Review of Health And Hospitals Corporation’s Response to COVID-19

Re: Review of H+H’s Response to COVID-19

Dear Governor Cuomo:

I am writing to relay the findings of the review into the performance of New York City Health +
Hospitals (H+H) to the COVID-19 pandemic conducted by my Office pursuant to your request.
Our evaluation included a review of public source documents and interviews with officials from
the City of New York, H+H, and representatives of H+H employees. The findings and
recommendations contained in this letter should be considered preliminary; I recommend a more
in-depth review be undertaken at the appropriate time to build upon our analysis.

To review a related matter of the City’s preparedness for this crisis, I have recently requested
from the City the records necessary to conduct a thorough investigation into decision making
within New York City government leading up to, and during, the pandemic. This investigation,
when completed, will provide an in-depth analysis of the successes and shortcomings in the
City’s response to the pandemic, and may contain findings that confirm or revise the findings of
this initial review.

COVID-19 has devastated New York City, claiming more than 22,000 lives as of mid-June. The
pandemic quickly placed extreme stress on New York City’s healthcare systems – including, but
not exclusively, H+H. Years of planning for the next pandemic and early action to obtain
necessary resources could not meet the challenge of this health crisis. This review found that
H+H, and the larger system within which it has operated during the pandemic, faced an
unprecedented situation for which no one was fully prepared. The lack of preparedness forced all
players to improvise responses, sometimes successfully, sometimes not – but inevitably at a cost
in human lives. Several deficiencies were noted, including inadequate access to needed supplies
and equipment, a lack of systems and procedures for managing patient loads across hospitals,
and insufficient protocols for deploying staff.

COVID-19 has also once again highlighted the deep inequities in access to healthcare in our communities: people living in lower-income neighborhoods, people of color, and those with
underlying health conditions have been more likely to die from the virus. These are the
communities that rely on H+H for care. A history of disinvestment in healthcare in those same
communities further increased the burden of care on H+H hospitals. Certain operational
deficiencies we identified can be addressed in the short term, but the deeper problem of
inequitable access to healthcare must be considered equally urgent, even though it will take more
time and resources to address.

H+H Serves a Population Disproportionately Impacted by COVID-19
COVID-19 has disproportionately impacted New York City’s lower-income communities of
color, a large component of the population H+H serves. For example, as of mid-May, the
age-adjusted death rate was twice as high for Black and Hispanic New Yorkers than for the
City’s white and Asian population. H+H’s outsized role in providing care to these vulnerable
City residents most severely impacted by COVID-19 is frustrated by its lack of resources and
financing.

In FY 2018, H+H facilities served 1.097 million patients through 4.13 million outpatient visits,
1.12 million emergency department visits, 187,000 inpatient visits, and 68,900 ambulatory
surgery visits. Prior to the pandemic, the City’s public hospital system provided 20 percent of
total hospital beds citywide (about 4,700 beds at 11 acute care hospitals) and 18 percent of the
City’s intensive care bed capacity.

Although they are not the majority of all patients served in New York City, H+H’s patients
disproportionately suffer from high rates of the conditions that make them uniquely vulnerable to
COVID-19. For example, of the total number of H+H encounters with patients in FY 2018:

● 894,000 visits involved a patient who was 65 years or older;
● 1.9 million visits involved a patient with a hypertension diagnosis;
● 1.5 million visits involved a patient with a diabetes diagnosis;
● 1.4 million visits involved a patient with a mental health diagnosis;
● 791,000 visits involved a patient with an asthma diagnosis; and
● 1.1 million visits involved a patient with a substance use disorder diagnosis.

H+H runs some of the busiest emergency departments (EDs) in the country, with more than one
million visits in 2019. Lincoln Hospital and Kings County Hospital ranked sixth and fourteenth,
respectively, in the nation for annual emergency room visits in 2018.

Busy does not translate to being seen promptly. H+H EDs perform relatively poorly on measures
of strain in the emergency room, e.g., how long it takes for patients to be seen, receive
medication, and be admitted or discharged. For example, at Elmhurst Hospital, patients must
wait on average more than four hours before being sent home from the emergency room, if not
admitted, and more than 11 hours to be admitted. At both Kings County Hospital and Jacobi
Medical Center, the average wait to be admitted is more than 12 hours. Across New York State,
the average wait to be admitted from the emergency room is approximately six hours and the
average wait to be discharged, if not admitted, is less than three hours.

H+H EDs are busy in part because they often serve larger surrounding areas, called “catchment
areas,” than private hospitals. Elmhurst Hospital, for example, serves a catchment area of
372,000 New Yorkers, compared to 127,000 for NYU Langone and 174,000 on average
citywide. The reliance on the City’s public hospital system to meet the needs of communities
without choices in healthcare has grown with hospital closures and downsizings that have
resulted in about 20,000 fewer hospital beds in New York State since 2000. In the last 2 decades,
at least 16 hospitals in New York City have closed, including four in Queens and three in
Brooklyn.

As a public hospital system, H+H’s mission is to treat those individuals unable to pay for
medical care. In FY 2019, about one-third of the approximately 1.1 million unique in- and
out-patients served at H+H facilities were uninsured. About 70 percent of H+H patients are
insured by Medicaid or have no insurance, compared to 40 percent for private (“voluntary”)
hospitals in New York City. As of the beginning of FY 2020, revenues from patient insurance or
payments covered just 61 percent of H+H’s expenses; the balance was provided by public
subsidies. In the first four months of FY 2020, after falling in recent years, the number of
uninsured H+H patients rose by 8 percent. Public subsidies fill the H+H budget gaps that are
caused by the number of uninsured and Medicaid patients it treats.

Among the most important sources of public funding are Disproportionate Share Hospital (DSH)
payments, which are Medicaid funds intended to aid hospitals that suffer financial losses from
providing care to relatively large numbers of uninsured and Medicaid patients, and Upper
Payment Limit (UPL) funds, which are Medicaid funds to cover some of the difference in
reimbursement rates between Medicaid and Medicare. These funds account for more than 20
percent of H+H revenues. While H+H is lowest in the hierarchy of recipients of DSH funding,
in City Fiscal Year 2020 H+H received over one-third of total statewide DSH resources ($3.7
billion), including $600 million in Inpatient and Outpatient UPL payments for FY20 and prior
years. H+H is the only hospital that receives inpatient UPL payments.

The adopted state budget for state fiscal year 2020-21 included $2.2 billion in annual cuts against
baseline Medicaid growth that could affect H+H’s bottom line. Changes in the DSH distribution
formula that reduced funding for better-off hospitals, however, are expected to provide roughly
$100 million in additional DSH funding to H+H (which will require the City to fund half). The
State and H+H are currently negotiating actions in the hope of generating incremental revenue
for H+H that exceeds the amount of State savings from Medicaid reimbursement cuts.
The federal CARES Act provides $175 billion for health care providers for expenses or lost
revenues related to COVID-19. Of the $87 billion in direct provider funding allocated in the
Federal CARES Act to date, H+H has received $1.1 billion, or 13 percent of total funding
awarded to providers in the State ($8.3 billion).

Planning
While no crisis can ever be fully anticipated, the general scenario of a large-scale pandemic has
been the subject of numerous planning exercises, studies, and hearings, spurred by past outbreaks
such as H1N1, SARS, MERS, and Ebola. Potential shortages in staffing, bed capacity, and
supply stockpiles needed to care for patients during a pandemic were identified as issues to
address, along with coordination issues.

In July 2006, the City’s Department of Health and Mental Hygiene (DOHMH) published
its Pandemic Influenza Preparedness and Response Plan (Plan) that anticipated many of the
problems the City faced during the COVID-19 pandemic nearly 14 years later. Among other
things, the Plan cautioned that, since the pandemic would be expected to be widespread in the
United States, supplies from the federal Strategic National Stockpile (SNS) might not be
available and local caches would need to provide necessary supplies. The Plan identified
problems that would likely occur, such as hospitals not being able to transfer potentially
contagious cases/patients, functioning at full capacity, and lacking adequate critical care
capacity. The Plan also anticipated that a pandemic would require sustained surge capacity at
hospitals. A work group was to be funded to develop a template hospital plan, including
strategies to enhance staffing, increase beds, and stockpile supplies. A model used by the Plan
(FluSurge2) estimated the need for critical care and predicted that critical care beds would be in
short supply and staffing and equipment (e.g., ventilators) would present challenges. The Plan
projected a ventilator shortfall of between 2,036 and 9,454 units and recommended a six- to
eight-week citywide stockpile of masks and gloves, with tracking systems to be implemented
that could detect rapid consumption of medical supplies.

A presentation on Medical Emergency Preparedness in New York City given by Debra E. Berg,
Medical Director of DOHMH’s Bioterrorism Preparedness Program in 2007, identified critical
benchmarks that included bed capacity, isolation capacity, personal protective equipment (PPE),
health care personnel, and equipment and pharmaceutical capacity. The presentation addressed
the already identified ventilator shortfall and assessed the pilot project (put forward in the 2006
Plan for purchasing a limited number of ventilators). A presentation slide indicated that for a
scenario similar to the 1918 pandemic, the City would have a shortfall of more than 8,000
ventilators, which would cost an estimated $70 million to purchase.

In a June 2009 hearing on the City’s response to H1N1 held by the City Council’s Committees
on Governmental Operations, Health, and Public Safety, Joseph Bruno, then the Office of
Emergency Management (OEM) Commissioner, testified:

This particular event occurred simultaneously throughout much of the United
States and the world. And a perception of need for the same resources at the same
time emerged almost immediately. We saw this in the first days of the event when
N95 respirators were not available at any price. We were reminded that the
sharing of critical assets between surrounding Counties and States that usually
occurs in response to other disasters might not occur here and these resources
might be scarce or unavailable.
Although describing H1N1, former Commissioner Bruno could have been describing
COVID-19.

New York State’s November 2015 Ventilator Allocation Guidelines also seemingly predicted the
issues preparing for a public health crisis. It described “The State’s current approach to
stockpiling a limited number of ventilators [that] balances the need to prepare for a potential
pandemic against the need to maintain adequate funding for current and ongoing health care
expenses.” It also predicted that since “… severe staffing shortages are anticipated…purchasing
additional ventilators beyond a threshold will not save additional lives, because there will not be
a sufficient number of trained staff to operate them.” It further warned that “[i]n the event of an
overwhelming burden on the health care system, New York will not have sufficient ventilators to
meet critical care needs despite its emergency stockpile” of 1,750 ventilators. This quantity was
not sufficient for “the most severe model,” and the State had no plans to buy enough ventilators
for the most severe model.

The gap between planning and reality is no doubt due to several factors, including the large and
abrupt scale of the COVID-19 pandemic. Planning and preparedness fell short in the current
instance in part because institutions – the State, the City, H+H, and private hospitals – faced
resource tradeoffs between the cost of preparing for a possible future scenario and the daily
reality of care delivery. The lack of preparedness forced all players to improvise responses,
sometimes successfully, sometimes not–but inevitably at a cost in human lives.

How H+H Pivoted to Address the Four Aspects of Emergency Preparedness: Space, Staff,
Stuff, and Systems

Preparing for—and meeting—the needs raised by a public health emergency require addressing
the “four S’s” of emergency planning: space, staff, stuff, and systems. Adding beds – space – to
any health care system also requires the additional resources to support and manage those beds,
including staff, supplies, and systems to coordinate the fulfillment of those needs among the
various facilities, whether within one healthcare organization or between different organizations.

Space

Prior to the pandemic, on a typical day about half of H+H’s hospital beds were empty. However,
capacity quickly became a crucial issue as the number of beds, and particularly ICU beds, were
insufficient to meet the needs of the pandemic.

On March 16, 2020, the State created a council to coordinate and develop surge capacity at all
hospitals, with a target of 9,000 additional beds. On March 22, 2020, with the ultimate goal of
doubling capacity, the State ordered all hospitals to increase bed capacity by at least 50 percent.
H+H announced plans to add 2,466 standard hospital beds and 762 ICU beds, which would triple
the number of pre-pandemic ICU beds, by May 1. Additionally, H+H also planned to add 350
temporary beds at Coler Specialty Hospital on Roosevelt Island. As a result of the state order,
within a month of the outbreak, statewide hospital capacity nearly doubled, expanding from
53,000 to 90,000 beds, including the addition of hotels, field hospitals, temporary converted
spaces, and the USNS Comfort. Ultimately capacity was added to a degree that it was not fully
needed.

Staff

The surge of patients and addition of beds at H+H hospitals required additional personnel,
including both medical professionals and support staff needed to provide care.

To handle the patient surge, H+H hospitals assigned existing personnel to areas where the need
was greatest. However, such action resulted in doctors and nurses being redeployed to
assignments that required specific skills they either did not have or had not used in many years,
often without adequate or needed training. This included, for example, assignment of neonatal
nurses to the intensive care unit, or of a physical therapist who had not worked as a respiratory
therapist for decades to treat COVID patients in respiratory distress.

Volunteer personnel also helped H+H provide patient care to those who needed it. However,
although the influx of much appreciated volunteers from in- and outside the City boosted staff
numbers, integrating those volunteers magnified redeployment issues. The volunteers needed to
be credentialed and did not have access to or knowledge of H+H computer systems. In addition,
H+H lost volunteers to private hospitals that did not have the same bureaucratic layers and could
pay volunteers for their services.

Stuff

H+H’s efforts to obtain the equipment and supplies needed to support its increased operations
highlighted the challenges of meeting a large-scale pandemic or medical emergency. Resource
constraints limited the City and H+H’s ability to maintain a stockpile of sufficient size to meet
the scale of the COVID-19 emergency, and H+H’s attempts to procure equipment were
hampered by nationwide—and even worldwide—supply chain issues. The global demand for a
limited inventory of supplies, a lack of coordination and sound guidance by the federal
government, and the lack of a sufficient City stockpile frustrated H+H’s procurement efforts, and
led to dangerous conditions for workers and patients alike.

The City’s 2006 Pandemic Influence Preparedness Response Plan warned that New York City
could be short as many as 9,500 ventilators. The City acquired a few hundred ventilators in a
pilot program, which ultimately were auctioned off because the City could not afford to maintain
them: it faced a tradeoff between spending its limited funds to maintain its stockpile of
ventilators or using those monies for immediate needs. Because immediate needs understandably
took precedence, the City’s supply did not meet the demand presented by COVID-19.
The City and H+H faced similar supply shortages of personal protective equipment (PPE). Most
hospitals, including H+H, do not have the capacity to stockpile large quantities of supplies and
equipment, so inventory is limited to what is typically needed for a limited period of time,
without additional resources for surge capacity. As with ventilators, City stockpiles of N95
masks and other necessary items could not meet the demand during the outbreak.

In January, when the World Health Organization (WHO) declared COVID-19 a Public Health
Emergency of International Concern , H+H sought to procure additional PPE. However, even by
that time, orders of supplies could not be fulfilled because the global supply chain was already
overwhelmed. H+H was thereafter forced to compete with local, national, and even global
entities for equipment and supplies needed to support its increased operations. H+H, as well as
the City and State, could not rely on the federal government to coordinate either the national
need or supply of PPE or other needed items. The supply chain issues left each hospital system
to itself to procure critical supplies. Existing re-supply contracts were rendered meaningless
because vendors did not have the inventory to fulfill demand.

In an attempt to remedy the lack of supply, on May 3, 2020, New York State indicated it would
order all hospitals to have a 90-day stockpile of PPE on hand. However, as of the date of this
letter, the State has yet to issue such order promised on that date. In addition, fulfilling the order
would be nearly impossible in the current supply-constrained circumstances.

The limited supplies of PPE led to changing guidelines about their use, starting with the federal
Centers for Disease Control and Prevention (CDC). Established medical protocols were amended
by the CDC in light of the crisis, and c onstantly changing guidance regarding acceptable use of
PPE was driven by lack of available supplies, rather than by science and medical standards. In
February the CDC issued guidelines that were inconsistent with previous medical standards of
care and approved limited re-use of PPE. For example, a N95 mask that previously had to be
changed after each procedure or patient exam could now be used for up to five days. The State
Department of Health disseminated the CDC guidelines, despite their obvious deficiencies, and
H+H and other hospitals followed them: the lack of sufficient supplies precluded them from
following more medically sound standards.

The changing guidance and ensuing confusion rendered H+H health care workers even more
vulnerable to COVID-19, with many becoming sick and dying. The New York State Nurses
Association reported that as of early June at least 35 of its members had died. Such risk is not
limited to the health professionals directly interacting with patients. For example, lab technicians
reported a lack of equipment required to safely perform their work, specifically a “bio-hazard
hood” needed to examine blood samples. In addition, the reported transfer of COVID-19 samples
by pneumatic chute along with other blood samples could spread COVID-19 contamination to
non-COVID-19 units and expose laboratory workers. Finally, according to reports my office
received, even supplies to clean patient rooms were inadequate, creating a risk of infection to
other patients and hospital personnel.

Systems

The expansion of hospital beds, transfer or addition of personnel, and requisition of supplies each
required systems and coordination to manage the surge of patients, for example, to effectuate the
transfer of patients at crowded hospital to available beds at one with available capacity. At the
outset of the crisis, the existing systems were not equipped to handle the need and volume.
On January 21 st , more than a week before the WHO declared COVID-19 a Public Health
Emergency of International Concern, H+H virtually activated its Central Office of Emergency
Management Emergency Operations Center. Two weeks later, on February 3, 2020, H+H
established a “Tiger Team,” including subject matter experts from various departments who meet
weekly to discuss situational facts, activities, accomplishments and barriers related
to COVID-19.

At the outset of the pandemic, there was little to no formal coordination among and between
H+H hospitals, but over the course of the pandemic, H+H management centralized allocation of
resources to a greater degree than pre-COVID. Patient load presents one prominent example:
The surge of patients requiring medical treatment at an H+H hospital was uneven across the
H+H system, as press accounts about issues confronted by Elmhurst Hospital revealed. In an
effort to address the disparities between the demand at each facility and its available resources,
individual H+H staff would telephone another facility to attempt a transfer. As this informal
process became untenable under the pressure of surging caseloads, it was replaced by a daily
conference call and ultimately an email portal that allowed users to view need and capacity at
H+H facilities and request transfers centrally.

Similarly, procurement and distribution of PPE was eventually centrally managed, with support
provided by the City DOHMH. In late March, DOHMH began weekly distribution of PPE from
its warehouse to all hospitals (H+H and private). DOHMH also fulfills emergency
requests—within 24 hours if possible—through a 1-800 phone number.

On a broader level, the management of patient loads across different hospitals and systems also
shifted from an ad hoc arrangement to a more centralized system with the creation of a central
State-level coordinating body jointly managed by the Greater New York Hospital Association
and Northwell Health on behalf of the State. The State activated the existing Healthcare
Evacuation Coordination Center (HECC), which has been used in prior emergencies to
coordinate patient transfers, but only for the purpose of facilitating transfer of non-COVID
patients from hospitals to the temporary field hospital established at the Javits Center.
Operations were later transferred to Northwell Health.

Conclusion

The COVID-19 pandemic has demonstrated that while planning is important, even the best plans
inevitably will not and cannot foresee or anticipate every eventuality, because each emergency
and crisis is unique. COVID-19 presented an unprecedented challenge and placed strains on
every part of the City’s healthcare system, both private and public. Planning and preparedness
must provide for a clear chain of command and responsibility to ensure a coordinated, timely,
and effective response and allow for the flexibility that our preliminary inquiry identified.
It is clear that H+H—or any individual healthcare system—cannot manage the need created by a
health crisis of the magnitude experienced with COVID-19 in isolation and without support and
assistance from state and local governments acting in concert with the entire healthcare delivery
sector. H+H’s challenges arose at least in part from insufficient and conflicting guidance,
originating at the federal level, and an initial lack of coordination among participants in the local
healthcare system. Many of these challenges were addressed “on the fly” by both the State and
City governments and by the hospital sector, including the Greater New York Hospital
Association (GNYHA), H+H, and private independent facilities. The cooperation exhibited by
all parties is to be commended.

As a result of this preliminary review, I recommend the following:

1. Planning must identify key roles and responsibilities for various players in the healthcare
delivery system in the event of systemwide health emergencies. The State and City
Departments of Health, the City’s Department of Emergency Management, and other
state and city government offices, and major providers, including H+H and voluntary
hospitals (through the GNYHA), should all be included, and the plan must provide for
clear chains of command and responsibility for different aspects of crisis management.
H+H should create the same plan for its system.
Planning must be inclusive of all parts of the organization. Good planning must take into
account the broadest possible range of expertise and insight from all members of the
organization.

2. Develop a plan to identify and obtain critical supplies in advance of the next health crisis .
Such a plan must assume contingencies for a lack of critical supplies or the assistance of
the federal government. Providers of critical equipment should be identified in advance
and the State and City health departments should work in concert with hospital systems to
put in place contingency contracts to ensure supplies are available when and as needed.
A centralized inventory and procurement system for key equipment and supplies should
be created to manage surges that exceed the capacity of individual hospitals to meet.

3. Review and formalize innovations created to address the COVID-19 pandemic as
standard operating procedures (SOP), including the enhancement of coordination within
H+H facilities and both between and among different health care systems. For example,
the mechanisms developed for the transfer of patients between and among H+H facilities
as well as other healthcare systems should be formalized and made permanent.
Contingencies for supply management in the event of excess demand should also be
institutionalized.

At the same time, there were practices and protocols that must be examined more closely by
H+H leadership and improved if a future large-scale health emergency is to be handled more
effectively. I further recommend that:

4. As part of regularly conducted pandemic drills and exercises, H+H doctors and nurses
should be cross-trained to support ICU and critical care staff.

5. Any transferred or volunteer personnel be provided with sufficient training or shadowing
opportunities to obtain the requisite knowledge to perform new duties or duties they have
not performed in a significant period of time. Appropriate training could consist of
shadowing an experienced staff member who currently performs the function to be
assumed or even classroom learning. Transferred staff might also need to be given access
to and trained on any computer systems or databases needed to perform the new duties
that they have not previously used.6. The State and City departments of health, H+H, and other hospitals should work together on health and safety protocols and guidance to avoid confusion and miscommunications.

Following federal guidance should be the default posture but should not be automatic if
doing so will likely compromise the health and safety of both healthcare workers and
patients if it can be avoided.

7. Like planning, operations during a health emergency must include all parts of the
organization. Management must include leadership of organizations representing all the
system’s employees at all levels and in all capacities to ensure the fullest possible
understanding of a dynamic situation, and that all members of the organization
understand and can execute decisions.

Above all, my office’s preliminary review of H+H’s response to the COVID-19 crisis found that
H+H’s ability to deliver proper patient care to the communities that need it the most in the face
of a health crisis requires the assistance of federal, state, and local governments to ensure that
H+H has the resources available to meet demand in the communities it serves. These resources
include sufficient funding, established coordination policies and procedures, and the assistance
and support of its governmental and private partners. The City and State must address the
underlying inequities in access to health care that both directly resulted in a disproportionately
high death toll among the City’s most vulnerable populations and threatened to overwhelm
existing capacity and systems.

The heroic dedication of H+H frontline staff at all levels ensured that H+H hospitals were able to
operate despite the myriad challenges. We have lost too much and too many during this crisis.
We owe it to all those impacted by H+H’s struggle to address this crisis—especially its frontline
healthcare workers and patients—to ensure that the City’s public healthcare system is as well
prepared as humanly possible for a possible resurgence of COVID-19 patients as well as the next
health crisis.

Sincerely,
Scott M. Stringer
New York City Comptroller