift at the children’s hospital where she worked as a nurse, Nicolette Mabeza‘s unit filled up with intubated children. She and the other nurses were frantic.

“It was just the entire floor running around,” said Mabeza, who worked in the intensive care unit at NewYork-Presbyterian Morgan Stanley Children’s Hospital in Washington Heights. “Some nurses had two intubated patients and they weren’t even right next to each other.”

Nurses stretched to the limit by understaffing would regularly cry on the job, she said.

“Not only does it make you feel that you’re being a terrible nurse,” said Mabeza. “You also wonder, why should patients come here if nurses can’t give the adequate care that they deserve?”

Feeling that she could no longer do her job in good conscience, she quit last April after less than a year at the hospital.

After years of complaints, understaffing has become a major point of conflict between the nurses union and private hospitals in New York City.

Around 13,000 nurses could strike this month if negotiations fail between the New York State Nurses Association and a group of three major hospital systems, union leaders say.

Nurses from Montefiore, Mount Sinai, St. Luke's-Mount Sinai West, and New York-Presbyterian hospitals authorized a strike last week and announced a rally for safe staffing on Monday, March 18 at Mount Sinai Hospital in East Harlem.

“We’re saying enough is enough,” said Carl Ginsburg, a spokesperson for the union, which represents 37,000 nurses. “No sooner do we make a deal than we drift back into this danger zone.”

He said contract negotiations have slowed to a crawl with the New York City Hospital Alliance, an informal bargaining group of private hospitals that includes Montefiore, New York-Presbyterian, and Mount Sinai hospitals.

On the bargaining table is an increase in nurse-to-patient ratios in emergency rooms and intensive care units. Staffing levels have reached dangerously low levels, putting the safety of both nurses and patients at risk, Ginsburg said.

“Sometimes where a nurse should be caring for five patients, she’s caring for eight or 10,” said Ginsburg. “Make no mistake – it’s dangerous.”

In 2018, more than 12,000 nurses signed “Protest of Assignment” forms to complain about unsafe conditions at Montefiore, Mount Sinai, and New York Presbyterian.

A spokesperson for the NYC Hospital Alliance said that hospitals are financially stretched because of state Medicaid cuts. He added that the recent “Protest of Assignment” forms account for a negligible portion of the total number of nurse shifts.

Understaffing at hospitals forces nurses to make tough choices, said Anthony Ciampa, a nurse at New York Presbyterian for the last 14 years.

“I had to make the decision whether to hang blood or to help an elderly patient eat,” said Ciampa. “No nurse should be forced to make these types of decisions.”

The elderly patient sat in front of the food – unable to eat – while Ciampa took care of the blood transfusion, he said. By the time Ciampa was able to help, the patient’s food tray had been removed, untouched.

“I’m still upset about that,” said Ciampa, who is currently representing the union in contract negotiations. “It was like torture to sit there with the meal in front of you and not be able to eat it.”

Outside Brooklyn Hospital Center last month, nurses were reluctant to talk about staffing conditions, fearing retaliation from their employers.

“Everybody’s understaffed,” said a medical assistant who requested anonymity and said she has worked at the hospital for more than 20 years. “The patients are not getting adequate care.”

But the NYC Hospital Alliance denied reports that understaffing is leading to unsafe conditions, and said that enforced staffing ratios would be costly and ineffective.

“The reality is that the union’s rigid, mandated staffing ratios would lower the quality of patient care by overriding the professional judgment of nurses and healthcare professionals and crowding out other members of the care team,” said Linden Zakula, a spokesperson for the group.

Zakula said that state budget cuts to Medicaid have resulted in a loss of $240 million in expected funding for the three hospital groups combined.

“Alliance hospitals respect our nurses and are committed to bargaining in good faith,” said Zakula. “We are doing everything we can to reach an agreement that is fair, reasonable, and responsible for all parties.”

In the last few years, several New York City Council members have shown support for more staffing regulation at hospitals.

“Nurses are some of the most important people in the hospital,” said New York City Council Member Carlina Rivera. “It’s important that they feel they have the resources they need to be supported in some of the most stressful environments.”

Rivera, who chairs the Council’s Committee on Hospitals, cosponsored a resolution in 2018 that called on the state Legislature to pass the Safe Staffing for Quality Care Act.

The bill would set specific nurse-to-patient ratios by hospital unit, and would ensure that nurses can’t be assigned to more patients than specified.  Hospitals that break the law would be fined.

But there is no vote in sight for either the Council resolution or the state bill, which are both stuck in committee.

For many years, safe staffing legislation was met with resistance from Republicans who controlled the New York Senate.

Last week, New York Assemblymember Karines Reyes said she was confident that the Senate’s new Democratic majority would bolster the bill’s chances of passing.

“Apart from the Republican Senate’s pushback in past years, the primary obstacle posed to the legislation stems from the conflicting opinions of hospital administrators,” said Reyes, who is also a registered nurse in the Oncology Department at Montefiore Einstein Hospital. “These points of view fail to acknowledge that safe staffing is about saving lives. The legislation is paramount to the safety and outcomes of patients while not only providing adequate staffing to nurses, but to ancillary staff as well.”

While several states have laws that address nurse staffing, California is the only state that requires hospital units to maintain a minimum nurse-to-patient ratio.

Under that law – in effect since 2004 – critical care units in California must have at least one nurse for every two patients. The required nurse-to-patient ratio varies by department, with 1-to-4 for labor and delivery units and 1-to-6 for psychiatric units.

A 2010 study published by the National Institutes of Health found that mandated nurse-to-patient ratios resulted in fewer patient deaths and better morale for nurses compared to other states without similar legislation.

***
Gaspard Le Dem is a freelance journalist. On Twitter @GLD_Live.
@GothamGazette

Note: this story has been updated to change $300 million to $240 million based on corrected information provided by Zakula of NYC Hospital Alliance.

]]>
New York Nurses Threaten Major Strike Over ‘Understaffing’ Tue, 12 Mar 2019 04:00:00 +0000
A Closer Look at ‘Vital Brooklyn,’ Cuomo’s Plan for ‘One of the Greatest Areas of Need in the Entire State’ https://www.gothamgazette.com/state/8144-a-closer-look-at-vital-brooklyn-cuomo-s-plan-for-one-of-the-greatest-areas-of-need-in-the-entire-state https://www.gothamgazette.com/state/8144-a-closer-look-at-vital-brooklyn-cuomo-s-plan-for-one-of-the-greatest-areas-of-need-in-the-entire-state billion vital bk

Cuomo & Vital Brooklyn (photo: Mike Groll/Governor's Office)


In March of 2017, Governor Andrew Cuomo unveiled what he described as a groundbreaking initiative to “bring health and wellness to one of the most disadvantaged parts of the state.” That place was Central Brooklyn, where roubling health indicators of all types plague residents, from diabetes rates to poverty levels to inadequate access to quality health care.

Cuomo said the plan, named Vital Brooklyn, came with $1.4 billion in state funds to pay for a long list of items across the borough, from playground renovations to job training to resiliency projects — all with the aim of fighting “entrenched pockets of poverty” in a comprehensive way, he said at the time.

“What is the area in this state that has the greatest social need? If you look at unemployment rates, food stamps, physical inactivity, number of murders, one of the greatest areas of need in the entire state is Central Brooklyn. And it’s not even close,” Cuomo said.

Since then, the governor has made nearly a dozen announcements related to Vital Brooklyn, six of them taking place from June to September in the lead-up to this year’s gubernatorial primary in which candidates for statewide offices heavily courted Central Brooklyn voters. At those events, Cuomo emphasized state funding for an oyster reef restoration project ($400,000), 22 community gardens ($3.1 million), fresh food programs ($1.8 million) and a new 407-acre state park to be named after iconic Brooklyn Congressional Rep. Shirley Chisholm — an announcement made eight days before the primary.

In total, the governor’s office says there are 8,800 projects funded under the Vital Brooklyn umbrella, funded by the $1.4 billion (a dollar amount unchanged since spring of 2017, according to the state budget office). However, it’s important to note that those touted by the governor — such as those gardens, farmers markets and state park — make up a small slice of the total funding. The much larger pieces of the pie fall into just two (albeit very big) categories: housing and health care.

In fact, nine out of every 10 dollars spent through Vital Brooklyn fall into the housing and health care columns: $578 million for subsidized housing in rapidly gentrifying areas (for example, a 2,400-unit project just announced in East New York) and $700 million, allocated in 2015, for a new health care system that aims to restructure and revive three of Brooklyn's struggling hospitals.

While some aspects of Vital Brooklyn are quickly taking shape, others will take months or years to materialize. Some officials, including several who have excitedly joined Cuomo at celebratory announcements, are lauding the investments, but critics of the project worry it’s not enough — and take issue with how Vital Brooklyn was rolled out, and how the money is divvied up.

Brooklyn Borough President Eric Adams said in a recent interview that his office wasn’t asked to give input on the project (the state instead took comments from advisory boards convened through the area’s elected state Assembly members) and he feels the funding is too small in scope and dollar amount, even if the governor’s frequent appearances make it appear otherwise.

“We have to have a re-examination of the state allocations and are we doing what’s right by Brooklyn,” he said, particularly in relation to the Bronx, which Adams feels has gotten significantly more financial help from the state; Bronx Borough President Ruben Diaz, Jr. is a close ally of the governor.

Earlier this year, he put it more bluntly earlier in an interview on the Max & Murphy podcast.

“You can’t keep brushing off and rolling out the same billion-dollar project,” he said in May.

When asked to respond to that claim — and whether or not the Vital Brooklyn announcements were made in relation to this year’s primary — Cuomo spokesperson Tyrone Stevens’ comment was brief: “Bogus.”

“This is simple: Our significant new investment in Brooklyn is based on a multi-pronged strategy to uplift communities that have been ignored for too long,” Stevens said in an email. “We’re proud of this effort, and we will not be shy about talking to local residents about the important work we’re doing to make their neighborhoods a better place to live.”

Big Spending: Health Care
Of Vital Brooklyn’s $1.4 billion, fully half is dedicated to a new health care system for Brooklyn. That funding comes from a $700 million capital grant made through the Health Care Facilities Transformation Program included in the 2015-2016 state budget, allocated two years before it was announced as part of Vital Brooklyn.

The funding will go to One Brooklyn Health System (OBHS), a newly formed operator that will combine the management of three previously separate Central Brooklyn hospitals — Kingsbrook Jewish Medical Center in East Flatbush, Interfaith Medical Center in Bedford-Stuyvesant, and Brookdale University Hospital Medical Center serving Brownsville and East New York — into one not-for-profit corporation.

LaRay Brown, previously the president and CEO of Interfaith, is heading up the new venture. She says she’s been pushing for years for the “incredibly impactful” amount of state funding that will support dozens of major projects throughout the new health care system.

Inside the buildings, the $700 million will pay for “boring things, but essential things,” Brown said, like replacing elevators, repairing HVAC systems and updating an outdated fire alarm system.

“I say they’re boring, but they’re critical to providing safe and comfortable patient care,” she said.

The medical centers will get major upgrades to their patient facilities, too. According to Request for Proposal documents from OBHS, Brookdale will build out a new 33-bed intensive care unit, renovate a 40-year-old operating room suite and upgrade all of the facility’s inpatient psychiatric units among others improvements. At Interfaith, the medical center’s emergency room will be upgraded and expanded, inpatient medical units will be renovated and new equipment such as MRI and x-ray machines will be installed. Major medical equipment will be replaced at Kingsbrook, as well, the documents show.

Overall, the idea for the restructuring and redesign is to merge services among the three hospitals in order to form a more streamlined organization — and hopefully, in the end, become more financially stable.

That’s according to state officials from the Public Health and Health Planning Council who approved the creation of OBHS in December of 2016. A report to the council at the time concluded that, operating separately, the hospitals require hundreds of millions of dollars in operating subsidies from the state every year “and are otherwise not financially sustainable.” (According to budget data from a PHHPC report, operating funds given to the three hospitals from the state totaled $169 million in 2015-16, then rose to $245 million in 2016-17 and $250 million in 2017-18.)

“They've come together … in an effort to try to restructure and become more efficient and reduce its dependence on specialty subsidies,” state health department official Charles Abel told the council before it approved the OBHS application.

To achieve those efficiencies, OBHS will reorganize how certain operations run within the three hospitals. For example, Brown said, Kingsbrook will no longer have inpatient medical-surgical beds and, though it will still have an emergency room, patients in need of ongoing acute or complex care will be transferred elsewhere, likely to Brookdale, which Brown said will become the system’s “center of excellence.”

LaRay Brown Brooklyn“As the inpatient acute care role diminishes at Kingsbrook, that role increases at Brookdale,” said Brown (pictured).

But Brown is careful to note the restructuring effort should not be considered a consolidation. Current assessments by OBHS show no material difference between the number of current beds and projected beds in the system, according to OBHS’ Dona Green. In the end, Brown says the quality and quantity of services will expand.

“Because these hospitals are coming together and because of the state’s commitment to invest in these hospitals, the Central Brooklyn community served by these hospitals will get more services, and not less,” Brown said.

That sentiment was echoed by Assemblymember Latrice Walker of District 55 in Brownsville, who has been waiting for years to see this funding come through for the hospital system, particularly at Brookdale, where many of her constituents go for care — and where her own brother died of gunshot wounds when he was 19, she said.

“I’m confident the services will be reinvigorated and enumerated. I don’t think we’re going to lose anything here,” she said. “Quite the contrary — we’re actually gaining.”

By the totality of the health facilities in the works under Vital Brooklyn, that appears to be the case. A chunk of the initiative’s healthcare funding — $210 million in all — is allocated to create 32 new ambulatory care facilities, or community health centers, under the OBHS umbrella. The goal there is to create more medical offices, outpatient surgical facilities and urgent care options with a more long-term goal of reducing unnecessary trips to emergency rooms.

“We need to start moving toward people having primary care physicians so that the emergency room isn’t their doctor office,” Walker said.

Cuomo put it this way when announcing some of the 32 ambulatory care locations in July of this year: “It's not just about a hospital where you go when you're very sick.”

“Prevent the illness in the first place,” he continued. “Have more community-based healthcare systems that are focused on wellness, and health, as opposed to waiting for a person to get sick, and then be in acute need.”

These new ambulatory centers are meant to handle a diverse slate of same-day health services, including diagnostic work, rehabilitation, or even major procedures such as hip replacements, according to Bill Hammond, the Director of Health Policy at the Empire Center think tank.

Ambulatory centers have a lot of benefits, he said. For the patient, it’s generally a more comfortable experience to avoid spending a night at a hospital, and there’s less risk of infection. For hospitals, increasing outpatient services makes a lot of financial sense.

“It’s less expensive,” he said. “Hospitals come with a lot of overhead.”

That idea is in line with a healthcare trend more generally to move patients out of traditional inpatient hospitals and toward ambulatory centers for all kinds of services, from preventative doctor visits all the way up to certain surgeries. The move from “reliance on hospital-based services” to more outpatient services “is a major policy shift,” said Brown of OBHS. And it takes place within the context of years of financial struggle, and at times closure, for many hospitals, particularly those serving low-income communities, as costs have continued to rise.

To combat that, the Vital Brooklyn plan puts a priority on the financial viability of health care projects funded under the plan. Included in guidelines for evaluating applicants to Vital Brooklyn, the state’s website says it will consider “the extent to which the proposed projects further the development of primary care and other outpatient services; the extent to which the proposed projects contribute to the long-term sustainability of the applicant or preservation of essential health services; and the extent to which the proposed projects involve partnerships with community-based health care providers,” among other criteria.

With the funding for the new 32 health facilities, the state hopes to roughly double the number of ambulatory care visits in Central Brooklyn, increasing capacity for 742,000 more visits every year, according to the governor’s office.

Exactly where all that new health care capacity will be built is unknown; all 32 locations have not yet been finalized. But Cuomo announced plans in July for renovations and the expansion of several existing health care centers, including the Bishop Walker Health Care Center in Prospect Heights, the Pierre Toussaint Health Center in Crown Heights and the Brownsville Multi-Service Center. In addition to those locations, several health care providers including the Bed-Stuy Family Health Center, Community Health Network, and ODA Primary Health Care Network have been chosen by the state to build new health centers in Brooklyn, providing both primary and specialty care.

Some of the 32 new ambulatory health centers will be built within new developments underwritten by the second largest piece of the Vital Brooklyn funding: affordable housing.

Housing on State and Hospital Sites
In all, the state will spend $578 million — or more than 40 percent of the total Vital Brooklyn package — on subsidized housing, with a goal to build 4,000 new units over several years.

The governor has repeatedly linked overall health goals of Vital Brooklyn to housing, particularly in rapidly gentrifying areas such as East New York where speculative buying and building, combined with a 2016 rezoning, has put pressure on poor residents.

“It starts in the home, having the right housing, having the right environment, having the right support. And that's where we're going to start. We need afford affordable housing because out people are being displaced. Gentrification is everywhere,” the governor said at a Vital Brooklyn event earlier this year.

How all those units will be constructed is still up in the air, but details on some of the development sites are beginning to emerge. Late last month, the state announced four winning bids to develop housing on land owned by the three OBHS hospitals or on state-controlled land, including one complex in East New York that’s set to deliver the bulk of the subsidized housing funded under Vital Brooklyn.

On Nov. 29, the state chose Westchester-based L+M Development Partners, Harlem-based construction group Apex Building, and two social services organizations — RiseBoro Community Partnership and Services for the Underserved — to bring a massive, 2,400-unit development to the site of the former Brooklyn Developmental Center, a home for developmentally delayed adults that closed in 2015. The three other chosen projects — two to be built on land owned by Interfaith hospital and another on land owned by Brookdale Hospital — will bring another 328 subsidized units to the borough.

At the same time the state announced those projects, it rolled out another set of request for proposals (RFPs) on eight state-controlled sites around the borough, including several hospital parking lots set to be replaced by new buildings. Proposals for five of the sites are due by February 28, 2019 and the three others are due by April 30, according to the RFP documents.

A majority of the affordable housing will be funded by $568 million allocated through the state’s Homes and Community Renewal agency, with a goal of creating 3,000 units. In addition, the governor said in August $15 million in federal tax credits have been allocated by the state for future housing developments on land controlled by the New York City Housing Authority (NYCHA). In his announcement on that initiative, the governor said he hopes to support the creation of 1,000 units of housing. However, no specific sites for those developments have been announced and will be “reviewed on a rolling basis by HCR as NYCHA makes properties available through its disposition process,” according to a press release.

The need for housing is the number one priority for Brooklyn residents, Borough President Adams said, and he gave credit to Vital Brooklyn for addressing the issue. He also acknowledged the plans would bring much-needed resources — including park space and options for healthy food — to the area. But he thinks it doesn’t go far enough.

“We’re dealing with historical inequities. People who were denied food access before — OK, let’s give them more farmer’s market,” he said. “Those things are great. But if we’re going to invest, let’s be visionaries in our investment.”

He would have liked to see more funding allocated to grandparent housing, which is set aside for grandparents who are the primary caregivers to young children, and even more resources given to the hospital network, he said.

More criticism of the governor’s Vital Brooklyn plan came from the East New York district where the large Brooklyn Developmental Center site is set to be rebuilt under the initiative. The complex will have 100 percent subsidized apartments set aside for a combination of formerly homeless New Yorkers, households earning less than 50 percent of the area median income (AMI) — a federal guideline for determining the cost of affordable housing — and the rest for households earning less than 80 percent of the AMI. Currently for a family of three, 80 percent of AMI equals $62,150 a year.

That may sound like a win in a low-income area like East New York. But with the median household income of East New York at $34,512 per year (according to data from the city’s Housing Preservation and Development agency), the development doesn’t satisfy one of the neighborhood’s longtime leaders.

Assemblymember Charles Barron says his district needs even more low-cost units because only a fraction of its residents are in the 80-percent income range. And, overall, he thinks Vital Brooklyn doesn’t go far enough in a state with a $168 billion budget, and billions more in capital spending.

“You see $600, $700 million and think it’s wonderful and a lot of money,” he said. “That is peanuts.”

In particular, he wants to see more support for the healthcare system.

“It’s simply not enough money for three hospitals,” he said.

In response, Cuomo spokesperson Stevens said in a statement that the Vital Brooklyn investment is “delivering substantial resources and coordinated services to support neighborhoods that have long been neglected.”

“We believe this massive commitment is something to celebrate, not politicize with cheap attacks that are untethered to reality,” he said.

Looking for Results
The governor has often said, for him, Vital Brooklyn is a project that brings his own career full circle, from when he was working on housing in East New York as a young man, to now. In speaking about it, he says he has wanted to help turn Brooklyn around for years.

Cuomo Brooklyn“I never lost the inspiration, and the hope, and the optimism, of what you can do when you do it right,” he said in a speech on the project in April, nearly half-way through his eighth year in office. “For me, this is something special. This is something that is long overdue. It's an investment in people who desperately have needed help, and have been ignored for too long.”

But it may take quite a while to see all of the Vital Brooklyn projects come to life. Some of the smaller pieces of the puzzle, like a pilot program for youth-run food markets and construction on new playgrounds, are beginning this year and next, the governor has said. For the larger, more complicated parts, however, it could take years; for example, some of the first units of housing are estimated to come online in 2021 and others — like the East New York project — is not slated for completion until 2026, the governor’s office said.

The health center restructuring, too, will takes years to finish. When it’s finally complete, it remains to be seen whether the largest part of Vital Brooklyn — the $700 million in health care capital funding — will make a substantive difference to financially shore up the three Central Brooklyn hospitals.

Hammond of the Empire Center said if the plan is a good one that reconfigures the facilities’ operations significantly, it “could put them in a different position to succeed,” though he was hesitant to say whether he believes the restructuring will prove successful long-term.

But the health funding is not peanuts, as Barron said, nor is it a groundbreaking amount, as one may think from the governor’s announcements. The reality is somewhere in the middle.

“The state routinely spends billions and billions of dollars on health care all over the state,” both in discretionary grants and capital allocations, Hammond said. “On any given day, you could go to a different community and announce a very large-sounding dollar amount…and it would be absolutely routine.”

However, on a per-resident basis, Brooklyn is getting more than the average — while falling far below the state’s most generous allocations. Hammond found the state spent $190 per resident in capital health care spending in the last five years in New York State. In Kings County, the per-resident breakdown equaled $264 per resident, which is “significantly more than the state average,” he said. But that figure is dwarfed by another capital grant also given in 2015 to a hospital system in Oneida County, where spending totaled $1,297 per resident.

For all those funding plans, however, the dollars have not yet started to flow, according to Brown of OBHS. Before that happens, several bureaucratic steps must take place, including complying with transparency regulations approved by the state comptroller’s office. She hopes that will be complete in the new year.

“Everyone is endeavouring to get [approval]…by early 2019,” she said, while emphasizing it’s hard to make an exact estimate, as she and her team are figuring out the complexities of the project as they go along.

“We’re all entering a new journey here,” she said.

***
by Rachel Holliday Smith for Gotham Gazette
@rachelholliday
@GothamGazette

All photos via the Governor's Office on flickr.

]]>
A Closer Look at ‘Vital Brooklyn,’ Cuomo’s Plan for ‘One of the Greatest Areas of Need in the Entire State’ Thu, 13 Dec 2018 05:00:00 +0000
Expanding Health Insurance Enrollment Will Help Heal New Yorkers and Our Public Hospitals https://www.gothamgazette.com/130-opinion/7672-expanding-health-insurance-enrollment-will-help-heal-new-yorkers-and-our-public-hospitals https://www.gothamgazette.com/130-opinion/7672-expanding-health-insurance-enrollment-will-help-heal-new-yorkers-and-our-public-hospitals Carlina Rivera City Council

Council Member Rivera, one of the authors (photo: John McCarten/City Council)


Even in an era of relentless attack on health care by the Trump administration and its allies in Congress, New York City is continuing to reap enormous benefits from the Affordable Care Act. This year alone another 80,000 city residents enrolled in health coverage through our state’s Obamacare exchange.

But a huge number are still being left behind: an estimated 962,000 adults in the five boroughs remain uninsured. These New Yorkers -- many of whom are living in poverty -- often receive no health care until their conditions are severe enough to land them in the emergency room.

The trend is not good for those New Yorkers’ health, as they should have access to preventive care, regular check-ups, and other aspects of quality health care. What’s more, the current situation is also dealing a serious financial blow to our struggling public hospital system (known as Health + Hospitals), whose vital mission it is to serve those in need, including the uninsured. For H+H to avoid financial disaster we need to close the health insurance gap in New York City.

H+H serves over a million patients per year in a network of 11 acute care hospitals and dozens of other facilities throughout the five boroughs. These institutions are by far our city’s largest provider of care to Medicaid recipients, mental health patients, and -- critically -- those who are uninsured.

For decades our public hospitals -- Bellevue, Kings County, Harlem, Elmhurst and others -- have been the ultimate safety net for New Yorkers with nowhere else to turn. H+H’s diverse and committed staff, its proximity to low-income communities, and its sliding-scale fees have helped establish it as second-to-none in serving the neediest New Yorkers.

But balancing the books at our public hospitals has never been easy, in part because Medicaid reimbursement rates are so low. The system’s challenges have only gotten worse in recent years as federal and state safety-net funding has shrunk. And now tectonic changes in the health sector have dealt further blows, as care rapidly moves from inpatient to outpatient services.

The result: H+H is confronting a $1.3 billion deficit this year, projected to balloon to $2.1 billion next year.

This financial strain has real implications for patients, compounding long-running problems in the system. The wait time for appointments at H+H can stretch into the months. Many of the system’s buildings are crumbling, with leaking roofs at Harlem Hospital, deteriorated plumbing at Lincoln, obsolete electric systems at Metropolitan, and elevators throughout the system that are so outdated that their replacement parts are no longer sold.

H+H’s new CEO, Dr. Mitchel Katz, has laid out a multi-pronged plan to address this crisis. He has set out to reduce administrative expenses, more effectively bill insurance companies, and retain more paying patients, among other efforts.

But there is another critical strategy needed to save H+H: New York City urgently needs to enroll more people in health insurance.

Our public hospitals treat over 400,000 uninsured patients each year. That represents hundreds of millions of dollars of lost insurance billing for those eligible for coverage. Providing this health care regardless of ability to pay is the moral thing to do. It also affects the health of all New Yorkers by helping us prevent the spread of communicable diseases.

We need to tap health insurance as a way to make this important work financially sustainable. That’s why it’s critical that we dramatically ramp up our outreach and enrollment efforts.

Today, most funding for ACA enrollment is provided by the State, which spends about $12 million per year on a network of community-based organizations in the five boroughs offering health insurance navigation assistance.

Several City agencies also have dedicated teams doing enrollment, but the numbers are small: only about 50 staff at Human Resources Administration (HRA) and 70 at Department of Health and Mental Hygiene (DOHMH).

We need an aggressive, coordinated plan to take this work to the next level. And we need to be on the ground in neighborhoods. Community-based non-profits make ideal partners for this work, because of their cultural competence and because of the trust they so often have earned in low-income communities.

One group of New Yorkers can’t get enrolled no matter how much we spend on outreach: undocumented immigrants. But there’s a win-win possibility for them as well. By investing in a program to provide them access to primary care we can improve health outcomes and prevent the more costly H+H emergency room admissions that would otherwise occur.

A twin effort to enroll more New Yorkers who are eligible for insurance and to fund access to primary care for those who are undocumented would improve the health of our people while going a long way to shore up the finances of our public hospital system.

That would be a giant step forward to the goal of ensuring that each and every New Yorker, regardless of income or immigration status, has access to the affordable, high-quality care they need.

***
Mark Levine and Carlina Rivera are members of the New York City Council. Levine chairs the Council’s health committee, Rivera chairs its hospitals committee. On Twitter @MarkLevineNYC and @CarlinaRivera.

***
Have an op-ed idea or submission for Gotham Gazette? Email opinion@gothamgazette.com

]]>
Expanding Health Insurance Enrollment Will Help Heal New Yorkers and Our Public Hospitals Mon, 14 May 2018 04:00:00 +0000