Category Archives: Health

Bloomberg Administration Renews Plan to Close Two City-Run Immunization Clinics, Leaving Just One Open

Posted by Doug Turetsky, December 6, 2013

When New Yorkers look back on the administration of Mayor Michael Bloomberg, many are likely to think of the numerous public health initiatives. Indoor and outdoor bans on smoking. Calorie counts on menus. Eliminating transfats. And campaigns against salt and supersized sodas. So it may come as a surprise that during its last days in office the Bloomberg Administration plans to shut two clinics that provide immunizations to low-income New Yorkers.

There are currently three walk-in clinics run by the city that provide thousands of low-income patients with free or very low cost immunizations to prevent diseases such as mumps, rubella, and hepatitis B. The clinics in Tremont in the Bronx and Corona in Queens are set to close while the clinic in Ft. Greene, Brooklyn will remain open. In the first half of 2013 the three clinics served a total of 26,000 New Yorkers ages 4 and older.

To the city’s Department of Health and Mental Hygiene closing the clinics is a matter of dollars and sense. Closing the two clinics, which are each currently open two days a week for a total of 11 hours, will save $433,000 in city funds, according to the health department. There would be no layoffs connected with the closing, all staff would be reassigned; savings would come from leaving vacant positions unfilled and shedding the overhead costs for the two sites.

The city would also have to ante up more funds than in the past if the clinics were to stay open because of federal cutbacks in grants that help pay to purchase vaccines. The city’s health department expects federal funds to New York City for immunizations to fall from $5.4 million last fiscal year to $2.2 million this year.

Keeping the Tremont and Corona clinics open would entail taking on a level of city expenditure that doesn’t make sense to the health department since only about 1 percent of annual immunizations in the five boroughs take place at the clinics, according to the health department. The department notes that immunization rates have been climbing even though other clinics have been closed over the past decade. The health department reasons that by closing the two part-time clinics, the city can focus its resources on keeping the busiest of its three clinics open five days a week in Ft. Greene. Health department officials are assuming that only a portion of those that would lose access to immunizations in the Bronx or Queens will travel to Brooklyn.

This is the second time in recent months the Bloomberg Administration has sought to close the two clinics. Shortly after the City Council enacted the budget for the current fiscal year, which began on July 1, the health department announced it intended to shut the Tremont and Corona clinics, although it was not part of the budget plan. Public health and children’s advocates including the Commission on the Public’s Health System and Citizens Committee for Children protested the move, as did a number of elected officials and unions such as DC 37. The health department reversed the plan in August, at least temporarily.

While acknowledging the loss of federal funding, Anthony Feliciano, executive director of the public health commission, questions whether focusing resources on the Ft. Greene clinic makes sense from a public health perspective. Long commutes to Ft. Greene from the Bronx or Queens would undermine the walk-in nature of the clinics and discourage some individuals and families from getting needed immunizations.

Accessibility has apparently been a draw. Nearly 7,600 patients were seen in Corona during the first half of this year and about 6,000 in Tremont over the same period.

Although the health department contends there are 50 alternative clinics in the Bronx for free or low-cost vaccinations and 22 in Queens, Feliciano expresses concerns about language barriers and cultural sensitivity, especially for undocumented individuals. The Corona clinic sits in the community board with the highest share of foreign-born residents in the city.

Given Mayor Bloomberg’s emphasis on public health initiatives, closing the two clinics would make an odd coda to his last days in office.

School Nurse Cuts Would Hit Private Schools the Hardest

Posted by Jenna Libersky, June 11, 2010

Six years ago the City Council passed a law requiring more nurses on site at public and private elementary schools in the city. Mayor Bloomberg’s Executive Budget would “expel” some of those additional nurses from their schools.

The nurses affected by the Mayor’s plan are funded through the Department of Health and Mental Hygiene. The proposal has some challenges ahead, including the need to first have a change in existing law which requires the presence of a nurse at schools with a certain number of enrolled students. For the cuts to take effect, that threshold number would have to rise.

If that happens, the health department estimates that 19 public schools and 127 private and parochial schools would lose publicly funded nursing coverage for about 33,000 students. Others outside the Bloomberg Administration have cited larger effects.

The Mayor’s proposal would have a minimal effect on middle and high schools, as they are not currently required by law to have nurses on staff. The budget would reduce the number of full-time equivalent school nurses directly employed by the health department by 62 through attrition, saving the department $3.1 million in 2011 and more in subsequent years. Contracts with nurse providers that supplement the nurses on the health department’s payroll would also be reduced.

The department’s school health budget has grown from $53.4 million in 2004 to $90.6 million in 2009, with about 60 percent of the total coming from city funds. The number of full-time equivalent nurses on the department’s staff has increased from 697 in 2004 to 802 in 2009, with the bulk of the positions in both years filled with part-time nurses. The department also contracts out for nurses; currently, an additional 84 nurses work under contract with the agency.

The growing school health budget is largely the result of the changes in city policy. In 2004 the City Council enacted Local Law 57 to require more elementary schools to have nurses on staff. The law lowered the enrollment threshold at which an elementary school was required to have a nurse on staff to 200 students. The Department of Education has also been pushing the development of new small schools, further increasing the number of nurses required. Between 2004 and 2009, 68 new elementary schools were added to the list of sites requiring nurses. The total number of public elementary school sites with health department nurses now totals 717, excluding 52 sites where special School Based Health Centers provide more intensive primary health care services to children.

Not all of the schools that would lose a health department nurse due to the proposed increase in the eligibility threshold would be left without access to a health care professional during the school day. The Department of Education is responsible for providing nurses to public schools enrolling students with special medical needs as required by Section 504 of the federal Rehabilitation Act and the Individuals with Disabilities Education Act. The education department employed 549 full-time school nurses of its own in 2009, up 24 percent since 2004. The Executive Budget does not cut funding for Department of Education nurses.

The joint Office of School Health manages both the education department and the health department school nurses but maintains their budgets separately. Since there are many schools that qualify for a nurse based on both local and federal standards, the two agencies have reached a labor agreement to avoid duplicating efforts. Schools that fall into this category are assigned either an education department or health department nurse. The nurses from both departments are licensed professionals with either associate or bachelor’s degrees in nursing, have similar skill sets, and according to the labor agreement, provide similar services in the schools they serve.

The overlapping requirements that govern school nurse coverage mean that enrollment is not the only factor used to determine which public schools would lose their nurses under the plan. The Bloomberg Administration estimates that the proposed change to Local Law 57 would leave 68 public schools at risk of losing nurses based on current enrollment; however, 36 of these sites enroll students with daily medical needs that would qualify them for nurses under Section 504, leaving 32 schools at risk of losing coverage.

Moreover, many of the public schools in New York City are co-located with other schools. Even though co-located schools are administratively separate, the Department of Health and Mental Hygiene stresses that they could share a nurse if needed. Of the 32 schools that are eligible to lose a nurse, 13 of the schools share a site with another school whose nurse would remain. Consequently, if Local Law 57 is amended and the Executive Budget cut is not restored, 19 public elementary schools would lose nursing coverage, according to the Mayor’s estimate.

While Department of Health and Mental Hygiene officials estimate that 19 public schools would stand to lose a nurse, the result would be greater at private and parochial schools. The Bloomberg Administration estimates that 127 private and parochial schools would lose nurse services, meaning that 3,000 public school children and 30,000 nonpublic elementary school children could lose access to the services that school nurses provide. These services include monitoring vaccine compliance, administering daily medication, screening for hearing or visual impairments, and linking children to additional health services. Losing these services might be a hard pill for some New Yorkers to swallow.

Can the City’s Investment in Electronic Medical Records Net Health and Cost Benefits?

Posted by Jenna Libersky, February 11, 2010

As they wrangle over health care reform in Washington, one of the tools that policymakers count on to lower costs while improving medical outcomes is expanding the use of electronic health records. But well before national health reform took center stage, New York City embraced this technological tool.

For several years now, New York City’s Department of Health and Mental Hygiene has had its own initiative underway to help medical practices, particularly in under-served communities, integrate electronic records into their operations. The Bloomberg Administration clearly values the initiative: it added city dollars in the Preliminary Budget to offset state and federal cuts in Medicaid funds previously expected for the program at a time when other health services are facing the budget axe.

In 2007, as part of its Primary Care Information Project, the health department designed and began offering an electronic health record system to city physicians who care for the neediest patients. To qualify for the software and training package offered by the city, providers must have a client base made up of at least 10 percent Medicaid-enrolled or uninsured patients. Doctors must also be willing to bear the costs of hardware, installation, Internet connectivity, productivity loss during implementation, and a $4,000 fee to a fund that rewards providers for quality improvement. The fund offers on average $10,000 per physician for every patient with well-controlled cardiovascular risks and gives higher bonuses for Medicaid-enrolled or uninsured patients with health issues such as diabetes and heart disease.

The project’s budget for 2009 included $4.8 million in city funds and $13.5 million in state, federal, and private funds. One-quarter of the budget covered personnel costs, one-quarter covered supplies and equipment, and the remaining half was paid toward license fees for the software developer, eClinicalWorks, to support each provider that uses the technology. So far, over 1,600 providers have signed up.

The city’s role in this initiative is unusual, especially since many of the doctors derive significant income from private payers. The technology is more commonly used by large for-profit medical providers. But the city is targeting its efforts to smaller and less specialized practices.

Unlike standard electronic health records for which the purpose is simply to improve clerical efficiency, the city’s product has an additional goal: to improve public health by tracking health trends across all providers who participate in the system. Using the combined data from small practices can help health officials identify trends and potential risks to public health.

The health department’s system can also help individual patients by reminding doctors to monitor blood pressure and cholesterol, discourage smoking and alcohol use, offer vaccinations, and screen for depression, cancer, and sexually transmitted diseases. Practice-wide quality indicators and measures of indiviual patients’ progress are shared with the health department, and other participating physicians (with personally identifying information removed), and with the patients themselves.

The health department hopes the system will yield cost savings for the health system as a whole, as patients are less likely to need costly interventions to manage chronic conditions. But it is too soon to tell yet if the city’s investment in the system will actually result in savings. Academic research suggests that compared to paper records, electronic health records lower medical chart filing and transcription costs, increase revenue through more accurate billing, reduce the number of drugs and diagnostic tests prescribed, and prevent costly mistakes in administering drugs. One recent study showed net losses to providers within the first year of adoption but benefits that rose sharply in the years following, totalling $86,000 in net benefits per provider over five years.

Given the potential for savings, the city would expect a return on its investment. However, the direct effect of the new system on the city’s bill for health care—$5.5 billion for Medicaid and $3.5 billion for employee and retiree health benefits in 2010—is largely unknown. While electronic records can help doctors directly by lowering their administrative costs, a reduction in the city’s health care tab will depend on a couple of key factors. One factor will be the share of patients covered by plans that provide a flat fee to doctors for patient care. The other factor will be the degree to which private insurers and Medicaid managed care companies translate lower costs of care for doctors receiving a flat fee—mostly due to electronic records leading to fewer tests and procedures—to lower premiums paid by the city.

For the city cost savings from the health record initiative remain somewhat speculative. But, like other investments it has made (think calorie labeling and transfat bans), the city expects to see clear health benefits for its efforts.

Two Paramedics on an Ambulance—Only in New York

Posted by Bernard O’Brien, July 27, 2009

Each day in the city there about 880 serious medical emergencies reported over the 911 system which are deemed by Emergency Medical Services dispatchers to require response by highly trained paramedics. On average 15 of these daily calls are instead responded to by emergency medical technicians (EMTs) with less training because paramedics are not available.

Even when paramedics are available to respond, they can’t always do it as quickly as city officials want. The city has a goal of paramedics arriving within 10 minutes of a call 90 percent of the time. They hit that mark about 700 times a day—but they’d have to do it an additional 80 times a day to reach the goal.

Although a proposal announced last January by Mayor Bloomberg would perhaps help remedy these public safety concerns by changing the manner in which many fire department ambulances are staffed, the city has not yet been granted the state regulatory approval needed to implement the proposal. The city unsuccessfully sought this same change in 2005.

The proposed restructuring would allow some city ambulances, as well as those operated by private ambulance services, to be staffed with teams composed of one paramedic and one EMT rather than the current practice of putting two paramedics in the same ambulance. This would allow more ambulances with at least one paramedic to arrive at more emergencies without hiring additional staff.

The planned change in ambulance staffing would also have implications for the city budget. Since an ambulance with a paramedic charges more, revenue would increase. The recently adopted budget for 2010 assumes that the planned change in ambulance staffing would have been underway on July 1 and estimates that the restructuring would raise $2.1 million a year. The increased revenue would allow for a commensurate reduction in the city subsidy for fire department ambulance operations.

Understanding the staffing change requires a bit of background on the two levels of ambulance service provided by the fire department as well as the important differences between paramedics and EMTs. There are two types of ambulances: Advanced Life Support and Basic Life Support. Advanced Life Support units, currently required to be staffed with two paramedics, are dispatched to the most serious medical emergencies, such as heart attacks, choking incidents, and third-degree burn cases. Basic Life Support units are staffed with two EMTs and are typically sent to less critical emergencies such as complaints of heat exhaustion or respiratory distress.

Paramedics are more highly trained than EMTs, with the former receiving some 1,500 hours of training as compared with 120 hours to 150 hours for technicians. Paramedics’ higher level of training allows them to perform advanced medical procedures, including intubation and the administration of drugs. The city charges more for advanced medical care, receiving higher reimbursements from Medicare and Medicaid as well as from patients’ private insurance plans.

There’s only one place in the state where Advanced Life Support ambulances are required to have two paramedics—New York City. Regulations governing ambulance staffing in New York State are issued by entities known as regional emergency medical services councils. The membership of each council consists of physician representatives from public and private hospitals as well as local emergency medical services providers. There’s a council with responsibility solely for New York City.

Under current staffing and deployment levels, there are times when ambulances with paramedics are unavailable or unable to reach an emergency in a timely manner. In fiscal year 2009, in about 2 percent of serious medical emergencies—or about 5,500 incidents—paramedics were not available and EMTs responded instead. Even when paramedics are available to respond, it wasn’t always as promptly as the city aims for. In fiscal year 2009, 80.4 percent of serious medical emergencies were responded to by paramedics in less than 10 minutes, falling short of the fire department’s own goal of 90 percent for this performance indicator. (Responder and response time data cover ambulances operated by the fire department and the private services.)

By teaming paramedics with emergency medical technicians, more ambulances would be staffed with at least one paramedic, increasing the likelihood that an ambulance with a paramedic shows up when needed and on time.

In refusing the city’s 2005 request, the local emergency services council asserted that the city had not submitted convincing evidence that Advanced Life Support units responding to 911 calls within the five boroughs could be safely staffed with fewer than two paramedics. The union representing paramedics agreed, saying that working individually would put too much pressure on paramedics and be a risk to patients. The city’s latest proposal to reverse the unique two-paramedic rule for ambulances operating in the five boroughs has yet to change the council’s mind.