New York City area hospitals are being asked to take part in an unprecedented collaboration that would require public and private hospitals to share data, resources and transfer patients under one system, as part of an urgent state-coordinated effort to prevent the health care system from collapsing from a surge of coronavirus patients.
"We have to get those two systems working together in a way they never have before," Governor Andrew Cuomo declared during a press conference in Tuesday.
By most estimates, the plan is an ambitious undertaking, one that will try to transform within days what the governor himself has described as a sprawling and "balkanized" system: 170 hospitals in the downstate region segmented by geography, funding, size and specialties. Within New York City, the public and private voluntary hospitals have long been considered to be segregated, by resources, management style and to varying degrees, performance.
The 11 city hospitals are the largest public hospital system in the country, run by the NYC Health and Hospitals Corporation, a municipal healthcare provider controlled by Mayor Bill de Blasio. The roughly 40 private hospitals include Mount Sinai and NewYork-Presbyterian Hospital, two of the biggest hospital systems in the region. Unlike their counterparts, private hospitals are run by boards, which are often comprised of members recruited for their fundraising abilities.
Cuomo has made it clear that amid a crisis, these differences no longer matter. The distinction between private and public "has to go out the window," he said.
As of Tuesday, there were 44,635 confirmed cases of coronavirus in New York state, 6,481 of which are currently hospitalized. Prior to the outbreak, the number of hospital beds statewide totaled 53,000. Once the cases reach their peak, New York is projected to require as many as 140,000 beds.
The need for one system became apparent last week when Elmhurst, a 545-bed public hospital that is also a renowned teaching institution became ground zero for coronavirus patients, stretching the staff and equipment beyond capacity, according to the New York Times.
"If the battle is against the virus, we can’t pit hospital versus hospital," said Scott Stringer, the city comptroller who is working on the the plan alongside the de Blasio administration.
"We can’t fight over what nurses get the gowns," he added. "If there’s more resources at one hospital, we need to share them at another."
Carri Chan, a Columbia Business School professor who has studied patient flow through hospitals, and particularly intensive care units, said the governor's plan makes sense for both hospitals and patients. "From an operational standpoint, having a centralized system achieves massive economies of scale," she said.
Hospitals that suddenly become overloaded could transfer or have patients diverted to another one. Chan referred to the concept as "load balancing," where no single hospital gets overwhelmed. "If you think about it, it's one of the more egalitarian approaches," she said.
For patients, the benefits would be a reduction in total waiting time and access to better care.
Under the proposed system, New York hospitals will have to create a real-time dashboard on capacity data. Beyond the New York City area, Cuomo has said he foresees scenarios in which overburdened downstate hospital patients may need to be transferred to under-capacity facilities upstate. Indeed, the Albany Times-Union reports that this is already happening.
Currently, the Greater New York Hospital Association, a trade group which represents a network of private hospitals, tracks information on private hospitals. Kenneth Raske, president of the GNYHA, has been tapped by the governor to coordinate the effort.
Raske was unavailable for an interview, but during a press conference with the governor on Monday, he described the hospitals as "one cohesive family" in tackling the coronavirus crisis.
On Tuesday, a command center spearheaded by GNYHA began overseeing supply requests and purchasing for all of the hospitals.
Still, it was evident that news of the governor's plan did not immediately reach City Hall. On Monday, a spokesperson for de Blasio said the administration was not aware of having to develop a plan but added, "We’re working with GNYHA to share resources as needed and have a daily call with Ken Raske."
Dr. Irwin Redlener, the director of Columbia University's National Center for Disaster Preparedness, said that there has been good daily communication between the mayor and the city's hospitals.
But he also described the challenges of what is essentially a forced and unnatural merger.
"There's this very tricky balance between needs of hospital and its 'own patients' that may not be consistent with the level of serious cooperation that may be needed in a challenging medical crisis," he said.
The pandemic has already forced many hospitals to navigate unfamiliar terrain. Among industrialized countries, the U.S. has among the lowest hospital beds per capita and doctors per capita. All New York hospitals, many of which have spent years downsizing and cost-cutting, have now been ordered to expand their capacity by 50 percent. In New York City, the mayor has set out a goal of tripling the number of hospital beds, from 20,000 to 60,000.
And as opposed to fighting for patients, overwhelmed hospitals would now be incentivized to turn them away.
Redlener provided an example of a situation in which hospitals with backed up emergency rooms might find themselves with extra ICU beds at certain points. Do they offer them up to other hospitals or do they wait and save the beds for their own patients who will likely need them momentarily?
According to Chan, the plan is contingent on all hospitals having access to accurate real time information. Otherwise, she said, "You could end up with unintended consequences."
Redlener agreed. "The whole situation is going to be complicated," he said.
He envisioned a scenario in which all of the city's hospitals would be running above capacity. "No matter what is going to happen, it's not going to play out in a good way," he added.
On top of that, hospitals have traditionally been unwilling to make public any sensitive data, including the number of intensive care units or ventilators, a stance that Redlener criticized. "Hospitals are businesses and sometimes they behave like that," he said.
Some countries, like Ireland and Spain, have circumvented these potential problems by nationalizing the healthcare system for the duration of the coronavirus pandemic.
Redlener said the governor of New York has the power to seize control of all the hospitals and appoint a single healthcare czar.
But he argued that such a move would likely be the last resort in a society with strong capitalist values. "On some level we depend on local business leaders to carry out the policies that make sense," he said.
Chan agreed, saying it was would be better to secure "buy in" from all of the hospitals and have them appoint a leader.
Given the limited resources, a lack of cooperation by even one hospital would create a huge strain on the other members of the healthcare system.
On Tuesday, the governor used an analogy to describe the state's predicament.
"Our healthcare system is a chain," he said. "If one link breaks the whole chain breaks."
