Photography by Gary Wayne Gilbert
From her office on the campus of Montefiore Medical Center, at East 210th Street and Rochambeau Avenue, Amanda Parsons â97 can look out over a row of brick houses and see the wide borough of the Bronx spreading to the horizon. The houses give way to low apartment blocks and, in the distance, the Gun Hill public housing complex. Parsons is Montefioreâs vice president of community and population health, and has been since 2014. In the simplest possible terms, her job is to help the Bronxâs 1.5 million people lead longer, happier, healthier lives.
Itâs a Wednesday morning in May, and at 9:00 sharp Parsons pulls out her schedule. The dayâs lineup is crowded and typical, a sketch of the broad landscape of her concerns. When Montefiore was started by Jewish philanthropists in 1884 as a home for chronic invalids, its mission was to serve the âpeople whom other hospitals of the day would not help,â according to official history. Today, the Montefiore Health System is one of the countryâs largest, with 11 campuses, research facilities, and the Albert Einstein School of Medicine (where Parsons is also an assistant professor of family and social medicine). Services provided by Montefiore have earned it national rankings. Those services are badly needed. The Bronx is the unhealthiest county in New York State (and has been for seven years running), falling at or near the bottom in measures such as obesity, smoking, physical inactivity, and low birthweight. It is also the poorest county in the state, and among the poorest nationwide, with a per capita income of less than $19,000, according to the Census Bureauâs American Community Survey. Its rundown apartments, infested with mold, roaches, and rodents, contribute to a high incidence of asthma, especially among poor children (43 percent of the boroughâs children live in poverty). Children in the Bronx on the receiving end of Medicaid (a proxy for âpoorâ) are diagnosed with the disease at a rate 3.3 times the state childhood average. And one out of three Bronx residents, versus one in eight Americans overall, does not have enough to eat.
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Parsons with Christopher Panczner, a Montefiore system senior vice president, outside the Bronx New Way Deli & Grocery. The bodega is located a mile and a half from the Medical Center.
First up on this day is a meeting to address the problem of babies and smoking. Itâs difficult to bring a group of clinicians and administrators togetherâemergencies ariseâand this meeting must be cancelled. But Parsons lays out the challenges for a visitor: On one side of any solution are Montefioreâs pediatricians. Too often, they find themselves treating infants suffering the impacts of second-hand smoke, which include bronchitis, pneumonia, and increased risk of crib death. On another side are the medical centerâs specialists in helping grownups kick the cigarette habit (one in six Bronx adults is a smoker). Everyone wants the best for patients and their families, Parsons observes. But the medical records each side uses talk past each other; they donât mesh.
As Parsons spells out the problem, she reveals something of herself, professionally and personally. She speaks in paragraphs, with cool command of the complex issues. And her tall, athletic frameâshe used to compete in triathlonsâgives her a physical authority. Itâs easy to understand how she became a leader. But she also speaks in relatable terms, and with the âdash of sass, passion, and humorâ she touts on her LinkedIn profile.
âSo, I am the baby,â Parsons says, building a case. âThe mom says that I am exposed to second-hand smoke, because dad smokes or grandma smokes or something. And you, the pediatrician, want to refer said grandma or said dad to smoking cessation. But the pediatrician is sharing the babyâs chart, so smoking cessation says, âIâm not calling a six-month-old.â They donât even know, Is it the grandma? Is it the dad? Is it the mom? Weâre trying to figure out a way to solve that.â
The next appointment is a meeting to discuss coordinating the mental and cardiovascular care of Montefioreâs schizophrenic patients. In part because antipsychotic medications are strongly associated with weight gain (due to appetite-enhancing and metabolism-disrupting side effects), and in part because this âis not a cohort thatâs running marathons and leading organized lifestyles,â says Parsons with empathy, many of these patients die of heart disease.
âThe problem is that we bifurcate their care,â Parsons says: Psychiatrists look after the mind and physicians look after the body. It would be better if both sides kept an eye on all aspects of their patientsâ health, from establishing that their vaccines and diabetes tests are up to date to confirming that their prescriptions for antipsychotics are actually being filled. But this isnât happening. âThere are alerts in our health-records software that can prompt doctors to do the right thing,â Parsons says, but at Montefiore, âWeâve done something I think not quite bright, where your flu vaccine alert, for example, only goes to your primary care physician.â She contrasts Montefiore with the Kaiser Permanente integrated medical system, where alerts for both routine and patient-specific procedures go to every doctor a patient sees: âIf you walk into the dermatologistâs office at Kaiser and you havenât had your mammogram, the dermatologist will remind you.â Todayâs meeting, with administrators from Montefioreâs clinical-records department, is the latest of many she has had during the effort to move Montefiore toward a similar integrated approach to patient care.
More meetings tick past by the hour in Parsonsâs planner: on Montefioreâs âdata-informed opioid response collaborative,â involving community groups and social services in the Hudson Valley north of New York City; and on âSDH clinical documentation and codes.â As Montefiore screens its patients for social determinants of health (SDH) such as housing and education, says Parsons, âwe have to find a wayâ to align the additional data with âmedical coding lingo . . . the numeral codes that represent a diseaseâ (e.g., 140.9, for hypertension). Parsons will also meet this day with representatives of the Montefiore Nurse-Family Partnership, âa wonderful program for first-time moms, of which we have a lot here in the Bronx.â (Even after an almost 50 percent drop since 2005, teen pregnancy rates in the Bronx are the highest in New York City, at about 70 per 1,000 teenage girls.)
Diverse as the appointments are, common threads run through them all. There is a medical issueâa matter for Montefioreâs doctors and nurses. There is an organizational issueâa matter of enacting a new protocol, or opening a new line of communication. There are the patients and the communityâthe people of the Bronx. And there is the need for someone who can pull these threads together. âI work at a system level and at a community level,â says Parsons. âDoing one helps me understand what I need to do the other. I like having feet in both canoes.â
Thereâs a way in which Parsons would like to blur the distinction between the hospital and the community. In a given year, fully one-third of the Bronxâs residents pass through the Montefiore system. And in addition to being the Bronxâs largest hospital by far, Montefiore is the boroughâs largest employer; many of its 33,000 employees are locals. (Parsons commutes from Lower Manhattan.) When the hospital uprooted from Manhattan in 1913 and moved to the borough northward, the Bronx had just entered a 40-year population boom (a million people arrived between 1910 and 1950), which was followed by a 40-year demographic swing from mostly white to mostly non-white. And as the borough grew and changed, the hospital grew and changed with it. When Parsons talks about reaching out to the community, she is really talking about improving a relationship of long standing.
Parsons with Jimmy Ali, owner/manager of the Bronx New Way Deli and Grocery. Ali recently added low-sodium canned beans and whole-wheat pasta to the bodegaâs offerings.
The Bronx was never as lawless or as gritty as Hollywood made it out to be in movies such asÌęThe WarriorsÌę(1979). But it is still, for many of its residents, a tough place to live. Though crime rates have plummeted in every borough since the 1990s, the Bronxâs rates lead in many categories, including murder (with 54 in the first half of 2018), rape (214), assault (1,688), and robbery (3,092). Half a dozen major highways fragment the boroughâs neighborhoods and fill the air with fumes and soot. Its public housing complexesââthe projectsââisolate families from places of work, play, education, and worship. Ninety percent of Bronx residents are members of a minority group, predominantly Latino and black. More than half speak a language other than English at home. More than a third were not born in the United States.
None of these characteristics, on its own, accounts for another of the Bronxâs burdens: poor health. But all produce what Parsons calls âheadwinds.â An abundance of bodegasâcheap, all-night corner shopsâmeans junk food is everywhere, and many Bronx residents eat poorly, even when fresh fruits and vegetables are available. Obesity and diabetes are huge problems, affecting one in three and one in five adults, respectively (both rates well above the citywide average). And blood pressure trends high: 36 percent of adults in the Bronx suffer hypertension, versus 29 percent in New York City as a whole. The Bronx ranks first among New York Stateâs counties for death by heart disease.
One of Parsonsâs first efforts at Montefiore, in 2014, was the implementation of a diabetes prevention program. Studies elsewhere had shown that at-risk patients who met regularly, one-on-one, with a nutrition counselor had lower rates of developing diabetes than patients given medication. The counseling approach, moreover, was far cheaper than the pills. After the Centers for Disease Control and Prevention approved group sessions, the cost per patient per program dropped to just above $200. In the Bronx, nutrition counseling had been the bailiwick of the YMCA. Parsons helped shift the effort to the hospital. There patients, she says, were taught about âactivities, calorie tracking, shopping, when you fall off the wagon how to get back on, how to create infrastructure around you for supportâgenerally, all the things that, if you grew up in a healthy family, were always around you.â The goal of the 16-week course was to ingrain a whole new lifestyle. âYou canât do it over a weekend,â Parsons says. âThat would be the equivalent of, âWell, if one pill a day works, maybe Iâll take all seven on Monday.'â
It has proven astonishingly effective. âIn general, our participants lose about 3.5 percent of their body weight,â Parsons says, âwhich generally translates to a 27 to 30 percent reduction in the progression to diabetes in the next three years.â
The effort, called the Diabetes Prevention Program, helped establish the model for Parsonsâs continuing work. The typical approach to population health had long been to treat illnesses that already existed. (ââLetâs wait till someone has diabetes or kidney failure andÌęthenÌędo something,'â Parsons says acidly.) At Montefiore, the focus is on reaching people before they are sick and helping them manage and improve their healthâgetting fitter and happier. The strategy is not radical these days, but at Montefiore and a minority of hospitals around the country, it is now baked into the business model.
For about a quarter of Montefioreâs patientsâwhether on Medicaid, Medicare, or a commercial insurance planâthe hospital doesnât issue bills to be paid by patients and their insurers, the so-called fee-for-service model that predominates in this country. Rather, Montefiore takes a significant percentage of these patientsâ insurance premiums as a block grant from the insurers, with the license to spend the money more or less as it sees fit. Accountable Care Organizations, as hospitals that work this way are known, are becoming increasingly common in U.S. healthcare: âItâs an evolving field,â says Parsons, and Montefiore was an early adopter of the practice, beginning in 1996.
Under this risk-based model, Montefiore assumes substantial financial responsibilityâif a patientâs treatment costs more than the grant, the hospital covers the differenceâbut gains the freedom to be smart and creative about care. And if a patientâs care costs less than the grant, the âprofitâ can be plowed into programs to help people avoid getting sick in the first place.
As a result, Parsons says excitedly, âwe are incentivized to do preventative care. But also, we are no longer restricted by thinking about âwhat does Medicaid pay for?'â The majority of Montefiore Medical Centerâs patients rely on Medicare (37 percent) or Medicaid (45 percent). Her voice rises and her words rush. âMedicaid doesnât pay for an air conditioner. You canât bill an air conditioner to Empire Blue Cross. But that might be why the little old lady keeps coming back to the emergency room! Once you take the premium and have it as operating budget, you can buy her one. You untether from the restrictions of âbenefits.'â
This freedom has produced some remarkable programs. Take the Healthy Store Initiative: the effort, begun in 2015, to get bodegas, those all-night corner shops, to promote healthier foods. Parsons had her data analyst (âHeâs phe-nom-e-nalâ) identify Bronx census tracts with 300-plus diabetes patientsÌęandÌęa high number of bodegas, and then trained her persuasive efforts on them. There was no formal launchââWe just began approaching bodegas,â she says. For their part, the bodega owners were receptive to the ideaâbut warned that the healthy stuff had to sell. So Parsons and her team helped them with Marketing 101. âA lot of the bodega owners go and buy their fruits and vegetables in these boxes and then they leave them in there, where theyâre not getting aerated, and they spoil. So we worked with them on making displays.â But what about when the bananas eventually go brown?, the bodega owners asked. Answer: ââThatâs the perfect banana to put in a smoothie.â So we buy them blenders.â Mindful of the importance of sales, Parsons worked to build up a base of customers, too: The diabetes-prevention groups started taking bodega field trips, learning how to read nutrition labels and getting a taste for salads. In 2015, the Robert Wood Johnson Foundation awarded its Culture of Health Prize to the Bronx and its âpolicymakers, healthcare professionals, nonprofits, and individuals across [the] borough.â The foundation quoted Parsons about working âoutsideâ the usual silos and cited the bodega project.
Parsons, in the stacks of the Restaurant Depot/Jetro Cash and Carry, a wholesale food supplier located in a warehouse district in the South Bronx.
Under Parsonsâs guidance, the hospital system has tackled asthmaâin partnership with local clergy and other community groupsâby funding the renovation of mold- and vermin-afflicted homes; âhotspottedâ specific neighborhoods hit hardest by flu for free vaccination deliveries; and gathered troves of borough-wide health-related data via a survey of every Montefiore patient (âHave you struggled to feed your family in the past 12 months? Do you have pests in your home?â).
âEvery system is engineered for the outcomes it gets,â Parsons says. âAnd so whenever we want to change outcomes, we know itâs not a matter of, âWork harder, do better!â Itâs a matter of reengineering the system.â The projects change but the strategy of working with the community remains a constant. âIf you want to get rid of the problem,â Parsons says emphatically, âyouÌęhaveÌęto do these things.â
In a break between meetings, Parsons describes how she got here. At Boston College (and then known as Amanda Heron), âI was hyper-pre-med.â A freshman from North Brunswick, New Jersey, sheâd been selected to join the third class of presidential scholars, but âall my classes were science, all my electives were science-related. I was like a tunnel-visioned persona all through college.â She describes herself even then as an âadrenaline junkie in the healthcare setting,â working as an EMT with the North Brunswick First Aid and Rescue Squad, and volunteering in the emergency rooms at St. Peterâs and Robert Wood Johnson hospitals in nearby New Brunswick. Certain she wanted to be a doctor, after graduation she reluctantly took a summer desk job at a New Jersey cancer research company, Theradex, to kill a few months before medical school began. But to her surprise, she loved being part of a team analyzing research in an office environment. Sensing a new calling, she asked for a yearâs deferment to continue the work, and Columbia Medical School said yes.
At Columbia a few years later, and once again certain that medicine was her calling (âI was going to be an ER docâ), she stumbled onto yet another new interest, via her then boyfriend. âEverything I would describe about the [medical] system not working, he would have a solution for. I was like, youâre this weird tech guy from California, why is it that you know how to solve these problems and I donât? And his response was, âOh, from business school. Donât think of it as, We crank out bankers,â he said. âThink of it as a toolkit that you can use in your career.'â So Parsons entered a joint program at Columbia and earned her MBA as well.
With both degrees in hand, in 2003 she joined the international consulting firm McKinsey & Company (sheâd impressed during a summer internship, helping New Jersey Transit cut costs in its bus division). But still medicine called, so in mid-2005 she took a sabbatical to do a residency in internal medicine at Beth Israel Hospital in Manhattan. And finally she found peace: âAt the end of the year, I knew: Iâm not going to be a doctor. I get it now. I want to work on problemsÌęaroundÌęclinical situations.â
Back she went to McKinsey, where she specialized in teaming up with healthcare companies, and then, in January 2008, she joined New Yorkâs City Hall. âThe Bloomberg administration had a kick-ass health department,â she says, and Parsons fit right into the businesslike atmosphere. (She was nine months pregnant with her son when she appliedâParsons also has a daughterâand she was nervous about needing to take maternity leave so soon. âBut they said, âThatâs good, because it takes us six months to hire.â That was one thing Bloomberg was not able to fix, the speed of hiring.â)
Parsons rose quickly through the ranks, becoming deputy commissioner within four years, and leading initiatives to improve healthcare access for New Yorkers, expand electronic medical record-keeping, and reform outdated practices at Rikers Island, the cityâs jail complex holding some 7,500 mostly pretrial inmates. At Rikers, she says, âI worked very hard to bring down the number of people being held in punitive segregationâreducing the number of people sent there, reducing the amount of time they spent thereâand helped create units that allowed for more social contact and programing for inmates who were put in punitive segregation.â
During a conference call with Somos, a Bronx Hispanic physicians network, Parsons is joined by Montefiore administrators Anika Joseph (left) and Nicolette Guillou.
But âthe ultimate highlight,â she says, was working with her team âto create clinical alternatives to punitive segregation for inmates with serious mental illness.â She made it easier for medical professionals on the outside to obtain Rikers health records after their patientsâ release from jail, and she created channels for involving community mental healthcare providers in the discharge process. Six months after Bloomberg left office in January 2014, Parsons left city government for Montefiore.
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Itâs 1:00 now. Parsons has been on the phone for more than two hours, and it is time for a break and a bit of lunch. Before we set out, she takes a moment to reflect. âThereâs a lot of work that needs to be done in the Bronx,â she says. âYou never get out of bed and think, âEh, whatâs the need?'â She gestures out the window toward the streets. âThe potholes in TriBeCaââa wealthy Manhattan neighborhoodââwere cleaned up pretty nicely this winter. Thereâs still a bunch of them here. We have the greatest need and are the last to get services. So it feels good to do the work here.â
The sidewalks around the hospital are filled with patients, visitors, and hospital staff, their faces and clothing reflecting the Bronxâs patchwork. A lunch spot across the street from one of the hospital entrances proves popular with everyone. It was once a typical bodega, full of junk food, Parsons says. But in recent years, it has completely reoriented. Now the fridges are stocked with healthy sandwiches, fruit, and seltzer water, and behind a counter running the length of the store, deli workers are putting together greens and smoothies for a clamorous crowd.
Parsons picks up her salad and turns back toward her office, more meetings ahead.
Tim Heffernan is a writer based in New York City.