Ambulance Wars

How Private Ambulance Crews Steer Patients Away From Public Hospitals

Another doctor, who works in Bellevue's emergency room, uses Grand Central Terminal to explain the situation: "If they pick you up on the Metro-North level, chances are, you're going to Cornell [Medical Center]," he says. "But if you're on the subway level, you're probably coming here."

In fact, even while ambulances from New York Hospital, Cabrini, and St. Clare's steer patients away from Bellevue, the public hospital on First Avenue in Manhattan has become a destination for ambulances carrying homeless and drunk patients. One ambulance recently drove an intoxicated man to Bellevue all the way from St. Nicholas Avenue and 126th Street, passing Mount Sinai, Lenox Hill, and St. Luke's-Roosevelt, among other private hospitals, on its way to the public emergency room. The paperwork for the man's delivery indicated that the patient had chosen Bellevue, which could theoretically justify such a detour (if it had somehow added only 10 minutes to the trip), though a doctor who was present at the time of the delivery said the man was incoherent when he arrived.

The carting of insured patients to private hospitals—and away from public ones—also further weakens a public system that's already dangerously depleted. The number of patients in public hospital beds dropped 39 percent between 1994 and 1999. This year, the Health and Hospitals Corporation is in arguably the worst shape of its recent past, facing a $313 million deficit even as it treats a greater number of uninsured patients than ever before.

On June 7, an ambulance run for Montefiore by MetroCare responded to a 911 call on behalf of Michael Fusco, a 92-year-old man living in the Norwood section of the Bronx. Though he wasn't able to ride along, Fusco's neighbor and caretaker, James Diaz, told the paramedics to take the ailing man to North Central Bronx Hospital, where Fusco had been getting regular checkups. "There was nothing confusing about what I said," remembers Diaz. "I was speaking the King's English." Despite his clear request, though, the ambulance took the patient back to its home base, which is on the same square block as North Central Bronx.

Fusco, who turned out to have pneumonia, checked himself out of Montefiore the same day. When his symptoms worsened the following day, Diaz summoned another ambulance, this time riding along to make sure it reached the appropriate destination. But even with Diaz in the bus asking to go to North Central Bronx, the paramedic's homing instincts took over. "He started going down the ambulance drive to Montefiore," recalls Diaz. "I said 'Where are we going?' and then he turned and went back to North Central."

MetroCare's Zakheim, whose company wasn't working in New York City during the period of the comptroller's audit, denies that his ambulances are ever involved in patient steering. "We base the destination on either the patient's choice or the condition of the patient as per the Fire Department protocols," says Zakheim. "I receive no reward by bringing more or less patients to any hospital whatsoever."

According to paramedics and EMTs, there's considerable pressure to make trips to home base—and deliver paying patients to their employers. "If you work for a particular hospital, your marching orders are bring patients back there," says an EMT who has worked for both a private hospital and the Fire Department.

A former emergency director of one Bronx hospital, who didn't want his name used for this article, describes the intense financial competition for patients this way: "Every month we get statistics about exactly who's not bringing the patients back. EMTs had their jobs threatened if they didn't bring patients back to the mother ship," he says. "It's almost like the people who are good at that are given opportunities for promotion. There's a lot of pressure, because even for the uninsured you can sometimes get coverage."

Indeed, running their own ambulances or hiring private companies has proven to be a financial boon to hospitals. After Community Hospital in Brooklyn enlisted MetroCare, a private company, to run ambulances for it in March of last year, the number of patients in the hospital's emergency room leapt from 1896 to 3493. Similarly, after Kings Highway Hospital hired the same company in the summer of 2000, their admissions almost doubled.

And when private hospitals gain patients, city hospitals lose them. All but one public hospital had a reduction in ambulance deliveries between 1990 and 1999, according to the report. In that period, Queens Hospital saw its share of ambulance transports in the borough drop by more than two-thirds. It was this hemorrhaging of patients that first spurred Bernie Diamond, chair of the Queens Hospital Center Community Advisory Board, to ask Comptroller Hevesi to do an audit of the emergency medical system back in October of 1997. "The ambulance drivers were bypassing Queens Hospital and taking them to the hospital that paid their wages, but we couldn't prove it because we didn't have all the evidence," says Diamond. "So I asked the comptroller, since he had the staff to do audits."

Hevesi's initial response was prompt: "We will jointly evaluate whether EMS ambulances are diverting financially viable patients away from HHC hospitals," the comptroller wrote back to Diamond in December of 1997. After that, though, the investigatory process dragged on, leaving frustration—and speculation—in its wake. "The comptroller may be worried about making a mistake in his run for mayor," Diamond offered by way of explaining the report's delay.

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