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. I am, as always, pleased to be in Bronx, which is where I was born and raised. Needless to say, it is also the home borough of Lincoln, Jacobi, and North Central Bronx hospitals…and the New York Yankees. Champions all.  Although only the Yankees will get the ticker-tape parade tomorrow.

First, let me acknowledge our host Jose Sanchez, Network Senior Vice President and Executive Director of Lincoln Hospital, as well as William Walsh, Network Senior Vice President for the North Bronx, and Executive Director of Jacobi Medical Center.   I thank them and the other senior staff from our Bronx facilities and from our central office that are here tonight for the work that they do on behalf of the patients and communities that we serve. 
Before Mr. Levy calls upon tonight’s speakers, I will provide a brief overview of the challenges HHC is facing as well as our plans for addressing those challenges.  I will also highlight some of HHC’s accomplishments over the past year, particularly those that relate to our Bronx facilities.

FINANCIAL CHALLENGES/HHC ORGANIZATION-WIDE RESPONSE

Let me begin with the financial challenges going forward.  Some in this room may have heard me, Mr. Sanchez, or Mr. Walsh speak about the large financial deficits HHC faces in the years immediately ahead.  Those projected deficits 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.  And even as our Medicaid and other revenue sources are decreasing, the costs of prescription medications, medical equipment and other supplies, as well as the fast- growing cost of pensions and other guaranteed employee benefits, are rising alarmingly. 

In addition, the faltering economy has led to some reductions in City support for HHC and, compellingly, as unemployment in the City has risen, we have seen an increasing number of patients with no health insurance who are seeking care in HHC facilities.  In 2008, we served 450,000 uninsured patients, an eight percent increase from 2007.  And the number of uninsured coming through our doors continues to rise. 

And there is more.  HHC receives two forms of supplemental Medicaid payments:  upper payment limit (UPL) payments which cover shortfalls in Medicaid fee-for-service payments; and disproportionate share hospital (DSH) payments that cover shortfalls in Medicaid fee-for-service and Medicaid managed care payments and the costs of treating uninsured patients.  These supplemental payments to HHC facilities have averaged $1.4 billion annually over the last few years.  Starting next year they are reduced by $500 million annually.

As I said, all of these factors together amount to a financial perfect storm.  Unless we take action to address this situation, in our next fiscal year, which begins in July 2010, our projected expenses across our system will exceed our projected revenue from all sources by about $1 billion.  And this extraordinary budget deficit would get even worse in the following years.

We obviously cannot just sit back and let this evolving crisis unfold.  We have already taken a number of steps to address our projected budget deficit.  Working with all of our facility leadership we have identified various ways to cut costs and to legitimately increase our billing revenue.  We project that these measures, which include an ongoing hiring freeze, will save us about $200 million this year and about $300 million next year. 

As encouraging as these cost-cutting and revenue generating efforts have been, they are not sufficient to fully address the financial challenges we face.   We will, of course, continue to advocate strongly for more financial assistance from government at all levels to support our mission; however, we must be realistic in our expectations on this front, given the large budget deficits that both the City and the State now face.

And, realistically, we cannot look to healthcare reform to solve our financial dilemma.  While we still hope that Congress will pass healthcare reform legislation that will expand coverage for the uninsured, all of the pending health reform bills would -- long-term -- dramatically reduce the supplemental Medicaid and Medicare funding for HHC and other public hospitals across the country.   For HHC, this would mean the 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 recently engaged a consulting firm to help us think through how we might restructure our large system for greater efficiency and to better position HHC facilities to compete in a post-healthcare reform environment.  This restructuring plan, once complete, may mean that some services available at a number of HHC facilities now will need to be consolidated to fewer locations and this may inconvenience some patients.  However, we are going to strive to ensure that whatever changes we need to make are as fair to all our facilities and communities as possible, and that we retain the capacity to meet the full range of healthcare services that our patients across the City need.

We also are committed to ensuring that any changes to our system are designed to better support primary and preventive care; to better coordinate care delivery across inpatient, outpatient, home care, and long-term care services; and to better care for our patients with chronic disease. And whatever else may change, we will remain firmly committed to HHC’s mission: to serve all patients without regard to 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 the Bronx.  In 2007, we 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 continued to expand the type of quality data that we share publicly on our internet web site. 
For example, this year we posted to our web site for the first time the results of federally-mandated patient satisfaction surveys at each of our hospitals.  The results for HHC hospitals are encouraging, with our average patient satisfaction scores exceeding the scores of most New York City hospitals.  In the Bronx, all three of our public hospitals outscored the majority of New York City hospitals in overall patient satisfaction, with Jacobi Medical Center coming in a close second to Montefiore for the highest patient satisfaction scores in the borough.  

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 23,000 deliveries a year.  Of this number, last year 6,400 babies were Bronx-born.   Our data show that delivery is very safe in our facilities and we have extremely low maternal mortality rates, despite the fact that we handle a disproportionate number of the high-risk deliveries in our City.  As further evidence of our high performance in his important area, we are proud of Jacobi’s designation as a Regional Perinatal Center equipped to treat the most critically ill babies.

In another clinical area where HHC has excelled, our hospitals have made great strides in lowering the number of inpatient hospital infections through the consistent use of evidence-based best clinical practices in our ICU’s and in our operating rooms.  Our facilities have cut the rate of central line blood stream infections in half since 2005, and the rate of ventilator-associated pneumonia has been reduced by 90% during that same four- year period.    Here in the Bronx, Lincoln’s MICU has gone 24 months straight without a single central line infection, an achievement that very few other hospitals in the City can match.  In a related area, Jacobi, North Central Bronx, and Lincoln all perform better than the majority of hospitals in the national and in New York on most publicly reported performance measures related to the reduction of surgical infections. 

Last year, I reported that HHC was one of the first hospital systems in the nation to implement surgical safety checklists across all of our operating rooms.  This year I’m especially proud to report that Lincoln earned national and international recognition as a Surgical Safety Checklist Monitor Hospital, one of eight in the country designated by the Institute for Healthcare Improvement and recognized by the World Health Organization.

To note one further clinical accomplishment here in the Bronx, for the second year in a row Lincoln Hospital received an award from the American Heart Association for its exceptional treatment of patients who suffer from stroke. 

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.

For example, our award winning North Central Bronx Violence Reduction Protocol (VRP) continues to help identify and screen psychiatric patients with a potential for violence so that specialized treatment plans can be developed collaboratively with patients and staff.  This has reduced patient and staff injuries, and increased patient satisfaction with treatment.    At the same time, over the past two years, HHC has reduced the use of restraints and seclusion dramatically across our psychiatric units, with particularly strong results at Jacobi Hospital.

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.   Much of this disparity in life expectancy is attributed to poorly treated chronic disorders like diabetes and hypertension among the mentally ill.  We have made it a priority across our system to better integrate the treatment of chronic medical conditions into our behavioral health programs, and our Bronx facilities are focused on this agenda.

For example, at Jacobi and North Central Bronx Hospitals, staff have developed a “double-triage” method that means that psychiatric and medical evaluations can now occur simultaneously.  In addition, an internist is now co-located on the psychiatric floor at each hospital to ensure that inpatients receive appropriate treatment for their underlying medical conditions.

On a related development aimed at improving the integration of behavioral health and medical services, Lincoln Hospital recently was awarded $1.7 million to relocate its substance abuse services currently housed in the Recovery Center on East 140th Street to Segundo Ruiz Belvis Neighborhood Family Health Center.  The relocation will allow closer alignment and easier access to primary and preventive care and specialty services for substance abuse patients who commonly suffer from chronic health conditions.

We continue to make progress in chronic disease management for our general patient population as well.  As we have already done with diabetes, HHC is using advanced clinical information technology to drive better management of other chronic diseases that severely impact the long term health status of whole communities.  On May 1, the HHC Cardiovascular Risk Registry became available at all HHC hospitals. 

The registry is an electronic disease tracking program that greatly improves a doctor’s ability to understand, monitor and 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.

Our clinicians working with our diabetes registry continue to improve the health of more than 50,000 diabetic New Yorkers under care in HHC hospitals.  The number of diabetic patients with healthy blood sugar, normal blood pressure, and healthy cholesterol levels increased significantly from last year to this year. 

We also are using other state-of-the-art technology to assist patients in bringing their chronic disease under control.   HHC has piloted a telemonitoring program, House Calls, supported by our MetroPlus health plan, and staffed by nurse practitioners and other staff from our Health and Home Care Division.  The program uses common blood sugar meters that are connected to a telephone line to remotely monitor the health status of diabetic patients when they are in their homes.  Seventy percent of the patients in this program have seen significant improvements in their blood sugar levels, and telemonitoring of blood pressure now has been introduced.  More than 400 patients are now enrolled in this cutting-edge program.

COMMITMENT TO LOCAL COMMUNITIES

HHC has always prided itself on its deep connection to our communities and our success in providing healthcare access to community members that would otherwise be underserved.  

I was especially pleased this year that HHC received the Builders of New York Award from the New York Immigrant 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 specifically 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.

A further tribute to our focused work with new immigrant communities went this year to Maria Ramos, director of Lincoln’s Community Health Education and Outreach Program.  Her work earned a $125,000 grant from the Robert Wood Johnson Foundation for herinnovative efforts to provide healthcare services for 4,000 taxi drivers here in the Bronx, primarily first generation immigrants. 

And one final example of award-winning innovation among our Bronx facilities involves Jacobi Medical Center and North Bronx Central Hospital.  Both were the proud winners of the 2009 national NOVA Award for Project BRIEF, the innovative HIV rapid testing and treatment program. The program involves HIV testing in non-traditional hospital locations, most often the Emergency Department.  It uses interactive computerized tablets to increase access to screening, risk reduction education, and testing, and, in collaboration with community organizations, helps link those who are HIV-positive to proper care.  To date, more than 29,000 people have been tested through Project Brief, and 134 patients newly diagnosed as HIV positive have been linked to care.

JOINT COMMISSION SURVEYS

A brief word on Joint Commission surveys.  Every year, the Joint Commission conducts accreditation surveys of HHC hospitals. They conducted four in 2009, including Lincoln Hospital, and all did well.  It should come as no surprise that Lincoln received high praise from the survey team.  At the end of the visit, the survey Team Leader shared with Lincoln staff how impressed she was with the hospital and especially with the obvious commitment all employees had to the hospital’s mission and their active focus on quality, patient safety, and continuous performance improvement.

CAPITAL INVESTMENTS

Turning to capital investments, with the strong support of the Mayor and the City Council, HHC has undertaken the largest hospital modernization program in the city’s history.   Despite economic challenges now facing New York City’s public hospitals, smart building investments over the last 8 years are helping to improve the quality of care and safety of patients, while providing modern, comfortable high-tech therapeutic environments that support better clinical outcomes.  A total of $116 million in capital projects have been recently completed or are under way in our Bronx facilities and most of those in progress will be completed in the coming year.

In September, a new state-of-the-art labor and delivery suite opened here at Lincoln.  It completes the final phase of a multi-million dollar capital investment in maternity care that included modernization of adjacent post-partum, neo-natal, and nursery units.  It’s a family-oriented 12,000 square-foot space that uses advanced medical technology to better meet patient needs.
Lincoln’s new ambulatory care annex was completed earlier this year and the renovation and much-needed expansion of its busy Emergency Department is under way. 

Jacobi also saw significant capital investments.  In addition to the new four-story, 120,000 square-foot Ambulatory Care Pavilion, Jacobi’s Women’s Options Center was completed this year with funding from the City.  The hospital also upgraded information technology equipment, renovated and upgraded its detox unit, and expanded its medical and surgical unit. 

Currently, we are developing an Advanced Learning and Simulation Institute at Jacobi Medical Center which is scheduled to be operational in fall 2010.  The Institute will use computer-aided simulation and other advanced methods to further train clinicians and patient care teams to deal with complex clinical situations, and aims to significantly improve the clinical performance, teamwork and processes of care throughout the HHC system.

H1N1 

Before I bring my remarks to a close, I’d like to talk briefly about one thing that’s 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.  We took immediate steps to ensure patients received the care that they needed, despite drastically increased patient volume in our emergency departments and many of our primary care settings.   

While the supply of both seasonal and H1N1 flu vaccines continue to fall short of demand, we are working to provide vaccinations as efficiently as possible through our primary care clinics, as well as through our 11 designated Flu Shot Centers across the five boroughs.  The designated Flu Shot Center in the Bronx is the Health Center at Gunhill, located at 1012 East Gunhill Road.
We have been fortunate that our communities across the city are not yet experiencing the high levels of flu activity that many parts of the United States have seen in recent weeks.  But the number of patients presenting with flu symptoms are beginning to go up, and we continue to monitor the situation closely.

We are proud of the way our dedicated staff handled the flu-related challenges they faced last spring, especially here at Lincoln where the volume of patients coming to the pediatric emergency department was particularly high.  We have every reason to believe that our staff will meet the challenges of this flu season equally well.

CLOSING REMARKS

Even more than in years past, the achievements that I have mentioned this evening 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 our other elected officials; (PAUSE) and, of course, the compassion, creativity, and commitment of the men and women who staff our health centers and hospitals in the Bronx and the other HHC facilities throughout our city. 

As noteworthy as these 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 meet those challenges.  And we will be open and honest with our communities about whatever changes are necessary going forward.  With your support, in meeting the challenges we face on the road ahead we will become stronger, more efficient, and more effective in meeting the needs of our patients and communities. 

Thank you for your attention and your support of our public hospital system.  I look forward to hearing your comments.

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