In Intensive Care
Short-staffed and hemorrhaging cash, can the Westchester Medical Center recover?
by Nicholas Engstrom
Kevin Smith, a nurse at the Westchester Medical Center’s Post Anesthesia Care Unit, used to come to work at one in the afternoon and leave twelve and a half hours later. Lately, he says, he has sometimes been mandated by the hospital to work 16-hour shifts. Yet the 38-year-old Yorktown resident says he is not as overworked as some of his colleagues; other nurses, he claims, have been mandated to work 24-hour shifts. “Sometimes,” Smith confides, “I can’t see straight. I think I see one thing on the monitor when I’m seeing something else.”
Smith has worked for the 1,000-bed hospital for the past five years, but he says conditions for the staff have never been tougher. The scene Smith and other hospital insiders describe is one of overworked doctors and nurses, and a support staff that has been severely reduced by layoffs. Those staffers include couriers to take blood and urine to the lab, workers to change sheets, and janitors to clean up. As a result, nurses, some charge, must sometimes double as couriers—or janitors. A few weeks ago, according to Smith, a woman who had just come out of the operating room was bleeding onto the floor.
“Because the support staff was busy cleaning up somewhere else,” he says, “I had to go to the janitor’s closet, get a mop and disinfectant, and clean up the blood.”
On another recent occasion, a critically ill patient was hooked up to a ventilator, but, says Smith, the monitor to measure her heart rate and blood pressure wouldn’t work. “We had to move her to another station,” he says, adding that one of the two CT scan machines in the radiology room often goes down.
But the hospital’s most publicized problems have gone beyond staff shortages and broken equipment. In January 2004, the family of Michael Fisher filed a $100-million wrongful-death lawsuit against the hospital. Fisher, the heir to a real-estate fortune, died a day after coming to the hospital with a headache. He was 12 years old. That suit followed the death of Hassan Bolton, in which New York medical authorities faulted the hospital’s emergency-room staff for making the Peekskill man wait an hour for treatment while he complained of facial swelling, difficulty breathing and a toothache. Bolton stopped breathing 15 minutes after being seen by a doctor, and died within an hour. He was 27 years old. In 2001, a six-year-old boy was killed when a metal oxygen tank flew across the room and struck him on the head as he was about to undergo an MRI. Since then, the Medical Center has implemented new safety measures.
Then, this summer, seven very premature babies at the Medical Center tested positive for acinetobacter, a bacteria rarely found in infants. Four of the babies died. (Daniel Loughran, a spokesperson for the hospital, says that “since the original cases were identified, we have continued to test babies, and no new cases have been identified.” )
The management at Westchester Medical Center insists that the Medical Center is still the best hospital in the region. “There is no similiar institution in the area,” says its now retired president and CEO Edward Stolzenberg. “The Medical Center is indispen-sable to the overall fabric of the healthcare system in Westchester County. This is the only hospital that performs open-heart surgery, the only hospital with a pediatric ICU and specialty services, and the only hospital with kidney and liver transplants.” He adds that the hospital handles close to 200,000 outpatient visits a year.
The Medical Center’s management also insists that patient care at the hospital has not been affected by layoffs. Hospital spokesman Loughran says nurses have been asked “rarely” and “in serious situations” to work 24-hour shifts. “It is only used as a last resort,” he says. Interim President and CEO Mary Brown, head of a consulting firm that has been hired to restructure the hospital’s finances, told The New York Times on July 18 that the nurse-to-patient ratio is currently one nurse to every four to six patients and one nurse to every one to two patients in critical-care areas.
Smith and one of the other nurses we talked to question those numbers, and they worry that the cutbacks have hurt. “That isn’t to say the doctors and nurses here are not good at their jobs,” Smith says. “They are the best. But it’s not possible to provide the level of care we’re capable of providing in these conditions.”
Located in Valhalla on a 92-acre campus just south of the intersections of the Taconic, Sprain Brook and Saw Mill River Parkways, Westchester Medical Center, the only advanced-level care academic hospital between Manhattan and Albany, bills itself as “world-class medicine that’s not a world away.” Its resources are impressive. They include a trauma and burn center, the largest kidney-transplant program in the Northeast, centers focusing on heart disease and cancer treatment, and a new all-specialty children’s hospital. It is also the only hospital in the region with 24-hour air support provided by its own MedEvac helicopter service. It has on staff some of the best doctors in the metropolitan area. Each year, the hospital treats more than 400,000 patients. “Nobody has to go to the city to have anything [medical] done,” says Dr. Richard Moggio, former chief of the medical staff and cardiothoracic surgeon at the hospital who recently retired.
However, by most accounts, Westchester Medical Center is ailing. It is in precarious financial condition. When it split off from the county seven years ago to form a public-benefit corporation, its managers believed it would become a regional healthcare beacon, with the finest physicians in the country using state-of-the-art equipment to specialize in the most difficult procedures—and would consequently rake in revenues.
Instead, the hospital lost approximately $80 million in 2003 alone and has accumulated $278 million dollars of long-term debt. This has led to layoffs. According to Mark Genovese of the New York State Nurses Association, 192 nurses or 15 percent of the total nursing staff have been let go since March 2003; 43 nursing positions were eliminated this July. And, since April of last year, the hospital has laid off more than 350 workers including kitchen staff, couriers and others who are not involved in front-line patient care. The hospital has also suffered high-level resignations and charges of mismanagement. In particular, there have been allegations that money has not been well spent.
Recently, The Journal News reported that, over the last two years, a series of consultants hired by the Medical Center’s board to advise it on financial solutions have billed the hospital $11.6 million in consulting fees. One firm, Casas, Benjamin & White, the newspaper reported, billed the hospital thousands of dollars in expenses to stay at $385-per-night luxury hotels in Connecticut, took $1,000 to $1,500 plane flights from their office in Illinois to Westchester, and once booked a private jet for $3,429 to fly consultants and three board members from the Medical Center to Albany. (The $404 limo ride from Albany airport was added to the hospital tab.) After the article appeared, County Executive Andrew Spano and Chairman of the Board of Legislators Bill Ryan sent a formal request to New York Comptroller Alan Hevesi that the Medical Center be audited by the state.
To stem losses, the hospital hasn’t just laid people off—it has also cut back services. For example, in July, the hospital suspended its valued heart and pancreas transplant programs. Plus, its central distribution center for medical supplies, which once was open all the time, is now closed from 11 p.m. to 7 a.m., reports Kim Marsh, who until recently was a nurse in the cardiothoracic unit. “People evidently are not sick overnight,” says Marsh, now a representative for the nurses’ union. Marsh says she would sometimes need to pick up supplies like flowtron boots to prevent blood clotting but could not.
A number of hospital staff members are concerned about the situation; a Sleepy Hollow mother who has worked as a nurse at the hospital for more than a decade is an example. Although she says she is supposed to check on patients every 15 minutes, the nurse, who asked that her name not be used for fear of repercussions, says it is often 30 to 45 minutes before she gets back to each room. She reports that patients often wait for two hours after a 15-minute radiation treatment because there is no courier to take them back to their rooms; sometimes, she claims, doctors end up doing the courier’s work because the wait is just too long. Plus, she charges, chemotherapy patients sometimes come in for treatment but are turned down due to staffing problems. “Patients complain, saying, â€˜I came in to get my chemotherapy and now I can’t get it until tomorrow,” she says. “We are told by our supervisors not to admit that we are understaffed, so we say that we’re still checking their labs.”
As a result, morale, some insiders say, has plummeted. “Morale is at the lowest point I’ve ever seen it,” says Michele Fraser, a part-time nurse who has worked at the hospital since 1979.
Senior physicians deny that the quality of care has suffered because of the layoffs and budget mess. “The medical staff and the nursing staff still come to the hospital for one reason, and that’s to provide top-level care,” says Dr. Renee Garrick, a nephrologist. “Over the last decade, this has become one of the most respected hospitals for its care in the region.”
Some physicians are starting to leave as well. Three attending physicians have left the psychiatric unit since October 2003, and they have not been replaced, reports a doctor who did not wish to be named. All three cited low morale and frustration as their reasons for leaving, the doctor says.
Attending physicians are paid by the New York Medical College, which is affiliated with the center. The Medical Center is now $11 million in debt to the College for services that it and its physicians have provided, says Donna Moriarty, the College’s spokesperson.
Meanwhile, resignations in upper management have left a vacuum at the Medical Center as well. The chief executive officer, the chief financial officer, and a senior executive vice president have all departed in the past year. (It did not please some employees that in April, Joe Pisani was promoted from CFO to chief administrative officer, and his salary was raised from $275,000 to $480,000.)
As state and local officials scramble with hospital officials to devise a bailout plan for the struggling hospital, Westchester County residents have been left to wonder how Westchester Medical Center’s finances declined so quickly.
When the hospital broke away from the county in January 1998, the move was supposed to benefit the county and the hospital: The county, it was believed, would save money, and the hospital would be freed from the county’s restrictive procedures and requirements. The hospital would be able to invest in programs that would be initially costly but would provide greater profit margins over the long term.
“The hospital wasn’t able to get out on the competitive edge with other hospitals when it had these laborious processes to go through,” says Dr. Moggio. “When we were with the
county, large expenditures had to be approved by county legislators.”
Most of the doctors and nurses were for the split from the county, and the prognosis for hospital profits, like much else in the late ’90s, was optimistic. As recently as 2001, former president Stolzenberg said that he hoped that the Medical Center would eventually serve the entire northeastern United States. The hospital set out to hire top-tier doctors, enticing them by offering to give them whatever equipment they needed to make Westchester Medical Center a prestigious institution. This included purchasing the Novalis Shaped Beam Surgery, advertised by the hospital as “the future of radiosurgery and radiotherapy,” and the $1.4 million da Vinci Surgical System, robotic surgical arms that assist doctors in reaching different areas.
In early 1999, Westchester Medical Center recruited Dr. Edmund La Gamma from Stony Brook to head its neonatology unit. Stolzenberg, then head of the hospital, asked Dr. La Gamma what he needed in the way of equipment to move to the Medical Center, and the doctor gave him his wish list.
“I got the purchase orders before I left Stony Brook,” he says.
When Dr. La Gamma became the chief of the division of newborn medicine and the director of the regional neonatal center and ICU at the Medical Center, there were three neonatalogists. Now there are 23, though some are under contract to neighboring hospitals. There were four fellowship trainees; now there are 12. There were five nurse practitioners; now there are eight. In 2001 the neonatal ICU purchased two ECMO, or heart lung bypass machines, paying $350,000 for each. The ECMO machines are used on five to 10 infants a year.
“You can argue it both ways,” says Dr. La Gamma. “You can say our hospital wouldn’t be in financial crisis if this technology were not available. Well, some babies would be dead if this were not available. You can ask the parents of some of these patients if it was worth it.”
The Neonatal ICU is being moved to the Maria Fareri Children’s Hospital, a new unit of the Medical Center in a brand new 250,000-square-foot building. The building resembles a ski resort. Its whimsical design (“more Sesame Street than hospital,” opined one visitor) stands in stark contrast to the Westchester Medical Center’s adjoining main building, a comparatively drab structure betraying its county-hospital origins.
The original budget for the project, $90 million, was not quite enough to make the new unit “world-class,” says Bruce Komiske, the executive director of the Children’s Hospital. But thanks to philanthropic and community donations (some not monetary), he says, the Children’s Hospital will be among the best in the world. The new unit boasts a real train in the food court, a fire truck, a movie theater showing first-run features, a miniature golf course, an aquarium, a video arcade housed in the facade of three real subway cars, hockey and baseball history exhibits, and the world’s largest dollhouse.
The Maria Fareri Children’s Hospital will replace the hospital’s original children’s wing, and it will house a new adult and pediatric Regional Trauma Center. The area left vacant in the Medical Center’s main building is to be renovated and reconfigured for other care needs. This renovation is in the planning stages, despite the Medical Center’s financial problems.
Still Alfred Del Bello, the first chairman of the Medical Center’s board and a current board member, is optimistic. “When the Children’s Hospital becomes a great success, then a lot of the pain that we are going through now will be forgotten,” he says.
Gary Conley, the president of CSEA Local 860 in Westchester, the union whose members have suffered the most layoffs since the crisis began, isn’t as sanguine. Declares Conley: “You can’t ride around in a Cadillac if the best you can afford is a bicycle.”
That these expensive ambi – tions have led to the Medical Center’s current financial mess is not readily acknowledged by the hospital’s management. Westchester Medical Center is hardly the only hospital in the region, indeed the nation, to suffer financial hardship (“Every major academic center is facing the same problems,” says Dr. Moggio), and some of the Medical Center’s problems can indeed be traced to factors beyond its control. The management points to a statewide, even a national, trend of failing hospitals. According to a report by the Healthcare Association of New York State, New York hospitals have lost a combined $1.8 billion from providing patient care over the last five years. The losses have been multiplying: $134 million in 2000, $258 million in 2001, $726 million in 2002.
Inadequate HMO reimbursement and Medicaid payments from the government are partially to blame, maintains Ken Raske, president of the Greater New York Hospital Association. “The HMOs will say one day of a seven-day visit was too long, and they will question procedures and call them unnecessary,” he says. “Basically, they’re trying to fatten their bottom line at our expense.”
In 2002, HMO profits in New York reached $762 million, while hospital bottom-line losses for the same year came to $726 million. New York hospitals lost $1.5 billion on Medicaid reimbursements alone in 2001. Medicaid pays $95 dollars for each emergency room visit by a Medicaid patient, a rate that has not increased since 1991. New York hospitals lose more than $231 on every Medicaid patient treated in the emergency room.
Westchester Medical Center’s financial problems also are a consequence
of the separation deal between the hospital and the county, acknowledges Assemblyman Richard Brodsky, a Greenburgh Democrat, who wrote the 1997 legislation to split the hospital from the county. He says a series of agreements they made turned out horribly for the hospital. For instance, the Medical Center took on the responsibility for paying malpractice claims made while the hospital was county-owned. “Six to 12 million dollars in cash per year is being paid out of hospital revenues now for negligence claims made while the hospital was part of the county,” says Brodsky.
What’s more, because Westchester Medical Center was a county hospital until 1998, it was funded by taxpayer support, which means that when it switched from public to private funding, it had no endowment, unlike most major hospitals in the metropolitan area. Hospitals depend on their endowments to save them during hard times.
Still, management decisions—including the takeover of the failing St. Agnes Hospital, a small Catholic hospital in White Plains, which eventually closed, and the bankrupt Ellenville Hospital—haven’t helped its bottom line.
“The hospital’s situation is a structural problem caused by underfunding and compounded by mismanagement,” Brodsky says. “If they had been adequately funded by the three levels of government, we wouldn’t have any crisis.”
Conley, president of Local 860, sees it somewhat differently. “If the problems were strictly reimbursement failures by HMOs, Medicare and Medicaid, the hospital management would have been the first to lay out all the facts,” he says. “It may not have been intentional, but somewhere along the line this hospital was mismanaged.”
Westchester Medical Center board member Alfred Del Bello concedes: “It’s our fault. We were charged with running the Medical Center, and whatever the problems are, they have to stop at our doorstep.”
The medical center’s latest attempt at shoring up its finances came in March, when its board of trustees voted unanimously to turn management of the hospital over to Pitts Management Associates of Baton Rouge, LA, a consulting group that previously advised the hospital and the county. Pitts is being paid $375,000 a month for the first three months of its consulting contract—and $325,000 a month thereafter.
Interim President Mary Brown, head of Pitts Management, has said she doubts that there will be further front-line patient-care layoffs. Still, many staffers are nervous. “Five years ago I knew a lot of people who were damn proud to be working for a hospital that specialized in so many different programs,” Conley says, “but now they’re worried about their jobs.”
And the effect of previous layoffs is still being felt. “I was talking to a courier the other night,” says the nurse from Sleepy Hollow, “and I said, â€˜Look, I ordered this blood from the blood bank two hours ago, and it hasn’t come yet.’ The courier said to me, â€˜You don’t understand. I’m the only courier in the hospital right now.’”
Nevertheless, many observers say that the hospital is in no danger of going under; it is simply too important to fail. But as county and state officials meet with the hospital to try to construct a bailout package, chances are good those footing the bill will be Westchester residents.
The county continues to give the hospital an $85 million line of credit. It also guarantees some of the hospital’s bonds. The county’s bond ratings were lowered this year in part because of the hospital’s poor financial condition.
Not surprisingly, the county government isn’t happy about the situation. “The Medical Center got themselves into this mess,” says Larry Schwartz, the deputy county executive, “and they must demonstrate the will and competency to get themselves out of it. They can’t come back to the county every six to twelve months with hat in hand.”
The current situation has deeply saddened those who have been involved with the hospital for a long time. Del Bello has been close to the Westchester Medical Center since he was Westchester County Executive from 1974 to 1983, when the Medical Center was built.
“My wife picked out the brick for the main building,” he says, “which is why I go home at night crying about what’s happened to it.”
Nick Engstrom is a freelance journalist. He has written for this magazine as well as the Columbia Journalism Review and the Cambodia Daily newspaper in Phnom Penh.