B-HIP and SUNY Downstate Medical Center Release Report on Healthcare Resources in Northern and Central Brooklyn: First Ever Comprehensive Study

Aug 24, 2012

Unavailability and Underutilization of Existing Primary Care Capacity Lead to High Rates of Preventable Emergency Department Visits and Hospitalizations

The Brooklyn Healthcare Improvement Project (B-HIP), a coalition of Brooklyn hospitals, health centers, insurers, grass roots community organizations, and government agencies led by SUNY Downstate Medical Center, has released a report detailing the state of healthcare in Northern and Central Brooklyn. The report was funded through a New York State Department of Health HEAL-NY grant issued in February 2009.

"Making the Connection to Care in Northern and Central Brooklyn," is the first ever comprehensive study of the healthcare system to be conducted in Northern and Central Brooklyn, among the most densely populated areas in the country. The study findings and recommendations were presented to the New York State Department of Health in Albany on August 23.

"The extensive work of the B-HIP coalition and the Medicaid Redesign Team is an example of how community planning and input can support the transformation of the existing healthcare delivery system," State Health Commissioner Nirav R. Shah, MD, MPH, said. "The Brooklyn community is a priority of this administration, and this Report will assist and inform efforts to improve healthcare quality and stabilize the delivery system."

John Williams, MD, EdD, MPH, president of SUNY Downstate Medical Center, said, "As Brooklyn's only academic medical center, Downstate is in a unique position to lead this broad coalition of institutions dedicated to providing quality healthcare to the residents of the borough. We thank the State Department of Health and all the study participants for their support and hard work in this groundbreaking effort."

The Report provides a framework for regional healthcare planning. It also includes an invaluable window into the challenges associated with providing care to inner-city populations with significant levels of high-needs patients. While documenting that many emergency room (ER) visits are avoidable, it also documents widespread, deeply ingrained patient preference for using ERs for care instead of private physicians. Convenience, "one-stop care," and single instead of multiple co-pays play a critical role in patient decision-making.

The Report is based on a block-to-block canvass of physician offices and healthcare facilities and interviews with over 12,000 emergency department patients and caregivers, as well as analyses of census information, New York State planning data, and claim data sets from eight insurance companies. In addition, B-HIP has created a Provider Directory and an innovative Geographic Information System database and mapping tool that will allow public health researchers to drill queries down to the census tract level.

The data sets and tools created by B-HIP will provide information to planners, researchers, and policymakers implementing local health system reforms, including Medicaid Health Homes, ACOs, and other hallmarks of the Affordable Care Act. They should also provide evidence-based support for New York State's efforts to improve population health through reform of its Medicaid program.

The area surveyed consists of 15 contiguous zip codes encompassing 22.2 square miles and over one million individuals, comprising 5% of the entire population of New York State. It is also a highly challenged area, with over 80% of residents receiving Medicaid or Medicare or having no insurance. Median and per capita income here is far lower than the rest of Brooklyn, New York City, and New York State, fewer individuals have graduated from high school, and about two-thirds of households speak a language other than English at home.

"Although the B-HIP study area has only 42% of Brooklyn inhabitants, it generated 48% of all hospital discharges, 55% of all Ambulatory Care Sensitive Condition (i.e., potentially avoidable) hospital admissions, and 61% of ER visits without admissions in the borough," said Grace Wong, MBA/MPH, vice president, managed care and clinical business at Downstate, and B-HIP principal investigator.

Key findings include:

There is a shortage of quality, accessible primary care throughout much of the study area.
B-HIP found one full-time primary care physician (PCP) for every 1,502 individuals, with PCPs and other health services distributed unevenly across the study area. While only slightly over the federal Medicaid managed care plan-allowed panel size (the number of patients a provider can effectively care for) of one full-time PCP for every 1,500 patients, the numbers do not tell the complete story. In the survey area, there is a high prevalence of chronic disease and premature mortality, as well as language barriers, meaning that physicians may spend longer times counseling patients.
There is a shortage of primary care that is accessible after hours, or at times convenient for working people.
Of 11,623 total weekly operating hours for area PCPs, only 16% are on weekends or after 5:30 pm. However, survey results suggest that PCP appointment slots in the community are available during working hours and providers are looking to serve more patients regardless of insurance, an indication that PCPs in this area may be underutilized. 83% of providers would accept a patient regardless of their insurance type. 50% of those would accept a patient within one day, and 93% were able to accept a patient within a week.
Three "hot spots" – Brownsville/East New York, Crown Heights North/Bedford Stuyvesant and Bushwick/Stuyvesant Heights – represent 9% of all potentially preventable ER visits, 8% of all ACSC discharges, and 6% of total hospital discharges in Brooklyn, but only 4% of the borough's population.
Yet, each of these areas has a higher PCP FTE-to-population ratio than the rest of the B-HIP area.
A significant number of patients who seek ER care are insured.
81% of ER patients surveyed had Medicaid, Medicare or other form of insurance; 19% were uninsured.
A significant number of patients who seek ER care are there for non-emergent conditions.
41% of surveyed patients with insurance indicated they had come for reasons other than emergency care. Of the 19% of surveyed patients who were uninsured, 48% sought ER care for non-emergencies. When asked why they used the ER, 18% of all patients surveyed said because of convenience; 18% said their PCP office was closed; 15% said they had no PCP; and 17% said the ER is where they always get their care.
The majority of ER patients wanted or saw no other choice than to go to an ER.
When asked, "If not seen at this ER today, where would you get care?," 65% said they would go to another ER, and only 15% would have rather gone to see their PCP. Another 12% said they had nowhere else to go.
Many enrollees in managed care may not have a clear understanding of the managed care system.
Of the respondents who identified themselves as enrollees of Medicaid managed care, Child Health Plus, and Family Health Plus plans, 17% indicated they did not have a PCP or did not know if they had a PCP, even though they must have one under managed care guidelines. Further complicating this challenge is that the provider directories from various health plans have a high error rate. The door-to-door canvass revealed 19% of the locations listed as physician offices were either abandoned buildings, private homes, or other businesses.
Based on longitudinal analysis of insurance claims data, the majority of insured ER visitors have not seen any providers within weeks to months prior to or after presenting in the ER.
Less than 17% had any physician/outpatient visits during the week prior to the ER visit (increasing to roughly 38% if the time is increased to four weeks), while only about 27% of patients accessed post-ER visit follow-up care one week after the ER visit, which increased to 45% in four weeks. In addition, commercially insured patients appear to have worse pre- and post-ER visit connection to outpatient care than patients with Medicaid.
Based on mapping of hospital discharges, B-HIP area residents tend to use Brooklyn hospitals to a greater degree (79%) than residents of the non-B-HIP area (73%).
Reduction in avoidable care utilization in the B-HIP area would result in significant savings.
Reduction in rates of potentially preventable ER visits, total hospital discharges, and ACSC discharges to the Brooklyn-wide levels would result in at least $145 million in annual savings; reduction to the non-BHIP Brooklyn neighborhood rates would result in $465 million in annual savings.

The Report also offers numerous suggestions to address the healthcare challenges in Northern and Central Brooklyn. It strongly recommends that future interventions in this area include not only system reforms but strategies to improve patients' and the community's engagement in their own health care.

"One of the conclusions that can be drawn from the Report's analyses is that healthcare planners and policymakers need to look at how to change systems to better accommodate patients," said Ms. Wong. "We need to remember that it is the needs of patients, not of institutions, that must be met."

B-HIP partners include:

New York State Department of Health
The New York City Department of Health and Mental Hygiene
Office of the Brooklyn Borough President
SUNY Downstate Medical Center and its School of Public Health
Six hospitals: SUNY Downstate Medical Center/University Hospital of Brooklyn;
Kingsbrook Jewish Medical Center; Kings County Hospital Center; Interfaith Medical
Center; Brookdale University Hospital & Medical Center; Woodhull Medical & Mental
Health Center.
Nine health insurance plans: Healthfirst; HealthPlus (now part of Amerigroup/
Wellpoint); Aetna; Empire Blue Cross Blue Shield; MetroPlus; Emblem-HIP/GHI;Neighborhood Health Providers; United Health Care; and 1199 NBF.
Federally Qualified Community Health Centers: Bedford Stuyvesant Family Health
Center and Brownsville Multi-Service Family Health Center.
Local Community Boards.
Community based organizations: Brooklyn Perinatal Network; Brooklyn Congregations United; Caribbean Women's Health Association; Brooklyn Health Disparities Center; Church Avenue Merchants Block Association (CAMBA); Christopher Blenman Senior Center; and St. Gabriel's Senior Center.
Private sector/industry: Novartis Pharmaceuticals Corporation; Brooklyn Chamber of Commerce; Caribbean American Chamber of Commerce.
Health policy non-profit organizations: The Primary Care Development Corporation; United Hospital Fund; and Coalition of Behavioral Health Agencies.

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About SUNY Downstate Medical Center

SUNY Downstate Medical Center, founded in 1860, was the first medical school in the United States to bring teaching out of the lecture hall and to the patient’s bedside. A center of innovation and excellence in research and clinical service delivery, SUNY Downstate Medical Center comprises a College of Medicine, College of Nursing, School of Health Professions, a School of Graduate Studies, School of Public Health, University Hospital of Brooklyn, and a multifaceted biotechnology initiative including the Downstate Biotechnology Incubator and BioBAT for early-stage and more mature companies, respectively.

SUNY Downstate ranks twelfth nationally in the number of alumni who are on the faculty of American medical schools. More physicians practicing in New York City have graduated from SUNY Downstate than from any other medical school.