Editorial jumps

Toward health excellence;
Three large hospital companies have rare chance to compromise and progress

Three large hospital companies have rare chance to compromise and progress
Firmness, persistence and an unlikely example of political courage are needed to reconfigure and improve hospital care in New York, and the state will have a large say on how to do that late this year. Before that, Buffalo Niagara's hospital groups must reach a sensible compromise so an unreasonable one is not thrust upon them. This is an opportunity.

The Commission on Health Care Facilities in the 21st Century is due to report to the governor and Legislature, putting government and health care leaders to a stress test they dare not fail. New Yorkers' physical and financial health is at stake.

Many problems confront the health care industry, but one of the most pernicious is excess capacity. This is not just about the number of beds, but the number of buildings, MRI machines, heart surgery programs and emergency rooms. Hospitals are expensive structures that cost a lot to build, maintain and pay for. If there are too many, and most are half full, their costs siphon money from health care and quality suffers.

Such is the case in Western New York. Erie County alone has 13 acute care hospitals, which trace construction to the days when Buffalo brimmed and hospitals often served specific ethnic, class and religious groups.

Those days are gone. Not only is Buffalo a much smaller city than it was 50 years ago, but health care is vastly more expensive. It can't be efficiently provided in an excess of buildings approaching obsolescence and would, therefore, require hundreds of millions of dollars to update.

Consequences abound of operating too many hospitals in a shrinking region. With competing specialty programs such as cardiac care, hospitals must share a declining patient base, potentially preventing any facility from performing enough surgeries to achieve excellence, or economies of scale and cost savings. The region needs to reverse that trend, producing centers of excellence that draw patients -- and physicians -- from elsewhere and provide superior care to all with specialties properly focused instead of diluted through duplication.

Despite obvious challenges, hospitals do little of substance to address them. Their leaders talk with serious intent about overcapacity at the same time they unveil expensive new programs meant, in part, to ensure their hospitals remain viable.

The other problems hospitals face -- too many patients with terminal or long-term preventable illness -- should also be addressed by the commission. It should order and promote expansion of primary care clinics, of which Buffalo now has two. These nonprofit walk-in clinics, which most often service the poor and uninsured, can treat medical problems before they become full-blown diseases that hurt patients and add indigent costs to the health care system taxpayers support.

Western New York cannot afford overcapacity and duplication; not the dollars it costs and not the price in diminished quality. Inaction is not an option. The commission is due to make its statewide recommendations in November. Talk is that up to three Erie County hospitals may be closed, including Erie County Medical Center and one each from Kaleida Health Care and the Catholic Health System.

Any closure could carry significant baggage, but such a proposal at least moves in the right direction, and for several reasons. ECMC is a prime example. It serves the East Side of Buffalo and is the county's only designated trauma center. It has a highly respected heart program. But its costs are untenable.

Union contracts, forged by elected county officials rather than hospital management, provide benefits in excess of private-sector facilities, destabilizing the hospital and punishing taxpayers. Maybe closing is the way, with another hospital taking the trauma center, for county taxpayers to finally get out from under the suffocating annual subsidy they pay.

At Kaleida, meanwhile, there has long been talk of closing Millard Fillmore Hospital at Gates Circle. Its neurological and cardiac programs are well regarded, but Kaleida hasn't closed any hospitals. If it was plausible years ago to close it, it is more so now with expansion of Millard Fillmore Suburban Hospital.

To its credit, the Catholic Health System has acted, converting Our Lady of Victory Hospital from an inpatient facility to other uses in 1999. It was a difficult task, but the fact is the county still has too many hospitals. Almost certainly, it will have to be a part of a multihospital solution.

This all costs money, of course. Hospitals have enormous debts and the investors properly want what is owed them. The creation of the commission envisioned a wholly insufficient $1 billion statewide pot to finance the conversions it orders, but observers wonder if the money will really be there and whether it will be enough to even begin meeting the state's health care challenges. That is up to lawmakers and the governor, who must ensure that this opportunity does not go unused.

Lawmakers will also need stiff spines to resist pressure from powerful unions, doctors and hospitals that won't want to see jobs eliminated or, more likely, transferred to the private sector. The commission law only gives each legislative chamber a veto over the whole package of closures. Assuming the list is fairly and logically drawn up, legislators need to do right by the residents of a state where health care is under threat.

But before putting Buffalo Niagara's citizens and taxpayers in the hands of legislators who repeatedly ignore their needs, the leaders of this region's three health care giants need to find sensible and beneficial compromises to improve health services here. Don't wait for dictates. Act in the public interest.

These leaders have already had discussions and meetings. Solutions crashed on the rocks of self-interest. There now exists a brief window where these leaders can act pre-emptively, thoughtfully and help this region mightily. Time to get back around the table, demonstrate leadership and stay there until a deal is done.

The Syracuse Community Health Center has come a long way since its founding in 1978. But it has a long way to go before it reaches all those who could use its cost-effective services. And with hospitals facing "right-sizing" in coming months, community health centers could be heading for a fiscal crisis as new patients are diverted from emergency rooms and other acute-care facilities.
That diversion is not in itself a bad thing. A hospital emergency room is not the proper site for primary care. As much as $1.1 billion was wasted on avoidable emergency rooms visits to the state's hospitals in 2004, according to the Community Health Care Association of New York State.
The problem is that funding for community clinics has been flat. Thirty-two New York counties covering mostly rural areas still have no clinics. Federal dollars for new facilities are gone. Even as school-based clinics have sprung up in Syracuse and elsewhere, other school-based facilities have had to close for lack of funds.

In 1994, SCHC served some 47,000 adults and children per year at its two facilities south of downtown and on the east side, plus a part-time presence at the Southwest Community Center. Today, the SCHC has 65,000 patients at its 14 clinics, include one in LaFayette, another in the Onondaga Nation, and five school-based programs.
Most of the SCHC's annual budget of $72.6 million is covered by patient fees, of which nearly half is paid by Medicaid. But some $5 million each year must come from public or private grants and fund-raising.
Not surprisingly, community-based health care is both efficient and effective. Studies show Medicaid costs average 30 percent less at clinics than for other providers. Clinics focus on prevention, early detection and treatment major cost-saving factors.
Syracuse's clinics helped reduce low birth weights among its maternity patients by nearly 50 percent in the decade since 1994. They immunize babies and the elderly; conduct breast-cancer screenings and assess the risk of heart attacks for vulnerable patients.
But community-based clinics don't reach nearly all who could benefit, particularly in rural areas. Statewide, clinics serve only one out of five residents living below the poverty level, according to the most recent numbers. Only 12 percent of Medicaid clients use the clinics; just 10 percent of the uninsured.
Syracuse clinics' service area includes 70 percent of the population living below the poverty level and 75 percent of Medicaid recipients. But the SCHC wants to expand its reach. Its vision encompasses 10 school-based clinics within five years, and a doubling of the patient load.
A state commission is studying health care, with particular focus on hospitals and other costly institutional care. As the debate goes forward, it must include primary care in the conversation. Converting expensive hospital care into economical community-based care with the resources needed to build, expand and maintain facilities is the sensible way to go.

Copyright 2006 The New York Times Company

The New York Times
June 21, 2006 Wednesday
Emergency in the Emergency Rooms

The nation's emergency rooms have been stretched thin for at least a decade or more, but a new analysis suggests that they have reached a breaking point. Their plight underscores how dreadfully unprepared we are to cope with a major disaster like pandemic influenza or mass casualties from a terrorism attack.

The crisis in emergency medical care was laid bare in three reports issued last week by the Institute of Medicine, a unit of the National Academy of Sciences. Half a million times a year ambulances are diverted from emergency rooms that are full and sent to others farther away. Emergency room patients who need admission to the hospital often spend eight hours or more -- sometimes even two days or more -- on gurneys in the hallways, waiting for a hospital bed to open up.

Some emergency rooms lack the services of key specialists, such as neurosurgeons, who shy away from emergency room duty because many uninsured patients can't pay and their malpractice premiums would skyrocket because of the risky nature of emergency cases. What is not known is how many people die as a result of delays in treatment or inadequate care under chaotic conditions. No measurement system tracks such data.

The emergency room crisis has many causes, none of them easily or cheaply resolved. The number of people seeking treatment in emergency rooms has jumped sharply over the past decade or so, from 90 million in 1993 to 114 million in 2003. Over the same period, cost pressures forced the closing of some 700 hospitals, almost 200,000 hospital beds and 425 emergency departments. The result is severe crowding, exacerbated by a huge influx of poor people seeking routine care who are either uninsured or on Medicaid but unable to find doctors willing to treat them. By law, emergency rooms must accept all patients, whether they have insurance or not.

The institute's experts have many proposals for easing the situation, ranging from new regional systems to improve the flow of patients to the most appropriate and least crowded emergency rooms to an infusion of money to cover unpaid emergency care and to bolster preparedness for large-scale disasters. The most important change would be to stop diverting seriously ill ambulance patients and divert instead the poor patients who clog emergency rooms seeking routine care. That would require extending health coverage to the uninsured and providing more primary care clinics and doctors in poor neighborhoods.