As a physician, I sometimes have to give my patients and their families bad news. I try to do it as gently, but accurately, as possible, and always with an attempt to include any possible hopeful information that may exist. This article will follow that pattern with some very bad news, in my opinion, but possibly a small glimmer of hope. This view I’m expressing is not just the objective opinion of an outsider, since I live in the West Village and the availability of a health care facility here may have an effect on my needs at some time in the future. How we arrived at this point has been discussed in detail previously, and I will try and concentrate on what we need to do from this point on, except for one or two previously unexamined issues.
What Do We Face?
I have lived almost all of my life in New York City and I cannot remember a closed hospital ever being re-opened or replaced with a brand new hospital, other than planned replacement of older facilities with newer ones. To establish a completely new hospital in an area that has lost its old one would be, as far as I know, unprecedented.
Except for residents of the West side and most of their elected officials, nobody cares about the closing of St. Vincent’s Hospital to any great extent, other then to shake their heads and say “Isn’t that a shame,” or “How could that have happened?” This isn’t unexpected since many communities around the city have their own local problems. Except for a few healthcare activists, how many residents of the West side protested the closing of Cabrini, North General, or even St. Claire’s (aka “St. Vincent Midtown”) hospitals? The hospitals in Brooklyn, which are marked for closing, might as well be on another planet. Some groups, such as Physicians for a National Health Program and Occupy Wall Street have come to demonstrations, but not in great numbers. In other words, we are alone.
The costs for a new hospital will be tremendous. A figure of $500 million has been used, and this seems about right. If the proposed emergency care center has a price tag of about $100 million then a full sized hospital would be much larger. Recently, a $540 million, 223 bed hospital was opened in New Jersey and this is about the minimum size a hospital needs to be able to support a first class emergency room. The new hospital there was described by the New York Times as luxurious, but that may be exactly what we need also. The Times has also run several articles over the last year which describe how patients decide on which hospital to use, and appearance is a very important factor. Walking into the palatial atria of Mt. Sinai, Bellevue or Roosevelt hospitals compared to the cramped entrance of St. Vincent’s was like walking into Grand Central Station compared to Penn Station. Various attempts were made to attract financing for a new hospital, with approaches to a Saudi Arabian king, the National Football League and other real estates interests, but these all fell through. This half billion dollars is only the beginning, with ongoing expenses being incurred until the hospital becomes self-sufficient, if it ever does.
The CEO of a hospital or health system chain would look at these figures with dread. A new hospital would have to be affiliated with some system for a variety of reasons. A stand alone hospital does not have the bargaining power with the insurance companies that a large system does. Also, a teaching program is probably essential to any hospital operating in Manhattan and already, existing house-staff from other hospitals can rotate through a new facility until independent programs are established. Physicians in private practice in the community would also have to be coaxed into joining a new hospital and this won’t happen unless it has a lot to offer. Most physicians already have affiliations and to change, or add another, is a major step for an independent practitioner. A full time staff would also have to be recruited and this would take time and money. All of these can be done more easily by a well functioning hospital system rather than one new independent one. Any hospital system, including the Health and Hospitals Corporation of the city, would be taking a risky, possibly catastrophic, gamble with such an undertaking. Remember, it was St. Vincent’s Hospital taking on affiliations with other Catholic hospitals, to form the Catholic Health Care System, that was one of the main reasons for the financial collapse that got us into this situation in the first place.
Help from our political leaders is also unlikely to materialize. Both the Federal and State governments, and their departments of health, have operated for years on the assumption that New York City has too many hospital beds in general. Details such as traffic along 14th street and the uneven distribution of beds within New York rarely come up for consideration. How can the elected officials reverse this opinion? Even if West side demonstrations produced complete unanimity among our own politicians, how could they convince their colleagues to come up with a half billion dollars, plus operating expenses, to build a hospital in one of the wealthiest neighborhoods of the city when many other neighborhoods are so much worse off? The very most we can hope for is that if a hospital is built by someone, the state department of health would allow high reimbursements for Medicare and Medicaid patients, although the state has refused to do that in the past.
Hunter college did a study to examine the use of St. Vincent’s by the surrounding community of Chelsea, The Village, SoHo and Little Italy (which is available on the Community Board 2 website) and the hospital itself did studies to determine how many residents of the area used it for care. Although a great deal of data was generated, a few numbers stand out. Over a five year period, about 75% of area residents used the Emergency Department at some time or another, but 20-30% used various other services such as tests and out-patient facilities. St. Vincent’s itself said that only 12-15% of residents of the area actually used the hospital, and the Hunter study also concluded that about 17% of all in-patient hospitalizations of area residents were at St. Vincent’s. Inpatient hospitalization is the big dollar item that keeps a hospital afloat financially. Although there are many permutations to all these data, the fact is that many West side residents did not consistently use St. Vincent’s for many health services, except for the Emergency Department. When a hospital CEO or Department of Health policy maker looks at these figures, a natural question arises. If so many West side residents did not use a hospital with the history and roots in the community of St. Vincent’s, why would they use a new untested hospital, except for its Emergency Department? If an Emergency Department is well utilized, would this keep an entire first class hospital financially viable (this one is easy, the answer is “No”)?
What Have We Done?
Since the closing of the hospital, there have been numerous demonstrations and petitions involving local residents, politicians, health care activists and the organizations mentioned previously. Whether these actions are responsible or not, there will be preservation of some of the former St. Vincent’s buildings exteriors, a slightly smaller condo size, and a large free standing emergency center in the former O’Toole building. Construction and renovations in all of these buildings are ongoing and it looks like these are accomplished facts. However, all these activities have not gotten us a full scale acute care hospital or even a promise of such.
During the demonstrations I have gone to, and the articles I have read, there have been some pretty heated statements by proponents of a new hospital. Christine Quinn and Community Board 2 have both been criticized for their perceived lack of support, or at least lack of results, in obtained a new hospital. At this point, it is clear that this will be a long struggle, assuming there are still individuals who are willing to work on the issues, and potential allies like these shouldn’t be alienated because they weren’t willing to expend a sufficient amount of time, energy, or political capital on what could easily be perceived as a lost cause.
Yet there is one action of the community which preceded the closing that came out a while ago. When confronted at a public meeting, Stephen Berger, who headed the commission responsible for closing numerous hospitals, said that “If you didn’t give Rudin such a hard time you would have a hospital.” (WestView News, Jan. 2012 ). The assumption, and it is a big one, is that if Rudin had a free hand to build whatever it wanted, enough money would have been generated to built a new hospital and bail out St. Vincent’s debts. In essence, the hospital came to the community and asked for help, and the community said no. However, there were valid reasons that the community said no. The condo and the hospital were perceived by some as much too big, and destroying numerous buildings would seriously damage the principle of historic preservation. Furthermore, we did not know the true financial condition of the hospital. Exactly how much debt did the hospital have? Exactly how much money could Rudin contribute if it had a free hand to build what it wanted? If there was a difference, and I’m sure there was, where would the balance of necessary funds come from? Finally, was closing really discussed? At the meeting Community Board 2 held at St. Vincent’s, none of the speakers besides myself actually raised the possibility that the hospital would completely close down, if my memory is correct. The severity of the problem was hidden. As far as the community was concerned, this was just another case of a large institution wanting to get much larger and a real estate firm wanting to get much richer. Nobody would stand for that.
So far, what have we tried that has not succeeded in getting us a real hospital. Demonstrations and petitions have failed. Appealing to politicians has failed. Even pointing out the deadly consequences of the situation has failed. The many articles by Dr. David Kaufman make it clear to everyone that deaths will occur because of this lack of a hospital. In fact, anecdotal stories are already circulating that people have already died in transit to the East side, who might have been saved by a real Emergency Department on the West side. Describing the hospital imbalance between the East and West side of Manhattan also won’t help, since any argument of that type can be countered by comparing Manhattan to the rest of the city. Why build a new hospital anywhere in the one borough that already has the highest concentration, by a wide margin, of beds already? The situation appears hopeless.
What Can We Do?
Or is it? A desperate situation calls for desperate measures and I would like to propose a few. The overall approach should be similar to what was proposed for Pier 40, where a combination of real estate, housing and a new NYU affiliated hospital was suggested. (WestView News, May 2012 ). Although this proposal has not attracted a great deal of support just yet, it does try to use a large positive incentive to interest a plausible partner. Negative tactics such as demonstrations, petitions, attacks on politicians and predictions of death, however accurate, have not worked. So, if a stick doesn’t work, let’s try a carrot, a really, really large carrot.
The most obvious target of such an approach, assuming NYU isn’t interested in the Pier 40 proposal, is the North Shore/LIJ network. The fact that it is involved in the new emergency center shows that it has some interest in the area, even though most of its hospitals are on Long Island. A real lower West side hospital, along with its newly affiliated upper East side Lenox Hill hospital, will give a geographical contrapposto effect within Manhattan. In order to do this, we would need to work closely with them and possibly the city’s 911/EMS office, and maybe the Hunter College group that did the medical needs study. We would have to determine exactly how many of the emergency center patients were transferred out for in-patient admission, or how many 911 calls that could have went to a new West side hospital actually were sent to the distant East side. A hospital CEO would need to know precise numbers, not vague guesses, before making any major move. Since the emergency center is already in the neighborhood, maybe this would make construction cheaper, possibly even with a piggy back structure on top of the O’Toole building. The NS/LIJ system also has an excellent track record, so building a reputation to attract Westsiders could be possible. However, there should be cooperation between the community and the system, if it hasn’t started already, not conflict.
There is another major player who might be coaxed into helping out: the Rudin family. After several years of intense animosity between the community and the Rudins, it might seem unlikely that anything can be done. Yet, this proposal is business, not personal, and where there’s an incentive there’s a possibility. With the present proposed construction, the Rudins have agreed to donate $10 million for the new emergency center. What could they give if we were to allow them to build a lot more? On 57th street, a luxury condominium is being built which will be ninety, yes, ninety, stories tall. I don’t know if the construction on the former Coleman building has gone too far, but what would happen if we were to advocate for a zoning variance to allow such a building on this site, or somewhere nearby possibly out of the historic preservation area? I don’t know if the bedrock of the Village would support such a building, or it the market would absorb such an influx of apartments, or if the local schools could handle new students. This might provide a large enough economic incentive (a really, really big carrot) for Rudin to help build a new hospital with money, its considerable political influence and possible fund raising within the real estate community. I would even name the new hospital after the family if the contribution were big enough. If we can name a Lincoln center theater after a Koch brother, we can name a hospital after a Rudin.
Besides the financial incentive, there may be another one. Real estate people want to make money, that’s what they do. I also have the feeling though, that they take a certain amount of pride in their accomplishments. They like to be able to point to a prominent edifice, whether an apartment or hospital, and say, “I built that.” Instead of fighting this pride, let’s see if we can cooperate with it towards the common goal of a new hospital.
A proposal this desperate, and possibly delusional, would elicit a strong reaction from the community. Considering how the community has reacted to the O’Toole building, I think I can predict how it would react to an oversized condominium anywhere in or near the West Village. Initially, every community group and politician would be against it. After about 25 years, people would be grudgingly accepting of it. After 50 to 75 years every community group and politician would defend it as a symbol of the neighborhood, and possibly the city, as iconic as the Empire State Building, which was also ridiculously oversized for its neighborhood when first built.
If considering this proposal, or even working with the Rudins at all, seems beyond all possibility, then another question is raised. What is the community willing to sacrifice in order to get a new hospital? I’m not talking about sacrifices which were forced on us, but those which we were willing to make to get a new hospital. Are we willing to make a major exception to the historic preservation regulations in order to get a new hospital? I think we should. Do others?
After all the details and data are digested, and the proposals and protests are past, with what are we left? The fact is, the West side area comprised Chelsea, The Village, and SoHo is one of the wealthiest in the city. Any hospital system, whether NYU or NS/LIJ or whoever, that figures out how to tap into this has a potential for tremendous expansion, while providing a very worthwhile service. What’s more, it will have a monopoly on this area. The wealthy Upper East side is served by four general service hospitals (Metropolitan, Mt. Sinai, Lenox Hill, and Columbia P & S/Cornell) but the Lower West side will have only one. Let’s hope this final vision attracts somebody’s attention.