ALAN D. AVILES
HHC PRESIDENT AND CHIEF EXECUTIVE
REPORT TO THE BOARD OF DIRECTORS
January 31, 2013
HHC CONTINUES RECOVERY WORK AFTER HURRICANE SANDY
In recent testimony before the City Council, HHC estimated the cost of Hurricane Sandy to be more than $900 million. The estimate covers cost of storm preparation and response, protective measures, revenue losses and the current anticipated cost of reconstruction, including hazard mitigation costs to prevent future damage. The majority of the costs will involve repair and restoration to electrical, water, heating, air handling, and communications systems, as well as patient care areas, at Bellevue Hospital, Coney Island Hospital and Coler-Goldwater Specialty Hospital and Nursing Facility.
Earlier this month, Senator Charles Schumer visited Coney Island Hospital, toured parts of the storm-damaged first floor Emergency Room and basement, and vowed his support for securing the required federal aid for the HHC recovery, restoration and mitigation efforts. Soon afterward, on January 17, Senator Schumer visited Bellevue Hospital to announce that HHC will receive $103 million in federal aid from FEMA, the first funds released to the state for the benefit of our city's public hospitals and a down payment on the aid needed.
The two hospitals evacuated during the storm have been providing many outpatient services and limited emergency or urgent care services, but have not yet resumed full inpatient services.
The Bellevue Hospital Center Emergency Department is fully staffed and began receiving ambulances again for the treatment of non-traumatic and non-critical injuries on December 24. Bellevue has also now opened nearly all of its specialty clinics and ancillary services -- including radiology, nuclear medicine, and mammography services – in addition to the primary care and urgent care services that it has been operating since November 19. It is anticipated that Bellevue will reopen virtually all inpatient services and resume its role as a Level 1 Trauma Center by mid-February.
Coney Island Hospital restored full inpatient behavioral health services with the opening of the last 32 of its 64 inpatient psychiatric beds on January 14. Four days after the storm, the hospital opened a 24/7 urgent care center and began providing primary care services; it has been steadily opening additional outpatient primary care and specialty services and has now restored all of those ambulatory services. The hospital is phasing in the balance of its inpatient services over the course of the next two weeks, but it will continue to operate with an Emergency Department that is only one-third of its former size. The rebuilding of the balance of the Emergency Department will not be completed until mid-March.
As you know, the dedication to our patients that was demonstrated by many HHC staff during the storm was truly exemplary. The Office of Special Projects has compiled a collection of profiles of several HHC staff members whose performance during the storm was nothing short of heroic. The collection is called Rising to the Occasion and it has been printed for distribution today for the Board members. Some will also be sent to the facilities. The profiles are also on display along the 5th floor hallway; I hope you have a chance to read some of these remarkable stories.
The Hurricane Sandy Emergency Supplemental bill was passed on January 15 by the House of Representatives and on January 28 by the Senate. It was signed by President Obama on January 29. The bill totals $50.7 billion, which, when added to the $9.7 billion in flood insurance funding enacted the week before, brought Sandy funding to $60 billion.
The final bill includes $5.4 billion for the Federal Emergency Management Agency, which can reimburse state and local governments, non-profits, private entities and individuals for certain losses from Hurricane Sandy. Many of HHC's expenses related to repair, restoration and mitigation should be eligible for FEMA reimbursement. The bill also includes $16 billion for the Community Development Block Grant Fund (CDBG), which can be used by states to support critical and immediate community needs. This funding can also be used to reimburse hospitals for payroll expenses that otherwise would have been covered by storm-related lost revenues.
New York Senators Charles Schumer and Kirsten Gillibrand were instrumental leaders in moving the legislation through the Senate. New York Representatives Peter King and Nita Lowey led the bipartisan team which moved the bill through the House. Every Member of the New York City delegation played a very active role in securing passage of this bill. Governor Cuomo and Mayor Bloomberg also took strong leadership roles.
By late February, the President is expected to release his budget. On March 1, the previously enacted sequester is scheduled to begin cutting most spending by 8%, but with Medicare provider payments cut by 2% and no cuts to Medicaid. On March 27, the Continuing Resolution that funds the federal government expires, therefore, if it is not extended, government funding will cease. April 15 is the deadline for a Budget Resolution in both houses of Congress. On May 18, the Debt Ceiling is re-imposed although, through some manipulation, Treasury may be able to extend hitting the debt ceiling into June or July.
The recently enacted Fiscal Cliff legislation, the American Taxpayer Relief Act, included two provisions that reduced payments to hospitals and would negatively impact HHC. First, the legislation imposed a Documentation and Coding (DCI) adjustment, which will phase in the recoupment of past "overpayments" to hospitals made as a result of the transition to Medicare Severity Diagnosis Related Groups (MS-DRGs). This is a loss of $34 million to HHC in FFY 2014 - 2017, according to HANYS. The second provision would rebase Medicaid Disproportionate Share Hospital (DSH) payments by extending the Affordable Care Act (ACA) Medicaid DSH reductions for an additional year, resulting in a loss to HHC in FFY 2022 that could be as much as $471 million.
Several Medicare and Medicaid provisions of importance to HHC will likely be considered for significant cuts this year. Among these are: another extension of the Medicaid DSH cut to FFY 2023; reductions in payments for Hospital Outpatient Evaluation and Management services to align reimbursements with those received for visits occurring in physician offices, which would effectively cut HHC's reimbursement for such services by $187 million in FFY 2013 - 2022; a reduction in the Indirect Medical Education (IME) adjustment from 5.5% to 2.2% that would cut HHC by $626 million in FFY 2013 - 2022; a cap on Graduate Medical Education (GME) payments that would reduce HHC payments by $215 million in FFY 2013 - 2022; and a cut in Medicare bad debt support that would cut HHC by $26 million in FFY 2013 - 2022. In the aggregate, these cuts, if all are enacted, would reduce HHC's revenue by more than $1 billion over a ten year period beginning in October 2013.
STATE HEALTH AGENDA
The 2013 State Legislative Session got underway earlier this month when Governor Cuomo presented his annual State of the State address on January 9th. The following week the Legislature passed one of the key initiatives the Governor discussed, the New York SAFE Act. While the SAFE Act enacts new gun control measures, it also modifies "Kendra's Law," which allows court-ordered Assisted Outpatient Treatment (AOT) for mental health services and imposes new requirements for health care providers to report when patients are likely to engage in conduct that would result in harm to themselves or others.
Other State of the State priorities the Governor incorporated in his proposed State Budget for 2013-14 include new requirements for hospitals to adopt sepsis recognition and treatment protocols, an overhaul of Article 6 of the Public Health Law -- the means by which localities fund public health initiatives -- and reforms to the Certificate of Need (CON) process for health care facilities. Governor Cuomo also proposed changes to the way the State spends resources for affordable housing. As part of that effort, the Governor would add $12.5 million for Medicaid Redesign Team (MRT) supportive housing initiatives, bringing total annual spending to $87.5 million, and allocate an additional $3.85 million generated from the closure of hospital and nursing home beds for new supportive housing initiatives.
In addition to the announced State of the State priorities, the Governor's budget proposal contains numerous, far-reaching reforms to the New York's healthcare system. While staff is still analyzing the details, several key issues have emerged. Although the proposed budget does not appear to include new cuts for healthcare providers, it would extend MRT actions that were only agreed to as time-limited measures. This includes making permanent the Medicaid Global Spending Cap and extending until 2015 the corresponding "superpowers" of the State Health Commissioner to make cuts to keep spending within the Cap. The proposed budget would also extend a two percent across-the-board cut to Medicaid provider rates and permanently eliminate the Trend Factor adjustment for cost increases due to inflation, both of which would result in an estimated $47 million loss to HHC,
The proposed budget also would implement MRT-recommended reform of the State's system for distributing the Indigent Care Pool (ICP) funding to reimburse hospitals for providing Charity Care. HHC supports reforming the system to comply with federal Affordable Care Act (ACA) requirements to better target Medicaid Disproportionate Share Hospital (DSH) funding to hospitals providing care for uninsured and underinsured patients, as well as for losses incurred serving Medicaid patients. However, HHC is strongly advocating for a change to the way the proposed budget funds $25 million in transition payments for voluntary hospitals to offset losses under the new system. We are urging that the proposal be revised to utilize the Voluntary Inpatient Hospital Upper Payment Limit (UPL) instead of the supplemental Medicaid DSH/UPL that would otherwise make that $25 million available to augment HHC's revenue (50 percent provided by City and 50 percent by the federal government).
The proposed budget also includes new initiatives to allow for the State Health Commissioner to develop two pilot projects to allow private capital to be invested to assist in restructuring health care systems (one in Brooklyn and one in another location) and to allow publicly traded "convenient care" clinics. It also revises the Excess Medical Malpractice Pool to prioritize access for the highest risk specialties in the highest risk areas. Staff is still determining the impact on HHC physicians. Finally, the proposed budget makes eligibility and benefit changes to New York's public health insurance programs as part of its implementation of the Health Benefit Exchange under the ACA. Key among these changes is the repeal of the Family Health Plus program as most of those eligible for the current program are transitioned under the Medicaid expansion and exchange creation. As with all of the budget proposals, staff will provide updates on the effect of this proposal as more information becomes available.
HHC TESTIFIES AT CITY COUNCIL HEARING ON PUBLIC HEALTH RESPONSE TO HURRICANE EMERGENCY
The City Council has held a series of hearings this month on the many different aspects of the City's overall preparedness for storms and disaster management during Hurricane Sandy. On January 24th, the Council held a specific hearing on the emergency preparedness and disaster management activities of healthcare facilities in New York City. HHC presented testimony at this hearing along with our colleagues at the City Health Department and Senior Health Advisor Andrea Cohen from Deputy Mayor Gibbs' office. Next week, the Council will hold a hearing on the management and operations of the emergency storm shelters that were set up around the City. This will include a review of health services at the eight special medical needs shelters. HHC has been invited to this hearing to review our role in providing staffing and clinical supervision at these specialized shelters.
HHC RECEIVES DESIGNATION AS ACCOUNTABLE CARE ORGANIZATION
On January 10, the Centers for Medicare and Medicaid Services (CMS) announced that HHC ACO was designated as an Accountable Care Organization and will participate in the Medicare Shared Savings Program to improve the health of Medicare beneficiaries through coordinated, high quality care, while also reducing costs. Mayor Michael R. Bloomberg praised HHC's designation in a statement, saying, "We are proud that our Health and Hospitals Corporation has been selected as one of 106 new Accountable Care Organizations, which allows HHC to participate in an innovative new payment model that incentivizes quality care while also reducing costs. The selection reflects how HHC is on the leading edge of healthcare innovation, and it is a credit to HHC President Al Aviles and his team. " ALL HHC EMERGENCY DEPARTMENTS ADOPT NEW CITY-WIDE GUIDELINES
FOR TREATMENT USING OPIOID PAINKILLER MEDICATION
Also on January 10, Mayor Bloomberg released the initial report of the Mayor's Task Force on Prescription Painkiller Abuse, which includes new voluntary emergency room guidelines for the prescription of opioid painkillers to prevent abuse. The guidelines, which will be followed in all HHC hospitals, suggest that the emergency departments not prescribe long-acting opioid painkillers; recommend prescribing no more than a three-day supply of opioids; and suggest not refilling lost, stolen or destroyed prescriptions. The guidelines are designed to encourage judicious prescribing, patient education and referral to primary care and treatment for substance abuse when needed. These new guidelines effectively balance our mission to relieve patients' pain against concerns about drug abuse, dependency, a national steep rise in deaths from prescription opioid overdose and the illicit diversion of opioid medications. The Mayor made the announcement at Elmhurst Hospital in Queens, where he was joined by several public officials, including HHC Chief Medical Officer Ross Wilson, Senior Health Advisor Andrea Cohen, and Dr. Stuart Kessler, head of the Elmhurst Hospital Emergency Department.
HHC SIGNS CONTRACT WITH EPIC FOR DEVELOPMENT OF
ELECTRONIC MEDICAL RECORD
On January 16, HHC announced signing a $302 million contract with Epic Systems Corporation for a new, state-of-the-art electronic medical record (EMR) system to span all of HHC's patient care facilities. This Board approved the contract with Epic at the September meeting, after a multi-year comprehensive, competitive process to evaluate qualified vendors. We anticipate the system will be in full operation by 2017 for our 22,000 users and will replace our current EMR system, which is more than 20 years old.
The 15-year contract includes software and database licenses, professional services, testing and technical training, software maintenance, and database support and upgrades. The cost of the new system will be partially offset by funding that HHC has begun under the federal "meaningful use" legislation.
HHC was a pioneer of electronic medical records in the 1980's and became one of the first large hospital systems in the country to implement an EMR. While we have leveraged that system as much as we can and worked to improve it over the years, the current generation of EMR systems are highly advanced and offer robust decision support functionality, far better data mining and interoperability, and greater capacity to advance quality initiatives, care coordination, and efficiency.
The achievement of "meaningful use" of an EMR system by hospitals is required by the end of 2015 in order to avoid Medicare reimbursement penalties. It is also a requirement to meet and sustain Patient Centered Medical Home certification, which brings with it incentive payments based upon more robust primary and preventive healthcare, as well as more effective care coordination.
PAY FOR PERFORMANCE AGREEMENT WITH HHC PROFESSIONAL AFFILIATES
On January 12, HHC announced the new pay-for-performance program that was included in our most recent professional affiliation contracts with NYU School of Medicine, Mt. Sinai School of Medicine and the Physician Affiliate Group of New York (PAGNY). The program will reward doctors with up to $59 million in incentive payments over the next three years for meeting our goals to improve patient care, efficiency, and patient satisfaction and to otherwise align with the new demands of healthcare reform. Under the new contracts, physicians at our facilities will receive bonuses if they lower readmission rates, deliver more coordinated primary and preventive health services, improve communication with patients, decrease emergency room wait times, and help run more efficient operating rooms. The performance incentive payments also are tied to benchmarks that, if achieved, will help maintain or secure future reimbursement income to HHC. The new program represents a policy shift away from the cost of living wage increases or RVU-based (i.e. , volume and intensity of services) compensation incentives that have traditionally been part of our physician contract agreements.
The performance improvement targets included in these HHC physician affiliation contracts are based on meeting or exceeding benchmarks set by national healthcare and quality improvement agencies including the Centers for Medicare and Medicaid Services (CMS), the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), and the National Committee for Quality Assurance (NCQA).
PURCHASE OF CRITICAL ELECTRIC EQUIPMENT FOR COLER-GOLDWATER AFTER STORM DAMAGE
I want to inform the Board of a significant expedited procurement that will be completed shortly. This is an emergency solicitation; it departs from the routine process provided by Operating Procedure 100-05 in that it is not being presented to the Board for approval. This purchase is authorized under an existing Declaration of Emergency reported at the November meeting, in connection with recovery from the impact of Hurricane Sandy. Because of the large expenditure that this project will entail ($15.6 m), I am advising the Board of the award of the contract and its justification.
Because an existing electrical infrastructure and switch gear at Coler Hospital was destroyed by flood water, the hospital has been functioning without this gear by using temporary power from diesel generators, expensive to maintain and insufficient to meet higher energy demands required during cooling season. It is essential that this equipment be purchased and installed before May 31. To meet that deadline, an expedited solicitation was conducted. Liquidated damages will be included in the contract to ensure that deadline is met. An award to EJ Electric is scheduled to be executed on or about February 4th.
CONEY ISLAND WORK TO BE FEATURED IN NATIONAL DIVERSITY CONFERENCE
Coney Island Hospital's cultural competency partnership work with the Jewish Community Relations Council of New York (JCRC) and the Jerusalem Inter Cultural Center that began in 2008 will be highlighted in a workshop being delivered at the Eighth National Conference on Cultural Competency in Health Care in Oakland, California on March 11th. The presentation is one of only four round table sessions presented on the first evening of the conference. The Coney Island Hospital team's presentation is titled "Role of International Partnerships in Advancing Health Care Cultural Competency: Lessons from the Trenches of Jerusalem and New York City. "
HHC GLOBAL AMBASSADOR VISITS KINGS COUNTY HOSPITAL
HHC Global Ambassador Kasseem "Swizz Beatz" Dean paid a visit to Kings County Hospital Center on January 18 to meet with the facility's leadership, physicians, patients, and other staff members and learn about the hospital's service offerings. He also participated in a discussion about the Kings Against Violence Initiative (KAVI), a hospital and school-based youth violence intervention program, and exchanged views with the doctors leading the initiative -- Dr. Robert Gore, Dr. Reinaldo Austin, and Dr. Eric Legome.
During the visit, Mr. Dean toured the hospital's Wellness Center, Diabetes Resource Center, and Cancer Center, accompanied by clinicians in charge of those areas.
He also observed a session of the Recording Studio Project, a component of Kings' Behavioral Health Therapeutic Recreation program. The grant-funded Recording Studio Project is designed to provide psychiatric inpatients with the opportunity to experience the enriching process of creating their own music, to use technology to produce a finished product, and to discover the psycho-social benefits of working with others as a team. In addition, Mr. Dean toured the adolescent behavioral health unit, signing autographs and shaking hands with excited patients and staff.
Mr. Dean was also featured in a video published on HHC's YouTube channel on January 18 in celebration of Dr. Martin Luther King, Jr. Day. Dr. King was saved in 1958 from a knife attack through the efforts of a surgical team at Harlem Hospital, including Dr. John WV Cordice, who was honored at the Harlem Hospital gala opening this fall. You can view this inspiring video at http://youtube.com/hhcnyc.
SEA VIEW HOSPITAL LAUNCHES MUSIC & MEMORY PROGRAM
Earlier this month, Sea View Hospital Rehabilitation Center and Home launched HHC's pilot Music & Memory program, bringing iPods loaded with personalized music selections to patients with Alzheimer's disease or dementia. In line with reported results from other recently launched Memory and Music programs, this practice has reengaged remote and unresponsive patients suffering from cognitive loss. Facilities with established Music & Memory programs report positive outcomes, including increased patient engagement, attention and cooperation, minimized agitation, and improved sleep and restfulness. The Fund for HHC has been providing assistance to help launch this program at Sea View, and is also sponsoring an iPod donation drive in which HHC staff can help support the program by donating iPods.
The 15 residents participating in the program at Sea View were selected from two units in which individuals with dementia are often reluctant to participate in recreational activities. Staff interviewed families about the patients' musical preferences and created playlists specific to each participant. Sea View employees report that residents are enlivened by the music, tapping their fingers and feet to the songs of their youth and that the positive effects are sustained. Activity therapists find that after a Music & Memory listening period, residents are relaxed, calmer, and less likely to be disruptive, and that meal times are more cheerful and peaceful.
These anecdotal beginnings are quite promising, and are similar to reports from many other facilities where Music & Memory programs exist. Sea View will soon gather data -- tracking information such as changes in behaviors and medication doses -- to quantify the program's outcomes. The facility is also hoping to expand Music & Memory to other residents and eventually standardize the practice to use as a simple, friendly, and calming intervention when needed.
In 2012, Coler-Goldwater Specialty Hospital and Nursing Facility launched a pilot of a program called Well-Tuned, a collaborative initiative between Music & Memory and the Institute for Music and Neurologic Function. The hospital's staff reports similar positive and notable differences in attitude and behavior among the eight dementia patients in the pilot. Since piloting with eight patients, the Coler-Goldwater program expanded and now has 71 patients.
The Fund for HHC plans to help spread Music & Memory for the benefit of patients at other HHC facilities.
HHC IN THE NEWS HIGHLIGHTS
One On 1 Profile: HHC President Alan Aviles Nurses The City Back To Health After Hurricane Sandy, NY1, 01/14/13
HHC Program Pays Doctors For Meeting Service Benchmarks, Alan Aviles, HHC, NY1, 01/12/13
Lincoln Hospital Adds Extra Service for Flu Season, Dr. Fernando Jara, Lincoln Hospital, NY1, 01/15/13
Farley: 'Severe' Strain Of Flu Reaches Epidemic Proportions In New York City, Dr. Stuart Kessler, Elmhurst Hospital, WCBS/WINS Radio, 01/10/13
Local Hospitals Filled With Flu Victims, Dr. William Bateman, Gouverneur, WNBC, 01/10/13
Flu Vaccines, Dr. Melissa Schori, Lincoln Hospital, News 12 Bronx, 01/17/13
Bellevue Hospital Receiving Ambulances, NY1, 12/26/12
New Year's baby arrives at Lincoln Hospital, News 12 Bronx, 01/02/13
2 New York hospitals claiming first births of 2013, WABC, 01/01/13
Getting flu vaccine without having to travel, Dr. Shashikala Pillai, Coney Island Hospital, WABC, 01/16/13
Trauma Doctor Pleased By Obama's Gun Violence Proposal, Dr. Sheldon Teperman, Jacobi Hospital, NY1, 01/16/13
Vogue Magazine Photo Shoot, Bellevue Hospital, WNBC, 01/16/13
Schumer Tours Damage At Coney Island Hospital, NY1, 01/08/13
100 Million FEMA Funds for HHC, NY1, 01/17/13
Schumer Announces $103 Million In Sandy Aid For Hospitals, WCBS/WINS Radio, 01/17/13
Schumer Surveys Storm Damage at Coney Island Hospital, News 12 Brooklyn, 01/0/13
Bronx Doctor To Share Lessons Learned From Sandy, Dr. Sheldon Teperman, Jacobi Hospital, NY1, 01/25/13
Flu Season Strikes Again. . .and Again, Dr. Fernando Jara, Lincoln Hospital, The New York Times (VIDEO)
New York City Ties Doctors' Income to Quality of Care, Alan Aviles, HHC, The New York Times, 01/11/13 (Also covered in Modern Healthcare, The Chief, Becker's Hospital Review, Fierce Healthcare IT)
Paying Doctors for Performance, Editorial, HHC, The New York Times, 01/27/13
A Performance Pay Model for Doctors, Letters to the Editor, HHC, The New York Times, 01/18/13
New York City to Restrict Prescription Painkillers in Public Hospitals' Emergency Rooms, HHC, Dr. Wilson, Elmhurst Hospital The New York Times, 01/10/13(Also covered in NY Daily News, NY Post, DNAinfo.com, El Diario, Bloomberg News, Metro, The Epoch Times, Brooklyn News)+
HHC's ACO Gets Nod, Crain's Health Pulse 01/11/13
NYC system pegs Sandy costs at $810 million, HHC, Modern Healthcare, 01/08/13
(Also covered by WNYC, Crain's, Becker's Review, The Hill Blog, The Chief, Sheepsheadbites.com)
Schumer: $103 million in Sandy aid for hospitals, Coney and Bellevue hospitals, The Wall Street Journal, 01/18/13 (Also covered in Healthcare Design Magazine, Crain's Health Pulse)
Bellevue Hospital E.R. Reopens to Patients with Non-Critical Injuries, DNAinfo.com, 12/27/12
(Also covered in Reuters, NY Times, Daily News)
New Lessons for Bellevue in Post-Sandy Return, Dr. Rajneesh Gulati, Bellevue Hospital, WNYC, 01/24/13
Coney Island Health Clinic Damaged By Sandy Still Closed, Dr. John Maese, Coney Island, Bellevue, WNYC, 01/22/13
A double dose of help for future New York doctors, HHC, New York Daily News, 01/07/13
(Also covered in Staten Island Advance, Metro.com, Washingtonexaminer.com, Fpsnewswire.com)
Jacobi's chief trauma doctor to take his expertise and plea for tougher gun laws to fellow physicians Wednesday, New York Daily News, 01/09/13
Many hospitals serving needy Scroogish with charity care, HHC, The New York World, 12/23/12
Expeditious triage improves outcomes, Woodhull Hospital, Nurse.com, 01/14/13
Lincoln Medical Center unveils networking Teen Van, Bronx Times, 12/20/12
(Also covered in the Bronx Free Press)
New York's first baby of the new year, Elmhurst Hospital, New York Daily News. 01/01/13
(Also covered in El Diario, The Queens Courier)
Teen moms-to-be at Jacobi get to write own lullabies with Carnegie Hall musicians through special program, Jacobi Medical Center, NY Daily News, 01/27/13
Que la diabetes no te robe la maternidad, Dr. Ray Mercado, Dr. Gunter Gomez, Lincoln Hospital, El Diario, 01/14/13