Plan Reimagines Primary Care For Poor

Paul Bass PhotoTens of thousands of New Haveners next year will receive basic health care in a new spot with an experimental approach — if state and federal regulators say OK.

The new spot is 150 Sargent Dr., currently a Yale-New Haven Hospital-run ambulatory care building next door to the Long Wharf Theatre. Yale-New Haven is seeking permission to close its current main primary care center at 20 York St., as well as its primary-care satellites at 1450 Chapel St. and 2080 Whitney Ave., and move the whole operation to an expanded, renovated, more modern central facility at 150 Sargent. It’s looking to spend $15 million redoing the building as part of the deal.

That’s the new part. The experimental part involves its management. Yale-New Haven would no longer run the center under the plan. Instead it would contract with New Haven’s two grassroots neighborhood-based agencies — Fair Haven Community Health Care and Cornell Scott Hill Health Center
— to manage it.

So the move to a new Long Wharf facility would affect not only the 28,500 largely low-income patients currently served by Yale-New Haven, but the future of the two health centers and their 43,000 patients, not to mention the doctors and staffers who currently work out of the hospital’s primary care center.

“Change is inevitable,” observed Hill Health Executive Director Michael Taylor. “It’s going to happen, and we need to evolve with the industry.”

How will this change work, and what will mean for New Haven? Read on for an “explainer” based on an interview with Taylor and his counterpart running Fair Haven’s center, Suzanne Lagarde, and on answers provided by Yale-New Haven to emailed questions.

What makes this unique?

Rarely do large academic hospitals work with community health centers to run a primary care center serving large low-income communities. Lagarde and Taylor cited the University of Mississippi, which does it in Jackson, and said San Francisco has a similar center. They know of few others, especially with two neighborhood centers involved in the deal.

How will the plan work?

Yale-New Haven will pay the two centers an as-yet-unspecified annual fee to manage the center based on their experience providing community-based care to lower-income patients. Yale-New Haven’s current doctors and staffers would keep their jobs and move over to the new center, according to the hospital. The clinics might add some of their own staff as well.

What’s in this for the two neighborhood health centers?

Lagarde and Taylor took over their institutions several years ago at critical junctures. Both Fair Haven and Hill Health grew out of the War on Poverty; they were first-wave community health centers and established reputations as models. But as the health care industry changed, both institutions faced existential fiscal threats. Taylor and Lagarde have succeeded in stabilizing finances at their institutions, adapting to new medical needs, and expanding care. But these remain hard times for community health centers, especially with major federal cuts looming. This deal would help the centers stay financially sound. Both Lagarde and Taylor stressed that their existing neighborhood-based centers will remain operating as before.

The new operation on Sargent Drive will help the center achieve economies of scale and offer new services, they said. For instance: All three institutions will be connected to a central electronic medical records system (Yale-New Haven’s EPIC, which Hill Health does not currently use). That will help them manage care for patients at all their facilities, Taylor said. “We will all know in real time, for example, when someone is going to the emergency department. We can reach out to those patients and steer them towards more effective care.” “We will get internal alerts, because we’re all on the same platform. This is 21st century health care,” Lagarde said.

She said the clinics’ experience with community health care will enrich the learning experience for Yale Medical School interns and residents at the primary care center — and perhaps lure more of them to take permanent jobs at the health clinics.

How will Yale-New Haven calculate how much to pay the health centers?

A hospital spokesman gave this response: “It is set up so that the health centers don’t suffer any losses from their operation of these new clinics. We are providing start-up funding to each [center] to cover certain one-time costs associated with getting the program up and running. We also are providing in-kind donations of certain services and supplies. Going forward, we will establish a budget each year.”

Taylor and Lagarde said it’s understood that the annual payment will include a management fee on top of covering all costs. “We will incur no additional costs,” Taylor said.

What’s in this for patients?

On top of benefiting from their institutions’ knowledge and experience, Taylor and Lagarde said, the new center will be bigger than the current facilities and include “state-of-the-art” equipment.

Also, patients who now get behavorial health services and X-rays and be able to purchase pharmaceuticals at the same location where they see their primary care doctor, rather than have to travel to several different spots, Lagarde said.

Yale-New Haven also notes that primary care patients at the current Chapel Street site, at the St. Raphael campus, will move from “trailers” to “much nicer, roomier space” on Sargent Drive.

Isn’t Long Wharf harder to get to for most people?

Long Wharf is indeed in a less populated part of town than York Street or Chapel, and harder to get to without a car. The new facility will offer easier parking for people who drive. It is on a bus line, Taylor and Lagarde noted.

That said, some people in, say, the Hill, may find it easier to walk to Hill Health on Columbus Avenue to see a doctor rather than schlep to Sargent Drive. The move of the primary care center will definitely cause some people to switch locations for care.

What’s in this deal for Yale-New Haven?

Yale-New Haven estimates it loses an average of $174 on every visit with a Medicaid patient. That’s because government subsidies don’t cover the full cost. Declining subsidies forced the former Hospital of St. Raphael to the brink, leading it to sell to Yale-New Haven rather than close. The thinking is that Fair Haven’s and Hill Health’s expertise, along with the economies of scale, could deliver the same quality care less expensively.

So Yale-New Haven is looking to save money? Will some staffers lose their jobs?

Actually, they say cutting costs is not one of the goals.

“The goal of the Consortium is to continue to improve care to the community not to reduce cost or achieve savings. No one’s employment will be eliminated as a result of this change consistent with our practices and history,” stated a hospital spokesperson.

So how else can Yale-New Haven benefit?

If it can improve care for the poor — and strengthen two valuable neighborhood health centers — the hospital will be able to claim it is providing “community benefits.” Tax-exempt hospitals like Yale-New Haven are required by law to document that they provide community benefits. This recent story in Politico documents in depth how Yale-New Haven has worked hard to improve what had been a spotty community benefits record over the past 15 years, and the challenges that remain.

What does the public think about this?

Too early to know. The public will have a chance to weigh in as the regulatory process advances.

And how will that process work?

Yale-New Haven started the process on Dec. 7 by issuing a public notice in the New Haven Register classifieds section that it plans to apply for a certificate of need from the state Office of Health Care Access to close its current primary care center locations and centralize them at the renovated 150 Sargent facility under Fair Haven’s and Hill Health’s operation.

Now the hospital has until March 7 to file the actual application, according to OHCA Associate Health Care Analyst Steven W. Lazarus. OHCA’s review process then includes an opportunity for public comment. In addition, Yale-New Haven has started holding community meetings to explain the plan and solicit feedback.

Then, assuming OHCA grants the certificate of need, Fair Haven and Hill Health will need approval from the federal Health Resources and Services Administration. After that process end, the project’s organizers needs to convince the state Department of Health to issue a license to operate at 150 Sargent Dr.

That sounds like a long process.

Actually, work has begun on renovating 150 Sargent. Lagarde explained that once HRSA grants approval, the agency expects the facility to be up and running within 120 days. So that would not leave enough time to start then from scratch. Taylor said the new center could open within a year.

How does the public weigh in?

Thirty days after OHCA deems Yale-New Haven’s application “complete,” members of the public can request a public hearing within 30 days and/or submit written comments to state Deputy Public Health Commissioner Yvonne Addo. This web page gives details about all that.

Has anyone yet expressed concerns?

Privately, doctors at the primary care center have said they’re concerned about whether the new center will retain all the services found at the current center, such as patient legal services, patient relations, children’s health legal services, social work, and child life specialists for pediatrics.

What does Yale-New Haven say about that?

“It’s our goal to ensure a smooth transition to the new center with a patient-centered approach to meet the needs of our diverse patients and maintain and possibly enhance the resources” contained in that list.

What about the stuff Yale-New Haven currently does at 150 Sargent?

The hospital plans to keep all current services there until the new primary care center moves in. At that point, “radiology and blood draw will remain” at the center, according to a spokesperson.

And what will Yale-New Haven do with its the three current primary care center sites?

Something, for sure — but at this point it’s not sure.

Click on or download the above audio file or the Facebook Live video below to listen to the full interview with Michael Taylor and Suzanne Lagarde on WNHH FM’s “Dateline New Haven” program.


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posted by: Chrisssy on January 23, 2018  11:44pm

I think this is great news for the community and all the clinics involved. With that said, I’m sure there will be a ton of negative comments about YNHH being a big bully and taking over everything.  Nobody ever talks about the millions of dollars they dump into all these places that they purchase. The average person doesn’t realize that all the MD offices they’ve taken over along with St. Raphael’s were using such antiquated equipment (X-ray, MRI,etc) that it should have been in a museum. Yale comes in and brings in state of the art equipment that can detect things that older equipment can’t.  St. Raphael’s was so broke they had not replaced mattresses in 20+ years. Yale had to spend millions to get it up to the highest standards that they pride themselves on. Thank you Marna and company for bailing out so many places that would now be vacant buildings had it not been for your help. You’ve also saved so many jobs by doing so.
A grateful employee who understands the benefit and importance of having someone so brilliant in the CEO position.

posted by: Gretchen Pritchard on January 23, 2018  11:44pm

So, full circle in some ways, since that building began as CHCP—Community Health Care Plan—a single-payer community plan modeled on the Yale Health Plan but designed for the general public.  The doctors were on salary, not fee-for-service.  It was simplicity itself:  you signed up, paid your membership fees, and when you needed care you showed up, got care, and walked out afterwards without paying a cent.  No bills for hospital care either.

posted by: LivingInNewHaven on January 24, 2018  8:39am

Yale has no love for the poor community.  This is about control and dominance.  These two clinics should look for other options.  Eventually Yale will digest both of those agencies and they will disappear. Just like what Yale has done at HSR. 
A community needs choice when it comes to healthcare. 
This plan makes me nauseous. I hope the community fights it.

posted by: Chrisssy on January 24, 2018  9:18am

Livinginnewhaven - I would like to hear your thoughts on what Yale has done to HSR? Here’s mine
Bailed them out
Saved jobs
Spent millions getting them into this century with state of the art equipment, remodeling the delipatated patient units that had been in desperate need of repair but HSR never did.
Allowed staff to keep seniority regarding benefits.
Mind you, HSR executives spent their employees pension money prior to Yale buying them out
Furthermore why is it Yales fault that HSR went under?  HSR out of money and all those employees would have lost their jobs, HSR executives didn’t care.

posted by: 1644 on January 24, 2018  10:39am

HSR failed for a few reasons beyond its control:

1) Its main competitor had access to major capital contributors like Joel Smilow, while HSR did not.
2) Loyalty to the Catholic brand faded in its market, allowing it to lose market share.
3) Loss of of market share meant diminished pricing power with insurance companies.  HSR entered a death spiral where well-insured customers chose YNHH over HSR, meaning insurance companies had to pay what YNHH demanded but not what HSR wanted, and HSR was left with a greater proportion of money losing Medicaid patients without income from private insurers to subsidize their care.

Within ten years we shall likely have only two major hospital organizations in CT, YNHH and Hartford Hospital, simply because organizations need to be dominant to have pricing power.

posted by: Chrisssy on January 24, 2018  12:41pm

1644- appreciate your thoughts and I agree that in 10 years it will be two systems, Yale and Hartford. It’s just like the local hardware stores years ago closed when Lowes and Home Depot came in. I agree they need to dominant to have pricing power but Yale saw this coming in the early 1990’s and came up with a plan. Other hospitals sat back and did nothing and that is one reason why they failed. Yale created a health system in 1995 or so with Bridgeport and Greenwich when our CEO at the time said currently we all pay 50 cents for an alcohol wipe and if we become a system and by in buy in bulk it will cost less and save all of us money. Brilliant man that CEO was, he knew what was coming in the years ahead and he prepared yale well.

posted by: LivingInNewHaven on January 24, 2018  1:34pm

Ask the folks who worked at HSR? Ask the patients who have no other options except Yale options as to the quality of care given. Ask the poor people of New Haven how they are treated by BiG Brother Yale in all aspects of their health care. Yale decides what type and quality of care they deserve to get.
You are obviously a YNHH proponent.  Unfortunately Yale is not a savior it is a dictator.

posted by: Chrisssy on January 24, 2018  2:32pm

Livinginnewhaven, ask the people who worked at HSR? First, most still work there and should be grateful they still have jobs thanks to Yale. I’ve asked some and they told me of all the benefit perks,i.e. Birthday off with pay, free Heath insurance. And my response to them is that all those perks contributed to the demise of HSR. They gave employees all that and in the meantime they were using X-ray machines and other equipment from the 1940’s. Why don’t you ask them what happened to their pensions before Yale bought them out. The HSR CEOs couldn’t give them a straight answer.
The poor people and all people should appreciate having a world renowned hospital in New Haven. People from all over the world come to Yale for treatment. So negative comments made on NHI don’t hold weight. Go to another state and see how you get treated, actually start off at Midstate in Meriden and let me know how it goes.

posted by: Chrisssy on January 24, 2018  2:38pm

As far as how Yale treats the poor in terms of their care. The doctors and nurses have no idea if the patient they are treating has health insurance or not. That’s an entirely different dept. And the nurses and doctors don’t care if you have insurance or not cause at the end of the week their paycheck is the same no matter who they treated that week. And thank god because if their paycheck depended on how much patients and insurance companies actually pay they would earn below minimum wage.

posted by: 1644 on January 24, 2018  6:15pm

Living:  No one, HSR or anyone else, can provide good care when they are out of business.  HSR ran deficits year after year, didn’t maintain its physical plant and shorted its pension funds.  No one can stay in business running defeats year after year.  Particularly in the health care field, one needs to run surpluses to build up capital to keep one’s physical plant and equipment current.  HSR failed to do that.  To stay in business, HSR employees would likely needed to have taken pay cuts of 20%.  Were they dedicated enough to serving the poor to do that?
  BTW, yes, there has been some adjustment for some, particularly supervisors, but in general the former HSR employees I know are pretty happy to be working at YNHH.  The work is demanding, but the pay for clinicians is the highest in the area.  Plus, PIP checks.

Chrissy:  My wife works as a clinician at an outpatient clinic.  She is well aware of the Medicaid/private insurance mix, knowing too many Medicaid patients will kill the clinic.  Managers are also well aware of the bottom line, office by office.  The suburban clinics are meant to be profit centers, although they are often the only places around which take Medicaid.

posted by: Chrisssy on January 24, 2018  6:40pm

Very well said 1644!!! Agree with you 100% and I do not blame the employees of of HSR for their demise. It was the top executives jobs to keep them afloat and they failed to do that. I just wish that more people would put the blame where it belongs which is not on Yale.

posted by: wendy1 on January 24, 2018  11:37pm

Primary care clinics should be located in several of our neighborhoods not just one on Sargents Drive.  And when will Yale start treating homeless people?

Actually you dont have to be poor or homeless to get third world treatment from Yale.  They dont have enough staff of any kind.  Recently one AM, we were told there were only 2 doctors available in the ER dept. and we would have to wait—-my husband had kidney stones ( considered excruciating pain.)  It was 2 hours before he felt better.  Later I spoke to a Yale employee who told a similar story.  We are not the only middle class folks to notice a change.  And try to find a doctor or nurse upstairs anymore (excluding ICU).  Some of the techs are great, but not all and they dont give out meds.

And yes, I have written multiple letters—-no reply.

posted by: 1644 on January 25, 2018  9:08am

Wendy:  First, my sympathies to your husband.  I good friend of mine have kidney stones, and I recall him saying how incredibly painful they were.  Isn’t the treatment pretty much drinking water, though?

Second, I avoid the New Haven ER if possible and go to Guilford.  They New haven ER is crowded with folks who really don’t need an ER.  When my wife had chest pains, she was treated well and promptly, maybe overrated, at Guilford and then transferred to the New Haven chest pain center.  I also had a good experience with a friend with narrowing vision (possible stroke).  The triage seems to work for real emergencies were minutes matter.

As for the wards upstairs, when I had my hips replaced in 2015, nursing staff was abundant and caring.  Same for visiting my late father-in-law the same year:  caring nurses who were available.  (Attending doc’s were harder to come by and contact).  My experience with nursing staff at HSR with my mother-in-law was not as good.  The nurses just weren’t;t as responsive.  A YNHH nurse I know told me the PIP checks help, since customer satisfaction is one of the components.

posted by: wendy1 on January 25, 2018  10:46am

Thank you 1644.  I too was successfully treated by the Chest Pain Center in the ER more than once over the years and 2 years ago the ER saved my life when I stumbled in with anaphylaxis…because there were more than 2 doctors int he ER that night.

I am elderly and live close to the hospital on purpose.  And yes,  I know many of us try for St. Raph. or the Guilford facility in an emergency.  I worked at YNHH for many years and know about PIP.  For years I complained about staffing and the lack of unions at Yale and they couldn’t wait to get rid of me.  I wrote letters, heckled “million dollar Marna” in public, and joined the National Union for Nurses ($30).

And you are right about kidney stones, but Jim also needed 5 of Morphine and a catheter along with the IV flush and the wait was long.  Jim writhed and wept and this experience took another 3 years off my lifespan…good for Yale since I have donated our bodies to their med school.

posted by: Chrisssy on January 25, 2018  3:37pm

Wendy, we are all entitled to our opinion. I do agree the unions are weak and I feel bad that people have to spend hard earned money on dues to get nothing in return. I had no fear of being fired. I personally did not want the union. I did fear going outside on my break because the union would not leave you alone if you kept refusing to sign a card. The union was very intimidating and would follow you around and call your house constantly. It was a nightmare and I’m glad they finally gave up.
Let’s just say I worked with you at Yale and the department you were in was not a good fit for you. Sorry