Patient Dumping in New York City, 1877–1917

Abstract

Although the term “patient dumping” was rarely used before the 1960s, the practice started much earlier. In the late 1870s, the New York Times began to report that private hospitals were using ambulances to shift poor, moribund patients to Bellevue, the city's preeminent public facility. Many trips had serious medical consequences. Private hospitals also instructed ambulances to take critically ill patients directly to Bellevue regardless of the distance. Efforts to combat such practices took various forms. When transfers resulted in death, Manhattan coroners held inquests. In 1902, the Commissioner of Charities issued an order requiring that he be sent a full report from the superintendent of any hospital in which a patient transferred from another facility died within three days after admission. Four years later, the city passed an ordinance imposing a severe penalty on any hospital official who transferred an ill patient. Those reforms were only partially effective at deterring such transfers.

PATIENT DUMPING TYPICALLY refers to the transfer of a patient from a private hospital to a public one for economic reasons. Although the term rarely was used before the 1960s, the practice began decades earlier. This article describes New York City examples of patient dumping from the late 19th and early 20th centuries. By that period, the city boasted several private hospitals, including forerunners of most of today's major medical institutions. Bellevue was the preeminent public hospital. Soon after the arrival of the ambulance, the New York Times began to report that private hospitals were using their fleets to shift indigent patients in extremis to that facility. Many trips from one institution to another inflicted additional suffering; some hastened death.

THE ARRIVAL OF THE AMBULANCE

Drawing on his experiences first in the Civil War and then in New York City's 1867 cholera epidemic, physician Edward Dalton founded the first nonmilitary ambulance service at Bellevue in 1869.¹ The following year New York City's Commissioner of Charities wrote,

It has been the practice, when a person has been injured or taken sick in the public street, for the Police or passing citizens to take the patient to the nearest druggist, and after administering restoratives, convey him on a cart or other vehicle to a hospital or his home.

There was always a great suffering from the rude means of conveyance and great loss of time before the proper surgical aid could be obtained, resulting frequently in the loss of life.²

The New York Times lauded the new vehicles, which were “on springs and well cushioned, and … provided with restoratives, tourniquets, bandages, &c. for use, if needed.”³ No 19th-century springs and cushions could absorb all the jolts from cobblestone streets, but the ambulances represented a vast improvement over previous methods for transporting the sick. Medical interns rode in the carriages to provide emergency assistance both at the scene and en route to the hospital.

Although Bellevue's two ambulances initially traveled throughout New York City, private hospitals soon established their own services. As a contemporary medical reformer explain-ed, an ambulance carriage was “just the kind of thing many donors would like to give … its benefits being daily visible.”⁴ Emulating each other, philanthropists began to buy wagons and horses and endow ambulance barns for their favored facilities. By the late 1870s, Manhattan's fleet was renowned throughout the nation.⁵ In 1880, two years after Presbyterian Hospital inaugurated its service, 43% of admissions arrived by ambulance.⁶ In 1913, New York City ambulances treated more than 100 000 patients.⁷

Although the new service helped to advertise institutions and boost their reputations, it also added to their economic burdens at a time when financial management assumed a prominent place in hospital administration. ⁸ Private hospitals of the period increasingly sought to attract more patients who could pay privately while reducing the size of the population dependent on charity. But, in the words of one observer of the day, “the ambulance subject [was] usually a person in poor circumstances. One rarely sees a well-dressed occupant being carried to the hospital by ambulance.”⁹ In addition, ambulance cases often demanded a great deal of care. Even before acquiring its first wagon, the Board of Managers of St. Luke's Hospital complained:

Of late, there has been a great increase of what are called “accident-cases,” averaging throughout the year, more than one a week. Injured persons from every direction in a wide circle around us are brought by the police officers to our House… . They add largely to our expenses, being generally … more costly both in their treatment and in the requisite appliances, and also more tedious of cure, than any other class of patients.¹⁰

Put simply, ambulances delivered far more accident victims to hospital doors than had previously been the case.

The new service created an additional problem: many patients who arrived by ambulance never could be counted as cured. Seeking to counter the popular impression that they were repositories for the dying, 19th-century hospitals prominently displayed greatly inflated cure rates and very low mortality rates (typically less than 10%).¹¹ The need to woo a middle-class clientele to keep hospitals financially afloat gave turn-of-the-century administrators an added incentive to present their institutions as places for the production of health. Exaggerating the extent to which their predecessors had been sites for the dying, hospitals emphasized their distinctiveness.¹²

Bellevue Hospital, old and new buildings, circa 1896.

Source. Used with permission from the Museum of the City of New York, Byron Co Collection.

One solution to the problems ambulances posed was to use them only for private-pay patients.¹³ More commonly, however, administrators ordered the drivers to remove some of the most undesirable patients that they brought in. A physician who had ridden on the Roosevelt Hospital ambulance as an intern recalled:

The Bellevue outlet gave us a great leeway in the selection of patients… . Many trips to Bellevue were necessitated because our ambulance cases were not acceptable. As can be imagined, this occasionally led to hard feelings … on our part because we had gone to great pains to bring them in, for which act, we expected to be thanked, were refused.¹⁴

A Presbyterian Hospital physician added:

The ambulance service did cause considerable trouble for the Hospital. If a patient was transferred from any private institution to Bellevue and died on the way, the politicians, coroners, and newspapers were often loudly critical.¹⁵

Although transferred patients typically died after entering Bellevue rather than en route, he correctly remembered the outrage the practice provoked.

SHIFTING PATIENTS

The first transfer case reported by the New York Times was in 1877, when the Manhattan coroner held an inquest to investigate Michael Connolly's death from pneumonia. That death occurred at Bellevue 5 minutes after he arrived in an ambulance from the Chambers Street Hospital, a small emergency facility operated by New York Hospital. Although Chambers Street physicians testified that “they did not think at the time the condition of the patient was so precarious as to render his removal dangerous,” the “authorities at Bellevue Hospital alleged that death was accelerated by the removal of the patient.” The jury issued a statement that it “depre- cate[d] the manner of transfer, and recommend[ed] greater care to be exercised in similar cases in future.”¹⁶ That advice apparently went unheeded. When 8-year-old Julia Bictor was run over by a coal cart one December morning in 1884, an ambulance delivered her, too, to Chambers Street Hospital.

At midnight the little sufferer was placed in an ambulance … and driven over three miles to Bellevue Hospital… . Five minutes after reaching the hospital in Twenty-sixth street the child expired.

The night captain at Bellevue stated that although he had

… seen many hard cases … this one was enough to touch the heart of a stone… . The poor little thing had no covering but a muslin bandage around its arm and waist, and sending a patient out in the night air in that condition certainly did not prove of benefit to it.¹⁷

“Death Caused by Removal,” proclaimed a New York Times headline in August 1891. This time German (later Lenox Hill) Hospital “hurried a dying man from their institution to Bellevue, where he died seventeen hours after admission.” Although German Hospital authorities pointed out that they had loaned the ambulance to the man's father “as an act of charity,” Bellevue physicians called the patient's transfer “an act of inhumanity.” The Times added that the previous June, German Hospital authorities had been severely criticized for transferring a woman to Bellevue “while she was in a dying condition from puerperal mania and it was held by a Coroner's jury that the death of the woman was accelerated by her removal.” Nevertheless, the New York Times article concluded, “this censure does not appear to have resulted in breaking the practice.”¹⁸ The following spring, Chambers Street Hospital bundled John Cummings, a 47-year-old laborer, into an ambulance to take him “through the heavy rainstorm then prevailing” to Bellevue, where he died just over an hour after his arrival. “I disapprove of the transfer of patients in wet weather,” a Bellevue doctor commented.¹⁹

The coroner investigated two cases in 1896. Heat rather than rain added to the travails of Thomas H. Swart, who had been in New York Hospital for seven weeks while awaiting surgery. The New York Times reported that according to his son, Fred:

when the physicians at the hospital saw that my father was not likely to recover, they sent him to Bellevue … when the weather was very hot and when he was in a weak condition. He died there on the following Tuesday. ²⁰

Fred Swart also witnessed the removal of the second patient, Caleb Ford, and was “struck by the undesirability of taking away a man in [his] condition.”²⁰ Bellevue doctors agreed. According to a New York Times article:

The fact that Ford died at Bellevue is held to prove either that he was moribund when he was sent out of New York Hospital or that the rough journey over the street pavement accelerated his death.²¹

The February 1901 New York Times headline read: “Taken from Hospital at Dead of Night.” Although Presbyterian Hospital physicians asserted that symptoms of erysipelas (a contagious disease) had compelled them to remove a 31-year-old unemployed shoemaker, Bellevue doctors could find no evidence of that illness. The man had a high fever when he arrived at Bellevue and died soon afterward. “They killed my husband by taking him out in the cold night,” his widow declared. “I was too poor to pay any money for my husband's treatment. He was not dying when I saw him at 9 o'clock at night. He was doing nicely. It was the ride that killed him.”²²

In some cases, private hospitals instructed their ambulances to take critically ill patients directly to Bellevue regardless of the distance. That practice too aroused anger. When the wife of an ice-wagon driver was “seriously burned on the back, face, and limbs” in January 1897, the police summoned a Roosevelt Hospital ambulance, which then “hurried her to Bellevue” although Roosevelt “could have been reached more quickly and over a smooth asphalt pavement.” There “was a grave possibility,” the New York Times article concluded, “that the woman might die as a result of her injuries.”²³ According to a 1902 letter to the Times, a Saint Vincent's Hospital ambulance transported an elevator attendant who fell down a shaft to Bellevue. Not only was Saint Vincent's closer to the scene of the accident, but the ambulance also could have traveled there entirely on “asphalt pavements.” Instead, the letter writer noted:

the poor suffering man was compelled to endure additional suffering, as the ambulance was driven over cobblestones. The vehicle did not have rubber tires. If a well and strong man were compelled to lie on his back in an ambulance without rubber tires and go over the same route, he would be a pretty sore and sorry looking individual by the time he reached the hospital. How much worse, then, must it be for a man who is injured as was this elevator attendant?²⁴

Condemnation came from other sources as well. In January 1900, George F. Shrady, a prominent physician and editor of the influential Medical Record, reminded his colleagues that although “a low mortality rate” was a “result to be desired,” the public was “but little interested in hospital statistics.” What a sick individual wanted above all “was the feeling of assurance that he will be accorded all the care and attention necessary to his health and comfort, irrespective of the hospital receiving him.”²⁵ The following year Commissioner of Charities John W. Keller reported that of the 1720 deaths at Bellevue during the preceding 12 months, 107 were within 24 hours after transfer from private hospitals. Had those patients been allowed to die in the facilities they initially entered, Bellevue's mortality rate would be a mere 7%. Nevertheless, he concluded that “it would be impossible to stop the other hospitals from sending the poor, dying patient to Bellevue in order to lessen their own death rates.”²⁶

EFFORTS AT REFORM

Keller's successor, Homer Folks, disagreed with Keller's conclusion. A prominent social worker, Folks instituted numerous reforms during his two years as Commissioner of Charities. In 1902, he issued an order requiring that he be sent a full report from the superintendent of any hospital in which a patient transferred from another facility died within three days after admission. The following year, the Department of Public Charities announced, “As a result the number of such transfers has markedly diminished, and there are now practically no transfers of this character except under circumstances which make the transfer practically unavoidable.”²⁷

But the department spoke too soon. In March 1906, according to the Times, an ambulance transported a dressmaker “ill with heart disease” to New York Hospital. “There she became rapidly worse, but in spite of her condition she was put back into the ambulance and orders were given to take her to Bellevue. She expired on the way.”²⁸ That case so aroused the Chairman of the Manhattan Board of Coroners, Julius Harburger, that he pressed a state senator to introduce a bill providing that any hospital official who transferred an ill patient to another institution would either be fined $5000 or imprisoned for 5 years.²⁹ After that bill met defeat, Harburger proposed a city ordinance to impose a penalty of $100 for every case in which a hospital superintendent either refused admission to a sick patient brought in an ambulance or ordered the transfer of a critically ill patient. When private hospital administrators claimed that they never sent patients to other institutions to reduce their mortality rates, Harburger exploded in rage. Private hospitals were “murdering the poor,” he shouted. “Open your books, and show me one man of wealth who has ever been transferred.” His statistics were equally exaggerated. “Out of the 15,000 persons transferred from one hospital to another each year in this city,” he claimed, “5,000 died.”³⁰ (Recall Keller's far more modest figure.) Despite continued protests from private hospitals, the ordinance eventually passed. Harburger claimed success but soon was forced to acknowledge that his reform was only partially effective.³¹

The transition to motorized vehicles in the early 20th century helped to soften the rigors of the trip. Soon after Michael Reese Hospital in Chicago, Illinois, bought the first motor-powered ambulance in 1899, New York City's Roosevelt and Presbyterian Hospitals acquired similar vehicles.³² By 1915, more than half of New York City's 99 ambulances were motor-driven.³³ Nevertheless, critics continued to complain that private hospitals transferred too many indigent, moribund patients and that the trip remained too dangerous for them.

In March 1914, the Hospital Investigating Committee of the Board of Estimate concluded:

That eighteen patients brought to Bellevue in private ambulances (in the three-month period under consideration) died on the day of arrival indicates a marked tendency on the part of private hospitals to carry dying patients to Bellevue rather than their own hospitals.³⁴

Furthermore, the report noted, private hospitals in Brooklyn, which had become part of New York City in 1898, were “even more prone” than were those in Manhattan “to transfer patients on the point of death” to King's County Hospital, the borough's public facility.³⁴ Five years later, King's County officials wrote that during the past 12 months:

over one thousand deaths occurred in this hospital among patients brought to us by ambulances from other hospitals—patients that morally should have been cared for in their own institutions since they were sick enough to die… . The transfer of a case from almost any other ambulance district to this hospital is usually a long and tedious ride. It would seem therefore, even when the local hospital is crowded, only such cases that could be properly transferred should be brought to us, and that the patient in the more serious conditions should be cared for in the district institution.³⁵

THE PAST AS PROLOGUE

Transfers of very poor and seriously ill patients from private hospitals to both Bellevue and King's County hospitals again captured media attention in the mid-1960s. According to one report, those two hospitals received a total of 1300 critically ill patients from other hospitals in 1966.³⁶ One case involved a 45-year-old woman with malignant hypertension who died a day after Columbia-Presbyterian Medical Center sent her to Bellevue. In another incident, a 51-year-old patient who had suffered a major heart attack died minutes after he arrived at King's County from Brooklyn Jewish Hospital. New York City's health services administrator commented:

Patients shouldn't be dumped. But as long as you have one hospital able to pick and choose what it wants, and another which must take every case that it gets, you are going to be faced with the dumping problem.³⁷

Although hospitals still do not want death to occur on their premises, they no longer publicize both their cure and mortality rates.³⁸ Perhaps as a result, studies of patient transfers at the end of the 20th century have tended to focus exclusively on economic factors. Thus, analysts attributed the rash of patient dumping cases reported throughout the country during the mid-1980s to both the increase in the size of the uninsured population and the growing financial pressures private hospitals faced, especially from Medicare's prospective payment system.³⁹ The number of patient transfers to municipal hospitals rose from 70 each month in 1982 to more than 200 each month in 1983 in Dallas, Texas; from 169 in 1981 to 930 in 1985 in Washington, DC; and from 1295 in 1980 to 5662 in 1984 in Chicago. ⁴⁰ In place of the anecdotal reports that filled the New York Times during the late 19th and early 20th centuries, researchers conducted systematic studies to document the harm transfers inflicted. Summarizing a variety of recent studies, the authors of a 1987 Journal of the American Medical Association article concluded, “The medical implications of patient dumping are serious and sometimes shocking.”⁴¹

If attempts at regulatory reform moved from the local to the state level during the early 20th century, more recent efforts have focused on the federal government. The 1985 Consolidated Omnibus Budget Reconciliation Act⁴² required hospitals with emergency rooms to treat medically unstable patients, including women in active labor. Nevertheless, critics repeatedly have faulted the government for failing to enforce the law adequately.⁴³ The most egregious recent examples of dumping involve the discharge of indigent patients in unstable conditions without an assurance that they can receive care elsewhere. In 2006, a Kaiser Permanente Hospital in Los Angeles placed a homeless woman with serious, untreated health problems in a cab with instructions to take her to a skid row street.⁴⁴ Two years later, the New York Times reported that hospitals have sent undocumented immigrants requiring expensive long-term care back to their home countries. According to one emergency room physician, “Repatriation is pretty much a death sentence in some of these cases.”⁴⁵ Most recently, the January 2010 decision by Miami's public hospital system to stop paying for kidney dialysis for indigent patients left them with few alternatives.⁴⁶ The failure of past efforts to effectively combat dumping at the beginning of the 20th century and the dawn of the 21st suggests that the solution lies in a fundamental transformation of the US health care system to ensure that every patient is a wanted patient regardless of his or her ability to pay.