Health care reform necessary, advocates say

The local diagnosis is in.

As the debate in Washington over health care reform boils to ever higher temperatures, local health advocates in Upper Manhattan are keeping a close eye on the House and Senate proposals, and some are actively lobbying on the city, state, and federal levels.

Despite a wide spectrum of views on the contentious issues of resource waste, physician payment, Medicare and Medicaid, and the “public option,” health care experts in Morningside Heights, Harlem, and the Columbia University Medical Center all express fundamental concerns with aspects of the federal discussions. From the private owners of small Harlem clinics to top administrators and lobbyists at CUMC, experts are anticipating the ramifications of federal changes for the local system, both citywide and in individual neighborhoods.

Waste and more waste

Most locals who favor massive reform say any serious overhaul must begin with an understanding of the current system’s failures, beginning with what they see as systematic waste.
Daniel Baxter, chief medical officer at the William F. Ryan Community Health Network—which has a local health center at 97th Street and Columbus Ave.—said the American health care system is fragmented into a system of unnecessary inefficiencies.

“We need to return to basic preventative care that is comprehensive,” Baxter said, noting that patients can rarely get all the services they need at a single site, and are often shuffled through multiple hospitals and clinics that duplicate testing. He called for “medical homes” in which one center would be equipped with the resources to handle patients all the way from diagnosis through treatment, so constant referrals do not put additional strain on a system with continually rising costs and increasing demand.

Pat Monahan, director of the nursing program at Little Sisters of the Assumption Family Health Service in East Harlem, said that from the perspective of a small health center, immediate system cuts are needed.

“I am absolutely in favor of cutting health care costs—there is an awful lot of waste,” Monahan said, citing frustration with the “hidden costs of health care.”

Financially, Little Sisters cannot accept many small insurance providers, she said, and 13 to 15 percent of their visits are unpaid because patients cannot afford the cost.

The solution? A “public option” or a single-payer system, Monahan said, adding that smaller, incremental reforms do not fix the broader, fundamental problems. “Nothing changes at the bottom level,” she said. “Those sick in the doctor’s bed are still in the office. That stays the same.”

To be a doctor

For lobbyists at the Columbia University Medical Center on 168th Street, the question of waste boils down to a more basic examination of what it means to be a doctor practicing within the framework of the current health care system.

Ross Frommer, deputy vice president for government affairs and associate dean at CUMC, said CUMC officials have lobbied for reforms that would address the huge sums health care providers spend to avoid malpractice lawsuits.

“You order that X-ray when it may or may not be called for,” Frommer said. “You are practicing defensively.”

The threat of malpractice lawsuits also drives up costs to patients. “Individual doctors can be paying several hundred thousand a year for medical liability insurance,” Frommer said. “So how much do they have to charge in their rates to be able to earn a living?”

He said CUMC is lobbying for alternatives to the current civil malpractice litigation system and encouraging Congress to set up demonstration programs aimed at lowering malpractice costs in general—reforms included in the bill proposed by the Senate Finance Committee.

According to the Ryan Center’s Baxter, “Greed, fear, and paranoia all occupy and compete for attention in a doctor’s psyche.”

While he agreed with Frommer that unnecessary X-rays or other procedures done to avoid lawsuits burden the system financially, Baxter went further in criticizing what he perceives as widespread greed in the profession.

“The basic problem is that medicine has become a business,” Baxter said, adding that, aside from avoiding malpractice lawsuits, there are financial incentives for doctors to order unnecessary testing. This problem, Baxter argued, stems from problems with medical education.

“There needs to be a fundamental change in the criteria used to accept students into medical school. The brightest ones with the highest test scores are not necessarily the ones going into medical school for the right reasons,” he said, noting that many students, struggling with debts from their undergraduate education, are drawn by the medical profession’s high-salary reputation.

Frommer disagreed, saying financial interests are not the primary reason students attend medical school, and adding that graduate education is heading in the right direction, with an increase in class sizes at CUMC expected to meet growing demands in the system.

From the eyes of a worker

While administrators and advocates debate the changing role of doctors in the health system and the need to increase efficiency, workers on the ground who would be directly impacted by the pending federal reforms have expressed their own concerns.

Just last month, the local 1199 Service Employees International Union—which represents CUMC workers—completed a six-month contract negotiation process that was deeply strained by the health care debate.

According to Victor Rivera, president of the supporting staff association for 1199 SEIU for CUMC, the University administration proposed early in negotiations a plan that would have required workers to pay for health insurance that had previously been fully subsidized.

Over the summer, the negotiations sparked campus protests and walk-ins to the dean’s office. And while they were resolved with a contract that many union members supported—largely because it preserved the subsidized health care that had been threatened—funding cuts to hospitals in some federal reform proposals could make future contract negotiations even more unpleasant, said SEIU 1199 workers’ organizer Bennet Battista.

“If the cost factor becomes exorbitant because of whatever happens in Washington, it is going to make the next negotiations tough,” Battista said, calling for legislation that would include incentives for universities and businesses to offer subsidized health insurance programs.

Rivera expressed similar concerns, noting, “My workers that I represent are mostly concerned about the high cost of health care. They are always in fear at any given moment that management might turn around and start talking premiums that they can’t afford.”

CUMC’s Frommer declined to comment on specifics of the union negotiations, but said of the various federal reform proposals, “There are certainly added pressures on the Medical Center that could arise out of this.” He added that New York Presbyterian, a hospital affiliated with CUMC, recently faced a slew of cuts, though that did not impact Columbia directly.

“I would hate to see, in an effort to cut costs, that we lose sight of the importance that teaching hospitals in medicine play,” Frommer said.

Growing pains

“The escape valve that has helped make it all work—Medicare is in jeopardy,” said Scott Amrhein, president of the Continuing Care Leadership Coalition, a New York City-based advocacy group for long-term health care. The CCLC represents many local nonprofit nursing homes, including Jewish Home Lifecare on 106th Street between Amsterdam and Columbus avenues.

Amrhein said that if federal reforms cut funding for Medicare and Medicaid, it could force an aging population to make serious sacrifices. Between 80 and 90 percent of state funding for nursing homes comes from Medicaid, the government-funded health care program for low-income individuals. He cited national studies showing how “great a shortfall there is between what Medicaid pays and what it actually costs to run a nursing home.”

He said he was wary of proposals that would make systematic cuts to Medicaid and Medicare—the equivalent program for the elderly—over several years in order to finance improvements to non-long-term health care, noting that funding cuts have already strained these programs.

“I see one long-term care nursing home closing every month. Where is the inefficiency?” he said. “We are tightening our belt so much, the next step we will have to take is to cease operations.”

“Jobs get cut, patient care is cut, the amount of staff available to care for patients is reduced,” Amrhein said. “That has tragic consequences when caregivers are like their family.”

James Davis, CEO of Amsterdam House—a nursing home on 112th Street—echoed Amrhein’s concerns, noting that volunteers sometimes play a role in their services.

“We obviously need to reform the system—it is out of control,” Davis said. “My concern is that in the process of trying to pay for it, they cut Medicare and Medicaid.”

From the CUMC perspective, according to Frommer, such cuts would spell trouble for physician reimbursement rates. Though Congress has stepped in over the last several years to implement short-term fixes, Frommer said these do little in the long run to establish a sustainable financial model.

“In some ways it is a one-year Band-Aid,” he said. “It is almost like the wound continues to fester.”

On the streets of Manhattan

In Upper Manhattan, there is a particular sense of urgency, according to local health care advocates.

In the diverse neighborhoods these advocates represent—the Upper West Side, Morningside Heights, Harlem, Washington Heights, and others—the proposed bills in Congress are not just documents, but serious decisions that will impact locals’ lives.

“There is no doubt that Washington Heights-Inwood is a very interesting neighborhood from a health care perspective,” Frommer said of the residents that live in the area around the CUMC campus and rely on its services.

From the Jewish German communities that once dominated the area to the various ethnic enclaves of African, Dominican, Russian, Mexican, and Chinese-American populations, the area has an extremely diverse set of health care needs, which Frommer said creates challenges when considering federal overhaul.

“The population here has significant health problems,” Frommer said, beginning with the high percentage of uninsured patients. There are also “issues related to poverty, unemployment, lack of education, family situations,” all of which tie back to health care. On a basic level, these problems manifest themselves in higher costs of care, and Frommer emphasized that federally prescribed reforms tend to overlook the diversity within communities.

The Ryan Center has seen the number of uninsured patients double in the past year, according to Baxter. The center offers a sliding scale allowing uninsured patients to be seen, and some pay as little as $32 for all services, which Baxter called fitting for such a diverse neighborhood.

“I’m amazed by how incredibly diverse our patients are here. I think, frankly, our needs really reflect the needs of the country on the whole,” he said, adding that characteristically urban issues such as substance abuse, HIV, and depression appear more frequently at his clinic.

But this urban diversity poses challenges that may be difficult to address in national reform discussions, and the situation has gotten worse.

“Due to the recession, we’ve seen many people laid off from their jobs,” Baxter said, “and they really have nowhere else to go for care.”

In print, the quote of the day, “Greed, fear, and paranoia all occupy and compete for attention in a doctor’s psyche,” was incorrectly attributed to Ross Frommer from CUMC, and it should have been attributed to Daniel Baxter from the Ryan Center. Spectator regrets the error.

Tags: News, Sam Levin, Health Care