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 Queens annual public meeting, the second 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 Queens. Our hosts are Queens Hospital Center Executive Director Julius Wool and Senior Vice President of the Queens Health Network, Dr. Ann Sullivan. Also in attendance is Elmhurst Executive Director Chris Constantino. I thank them for the excellent work they do every day as leaders helping us to render the best possible care to Queens 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 Queens and Elmhurst Hospital 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 hospital facilities in Queens sustained no serious damage, 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 Queens 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 Queens, and to other non-HHC hospitals. Transfer information was made available to families as quickly as possible.

Extensive clean up, repair and restoration work is under way at these two hospitals. Coney Island Hospital re-opened a portion of its primary care services just two days after the storm and is now preparing to open more of its specialty outpatient services. On Friday, Coney also began offering urgent care services around the clock, but does not yet have full emergency services. Bellevue Hospital Center also has resumed providing primary care services and is steadily opening its specialty ambulatory care services over the next two weeks. We expect Coney Island Hospital to resume full emergency department and most inpatient services by January and Bellevue to do the same by 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.

As Hurricane Sandy approached the New York City area on Saturday, October 27, and as they had done before Hurricane Irene last year, staff from Elmhurst and Queens Hospitals led the effort to set up and operate a Special Medical Needs Shelter (SMNS) at York College and another at Queens College. These shelters, which were staffed in 12 hour shifts by administrators, physicians, nurses and other employees from our two hospitals in Queens, housed and met the medical needs of vulnerable residents displaced by the storm, including nursing home and adult home evacuees. Our Queens HHC staff at these shelters worked collaboratively with federal Disaster Medical Assistance Teams, as well as personnel from the City Department of Health and Mental Hygiene, Department of Homeless Services and Office of Emergency Management.

There were so many HHC superstars during the storm. Let me highlight one staff member, Ramon Cabreja of the Queens Hospital Department of Environmental Services, who worked long hours providing housekeeping services at the Special Medical Needs Shelter at York College. Mr. Cabrera was singled out for praise by the shelter administrator and the personnel of other agencies on site for eagerly doing whatever was necessary to keep the Shelter residents comfortable, safe and fed. Several mentioned the empathy he showed towards many of the evacuees -- people who were often disoriented, anxious, and medically fragile -- taking time out to speak with them, comfort and encourage them. Ramon exemplified the positive and generous spirit that characterized the compassionate work of so many HHC staff across the Special Medical Needs Shelters, and I don’t doubt that it reflects the contribution that he makes every day back at Queens Hospital.

Mayor Bloomberg and the City Council have set aside $500 million to help schools and public hospitals to repair the extensive storm-related 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 repair 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 those 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

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

At the city level, as a result of a projected $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 very 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 our cost-containment initiatives is a new contract for dialysis services that will enable us to increase our dialysis services 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 for all patients without regard to insurance or immigration status, 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, without negatively affecting access to care and without 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 affiliate staff have been involved in Breakthrough activities, leading to roughly $284 million in new revenue and cost savings.

Elmhurst Hospital used Breakthrough to improve patient flow in its Primary Care Medicine Clinic, increasing doctors’ productivity so they can see more patients each day. As a result, in fiscal year 2012, Elmhurst’s primary care clinic saw almost 4,500 more patients then in fiscal year 2011. This effort was so successful that it was spread to the Pediatric Clinic and the Women's Health clinic.

Using Breakthrough the Queens Hospital Center Psychiatry Department recently implemented a new program to involve patients in the process of developing their own treatment plan. Under this new program, patients participate in a meeting with the hospital team responsible for their care to discuss treatment goals and specific activities scheduled during the course of their inpatient stays. Prior to implementation, not all patients were involved in development of their treatment plans. Now 90% participate and the feedback from both staff and patients has been extremely positive.

These are many other examples from all HHC facilities that show how our employees are helping to improve the patient experience using the Breakthrough team-based improvement process.

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 Queens, HHC provides 86% of all hospital-based clinic visits and 29% 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). Such medical homes match each patient with a dedicated team 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 Queens, Manhattan, 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. Although the health home program has already begun in Brooklyn and the Bronx, we are still awaiting the State’s initiation of the program for Queens and Manhattan. 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 Queens

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

At Elmhurst Hospital, there were no ventilator associated pneumonias in fiscal year 2012 and at Queens Hospital Center the rate of ventilator associated pneumonia decreased more than four-fold from fiscal year 2011 to 2012. Both facilities also experienced significant decreases in catheter-associated urinary tract infections between 2011 and 2012.

Based upon the most recent patient satisfaction standardized measures that are publicly reported, Queens Hospital Center was the second highest rated facility in the borough and Elmhurst was third.

Elmhurst celebrated its 180th anniversary this year. Proceeds from the gala went to a new Women’s Healthcare Pavilion set to open in spring 2013.

With the help of funding from the City Council, Elmhurst opened a 13-bed observation unit for patients with chest pain in the Emergency Department. This unit is expected to reduce preventable readmissions and decrease ED waiting time, particularly for seniors.

During the past year the LeapFrog organization – established 10 years ago by large employers and insurance companies -- released its first national hospital patient safety ratings. This year Queens Hospital received a score of ‘A’ , the highest possible rating. This score indicates that Queens is in the top 20% of hospitals across the country with respect to a series of 26 patient safety indicators, including avoiding hospital acquired infections and surgical complications, administering medications in a safe manner and creating a hospital wide culture of safety.

New capital improvements to Queens Hospital, which are either complete or near completion, include a new Psychiatric Emergency Department, new and expanded Post Anesthesia Care Unit, an expanded Intensive Care Unit, an expanded Neonatal Intensive Care Unit and a new Geriatric Clinic.

Conclusion

I appreciate and am proud, especially after Hurricane Sandy, of the work that our dedicated HHC staff performs every day here in Queens 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.