Remarks by Alan D. Aviles
President, NYC Health and Hospitals Corporation
Good evening. I am Alan Aviles, President of the New York City Health and Hospitals Corporation (HHC). Thank you all for coming tonight. This is somewhat later in the year than usual for our annual public meeting, but it’s right on time for me to officially wish you all a happy holiday season and a happy and flu-free New Year.
I’d like to recognize our Manhattan leadership team – including our host, John Palmer, Executive Director of Harlem Hospital Center, which is part of our Generations Plus network; Lynda Curtis, Network Senior Vice President for the South Manhattan network and Executive Director of Bellevue Hospital Center; Meryl Weinberg, Executive Director of Metropolitan Hospital Center; Robert Hughes, Executive Director of Coler-Goldwater Specialty Hospital and Nursing Facility; and Mendel Hagler, Executive Director of Gouverneur Healthcare Services. I thank each of them and their staffs for the exceptional work that they do every day on behalf of the patients and communities that we serve.
Before Mr. Levy calls on tonight’s speakers, I will provide a brief overview of the challenges HHC is facing as well as our plans to address them. I will also highlight some of HHC’s accomplishments over the past year, particularly those related to our Manhattan facilities.
FINANCIAL CHALLENGES/HHC ORGANIZATION-WIDE RESPONSE
Let me begin with our financial challenges. Some in this room may have heard me, and other HHC leaders, discuss the large financial deficits HHC faces in the years ahead. They are the result of a kind of perfect storm that began with the national financial downturn and the enormous -- and still growing -- New York State budget deficits that have resulted in deep cuts in State Medicaid reimbursement to every HHC facility. As Medicaid and other revenue sources are decreasing, our costs -- for prescription medications, medical equipment and supplies, and pensions and other guaranteed employee benefits -- are rising alarmingly.
In addition, the faltering economy led to reductions in City support for HHC, with more on the horizon, even as an increasing number of patients with no health insurance are seeking care in our facilities. We served 450,000 uninsured patients in 2008, an eight percent increase from 2007, and that number continues to rise.
And, as if those challenges were not enough, there’s more. HHC receives two kinds of supplemental Medicaid payments to cover shortfalls in fee-for-service and managed care payments, and to cover the costs of treating uninsured patients. For the last few years, these payments have averaged $1.4 billion annually. Starting next year, they are being reduced by $500 million. I will say that again: we will experience a half-billion dollar loss in anticipated federal revenue on an annual basis starting in our very next fiscal year.
Unless we take action to address this evolving crisis, by our next fiscal year, which begins in July 2010, our projected expenses will exceed our projected revenue by about $1 billion. And this extraordinary budget deficit will only continue to grow.
Working with our facility leadership, we have identified various ways to cut costs and to legitimately increase our billing revenue. Some of this work involves operational improvements, greater efficiencies, and the reduction of waste through a team-based process improvement methodology we call Breakthrough. We project that these measures – as well as a hiring freeze implemented in December 2008 – will save us about $200 million this fiscal year and $300 million next year.
Breakthrough will play a greater role in our efficiency efforts as we ramp up the number of rapid improvement events over the course of the next year. Metropolitan was an early adopter of Breakthrough, and an excellent example of its effectiveness in tapping the talent and knowledge of our front-line staff in helping us streamline our operations. The facility has conducted more than 50 highly targeted projects that have already resulted in more than $3 million in savings this year, with the implemented improvements projected to yield even greater savings in the year ahead.
These are all encouraging results, but they’re not enough. We will continue to advocate strongly for more financial assistance from government at all levels to support our mission; however, our expectations must be realistic given the still deepening City and State budget deficits.
And, unfortunately, we cannot look to healthcare reform to solve our financial dilemma. While we are optimistic that Congress will pass legislation that will expand coverage for the uninsured, the pending bills would -- long-term -- dramatically reduce supplemental Medicaid and Medicare funding for HHC and public hospitals across the country. For us, this would mean the further loss of hundreds of millions of dollars in federal funds that cover the costs of serving uninsured patients – including undocumented immigrants who will not be covered by federal healthcare reform.
Given these harsh realities, HHC has hired a consulting firm to help us determine how to restructure our large system for greater efficiency and to better position HHC facilities to compete in a post-healthcare reform environment. This restructuring plan may mean that certain services available at a number of HHC facilities now will be consolidated to fewer locations and this may inconvenience some patients. However, we will strive to ensure that whatever changes we make are as fair to all our facilities and communities as possible, and that we retain the capacity to provide the full range of healthcare services that our patients need.
Finally, we will remain firmly committed to HHC’s mission: to serve all who come to us without regard for their ability to pay or their immigration status.
TRANSPARENCY AND PATIENT SAFETY
Let me now turn to some of our recent accomplishments across our system and here in Manhattan. In 2007, HHC became the first hospital system in our State to make public system-wide and hospital-specific performance data related to quality of care and patient safety. This past year we have expanded the quality data that we share publicly on our Internet site.
For example, we posted the results of federally-mandated patient satisfaction surveys at each of our hospitals. Those results are encouraging, with our average patient satisfaction scores exceeding those of most New York City hospitals.
This year we also published data to our Web site that reflects the quality of our maternity and infant care services, an especially important area of focus for us because our hospitals deliver one out of every four babies in New York City – about 24,000 a year. Close to 5,000 of our babies began life in Manhattan this year. We are proud of the excellent care rendered in our obstetrical units and our extremely low maternal mortality rates, despite handling a disproportionate number of New York City’s high-risk deliveries.
By consistently implementing evidence-based best clinical practices, HHC facilities have also excelled in lowering the number of hospital-acquired infections in our ICUs, operating rooms, and inpatient units. Our facilities have cut the rate of central-line blood stream infections by more than 60% since 2005, and the rate of ventilator-associated pneumonia has been reduced by 90% during that same four-year period. One of Bellevue’s ICUs and two of Harlem’s ICUs are on track to report 24 months without a ventilator associated pneumonia infection, and two of Metropolitan’s ICUs have gone without a central line bloodstream infection this entire year. Very few hospitals in our City can match those infection control accomplishments.
At Coler-Goldwater and Gouverneur, the incidence of patient falls is approximately 1/3 of the national average, reflecting the staff’s concern for keeping patients safe and their diligence at doing so. And Gouverneur was one of two HHC facilities that received the highest rating available – five stars – when the federal Centers for Medicare and Medicaid services (CMS) launched a new quality rating for nursing homes in December of 2008. Only 12% of the nearly 16,000 nursing homes rated nationally received this top rating, which is based on health inspection surveys, quality measures, and staffing.
Finally, Bellevue won the grand prize at HHC’s 2009 Patient Safety Expo for its HELPix initiative, a health literacy intervention designed to decrease medication errors among pediatric patients. HELPix uses easy-to-understand graphics to help patients administer to their children the right dose of medication at the right time for the right number of days. Medication accuracy rates rose from 57% before the program to 97%. Early next year, Bellevue will introduce a web-based program that will enable staff to print customized and graphic-enhanced instruction sheets for each patient in English or in Spanish. HHC plans to eventually expand this program to all of our pediatric programs.
BEHAVIORAL HEALTH/CHRONIC DISEASE MANAGEMENT
Two other areas where we have made significant strides over the past year are behavioral health and chronic disease management.
HHC facilities provide nearly 40% of hospital-based inpatient mental health services in the city, and we serve a disproportionate number of New Yorkers with serious and persistent mental illness. Those who suffer from serious mental illness have life spans that are, on average, 25 years shorter than the general population.
Children and adolescents with behavioral health problems – and their families -- face a unique set of issues, and Bellevue is addressing them by building a $1.1 million Children’s Comprehensive Psychiatric Emergency Program (CPEP). In addition to creating a physical separation between younger patients and adults, this innovative service model for child and adolescent patients in psychiatric emergency will use a specially-trained interdisciplinary staff of psychiatrists, nurses, and social workers. It will help transform a system that children and adolescents often find alienating into one that meets their specific needs with sensitivity and empathy. Combined with Bellevue’s Home-Based Crisis Intervention program, the Children’s CPEP will provide a seamless model of care from emergency intervention to inpatient admission or immediate outpatient clinic follow-up, and home and clinic-based support to children at risk of psychiatric hospitalization.
Metropolitan Hospital will soon open a Model Addiction Recovery Center, one of four demonstration programs approved by the New York State Office of Alcoholism and Substance Abuse. Met has also collaborated with the Board of Education to create a unique behavioral health program -- the Star Salon. The salon, which opened in July and provides a full range of grooming services for behavioral health inpatients, operates two days a week in the Behavioral Health Pavilion.
HHC also continues to make progress in other areas of chronic disease management. On May 1, the HHC Cardiovascular Risk Registry became available at all of our hospitals. The registry is an electronic disease-tracking program that greatly improves a doctor’s ability to comprehensively monitor and more effectively manage cardiovascular disease among patients. Thus far, the registry has identified more than 42,000 patients with high blood pressure and 26,000 patients with high cholesterol whose treatment is being closely monitored and better managed.
Working with our diabetes registry, our clinicians continue to improve the health of more than 55,000 diabetic New Yorkers under care in HHC hospitals. And the number of our diabetic patients with healthy blood sugar, normal blood pressure, and healthy cholesterol levels increased significantly from last year to this year.
For the third year, Harlem Hospital collaborated with other HHC facilities, the New York City Department of Parks and Recreation, and the American Lung Association to offer a summer camp – Superkids Summer Experience – for children suffering from asthma. In addition to games and arts and crafts, the children, from grades two through six, are taught about what triggers their asthma attacks, steps they can take to avoid them, and the importance of staying strong and fit by exercising and eating healthy. Programs like this are particularly important in Harlem, where asthma rates are five times the national average.
COMMITMENT TO LOCAL COMMUNITIES
HHC facilities are deeply engaged with local communities, and respond to their specific health needs by creating a variety of programs that are effective as well as culturally sensitive.
I was especially pleased this year that, in recognition of this work, HHC received the Builders of New York Award from the New York Immigration Coalition, an umbrella policy and advocacy organization of more than 200 groups in New York State that promotes fairness and opportunity for immigrants and refugees. We were cited for our significant innovations in expanding access to care for immigrants, including our financial assistance policies that provide deeply discounted fees for the uninsured, our comprehensive communications assistance for limited English proficiency patients, and our strictly enforced confidentiality policies that afford new immigrants a sense of security in accessing needed care.
And in November, Harlem Hospital celebrated the opening of the Medina Clinic, developed in response to the continuing growth in Harlem’s West African population. This largely immigrant population faces cultural, religious, linguistic, financial, and educational barriers to seeking healthcare services. The multinational, multilingual clinic has two sites – on the Harlem campus and in the community – and a growing number of patients who are receiving access and treatment in a culturally sensitive and respectful manner. Funding for the Medina Clinic came from the New York State Health Foundation, the Avon Foundation, and the HHC Foundation.
Our long-term care facilities in Manhattan have also been responsive to the needs of their communities. Both Coler-Goldwater and Gouverneur are moving forward with a resident-centered care model called Culture Change, which creates a more home-like, community-oriented environment and has resulted in better long-term resident care. Coler holds monthly community meetings with staff and residents to improve communications and resolve problems, they have changed the assignment of nursing aides so that residents have consistency and more personalized care, and they have held a series of leadership training sessions around the Culture Change concept.
And Gouverneur received $380,000 from the federal department of Housing and Urban Development, thanks to the efforts of Congresswoman Nydia Velazquez, to help fund the design of their new nursing facility in line with the Culture Change model. The new design will include more inviting dining areas, new bathrooms and bedrooms, and new recreational spaces.
Turning to other capital investments, despite economic challenges, our hospital modernization program continues to create modern, comfortable high-tech therapeutic environments supporting better clinical outcomes.
A total of $587.6 million in capital projects have been under way at our Manhattan facilities, $30.3 million of which were substantially completed this year, and $55.8 million which are projected for completion in 2010.
In addition to the capital projects I’ve already mentioned at Bellevue and Gouverneur, Harlem Hospital’s multi-year modernization project reached a milestone with the September 17 steel-topping of its new 194,000 square- foot patient pavilion. This is part of a $272 million renovation and expansion of this vital community institution. The pavilion includes a new Emergency Department, state-of-the-art critical care and diagnostic units, and new operating rooms. Harlem also received a $150,000 grant from the United States Department of the Interior to fund the restoration and preservation of its WPA murals as part of the federal Save America’s Treasures initiative to preserve significant historic properties and collections.
We had a second steel-topping in September at Gouverneur for their new 108,000 square-foot addition that is part of a $182 million renovation to the institution that has served the Lower East Side community for more than a century. This addition will result in a state-of-the art residential home for older community residents, and a new ambulatory care center with a full range of primary care and specialty services.
However, because of our fiscal constraints we may be challenged to complete these essential capital programs as we had originally envisioned. We will need the advocacy of all of our community stakeholders to obtain all the funding needed for the final phases of these projects.
Though our capital investments to modernize our physical infrastructure are important, our most important resource remains our people. Tonight I’d like to mention several Manhattan staff members – and a volunteer – who were recognized as leaders in their fields this year.
Cecil Almendra, a nurse, educator, and mentor at Coler-Goldwater, will soon be joining a small and very exclusive group – she will be one of the 1% of nurses in this country with a Ph.D. in her field, thanks to a scholarship from the Charles Spear Charitable Trust Foundation.
A Harlem Hospital physician received a special honor in 2009. Dr. Wafaa El-Sadr, Chief of Infectious Diseases, was named by Rolling Stone as one of the Top 100 Agents of Change for 2009. The magazine described Dr. El-Sadr, who was also a MacArthur grant awardee in 2008, as a “global health visionary, fighting AIDS one family at a time.”
And we can’t forget HHC’s Volunteer of the Year, 84-year-old Gloria Calderon, who has been a foster grandparent at Bellevue for 21 years. Her volunteer career began after she retired from her job as a maintenance crew supervisor at Coler-Goldwater, and since then, she has logged 39,920 volunteer hours. Ms. Calderon received her honor at Gracie Mansion as part of National Volunteer Week last April, where HHC officially recognized 16 of the 8,000 volunteers who put in 1 million hours of service to the city’s public hospital system this year.
Before I bring my remarks to a close, let me briefly mention something that’s been on everyone’s mind – the flu. From the beginning of the H1N1 outbreak last spring, HHC has played a critical role in the city’s coordinated emergency response and preparedness efforts, and our Manhattan hospitals performed particularly well. We took immediate steps to ensure that patients received the care that they needed, despite dramatically increased patient volume in our emergency departments and many of our primary care settings.
We have opened a Fast Track Flu Center in Manhattan to help meet public demand for both seasonal and H1N1 flu vaccinations. HHC has already given 200,000 flu vaccinations to adults and children.
We have been fortunate that our communities across the city have not yet experienced high levels of flu activity. But whether the flu season has peaked, as some are suggesting, or will surge again in the months to come, we will continue to monitor the situation closely and will be prepared.
The achievements that I have touched upon would not have been possible without the collaboration and advocacy provided by our Community Advisory Boards and our labor partners; the contributions of our volunteers and auxiliaries; the steadfast support of Mayor Bloomberg and other elected officials; and, of course, the compassion, creativity, and commitment of the men and women who staff our health centers and hospitals in Manhattan and our other HHC facilities throughout the city.
As noteworthy as our achievements are, I must close by coming back to the significant challenges that lie ahead for HHC. I want to assure you that we will do what is necessary to preserve our ability to carry out our mission, and we will always be open and honest with our communities about whatever changes are necessary.
Thank you for your attention and your commitment to our public hospital system. I will now turn the microphone over to our moderator, Mr. Levy, and I look forward to hearing your comments.