Saving Lives Is Not a Business Decision


Thirty years ago a young David Kaufman walked into St. Vincent’s as an intern and ended as an intense, informed and at times angry critic of all those who after 161 years let it become luxury condos. Here he lets it all out again as yet another financially failing community hospital is sold to developers.

“Who is in charge”? he asks as the need for a West Village community emergency room and hospital grows and the Department of Health, hospital business management and politicians remain in wide-eyed innocence and self-serving silence.

By David L. Kaufman, M.D.

On April 30, 2010, St. Vincent’s Hospital was forced to shut down, suddenly transformed by rough plywood and cyclone fencing. I will not review the pathetic and corrupt history that led to that collapse and the care vacuum it created. I will not waste time reviewing the even more egregious, utter failure of the politicians, regulators, and most importantly, the NYS Department of Health to respond to that vacuum, abdicating their responsibility to rationally plan, implement, and maintain a health care system that meets the needs of all New Yorkers.

WHY DO HOSPITALS DIE? On April the 30th, 2010, West Villagers seeking the St. Vincent's Emergency Room were met by a coffin wall of plywood. Dr. Kaufman asks why after 161 years did it have to die? Photo by Maggie Berkvist.
WHY DO HOSPITALS DIE? On April the 30th, 2010, West Villagers seeking the St. Vincent’s Emergency Room were met by a coffin wall of plywood. Dr. Kaufman asks why after 161 years did it have to die? Photo by Maggie Berkvist.

Is history repeating itself? Let’s focus on some facts. Since 2000, twenty hospitals have closed throughout New York City. Since 2000, the population of this city has grown from 1.54 million to 1.65 million in 2015. In Manhattan, since 2007, there have been three closures: St. Vincent’s Midtown (formerly St. Clare’s) in 2007, Cabrini in 2008, and St Vincent’s Manhattan in 2010 representing the loss of 1,381 beds, three Emergency Departments, one Level One Trauma Center, and dozens upon dozens of outpatient clinics, outreach departments, home visit programs, and homeless shelter service centers. Perhaps not surprisingly, these three hospitals provided comprehensive care to hundreds of thousands of poor, uninsured, and Medicaid covered New Yorkers who had difficulty accessing care elsewhere. There is (I should say was) a reason they were called safety net hospitals.

Let’s drill down further and focus on St. Vincent’s, Manhattan. Prior to closing, it had an average daily bed census (beds with bodies) of 340. It had 22 operating rooms functioning daily. It had 23 outpatient clinics with 263,000 individual patient visits, 18 mental health clinics, 3000 employees including 880 nurses and over 1000 physicians. With over 64,000 annual visits, the Emergency Department provided life saving services to New Yorkers experiencing heart attacks, strokes, infections, overdoses, psychotic episodes, and suicide attempts. Over 13,000 of these patients were so acutely ill they required immediate admission to the hospital. And as the only Level One Trauma Center from South Ferry to 114th Street on the West Side, it was a critical provider of care for mass casualty events like the World Trade Center attacks, as well as for gunshot wounds, stab wounds, and life threatening physical trauma.

How did the Department of Health fulfill its responsibility to the residents, commuters, and visitors on the Lower West Side? How did the politicians and regulators respond to this enormous loss of health care resources? They licensed and supported a “free standing emergency room”, a facility with no operating rooms, no major trauma care capability, and limited, almost band-aid like, resources to deal with the acute, critically time dependent care of strokes, heart attacks, sepsis and shock. The population of the Lower West Side was, however, reassured repeatedly that ambulances stood ready to transfer these critically ill patients either 70 blocks north and west to Lenox Hill or (less likely since the replacement is owned by Lenox Hill) to Beth Israel, a mere 18 blocks away through cross town traffic. Oh yes, I almost forgot. The DOH and politicians also reassured us that there were two observation beds. Lucky us.

Six years have passed. Here the facts get murky because they are purposely unavailable. We will never know what happened during ambulance transfers from that “free standing emergency room.” Did patients die en route? Did their early heart attack rapidly progress to massive muscle loss and permanent heart failure or death because of delays in door to cath lab time? There are national standards for this door to needle time for very good, life saving reasons. Why aren’t those statistics available for these patients? Why aren’t we given a breakdown of times: how long from front door with chest pain to ambulance; ambulance to Lenox Hill ED; ED to cath lab; outcome? The same standards exist for stroke patients. There is a reason that a system of certified Stroke Centers was established. That reason is brain cell death. Every minute, indeed every second, is critical for the preservation of brain function. The same life threatening ticking clock plays out for major trauma, major bleeds, dissecting aortas, perforated stomachs, and even overdoses.

Do we have any of these facts, do those statistics even exist? Hello? Is anyone home, is anyone doing their jobs at the DOH, at City Hall, in Albany? Do they even know what’s happening? Do they care? One needs to ask a hard question here: are they simply dumb and stupid or are they totally dishonest and uncaring? Ignorance may be bliss, but not for those who suffer because of it.

Flash forward now, 74 months later, to the present. Why review old news? Why review the tip of the iceberg facts and wonder what sad and outrageous stats lie below the water, hidden from our examination? The answer is simple: history is about to repeat itself.

Mt. Sinai bought Continuum Health Care and, as part of that deal, assumed ownership and management of Beth Israel Hospital. Predictably, they have announced their intention to close the hospital. All the usual reasons are given and I will not repeat them. The bottom line is that closure will mean the loss of 672 beds, innumerable outpatient clinics and, critically, another full service Emergency Department that was recently doubled in size in order to responsibly and professionally meet increased need. Note also that Beth Israel, like St. Vincent’s Manhattan, St. Vincent’s Midtown, and Cabrini, is/was a hospital that provided access and care to tens of thousands of poor, uninsured, and Medicaid New Yorkers. Another safety net hospital about to be closed. Is there a theme here?

A COMMUNITY OF DOCTORS DIES WITH ST. VINCENT'S: As Doctor Kaufman pleads, a decades-old irreplaceable community of doctors that trustingly exchanged diagnoses and medical opinion dies with St. Vincent's. Photo by Maggie Berkvist.
A COMMUNITY OF DOCTORS DIES WITH ST. VINCENT’S: As Doctor Kaufman pleads, a decades-old irreplaceable community of doctors that trustingly exchanged diagnoses and medical opinion dies with St. Vincent’s. Photo by Maggie Berkvist.

Sinai claims it will replace those 825 beds and services provided by a financially dying hospital with a new facility not yet built. They claim it will have 70 beds, a “full service emergency department,” etc etc etc. Or should I say blah blah blah. Since we have no real substantive details about this new facility it is not truly possible to judge whether it is an even remotely reasonable replacement for the death of another major hospital.

But, luckily, we do not need to make that impossible assessment. Why? Because the proposed facility makes no sense, will not be economically viable, and will never be built. A 70 bed hospital has the same safety, regulatory, and professional requirements as a 300 bed hospital but clearly cannot realize the same revenue to support those costs. It is simple arithmetic. And remember, we are talking about the same hospital and the same Board of Trustees that, at the eleventh hour, after numerous promises, guarantees, and reassurances, abandoned partnering with St. Vincent’s Manhattan. Why? Because the NYS Commissioner of Health had a “conversation” with Sinai leadership, and based on that conversation the Board of Trustees decided it was not financially prudent to take over St. Vincent’s. Of course, no one will reveal or discuss the contents of that “conversation.” Poof, gone, and no healthcare replacement for the entire Lower West Side.

With or without a new facility, the healthcare facts remain the same. Before the closure of Beth Israel, back in 2010, we asked how adequate services would be provided for the more than 153,000 of the Lower West Side. Those questions were totally ignored. Since 2010, that population has grown. New luxury condominiums are sprouting up, a new museum brings in even more tourists, and a booming financial center is, as a result of the Brexit vote, about to explode further.

Now look at the Lower East Side. It has a residential population of 167,000 that includes the less wealthy communities of Chinatown and Alphabet City for whom access to care is always a problem. There will be no hospital, no beds, no Emergency Department, no clinics at Beth Israel. Where will these patients go when they have chest pain, stomach pain, sudden paralysis? Who will monitor their blood pressure and sugar? The list of questions is endless.

It is critical to understand the true population data in order to fully comprehend the real and potential impact of all these closures on the delivery of accessible healthcare and emergency services. Ironically the following information comes from a report developed at the Rudin Center, Wagner School of Public Service, NYU in 2012. The report dives deeply into the Manhattan population figures, focusing not just on overnight residents, but commuters and visitors, and even breaks this data down by weekdays, weeknights, and weekends. It is enlightening and scary. And while they do not give a breakdown by community neighborhoods, the numbers remain compelling.

The weekday daytime population of Manhattan is 3,940,000. It is composed of 1,460,000 residents, 1,610,000 commuters, 780,000 visitors, and 70,000 commuting students. Where in Manhattan do all these non-residents go? Consider that New York University has over 45,000 students, the Financial District explodes with commuters daily, and tourists flock to the WTC Memorial, the High Line, the Whitney, etc. Suffice it to say that the daytime population of Lower Manhattan, soon to have only one hospital with 170 beds, probably swells to about 2,000,000 people. And on weeknights, when the Manhattan population is 2,050,000, a very large percentage of those visitors are in Village restaurants, Chinatown, Little Italy, the Theater District, etc. The statistics for weekend population follow a similar pattern. It is worth spending a minute reviewing the accompanying charts from that report.

So what does all this mean? I can tell you that during the fight to save St. Vincent’s not one politician, not one DOH administrator ever highlighted and discussed these real numbers. Remember, we are now talking about a total at-risk population on the order of 2,000,000 people. On the West Side, they will have no access to emergency care, (with the lone exception Downtown Hospital) from South Ferry to 60th Street and no Level One Trauma services from South Ferry to 114th St. That is one long trip when you are dying. On the East Side, realistically, they will have only Bellevue Hospital, a facility that continues to be severely stretched and strained even with Beth Israel open and functioning.

These are scary numbers and the pending scenario is morally outrageous. Compare this to the rest of Manhattan. On the East Side there are 8 hospitals and two Level One Trauma Emergency Departments between 60th St and 100th St for a population of 224,000. To be crystal clear, these hospitals have a total of almost 4,400 beds, for a population of 224,000 compared with 2,000,000 in Lower Manhattan. On the West Side, between 60th and 160th with a population of about 200,000 there are three hospitals, 2,023 beds and a Level One Trauma Center and Emergency Department.

HOSPITALS CLOSE AS NEED GROWS: Lower Manhattan has the largest population but with the loss of St. Vincent's and now Beth Israel. the greatest need for an emergency room. Each ambulance minute to an Upper East Side hospital can mean brain cell death.
HOSPITALS CLOSE AS NEED GROWS: Lower Manhattan has the largest population but with the loss of St. Vincent’s and now Beth Israel. the greatest need for an emergency room. Each ambulance minute to an Upper East Side hospital can mean brain cell death.

Ponder these numbers. Do the math. And compare it to what will happen when Beth Israel closes. Below 23rd Street on the East Side and below 60th Street on the West Side, there will be 170 beds and one Emergency Department for 2,000,000 people.

Two Million. And that’s on a slow day, with no parades, no market crashes, no terrorist actions.

This situation is irrational, immoral, and socially outrageous. Look closely at the map, gaze at the hospital locations. Consider the social, political, and economic implications, not to mention the enormous impact on healthcare delivery that play out on that map.

Will we let history repeat itself? Will the powers that be wait, as they usually do, for another calamity, another terrorist mass casualty event, another healthcare epidemic like HIV (Zika?) to occur before reacting and responding, too little and too late? We elect politicians to govern, to manage, and to plan. They appoint regulators and commissioners to articulate policy, implement decisions, and monitor outcomes. They, politicians and the others, are expected, obligated, to make rational decisions in the best interests of the population—all of the population. They need to be held responsible and accountable for their decisions, and even more importantly their lack of decisions.

What can be done to prevent reliving history yet again? Simply look at the map, look at the population charts and remember the numbers. In that same report, the population density of Lower Manhattan is reported as just over 1,000,000 people per square mile. How could any responsible, rational, honest politician or Commissioner of Health not recognize that Lower Manhattan absolutely needs a new full service hospital with a full service Level One Trauma Center and Emergency Department? While population statistics and current service capacity (beds, clinics, EDs) strongly suggest placement of a new facility on the West Side, that is a subject for careful study and rational, professional planning. But the clear and present need for a new hospital needs no further debate. A 300 bed full service hospital would be financially viable and, far more importantly, would meet the desperate healthcare needs of this population.

What is needed is action. If the facts and statistics outlined above are not enough to convince a responsible politician, just imagine what the hidden stats might tell him or her.

Will history repeat itself? Only if we let it, only if you let it. We also learn lessons from history. And we should not, cannot forget the lessons of 2010. We cannot rely on politicians and regulators to do the right thing. They have too many conflicting interests, too many elections to fund, to many favors to return. We cannot match the economic power of those interests but the residents of lower Manhattan do have the power to speak loudly and shout in unison. Squeaky wheels do get heard. Politicians want to get re-elected and they need your votes to do that.

This is not a decision to be made by the mega healthcare systems of New York. It is not up to Sinai or NYU or North Shore. They do have great latitude (far too much) regarding the curtailing or closing of facilities and services. But they cannot open a new hospital without the blessing and support of the government.

A MILLION VISITORS A DAY: Between commuters and visitors New York adds one million potential emergency room users each day. Sources: US Census Bureau 2010 American Community Survey, NYC & Company, Audience Research & Analysis, US News and World Report, New York University
A MILLION VISITORS A DAY: Between commuters and visitors New York adds one million potential emergency room users each day. Sources: US
Census Bureau 2010 American Community Survey, NYC & Company, Audience Research & Analysis, US News and World Report, New York University

In 2010, at the height of the struggle to partner and save St. Vincent’s, the CEO said this: “If the Department of Health wants it to happen, it will happen.” The Commissioner did not want it to happen in 2010. He and his Department along with the political powers of this city and state cannot be allowed to make that decision again. Lives depend on it.

After earning a BFA from New York University, an MA from Columbia University, and his MD from New York Medical College, Dr. Kaufman completed his Residency training at St. Vincent’s Hospital and Medical Center. During the course of his 32 years in practice in NYC, he has been privileged to provide primary care to multiple family generations and to a widely diverse population of patients. Over his many years of practice he was consistently cited in the New York Magazine listing of Best Doctors in New York and has been recognized by the Castle Connolly listing of Top Doctors: New York Metro Area from 1998-2012. After moving to California in 2012, he joined the Open Medicine Institute, an organization focused on clinical care and research.

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