The CMO of Montefiore Medical Center explores what they got right during the height of the pandemic — including playing music — and how to apply those learnings in the future.
During a health crisis, it’s important to have humility during unprecedented times, says the CMO of Montefiore Medical Center, but it’s just as crucial to know what you’re good at and exploit your comparative advantages. He shares Montefiore’s successes during the height of the Covid-19 pandemic, the mistakes, and what future epidemic responses might look like.
Thomas H. Lee, MD, MSc, interviews Andrew Racine, MD, PhD, Senior Vice President and Chief Medical Officer of Montefiore Medical Center.
This is Tom Lee, the Editor-in-Chief for NEJM Catalyst, and we’re talking today with Andy Racine. He’s the system Senior VP and the Chief Medical Officer of Montefiore, one of the [United States’] largest health systems, and one that has a deep commitment to serving vulnerable populations in the Bronx and surrounding areas. We’re talking with him today about how he and his system are thinking about the medium-term outlook for Covid-19, that is, how they’re thinking about the next 2 or 3 years.
Andy’s a professor at Albert Einstein College of Medicine, so he has a deep familiarity with the clinical and the scientific issues of Covid-19. He also has a PhD in economics and has a good grasp of the bigger societal issues for his region and the country. Before we turn to Covid-19 today and Covid-19 tomorrow, Andy, can you give our listeners a quick overview of Montefiore?
Absolutely, Tom. First of all, let me thank you for inviting me to participate. This is an excellent opportunity to cover some of these questions. Montefiore is a large academic health system in the Bronx, Westchester, and the Hudson Valley. We’ve got 11 acute-care hospitals within this system, about 3,200 beds, 30,000 employees. We’re the largest employer in the Bronx, [with] 7,000 medical and allied staff.
We have an ally in the Albert Einstein College of Medicine that is part of the Montefiore system, in addition to a nursing school. We’re a totally vertically integrated system, in the sense that we have a large primary care network [that] looks after about 300,000 patients. We have a home health care agency that delivers 700,000 visits a year. We do 3 million specialty visits a year.
We’ve got a care-management organization that coordinates risk-based contracting and manages patients when they’re not in the exam room. We’ve got the first freestanding emergency department in New York state, a skilled nursing facility, a rehabilitation hospital. This is a very large, comprehensive, and integrated system that delivers, essentially, everything from primary care to heart transplants.
Before we turn to what you think is coming down the pike, let me ask, how are things going now?
We’re feeling, as with many other parts of the country, an enormous sense of relief, compared to where we had been. If you look at our current inpatient census for Covid-19 patients, it’s now at about 100 patients throughout our entire system [as of this recording on May 11, 2021]. At the peak of this pandemic, back in March and April of last year, we had 2,000 patients in our system.
The only real metaphor that matters [is] you need to be in constant transparent communication with your troops.
The number of people coming into our emergency department now who are testing positive for Covid-19 is down to about 5%, and a couple of months ago, in the winter, that was up to 25%. We’ve delivered 130,000 vaccinations. We feel pretty good about our current staff with regard to their vaccination rates, although we still have more work to do there.
[With] testing, which is another important part of maintaining our tabs on this pandemic, we’ve run about one-third of a million tests over the course of this past year. When we used to be much more locked down, where visitation was restricted and our workforce was quite anxious about exposure, now PPE is plentiful. We’re relaxing our visitation procedures and policies, and our outreach to bringing in patients who we know have been delaying their care has been ramped up. We’ve got enormous amounts of investments in telehealth and electronic messaging for our patients.
And finally, we’ve learned a huge amount about how to care for this particular pathogen. That has meant that our case fatality rate, which is one of the measures that we use for our effectiveness, is less than half now what it was at the peak of the epidemic. All of which is to say that we’re breathing a bit of a sigh of relief. We’re not completely out of the woods yet. We know that there is work to be done, and we know that there are vigilances that we need to maintain, but we are feeling much, much better than certainly we did last spring, or even than we did in the middle of this past winter, when we were having our second big surge.
Looking back at the last year, how would you say Montefiore did? What do you think you did right that kept things from being worse than they otherwise would’ve been, and is there anything you wish you had done differently now?
That’s a great question that we ask ourselves all the time. Looking back, I would say there were a few critical things that I think we got right. The first one was the issue of communication. I know that may not sound like the top of the list for most people, but I remember distinctly the CEO of Montefiore, Phil Ozuah, who is also a general pediatrician, came to the leadership early in this pandemic, and he said, “You’ll be hearing a lot of these military metaphors with regard to the confrontation with this pathogen. But let me tell you the only real metaphor that matters, and that is, you need to be in constant transparent communication with your troops, because if you are, and you treat them with the respect of making sure that you’re attentive to their anxieties and that you’re giving them all the information they need as soon as they need it, in a transparent and honest way, they will do anything for you.” And he was absolutely right about that.
Maintaining the efficiency of our operations was a question of making sure that the people we were calling on to do this work felt that we were telling them everything that we possibly could about what we knew was going on. As a consequence, Dr. Ozuah was on daily phone conversations. And it was a conversation — it wasn’t as though he was just getting on the phone to deliver information. What he would do was he would solicit questions from the entire workforce, 30-some-odd-thousand workers in the workforce, and then he would go through the questions, and answer. Some of these were tough questions, about what people were facing and the things that they were concerned about, but he would not shy away from any of that.
That authenticity and that constant communication, and the fact that it was him, the CEO, who was delivering it, made a huge amount of difference in terms of how we managed to get through this. So, I would say communication’s a big thing.
A lot of the institutions around our area were playing music periodically throughout the day when we were discharging patients, to indicate to people that things were not as bleak as they might have appeared, because we were actually having successes.
The second thing was — and these are things that you’ll hear from lots of institutions, not just around this issue — whenever there is an emergency, you need a leadership cadre that has situational awareness, meaning you have to have access to good data in real time. You have to have people pouring over that data several times a day to make sure that they are making the recommendations to the institution about how to confront the changes that they’re observing, in such a way that they keep on top of it, and that they anticipate the things coming down the pike.
There may be a couple of other things. One is that you have to know what you’re good at, you have to exploit your comparative advantages. We’ve got one of the nation’s top medical schools in our system, and these folks early on developed their own antibody testing. We could do antibody testing early in this pandemic, because we had the clinical and the research expertise to be able to develop it. The same is true of our relationships with ABET. We had been building this up for a long period of time, so when everybody was trying to get at reagents, we had this pathway to do that.
[Another] thing was the attention to the mental health of our associates. Our psychiatry department was aggressive early on, and proactive in reaching out to people, not waiting for them to get to them with problems, but checking in, particularly in the areas that we knew were the hardest-hit: the emergency department, the ICUs, places where we were deploying ambulatory people to go into the inpatient service, our children’s hospital where we were putting adult patients to be cared for by the pediatricians. These are very stressful times, and having the psychiatry department out there in front was a huge undertaking, really important for us.
The last thing that we got right — this is very important — is that early on, a lot of the institutions around our area were playing music periodically throughout the day when we were discharging patients, to indicate to people that things were not as bleak as they might have appeared, because we were actually having successes.
The question was, what music are we going to play? I remember distinctly being in my office, and I was sitting there with the System Senior Vice President for Operations, Susan Green-Lorenzen, and we were thinking about this. She turned to me and said, “I know what we have to do.” I said, “What’s that?” [She said,] “ Alicia Keys’ ‘New York,’ that’s the only thing we can play.” And she was absolutely right; it was anthemic, it was fantastic. It capsulated everything that you needed to hear, you know? If you’re in New York, it’s going to be fine.
I’m going to have to play that right after we’re done with this podcast.
You definitely should, it’s a great song. I love that song.
Anything that you wish you had done differently?
Sure, there’s plenty of things that we should have done better. A lot of this has to do with the fact that we had learned all kinds of lessons from previous brushes, if you will, with bad infectious pathogens. I think back to the H1N1 crisis back in 2009, I think back to the Ebola crisis in 2014. We repeated — and by “we,” I don’t mean just Montefiore, we as a system repeated — the same mistakes every time.
We simply don’t seem to be able to learn how to coordinate. What happened this time, which is exactly what happened with Ebola and exactly what happened with H1N1, is that each health system was on its own, essentially, to find the PPE and to source it, to buy it, and to get it. Same thing was true with ventilators, with oxygen, with all of the things that you need in order to treat this pandemic, and that is a huge mistake.
When you are confronting a pandemic of the magnitude that we were confronting, this is not something that institutions alone should be left to try and figure out.
The reason we have supra-institutional agencies, meaning the government, is precisely to be able to coordinate these things, so that essentially, you’re not finding everybody competing with one another for scarce resources, rather than trying to do this all as a single system. We didn’t do that this time, and it was a big mistake, because it meant that all of the different institutions were anxious about what they were going to be able to get.
The people working in those institutions felt that same anxiety, and although there were attempts made — and I have to credit the state government in New York for doing this — to try and do this, it was nowhere near as complete, as comprehensive as it needed to be. Partly, it was because they couldn’t depend upon the federal government to deliver these kinds of things. But that’s really what you need. When you are confronting a pandemic of the magnitude that we were confronting, this is not something that institutions alone should be left to try and figure out. That’s no way to run a railroad, and I don’t think we did that well.
That’s a huge lesson to be learned, and it’s a learnable one. Now, looking ahead, we know you don’t have a crystal ball, but can you give us your best guess for what the fall and the winter are going to hold for us in 2022? There is your best guess, and then there’s what you’re preparing for at Montefiore: return to normal [or] another surge?
There are infectious disease experts and epidemiologists who have far more expertise than I do about this, but I think the consensus is that while there may be blips that we’re going to be confronting in the fall, and pockets of areas where there may not be as much vaccination as we need it to be, or there may be age groups that simply haven’t gotten their vaccines yet, the magnitude of the immune response based on both vaccines and previous infections will be such that we will not be experiencing next winter the kind of surge that we experienced this winter.
And that’s a good thing. Now, we’re going to have to make some decisions with regard to how we run these institutions when we get to that point, meaning what we’re going to do with regard to where we’re going to put patients, and how we’re going to do visitation rights, and what we’re going to do with these kinds of things. But I expect that we are going to have a much, much smaller surge, if at all, next fall and winter, than we experienced this past fall and winter.
What that means from the institutional standpoint is that we’re going to get to a point, ultimately, where the coronavirus, too, is going to be a manageable pathogen, the way we manage lots of other things. It’s clearly more severe than seasonal influenza, but if you think back on it, Tom, we usually lose between 35- and 60- or 70,000 people a year from flu, and that’s in a normal flu season. We have hundreds of children who die from flu every year.
What’s going to happen is, we’re going to be a lot more cognizant of our ability to control the spread and the dissemination of respiratory pathogens, and we’re going to be doing things more routinely than we have up until now. By that, I mean essentially during these seasons wearing masks and practicing some form of social distancing in order to try and cut down on the transmission rates. And we’ll be probably successful.
That is one of the stunning findings from this period, how the adherence to social distancing and wearing masks led to such a decrease in flu rates, so much so that CVS earnings are way down because people haven’t needed to go in and buy all the supplies.
It’s not just flu. I’m a pediatrician. We barely saw RSV [respiratory syncytial virus] this year in our hospital. Same thing for the rotavirus, interestingly, we saw very little rota. We have an effective vaccine for rotavirus, but nevertheless, it’s not just rotavirus, it’s other infectious diarrheal diseases that we saw a lot less of, because of the way people were behaving during that period of time.
What’s going to happen is, we’re going to be a lot more cognizant of our ability to control the spread and the dissemination of respiratory pathogens, and we’re going to be doing things more routinely than we have up until now.
When you look down the road [to] 2022, 2023, what are the lessons learned and the probability that we’ll be trying to control Covid-19 and other viruses? What does it mean for Montefiore, and how are you thinking that it should affect the way Montefiore works with other societal institutions? One comment I read by you was that you don’t control a pandemic in the hospital. What’s Montefiore health system thinking about that it should be doing to try to help control the threats of Covid-19 or other viruses going forward?
Unfortunately, you’ve given me an invitation to get on a bit of a soapbox, because I think about this a lot, and I talk about it a lot. The most important thing from the standpoint of health systems like ours is to maintain a certain degree of humility about this. If you look at what are the determinants of health status of any population of people at any age in any venue, most of the things, if you’re trying to predict variation in health status in the left-hand side of your model, most of the things on the right-hand side, the powerful predictors, are things like genetic endowment, education, good nutrition, housing, clean air, clean water, no lead exposures.
The receipt of medical services can make something of a difference in health status on the margin, but the coefficient of that variable in that model is small relative to those other things. Our ability as health systems to do this is not as great as we credit ourselves as it being, first thing. Second thing is that if you’re going to think about those things, and what contributions health systems can make, it’s by trying to get those other issues addressed. What does that mean, what does that look like for a health system?
For one thing, it looks like your health system has to be deeply, deeply embedded within the community of people whose care is being sought at your institution. You can no longer be in the posture of having people come to you for high-end care, and that’s your responsibility. We deliberately, over many decades now, have disseminated the primary care network system throughout this community, for this very reason. You have to be able to deliver care close to where people are, so that you know a little bit more about what their needs are.
From a pediatric standpoint, the other thing that I am proud of with regard to what we’re doing is the idea that 15 years ago, we came to the realization that if you’re going to deliver primary care, for example, in pediatrics, you have to colocate infant mental health in your primary care setup, because that’s what is going to enable those children to grow up to be healthy.
That’s also true of adults, by the way, so that we have the largest colocated infant mental health system in the country, at a certain point. I don’t know if it still is, but that’s true. We have the largest school health program in the country, because you’re going to have to be able to partner with educational institutions in order to promote the health of school-age children. Those are the things that are going to lay the groundwork for what’s going to be coming down the pike in another generation or two.
Your health system has to be deeply, deeply embedded within the community of people whose care is being sought at your institution.
For example, the fact that we’re going to have fewer cases of hepatitis, and we’re going to have fewer cases of liver cancer, is because we’re immunizing children against hepatitis B. We’re going to have fewer cases of cervical cancer if we can get our HPV vaccination rate up to 80 or 90%, and those are the things that you have to think about in a forward-looking way, if you’re going to be doing this.
The other thing about that is that you have to be willing to find out this information from the people who are coming to you for care, doing social-needs assessments on everyone, and being able to link them with whatever community-based organizations are available to help them with housing, or clean water, or their legal troubles, or transportation, or whatever it is that they need in order to be able to live healthy lives.
For a long time, this wasn’t considered the purview of health systems, but more and more, that’s exactly what’s going to be the case. And so, we’re actively working in those areas as well.
This is exactly the kind of insight that I was hoping that you would be bringing to the audience today, how Montefiore, with your special culture and your challenging setting, the ways in which you’re going beyond the boundaries of what people think of as traditional health care. It’s clear the rest of health care has a lot to learn from the innovations that you guys are pursuing, things like your school health program.
I’m hoping that we’ll be able to spread more of those through NEJM Catalyst. We’ll be watching how it goes over the next year or two, and I’m sure we’ll be coming back to you for more of Montefiore’s experience and insights. Thanks very much for your time today.
Tom, it was a pleasure. I appreciate and am grateful for you to have invited me, to get to talk to you about this. It’s something that’s of great importance to all of us, and I appreciate the time. Thanks.
Andrew D. Racine, MD, PhD
Senior Vice President and Chief Medical Officer, Montefiore Medical Center, Bronx, New York, USA; Professor of Clinical Pediatrics, Albert Einstein College of Medicine, Bronx, New York, USA
Thomas H. Lee, MD, MSc
Editor-in-Chief, NEJM Catalyst Innovations in Care Delivery; Co-Chair, NEJM Catalyst Editorial Board; Chief Medical Officer, Press Ganey Associates, Inc., Boston, Massachusetts, USA; Member, Editorial Board, New England Journal of Medicine