Heads could roll on hospital boards and in C-suites in Brooklyn and possibly the entire state of New York if some groundbreaking recommendations in a new report are adopted.
Put on notice
New York report could have hospital execs, boards looking over their shoulders
Last week's report, requested by Dr. Nirav Shah, New York state commissioner of health, as part of an effort to reform Medicaid, urges drastic measures be taken to revive a healthcare system in Brooklyn that is in disastrous shape with the understanding that if it's successful it may be applied more broadly in the Empire State.
The authors suggest, among other things, that the state health commissioner be given the authority to replace hospital management and remove board members as part of the effort to force self-interested and unqualified hospital officials to reverse the declining quality of care in the borough.
The audacious recommendations raise questions about whether the government can decide when healthcare leaders can no longer be entrusted with the responsibility of managing a healthcare system.
The 86-page report, called At the Brink of Transformation: Restructuring the Healthcare Delivery System in Brooklyn, also suggests giving for-profit hospital chains a bigger role in New York than the very limited amount now allowed by state law.
And the report's authors—a group called the Brooklyn Work Group of the Medicaid Redesign Team and led by financial executive Stephen Berger—also make some specific recommendations regarding the closure, merger or downsizing of six acute-care hospitals and one psychiatric hospital with a total of more than 3,000 staffed beds.
It is the recommendations concerning governance and management oversight that could have far-reaching consequences beyond Brooklyn's 15 acute-care hospitals, with the authors and the state seeking to apply the report's solutions to the entire state.
In addition, some experts say that such an approach may be needed across the country to push some hospital board members out of complacency and into action. “One thing that's really been clear is that hospital boards have abdicated responsibility” of ensuring hospital quality is appropriate, and the Brooklyn report's suggested course of action may be necessary, said Dr. Ashish Jha, associate professor at the Harvard School of Public Health.
Research that Jha has helped conduct indicates that many boards are not focused on the right issues—only 44% of board chairs placed clinical quality as one of the top two priorities for evaluating clinical performance of CEOs—and the authority to forcibly remove management or board members may be appropriate in some cases if it means saving lives (Nov. 16, 2009). “I am very sympathetic to hardball approaches,” Jha said. “People are dying unnecessarily.”
The authors suggested that the health commissioner be given broad powers over management and governance. “Legislation should be enacted to give the commissioner authority, at his or her discretion, to appoint a temporary operator for healthcare facilities that present a danger to the health or safety of their patients; or have operators that have failed in their obligations; or are jeopardizing the viability of essential healthcare capacity, absent intervention by the state,” according to the report.
In addition, the authors wrote that “legislation should be enacted to give the commissioner authority to replace healthcare facility board members who are not fulfilling their duties to the organizations they are charged with governing.” The move would be much stronger than a state law passed by neighboring New Jersey that mandated education for hospital trustees (May 28, 2007).
The report's conclusions regarding increased power for the commissioner were greeted warily by representatives of New York's hospital community. “We're generally opposed to that,” said William Van Slyke, spokesman for the Healthcare Association of New York State. Van Slyke asked what the determination process would be and what criteria would be used. The proposal “would essentially grant to the commissioner of health the authority of being the hospital administrator for the entire health system of New York state,” he said.
Similarly, Greater New York Hospital Association President Kenneth Raske said in a statement that the association will work to ensure that such regulations do not give the commissioner excessive powers. In an interview, Raske said the borough's hospitals may be willing to swallow that bitter pill, though, in return for a share of $450 million in state grant money that will be made available in early 2012 to healthcare facilities that participate in mergers and realignment under the commission's purview. “You can't take money from the state of New York without paying a price for it,” Raske said.
Prompting the report was the view that the healthcare system in Brooklyn is failing, in part because of poor governance, according to the authors. “The boards of some of these hospitals have failed to satisfy fully their responsibilities to the organizations and their communities. They have not evaluated financial and clinical performance, set strategic goals to address them, and held management accountable for achieving them. Instead, they have adopted a strategy that seeks merely to be the last man standing in their communities. It is clear that this strategy is a failed one.”
The report's conclusions in general regarding Brooklyn are accurate, said Dr. Richard Becker, president and CEO of Brooklyn Hospital Center, which was cited by the authors as being a success story in the borough. “There's some competition that really doesn't benefit anybody” and it is inefficient, he said.
The authors recommend that the 312-bed Brooklyn Hospital Center take the lead in integrating with 277-bed Interfaith Medical Center and 279-bed Wyckoff Heights Medical Center, a possibility that was welcomed by Becker. Although there are many unanswered questions, the creation of a more integrated health system in northern Brooklyn is a good one, he said.
Becker praised the report for the most part, but reserved judgment on the concept of giving the commissioner more power and disagreed with the conclusion that Brooklyn Hospital Center could not survive on its own. “We take an opposite view” and believe the hospital is positioned to succeed, he said.
He also said that, as a former executive of a chain, he thinks for-profits can play a positive role in New York in the right circumstances. Nonetheless, “at this point I'm probably in the minority” in New York, he said.
The report's restructuring section also suggests that 864-bed Kingsbrook Jewish Medical Center take the lead in integrating with 419-bed Brookdale University Hospital and Medical Center, reducing total bed counts between the two in the process. Kingsbrook has begun planning for integration with Brookdale, Kingsbrook CEO Dr. Linda Brady said in an e-mail from a spokeswoman.
SUNY Downstate Medical Center, with 339 beds, was urged by the authors to consider consolidating inpatient services at its recently acquired Long Island College Hospital, which has 337 beds, and to reconsider some expansion plans under way.
The 290-bed state-run Kingsboro Psychiatric Center is recommended to close inpatient services altogether.
An overarching goal of the report is to align with national healthcare trends toward integrating care across the continuum, de-emphasizing hospital-based care and reducing waste and costs.
The report is likely to carry weight in the state. Berger also led a statewide restructuring group called the Commission on Health Care Facilities in the 21st Century that was commonly known as the Berger commission. The commission, created by a 2006 state law, issued mandates that included the closure of nine hospitals and the reconfiguration, affiliation or conversion of 48 others (July 7, 2008).
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