August 2008 1400 AM WAMC - Host: Dr. Alan Chartock

Albany Medical Center President and CEO James Barba discusses the history of Albany Medical Center.

Alan Chartock: Hi, Alan Chartock here. Joining me today is James Barba, President and CEO of Albany Medical Center. Albany Medical Center is the region's only academic health sciences, and is nationally recognized for excellence in education, research, and its patient care programs. James Barba has served as President and CEO for more than a decade. He led the way in combining Albany Medical College with the hospital, creating the unified medical center that exists today.

James Barba, welcome and thanks for being here.

James Barba: Thank you, Alan. It's great to be with you today.

Alan Chartock: So I see a wonderful book in front of me called The History and Formation of Albany Medical Center. Now when your wonderful colleague Greg McGarry sent it to me, I said to myself, "You know we share this common history. It's WAMC." And a lot of people slap themselves on the side of the head when I tell them, "WAMC stands for Albany Medical College", or it did in the old days before you guys were kind enough to allow us to separate out and go on our own way.

James Barba: Are you telling me it doesn't still stand for Albany Medical College, Alan?

Alan Chartock: We have always been grateful for that opportunity. And it really, really mean that. So as soon as I say this I said, "You know, we really ought to have an hour with Jim Barba and have a discussion of how all of this came about. Because it's a fascinating thing. What you've done is just miraculous, what's become of this little hospital. Maybe you could just start us off by giving us a little bit of a history lesson in how all of this happened

James Barba: Certainly. To begin at the beginning, in 1839 Dr. Alden March, who was a local practicing physician, managed to convince the New York State Legislature to charter a medical college here in Albany. Interestingly, he began that process about 15 years earlier, in 1824. And every year he'd go back to the legislature saying I assume, "Please give us a charter this year. Please give us a charter this year."

So I guess the more things change, the more they stay the same in Albany, Alan. But finally 15 years later, in 1839, he got his charter. And he began a medical college. Began teaching students. Ten years after that, in 1849, he actually opened a very, very small hospital. It was in a house. And the house is still standing. It's on the southwest corner or Madison and Dove. And you can drive by that and see a very unimposing red brick building, I think three stories tall. That was the original Albany Hospital. In any event,

these two institutions, the college and then the hospital were founded by Dr. Alden March.

Fast forward to about the year 1900 when the commissioners of Washington Park gave the hospital the plot of land on New Scotland Avenue on which it has sat ever since.

Alan Chartock: Had that been Washington Park?

James Barba: It was part of Washington Park at the time, yes. So they gave them this plot of land. The hospital moved to New Scotland Avenue. And I believe it was two decades later the college, which was down on the old part of Lancaster Street in Albany, a part that doesn't exist anymore ... the Empire State Plaza took all that away ... moved from its spot on Lancaster Street up to the New Scotland Avenue campus, physically next to the hospital. And actually they build their building so that they adjoined and integrated. You could go from one building to the other without going outside. And there they sat for the better part of 60 years.

Alan Chartock: Are any of those buildings still there?

James Barba: Oh, yes. Oh, yes. The main, the original building of the hospital we call the main building or the end building. That's where the pillars are, the famous pillars of Albany Medical Center. And if you were to go around ... If you're facing the pillars and go around to the left side of the building, you'd see the original entrance to the Albany Medical College, which was actually transported from Lancaster Street to the building that was being built for the college and put in place there. So the buildings are still all there. We rarely take anything down. We just keep adding and adding and adding more buildings.

In any event, there they sat, two completely independent organizations but dependent on one another for the delivery of missions. And there grew up over those 60 or so years very, very complicated inter-institutional agreements with respect to who did what, and who owed what, the money for doing what, and so forth. Finally in 1970, a couple of members of the hospital board, a couple of members of the college board began conversations about possible merging the two institutions in some fashion.

That conversation occurred over the succeeding 12 years, from 1970 to 1982. And it had many, many ups and downs. I actually happened to be a party to it for the last three years. I went on the college board in 1979. But during the 70s at two separate times it looked like an agreement was at hand when at the very last minute, literally, the college would pull back. And there was always a great fear ... and I know this first hand ... There was always a great fear on the part of the college that the hospital, which was a bigger organization and had a different mission ... It had a service mentality as opposed to an academic mentality or milieu ... that the hospital would overreach in any such combined organization and steal the college's endowment, as pitiful as the college's endowment was in those days.

So they kept backing away. But the times were very difficult, and I can recall when I came on the college board in '79 the college faced a one million dollar deficit that year.

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A million dollars is still a lot of money today but 30 years ago it was a tremendous amount of money, especially for a college that was very, very poorly endowed, that had no natural source of revenue to go to.

Alan Chartock: And how was the hospital doing financially at that time?

James Barba: The hospital was doing okay at that time, in the late 70s, early 80s. It wasn't doing tremendously well. It would face its own difficulties financially during the 1980s.

Alan Chartock: So in '79 they had a million dollar deficit?

James Barba: Yes.

Alan Chartock: And that's when WAMC certainly got born.

James Barba: Yes, indeed. You are a product of those difficult days.

Alan Chartock: Of that time. Okay. So that's real interesting. And then you became a sort of instrumental figure in making this happen, didn't you?

James Barba: Well, I wouldn't say so at that point in time. I mean I was a young kind of wet behind the ears, a third tier trustee on the college board.

Alan Chartock: As well as a first rate lawyer, I may add.

James Barba: Well I guess that's open to some discussion, but ... So I participated in what became the final debate, the debate that finally concluded that we would in fact create an organization. We couldn't really legally merge the hospital and the college because they exist under separate state laws and the college had to be a degree granting institution, the hospital had to be chartered under Article 28 of the Health Law. It's more complicated than I'm making it.

So what the boards decided to do, with some expert help from the outside, was to create a parent holding company that would sit on top of these two institutions and would have all the powers and all the authorities to do whatever it needed to do, and to control all the money. And that seemed to satisfy, to the extent necessary to get an affirmative vote, the governors of the hospital and the trustees of the college.

So we said yes. In 1982, we said yes. We all sat back and congratulated ourselves that, after this long 12 year debate on again off again, we finally had done it. We had created the Albany Medical Center and from then on everything was going to be hunky dory. There was going to be the recognition of economies of scale. It was going to be combinations of departments, so one finance function, one human resource function, etc. And we expected it would happen. And it didn't. It didn't. Because there was no real buy in on the part of the managers of the hospital and the managers of the college.

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There was some, but there wasn't the type of buy in that was going to be necessary to truly actualize what these directors thought they had created. So we had this parent holding company. And it had very, very small board, a couple of hospital directors, a couple of college trustees. And it hired its first CEO, Dr. Richard Gaintner who came up here from Johns Hopkins, was a fabulous talent. But the resistance was such underneath that not much ever got done.

Alan Chartock: And did Gaintner have a tough time of it?

James Barba: Gaintner had a very, very tough time of it. As I've just said, he was a remarkably talented individual. He had a vision for creating these two disparate organizations as an academic health sciences center, a concept that was relatively new to the nations at the time. And he managed to get the medical center down that path a ways. He couldn't get it all the way. And he certainly never realized the kinds of vision that the directors thought they were articulating when they created the medical center.

Alan Chartock: So how long did he last?

James Barba: I think he came in 1983 and he left, if my memory serves, in 1989. And thereafter we had a couple of interim CEOs, one was John Beach, a very prominent lawyer in town, an excellent lawyer. And then after John was not able to do the interim CEO position any more, we had Dr. Robert Whalen, who had been New York State Commissioner of Health, who did it for a while.

Alan Chartock: Very famous name.

James Barba: And a very outstanding human being. And then finally in 1990 the board searched for and found a gentleman named David Cornell from Ohio, who came here and became CEO for a couple of years. He, too, faced exactly the same kinds of problems that Dr. Gaintner faced. There wasn't any buy in still. The cultures, the cultures were at war with one another between the hospital and the college. There was not buy in. And David's appropriate claim to fame was that he came as CEO when we just beginning the construction of the then new patient tower at Albany Medical Center, and he stayed through to see it completed and opened. So he did a wonderful job with that project. But I think probably was disappointed in his inability to, again, actualize the vision of an integrated academic health sciences center.

Alan Chartock: So the underlying dark music, which we should be hearing here, was the fact that the hospital people were somewhat guarded about their rights and prerogatives, and the academic people were the same. If you take a look back, who is really sort of more responsible. Was it the academic side?

James Barba: I'm not going to point fingers or cast blame. They were both equally to blame. There was just a lot of bad blood. To show you how different it got. When Dr. Gaintner was CEO he actually managed to combine the human resource functions and the information systems functions.

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Alan Chartock: So the hiring and the computers?

James Barba: Exactly. Into a single function at the level of the holding company, no longer at the level of the hospital or the college.

Alan Chartock: Telephones, too?

James Barba: Telephones too, although that was ... There was quite a debate over the telephone system. When David Cornell came he was under such pressure and wanted to focus on getting the building project done, that he was actually prevailed upon to split up those HR and IS functions back into their separate college and hospital components.

Alan Chartock: When you say prevailed upon, was it successfully done? Was it done?

James Barba: They took them apart, yes. Absolutely. So we were kind of back to square one. And there were many other similar examples that I could give you and your listening audience. Suffice it to say that by 1994 when I was asked to be chairman of the board, very, very little had been accomplished in those intervening 12 years, from 1982 when the vote was taken, to 1994 to actualize this resolution that created an Albany Medical Center.

Alan Chartock: You had been sitting on the board. Were you always preeminent or were you a back bencher for a while?

James Barba: I was definitely a back bencher, no question about it. I was a back bencher. I had some opinions. Occasionally I would voice them. They were not always universally popular.

Alan Chartock: They were what they were.

James Barba: I believe ... I was one of the people who voted for this omnibus resolution to create the medical center. I believe that we meant to do it. And occasionally I would ask the board if they felt the same way. Those were difficult times and difficult conversations. And they were all had now against the backdrop in the early 1990s of very serious financial problems for the hospital and for the college. Those problems were coming at us at warp speed and we were struggling as a board, and the management team was struggling as a team, to deal with them. And, frankly, I don't think any of us was having a modicum of success.

Alan Chartock: So, once again, the fiscal crisis in effect gave a certain amount of energy to making this happen, and we have seen this many, many times in different places. And there must have been some push back at the time you were trying to get this done.

James Barba: Of course. What I was trying to do was go against the current of those cultural differences. I think I recognized a couple of things in my very first days as board chair. The first issue that had to be tackled ... and we tackled it immediately ... was a rather curious one. We had a board at the Albany Medical Center. It was composed of approximately 24 people, yet because the separate corporations, the college and the

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hospital, had to continue to exist, they needed boards as well. So what had been done during the 12 years from '82 until '94 is that half of the center board became the college board. The other half of the center board became the hospital board. So that when these men and women came together as center directors they were bringing their individual institutional portfolios with them.

I believe it was at my very first board meeting as chair I said to the group, "Those days are finished. We will never get beyond the cultural issues if we continue to govern that way. From now on all 24 of us are going to be hospital directors. All 24 of us are going to be college trustees. We'll have very small committees from the board that oversee each of those two institutions. But when we sit in this boardroom we will sometimes put on hats, we will sometimes put on hats that say college, we will sometimes put on hats that say Albany Medical Center. And in that way we will work through these issues." Even as I was proposing it and the board was agreeing, I could not imagine how successful that one notion would become.

Alan Chartock: I see.

James Barba: But almost overnight, Alan, it eliminated on the board level the distinctions that had kept the institutions separate. The second question I asked was, "Are we sure we did the right thing 12 years ago in creating the Albany Medical Center? Do we want a unified academic health sciences center?" That question was a little bit more difficult to answer. And so what I proposed was that we create a small commission of directors, chaired by Matthew Bender, and give them the charge to take a look at what other institutions around the northeast had done.

So they went down to Mount Sinai. I think they went to Strong in Rochester. They may have gone to Johns Hopkins. I'm forgetting. But they toured a number of these academic medical centers. And after five or six months came back with a formal written report that said we absolutely did the right thing in 1982. We absolutely should actualize this notion of a unified integrated academic health sciences center. Jim, go and do it.

Well, I was still board chair. I wasn't CEO, so it wasn't a matter of my going and doing it. It was a matter of the CEOs being handed that responsibility. So we, the board looked at the report and said, "Fine". The problem was we were having management turnover difficulties still. David Cornell resigned as CEO three weeks after I became chair. We're now five months into my first term as chairman. We either had no CEO for much of that time or at the very end of it, in the end of 1994, we managed to recruit a gentleman from Tufts who came over and became the CEO for just a very, very brief period, three months. And then he had some issues and he resigned.

So there wasn't really anyone to whom to hand off this recommendation that we were serious. The board was serious. We were going to integrate the medical center. So it was in early 1995 that the board asked me if I'd be willing to become the CEO. That wasn't a request that I took lightly, Alan. When David Cornell left, six months or eight months earlier I guess it was, a couple of board members asked me at the time if I'd be willing to do that. And I was very, very critical of them saying essentially, "Don't you understand. We can't pick somebody who has no experience whatsoever to do this very Barba James J - History of Albany Med - 2008 Page 6 of 19

complicated joBarba We can't pick someone who has no track record whatsoever to do this joBarba"

And so they went away. And we didn't have much of a discussion. Then came about five months during late 1994 when there was not CEO. And because the management team was fairly dysfunctional the board just expected as chairman that I would keep the place running.

Alan Chartock: And the management team was still the component part guys, is that right?

James Barba: Yes. Some hospital. Some college. A few center. We had a center chief financial officer for example. But he had very little authority because the hospital had its own chief financial officer, and so did the college.

Alan Chartock: Gotcha.

James Barba: And so it just wasn't working. So I tried to keep body and soul together for those five months until we had this gentleman from Boston for three months. And then he left and the board came back to me this time in greater number and said, "We really think you ought to step up. We watched you during that interim as you tried to do the job, and we liked what we saw." So I had a decision to make. I had been in a law partnership for 25 years. Very much enjoyed practicing law. The life of a senior counsel to a successful law firm is a pretty easy life, quite frankly.

And what they were asking me is not only to step out of that into something that no one had been able to be successful at doing, but also frankly for at least my wife if not also my daughter, to suddenly become very public figures. None of us was used to doing that. We had a family discussion. My wife very graciously said, "You have to do what you think is the right thing to do, and I will support it no matter what that is." So I said yes.

Alan Chartock: Wait. Wait, what about your daughter? What did she say?

James Barba: My daughter Ann is a very, very intelligent individual. She at the time was just beginning a PhD program. She'd just graduated from Wellesley. She was just beginning a PhD program at the University of Albany in psychology. And so she was very, very busy with her academic life and trying to do what she needed to get done. She too said, "I think you might be happy doing it, but you have to think very carefully about it."

I think there certainly was a gamble there but I also had a safety net under me that I don't think the law firm would have said no to me if I wanted to come back a year later. So while it was a big decision, it wasn't a life or death decision.

Alan Chartock: What about money? I'm sorry to be so intrusive here but you obviously were making a lot of money as a lawyer at that point in the game. As the head of a not for profit were you going to do as well?

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James Barba: Yeah. I was going to as well. The board, both with Dr. Gaintner and with his successor, David Cornell, always went to a national compensation firm to take a look at what it should be necessary to pay the right person to be CEO of an academic medical center. So they were offering a salary which was compensable. It was certainly not something that I had to go home and say to my family, "Look, we're-

Alan Chartock: Taking a vacation.

James Barba: "Look, we're going to sell the house. We're not taking a vacation", exactly. That was not an issue, happily.

Alan Chartock: Okay. So now here you are, James Barba, you're chairman of the board, but you're also the executive who is running this thing. What kind of resistance did you get?

James Barba: Tremendous. Tremendous. On the college side I was clearly not an academic although I certainly would debate with them then. Today I think nobody would say that to me.

Alan Chartock: Well, A: and years later, it's all the rage now. Lawyers are running most, or a lot of academic institutions.

James Barba: Most days, Alan, I just forget that I'm a lawyer. And then on the hospital side there was a kind of curiosity I guess about me. No hospital background, what can this fellow possibly think he's going to know how to do? But I had already, with the cooperation of the board, resolved the board issue. And that was a big help. So I had a solid board, a united board behind me. What I knew the first step on the management front had to be was that I had to get a united management team as an Albany Medical Center team. Which meant that there could no longer be financial officers in the college and the hospital. There was only going to be one, and that was at the center.

That was among my very first important moves, and you know when you take the purse strings away from organizations that have been used to controlling them for a long time, not a very popular one. But I chose an individual who certainly had the skills to be a chief financial officer for the center. And who I think quickly won over the confidence of people on the hospital side. And then a short time after that on the college side.

And then I just went department by department and began to pull the dual departments out of the organizations in the hospital and the college centralizing them in the center, so that we could create an organization that looked at ourselves as an integrated whole, that managed through those integrations to save an awful lot of money.

Alan Chartock: Okay. So just in terms of everybody who's listening right now if you have a hematology department at the academic component, at the college, and you have a hematology department at the hospital, it makes some sense to bring them together. Is that right?

James Barba: Yeah. Interestingly, the clinical departments or divisions weren't really an issue because over time the hospital and the college had sort of worked that all out by themselves. So if we had a department of medicine, as we do in the college, then the chair of the

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department virtually always was the chief of that specialty medicine, specialized clinical discipline in the hospital. Chair of Medicine becomes the Chief of Medicine. The Chair of Neurology becomes the Chief of Neurology. And all that had worked out.

What I was dealing with were the administrative issues.

Alan Chartock: So, for example?

James Barba: Human Resources. Why in the world do we have two human resource departments? Why not just have one and create an integrated human resource approach for the medical center? Certainly why would you ever have more than one information system? Do you really want computer systems in a college and a hospital that can't inter- operate? That can't speak to one another? We had them.

Alan Chartock: So was there push back on that?

James Barba: Oh, there was huge push back.

Alan Chartock: And what was the substantive push back? In other words what were they saying?

James Barba: It was hegemony. We don't want to give up jurisdiction. And usually carefully, sometimes not, these individuals had to understand that the legal authority had shifted, and was no longer in the component institutions. It was in the Albany Medical Center. That's what that resolution in 1982 said. And suddenly there was someone around who was saying, "You know what? It's says that, and we're going to enforce it." It wasn't an easy time.

Alan Chartock: Anybody quit?

James Barba: Yeah. There were people who quit. There were unfortunately people whose skills in my opinion weren't adequate to the task, whom I had to ask to leave. But at the end of the day ... and I'd like to say that I always tried to do that as humanely as possible. Soft landings where we could arrange that. And it was usually arrangeable. But at the end of the day what we started to build was a single, I'd like to think excellent, management team on the center level that then ran the entire organization.

So, for example, the dean of the college, who had historically only involved himself with college matters, now became a member of the CEO's management team and he got involved in hospital issues. He got involved in Albany Medical Center issues. I would no longer allow the dean ... and we've had a female dean, either him or her ... I would no longer allow the dean to just stay behind the closed doors of the college.

The same was true for the hospital general director. I wanted that individual, whoever served in that position, to be very, very conversant with college issues. So that when we met as a management team on the center level, we would be able to speak each other's language. We would be able to deal with the issues that a component institution was presenting to us.

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Alan Chartock: We're talking to James Barba, President and CEO of Albany Medical Center. Jim, let's go to some specifics. One of the questions is, I simply have never understood these clinical practices. What are they?

James Barba: The college has two types of faculty. One is a basic science faculty and I think that term is descriptive. Those individuals do typically bench research in our college laboratories. The other is a clinical faculty. Physicians, MDs, and others ... we have some PhDs ... who see patients. The MDs practice medicine and prescribe. And they do that both in an office setting, so if for example, Alan, you were concerned about a heart issue for example you might go to see one of our faculty members who was a cardiologist. But the same cardiologist would also cross over the line into the hospital and when his or her patients were hospitalized see them and treat them in the hospital setting.

The college clinical faculty had grown in the late 90s to about 350 individuals. It was very large and for most of its history it had operated inside the college framework in 14 different departments. So we had a department of medicine, again, the department of neurology, etc. What was interesting and inefficient certainly from a business point of view about that is that the chairs of those 14 departments were the CEOs of their own small businesses. So while they operated presumably under the direction of the dean, chairs who were powerful, such as the chair of medicine, the chair of surgery, for example, really ran their own empires. And they would do it according to their own rules, irrespective of what the rules in the other 13 empires suggested was proper practice.

Alan Chartock: So can you give us some examples of what some of the differing rules might have been that you're talking about?

James Barba: Well, hiring. Hiring. The chairs of those departments would decide how to hire and whom to hire and when to hire. They also ran their own finances. Although back in the day before the integration the college had its own chief financial offices, each one of these 14 departments had a financial person. And it was really very, very chaotic but what it was at its base was extraordinarily expensive.

Alan Chartock: For the college to preserve this? For the center to preserve this?

James Barba: For the center to preserve this type of operation. What I suggested a couple of years after I became CEO was that we not do away with those departmental separations but rather there be an organization that ran them according to a common set of rules and protocols.

Alan Chartock: That must have been very popular. I have all these doctors running these various little empires. So there's the surgery empire, and then there's the medicine empire. And all the other stuff. And you're coming ... and they're making a lot of money, right?

James Barba: Yes, they're being appropriately compensated.

Alan Chartock: And they were setting the rules for compensation, weren't they?

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James Barba: Well, to a certain extent. All such rules had to be reviewed by the dean and the dean, once we integrated the center, was operating under a protocol that said, "Look, we can't just go and set salaries by ourself. We need benchmarks. We want both regional benchmarks, northeastern United States, and we want national benchmarks." But there was a lot of play in the system, as you might imagine. And you're right. It was extraordinarily unpopular that I suggest we operate all of these according to a single protocol.

Alan Chartock: Was that you most difficult moment in this evolution?

James Barba: In this particular evolution, the creation of the center, yes, I think that was my most difficult moment. My most difficult moment as CEO during the almost 13 and a half years that I've been CEO was the heart transplant issue, which maybe we'll get into a little bit later if you want to.

Alan Chartock: I do.

James Barba: Okay. But to end on the integration of the practice, it was extraordinarily unpopular. There were very important physicians who threatened to quit if I went through what I was suggesting. And it all came to a show down one afternoon when I gathered, I asked the faculty to join me in one of our large conference halls and said that I was completely serious. That we could not afford to continue operating faculty practice the way we had been, and that we were going to have an integrated system again for that operation. One that made sense, and the chairs would still be in charge, and the dean would still be in charge of the chairs. I had no desire to try to extend my influence as CEO into that area. But we were going to integrate.

And there was a lot of hostility. There were a lot of hostile questions. And I finally said that in my opinion it was for the good of the medical center. I had the support of the board, who knew what I was doing. And finally at the end of a very contentious session I said, "Tomorrow's Friday. I'll be in my office from morning until night. The door is always open. I have an open door policy as CEO. Any one of you who feels that you just can't live under this system, please feel free to come in and talk to me. And if you want to bring your resignation with you, bring your resignation. And I'll reluctantly accept it."

Alan Chartock: You mentioned the heart transplant crisis. Why don't we go to that one now?

James Barba: Thank you, Alan.

Alan Chartock: Hey you brought it up.

James Barba: I thought you'd never ask. You know that was ... I've already described it as the most difficult thing that I've had to do yet, or that happened yet as CEO. I'd like to speak very personally here. I was somebody who very, very much wanted us to have a heart transplant program. I believed that the need for it in our region was proven. I had a very, very serious concern ... as somebody who's a native of this area. I didn't come in from Cleveland, or Sacramento, or some other area. I was born in Albany. I believed

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there were people in our region who were dying from their heart disease because they needed transplants and could not afford, even if they were insured, could not afford to go to New York City, or go to Boston, to live there, to have their families live there while they went through all the prep work, and then the surgery, and then the follow-up, the rehabilitation.

So we worked very hard to convince the health department that we needed such a program. And it took a long time. It took a couple of years before the health department said, "Okay. We believe you're right, and we're going to allow you to start the program." So we did start it. We started it in the year ... The first transplant was done in the year 2000. And we went along for a few years, and then ... I will never forget this ... I was actually on vacation when I got a call from one of our clinical officers who said to me the agency that oversees and regulates transplant programs was in to do an audit about a month ago of our heart transplant program.

And I can remember saying, "Well, that's impossible. I certainly would have been told that." And the answer was, "Well, none of us was told." The physician who was doing the transplants believed that he could handle the audit by himself, and so he did.

Alan Chartock: So the physician never told you guys that it was coming?

James Barba: Yeah. The line of communication would have been from the physician to the chair of surgery, from the chair of surgery to the dean, from the dean to me. And that didn't happen. That wasn't the bad news. The bad news was that there were some serious issues about whether or not certain people who were on the transplant list at our hospital were of the A1 ready to transplant or in emergent need of transplant category. And there was some suggestion by the regulators that perhaps some of the clinical documents were written in such a way as to suggest that they were, when in fact they were not.

Alan Chartock: The implication of this being preferential treatment?

James Barba: Preferential treatment, exactly right. And there are only so many hearts to go around. And the rule is that those who are the sickest, as established by the clinical documentation, are those who get the hearts first.

Alan Chartock: Well, this is hardly indigenous only to Albany. We see this popping up from time to time all over the country. Politicians are those who go to the head of the list.

James Barba: And there are those issues. I can only speak to what happened at our medical center with our issue. So obviously this was devastating news. I got on a plane the very next day. It was late that afternoon. I couldn't get on a plane that afternoon.

Alan Chartock: Where were you?

James Barba: I was in Hawaii. Came home. Got right off the plane in Albany. Came right into the medical center. And we held meetings over three or four hours in which then the dean

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and the chair of surgery managed to lay all of this out for me because now they understood what was going on. And what we decided we had to do was to temporarily suspend the heart transplant program. And we made the decision right then to do it. I can remember it was on a Friday. At about 9:00 at night on that Friday, I went before the television cameras and microphones to announce what we were doing.

Alan Chartock: I remember that.

James Barba: It was just the worst possible thing. I mean as the days and months went by after the announcement, there were many transplant patients and their families who felt that I was being a cold-hearted, unfeeling, not caring about what they had gone through. When, in fact, just the opposite was true. And I think they understand that now. Just the opposite was true. That if we were to have any hope whatsoever of bringing the program back online, we had to be the ones who halted it then. We had to be the ones who turned ourselves in to the regulators and said we think that the suggestions in your audit are correct as we have done our investigation. And so we're going to stop it right now. We're going to do the discipline where discipline is necessary.

Alan Chartock: Was that done?

James Barba: It was done. And we're going to rebuild the program strictly according to the rules. And there would be checks and balances all along the way so that there would never be an opportunity or possibility for a recurrence. And that's exactly what we did.

Alan Chartock: Is the program coming back?

James Barba: We've been transplanting hearts for the last three or fours years now. Yeah. We managed to put the program back together. Now, it's interesting and I'm constantly being educated about all of this since I'm not a MD myself, but the advances in the treatment of heart disease, even in the last three or four years, have been such that there are fewer heart transplants around the nation now. The medications are better. Our ability to intervene through angioplasty and cardiac interventions are just much better than they were.

So I would think that most patients would like to avoid heart transplant if they could. And right now we're in a position where that is happening. I think in that last 12 months, Alan, we've done about four heart transplants.

Alan Chartock: Is it cost effective for a center to do those because they're obviously very expensive?

James Barba: They're very expensive. It is not cost effective, no.

Alan Chartock: The Albany Medical Center has just proven to be a huge benefit for our region. It keeps growing. How do you, as the CEO, manage that growth without its getting too much? In other words too much too soon?

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James Barba: It's a balance for sure. I think most of the explanation ... Well, there are two components to the explanation for the growth. One is that we continue to build the correct programs to treat conditions and diseases that we see prevalent in our region.

Alan Chartock: So, for example, let's just take AIDS for a moment.

James Barba: Yes.

Alan Chartock: When the Albany Medical Center was named as a major AIDS facility in New York State, center. Was that something that had two sides to the sword?

James Barba: It certainly did. And I'm very proud of the fact that the medical center stepped up to the AIDS issue in a day when there was just unbelievable discrimination against people with AIDS. They were pariahs. We believed that they were patients, and that they deserved the kind of health care that science and medicine such as it was in those early days could give them. And it was very poor in the early days as you know, Alan.

Today, I'm proud for example that during the 90s we got to work with the Centers for Disease Control in clinical trials on the protease inhibitors that had become some of the most wonderful drugs in treating AIDS.

Alan Chartock: This is the cocktail?

James Barba: Yes, this is the cocktail and the pills. Today, by and large, not entirely but by and large, AIDS can be a chronic disease. It no longer has to be a death sentence. And it's because of places like Albany Medical Center, and only a few others around the country quite frankly, stepping up when they did in the early 80s and mid-80s when we first discovered that there was this terrible new disease out there that so few physicians and scientists understood.

But that's what we do. We understand that we are the regional asset for so many of these things. We are the only trauma center, for example. And interestingly, we're the busiest trauma center in New York State.

Alan Chartock: I know this is going to seem naïve to you, but there are people out there who don't know what that means, trauma center.

James Barba: Trauma center is some place you are taken if you should be so unfortunate as to be involved in a catastrophic accident that involves catastrophic injury. The most sophisticated of these trauma centers are known as Level 1 Trauma Centers. And we're a level 1. If you get there, if you manage to survive the accident, and you get there with any kind of injury except serious brain injury, serious head injury, you get there in the first hour, chances are excellent that we're going to save your life, and you're going to go out and lead a relatively normal life thereafter.

Alan Chartock: Why did you say except for brain injury?

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James Barba: No one, scientists have not yet discovered how to unscramble a brain that's been very seriously scrambled. I'd like to think that the day will come when they'll be able to do that, but we can't do that yet.

Alan Chartock: So let me ask you this. How wide is the catchment area for Albany Med?

James Barba: It's enormous. We go from Albany to the Canadian border north. We go down to Westchester south. We go to Syracuse west, and we go at least to Springfield east, but usually to Boston, given some of the programs.

Alan Chartock: I hate to do this, but it sounds an awful lot like WAMC's catchment area.

James Barba: Well, we overlap in a number of ways.

Alan Chartock: Okay. So the question that almost everybody asks, whether they're in Great Barrington where I live or other places is, Because of this should I go there or should I go to New York City? Or to Boston?

James Barba: In large part, we can do at Albany Medical Center every thing that another academic health sciences center, be it in Boston, New York City, Chicago, or Los Angeles, can do. Now there are some programs that don't overlap because they're just too expensive. We don't have that many occasions to use them. For example, the medical center used to be a burn treatment center. Happily we don't have many burn victims any more. That's very good news. So what we do with burn victims when we get one is to support the program at Westchester Medical Center, where they have an excellent burn center. But by and large, we can handle any kind of disease, illness, or injury, certainly injury, at our academic medical center that can be done elsewhere.

Alan Chartock: Okay. So if you have cancer ... I'm not telling you anything you haven't heard ... There'll be somebody that says, "Well, you have to go to Dana Farber" or you have to go to a place in New York City which specializes in this. Is the technology, are the docs good enough to be all on a single par, or do you really get something better if you go to one of these places?

James Barba: Often it's just the designer name, but I would be the first to admit if you have a very unusual form of cancer, or it's in a very difficult location, what you would like to have in terms of treatment is a physician who has seen that type a lot, and done that type of treatment a lot. So for the very rarest of cancers you might want to begin at Albany Medical Center, but then you would probably hear one of our physicians say, "You know this is very unusual, and we'd like you to go to the Mayo Clinic in Rochester, Minnesota" or we'd like you to go to some other academic medical center. That does happen.

Alan Chartock: Following up on that. What's the biggest misconception, you think, about Albany Med?

James Barba: I can answer this as a negative. Most people think of Albany Medical Center as a hospital. So even today when I'm out in the public or just having lunch at a restaurant people will say to me, "So how are things at the hospital?" And my answer will be,

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"They're great." And they're great at the college. And they're great at the research foundation. And they're great in all the other various aspects that are now gathered under this umbrella that we call the Albany Medical Center.

I think the other misconception, again as a native, is we can't possibly have something as great as an academic medical center in Albany, New York. It can't possibly be as good as one of the five in Boston, or one of the eight in New York City. It can't possibly be. I would say to those people, "Yeah, it is. It really is. It is an astounding, unbelievable regional treasure. An indispensable regional treasure." And, "Well, I hope you never need it. Should you need it as I did myself as a patient about 18 years ago, you're going to thank God that it's there."

Alan Chartock: When you get ... We all have to operate in the world of grants. Certainly we here at the radio station do. You do at Albany Med. That's got to be a very fascinating way to do things. When you get somebody, and you say, okay you bring in an outstanding microbiologist, and say to them, "You have to justify your being here." In other words, you have to bring in the money otherwise we can't afford to keep you here. Does that go on?

James Barba: Yeah. We live in such a world, unfortunately. There's a lot of pressure on scientists to use your example to get grants. The situation that I inherited in 1995 was one in which the basic science was smaller, a little bit smaller than it is now but they weren't doing ... By and large they weren't doing what I call peer review research. It wasn't research that was going out into the general stream of basic science research findings and being critiqued by peers.

Today that has reversed completely. We only do peer review research. We're very proud of the number of NIH, National Institutes of Health, grants that we get. National Science Foundation grants that we get. Private foundation grants that we get to do this research. It's important stuff.

We announced a multi-year grant from the Department of Defense for our chair of neurology, and other neurologists in the department, who are going to be working with the scientists at Wadsworth.

Alan Chartock: That's Wadsworth Labs.

James Barba: Wadsworth Laboratories here in Albany, to develop the notion that there are parts of the brain that can actually trigger physical responses, that is the movement of a limb, just by thinking it.

Alan Chartock: So if you're quadriplegic this is big stuff.

James Barba: This is big stuff, absolutely. It's very, very big stuff. And, as I say, it's a multi-year grant. I think the first year is well over a million dollars.

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Alan Chartock: Do you have contemporary frustrations that are different from the ones you had when you were facing all this crisis and trauma about combining the center and the hospital?

James Barba: Sure. For one thing the system of regional hospitals, community hospitals, that's grown up around the medical center has for a number of reasons begun to diminish. And as they do, as they can no longer attract physicians, as they can no longer afford expensive technology, more and more patients are being referred to Albany Medical Center for their treatment. That's a good thing I think if you're a patient, because you are going to come to a place where you can be treated well, and with a high degree of quality.

But for us, as an organization, it's a challenge. In an era where with the Berger Commission-

Alan Chartock: This is a little interruption here. The Berger Commission was set up by the state and resulted in the combining and downsizing of many medical facilities around New York.

James Barba: Right. With the Berger Commission suggesting that there ought to be fewer beds, hospital beds, in New York State we find ourselves in the peculiar position now of having an application pending before the Department of Health asking for an increase in our number of beds. Too frequently in recent years we have had to say "No" to patients who needed to be transferred into our hospital from regional hospitals.

We had to say "No" 300 times in 2007. In January of 2008 alone we had to say "No" 90 times. That is not consistent with our philosophy, that we will take anybody at any time who needs to be at the medical center. So it's a different kind of frustration. It's no longer the frustration that financial caused. This is I guess an appropriate frustration. These are the things we should be concerned about, making sure that patients get treated.

My management team really gets sick and tired of hearing kind of a standard lecture from me that I consider as CEO of a medical center my most important job to be the care of patients in that vast geography that I described earlier. And I say that in all sincerity even though I can't treat a patient. I'm not an MD. But that's my responsibility. So if we have to say "No" to an individual who needs to come to the medical center for care, maybe languishing at a local hospital, if we have to say "No" that's a very, very painful thing.

Alan Chartock: So, you're not an MD. You trained as a lawyer. You've been doing this all this time, but obviously in order to make decisions about priorities and where things go, you have to get to have known a little bit about medicine so you can say, "Okay, let's put some money here" as opposed to putting some money there.

James Barba: Yeah. And I think you pick that up, as you might in any business over a course of time. Let me say quite clearly however that I am not licensed to practice medicine. I'm not an MD. So, of course, I have to listen very carefully and take the advice of clinicians when they give it.

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Alan Chartock: I want to talk to you a little bit ... We only have a few minutes left, unbelievably, which means I have to invite you back. Or insist you come back. But talk to me about emergency rooms for minute. There are a lot of people out there who are listening who have had to go to emergency rooms either at Albany Med or other places and sit around for an awful long time before they get served. Is there any help on the horizon? Is it a national health care system that we may be looking at that would alleviate some of this? Have the emergency rooms become the clinics? What's the deal?

James Barba: I think I saw on the news last night or read a report yesterday that the average waiting time in emergency rooms in the state is now up to an hour. That's really unacceptable. And it does happen for the reasons that you suggest. Many people who don't have access right away to a primary care physician for example will come to an ED as a substitute. There're also millions of people in the state who are uninsured, who have no other place to go or so they think. And so they come to EDs, emergency departments, for their care.

And then, if you're Albany Medical Center and you're the trauma center, and you're the children's hospital, and you have all these very unique programs, you're bound to attract, and we do, just a higher number, or higher percentage of patients to your emergency department to begin with.

It's interesting, Alan. Three or four years ago, I think it was four years ago, I asked the board for 12 million dollars to expand our existing ED. The existing ED at the time was only about 10 or 11 years old. And we thought when we built it 10 or 11 years ago at the time that we were building for a couple of generations. So here it is in like 2002 or 2003, I'm asking for 12 million dollars to expand it so that we could see perhaps 75,000 patients a year instead of 45,000 patients a year.

And the board saw the need for that and we found the funds to do it. And we did it. This year, in 2008, having thought the second time that we were building it or expanding it for another generation only a couple of years ago, in 2008 we're going to see 75,000 patients. And it's now no longer big enough. Or won't be in the next year or two.

So we're constantly being challenged by issues like that. But, again, I think the good news is that there is a board, and there is a management team, and there are physicians, and 7,000 employees at Albany Medical Center who understand these critical needs and day in and day out ... We're open 24 hours a day, 365 days a year ... They step up to that need and they take care of it.

Alan Chartock: Well, James Barba, WAMC is very proud of AMC, the Albany Medical Center and our past relationship. And we really thank you for giving us this incredibly valuable time. With that said I know you have a lot more to give and I want to make sure we get you back here. And the next time I just want to talk about philosophy, national health care, other things that you've seen up front. So thank you again for being with us.

James Barba: Thanks, Alan. I'll be very happy to come back and talk about national health care.

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Alan Chartock: Our guest has been James Barba, President and CEO of Albany Medical Center. It's been a great pleasure and honor to have you here.

Speaker 3: You've been listening to Dr. Alan Chartock, President and CEO of WAMC Northeast Public Radio and professor emeritus at the University at Albany. For more information on the In Conversation with Alan series, or to order additional copies of this or any interview in the series call 1-800-323-9262, or visit us on the web at wamc.org.

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