Public Reports and Testimonies

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, our City’s public hospital system. Thank you for being with us tonight for our Bronx annual public meeting, the first of five borough-specific meetings we convene each year. As always, I am eager to hear what HHC’s communities have to say about our performance, especially during what continues to be a challenging time in healthcare generally and for HHC specifically.

First, let me recognize HHC’s senior executives here in the Bronx. Our host is Bill Walsh, Senior Vice President of the North Bronx Healthcare Network and Executive Director of Jacobi Medical Center. Also in attendance is Iris Jimenez-Hernandez, Senior Vice President of Generations Plus Network and Executive Director of Lincoln Hospital. I thank them for the excellent work they do every day as leaders helping us to render the best possible care to Bronx residents.

I also want to acknowledge the support and guidance of our Board of Directors, under the leadership of Dr. Michael Stocker. My special thanks to Board members who are here tonight and to the members of our Lincoln, Jacobi, North Central Bronx, Belvis, and Morrisania Community Advisory Boards, who advocate on behalf of our public system and help keep us grounded and responsive to the needs of our patients and communities.

Hurricane Sandy

I want to speak briefly about Hurricane Sandy and its dramatic and wide-ranging effects on HHC. First, let me say that in the face of this unprecedented event, it was the diligent planning, hard work, bravery and selfless dedication of thousands of HHC staff that protected our patients from harm, and helped relieve their discomfort and anxiety during the storm and in its immediate aftermath. Many staff, often despite their own concerns for family and home, worked tirelessly over multiple shifts in their determined focus on ensuring the wellbeing of our patients.

Before the storm, HHC Central Office Emergency Management and local facility leadership activated Emergency Response Plans, emergency generators were tested and fully fueled; and extra supplies and food were secured. Disaster staffing patterns were set in motion, and preparations were made for staff to sleep over at their facilities. Eight Special Medical Needs Shelters were opened, and staffed round the clock with the help of HHC personnel who worked extended shifts caring for some of the City’s most fragile residents, including evacuees from nursing homes and adult homes.

While our facilities in the Bronx were not damaged, our employees certainly suffered storm-related effects as many found it difficult to get to work because of transportation disruptions and fuel shortages, and some experienced personal hardships that were storm-related. Despite these challenges, our Bronx facilities remained adequately staffed throughout the storm and in the difficult days that followed.

As you know, two of our other healthcare facilities, Bellevue Hospital in Manhattan and Coney Island Hospital in Brooklyn were severely damaged by the extraordinary storm surge and both had to be evacuated. I was in the emergency command center at Coney Island Hospital on the night of the Storm and witnessed the exemplary performance of the hospital leadership and staff who reassured and protected patients as the rising waters flooded the basement and eventually washed through the first floor of the hospital.

Hospital evacuations present a significant risk to patients, even when performed under the most optimal conditions and this is why a decision to evacuate before a forecasted storm is not made lightly.

It is a testament to the skill and commitment of our staff at both Bellevue and Coney Island, that nearly 1,000 patients, including many critically ill patients, were evacuated safely. All of these patients were transferred without incident into the hands of caregivers at sister HHC facilities, including those here in the Bronx, and to other non-HHC hospitals, and transfer information was made available to families as quickly as possible.

Extensive clean up, repair and restoration work is underway at these two hospitals. Coney Island Hospital has resumed providing primary care services and is making them available for extended hours, seven days a week. We expect to have Coney Island’s emergency department begin providing limited services by the end of this month.

Today Bellevue re-opened its doors to begin offering primary care services for adults and children during extended weekday hours, and it will offer walk-in primary care services 24 hours a day, seven days a week until its emergency department can re-open in mid-December. Since the storm, many of HHC’s other hospitals also have been offering primary care walk-in services with extended hours of operation.

We hope to have Coney Island Hospital and its ED operating at nearly full capacity by early January, and Bellevue Hospital and its Level 1 trauma service ED fully functional by early February.

The Coler campus of the Coler-Goldwater Specialty Hospital and Nursing Facility, one of our long-term care facilities which serves some of the City’s physically fragile and chronically disabled, lost power and heat after the storm. As a result, 104 medically fragile patients were safely transferred to Goldwater. More than 500 patients remained at Coler. The facility now has power and heat. However, there is significant work to be done to permanently repair damaged electrical and heating systems.

Finally, some of our central office locations sustained damage from the storm. Most notably, more than 1,200 staff members working in key areas such as the Finance Department, Health and Home care, the IT Department, and MetroPlus have been displaced from 160 Water Street. Despite being deployed among several sites across the City, these resilient and dedicated employees have kept our core functions operational. We are hoping that the 160 Water Street building management will have the space ready for re-occupancy by the end of February.

There were so many HHC heroes during the storm. Let me tell you about one group – the 19 non-emergency transportation team members from Lincoln and Harlem. They were fearless in the face of strong winds and rain, and drove through dangerous conditions to pick up and drop off doctors, nurses, and other clinical staff so they could get to and from work. They also transported patients in need of treatment such as dialysis back and forth to their appointments. When asked if he felt like a hero, one of the drivers who had picked up dialysis patients during the worst of the storm said, “It’s not heroism when you respond to someone in need. It’s our responsibility.”

Mayor Bloomberg and the City Council have set aside $500 million to help schools and public hospitals to repair extensive damage to buildings. HHC will receive $300 million for structural restorations, new boilers, new mechanical and electrical systems, roof repairs, flood remediation and more. In addition, we have begun the process of applying to FEMA for funds to rebuild facilities and replace equipment. These funds do not cover lost revenue from Bellevue and Coney Island, which amounts to $15 million a week in total, so it will not completely make up for what we are losing between now and when the two facilities are fully open and operational.

HHC has faced adversity before, and we have come out of it stronger. We expect the same to be true in this instance, though the physical and financial damage to these facilities are significant, and will strain our budget and our ability to continue to implement strategic planning initiatives in the coming year. I have full confidence in our ability to rebuild primarily because of our incredible staff both at our facilities and in our central offices, who work tirelessly to ensure that we sustain our mission in serving all the patients who need us.

The Challenges

I will now focus on the very significant financial challenges HHC faced before the storm that will continue to intensify.

At the city level, as a result of a forecasted $2.5 billion budget gap for the fiscal year beginning on July 1, 2013, City agencies have been required to submit spending reduction proposals. For us, this means a 5.4% reduction to our baseline City funding in fiscal 2013, or a $4 million cut. This will increase to an 8% reduction, or a $5.1 million cut in 2014 and beyond.

We also face diminishing state and federal funding. Under the Budget Control Act of 2011, an across the board cut totaling $1.2 trillion over ten years will begin in January 2013—you may have heard this called the “fiscal cliff”. This massive cut will take place unless Congress adopts an alternative approach by the end of December 2012. An across the board 2% cut in Medicare – as currently planned -- would result in HHC losing nearly $10 million in 2013 and more than $83 million from 2013 to 2021 in Medicare reimbursement.

Beyond these looming reimbursement cuts, we are increasingly in an environment where we will be expected to deliver better care, with better patient outcomes at lower costs. More and more of our reimbursement will be tied to our ability to accomplish these three things.

Healthcare providers throughout the country are also dealing with these same expectations, however the challenges for HHC are greater because we provide care for so many uninsured patients, yet continue to receive less and less funding for that work.

Even as we make steady progress in closing the budget gap through our cost containment and restructuring initiatives that I described last year, we have seen more financial challenges arise.

The Affordable Care Act, sometimes referred to as Obamacare, was upheld by the Supreme Court in June. As you know, it includes the individual mandate, requiring all Americans to buy health insurance. An estimated 1.2 million New Yorkers may gain coverage as result of Obamacare when it is fully implemented. However, health reform does not provide coverage for undocumented immigrants, who make up a significant portion of our patient population.

Additionally, the ACA includes deep Medicaid and Medicare Disproportionate Share Hospital (DSH) cuts to partially pay for the major coverage expansions. DSH payments come from the federal government to ensure that hospitals that serve large numbers of low income Medicaid and Medicare and uninsured patients receive some compensation for these services. Under the ACA, HHC stands to lose more than $2 billion in DSH funds over an eight-year period.

It is important for our communities to understand the magnitude of these financial threats to our mission and why we have resorted to measures such as workforce reductions through attrition and targeted layoffs, as well as the consolidation or outsourcing of certain services to lower our expenses.

We are in the third year of a four-year cost containment and restructuring plan projected to yield $600 million in new revenue and cost savings. We remain on target with this plan, and our efforts to date have closed our gap by roughly $400 million. Our workforce has more than 2,700 fewer full-time employees than three years ago. Most of this workforce reduction has not involved direct patient care positions and, to the credit of our dedicated employees, we have maintained virtually the same service capacity across all care settings.

One of the cost-containment initiatives is a new contract for dialysis services that will enable us to increase our capacity by 35% over the next three years while saving an estimated $100 million over a nine-year contract period. We will continue to guarantee access to dialysis services, and no HHC staff member will lose employment as a result of this contract.

HHC’s senior leadership team is fully committed to keeping our financial plan on track while continuing to provide high quality, safe care to our patients. Let me stress that we are looking at every conceivable way to close our budget gap without adversely affecting our capacity to serve our communities, negatively affecting access to care or diminishing the stellar gains in safety and quality that we have made. That said, given the looming reductions in federal funding starting next year, it will be considerably harder to achieve these aims.

Another way we are meeting the challenge of achieving greater efficiency is through our continuing redesign of our operations using Breakthrough, our employee-driven process improvement approach. With Breakthrough, we use the experience, skill, and creativity of staff at all levels to help improve services, take out waste, and reduce cost. Since its launch in 2007, more than 7,500 employees and affiliates have been involved in Breakthrough activities leading to roughly $284 million in new revenue and cost savings.

For example, Jacobi staff used Breakthrough to improve the process for preparing patients for surgery. By evaluating all of the steps patients had to go through prior to an operation, a team of staff found and eliminated unnecessary steps and created a streamlined, patient friendly process leading to a reduction in flow time from 4 hours to 1-2 hours. In fact, the work that Jacobi is doing in the operating room is intended to be a model for other HHC sites. We look forward to learning from Jacobi and replicating their good work in this service.

Using Breakthrough methods, Lincoln Hospital staff reduced the number of no-show appointments in its Adult Medicine clinic by 27 percent by ensuring referrals were appropriate for clinic services. They also reduced length of stay for the Emergency Department’s treated and released patients by 40 minutes; and reduced patient waiting time for seeing a doctor after triage by 25 minutes.

North Central Bronx Hospital used Breakthrough to reduce the time to prepare an operating room between patients from 45 minutes to 15-20 minutes by changing and efficiently coordinating the use of all operating rooms.

In addition, patients arriving via ambulance for psychiatric care in the North Central Bronx Emergency Department now have all of their needs assessed by a single triage team. By modifying the order and timing of certain processes, these patients now go through triage 44% faster.

Our diagnostic and treatment centers in the Bronx, Belvis and Morrisania, began Breakthrough activities this year. By standardizing processes for information collection, installing improved signage, and verifying insurance information before appointments they reduced the average registration time by 30% from 27 minutes to 19 minutes.

These are only a few of the many examples from all HHC facilities that show how our employees are helping to improve the patient experience.

The Opportunities

As we work to make our system more efficient, and manage our ongoing financial challenges, we continue to be responsive to the needs of our communities. HHC facilities provide nearly 220,000 hospital inpatient stays, more than 1 million ED visits, and more than 5 million outpatient visits annually. In the Bronx, HHC provides 70% of all hospital-based clinic visits and 41% of all inpatient stays made by uninsured residents. And we continue to provide our patients with a full range of primary and preventive care services, emphasizing early detection of disease and effective management of chronic diseases such as asthma, diabetes, and hypertension.

HHC has moved forward in a number of areas that will help us transform care in a positive way for our patients. This past year, we have met new federal standards for implementing effective health information technology, including electronic medical records. As a result, we are slated to receive $82 million in federal funding to support our further development of our health information technology. Payments began in June 2012 and we have already received more than $17 million of these funds.

Improved healthcare information technology is more than just the electronic patient medical record. We also have been upgrading our appointment system to make it easier for patients to schedule appointments. In addition, this past year we greatly improved our corporate wide e-commerce system to streamline our purchasing and reduce our costs.

Last year I spoke about our successful efforts to convert HHC’s primary care clinics into Patient Centered Medical Homes (PCMH). Medical homes match each patient with dedicated teams of providers who offer coordinated, comprehensive care. Medical Homes improve continuity of care for patients and earn additional reimbursement. New York State is building on the medical home program by offering financial incentives to help organizations transform primary care teaching programs at hospital and community sites into medical homes. HHC has applied for $28 million to support the continued strengthening of patient-centered medical homes at our teaching facilities.

In addition to our work in developing patient-centered medical homes, HHC and our health plan, MetroPlus, received New York State designation as a Health Home for Manhattan, Queens, Brooklyn and the Bronx. Health Homes are paid to be responsible for assuring that people with mental illness and multiple chronic conditions – that is, high users of healthcare services - have better access to primary care as well as improved coordination and care management so they can have better outcomes. Our Health Home program launched in the Bronx in June. Assuming responsibility as a Health Home is a part of our effort to strengthen services for vulnerable populations, improve outcomes, decrease unnecessary Emergency Department visits, and decrease unnecessary hospital admissions.

HHC has also applied to participate in the Medicare Shared Savings Program as an Accountable Care Organization (ACO). This initiative creates a new model to offer Medicare beneficiaries higher quality care while reducing costs through increased efficiency and integration of services. To receive incentive payments, The HHC ACO will have to measurably improve the health status of patients through evidence-based clinical practices, and lower spending for the Medicare program by reducing unnecessary hospitalizations, re-admissions, and Emergency Department visits for designated Medicare patients. If approved, The HHC ACO will begin operations in January.

Robust primary care is the foundation of health reform, and as a step toward meeting the need for more primary care doctors in the future, HHC and St. George’s Medical College have collaborated on the City Doctor’s Scholarship program. Over the next five years, we will offer $11 million in tuition-based scholarships to New York City residents who attend St. George’s Medical College and commit to practice primary care medicine at an HHC hospital. Eleven scholarships were awarded this past year, and more scholarships will be awarded this coming January.

Our Work in the Bronx

Here in the Bronx, our public hospitals continue to exceed national benchmarks on many important publicly reported measures of quality and patient safety.

At Jacobi, ventilator associated pneumonias in the surgical and medical intensive care units have declined steeply since 2009, and the cardiac care unit had none throughout the entire fiscal year 2012 period. Similarly, there were no central line bloodstream infections in the surgical, cardiac care, or pediatric intensive care units during the 2012 fiscal year.

For two consecutive years, Jacobi Medical Center received the Northeast Business Group on Health’s Leapfrog Recognition for Quality and Safety as one of the region’s safest hospitals. Jacobi was also recognized by US News and World Report, for the second year in a row, as one of the region’s top 50 hospitals.

Both North Central Bronx Hospital and Jacobi Hospital received a Health Association of New York State Pinnacle Award for safety improvements in obstetric for its Reducing Adverse Outcomes on Labor and Delivery initiative.

In July, Lincoln Hospital received the American Hospital Association /McKesson Quest for Quality Finalist Award, a national recognition for outstanding quality of care achievements.

In addition, Lincoln Hospital received accreditation by the National Accreditation Program for Breast Centers (NAPBC), a program administered by the American College of Surgeons. Lincoln's Breast Center is the only such accredited Breast Center in New York City and one of only five in New York State.

Lincoln Hospital also is one of two hospitals in New York City to receive The Joint Commission’s Advanced Certification for Palliative Care. This designation recognizes Lincoln for its adherence to the highest level of care for patients with serious illness.

Our facilities in the Bronx also continue to invest in capital improvement to address the needs of the communities we serve.

Jacobi replaced a Medical Surgical Unit from one of its older buildings by fitting out space in its new building. The facility also is making the hospital campus safer and more pedestrian friendly by improving access to public transportation as well as handicapped access.

North Central Bronx Hospital has started construction to more than double the space in its Psychiatric Emergency Room, and the new space will be redesigned for improved care.

Lincoln continues the construction of its expanded emergency department which is scheduled for completion in December 2013.

Morrisania recently received $340,000 in City Council Funding for equipment and technology to renovate its dental suite serving families. We anticipate completion in spring 2013.

Conclusion

I appreciate and am proud, especially after Hurricane Sandy, of the work that our dedicated HHC staff performs every day here in the Bronx and across our city to provide accessible, high-quality healthcare to our patients. I can assure you that the leaders across our organization, as well as our Board of Directors, are advocating at every level of government to secure resources so that HHC can continue to effectively meet the needs of our vulnerable patients and communities.

We appreciate the strong advocacy support that we receive from our partners in labor, our community advisory boards and auxiliaries, and many community-based organizations that care about our mission. Our strong connection to, and support from, the communities we serve is one of our most important assets.

Thank you for your attention and your attendance. I will now turn the program over to Mr. Russo. I look forward to hearing your comments.