WHY JEWISH HOSPITALS ARE DISAPPEARING DAVID A. GEE President Emeritus, The Jewish Hospital, St. Louis, Missouri AND ALAN WEINSTEIN President, Premier Hospitals Alliance. Westchester, Illinois

Only half of the Jewish hospitals that were in existence 30 years ago are still operating today. Jewish hospitals no longer play their historical role as a haven for Jews, and they face greater challenges than other community and religiously affiliated hospitals—larger size, heavier financial burdens, secondary teaching status, high CEO turnover, and overmanaging boards of directors.

nly half ofthe 44 Jewish-sponsored United States was organized in 1850 in O hospitals that were operating in the Cincinnati, followed 2 years later by the Mt. United States 30 years ago still exist today. Sinai Hospital in New York City. And, of the remaining 22 Jewish hospitals, By the end of the 19th century, anti- several are on the verge of merger with non- Jewish campaigns in Eastern Europe and Jewish facilities (Tables 1 and 2). especially in the Jewish Pale of the Ukraine, Why have so many Jewish hospitals Byelorussia, Silesia, and Lithuania brought closed or merged with other facilities over thousands of Jewish immigrants to this the last three decades? The reason is two­ country. To meet the needs of the Eastern fold: first, the role assumed by Jewish European immigrants for family and social hospitals historically is no longer the role services, job placement, income support, that those institutions play today, and sec­ and medical care, established German- ond, the challenges faced by Jewish- Jewish communities created a Jewish social sponsored hospitals are greater than those service network for the new arrivals. Many of other community and religiously aflfili- services were designed to enable observant ated institutions. Jews to maintain halacha, the body of law governing many aspects of Jewish life, such fflSTORICALROLE: A HAVEN FOR as eating kosher food. JEWS Anti-Semitism, particularly its impact on the training of Jewish physicians, was Jews began coming to this country in col­ another contributing factor in the develop­ onial times when Sephardic Jews from ment of Jewish hospitals. Until World War Portugal and Spain setUed in New York and I, Vienna and Berlin were the medical New England. German Jews arrived in education centers of the world; many Jewish large numbers between 1815 and the mid- physicians received their training there. nineteenth century, creating the mercantile However, Jewish students who wished to empires that became the financial backbone train in this country were often turned away of American Jewish communities. by local hospitals. As a result, the charters Although New York City was the chief of many Jewish hospitals specifically refer port of entry for German Jewish immi­ to the training of Jewish physicians, even grants, backpacking peddlers soon spread when they specify that patients will be cared across the country and formed the core of for on a nonsectarian basis. small but numerous Jewish communities By the start of World War I, there were throughout America's heartland. Not 19 Jewish hospitals in the United States. surprisingly, the first Jewish hospital in the

94 Why Jewish Hospitals Are Disappearing / 95

Table 1. JEWISH HOSPITALS IN OPERATION IN 1991

HOSPITAL CITY FOUNDED

Jewish Cincinnati 1850 Mt. Sinai New York 1852 Touro Infirmary New Orleans 1852 Sinai Baltimore 1868 Albert Einstein" Philadelphia 1865 Montefiore New Yoric 1884 Maimonides'' New Yoric 1886 Beth Israel New York 1889 Beth Israel Boston 1896 Jewish St. Louis 1900 Beth Israel Newark 1902 Jewish Louisville 1903 Mt. Sinai Cleveland 1905 Bumert Paterson, NJ 1908 Mt. Sinai Chicago 1918 Cedars-Sinai' Los Angeles 1920 Brookdale'' New York 1921 Miriam Providence 1925 Beth Israel Passaic, NJ 1926 Menorah Kansas City 1931 Long Island New Yoric 1949 Mt. Sinai Miami 1949 Sinai Detroit 1953

"Albert Einstein is the merger of the Jewish Hospital of Philadelphia (1865), Mount Sinai Hospital of Philadelphia (1900), and the Northern Liberties HospiUl. "Originally known as Beth David Hospital. The name was changed in 1910. 'Created by the merger (1963) of Mt. Sinai (1920) and Cedars of Lebanon Hospital (1930). "Originally named Beth El.

Table 2. JEWISH HOSPITALS WITH RECENTLY CHANGED STATUS

HOSPITAL CITY FOUNDED CHANGE

Michael Reese Chicago 1879 Sold to Humana, 1991 Mt. Zion San Francisco 1887 Merged UCSF, 1991 Jewish Brooklyn 1901 To City of NY Mt. Sinai Milwaukee 1902 Merged Jewish Memorial New York 1905 Closed Montefiore Pittsburgh 1908 SoldtoU. Pittsburgh, 1990 Mt. Sinai Hartford 1923 Merged St. Francis, 1990 General Rose Denver 1949 Merger discussions Mount Sinai Minneapolis 1951 Merged, then sold 96 / Journal of Jewish Communal Service

Another eight opened between 1918 and the a whole. Profit margins for the typical U.S. endofWorld Warll. Five more were hospital in 1989 were 2.6%, compared to organized ailer that war. In addition, less than 0.05% for Jewish hospitals. another 12 institutions were identified as Regardless of religious sponsorship, having been organized under some type of location of hospitals in the inner city is an Jewish auspices. invitation to sidfer negative economic consequences. Jewish hospitals tend to be CHARACTERISTICS OF JEWISH- situated in central cities where the Jewish SPONSORED HOSPITALS population was concentrated when they were first built. The upward mobility of Little Exclusively Jewish Jewish populafions has left Jewish hospitals Today, very httle remains that is exclusively behind in neighborhoods that are no longer Jewish about a Jewish hospital. Catholic Jewish. hospitals now routinely serve kosher food; a Hospitals, which have complex physical brit milah, or ritual circumcision, is structures and capital-intensive plants, are performed in all hospitals. Although latent not easily moved. Yet, some have at­ anti-Semitism persists in the United States, tempted to follow relocating Jewish commu­ it is not a deciding factor in many patients' nities. In Baltimore, for example, the Sinai selection of physician or hospital. Hospital occupied an aged and obsolete structure across the street from the Johns Larger Size Hopkins Medical School in a decayed and unattractive section of Baltimore. A new What is characteristic of Jewish hospitals Sinai Hospital, this one handsome and today is that on the whole they are larger, modem, was buiU in I960 in a more serve greater numbers of the disadvantaged, suburban part of the city. Yet, it was only a and are suffering more financially than both few years before the Jewish community the typical community and religiously relocated again, leaving behind a largely affiliated hospital, according to research indigent black population. Having given up conducted by Premier Hospitals Alliance. the benefit of proximity to Hopkins, Sinai Premier, a cooperative of 49 major teaching failed in the long mn to gain from its new and research hospitals of which al>out one- location. third are Jewish-sponsored, conducted the research in 1990 at the request ofthe Sinai Hospital in Detroit made a similar Council of Jewish Federations. decision by moving to the center of the Jewish population in 1953; the Jewish In 1989, the average Jewish hospital had community then moved north to the 470 beds, compared with an average size of suburbs, leaving the hospital behind. A 100 beds for a community hospital and 200 more practical, long-range approach might beds for a religiously affiliated hospital. have been to locate the Jewish hospital near However, the average size of Jewish the Wayne State Medical Center Campus hospitals has been falling over the past 5 where it could have enhanced its academic years, from 580 in 1985 to 470 in 1990, position. whereas the average sizes of both the community and the religiously affiliated Partly because of location, but also hospital have held virtually constant. because of liberal social philosophy, Jewish hospitals also have a disproportionate share of indigent patients. Among Jewish The Financial Burden hospitals, according to Premier's research, Premier's research on Jewish hospitals also 17.8% of all patients were Medicaid shows that Jewish hospitals are significantly recipients in 1988, compared with 8% worse off financially than U.S. hospitals as among hospitals nationwide and 8.2% Why Jewish Hospitals Are Disappearing / 97 among religiously affiliated hospitals. That California at San Francisco. represents a disparity of more than 100%. High CEO Tumover/Overmanaglng Boards "Second-Class" Teaching Status Although the annual tumover rate among During the post-World War II years as anti- hospital chief executive officers (CEOs) has Semidsm declined, training opportunities dropped from 33% to 24% over the last 4 for Jewish physicians began to increase as years, the fact that almost a quarter of CEOs they were accepted and evenly sought out by lose their jobs each year suggests manage­ other medical schools and teaching hospi­ ment instability in the hospital field. tals. Today, in a nation where only about Financial exigencies, an inability to deal 2% ofthe population is Jewish, 18% of all with a rapidly changing environment, and physicians are Jewish. Many enjoy the clashes with medical staffs and boards of reputation ofbeing the best-trained doctors. directors are all contributing factors to this Most Jewish hospitals continue to reflect high tumover rate. their original mission of serving as a Yet, hospitals under Jewish auspices training ground for Jewish physicians by have experienced even higher CEO tum­ providing some form of medical education over rates. Between 1984 and 1986, for program or being affiliated with a medical example, there was a 50% tumover rate school. Most, however, are not the primary among Jewish hospital CEOs. Of the 22 teaching hospital of the medical school with hospitals now under Jewish auspices, only which they are affiliated. Notable excep­ four CEOs have held their cunent positions tions include Mount Sinai Hospital and for longer than 10 years. Four of the cur­ Montefiore Medical Center, both in New rent CEOs have been in office since 1986, York, as well as Beth Israel Hospital in and four others date back only to 1989. Boston, which is well positioned because of When a large and prestigious Jewish the way in which Harvard Medical School hospital was recentiy sold, one of the affiliates with hospitals. reasons cited for its fiscaldifficult y was the Sinai Hospital in Baltimore, however, is high tumover rate among its CEO and CFO subordinated in terms of faculty to Johns positions. No one in a senior executive pos­ Hopkins; Mt. Sinai in Cleveland and Jewish ition had been at the hospital long enough Hospital in St. Louis have similar relation­ to grasp the significance of the factors that ships with Case-Western Reserve University were impairing the hospital's financial Hospital and Barnes Hospital, respectively. health. This secondary teaching status of many Although never documented, Jewish Jewish hospitals could pose a greater hospitals also have a reputation for being problem in the future, particulariy if federal overmanaged by their boards of directors. regulations limit medical education fiinds to According to the bylaws of several Jewish one primary teaching hospital. hospitals, the board chairperson, not the Of more immediate importance is how hospital president, is the CEO. In some differing missions and economic pressures Jewish institutions, the board is closely make existing relationships fragile between involved in the day-to-day operating teaching hospital and medical school. functions of the hospital. Michael Reese Hospital in Chicago and Boards representing tightly knit commu­ Montefiore Hospital in Pittsburgh both nities, such as Jewish communities where succumbed to those and other pressures last board members often are direct descendants year and subsequently were sold and of the hospital's founders, tend to take a acquired in a merger, respectively. Another proprietary interest in the institutions they respected institution. Mount Zion in San have created. Jewish hospital boards Francisco, merged with the University of generally include professionals, small 98 / Joumal of Jewish Communal Service business people and community leaders and federation and Jewish Hospital in St. Louis tend to be much more involved than boards both had annual operating budgets of $1 comprising corporate executives. In con­ million. Forty years later, the federation trast, hospital boards with Fortune 500 was operating on $10 million while the company or major local business representa­ hospital had grown to a $200 million tives typically expect management to do its budget. The community perception is the job and do not interfere with operating federation is the social safety net, and the fiinctions. hospital is "big business." Every Jewish hospital has anecdotes Nevertheless, Jewish communities about board interference in the management traditionally have strong emotional ties to process. One hospital cited 22 board com­ their local Jewish hospital. Even though mittee and other similar events each week Jewish physicians may now practice in on average for the year. In another Eastern Catholic or Protestant institutions and admit Jewish hospital, board members have allied Jewish patients to those hospitals, many still themselves with specific chiefs of clinical feel that a Jewish hospital represents a ha­ services, thereby establishing multiple ven in the event of the resurgence of anti- constituency groups of which many work at Semitism. Jewish communities in Minne­ cross-purposes. apolis, Milwaukee, and Hartford have Premier Hospitals Alliance is currently mourned the loss or restructuring of their conducting a study to gain greater insight Jewish hospitals. into how the values and attitudes of a hos­ Many Jewish communities also believe pital's governing board affect its decision that their hospital is the chief bulwark making. against anti-Semitism because it is the practical representation of how the Jewish Jewish Priorities community serves the community at large. Mount Sinai Hospital Medical Center of The absence of overt anti-Semitism, the Chicago, which today serves a predomi­ lack of Jewish identity among Jewish nantly African-American and Hispanic hospitals, and the relocation of Jewish population, is an excellent case in point. communities away from Jewish hospitals have diminished the perceived value of the It seems likely that at least a few more Jewish hospital as a Jewish institution. Jewish hospitals will close because they Today, the needs of Israel, Jewish educa­ have ouUived their original mission and tion, resettlement of Russian Jews, and because their present-day burdens are programs for the rapidly aging Jewish pop­ simply too great to maintain. Yet, it also ulation clearly have taken priority over seems probable that, of the remaining Jewish hospitals. Jewish hospitals in this country, many will continue to be highly regarded, not because Furthermore, although Jewish hospitals they are inherently Jewish but because they historically were an integral part of the are responsive to community needs, pro­ social framework of the community, today mote excellence in a complex field, and are they are large and complex and have out­ models of quality both in terms of the health grown their sponsors both in dollars and care services they provide and the way in influence. For example, in 1950 the which they are managed.