Dueling Prescriptions for Brooklyn's Hospitals

Brooklyn’s hospitals are in extremis, with at least five of its now 13 hospitals on life support, health care professionals warned this past Friday at a public hearing in borough hall.

Without a significant infusion of cash, testimony indicated that Brooklyn’s poorest neighborhoods are going to be left stranded by lack of access to acute care facilities—a situation made all the more dire by breaking news that morning that the trustees of SUNY Downstate had voted to close the 506-bed Long Island College Hospital in Downtown Brooklyn to prevent it from bankrupting the entire SUNY hospital system. 

"This is a crisis in health care. We’ve never faced anything like this in Brooklyn," State Assemblyman Robert Gottfried, chair of the Assembly health committee, acknowledged to the standing-room-only crowd packed into the hearing room on the second floor of Brooklyn Borough Hall. 

The thrice cancelled hearing, which proceeded despite blizzard warnings and train delays, was a much anticipated event, as doctors, nurses, hospital officials, union representatives and community advocates lined up to respond to the findings and policy suggestions of the Brooklyn Working Group of the Medicaid Redesign Team.

Commissioned by Governor Andrew Cuomo in 2011 as part of the state’s overhaul of Medicaid reimbursements, MRT was launched to investigate the status of Brooklyn’s hospitals and outline remedies for improving access to care and institutional safety in the borough. 

No one in the room took issue with the main points of the working group’s report—that Brooklyn’s hospitals were in trouble, that more than 40 percent of people using its emergency rooms were there for non-emergent conditions and that the flow of private insurance out of the borough (as people sought health care in Manhattan and Long Island) had created a yawning deficit for local hospitals that Medicaid and Medicare reimbursements could not cover.

But one by one hospital administrators and health care advocates warned the health care committee that the report’s recommendations for merging and closing hospitals meant endangering key life lines for people living in medically underserved communities.

Doubts that clinics can replace hospitals

Refuting the working group’s thesis that Brooklyn’s hospital system was irrefutably "broken," and that the entire system could be turned around by closing struggling hospitals and investing in more primary care facilities and 24-hour emergency rooms, hospital administrators and community advocates alike rejected the idea that clinics could take the place of acute-care hospitals.

"There is an enormous impression that ambulatory care—in general, primary care—will take the place of the overuse of acute care facilities like hospitals. I think there is a big fallacy in that thinking," warned Claudia Caine, chief operating officer and executive vice president of Lutheran Medical Center. "An investment in primary care is great – we have 65 primary care sites—but to say that ambulatory care is all that is important and will solve the whole health care crisis is oversimplified and a little short-sighted."

The heart of the issue, said Caine, was the lack of fairness in the distribution of money from the federal government to provide health care to indigent people.

Known as the Disproportionate Share Funds, the money was supposed to go hospitals that served a majority of Medicaid, Medicare and uninsured, said Caine, pointing out that Lutheran, one of the financially healthier hospitals in Brooklyn, had 80 percent of its reimbursements from Medicaid and Medicare.

But state-level politics made it impossible for hospitals serving mostly poor communities to get their fair share of the federal dollars. And with further cuts coming down the pike under the Affordable Health Care Act, the hospitals are all struggling for an even smaller piece of the federal pie.

"We really need the legislators to understand that there are indigent care funds and they are meant to go to the safety-net hospitals," stressed Caine, who praised Gottfried as one of the few legislators willing to work on a real definition of safety-net hospitals. Without one, she warned, the money would continue to be a political football, dispersed among wealthier hospitals across the city while Brooklyn’s health care system continued to be starved of dollars.

Some see "big box" advantages

The idea that communities could be served by 24-hour emergency rooms was ridiculous, agreed Ari Moma, a nurse at Interfaith Medical Center for the past 17 years. While Interfaith, which declared bankruptcy two months ago, was in a terrible way financially, it was a "big box" hospital that was absolutely crucial to the community.

"Many of our patients cannot be treated in the emergency room. They have high blood pressure, heart disease, HIV and AIDS, sickle cell [anemia]. We can’t do transfusions in the emergency room," said Moma.

The idea that ERs could do triage and that primary care clinics could handle the rest was unrealistic. The Crown Heights/Bedford Stuyvesant community needs "Interfaith as a full service hospital," he added.

But with the Interfaith’s bankruptcy and working group’s recommendation that it merge with Brooklyn Hospital Center, the writing was on the wall for another hospital in Brooklyn, he concluded grimly.

Delivery system needs surgery

Harvey Lawrence, president of the Brownsville Multi-Service Family Health Center, said he was disappointed that by the amount of time the chair of the working group, Stephen Berger, the former head of a 2004 commission on hospital closures convened by then Gov. George Pataki, was given on Friday to make his presentation. Berger, a member of the Medicaid Redesign effort, had the floor for two hours before anyone else could speak, and while his working group’s report had some good ideas, more planning and work needed to be done, said Lawrence.

"We need to be sure that everyone who has to be hospitalized has access to the best possible care, care that is timely and of the best quality," said Lawrence. But at the same time, there needed to be greater synergy between the hospitals and the health care delivery systems that did exist in neighborhoods.

"Right now, with so many patients showing up in ERs with non-emergent or emergency conditions, those patients should be distributed back to the health care delivery system" in their neighborhood.

"There should be some motivation on the part of the state and the hospitals to ensure that the ER is reserved for emergencies and that non-emergent visits are distributed back in to the health care delivery system in the neighborhood. What is being done," asked Lawrence, "to educate and retool the delivery system?"