REPORT TO THE BOARD OF DIRECTORS – October 2018

Federal

On October 10th, the U.S. Department of Homeland Security published a proposed change to its “public charge” rules, which would limit an immigrant’s ability to successfully apply for immigration relief if they have used certain government benefits in the past (including Medicaid), if they have a costly medical diagnosis, if they are low-income, and for other reasons which an immigration official would consider with great discretion. If the rule is finalized as proposed, tens of thousands of NYC Health + Hospitals patients could be impacted, and many thousands more could be deterred from seeking care or enrolling in coverage out of fear of negative impacts.

We have been communicating affirmatively with staff about these proposed changes, encouraging them to counsel patients to continue getting the care and coverage they are eligible for and need, as this rule is not final and will not penalize people for benefits used now before the rule is final. We are coordinating with the Mayor’s Office of Immigrant Affairs, Greater NY Hospital Association, America’s Essential Hospitals and others in an effort to push back on this dangerous proposal. To create greater engagement in the broader health care community, Dave Chokshi and I wrote an article that was published in JAMA; the article details the harms of the proposal and flags how difficult this proposed rule change would make it for doctors to provide care to undocumented patients. The public comment period for the proposed rule closes on December 10, 2018 and the earliest the final rule could become effective is around March 2019. We anticipate a number of entities will take legal action to prevent any final rule from taking effect if it looks similar to this proposal.

State Update

On October 10th, the State Department of Health convened its third meeting of the temporary workgroup on indigent care funding of which I am a member. Concerns were raised about the risk of adverse federal policies, such as federal Disproportionate Share Hospital (DSH) cuts and Public Charge, which would have an impact on the State and NYC Health + Hospitals specifically. There was consensus that the Workgroup’s report should acknowledge that if federal DSH cuts occur, then the current State law would need to change to protect NYC Health + Hospitals. We would like to thank the Community Advisory Board members who attended the meeting to advocate on behalf of protecting NYC Health + Hospitals. The final meeting of the Workgroup is next month, and we are expecting to review the report’s policy recommendations, which will be presented to the Governor and the State Legislature in December.

City

On October 3, Matthew Siegler, NYC Health + Hospitals Senior Vice President for Managed Care, Patient Growth, and Interim Director for Government & Community Relations, testified before the members of the New York City Council’s Committee on Hospital Systems at an oversight hearing on changes in the delivery of health care services, and moving towards a community-based outpatient model. Chairwoman Carlina Rivera and members of the committee convened the hearing to learn more about hospital closures and consolidations, and the corollary impact on the health care delivery system in New York City, and specifically the impact on NYC Health + Hospitals. Additional themes that were addressed in the hearing were hospitals’ work in reducing avoidable hospitalizations and health care moving away from reimbursement based on volume and type of services to value-based reimbursements.

NYC Health + Hospitals’ testimony acknowledged the timeliness of the hearing, as we are currently capitalizing on the shift from inpatient care to outpatient care, which was a key strategy outlined in the “One New York: Health Care for our Neighborhood” report to transform the public health system into a high-performing, competitive, and sustainable community-based system. We also highlighted our current strategy to transform the health system’s vast ambulatory care operation, outlined below.

You have often heard me say that fixing primary care is key to our financial turnaround and vital to our promise to be responsive to the health needs of the communities we serve. I’m very pleased to report that this month we announced a series of strategic initiatives designed to transform the health system’s vast ambulatory care operation, improve access to in-demand primary and specialty care, and reverse the recent trend of declining outpatient visits.

This new five-point strategy will be adopted across our health system’s community-based health centers, including 11 hospital-based outpatient operations, which together provide more than five million outpatient visits to children and adults every year. The specific plans reflecting the five points will be implemented system-wide over the next six months.

The five major areas of strategic improvements are:

• Fix Continuity of Care and Build Fidelity with Assigned Primary Care Clinician
• Reduce No-Show Rates and Use Technology to Help Patients Come to their Appointments
• Expand eConsult to Reduce Long Wait Times for Specialty Care
• Improve Clinic Management by Empowering Doctors and Nurses to Practice at the Tops of Their Licenses
• Increase Revenue by Improving Billing and Coding

Through our plan, I’m confident we will improve patient care, patient experience, and our public health system’s financial standing.

We are seeking to recover $40.1 million from United Healthcare for wrongfully denied payments for the care we provided to more than 4,000 of their beneficiaries between July 1, 2014, and December 31, 2017. These cases include:

• A one-year-old girl who was admitted to the hospital with an elevated heart rate and a fever associated with an abscess, for which she required surgery consultation for incision and drainage, as well as IV antibiotics.
• A 25 year-old woman with a history of multiple miscarriages was admitted at 22 weeks gestational age for medical treatment and observation because she was at high risk for losing her baby, evidenced by cervical shortening noted on ultrasound.
• A 32 year-old man was transferred from a psychiatric unit, where he was receiving care for acute psychosis and paranoid schizophrenia, to a medical unit for treatment for the flu and his 103.3-degree fever—both to enhance medical care and to prevent spreading the flu to other vulnerable patients in an open psychiatric unit.
• A 62 year-old woman was admitted after presenting in the emergency department with vision changes, chest pain, right arm sensory deficit, and right leg weakness—multiple risk factors for heart attack and stroke—just three days following discharge from another hospital for acute stroke.

I not only stand by our doctors’ decisions to admit these patients, I would be shocked if they’d have come to any other decision. Our clinicians have no incentive to admit patients needlessly, while United Healthcare has an obvious conflict of interest: They want the premiums from their beneficiaries and don’t want to pay for their care. Rather than provide appropriate reimbursement for services rendered, they prefer to give more money to their shareholders and reap big bonuses for themselves. The priorities are skewed. It’s our responsibility to stand up and challenge wrongful denials, as all health systems should.

First Lady Chirlane McCray and NYC Health + Hospitals announced a new initiative aimed at increasing access to birth control in the City’s public hospitals, doubling down on the City’s commitment to be a national leader in reproductive rights. This fall, NYC Health + Hospitals will increase its stock of long-acting reversible contraceptives at all 11 of the city’s hospitals and six Gotham Health ambulatory care centers, making these contraceptive devices available to women who request them during their primary care visit. Under its initiative, NYC Health + Hospitals will purchase 13,000 contraceptive devices over the next three years – more than doubling the system’s current supply. Health + Hospitals currently serves approximately 113,000 female patients of reproductive age (13 –49 years) across the public health system’s ambulatory care centers and neighborhood clinics in the five boroughs. The increase in contraceptives will help protect nearly 5,000 more women against unwanted pregnancy. The initiative will also include:

• “Pregnancy intention” screenings for women of reproductive age: This screening will become a routine part of primary care, with the aim of connecting women as early as possible to the appropriate pre-pregnancy care, prenatal care, or birth control of their choice.
• “Health readiness” assessments for women planning a pregnancy: The screenings will help identify and manage chronic medical conditions – such as obesity, diabetes and hypertension – that increase the risk of maternal complications and deaths.
• Faster access to contraceptive devices for adolescents: Women ages 13 to 18 will be able to get same-day access to intrauterine devices in ambulatory clinics that offer women’s health services. The current process requires adolescents first visit a pediatrician, then be referred to a gynecological specialist to get an IUD.
• Additional Staff: A new women’s health Nurse Practitioner and support staff will be added to the family planning clinics at each of the 11 hospitals and six large community-based health centers.

NYC Health + Hospitals/Bellevue completed a major expansion of its Adult Primary Care Clinic with newly repurposed space that supports the co-location of all Adult Primary Care services, improves access and continuity of care and reduces wait times for an appointment. The recently expanded clinic, located on the second floor of the Ambulatory Care Building, has added 12 patient exam rooms and increased available space by 2,200 square feet. The expanded space now accommodates 26 new staff members and supports an expanded collaborative care team that includes registered nurses, primary care providers, nurse practitioners, chronic disease care managers, patient navigators, patient care associates and administrative support staff. This expansion, along with other recent improvement efforts, have helped reduce wait times for a primary care appointments, with the average time a new patient has to wait for an appointment reduced to 14 days from 40 days.

NYC Health + Hospitals/Coney Island received key approval from the state to build an 11-story, 350,000-square-foot tower as part of a major hospital campus renovation that will replace and repair flood damage from Superstorm Sandy. The state Public Health and Health Planning Council’s Establishment and Project Review Committee approved the hospital’s application on October 11. The $738 million project includes a new critical-services tower, which will house a flood-resistant emergency department. It includes the renovation of its main building and existing tower, which were built in 1954 and 2005 respectively, demolition of an older building significantly damaged in the storm, and construction of a flood wall around the campus to protect it from future storms. The project will be funded mostly through a $1.7 billion award the Federal Emergency Management Agency provided NYC Health + Hospitals to rebuild its facilities in late 2014. Of that total, $922.7 million was slated for repairs in Coney Island. The renovations will enable the hospital to endure future natural disasters, improve the health care environment for patients and achieve greater operating efficiencies with a stronger, more resilient hospital.

NYC Health + Hospitals/Correctional Health Services announced that its Creative Arts Therapy Program conducted approximately 4,000 group sessions of individuals detained at Rikers Island since expanding in December 2016. The expansion, part of First Lady McCray’s ThriveNYC initiative, has enabled our correctional health staff to enhance the country’s oldest and largest jail-based creative arts therapy program. Our correctional health team also hosted a very special art exhibit this month that featured powerful narratives of Creative Arts Therapy Program participants. The exhibit included approximately 80 pieces, ranging from self-portrait drawings and collages to poems and music compositions created over the past year under the guidance of creative art therapists. The art exhibit was made possible with the support of the School of Visual Arts.

The Mayor’s Office of Criminal Justice and NYC Health + Hospitals/Correctional Health Services launched a pilot program that streamlines psychiatric evaluations for defendants in the Queens Criminal Court. The pilot program at Correctional Health Services’ Queens Forensic Psychiatric Evaluation Court Clinic focuses on court-ordered psychiatric evaluations, which largely comprise of fitness-to-stand-trial examinations — also known as “730” evaluations. As the large majority of these evaluations are conducted for individuals who are incarcerated and awaiting trial, delays in the evaluation process can lead to longer lengths of stay in jail. In fact, the Mayor’s Office found that defendants ordered to take 730 exams spend nearly three times longer in custody than the general population does for similar charges. The Queens pilot program aims to complete the 730 evaluation process in 14 business days for felonies and 7 business days for misdemeanors. Since the pilot launched in June, more than 84 streamlined psychiatric evaluations have been completed.

In recognition of National Depression Screening Day on October 11, NYC Health + Hospitals offered free, confidential depression screenings and treatment referrals to mental health providers at 14 patient care locations throughout New York City. Screenings were conducted by our expert mental health professionals for individuals, private consultations to help identify symptoms of depression and mood disorders. Patients requiring follow-up were referred for personalized tailored treatment within each location. Timely access to mental health care services is important to the well-being of our patients, which is why we seek different ways to engage them, including by integrating screening and treatment for depression into primary care, pediatrics, adolescent medicine, and obstetrics.

Bonadio & Co., LLP, was engaged to provide independent external operational audit procedures over the Partner Selection, Partner Payments, Partner Portal controls, and Quarterly Reporting to assist NYC Health + Hospitals and OneCity Health in the controls of the OneCity Health Partner Portal and Partner interaction. The audit fieldwork was completed in August and the final audit report was presented to the OneCity Health Services Board of Directors on October 9.

Bonadio & Co. concluded that OneCity Health has developed the necessary core infrastructure to be in a position to achieve its organizational goals relative to the DSRIP program. The auditors concluded: there are sound operational and internal control policies and procedures in line with the DSRIP program; OneCity Health has a culture of continuous improvement and is not complacent with its policies; and the policies in place result in fair and equitable treatment of OneCity Health PPS partners, efficient use of resources and complete, accurate and timely reporting to the Department of Health.