Hospitals Aren’t Waiting for Verdict on Health Care Law

By Nina Bernstein for NY Times

Giant aquariums now soothe pediatric patients at Maimonides Medical Center in Brooklyn. It has added welcome signs in 10 languages, a state-of-the-art cardiac operating room and programs to keep chronically ill adults safely at home. But as Pamela S. Brier, the chief executive, was walking to the main entrance last week, she spotted a rain-soaked plastic bag on the front steps.

Millions of dollars in revenue now depend on improving patients’ perceptions of the hospital. “I can’t stand it,” Ms. Brier muttered, and she darted over, her cream chiffon dress fluttering, to scoop up the litter herself.

It was the first Monday in June, counting down to a United States Supreme Court decision that could transform the landscape of American health care. But like hospitals across the country, Maimonides is not waiting around for the verdict.

Win, lose or draw in court, administrators said, the policies driving the federal health care law are already embedded in big cuts and new payment formulas that hospitals ignore at their peril. And even if the law is repealed after the next election, the economic pressure to care differently for more people at lower cost is irreversible.

“If the Supreme Court overturns this law — I pray it won’t — the world will go on changing,” Ms. Brier said. “In some ways, we’ve changed ahead of it.” But she added, “Trying to manage all these different aspects of the health care system as they are changing does make you crazy.”

The century-old hospital, at the Borough Park crossroads of Hasidic, Asian, Caribbean and Hispanic neighborhoods, is often cited by state regulators as an example of good management and community service.

It has been in the black since 1996, after Ms. Brier took charge of operations, and has increased patient volume every year while achieving some of the nation’s best clinical outcomes, including exceptionally low mortality rates for pneumonia, heart failure and heart attacks.

Yet even in a city with notoriously cranky consumers and cramped spaces, Maimonides’s patient satisfaction scores are abysmal — especially in its maternity units, which deliver 8,000 babies a year. And starting next year, under “value-based purchasing” contracts mandated by the health care law and already entrenched in Medicaid and Medicare rules, failure to improve the satisfaction of surveyed patients will cost hospitals.

Some hospitals have resorted to hiring outside consultants who coach nurses to recite a script praising the care — a strategy resented by short-handed staff members and denounced by their unions. Maimonides (pronounced my-MON-eh-deez), a 711-bed hospital that recently added valet parking and free Wi-Fi, instead asked labor-management teams in every unit to invent their own improvement projects. In one initiative, nurses are making hourly rounds to offer patients extra help.

Last Monday, a new father spoke with heartfelt gratitude of the night nurse who had explained that the chair where he was dozing upright opened into a bed.

“They treated us like family,” said the father, Iftekhar Aslam, 23, an American citizen born in Pakistan, beaming under his baseball cap at his wife, Sobia Khanum, and their newborn son.

He had not minded sharing the room, divided by a curtain, with another pair of new parents — “Israel people,” he said, adding joyfully, “That’s New York — it’s freedom here!”

Ms. Khanum, 26, was pleased, too, but mentioned that her husband had been so ill with fever before her due date that she had feared he would miss the birth. As a contractor without insurance, she said, “he didn’t go to the hospital because they send a huge bill.”

In theory, if the health care law works as intended, Mr. Aslam could become part of an influx of newly insured patients, offsetting government cuts in payments to hospitals that treat a disproportionate share of the poor and uninsured. But no one at Maimonides is counting on it.

“Quite frankly, if everything goes perfectly and everything is upheld, there’s a lot of confusion and a lot of uncertainty here,” said Dominick Stanzione, the hospital’s chief operating officer. “We also have an election coming up.”

The cuts, on the other hand, seem inexorable, and not only because Medicaid and Medicare budgets are strapped. The policy thrust in health care financing, private as well as public, is to abandon reimbursements to hospitals according to the number of days patients spend in a bed, in favor of models that use a fixed sum per patient or set of patients over time, regardless of where care is delivered or how little it costs.

Maimonides’s own successes have helped sell policy makers on the idea. Its collaboration with a state psychiatric hospital a few years ago, for example, put medical-mental health teams in storefront offices to manage the care of low-income patients with serious mental illness. Such patients, who are eligible for both Medicaid and Medicare, are among the health system’s most expensive and tend to have the worst outcomes. The program cut hospitalizations in half and reduced emergency-room use by 30 percent.

“When the State Health Department people saw our data, the little dollar signs danced in their heads,” Ms. Brier said.

Now, under a government contract, Maimonides is gambling on a bigger version of that program in partnership with 50 community agencies and Lutheran Medical Center, its closest competitor, to care for 15,000 mentally-ill people in what policy makers call a Health Home.

Such models immediately mean fewer visits to the emergency room, which is still a hospital’s “cash cow,” said Dr. Karen R. Nelson, executive director of the Health Home consortium. But ways for hospitals to reap part of the government savings are still in development, and patients excluded from the Affordable Care Act as illegal immigrants will still require costly emergency care.

“For a hospital to undertake this when A.C.A. is uncertain is very scary,” Dr. Nelson said.

At the same time, Maimonides is competing on the old fee-for-service turf by recruiting surgical and cancer specialists, partly to woo more commercially insured patients.

There, too, pitfalls abound: a growing share of the hospital’s unpaid medical bills are for patients who have private insurance but have been pushed into high-deductible plans, administrators said. Moreover, such plans typically do not reimburse care in the collaborative models the hospital is working so hard to develop — a problem that could intensify, they said, if the court rejects the individual insurance mandate but lets the rest of the health care law stand.

The gulf between model and reality was evident last week in the emergency room, which had more than 114,000 visits last year, up from 83,000 eight years ago.

In a section where triaged patients are seated to save space for more stretchers, one of those known as “frequent fliers” was back for the seventh time in six months, covered by Medicare.

The man, Lewis Rosen, 62, who said he had to come in for a psychiatric visit anyway, was unhappy with the rate of healing of an incision in his leg, despite treatment at an outpatient wound care center and home visits by a nurse.

“We’re our own worst enemy,” said Dr. Kenneth Sable, head of the emergency department, scrolling through Mr. Rosen’s electronic medical record. “Instant gratification is what people have come to expect.”

An older man hunched on a stretcher began to cry. It was his third visit in three days with a complicated story about a dental problem that he said had affected his mobility. After tests, he had been referred to a neurologist, but had not gone.

“I don’t want pain medication,” cried the man, Salvador Monduori, 68. “I don’t want to go home.”

Seven hours later, when doctors concluded that there was nothing more to do, they had to call security to make him leave, Dr. Sable said.

On a gurney at the other end of the room, Luis Velecela, 36, a construction worker, was confused but stoic after a diagnosis of stomach cancer. He had no insurance, he said, and had been treating his pain and nausea with antacid pills until an endoscopy at Maimonides revealed the tumor.

“All hospitals in the country are facing the same changes,” Dr. Howard L. Minkoff, head of obstetrics, said later. “We are doing it without a net.”