Aspirin is often the first drug physicians turn to when a patient arrives at the emergency room showing symptoms of heart failure. “But if the doctor prescribes an aspirin and the patient has a history of taking Coumadin” – a blood thinner used to treat blood clots associated with many chronic diseases – “that could be a real problem,” explained David Liss of Columbia Presbyterian Medical Center.
Unfortunately, doctors at Columbia Presbyterian don’t always know whether their patients are taking Coumadin. In fact, they often know little about their patients’ medical histories because they rely on phone calls, faxes, or even the mail to get information from other health providers. Clearly, this can be dangerous for those being treated. Such communication barriers are also expensive, since the only choice is often to repeat tests.
So when Liss began meeting with his counterparts from other hospitals in northern Manhattan about collaborating to serve their patients better, they quickly agreed to focus on improving communications. The result is the Upper Manhattan Health Information Initiative, a program they are developing to help hospitals use advanced technology to share data on patients more easily.
Both the potential savings and the up-front costs of implementing health information exchanges are enormous, according to Jan Walker, executive director of the Center for Information Technology Leadership at Partners HealthCare System.
In a recent study, Walker’s organization found it would cost $28.5 billion to establish a way to exchange “encoded, standardized electronic transactions” for the New York State’s entire health care system. Once in place the system would cost another $1.75 billion annually to maintain. But it also found that the benefits would more than offset the costs. Walker estimates that after the program was established the state would save $4.54 billion a year, and health care providers would save $1.8 billion annually.
This is exactly the kind of savings that candidates for public office often advocate as part of the solution to the ever-mounting cost of health care. Improving technology has been cited in particular as a way to reduce the expense of the state’s $44 billion Medicaid program.
Northern Manhattan, of course, is not the only place whose hospitals face serious communications problems. Studies show that between eight and twenty percent of laboratory tests and x-rays across the country are carried out simply because doctors cannot find results of tests that have already been conducted. Nor is New York the only place where so-called health information exchanges are being considered. Health care providers nationwide are looking into such programs in varying forms, and the federal government provides grants to do so.
But experts say that New York is positioning itself as a national leader in the field by preparing for such an investment.
“Everyone says that it's a good idea to bring [information technology] into health care,” said Jon White of the federal Agency for Healthcare Research and Quality, which funds health information exchanges. “One of the big issues is how do we pay for it, and New York is well ahead of the country."
In its most recent budget, Albany set aside $1 billion over four years for improving technology and restructuring the health care industry. The state also hopes to get federal funding.
But it’s not just about money. There is some concern that even if it is financially responsible, converting to computerized communications in health care could compromise confidentiality by increasing the likelihood of accidental leaks or deliberate attacks from hackers. These questions have to be fully addressed in order to move forward, said James Tallon of the United Hospital Fund.
“Where are the patients, where is the consumer in this conversation?” he asked. “They are clearly out there ready to be part of a privacy backlash.”
Those working to develop health information exchanges are still looking for the correct balance. One group of New York health providers and insurance companies working on a health information exchange has ruled out establishing a common database, or even a system where members would be able to access one another’s files automatically after deciding that privacy couldn’t be guaranteed in such systems.
Instead, participants would have to request tests and records from one another, just as they do now, said Kenneth Ong of St. Vincents Catholic Medical Center, one of the participants in the project. The only difference would be how the records are sent once they are located.
“The patient [will have] already consented by the time we move forward,” he said.
Nor are the benefits only financial. For his part, Liss focuses on the active improvements to care that information technology can bring.
The Upper Manhattan Health Information Initiative will do more than get patients’ histories into doctors’ hands more quickly, he said, describing an electronic system to help diabetics. Currently, such patients keep daily blood sugar and blood pressure diaries, showing the results to a doctor about once a month. Instead, he says, patients could have a machine at home that would record the levels and automatically enter them into the system’s database.
Such a database may also be programmed to let a doctor know immediately if there is anything important in the medical history of a patient showing up in the emergency room like, for example, whether she is on Coumadin.
“The system itself can recognize when there’s something that needs the physician’s attention,” said Liss, “and then draw his attention to that.” Â
Working at the Yorkville Common Pantry on East 109th Street in East Harlem, Deborah Goldstein decided to do something different. Rather than gather the usual anonymous statistics on the people lined up for emergency food, she decided to listen to them instead. In "The Faces Behind the Statistics," one of two reports released in September by the New York City Coalition Against Hunger, she profiles four people on the hunger line:
Maria is 45, has four children, and suffers from depression. Magrit, 59, lost her job of 17 years when she had to take time off to heal a broken ankle. Jack, 57, used to paint houses, but had to stop because of physical problems, and is now disabled. Sianne, 41, takes care of a family of nine.
"I didnÂąt know why all these people were standing in line," said Goldstein, a recent graduate from a MasterÂąs program at Hunter College School of Social Work, "and I wanted to know."
A staggering 37 percent of East Harlem residents live below the federal poverty guidelines. Some 600 of them go to the Yorkville Common Pantry for food every week. The majority of those seeking help are the working poor, some of them thrust into hunger (and, often, homelessness) by a sudden disaster.
"Hunger is not about individual failings,” Goldstein said. “It’s about a failed system."
In addition to the four individual stories in GoldsteinÂąs report, several initiatives are proposed:
Copies of the report have gone out to government officials, funders, activists, and the media, but the reader Goldstein most hopes to capture is Michael Bloomberg. "IÂąd love for the mayor to read it or, even more so, to have the mayor stand on line to get food stamps," said Goldstein.
Mayor Bloomberg vetoed three City Council bills this past summer that would have provided additional access to food stamps for low-income families. Despite repeated requests, we were unable to get a response from the mayorÂąs office about why he vetoed the bills. According to a New York Daily News story that appeared shortly after the decision, Bloomberg said the bills would have violated state and federal law. This claim was disputed by the New York City Coalition Against Hunger.
The vetoes were particularly unsettling to many advocates for the poor because food stamps are considered a long-term solution to hunger rather than having people line up for food at a pantry or soup kitchen.
"One of the bills," Goldstein explained, "would require representatives from the Human Resources Administration to go to the pantry lines and help people sign up for food stamps; the second would waive face-to-face interviews for people working 40 hours or more a week (and for people who are disabled or facing other hardships); the third bill would allow online (and fax) applications for food stamps."
Democratic mayoral candidate Fernando Ferrer has used the mayor's vetoes in his campaign, bringing it up, and other food stamp related issues, at a campaign stop in East Harlem recently.
The City Council overrode the mayorÂąs veto on all three bills. The question now is, will the mayor allow the laws to be implemented or mount a court challenge?
There is another face now visible among those living in poverty: obesity.
Contrary to popular belief, obesity is not a sign of affluence, but rather an indicator of poverty, as the study, "Hunger and Obesity in East Harlem" by J.C. Dwyer makes clear. The other report released by the New York City Coalition Against Hunger in September, Dwyer compares conditions between East Harlem and the Upper East Side, two neighborhoods divided by 96th Street that provide a stark contrast, representing the highest and lowest figures in poverty and obesity.
In East Harlem, 38 percent of children are born into poverty; on the Upper East Side, just five percent. East Harlem has the highest incidence of obesity and diabetes in the City; the Upper East Side has the lowest.
Dwyer outlines the link between obesity and hunger clearly and simply: it is about choice and control. People who have more choices and more control over what they consume have lower obesity and poverty rates and healthier eating.
The Upper East Side has more supermarkets which afford residents more nutritious choices. East Harlem has more bodegas, fast food restaurants, and emergency food programs.
Emergency food programs themselves can be part of the problem, dependent as they often are on donations from food banks. Many food banks receive corporate products that failed their target marketing and are not selling--a new line of crackers perhaps. They may be plentiful, but not necessarily nutritious.
Dwyer makes the point that even the large funders contribute to the problem, concerned as they are with short term solutions like funding food pantries, but doing little to ensure that nutritious foods are offered in these programs. "Funders are still stuck in the emergency food mentality," said Dwyer. "But a lot of people arenÂąt relying on the pantries and soup kitchens for emergency food only. This is about long-term hunger."
And the cash strapped food pantries, some existing on a budget as low as $17,400 a year, cannot afford to purchase more expensive nutritious items like produce. Bodega owners, too, are often caught in the market forces that make it impossible for them to offer affordable fresh produce.
The solutions are far from simple and they have to emanate from the top down, says Dwyer. "Otherwise, the bodega owner, the working mother, the soup kitchen manager wonÂąt be able to make these kinds of decisions. We need subsidies, tax rebates, and for the culture of charity to change."
The culture of charity, explained Dwyer, encourages us to donate a turkey or a few cans of food at Thanksgiving or to volunteer for a few hours at a soup kitchen, but falls short of demanding structural and systemic changes, and assistance from government.
Dwyer advocates for a New York City Food Policy Council, with an office under the mayor. "We need an overarching policy," he explained. "Mayor Bloomberg recently created a council to address the flight of manufacturing businesses from the city. They looked at the problem from the business side and the manufacturing side. We need a similar model for food, a food czar.” This is a growing trend in city planning circles, according to Dwyer, with sterling results in places like Toronto and Connecticut.
Dwyer also stressed the importance that government action never take the form of a sin tax or punishment for unhealthy eating. "These people just donÂąt have the money to spare. Incentives work better," he said.
Dwyer illustrated the dilemma poor people often face when making decisions about food. "If you were offering low-income people the choice between an apple or a sleeve of cookies, most will buy the sleeve of cookies. Why? It lasts longer, it will fill you up more, it makes the kids stop crying, and it is more readily available. In the long term, it will make you fat and it isnÂąt nutritious, but that wonÂąt be enough to change short-term behavior. People are more concerned in the short term with survival, not long-term health."
One solution to hunger and poverty, and the obesity that results from it, is jobs that pay enough for people to feed themselves and their families. But obesity can cause ambulatory problems, making it difficult to work. In addition to having the cityÂąs highest rate of obesity and diabetes, East Harlem also tops the list for diabetes-related amputations.
"I wanted to take down the myth that obesity is a product of natural prosperity," said Dwyer. "ThereÂąs a logical flaw in that argument. If obesity were a sign of prosperity, it would be the rich who are fat and not the poor.”
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When Katrina McCloud was one year old, she hit her head on a coffee table in her Brooklyn home. Her mother, Harriet, rushed her to the emergency room at nearby St. Mary's hospital.
That was 31 years ago. The McClouds still rush to St. Mary's emergency room -- they actually did so almost 20 times in the last year. Now, though, the roles are reversed. Harriet, who has developed diabetes, is in a wheelchair; Katrina lives with her and helps her mother with a condition that has become increasingly serious.
One morning two weeks ago, Katrina noticed that Harriet's blood pressure was spiking to a dangerously high level, one of the main risk factors for a stroke. Immediately, the two women took off for St. Mary's, which is only a block away from their home. "I pushed her in her wheelchair to the emergency room myself instead of waiting for EMS," said Katrina. "If it wouldn't have been for them being there she would have had a stroke."
This type of trip will no longer be possible after October 4. The emergency room at St. Mary's -- which received 35,000 visits last year - is shutting down, and the entire hospital will be closed within 90 days. Katrina and Harriet McCloud will have to find somewhere else for Harriet's regular medical needs.
St. Mary's will be the eighth hospital in New York City to close since 2003. It is unclear how many more of the 73 remaining hospitals in the city -- 11 of them publicly owned -- are in danger of failure, but there is a general agreement that New York's hospitals are facing financial crisis.
To an increasing number of experts, these financial problems signal a major change in the health care industry to which New York must adjust. Walk-in clinics are providing an increasing range of services once provided only by hospitals, they say, and the state should have fewer hospitals as a result. The state, which must approve hospital closings, has taken this view. Governor George Pataki recently appointed a commission to determine which hospitals should be closed.
Others sharply disagree. The main problem with the health care is not financial, they say, it is a lack of access to health care. Simply closing hospitals will not only fail to solve the industry's financial problems, they argue, it will aggravate the serious inequities already present in health care. Most of the struggling hospitals are those in the communities that need them the most, and those likely to suffer from future hospital closings are people like the McClouds -- residents of low-income, medically under-served areas who are already affected disproportionately from every chronic disease ranging from diabetes to cancer to AIDS.
Because many people in such neighborhoods do not have health insurance or access to reliable transportation, their health care options are limited. Closing their local hospitals will mean -- as it has meant in the past -- that many who need care will simply stop getting it.
There is no doubt that New York's hospitals are in bad shape financially. The industry in the state has lost money for five consecutive years (in .pdf format), even as hospitals nationwide post profits. A smaller proportion of New York hospitals have access to sufficient capital funds (in .pdf format) than in any other state, while also carrying the most debt.
Last year the city's public hospital system -- the Health and Hospitals Corporation -- ran a $200 million deficit. Operating losses at the city's private hospitals (in .pdf format) are also rising at a shocking rate. As a whole, private hospitals lost $190 million in 2003, close to five times the $39 million they lost the year before. The percentage of private hospitals that ran deficits rose to 54 percent from 40 percent over that same period.
Many things are contributing to the weak financial state of New York's health care system:
Federal and State Regulations:
Albany determines how much money hospitals can make from certain services, places restrictions on how much they can invest in infrastructure and other capital projects, and prohibits certain types of investors from owning hospitals. These regulations were put in place to keep hospitals from making unwise or unscrupulous financial moves, but most experts agree that they are placing a burden on the state's hospitals.
On the federal level, changes in aid for teaching hospitals have affected New York's community hospitals. Proposed cuts in Medicaid will mean less money for those hospitals serving low-income communities.
Changes in Health Care Delivery:
Long-term trends in health care have also taken a financial toll on New York City hospitals. Since the 19th century, when philanthropists, religious groups, and the city itself began enthusiastically building hospitals, a large proportion of medical care has been given through hospitals. Today, New York City has more hospital beds per capita than other American cities. But over the past few decades, health care has shifted away from hospitals. Improvements in medical care have allowed patients undergoing procedures that would have kept them in the hospital for long periods to go home earlier. Advances in drug treatments for AIDS, for instance, have allowed patients who in the past have been hospitalized to live reasonably normal lives.
Having clinics provide services that once required hospital admissions has improved the lives of patients. But New York's hospitals have found themselves under strain as they look for ways to adjust.
"Health care is a service or set of services that continuously feels the pressures of change," said James Tallon of the United Hospital Fund. "If you were at the top of the mountain in the hospitals' heyday then you've got a little bit steeper slope as you face the changes."
Concentration of Services at Specialty Hospitals:
Such pressure is not being felt equally by all medical institutions in New York City, however. Complicated surgeries and other procedures that must be handled in hospitals are being concentrated in the academic specialty hospitals such as Mount Sinai and Columbia Presbyterian that can afford to invest in increasingly sophisticated equipment. These procedures bring in money, and these hospitals have remained in good financial standing as a result.
The situation is much different in smaller, community hospitals. Because community hospitals are more likely to serve patients without health insurance, they have less income than specialty hospitals. As a result, they do not have funds to invest in the equipment for advanced procedures - the kind that would allow them to develop a specialty and bring in more income.
It is these hospitals that are in the greatest danger of closure, and there is little disagreement about their perilous financial state. There are diverging views, however, on why these hospitals are in such trouble -- and on how best to respond.
After years of financial trouble, Brooklyn Hospital decided to close one of its branches - the Caledonian Division in Flatbush - to preserve its main branch in downtown Brooklyn.
"It became increasingly evident that we needed to do something in terms of a financial turnaround plan, or the place wasn't going to be a viable organization anymore," said Nancy Peterson, Brooklyn's director of planning.
The plan worked. In 2002 the hospital had lost $20 million; last year it made $4.6 million.
Brooklyn Hospital made a choice that other hospitals in the city and across the state have also faced in recent years. An increasing number of public officials, health care industry groups, and representatives of organized labor are saying that the state itself must follow Brooklyn Hospital's lead. By closing hospitals in a rational manner, they say, the state can make the health care industry more sustainable without reducing access to care.
This spring, Governor George Pataki created a commission to examine how to best 'right size' the hospital industry. This commission, the Commission on Health Care Facilities in the 21st Century, will make decisions about which hospitals to close by the end of next year, though it is unclear what will happen with this list once it is formed.
The state and the commission itself insist that it will do more than simply make a list of hospitals to close -- it also intends to look, for example, at issues like the way hospitals are paid for serving Medicaid patients. That said, its structure is based on the federal commission that decides which military bases to close. The recommendations of the commission are binding unless voted down by both houses of the legislature in their entirety -- lawmakers cannot pick and choose what to implement. The reason to have a commission that functions this way is keep officials from deciding which hospitals to close based on political considerations.
The commission operates on the belief that some closures are inevitable. "The marketplace is driving some changes and contractions," said the chairman of the state commission, Stephen Berger, last week. "We're not going to change that."
Berger and others believe that there are too many hospital beds in New York, a fact illustrated by dropping occupancy rates in New York hospitals. According to the state's department of health, hospitals operated at only 60 percent capacity in 2004, down from 73 percent ten years earlier. Dennis Whalen, the department's executive deputy commissioner, has said that as many as 20,000 of the state's 63,000 hospital beds are unnecessary. These empty beds are straining the entire system.
The purpose of doing facilities in a comprehensive manner, instead of dealing with each hospital closure issue as it emerges, is to improve the overall efficiency of the health care system, allowing continued access to medical care. This would not necessarily happen if the state simply allowed the hospitals that were suffering financially to fail.
"The most important institutions may or may not be the institutions with the best balance sheets," said Berger.
Critics question whether Berger and the commision really undertand this. They say that recent discussions about hospital closures have allowed financial considerations to subvert the real issue posed by struggling hospitals: how the communities that rely on them are being affected.
"Is [the health of these communities] going to be the tenth consideration after a list of other things, or is that going to be the starting point," said Louis Guida of the Save our Safety Net Campaign, an umbrella group of organizations concerned about hospital closures. "We think that should be the starting point."
Opponents of systematic hospital closures question the accuracy of official occupancy rates, saying they disregard the reasons for low rates. At St. Mary's, for instance, the beds in the maternity ward were listed as empty in discussions leading to the hospital's closure, driving the occupancy rate to jut above 60 percent. But these beds were not empty because women didn't want to give birth at St. Mary's. They were empty because the hospital had closed the ward in 2003 because it couldn't afford to operate it.
Supporters of hospital closings have also played down how disruptive such closings are to patients, critics say. According to Alan Sager, a professor at Boston University School of Public Health who has studied urban hospital closures across the country, 30 percent of patients whose hospital closes simply stop receiving inpatient care.
"Patients displaced by a closing often take months or years to re-weave the fabric of their medical services," he said. "Vulnerable patients are made more vulnerable when hospitals close."
In addition, hospital closures tend to take place in areas with vulnerable patients. This pattern certainly continues at St. Mary's. Residents of central Brooklyn suffer disproportionately from every single category of health problem that the city's department of health keeps statistics on: from chronic diseases like diabetes, to violence, to mental health problems and drug-related conditions. People in the area are hospitalized at 30 percent higher rate than city residents as a whole, and still 30,000 central Brooklyn residents go without necessary medical care.
Such closures aggravate the very inequities that often caused the hospital's financial problems in the first place, say health care advocates. In order to confront these issues, advocates say New York must:
Unless these issues are addressed, closing weak hospitals to improve the financial standing of more stable ones will only shift the high costs of health care in New York, not eliminate them.
Like many of their neighbors, Katrina and Harriet McCloud tried to stop St. Mary's Hospital from closing. Katrina, working with an ad-hoc coalition of groups called the Committee to Save Our Hospitals, organized her neighbors and traveled to Albany to meet with state officials about keeping the hospital open; Harriet was the plaintiff in a lawsuit to keep the state from allowing the hospital to close. Hundreds of their neighbors packed into the basement of a local church to voice their concerns to public officials and hospital management; dozens filled courtrooms during the bankruptcy proceedings of St. Vincent's Catholic Medical Center, which runs St. Mary's.
But in the end, the financial burden was too much to overcome. Last Tuesday, a judge gave St. Vincent's permission to begin closing the 123-year-old hospital. It has already arranged for ambulances to stop coming to its emergency room, and is making plans to move the 70 or so patients that are currently staying there to other facilities. St. Vincent's is beginning to look for buyers for the physical hospital, and says it hopes to find a developer who will build affordable housing on the site.
The hospital's management says that it has made appropriate plans to help those who were served by St. Mary's find replacement care. It notes that there are several hospitals nearby, the closest being Interfaith Medical Center on Atlantic Avenue, less than a mile away. But members of the community don't think will be an easy adjustment. The Committee to Save Our Hospitals singled out St. Vincent's plans to move the hospital's mental health and detoxification units to Mary Immaculate in Jamaica, Queens for criticism. By public transportation, the hospital is over an hour from St. Mary's. In addition, St. Vincent's has said that it is looking for buyers for the Queens facility - a signal that St. Vincent's is having trouble paying to maintain it.
The McClouds, who visit one of St. Mary's clinics or its emergency room almost weekly, have not begun to consider an alternative. Katrina says she has no idea what she would have done when her mother's blood pressure shot up had there not been an emergency room so close.
General Health Care Links
New York State Department of Health
New York City Department of Health
Commission on Health Care Facilities in the 21st Century
United Hospital Fund
Greater New York Hospital Association
Reports Etc.
New York City Department of Health: Community Health Profiles, by New York City Department of Health
Greater New York Health Association: Testimony Before the City Council Health Committee's Hearing on Hospital Closures (in .pdf format)
United Hospital Fund: Health Care Annual, 2005 Update Data on Hospitals and Ambulatory Care Facilities in New York City (in .pdf format)
United Hospital Fund: Hospital Watch, Trends Through December 2004 (in .pdf format)
United Hospital Fund: Drop in Severity of Illness Further Strains Hospital Finance (in .pdf format)
Law Creating Commission on Health Care Facilities in the 21st Century (.pdf format)
Health Reform Program by Alan Sager
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