Testimony on the Brooklyn Healthcare Crisis

Thank you Assembly Health Committee Chairman Gottfried, Brooklyn Assembly Delegation Chairman Lentol, and Assembly Members for the opportunity to testify today.  The Primary Care Development Corporation (PCDC) is a nonprofit dedicated to expanding access to high quality primary care in underserved communities throughout New York State.  PCDC provides low-cost capital financing and expert technical assistance to primary care providers in underserved communities, and works with lawmakers to develop policies that grow and sustain the primary care sector.

Since 1993, PCDC has created investments of $415 million in more than 100 primary care health center projects throughout New York State – including more than $70 million in 18 Brooklyn projects - leveraging more than $5 of private investment for each $1 of public investment. 

In total, these projects have created primary care access for more than 900,000 New York residents, created more than 4,600 jobs in low-income communities, and transformed more than 840,000 square feet of space.   PCDC has also trained and coached hundreds of primary care organizations to deliver high-quality patient-centered care, increase productivity, effectively implement electronic medical records, and prepare for emergencies. 

I would like to thank the Assembly Health Committee and the Brooklyn delegation for holding this hearing and focusing attention on the Brooklyn Healthcare Crisis. I would also like to recognize the important work that has been conducted over the last few years, including by the MRT Brooklyn Health Systems Redesign Work Group, the Brooklyn Healthcare Working Group organized by Senator Sampson and Borough President Markowitz, the United Hospital Fund, the Brooklyn Health Improvement Project, and the Community Health Care Association of New York State.  

The Primary Care Crisis in Brooklyn

Brooklyn has long struggled with a primary care shortage.  Despite the presence of some high quality providers, there are simply not enough to address the critical primary care needs of Brooklyn residents.  Now it faces a looming and predictable crisis.  At-risk hospitals in Brooklyn (those with a current asset to liability ratio under 1) provide nearly 400,000 annual primary care visits to low income New Yorkers.  As hospital administrators wrestle with financial survival, primary care is not and cannot be a priority.  As a result, their outpatient departments lose money, operate well below capacity, and do not offer the kind of patient-centered care that is critical to improving the health of Brooklyn residents and reducing ER visits and hospital admissions.    As financial conditions worsen, hospitals lose outpatient volume and close clinics, eliminating sometimes the only primary care option for thousands of patients.  This is not theory – it has happened time and time again in communities throughout New York City.

Were the shortage not serious enough already, Superstorm Sandy dealt primary care providers another blow.  We are particularly concerned with reports that Coney Island, which relied largely on small primary care practices, may not see many of those practices come back anytime soon. 

Recommendations

 A high-performing, cost-effective health care system requires strong primary care at the center.  The health system is moving in this direction, as new models of care delivery and payment like health homes and accountable care organizations begin to shape the healthcare landscape.  Communities that do not recognize and prepare for this will suffer.

A Primary Care Plan

The preservation, strengthening and expansion of Brooklyn’s primary care capacity must be a top priority.  This includes building new primary are capacity where it does not now exist.  As importantly, we need a monitoring system for primary care that will give us early warning signals when primary care capacity is in jeopardy, allowing the community, the State and other providers to step forward with a plan before the capacity is lost.  Once sites are closed and providers and patients dispersed, the rebuilding process will be long, slow and expensive.  It doesn’t take a primary care practitioner to tell you that prevention is better than cure.

Alternative primary care providers are available who can effectively operate these primary care facilities, including community health centers, other hospitals, and private practices (which will receive substantial Medicaid increases for two years under the Affordable Care Act).   All providers—current and prospective must meet the standards of high-performing, high-functioning patient-centered primary care.  Brooklyn’s communities deserve nothing less.  These characteristics include:

• Focus and priority on primary care;
• Demonstrated capability of delivering a high-performing, cost effective, patient-centered model of primary care;
• Financial stability, with a strong current ratio, cash flow and accounts receivables;
• Effective management and governance;
• Active engagement with the community and alignment with the its needs, culture and language;
• Integration into a network that includes a hospital, specialists, social services and other services needed to meet the full health care needs of the community.
• Use of electronic health records, including connection with the Regional Health Information Organization (RHIO) and the ability and willingness to exchange health information electronically with other providers.

Resources/Technical Assistance to Create More “Medical Homes.”

One mark of a high-performing primary care provider is recognition by the NCQA as a “Patient Centered Medical Homes.” This type of provider is in short supply – in Brooklyn and throughout New York State.  A recent United Hospital Fund study found that Brooklyn had just under 600 primary care providers who had been granted that status or about 22 medical home providers per 100,000 population.  Achieving and sustaining this model of care is incredibly challenging and time consuming, particularly for hospitals and small practices.  For hospitals, the rotation of residents through outpatient departments makes coordinating patient care quite challenging. For small practices, the lack of staff and resources to implement new care models – including care coordination – can be daunting.

To accomplish this, New York State should make available funds to help providers transition to patient centered medical homes.  We know from experience that training and technical assistance can make a big difference.   A recent Health Affairs study of New York City’s Primary Care Information Project noted that higher levels of sustained technical assistance were associated with improved quality of primary care. 

Make transitioning primary care seamless

Taking over an at-risk or failing primary care operation is not easy, but it is essential that facilities do not close – even for one day, as this can severely disrupt care for thousands of patients. It is much more difficult to reopen and reintroduce a closed facility than to put an existing primary care clinic under new ownership or management.  The State needs to offer a single point of contact and coordination to streamline the necessary State approval processes.  Thankfully, a provision in the 2013-14 Executive Budget eliminates the Certificate of Need requirement for primary care facilities.  When enacted, this should lift a significant hurdle to primary care expansion. 

Operating and capital funds – and a Primary Care Investment Fund

Preserving and expanding primary care will also take capital for providers to acquire, renovate and expand existing primary care facilities, or to build new capacity.  Operating dollars are also required for startup costs to ramp up operations.  This is particularly important in facilities that have been neglected and underutilized for years.   

PCDC has long advocated for the creation of a Primary Care Investment Fund that would do just this.  Accessing capital for primary healthcare facilities continues to be a major challenge, and this is particularly evident in Brooklyn.  If New York State committed capital funds to a Primary Care Investment Fund, it would make investment by banks and nonprofit community lenders more attractive and make borrowing for primary care providers more affordable.  The impact would be to catalyze major expansion of sustainable primary care capacity in Brooklyn’s underserved communities. 

Conclusion

While we seek to avoid an imminent crisis, our recommendations would serve Brooklyn well regardless.  Brooklyn needs more and better primary care that is fully integrated into the larger health care delivery and social service system.  That means finding smart, high quality operators that know their business and play well with others.  It means providing training and technical assistance to develop and sustain more patient-centered medical homes.  And it means securing more capital resources to build the primary care infrastructure. 

PCDC looks forward to assisting in this critical effort.

Thank you.