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Commissioner Howard A. Zucker, M.D., J.D.

New York State Department of Health

Corning Tower, Empire State Plaza
Albany, NY 12237

December 9, 2019

RE: DOH consideration of Mount Sinai Beth Israel CON application

Dear Commissioner Zucker:

We write on behalf of residents of lower Manhattan who utilize the services and rely on the presence
of Mount Sinai Beth Israel Medical Center (MSBI) as their community hospital. The planned closing and
sale of the current Beth Israel facility for real estate development, and the proposed replacement of
Beth Israel with a much smaller hospital with fewer services, will create significant changes in the
health delivery system in lower Manhattan. As you evaluate MSBI’s Certificate of Need (CON)
application for construction of the new hospital, we call on you to carry out your critical oversight role
and protect access to a full-service hospital for lower Manhattan residents.
Ideally, review of this CON would be carried out with the benefit of an independent assessment of
consumer needs for health care in lower Manhattan, and projections of what the impact of this
proposed Beth Israel transformation would be on community access to care. We urge that a full review
of this type be carried out to inform your Department’s review of proposed transactions affecting the
health delivery system in Lower Manhattan, including the Lower East Side, Chinatown, Little Italy,
Soho, East Village, Central Village, West Village, Chelsea, Gramercy Park, Stuyvesant Town and Peter
Cooper Village. We note there is residential and commercial development occurring within these
neighborhoods that could increase future consumer demands for health care services.

Recognizing, however, that your Department is already engaged in evaluating the MSBI CON
application, we have carefully reviewed the application from a consumer standpoint. In addition, we
have conducted two community forums, in partnership with elected officials, to hear from lower
Manhattan residents who will be most affected, and we have sought analysis of the CON by a hospital
administration consultant. Through this process, we have emerged with a set of key concerns about
the proposed facility which, contrary to MSBI’s claims, will not be a “full-service hospital.”
At minimum, we would like to see (1) confirmation that the size of the new, smaller Emergency
Department (ED) will be sufficient and not create lengthy delays at either the new Beth Israel ED or at
nearby EDs; (2) creation of a birthing center in the new facility or an adjacent MSBI building to partially
replace the loss of the Labor and Delivery unit closed at BI under a previous CON given your
administrative approval; and (3) presentation of a concrete plan for patient coordination and
transportation from the new Beth Israel facility to other hospitals and outpatient centers for services
that will no longer be offered at MSBI.
(1) Emergency Department
First, we are concerned about the downsizing of the Emergency Department. According to the MSBI
CON, the new ED would accommodate 70,000 visits a year. That is far less than the 87,000 visits to the
existing ED last year. Mount Sinai calculated the future need for ED visits based on a “compounded”
annual reduction rate in ED use of 5 percent from between 2014 and 2018. However, Mount Sinai’s
own data show ED use went down only 1.8 percent between 2017 and 2018, when there were 87,880
ED visits. Moreover, a hospital administration consultant who reviewed the architectural component
of the MSBI CON application for Community Catalyst has suggested the ER would actually only
accommodate about 40,500 ED visits a year1.
We urge you to pursue independent assessment and confirmation that this smaller ED will, in fact, be
large enough to serve the needs of lower Manhattan, particularly in the case of a public health
emergency such as a flu outbreak, hurricane or terrorist incident, without overwhelming the EDs at
nearby hospitals. Your department should also consider what the impact of this downsizing will be on
patient wait times in the ED, as well as the additional wait that would be created when a patient needs
to be transferred to another hospital because the new facility no longer has the appropriate inpatient
services. MSBI’s average wait time in the ED before admission is about eight hours now, according to a
September 2019 report from ProPublica (ER Inspector), and the American Hospital Directory quality
reports. We would not want to see this wait time creep up toward that at Mount Sinai’s main campus
uptown, which has an average wait time of about 12 hours and 10 minutes.

The architectural report included in the MSBI CON states (on page 131) that there would be a total of 18,885 gross square
feet of space in the new ED. A hospital administration consultant who reviewed the CON for Community Catalyst said that
would mean 13,489 net square feet of space (using 1.4 as the net to gross ratio, or 18,885/1.4=13,489 net square feet).
According to the consultant, the rule of architect/planning thumb is 1 net square foot for every three ED visits per year. So,
13,489 net square feet multiplied by three visits would equal 40,467 visits, not 70,000, per year.

(2) Maternity Care

Second, we believe this proposal would leave a permanent gap in access to high-quality maternity care
services. Since the closure of the Labor and Delivery unit at Beth Israel in mid-2017, through your
administrative approval of MSBI’s CON submitted for that purpose, we have heard multiple stories of
women who had to deliver at neighboring hospitals in conditions of severe overcrowding. For example,
a lower East Side resident named Kelly has described for us how she was forced to labor in the hallway
and then the triage room at NYU for close to 30 hours because no birthing rooms were available. She
said the hospital was so overcrowded that staff were not available to respond in a timely manner,
forcing her to labor without privacy or access to valuable pain management strategies, delaying her
ability to deliver and increasing the risk of complications. Another pregnant patient who was diverted
to Mount Sinai West immediately after the MSBI maternity unit closed described similar conditions of
overcrowding and understaffing.
These stories suggest that nearby hospitals were not equipped to easily absorb BI’s patient population
and that the loss of that unit has had important consequences for access to quality maternity care.
MSBI had a sought-after obstetrics practice with the lowest C-section rate of all NYC hospitals in 2016
and a strong OB-midwifery team model. Without it, NYC has lost a high-quality service. Mount Sinai
does not plan to replace the Labor and Delivery unit in the new facility. We think that an independent
assessment of how the loss of MSBI’s maternity services has affected access to maternity care in lower
Manhattan is critical. Particularly at a time when the state is attempting to tackle severe disparities in
maternal morbidity and mortality, we must ensure that decisions made about maternity units are
driven by public health and patient imperatives.
During their transformation planning, Mount Sinai leaders had considered replacing MSBI’s Labor and
Delivery unit with a birthing center at or adjacent to the new facility. A birthing center could be a
valuable addition to the maternity landscape in NYC by expanding opportunities for respectful
maternity care. Birthing centers serve low-risk patients and therefore can operate at lower volume,
making this option a more feasible choice for Mount Sinai. However, Mount Sinai has abandoned this
idea entirely. We believe the state must ensure that access to high-quality, respectful maternity
services is maintained for all New Yorkers giving birth. We urge your department to ensure that MSBI’s
transformation does not further exacerbate the maternal morbidity and mortality challenges faced in
this city, but rather actively expands access to high-quality maternity care. A birthing center in or
adjacent to the new facility would have this effect.
(3) Patient Coordination and Transportation
Third, we believe Mount Sinai must prioritize patient coordination and transportation between its
hospitals and outpatient facilities, as well as to other Manhattan hospitals for services that would no
longer be provided at the new MSBI. Mount Sinai’s “enhanced downtown network” requires patients
to navigate among multiple locations, each offering different services, instead of utilizing one
centralized location. This situation poses significant barriers to people with mobility, language access
and literacy challenges. At our community forum, residents repeatedly expressed concerns about these

barriers. Elderly people and people with disabilities voiced concerns about how they would get
between facilities if they went to one that did not have the service they needed. They raised concerns
about the cost of cabs and the unreliability of public transportation, particularly during a moment of
medical need. A physician reported that an elderly patient of hers (who requires two people for
assistance in transferring from bed to a wheelchair) was referred to the main Mount Sinai hospital on
98th Street for a diagnostic procedure that, in the past, would have been performed at MSBI near her
home. Another elderly patient with a spinal cord injury who uses a cane was directed to an 8 a.m.
appointment at a subspecialty clinic of Mount Sinai uptown, instead of within the Mount Sinai
downtown network. Residents also said the new de-centralized network made it confusing to know
where to go when you needed care and how to know which services are offered at each facility.
We urge NYSDOH to require Mount Sinai to present concrete plans for expanded patient coordination
and transportation strategies. These plans should address the particular needs of vulnerable patients,
with attention to low-income people, people with disabilities, elderly people and people with limited
English language proficiency. For example, Mount Sinai could pursue ride-share vouchers for patients
to navigate between facilities, a robust patient education campaign on which facility to go to for which
health concerns, and a robust patient coordination staffing system. Active consultation with
community groups, such as those signing this letter, would be beneficial.
Finally, a condition of any approval of this CON should be that Mount Sinai create and actually utilize a
Consumer Advisory Board (CAB) for MSBI and the entire downtown Mount Sinai network. We find it
shocking that Beth Israel does not have an active CAB and believe this is a necessary requirement for
continued attention to meeting community needs.
We urge that these concerns be satisfactorily addressed before MSBI’s CON is sent to members of the
state Public Health and Health Planning Council for their consideration. Moreover, we once again
request that PHHPC consideration of the MSBI CON be scheduled when the Council will be meeting in
Manhattan, not Albany.
Your department plays a critical role in ensuring that changes in the health system act to improve the
health of New Yorkers. Mount Sinai’s proposed transformation presents significant concerns that, if
unaddressed, would do the opposite. We thank you for your consideration of these requests.

Lois Uttley, Women’s Health Program Director Anthony Feliciano, Director

Community Catalyst Commission on the Public’s Health System
212-870-2010 Mark Hannay, Director
Metro NY Health Care for All

Penny Mintz, Organizer Benjamin Anderson

Coalition to Save Beth Israel Hospital Director of Poverty and Health Policy
Children’s Defense Fund-NY
Kathleen Webster
Neighbors to Save Rivington House Robert Cordero, Executive Director
Grand Street Settlement
Heidi Siegfried, Health Policy Director
Center for Independence of the Disabled Eric Diaz
Vision Urbana, Inc.
Max Hadler, Director of Health Policy
New York Immigration Coalition

CC: Tracy Raleigh, Director of Health Facility Planning

NYS DOH Office of Primary Care and Health Systems Management

Paul Francis, Megan Baldwin and Dan Dornbaum, Executive Chamber

State Assemblymembers Richard Gottfried. Harvey Epstein, Deborah Glick and Yuh-Line Niou
State Senators Brad Holyman, Liz Kreuger and Brian Kavanaugh
New York City Council Speaker Cory Johnson
New York City Council Hospitals Committee Chair Carlina Rivera
New York City Council Health Committee Chair Mark Levine
New York City Councilmember Margaret Chin
Manhattan Borough President Gale Brewer