The Out-of-Towners

“I had thought Manhattan would have the newest equipment, but I was proven wrong,” says Runge, who noted with pleasure the absence of side effects and, with almost equal delight, the presence of valet parking.

“Everybody also says Manhattan is the place to go because they have the best doctors, et cetera, et cetera,” he adds. “And I think they may have some of the best but not all the best.”

A brief pause while hospital administrators in the hinterlands, that area loosely defined by New Yorkers as west of the Hudson River and north of Van Cortlandt Park, take the floor for an “I told you so.” It’s been a long time coming. For years, they say, they’ve played Avis to Manhattan’s Hertz. “We had years of the philosophy that if you were sick, you’d go to a New Jersey hospital. If you were really, really sick, you’d go to New York,” says Ronald J. Del Mauro, president and CEO of Saint Barnabas Health Care System in West Orange, New Jersey, where admissions have jumped more than 16 percent since 1997. “For years, New Jersey health care was defined almost as a roadway between Pennsylvania and New York.”

It hasn’t helped the cause of these hospitals that many suburbanites work in New York City, perhaps grew up here, and retain doctors here. “It’s a constant effort on our parts to place our capabilities in front of our consumers and say, ‘We have everything here that you need,’ ” says Marvin O’Quinn, executive vice-president of Atlantic Health System, two of whose hospitals—Morristown Memorial and Overlook—have seen a 7 percent increase in admissions and a 20 percent increase in outpatient procedures over the past four years. “Everything” includes a new neuroscience center with separate epilepsy, brain-tumor, and stroke services at Overlook, and a cardiovascular center at Morristown that racked up 1,531 surgeries last year—more, O’Quinn points out, than Mount Sinai.

There’s also the cyberknife—robotic radiosurgery for inoperable brain tumors— that’s due exclusively at Overlook later this year and may well compel some reverse commutes. “For a lot of folks, this is their last chance,” says O’Quinn. “We’ll get people from New York.”

“What we have to do to maintain our position in the marketplace is keep adding services. That’s the whole reason we went into liver transplants.”

Suburban-hospital administrators believe they have as much reason to talk about their high-flying personnel as they do about their high-tech paraphernalia. Mount Sinai and Columbia Presbyterian were the last mailing addresses of several cardiologists at Westchester Medical Center in Valhalla, where operating-room procedures have jumped 57 percent since 1988. “And our whole liver staff is from Mount Sinai,” says the medical center’s president and CEO, Ed Stolzenberg (discreetly not mentioning the scandal that hit Mount Sinai’s liver-transplant unit last year).

Indeed, “more and more doctors trained in New York have started spreading out to the community hospitals,” says Stephen Michaelson, chief of staff at Norwalk Hospital in Connecticut. Such migratory patterns could be the result of staff cutbacks at New York City med centers as well as, Michaelson suggests, the fact that “people come out here to practice because of the quality of life.” “What happens sometimes,” adds his colleague Eric Mazur, chairman of the department of medicine, “is that commuters who have doctors in the city get sick at night, come to the emergency room, and like how they’re taken care of, and because of our doctors think to come back again for a nonemergency procedure.”   Packaging cannot be overlooked in the suburban sell. Morristown offers amenities like two branch outlets of Au Bon Pain and concierge service on each patient floor, says O’Quinn. Atlantic Health System also offers something mighty hard to come by in Manhattan: privacy. “Some people who are high up on the economic food chain in New York come here for plastic surgery because of their concern for confidentiality,” says O’Quinn.

Indeed, when the ex-Beatle George Harrison was fighting brain and lung cancer in late 2001, he came to Staten Island University Hospital, where he was treated by Dr. Gil Lederman, a pioneer in a high-dosage radiation procedure. (Yes, I know Staten Island is only a suburb in the minds of some Manhattanites; nevertheless, Harrison’s presence there certainly raised eyebrows.)

“New York doctors who come out here are uniformly surprised by what’s here. They’ll say, ‘I didn’t know you had all this.’ But still, we do have to try harder,” O’Quinn concedes, “because we’re fighting against a history and a mind-set.”

He acknowledges a certain logic behind that mind-set. After all, Mount Sinai, New York-Presbyterian, and NYU are all venerable institutions with reputations that span continents and decades. And as academic medical centers, they’ve long been staging grounds for clinical trials, for esoteric protocols for esoteric ailments. “But,” O’Quinn says, “for the last four or five years, we’ve been beefing up our own research capabilities and we now have an enhanced affiliation with the University of Medicine and Dentistry of New Jersey, so we can do more clinical research and get more protocols available to us.”

Success in the battle for market share requires the ability to anticipate trends in medical-care delivery along with the courage—and dollars—to act on them.  For example, primary care (that annual check-up) and secondary care (a visit to a specialist), once the bread and butter of suburban hospitals, are being delivered more and more in doctors’ offices or on an outpatient basis. Tertiary care (surgery, neonatal ICU, burn unit) “is almost our whole product line now, because we want to be competitive with New York City,” says Westchester’s Ed Stolzenberg, enumerating “products” like open-heart surgery, trauma care, and a new children’s hospital. In place are ad campaigns to attract customers—er, patients—and professional campaigns to recruit marquee docs from Manhattan.

“But what’s tertiary keeps changing,” he acknowledges. “MRIs used to be tertiary care. What we have to do to maintain our position in the market is to keep adding services. That’s the whole reason we went into liver transplants, minimally invasive surgery, and robotic surgery.” So if some of those suburbanites who once headed to the big city for big surgery are now staying put, does this mean pain for hospitals in New York? “It’s going to be somebody’s problem that there aren’t enough patients to go around,” says Stolzenberg. “We all may be developing too much tertiary care. Probably some things will close down; the market will determine that.

“I think,” he adds, “that the New York hospitals need to make a real effort. Ours is an attractive population because they’re insured, and they’re attractive from a development standpoint.” Herbert Pardes, president and CEO of New York-Presbyterian, seems unfazed. “Most suburban hospitals can’t maintain the repertoire we have. And one thing you have to watch out for is that patients do best when they’re going to a doctor who’s  done the procedure many times, which may mean going to an academic medical center. And for some things, you’re going to want to go to the person who’s the world specialist, also at an academic medical center.”

“Consumers don’t like to travel for their medical care,” says Mark Chassin, senior vice-president for quality control at the Mount Sinai School of Medicine. “If they can be served with the highest standards of quality and safety close to home, great.

“I don’t see this as a major fiscal problem for us,” Chassin adds. “But it does make everyone sit up and take notice. And it puts pressure on academic medical centers to differentiate themselves from the community hospitals—to get access to research for the current cutting-edge treatments, to develop the next generation of tertiary care. Centers like ours are the only places where science and the bedside manner work together every day.”

The Out-of-Towners