As with many storied partnerships, a crisis brought together Ronda Kotelchuck and David R. Jones.
Each was already renowned: Kotelchuck, for her civil rights work and primary care advocacy; Jones, for tackling urban poverty as President and CEO of the Community Service Society (CSS) of New York.
Then came CSS’ urgent 1990 report about New York City’s dearth of primary care access. The figures were bleak: only one physician for every 60,700 patients in the city’s most underserved neighborhoods. Treatable diseases had already become life-threatening conditions for thousands.
Following a call to action by Mayor David Dinkins, the Primary Care Development Corporation (PCDC) launched in 1993. It was a bold experiment without precedent or promise of success, led by Kotelchuck as Founding CEO and Jones as a Founding Board member.
Twenty-five years and $1 billion later, PCDC is thriving in its mission to finance, enhance, and advocate for primary care, having assisted over 1,000 practices in 40 states to date.
Recently, Kotelchuck and Jones — this year’s Founder’s Reception Champions — met with PCDC CEO Louise Cohen [center] to reflect on transforming the health landscape. Excerpts from their far-reaching discussion are below.
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Cohen: The question still comes up: why primary care? I’m interested in hearing why you thought that primary care was the answer 25 years ago.
Jones: I guess it goes back to the Sydenham Hospital-closing disaster and the Koch administration…. The real issue was that we hadn’t done much to cultivate community-based physicians who had these connections with hospitals to provide adequate primary care.
Of course, we were also up against some moneyed interests that were running Medicaid mills and methadone clinics. They were always pushing against [primary care] because there was always so much money to be made by churning people over quickly.
And “emergency room care” was happening. Anyone who spent time in an ER — and I did when I was on the board of NYC Health + Hospitals — knows it’s a lousy way to provide care. Overly expensive, enormous wait times, a tendency to try to shuffle people — not very good, as opposed to having a physician.
I don’t think it was any question that having a basic physician who could interact with the family and individual was the way to go. But how do you build the capacity? That was clearly what we were looking at.
Kotelchuck: You had these Medicaid mills just raking in money. New York State’s solution to combating fraud was to freeze the free-standing physician rates, but at 1970s-era levels — and then never raise them.
That was the death knell for neighborhood practitioners who wanted to serve low-income communities. You lost a whole battery of people.
Also, if anyone remembers the late ’80s, there was a point when hospitalization rates suddenly soared because of epidemics in New York’s low-income communities: HIV, STDs, respiratory disease, asthma, etc. And if you looked at the structure of health services available, there was nothing that could stop those epidemics.
We were able to make a case based on facts, statistics, and epidemiological evidence: People without primary care wait until they’re quite seriously ill, then they go through the emergency room experience — and it doesn’t work. That was, I think, a very powerful argument.
How did you begin financing?
Kotelchuck: Our capital program started with bond financing. There was little understanding about lending to primary care providers when we began. We had to treat it in a pristine fashion so that people saw it was a straightforward, merit-based, criteria-based process.
We bundled three organizations for our first bond issue: Settlement Health, an FQHC; Callen-Lorde, which was not then an FQHC; and the former Catholic Medical Center in Queens.
It was enormously complicated: the bonds, the particularities, everything. But we did it. Kind of amazing.
We’re here at Callen-Lorde today. Why this project specifically?
Kotelchuck: As we were going through this process — and it was a public process — people came to us and said, “What about underserved populations that are not specific to a geography?” For instance, the LGBT community throughout New York City. We said, “That’s absolutely valid. All we need is evidence of an underserved population and we will treat it exactly the same [as a neighborhood].”
Callen-Lorde had been working in the West Village in a very small facility, seeing many AIDS patients in partnership with Bellevue Hospital. We just thought we’d be taking a small operation and helping it expand.
What became the Callen-Lorde piece was truly a startup. They had a constituency, they had enormous support in the community, but starting up an operation when you’ve taken on a lot of debt and built a very large facility — it’s really a stiff uphill climb.
PCDC, unlike other lending institutions, cares about the outcome. The mark of success is not, “How many loans do we make?” Instead it’s, “There is a health center that didn’t exist before and now it’s up and running and serving its community.”
Yes, people do have to be able to repay their debt, but we will do everything on earth to help them get to the point where they can do that. We have spent tons of energy. No commercial entity could expend that amount of resources on helping their clients get to the point where they could repay it.
That’s certainly still true today. And even though the issues weren’t well known when you started, your strategy was quite successful.
Kotelchuck: You could take a vast array of statistics that look at inequality and you’ll see the same communities every single time.
Most cities prioritize hospitals over primary care. What will it take to shift the balance?
Jones: My wife’s a neuropsychologist and psychologist and she can’t take Medicaid and Medicare. It’s ridiculous — particularly for behavioral health. This notion that you’re going to train lay people to identify mental health issues, but not have the backup of trained professionals… It doesn’t have to be psychologists necessarily, it can be staff with MSWs.
But this unwillingness to change the rate of reimbursement — it means you can’t hire anyone, even if they wanted to work [in behavioral health]. They’d go bankrupt, particularly given what’s required to remain qualified for Medicaid and Medicare.
I think it’s true for primary care physicians, even more so. How could they do this viably?
Kotelchuck: There are two things that are irritating about this issue. One is that people will come to agree with you and say, “Oh yes, primary care is important. Since we can’t redistribute what it is we’re paying, you will have to do more with less.”
The second is, what drives the economics isn’t the total amount of money that you pay for a service. It’s the margin. Hospitals get big margins on those intensive services.
A growing awareness of the need for population health is very encouraging. But we’re not there. We’ll know we’ve won the battle when we see the economics change.
Jones: In New York State, there are some signs of recognition that the current system is not sustainable. As to really getting into the meat of it — a higher reimbursement rate for primary care providers in poor neighborhoods — we’ve got a ways to go.
PCDC has had great success nonetheless, financing half of the FQHCs in New York City, for example. What are you especially proud of?
Jones: Well, I’ve been off the board for a long time. But the thing that really excites me is how PCDC has expanded. I was fascinated that something could go from just New York City to other parts of the state to other parts of the country. It’s very rare. That’s a great achievement.
Kotelchuck: PCDC’s board gave a lot of thought to the first step, which was moving from New York City to New York State. There’s a compelling reason in policy terms: you have to be working statewide to win support from other corridors in the state. That was crystal clear.
The second thing that kept happening was, once we’d financed health centers in New York City, people across the border in Westchester running health centers would say, “Why can’t you finance us?” And then people from Buffalo started asking the same. Our reaction was, “This is doable. Why not?” Between those two factors we made the decision.
I think it’s an accurate term to describe those who we serve or bring the loans to as “partners.” They’re our partners in achieving the mission. Our mission is not making loans. Our mission is getting care to people, which we can’t do without our partners.
What would you tell young leaders who are coming up in the world?
Kotelchuck: Never, never underestimate the importance of relationships — with every kind of person at every level. The Mayor’s Office, City Council, our colleagues who worked in city agencies, the community boards, the allied organizations: you never do anything alone.
It’s because you bring all of those people along. It’s the partnerships. PCDC is the superb partnership organization. Public/private partnership with lending institutions, the whole works.
What drew you to health care in the first place?
Jones: Everyone comes to this work with different drivers. The health work, even when I started at CSS, was driven by some of my experience growing up. I was in a very cloistered environment growing up in Crown Heights. My parents protected me from everything, but then the outside world started creeping in.
My first real understanding of that came when my babysitter had a botched abortion and was left in a corridor to bleed out at St. John’s Episcopal and died. Nothing was done.
The general reaction was just, that’s part of life — you’re poor, you’re of color, you’re a woman. She was 16. And I think it typified that this was not fair, particularly that health care was not fair. It keeps coming back, all the health work we’ve done — a recognition that discrimination and poverty is something you’re going to have to fight and do things about.
That’s clearly part of the reason I’m in this work. It was jarring for someone who was 11 to learn, when they finally sat me down to tell me what had happened to my babysitter, that nothing could be done.
I think that’s a realization [for many] — that you have to experience things yourself to have this sense of connection, or know people who are experiencing it, to say, “That’s not fair.”
Those are the kinds of things that drive people to actually stay in this work instead of…. I could be litigating. I was a litigator for Shell Oil and IBM before I went into this. [Laughs.]
Well, we’re happy that you did. Thank you both.
Kotelchuck: Absolutely. It’s fun. It takes me back to those days, a long time ago.
Jones: It is a long time.