High Quality Care Can Lower U.S. Healthcare costs: A case study from Brooklyn
This article was originally published by STAT News First Opinion.
After two decades spent working as a cancer and HIV/AIDS researcher at the Dana-Farber Cancer Institute and Harvard Medical School and another 12 years heading a biotech company, I started a foundation in 2007 to identify and write about best practices in global health care, and then to find people who wanted to apply these practices and help them to do so. Little did I know then that an improbable story in delivering excellent patient care was beginning to unfold in my own backyard.
At the time, New York University’s medical center was in trouble. Its quality of patient care ranked 60th among 90 academic medical centers in the U.S.; its medical school and medical research standards were mediocre, and declining. The faculty and staff had been in continual turmoil, if not rebellion, for a decade. As financial losses mounted, university trustees worried about the finances of the entire university.
Unlike many New Yorkers, I wasn’t aware of the troubles at NYU’s medical center. I didn’t learn about them until 2013, well into its spectacular turnaround, when I was helping NYU develop several innovation programs in Shanghai.
Curious about what had happened, I reached out to Dr. Robert I. Grossman, the former chair of radiology who was tapped in 2007 to lead what is today known as NYU Langone Health, and asked if I could study his organization as an arms-length researcher with long experience in medical education, medical science, and biotech companies. I thought it would be a good lens through which to see the broader potential for improving what we get for our money in the U.S. health care system.
As part of this research, I interviewed more than 30 key executives, deans, clinicians, and trustees, as well as many patients during a time when I was treated successfully for cancer at NYU Langone. Neither NYU nor NYU Langone compensated me in any way for this work, and the analyses and conclusions detailed in my book, “World Class,” are my own.
The U.S. pays twice as much for health care than other industrialized nations, yet our outcomes are mediocre, and falling. In a recent Bloomberg analysis, the U.S. ranked 35th among more than 160 nations, five notches below Cuba. How can we improve this dismal standing? Delivering high-quality care at every turn is the essential first step.
Many policymakers and health care administrators in the U.S. do not recognize the bonus of emphasizing high-quality patient care: Quality reduces costs. Outside of the health care sphere, successful senior executives have made quality their guide for years. Get it right the first time. Avoid costly do-overs and customer complaints. Measure progress. Hold people accountable. And so on. This rigor is a big part of how Apple, Toyota, Starbucks, and other leading brands built their reputations.
When an institution is not doing well, people become complacent. When they see leaders who want great results, people get on board. They come out of the woodwork to help you, especially in the medical field.
Grossman started like this: He asserted in his inaugural speech that NYU Langone should not be satisfied simply to recover from crisis. Why not be the best, he proposed, and compete with “the Hopkinses, Harvards, and Penns”? To get there, he said, every decision taken at every level must answer one question: Will this improve patient care? Nursing schedules. Executive and dean appointments. Emergency department staffing. Elevator maintenance. Ambulance routes. Lighting. Everything. Will this improve patient care?
With that question as a North Star, Grossman and his colleagues sparked a revival. NYU Langone today ranks among the most efficient U.S. medical centers in delivering high-quality care to its patients. It is in the upper tier in quality of patient care, medical education, and medical research.
Its transformation of Lutheran Medical Center, a struggling 450-bed safety net hospital in Brooklyn’s Sunset Park neighborhood, offers insights for how the systems that NYU Langone applied in Manhattan for a dozen years can benefit hundreds of mainstream health care institutions across the U.S.
Lutheran Medical Center was established more than a hundred years ago. The neighborhood it serves has more people enrolled in Medicaid than any other ZIP code in New York state. The hospital’s survival has long depended on government support. (That’s a far cry from the many higher-income, well-insured patients seen at the main NYU Langone hospital across the East River in Manhattan.) Brooklyn has long been an important market for NYU. For example, approximately half of the babies born at NYU Langone’s Tisch Hospital go home to Brooklyn.
When NYU Langone took over management of Lutheran Medical Center in 2015, the hospital was confronting the same challenges that faced many safety net hospitals: uneven staffing resulting in inefficient care, limited resources for improving quality and providing special services, and an aging facility. But it offered NYU Langone an opportunity to expand its care systems across Brooklyn and its 2.6 million residents.
When the NYU Langone team arrived with its passion and playbooks, it went to work using the same question at the heart of its revival of the Manhattan medical center: Will this improve patient care?
The team looked at how each function in the hospital affected patient care. It started at the top and kept the staff largely unchanged.
Internal measures of patient service and quality of care now match and, sometimes exceed, the ultra-high scores at NYU Langone in Manhattan. Lutheran Medical Center, now called NYU Langone Hospital—Brooklyn, breaks even financially.
It’s an administrative success that has real significance for patients who receive care there. An Uber driver overheard me talking on the phone about my description in the book of the Brooklyn hospital’s turnaround. “I need that book,” he said. “You do?” I said, taken aback. “Why?” He told me that he, his grandmother, mother, and brother were all patients at the hospital.
He was ecstatic about the changes he and his family members had experienced since NYU Langone took over the hospital: shorter wait times in the emergency room, friendlier staff members, better care and follow-up. The driver told me about a day he and his grandmother went to the emergency department. A doctor saw them within minutes. Upon learning that the grandmother spoke only Arabic, the doctor retrieved a tablet with an app that translated what she was saying into English. Minutes later, an Arabic-speaking translator appeared.
Cadets at the U.S. Military Academy, our future Army leaders, are taught that there are no priorities among essentials. It’s a keen insight for any organization. Here are five essentials from the management playbook honed in Manhattan that NYU Langone applied in Brooklyn to rapidly improve quality of patient care and rein in costs.
Leadership. Change requires committed leaders. Administrators and clinical directors from NYU Langone’s bench in Manhattan replaced a number of administrators and most clinical chiefs in Brooklyn, aiming to bring the same expertise that had revived NYU Langone, while most of the full-time clinical staff and employees remained. Good leaders define and support the optimal path to get their organizations to the desired goal. At NYU Langone—Brooklyn, as in Manhattan, leaders provided the staff with more clarity on how their performance would be measured, on how equipment and maintenance would be upgraded, and how the staff needed to improve patient satisfaction scores.
Quality. Treating patients with the right medicine at the right time in the right way is cost-effective. It usually means you don’t have to repeat those steps. NYU Langone—Brooklyn eliminated unnecessary diagnostic tests and blood transfusions, redesigned clinical practices, and discharged patients when they were ready to leave rather than having them linger in the hospital waiting for nonmedical, bureaucratic tangles to get sorted out. For example, some patients had to wait weeks for official immigration documents to arrive. Others with little or no family support feared living on the streets. Small teams of medical staff members and social workers were able to resolve those and other issues more quickly.
Convenience and technology. Before the merger, Lutheran Medical Center had dozens of ambulatory clinics in neighborhoods near the hospital that offered mainly basic, primary care to nearby schools. Few of them were using the kind of modern medical technology that now makes it possible to do things in neighborhood facilities that once could be done only in hospitals — and sometimes even do them better. Even before it agreed to merge with Lutheran four years ago, the NYU Langone health system already had a growing network of ambulatory care centers in Brooklyn neighborhoods, with about 100 doctors active across ten sites. There are now 65 locations. Most are quite sophisticated, some staffed with surgeons and state-of-the-art equipment. Adding these facilities to the NYU Langone—Brooklyn network enabled the hospital to provide more services where people live. These facilities are less expensive to operate because they do not have a hospital’s high fixed costs.
Financial discipline. Although hospital admissions fell 30 percent last year, revenues from hospital stays at NYU Langone—Brooklyn were only modestly lower. One reason is the system’s billing process is more efficient in collecting payments from the government, insurers, and patients for the varying levels of care provided. Bills also are calculated more accurately and consistently.
Today, everybody talks about what the government should do to improve health care. We should be talking more about what health care providers themselves should do. I am convinced that NYU Langone’s approach can help communities anywhere in the country accomplish what we all want: high-quality health care at lower cost.
William A. Haseltine, Ph.D., is chair and president of ACCESS Health International, a global health foundation; former head of the Dana-Farber Cancer Institute laboratories in cancer and HIV/AIDS research; former professor of medical sciences at Harvard Medical School; and a biotech entrepreneur. He is also the author of “World Class: A Story of Adversity, Transformation, and Success at NYU Langone Health” (Fast Company Press, 2019).