ALAN D. AVILES
HHC PRESIDENT AND CHIEF EXECUTIVE
REPORT TO THE BOARD OF DIRECTORS
NOVEMBER 19, 2009

As I reported last year, the House Calls telemedicine program developed by HHC Health and Home Care, with support from MetroPlus Health Plan, continues to expand and help our patients with severe diabetes significantly lower their blood sugar levels, avoiding hospitalizations and trips to the emergency room. This month, House Calls celebrated its third anniversary at a luncheon to honor nearly 100 patients who have made progress in the program.

Seventy-six percent of the patients enrolled in House Calls for at least six months have significantly decreased their A1C levels, and of those, 22 percent reached the recommended goal of an A1C of 7. When they first started the program, A1C levels ranged from more than 9 to as high as 14. Moreover, MetroPlus Health Plan's most recent data shows that unplanned doctor visits, hospitalizations and emergency department visits by House Calls patients were reduced by 50%, a savings of thousands of dollars per patient. Thus far, more than 500 patients have been enrolled in the program.

Recently the NYS Health Department made it mandatory for Medicaid Managed Care plans to cover telemedicine services such as this for patients who meet specific requirements after a risk assessment. This regulatory change should help us to offer these services to other eligible diabetic patients in our care. More than 50,000 diabetics receive care at HHC facilities.

HHC's Institute for Medical Simulation and Advanced Learning -- IMSAL -- has started its mobile skills training program. While construction progresses on a permanent space for the IMSAL Center in Building 4 on the Jacobi campus, courses are being delivered on site at each of our hospitals. The first course, Central Line Placement, will be offered to residents from Emergency, Surgical and Medical Services. It has been scheduled at seven hospitals through the end of February 2010 for nearly 300 learners. This first course has been very well-received, with attendees giving it an average of 3.9 out of 4 points for overall satisfaction. Completion of construction on the permanent space is anticipated in the fall of 2010.

This January, IMSAL will have a prominent role at the Tenth Annual Society for Simulation in HealthCare Meeting in Phoenix. IMSAL Director Dr. Haru Okuda has been invited to conduct a SIM Wars Session, an interdisciplinary team 3-day competition developed and popularized nationally by Dr. Okuda. IMSAL staff will be leading the roundtable discussion on the use of simulation to improve patient safety. Workshops will also be conducted by Dr. Okuda and by IMSAL Simulation Specialist Timothy Clapper on evaluation strategies for skill-based central line simulation.

As you know from my previous reports, the HHC Connectx program was initiated last year to expand our partnership with the community healthcare providers who treat patients in the communities served by our hospitals. Many of them have not been aware of the extensive specialty services available at HHC facilities. Thanks to the efforts of the HHC Connectx team, referrals to HHC hospitals from community physicians have been steadily increasing. A total of 3,091 community providers made a referral during Fiscal Year 2009, from July 1, 2008 to June 30, 2009, and HHC referral offices processed a total of 60,670 referrals during the same period, averaging 5,056 referrals per month. In addition, the time to process referrals from these physicians and to schedule an appointment for their patients became significantly faster, even as the referral volume from these physicians steadily increased. I want to thank Senior Assistant Vice President Irene Kaufman for her leadership in developing and promoting the HHC Connectx program.

As a related service for HHC Connectx community providers, and to maximize reimbursement under revised Medicaid Clinical Risk Group reimbursement methodology, the HHC Connectx team collaborated with MetroPlus and Health First to perform outreach and training to our community providers whose managed care patients had not received annual visits with their primary doctors -- also called "non-users." Techniques included webinars and scripts for hospital provider relations staff who called individual community practice staff to raise awareness about the issue. The campaign reduced the number of "non-users" across MetroPlus and Health First by over 50 percent. In addition, HHC Connectx collaborated with the health plans to develop training materials for community providers to guide their coding and submission of claims as a result of revised Medicaid reimbursement regulations.

Early this month, HHC reached an agreement with Aetna insurance to offer the New York City members in all Aetna insurance plans in-network access to inpatient and outpatient services in all our facilities. The new three-year agreement expands Aetna's current relationship with HHC's Elmhurst Hospital Center and Queens Hospital Center. Our entry into this large network of commercial health insurance underscores our competitive, quality services and our recent significant achievements at the leading edge of patient safety, health information technology and chronic disease management. This new partnership also supports our work to further diversify our patient base and attract more referrals from the thousands of community physicians with whom we have forged relationships. Aetna provides health benefits to approximately 1.8 million members in the New York Metropolitan area.

Earlier this month, and at my request, HHC Executive Vice President, Dr. Ramanathan Raju, issued a notice to all our facilities regarding influenza vaccination reminding staff of our need to continue prioritizing vaccination of high-risk patients due to limitations in vaccine supply. We have administered approximately 200,000 doses of vaccine, including more than 25,000 doses to our own workforce, and now will continue to focus on high-risk patients for both seasonal influenza and the H1N1 vaccine until such time as the supply of vaccine is more plentiful. Our public fast-track flu vaccine centers remain open during evening and weekend hours to make vaccines available for all New Yorkers, especially those who do not have a primary care physician.

New York City thus far has been fortunate that the level of influenza illness here has not been as high as in other parts of the country. A number of our facilities have begun to experience a gradual increase in the number of patients presenting to our ED's with influenza-like-illness, especially among pre-school age children. Those increases are consistent with the citywide surveillance trend in the last couple of weeks. We continue to work with the City Health Department to secure our share of the limited vaccine supplies that are available and to monitor ED trends. Should the situation change, all our emergency departments are well prepared to respond thanks, in part, to the extensive and early preparedness planning conducted by the City and HHC over the summer.

Last night, Senate Majority Leader Harry Reid (Democrat-Nevada) unveiled the awaited Senate health care reform bill. The Congressional Budget Office (CBO) score was a cost of $849 billion over 10 years. The bill is mostly a blend of legislation already produced by the Senate Finance and the Senate Health Education, Labor and Pensions (HELP) Committees. Key features include: a Public Option, including an opt-out provision for States; a national Medicaid expansion to 133% of Federal poverty level (FPL); provisions estimated to provide coverage to 94% of legal American Residents- insuring an added 30 million persons, leaving an estimated 24 million (including undocumented immigrants) uninsured; retaining an individual mandate to purchase Health Insurance, with modest penalties for non-compliance ( a maximum of $750); and an expansion of the 340b program to inpatient pharmaceuticals which would save HHC about $1.8 million per acute care facility -- a total of almost $20 million in reduced pharmaceutical costs. Senator Reid is now working to secure the 60 Senate votes necessary to take the legislation to the Senate floor. It is expected that many amendments to the bill will be offered and adopted. The hope is to have a final bill approved in December.

Of prime importance to HHC, thirteen (13) Senators, led by New York's Kirsten Gillibrand and Minnesota's Amy Klobuchar had signed a letter to the Senate Leadership calling for the proposed DSH cuts in the Senate Legislation to match the lower level of the House Bill, which is $20 billion over 10 years. Unfortunately, the legislation released last night includes a total of $43 billion in DSH reductions over 10 years.

On Saturday, November 7th, the House voted by a narrow 220-215 margin to approve its healthcare reform bill, HR 3962 -- The Affordable Health Care for all Americans Act. Key features of this bill include expanding Medicaid to persons earning up to 150% of the Federal Poverty Level; limiting Medicaid DSH reductions over the next ten years to $10 billion starting in 2017; and a negotiated rate public plan option. It should be noted that most voluntary and for-profit health care providers are vehemently against a public option, especially one based on Medicare rates; many moderate and conservative Democrats were only willing to support a public option if the rates were "negotiated" with providers, in a similar fashion that insurance companies negotiate with hospitals which would provide higher reimbursements. The bill is projected to provide insurance coverage to 36 million Americans, leaving about 18 million persons, including undocumented immigrants, uninsured. Some 97% of legal American residents would be covered.

The House bill would also provide enhanced federal Medicaid matching funds for many current Medicaid recipients, thereby not penalizing states - like New York -- that have more expansive programs. All states would receive the same matching percentage -- 100% in 2013 and 2014 and 91% starting in 2015. States would receive enhanced federal Medicaid matching funds for all childless adults receiving Medicaid with incomes up to 150% FPL and for all Medicaid recipients between 100-150% FPL. We are disappointed that the provision expanding the 340b Drug Discount Program to include inpatient drugs was stripped from the House Bill.

The House's health reform bill was almost derailed because of two important issues which included coverage of abortion services and the ability of undocumented immigrants to purchase health insurance through health insurance exchanges. Forty (40) House Democrats, led by Congressman Bart Stupak of Michigan, refused to vote for the bill unless there was a clear ban on coverage for abortion services for any health plan receiving any federal subsidies on a health insurance exchange. To garner their support, Speaker Nancy Pelosi agreed to allow a vote on an amendment by Congressman Stupack which would ban coverage for abortion services. The amendment passed with the support of 64 Democrats (a quarter of the caucus) by a margin of 240-194. In contrast, the Senate Bill retains language prohibiting federal subsidies to pay for abortion (the Hyde Amendment) but would allow plans subsidized and sold on the exchange to offer such services with segregated private funds.

There was much debate regarding undocumented immigrants' ability to purchase health insurance through the health insurance exchanges. The Hispanic Caucus, which is comprised of 20 members and led by Congresswoman Nydia Velazquez of Brooklyn, threatened to oppose the bill if language was added that would prohibit undocumented persons from using their own funds to buy health insurance through an insurance exchange. The White House had urged the House to include such a ban. Although the prohibition was not included in the House Bill, this provision is included in the Senate bill released last night.

It should be noted that both Houses include in their proposals significant Medicare reductions. The primary savings are achieved by reducing yearly Medicare Market Basket (inflation) increases for all providers, including Hospitals, Home Health agencies and Long Term Care Facilities and by cutting payments to Medicare Advantage Programs to levels more comparable to Medicare fee for service. There are also service delivery reforms including penalties for services related to readmissions and for some health care-acquired conditions. The Senate Bill also raises the Medicare tax on individuals making over $200,000 and couples making over $250,000 a year by .5%.

The House is now waiting for the Senate to debate, amend and vote on its bill. Although it is the administration's goal to have the Senate bill voted upon by the Christmas break, it is unclear whether that will happen.

Turning to the State Budget, the Governor called Legislators back for a special session that began earlier this week and is still underway today. Governor Paterson continues to reiterate on a daily basis his desire to have the Legislature act immediately to bring the budget into balance citing the consequences if the state temporarily runs out of cash next month.

Both the Assembly and Senate are debating different sets of alternative proposals to the Governor's initial deficit reduction plan that would cut state spending this State Fiscal Year and possibly into next year. While there seems to be consensus in some areas, there is no overarching agreement that has been reached at this point. We have heard that there is general consensus for healthcare cuts totaling approximately $87 million that would be achieved by lagging some HEAL-NY payments into State Fiscal Year 2011-12, forgoing payments for certain State Health Department programs until SFY 2010-11 and re-estimating the trend factor for hospitals, nursing homes and home care providers. Since a deal on the budget doesn't seem to be imminent, it looks like the session may stretch out into next week - or later.

As you know we have been pressing our case with legislators and we have been working with DC 37 and our Community Advisory Board members on budget advocacy efforts. Several dozen DC 37 members went to Albany last week and again this week to talk to the Assembly and Senate about the impacts of the proposed deficit reduction cuts. CAB members have been making calls and emails for weeks now. I'd like to thank them for their ongoing advocacy efforts on our behalf.

In accordance with the authority granted to me by Operating Procedure 100-5, I have authorized the award of a sole source contract based upon emergent circumstances. Since the services to be performed by the contractor concern matters of quality assurance, the subject matter of that contract will be discussed with the Board of Directors in executive session following our public meeting.

Jacobi Medical Center and North Center Bronx Hospital's Project Brief - an innovative HIV testing initiative which has already received numerous recognitions, including the recent NOVA award from the American Hospital Association - has been accepted as an abstract presentation at the most prestigious global annual HIV conference, the 17th Conference on Retroviruses and Opportunistic Infections (CROI 2010) to be held February 16-19 in San Francisco, CA. Drs. Jason Leider and Yvette Calderon will proudly represent HHC at this scientifically focused meeting of the world's leading researchers working to understand, prevent, and treat HIV/AIDS and its complications. Project Brief, a rapid HIV testing program that uses a multimedia tool as a counselor, has proven that a busy inner-city hospital ED can effectively test a large number of patients, provide consistent prevention messages to patients who report multiple HIV risk factors and link a large percentage of HIV-positive patients to existing health care services. This is one of the most innovative programs to emerge out of HHC's work to make HIV testing part of routine medical care.

Last month, HHC upgraded its data warehouse, the massive database which stores virtually all of the Corporation's electronically captured clinical data. The powerful new hardware and software platform allows us to exploit new processing power and flexibility in conducting data warehouse analyses. Most tasks can now be completed three times more quickly than previously. In recent years, HHC has used such sophisticated data analysis to generate fine-grained trend analyses, “what if” scenarios, and other ways of learning from past practice to better strategize for the future.

Last week Lincoln Hospital received news that their Trauma Director, Dr. Robert V. Madlinger was recipient of the NY State Trauma Physician Distinction of the Year Award. The recognition came from the New York State Division of the American Trauma Society. Dr. Madlinger has been a trauma surgeon at Lincoln since 2006 and became Chief of Trauma at Lincoln last year. He is Vice Chairman of the NYC Regional Trauma Advisory Council and Director Lincoln's Advanced Trauma Life Support Course which offers quarterly classes to physicians from around the world. Dr. Madlinger is a member of numerous trauma organizations and medical societies, is certified by the Dept. of Homeland Security and FEMA on emergency preparedness, and is active in research. Congratulations to Dr. Madlinger for this distinguished recognition.

• Experts give kids a hand at learning how to prevent cold and flu germs, Elmhurst Hospital featured, New York Daily News, 11/16/09
• Reforming the cost of diabetes care, HHC House Calls featured, Crain's Health Pulse, 11/12/09
• Dr. Seligman of Queens Hospital Center Talks About Lung Cancer, Fox 5 News- TV, 11/11/09
• Drug discount out, Cuts to 340B plan, Modern Healthcare, 11/09/09
• Ready, Set, Parent! Program added to Jacobi Medical Center Maternity Unit, Yournabe, 11/06/09
• Aetna Signs Agreement with New York City Health and Hospitals Corporation, The Wall Street Journal, 11/02/09
• Nursing Program at Goldwater Hospital, WNBC-TV, 11/02/09
• HHC, New York City, Receives $28M in HEAL Grants, Advance for Nurses, 10/29/09
• Help Me Howard: Kings County Hospital helps young woman get a free breast exam, WPIX News-TV, 10/28/09
• Patient Safety, 2009, AHRQ newsletter, HHC patient safety programs featured, November 2008