Metropolitan Anchor Hospitals: Anchoring Community Health With NYC Health + Hospitals

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Tom Haederle
The crowds, the skyscrapers, the excitement. Everything about New York City has always seemed magnified, bigger than life. That's equally true of New York City's Health + Hospitals, also known as H and H -the Big Apple's public health system that is the largest of its kind in the country. Extending comprehensive care to everyone, regardless of their ability to pay, with dignity and respect, is just part of its vast mission.

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Tom Haederle
Systems like H and H serve as anchors within their community, providing care and being active community members. And while each metropolitan anchor hospital serves a unique role within its community, the challenges these hospitals face are common.

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Tom Haederle
Welcome to Advancing Health, a podcast from the American Hospital Association. I'm Tom Haederle with AHA Communications. With the mission of taking care of every patient who walks in their doors, New York City Health + Hospitals deals every day with challenges that affect most care providers, but on a larger scale. The system has also come up with some innovative solutions to these challenges,

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Tom Haederle
for example, an effective program to recruit and retain badly needed behavioral health professionals. In this podcast, Deborah Brown, senior vice president of External and Regulatory Affairs and Communications at New York City Health + Hospitals, is speaking with Ben Finder, vice president of Coverage Policy with the AHA, about the current trends and developments in the field and the many ways in which the massive public health system lives up to its responsibility to patients and the communities it serves.

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Tom Haederle
They also discuss why metropolitan anchor hospitals like New York City Health + Hospitals need more federal recognition and support.

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Ben Finder
Deborah, thank you for joining me this morning. I'm wondering if we can start our conversation by talking a little bit about your hospital and health system and NYC H + H and the patients and the communities that you serve.

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Deborah Brown
Absolutely. First of all, thank you for having me. Thank you for having us. We always are proud to tell the story of H + H. So, New York City Health + Hospitals also known as H + H. We are New York City's public health care system. We are the largest municipal health care system in the country. We have 11 hospital sites, acutes.

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Deborah Brown
We have five post-acutes, including one LPN. We have about 30 clinics in our FQHC, which is called Gotham. We provide all of the health care services on Rikers Island. We provide services through our homecare agency and we also have an insurance plan, Metroplus Health as a subsidiary. So our goal is to be a fully integrated system. We are a safety net system and proud to be one.

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Deborah Brown
We are here to serve anyone who needs care, regardless of ability to pay, regardless of income, regardless of insurance status. What that means really is that we have 70% either Medicaid or uninsured patients, inverting the conventional wisdom of what a pyramid should be. We're actually relatively small on Medicare side, relatively small on commercial insurance.

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Ben Finder
So you're in people's homes or in people's lives that are the cards that they carry. You're the places they go to. With all of that experience, I wonder if you could tell me a little bit about the trends that you've seen in recent years in terms of the patients and the community's needs?

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Deborah Brown
Absolutely. I mean, I think it's no secret that we're all facing a behavioral health crisis, and I think that is potentially born of COVID, but it is also just the reality of where we are no matter how we got here. So one of the things that we are really focused on is ensuring that there is behavioral health and ensuring that there is behavioral health accessible to all.

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Deborah Brown
We are the largest provider of behavioral health services in New York City. We're also the largest provider for people experiencing homelessness. And there is certainly an overlap in that population. We are looking at how we can continue to augment our excellent behavioral health care staff. That includes we've developed our own privately funded support program to support loan forgiveness for behavioral health workers who agreed to a three-year commitment in our system.

00;04;15;15 - 00;04;27;17
Deborah Brown
And we're very grateful to outside donations that help make that possible. We're working with the state on any number of ways to ensure that we have behavioral health beds open. It is an enormous priority for our system.

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Ben Finder
The loan forgiveness program sounds really interesting. So you're trying to address the needs of your patients in the community in terms of behavioral health care needs, which are trying to help make the workforce more robust. And we've heard so much about workforce issues for the last couple of years. I wonder if you could tell me a little bit more about how that program works.

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Deborah Brown
Absolutely. Again, first of all, you know, a lot of gratitude to private donors who supported us in this. And just to put in a little plug: though we are a public health care system and a public benefit corporation, we're also a tax exempt organization. Thus, we can accept donations in a way that I think conventionally people don't think that government agencies can.

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Deborah Brown
And that's really helpful. And actually, philanthropy is one of the things in my portfolio. So what we did with this private donor is we set up a program whereby they donated a certain amount of money. We then can allocate that to behavioral health workers, either those we are recruiting or those we're either trying to retain. And we have a committee that sort of selects the people based on a series of criteria, and then we can provide support between $30,000 and $50,000 for each worker.

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Deborah Brown
So it's not going to take care of their entire debt, but it might just be that little kind of tipping point that allows them to stay in our job. Because the reality is the work they do for us is very hard work. It is often physically taxing work, and we want to create the kind of stickiness that helps them help our communities, right?

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Deborah Brown
They want to do this work. They've chosen to be here. We're incredibly grateful for that. And so and yet we need them. Without our workers, we can't provide services that our community needs. So we're doing lots of things to try to encourage our workers to stay. It's certainly a challenge.

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Ben Finder
It's clear to me that the staff in the hospital itself are very mission driven, supporting the community and the patients. That's at the first priority of everyone's mind. I wonder if we can switch gears a little bit. You talked about the hospitals. About 70% of your patients are on Medicaid. With most of the patients you seen being covered by Medicaid or being uninsured,

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Ben Finder
can you talk a little bit about how this program helps your patients or how it supports your patients? And how important these programs, Medicaid program is for H + H.?

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Deborah Brown
We are happy to practice in a state where we do have a relatively generous Medicaid program. However, that program still pays hospitals 30% less than the cost of care. And we always say we give 100% to our patients, our Medicaid patients, all patients. We hope that our state program can cover that cost of care. So we are working with our associations, with hospitals across the state on an ongoing advocacy campaign to get to that 100% cost of care.

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Deborah Brown
And that's, of course, a financial issue, but it's also an equity issue. We want to make sure that our patients who work through the Medicaid program get care through the Medicaid program, through providers like ours, that we have all the resources that we need to continue to care for them in a high quality and accessible way. Our Medicaid program is key to everything that we do.

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Deborah Brown
We are very lucky to be in New York State where there is a robust Medicaid program, but even there, Medicaid only covers 70% of the cost of care. So we're always seeking Medicaid expansion to make it bigger, better, stronger, more rewarding. We are also heavily reliant and not ashamed to say it on DSH payments. Those federal this payments are enormously important, and that view has been - remains - our number one advocacy priority in D.C. and will be you know, we appreciate the ongoing postponements of those DSH cuts.

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Deborah Brown
We would love to get rid of them altogether. The other thing that we do have, which I think is really exciting, as I said, it's a 70% that is both Medicaid and uninsured people who are unable to access insurance. One thing that we have is a direct access program called NYC Care, and we set that up with New York City probably about four years ago now.

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Deborah Brown
And it allows people who don't have insurance to come into our system, as they always would. They get a card, they get assigned to a primary care physician. They're guaranteed a first appointment with Medicare within two weeks. And it really becomes a direct pathway to create that longitudinal primary and preventative care that is so important - and for some people that they have not had the opportunity to access.

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Deborah Brown
We are at about the 120,000 mark in terms of patients. It's been incredibly exciting and rewarding. It really exemplifies how we try to serve our community with dignity, with compassion and with access.

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Ben Finder
Wow. 120,000 patients is really something to be proud of. One of the things that we've all learned about is the Medicaid redeterminations, right? That's become a hot topic over the last year. So this was the support that Congress provided during the pandemic was to not require states to conduct these eligibility redeterminations. And now, as we unwind ourselves from the public health emergency, we're having to conduct redeterminations and our goal forms renewals for many of the Medicaid beneficiaries.

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Ben Finder
Can you talk a little bit about how this has affected H + H?

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Deborah Brown
Yeah, I mean, I think again, we're really we're really grateful to the federal government and we're really grateful to the state for their kind of operational support on this. You know, we've been doing kind of a long, a long ball program to make sure that people are aware and to make sure that we can get people recertified. We're at about 80%, which I think is really good.

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Deborah Brown
And I think slightly above the national average. And, you know, it's something frankly, we're just grinding on. It is so important for our patients, so important for us.

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Ben Finder
Great to hear about how you're engaging with the patients and trying to connect them or keep them connected with their coverage. You talked a little bit about Medicaid DSH. I think we know that historically Medicaid and Medicare have paid hospitals less than the cost of providing care for their beneficiaries. How does that shortfall affect H +H?

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Deborah Brown
It's a great question. I mean, the reality is, as a public health care provider, which we are proud to be, we don't necessarily have all the bells and whistles. That doesn't mean it's not great care. It is. It doesn't mean it's not great staff. It is. But there are certain things, you know, we fill a different role in the ecosystem than some of the better resourced, more commercially reliant private hospitals.

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Deborah Brown
And that's OK. We are proud of what we do. And so I think for us, it's always a matter of identifying what is the patient need, what is the community need, how do we best serve it? How do we do so in a way that is not just respectful and compassionate for our patients, but also for our staff?

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Deborah Brown
And it's, you know, that's kind of the ballgame. We are never going to be in a position where we are anything but heavily Medicaid reliant. We love it, commercial insurance. We want more commercial insurance. We think that, you know, we have so much to offer. We welcome those patients. But we're also very mindful of the reality.

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Ben Finder
The last few years have been incredibly challenging for the hospital field with record inflation, rising costs. You've talked a little bit about the workforce issues that you face and the COVID 19 pandemic. Can you share what specific workforce issues or staffing and financial challenges H + H is experiencing?

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Deborah Brown
I mean, I think we're in many ways probably similar to a lot of AHA members, which is we are concerned about behavioral health workforce, we are concerned about nurses. Traveling nursing is a phenomenon that really took off during the pandemic and God bless them, everyone needed them. I think now what we really want to do is try to convert some of our temporary nurses or ideally all of them to permanent staff.

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Deborah Brown
And we have a really kind of dedicated initiative on that. Our chief nursing officer is excellent and we're really having success there. Our nurses are in many ways the backbone of our system and we want them to be at home with us.

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Ben Finder
We talked a little bit a minute ago just about commercial insurance rates and how they help support some hospitals. Your hospital relies mostly on Medicaid, which we knew historically pays less than the cost. I wonder if you could talk a little bit about the gaps that that causes and how you patch some of those gaps without having a commercially covered population to rely on?

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Deborah Brown
Yeah, it's a great question. I think part of it is identifying what our priorities are and where we're going to put our resources. You know, we're not here or able to create a surplus. So when the dollars in our dollars out on patient care, on our staff, identifying, as I said, what communities need and trying to fill those holes. We are lucky enough to enjoy some support from private donors.

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Deborah Brown
You know, it's it's a different model for us, right? A lot of private donations are based on a grateful patient model, which is wonderful. Our patients are largely not people who would have the means, even if they're delighted with the care. And I think many are. It's just sort of a different paradigm. So we are really creative. We try to we really creative in our fundraising.

00;13;22;20 - 00;13;43;07
Deborah Brown
We are really lucky that we have donors who understand that we are immodestly vital to New York City, vital to our our New York City functioning in a little "d" democratic way. Often That, I think, is what compels people to join in our mission and support us. And we're very grateful for that.

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Ben Finder
You talked a lot about the population in the city and being vital to the city. I wonder if you could talk about some of the challenges of providing both clinical and non-clinical care to an urban population. You talked a little bit about housing instability. Are there other challenges that your population faces?

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Deborah Brown
Yeah, and actually, I want to stay on housing for a second. One of the things that we are doing and this is really a priority project for Dr. Mitch Katz, our CEO, who is my boss, is we've created a Housing for Health program, which is we're taking unused lands on our campuses. As I said, we have 11 hospitals sites around the city.

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Deborah Brown
Some of them are quite large and have areas that we can kind of leverage. We're using those areas to partner with nonprofit developers, nonprofits service providers and our city colleagues at HPD, which is the Housing Preservation and Development Agency, to work with us on financing the models. And we create supportive housing, supportive and affordable housing specifically to serve our patients.

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Deborah Brown
I don't know what it's like nationwide, but at least in New York City, there is often a gap whereby a patient who has significant medical needs, they don't need to be in a hospital. They're not right for a SNF, nor are they right for a homeless shelter. Homeless shelter does many great things, but it doesn't necessarily provide the medical, the ongoing medical care that someone needs.

00;15;07;28 - 00;15;32;03
Deborah Brown
So we're trying to really fill that gap again that we've identified as a need for our patients. We're not going to be the city's largest real estate developer, but we have two major projects in the queue right now. We've done about three to this point, maybe more to this point. And it's really something that I think is a differentiating factor in a way in which we really try to engage in self-help for our patients.

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Ben Finder
It's incredible to hear the different ways that hospitals and health systems have evolved beyond just providing care within the four walls. Are there any other programs that you want to talk about or would highlight for us?

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Deborah Brown
Yeah, for sure. So we have a program called SHOW, which is street health outreach and wellness, and these are mobile vans that are developed to provide health care to people experiencing homelessness. They go to certain identified corners. There's sort of a route and they are there. They are meant to be reliable. It allowed us to access more people to provide COVID vaccinations during the beginning of the, I guess, the heavy points of the pandemic.

00;16;11;01 - 00;16;34;17
Deborah Brown
But it's also really blossomed into developing ongoing longitudinal primary care relationships, trying to get people in to see doctors because it becomes a trusted part of the community. And it does, you know, wound care. We've done A1C, there's a whole kind of suite of services that can be provided and that's something that didn't exist before. We're really, really proud of that.

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Deborah Brown
We have one of the largest community health worker programs, or I should say, hospital based community health workers in the country. We have over 250 CHWs and they are really members of our communities. It's really important to us that we kind of retain that organic nature, not create too many barriers for CHWs to come in and work with us.

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Deborah Brown
And that sort of lived experience can often help people as they're trying to find housing, as they're trying to find legal assistance, financial assistance. Those are the things that often our patients need in sort of a wraparound way.

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Ben Finder
Your commitment to the mission and improving the health and well-being of your patients and community is really inspiring. You're doing all of this on on Medicaid, predominantly Medicaid reimbursements. I wonder if you could talk a little bit about the Metropolitan Anchor Hospital proposal, which AHA asking Congress for. This is a proposal that Congress would create a specific designation for hospitals like yours that are serving urban communities, that are serving patients that are predominately covered by Medicaid, Medicare, or are uninsured.

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Ben Finder
Can you talk a little bit about as an integrated health system in New York City, supporting neighborhoods across all five boroughs and the diverse population? How would this designation be helpful to your organization and your community?

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Deborah Brown
To be blunt, any additional funding is going to be helpful for us, particularly funding that doesn't disrupt our DSH allocation, doesn't kind of get in the way of existing existing funds. And that's something that's been really important, I know, to the AHA and all of us participating in developing this kind of model. So I think A) it's just the flat out funds is really important, but also really identifying who we are and what we do and that we are essential for health care delivery.

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Deborah Brown
And we are lucky enough to to provide that essential role in New York City. But we've got peers all around the country doing this great work. And I think for not only the AHA, but, of course, Congress to recognize the importance of what we do and to codify that. I think that is really helpful financially. I think that is really helpful for sort of a reputational and almost emotional validation.

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Deborah Brown
It's hard stuff. Not not what I do. It is hard stuff what our doctors and nurses and social workers and techs do. And having that recognized is really important.

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Ben Finder
What should lawmakers in Congress know about metropolitan anchor hospitals?

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Deborah Brown
It's a great question. We are really special places and we're lucky enough to have great relationships. An incredible New York City delegation or specifically the delegation that that represents H + H. They're just wonderful and supportive. I can't say enough good things about about our champions in D.C. But we always try to get them out to our facilities. We always try to get their staff out to the facilities because there is something incredibly sort of magical and humbling, I think, about being in our places.

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Deborah Brown
Our staff is unbelievable. Our people, you know, the people care so much about patients, you know, sometimes in a lighthearted way. I know what we do is very serious. And there might be kind of a misperception that we're doom and gloom all the time, like we're human beings interacting with other human beings, and our facilities are really special places.

00;19;52;20 - 00;20;19;22
Deborah Brown
One of the things I love about our system is, as I said, we have 11 acute care sites and each of them is really organically representational of our community. It is really important for us to try to hire from the community. It's something that we are very successful in doing. We really serve as, as the designation says, as anchors for our community, not just as health care providers, but as employers, as sort of trusted agents as part of the culture.

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Deborah Brown
Please come down. Well, we'll tour you through everything you want to see and just show you how special it is.

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Ben Finder
An anchor is part of the culture and the community. I wonder if if we could end on a what are you most hopeful about in the in health care and in the future?

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Deborah Brown
I'm really excited that there is kind of a growing understanding of the importance of social care needs. And I will shout out our state and CMS for the development of our new waiver, which is really about health equity and really about social care needs. This is work that again, sort of bubbles up organically in what we do.

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Deborah Brown
And I'm using the royal we. The much more important people are the people doing the actual health care delivery in our facilities. But to understand that giving someone a prescription. It's wonderful. We want people to primary care. We want people to have preventative care. But there are a lot of aspects to health and to wellness even So, the fact that we're really seeing a commitment in funding and in action to those kind of services, that is super exciting.

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Deborah Brown
We are big believers in value based care. Even as a safety net hospital, it is something that is very important to us. So that ongoing march is something that is exciting to us. I think there's a lot of opportunities for collaboration and innovation and just being able to continue to serve our patients is a privilege.

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Ben Finder
Well, Deborah, it's been wonderful to learn more about H + H and the work that your hospital health systems are doing in your communities. Thank you again for joining me today.

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Deborah Brown
Thank you so much for spotlighting us.

00;21;55;09 - 00;22;03;22
Tom Haederle
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