In a closed-door meeting in early July, Montefiore Health System administrators told staff at a highly regarded family medicine clinic it had decided to move them from their Fordham building to another location two and a half miles away.
Multiple doctors at the clinic told New York Focus the move would be disastrous for their patients, who largely come from low-income, immigrant communities. On August 5, following staff pushback and organizing efforts from community advocates, the administration walked part of the plan back in a compromise that leaves many of the clinic’s providers unsatisfied.
The relocations, which were reportedly designed in consultation with McKinsey & Co., entail a sequence of cost-cutting real estate consolidations within the health system’s Bronx facilities. Montefiore would move its Grand Concourse internal medicine clinic, also in the Fordham area, into the building that currently houses the Family Health Center, and relocate part of its operations at the family clinic to the far-flung Williamsbridge Family Health Center.
Montefiore rolled out the plan without community input ahead of the start date of two wide-reaching state health policies. Opponents say the health system is rushing to get the move done before the implementation of one of those new laws, the Health Equity Assessment Act, which could force the state to consider how the move could negatively impact its patients.
Montefiore has insisted that none of its patients will lose services in the move, and thus that it doesn’t have to ask for permission from the state. Staff and local health advocates dispute this, arguing the inconvenience of the move could potentially leave thousands of patients without access to the Family Health Center’s vital programs.
“This is devaluing primary care and devaluing the community that we work within, and decreasing the access to those important services in the name of profits,” said one physician at the clinic.
The move also may have its fiscal roots in another state policy. In early 2023, the state health department is set to change the often-lucrative way that federally subsidized pharmacies, like the one located in the Family Health Center, receive reimbursement for Medicaid purchases. Though the state has promised that it will provide reimbursement for the lost revenue, many providers are skeptical it will be enough.
“I feel betrayed”
The Family Health Center is designed to serve as a one-stop shop for its patients: it provides prenatal care, an HIV program, counseling for substance-use disorders, and reproductive health services like long-acting reversible contraceptives, medication abortions and procedural abortions up until 11 weeks.
The center also has a mental health clinic catering to the surrounding area’s Southeast Asian population, which includes Cambodian and Vietnamese refugees — groups that commonly struggle with high rates of depression and PTSD stemming from aftermath of the Cambodian genocide and the Vietnam War.
The Fordham area has a substantially higher rate of psychiatric hospitalization and premature death than the city’s average. The Bronx is tied with Queens and Staten Island for the lowest ratio of healthcare workers to the general population.
The Family Health Center is a federally qualified health center, meaning it receives federal funding to provide subsidized healthcare to people on Medicare and Medicaid, as well as to the uninsured on an affordable sliding scale. It serves roughly 12,000 to 13,000 patients per year, according to data provided by staff.
The hospital’s first plan would have moved all family medicine doctors and residents to the Williamsbridge Family Practice Center, over 2.5 miles away. The new plan would still send all residents and a third of the attending physicians to the Williamsbridge location, but it would allow the remaining two-thirds of the doctors to stay, squeezed into one of the four pods they currently occupy.
That would mean that around 3,000 patients would be expected to travel about 2.5 miles further to visit their doctor. Some doctors, who requested to remain anonymous to protect their employment, told New York Focus that many of their patients have indicated they would not make the trip, even though Montefiore has promised to provide a shuttle to the Williamsbridge clinic.
“If you were talking about a suburb where everybody has a car, two miles away is not a big burden,” said Lois Uttley, a senior adviser for the Hospital Equity and Accountability Project.
“But we’re not talking about that. We’re talking about an urban neighborhood where it’s not so easy to travel two miles.”
Deatrice Archer, who has been a patient at the FHC since 1987, told New York Focus she is disappointed that Montefiore did not consult its patients before making such a consequential decision.
“I feel betrayed,” she said. “I could have been notified, maybe we could have done something else. But they just went full steam ahead and assumed that this is gonna be the right thing. And it’s really not for the patients who come here.”
A hub-and-spoke approach
Staff who were in the July meeting with management said the decision came from advice the health system received from the consulting firm McKinsey & Co.
Montefiore did not respond to a question about whether it had contracted with the management company, but the health system’s public financial records show that it partnered with an unnamed consulting firm with the aim of saving $500 million in its annual budget, Crain’s reported.
Montefiore’s relocation plan closely matches strategies that McKinsey has publicly promoted. In 2019, McKinsey published an article on the “hub-and-spoke” approach to healthcare restructuring, which aims to enhance “efficiency and productivity” by centralizing services in larger hospital facilities.
This McKinsey model attempts to increase the volume of specialized services in “regional hub” hospitals by “vertically integrating” patients from smaller hospitals and community-based care centers.
Over the past few years, Montefiore has focused on purchasing a real estate portfolio for new medical facilities further north into Yonkers and Westchester County, both wealthier areas than Fordham. The health system has also recently opened a “brand new, state-of-the-art 10,000 square foot” facility in Manhattan’s Hudson Yards, and is advertising “non-academic concierge/executive medicine” jobs at the location.
Last August, the health system bought a $38 million development site in White Plains. It has also developed specialized services in its existing facilities, like the $44 million, state-funded revamp of its New Rochelle hospital, featuring an expanded emergency department facility, a new health center and upgraded radiology department.
In a statement provided by the company, Chief Medical Officer Dr. Andrew Racine said that “the Family Health Center is not closing and will continue to offer its full complement of health care services to the community including primary care, family planning, addiction medicine and HIV care.”
Ahead of the curve
The Bronx reshuffling could allow the hospital to get out ahead of coming payment reforms. A delayed carve-out enacted by former Gov. Andrew Cuomo will go into effect early next year, cutting off a crucial funding stream. The policy will end the state’s participation in the federal 340B program, which requires pharmaceutical companies to provide rebates for outpatient medication purchases for Medicaid recipients. These reimbursements allow providers like the Family Health Center to provide discounted or free drugs and use the savings to fund other critical services.
“Federally qualified health centers today draw down a lot of money, thanks to the 340B program,” explained Assembly Health Chair Richard Gottfried. “They only get that extra money if the 340B prescriptions flow through a Medicaid Managed Care Plan.”
This is sort of a sentiment that’s been felt among other primary care providers across Montefiore, including in pediatrics and internal medicine, that they feel like their community-based clinics are next.
The state has said that they will provide alternate funding to 340B pharmacies to make up for the loss, but providers have expressed skepticism about whether the state subsidy will be adequate. Community health clinics and other qualifying providers across the state have urged Hochul to repeal the carveout.
Montefiore administrators have presented the move as an attempt to consolidate leased space, according to staff present at the July meeting. They explained that productivity of the building and the room utilization in the clinic are too low to justify how much space they take up, staff said.
Clinic doctors respond that the number of patients has remained consistent over the past three years. The restructuring leaves them wondering what other community programs might be downsized.
“This is sort of a sentiment that’s been felt among other primary care providers across Montefiore, including in pediatrics and internal medicine, that they feel like their community-based clinics are next,” said an attending physician.
Staff and advocates say they plan to continue to build pressure on the hospital’s leadership to prevent the relocation.
Chhaya Chhoum, executive director of Mekong NYC, a Southeast Asian-focused advocacy group that has begun to organize against the plan, said she thought that Montefiore’s haste in announcing the move without stakeholder or patient input could be intended to avoid getting drawn into the requirements of the Health Equity Assessment Act.
“We think that’s why they’re rushing to the decision to be as quickly as November, because it’s not implemented yet,” Chhoum said.
That law, which won’t go into effect until June 2023, was spurred by hospital bed shortages at the peak of Covid-19. It will reform the Certificate of Needs process, which hospitals and clinics have to go through before they merge or close facilities or “substantially reduce services.” Before the state can grant approvals, healthcare systems will have to assess the impact their proposals will have on uninsured and Medicaid patients’ access to care.
Under the timeline Montefiore announced, it would not have to undergo that process.
Uttley, a policy expert who helped advocate for the health equity assessment bill, said that Montefiore would still have to file a Certificate of Need application with the state in order to consolidate the clinics if they are state-licensed treatment centers. She added that she raised this question to a top health department official, who told her the department is looking into whether the clinics are licensed as treatment centers or private doctor’s offices.
After this article first published, a health department spokesperson told New York Focus that the Grand Concourse Clinic is considered a private medical practice and therefore is not under the agency’s jurisdiction.
The health department also said it agreed with Montefiore’s assessment of the impact to the Family Health Center and therefore that it would not need state approval.
“As you know, the Family Health Center is not closing and is remaining a primary care extension clinic,” wrote a Montefiore spokesperson. “As a result, there is no impact to the operating certificate or services at the Family Health Center (nor at Williamsbridge) which means the state does not require notification and approvals from the state are not needed.”
The prime sponsor of the Health Equity Assessment Act has so far tried to stay above the fray. Senate Health Committee Chair Gustavo Rivera, who represents the district in which the clinic is located and is a week away from a contested primary election, said in a statement he was “committed to ensuring all parties work together to ensure that a comprehensive level of care remains in the Fordham neighborhood.”
The story has been updated to reflect information provided by a state health department spokesperson sent after this story first published.