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This week, Comptroller Alan Hevesi's office is finally releasing a long-awaited report showing that ambulances from private hospitals tend to take patients back to their own rather than the nearest emergency roomseven when the patient has a life-threatening condition. Analyzing strictly guarded data from the Fire Department (which now runs city ambulances), the report proves that private hospital ambulance crews have been steering patients back to the hospitals that pay them and away from the public hospitals. This dangerous and sometimes illegal practice is financially devastating to the city's cash-strapped public hospital system.
Private ambulances are 10 to 25 times more likely to go back to their sponsoring hospitals than are city ambulances in the same zip code, according to the report. Ambulances operated by Our Lady of Mercy Medical Center in the Bronx, for instance, were roughly 16 times more likely than city ambulances to bring patients in a certain area back to that hospital, even though it entailed bypassing the closer public hospitalNorth Central Bronx. The report also showed that private hospitals stole patients from each other.
Perhaps most damning, the studywhich was based on the records from more than 300,000 transports made in five months of 1999found that private ambulances are twice as likely to steer insuredas opposed to uninsuredpatients to their home base. The findings confirm the results of a months-long Voice investigation of patient poaching and ambulance drop-off patterns. They also provide statistical evidence of what emergency-services veterans have long referred to as the "wallet biopsy." "Make sure the patients you bring back are the ones with the AmEx and Visa cards," is how one paramedic who used to work for a private hospital explains the unofficial procedure.
City-operated emergency-services vehicles and private ambulances have shared the responsibility for answering New York's 911 calls for more than 20 years. And for perhaps as long, the two sides have accused one another of selectively snatching paying patients. In February of last year, MetroCarewhich is arguably the largest ambulance company and is owned by Giuliani contributor Steve Zakheimbecame the first of several independent ambulance companies to work on behalf of private hospitals, when it contracted with St. Barnabas Hospital in the Bronx.
Now, with financial pressure on hospitals heating up (at least two private hospitals in the city have flirted with bankruptcy in the last year), competition for insured patients has gotten even more furious. A few hospitals woo ambulance crews with free food and coffee; multiple ambulances sometimes vie for the same call; MetroCare even sends direct-mail follow-up suggesting that in the future patients call them directly in an emergency.
"In the last three or four years, people have begun fighting over patients," is how the director of the emergency department of one municipal hospital sums up the climate. "There's no oversight of who goes where."
The city doesn't pay private hospitals for providing emergency service. Instead, there's a tacit trade-off: In exchange for tending to car wrecks and heart attacks, private hospitals and the private ambulance companies that work for them use their "buses," as emergency workers call them, to bring revenue-generating patients back to their hospitals. Moreover, under a deal formalized last April between the Fire Department and the Greater New York Hospital Association, private ambulances are allowed to charge whatever they want. Patients picked up by private ambulances could pay as much as $800 when the city's top rate is $450 (see sidebar).
With the exceptions of trauma, burn, and dismemberment victims, who must go to specialized centers, those with life-threatening emergencies must go directly to the nearest qualified hospital, according to FDNY regulations. If they're not on death's door, though, patients are allowed to choose to go to a more distant hospital as long as it's not more than 10 minutes from the nearest one. But insiders say ambulance operators flout those rules in several ways, including taking unconscious or confused patients to the ambulance's home-base hospital even if it's not the closest; not letting patients know they have a choice of hospitals; and sometimes even overriding patients' choices.
The pull of finances can do more than critically lengthen ambulance rides. It can also slow response times, according to emergency physician Stephan Lynn. "When patients are driven further, the next patient that calls an ambulance pays the price," says Lynn. The ambulance "takes itself out of service for an additional five or 10 minutes and the system becomes less effective."
Directing well-heeled patients to private hospitals and poor people to increasingly struggling public hospitals also helps shape a divide between the health care of the rich and poor so deep it's become a part of the city's medical culture. The "wallet biopsy" partly explains how more than 40 mostly black and Latino patients made their way to Bellevue's emergency room on a recent afternoon, while a mere six patients awaited attention a few blocks uptown in NYU Medical Center's air-conditioned emergency room. But the effects of patient-sorting by ambulance crews can be even subtlera matching of patient and hospital that goes beyond mere dollars.
"EMTs and paramedics are not likely to ask the question 'Do you have insurance?' " as one physician who specializes in emergency care at a city hospital explains. "They're likely to look at what car you're driving, what clothes you're wearing, what neighborhood you live in, and then make a judgment" about where to take you.