A Nice Place to Live, But I Wouldn’t Want to Get Sick There

Inside Brooklyn's Hospital Crisis

John Jay Cabuay/The Observer.

Illustration by John Jay Cabuay

Brownstone Brooklyn has, over the last few decades, become a kind of shorthand for the good life, the profusion of farm-to-table restaurants and bespoke boutiques along its tree-lined streets proclaiming that one need not sacrifice the sophistication of city life for the bucolic charms of the suburbs. In Brooklyn, one can have it all, or so the story goes, a narrative whose popularity is reflected in the borough’s ever-rising real estate prices—a Brooklyn Heights manse that sold for $12.5 million, Park Slope townhouses that cost as much as those on the Upper West Side, $3,000-a-month Williamsburg studios.

For those who can afford to partake of its many delights, Brooklyn is an ideal place to live, save for one major and deeply troubling exception: it isn’t a very good place to get sick.

The borough’s severely distressed healthcare system, which had been limping along for years in a state of near-crisis, is now in one of effective collapse. This past year, one hospital—Long Island College Hospital, or LICH—was shuttered, but for the vestige of an emergency room and another, Interfaith, was saved from the same fate by an infusion of emergency funding from the state, given with the understanding that its closure would have disastrous consequences for the surrounding Bed-Stuy community. The two hospitals had been losing $13 million and $3 million a month, respectively.

Moreover, LICH and Interfaith weren’t outliers—a state report from 2011 identified at least three other Brooklyn hospitals “at risk of imminent financial collapse” and warned that with thin margins “even many well-managed hospitals that are doing good work lack the resources to make necessary investments in physical plant, staff, medical talent, information technology or new models of care.” Averting catastrophe, the report advised, would require major changes: multiple mergers and the creation of a vast outpatient network across the borough, recommendations that in the three years since have gone almost entirely unheeded.

That Brooklyn’s hospitals have been seemingly untouched by the waves of affluence lapping ever further into the borough may seem surprising, but many of Brooklyn’s new arrivals assiduously avoid its hospitals—in 2010, 35 percent of commercially-insured patients traveled to Manhattan for hospital care, much of it the kind of high margin procedures that help hospitals offset other costs. And those who end up in the borough’s ERs often express shock; one man described conditions at Brooklyn Hospital’s ER as “third world,” a strangely incongruous state of affairs for an institution that backs up onto Fort Greene Park, where on Saturday mornings one can buy wild-caught salmon from Suffolk County.

In the playgrounds of brownstone Brooklyn, tales abound of children with broken bones, open wounds and even serious allergic reactions being ferried across the river to Manhattan. One Brooklyn Heights mother at Pierrepont Playground with her daughter confessed that her well-regarded local pediatrician used to send parents to LICH, but now recommended Children’s Hospital of New York-Presbyterian Weill Cornell on the Upper East Side. “It’s far, but she says to just do the hike. I guess if it were really an emergency …” the woman paused, an evanescent frown passing across her face. “All of the other moms I know have never had a problem getting into the city.”

But can you really opt out of the healthcare system where you live? When illness or injury strike, are we not all, to an extent, at the mercy of time and place? Isn’t the delight of living a five-minute walk from amazing pour-over coffee and boutiques with the perfect Swedish clogs somewhat diminished by the knowledge that getting to the ER could take a good 45 minutes in traffic?

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When a hospital closes, the burden on neighboring institutions increases. (Arman Dzidzovic/The Observer)

When a hospital closes, the burden on neighboring institutions increases. (Arman Dzidzovic/The Observer)

While Brooklyn arguably has the most imperiled hospitals in the city, the challenges that they face are not unique, but have their roots in much broader changes to healthcare delivery, funding and reimbursement. Falling Medicaid reimbursement rates, a shift away from inpatient care—many of the medical services that in the past required hospitalization can now be performed in an outpatient setting—and insurers that negotiate vastly different rates for the same procedure depending on the size and popularity of a hospital have forced massive changes across the city. Since 2000, 19 New York City hospitals have closed, though some of them were partially taken over by larger networks—size being one of hospitals’ best bulwarks against financial ruin.

Of the many closings and consolidations that have hit New York in the last decade, St. Vincent’s, which shut its West Village doors in 2010, $1 billion in debt and losing $10 million a month on top of that, came as perhaps the greatest shock: a high-profile institution in an affluent neighborhood surrounded by other affluent neighborhoods, with no nearby alternatives. If St. Vincent’s couldn’t survive, many wondered, what hospital could?

But St. Vincent’s had a number of things in common with Brooklyn’s ailing institutions: namely, a lot of empty beds and a clientele that skewed increasingly toward Medicaid recipients and the uninsured, a population inclined to use the emergency room in lieu of a primary care provider. In 2008, 86 percent of the people in the increasingly wealthy area around St. Vincent’s elected to make their hospital stays elsewhere.

In Brooklyn, some 1 million residents, roughly 40 percent of the population, is on Medicaid—a federally and state-funded program for the poor that reimburses healthcare providers at much lower rates than commercial insurance. As of 2010, another 15 percent were uninsured, according to the Department of Health. Less than half of Brooklyn’s population carries private insurance, with a full 35 percent of those who do traveling to Manhattan for hospital care. (And experts say that those who do stay tend to favor Maimonides Medical Center, New York Methodist Hospital and Lutheran Medical Center, though those hospitals also struggle to attract patients for high-margin specialty procedures; one high-placed health official, who said he truly believes 98 percent of problems can be treated at local hospital, recounted telling a friend who had landed at Methodist with a racing heart and needed minor heart surgery that he had to leave the borough immediately. “I said, ‘you have to go to Manhattan right now. Have them send a transporter over.’”) Along with Manhattan’s sterling reputation, Brooklyn hospitals also lack its deep-pocketed donors.

“There’s not a hospital in Brooklyn making a lot of money,” said one policy expert. “Even the better ones are just breaking even. Everyone should be worried about every hospital in Brooklyn.”

In recent years, ongoing funding cuts to Medicaid and rising expenses have left healthcare providers that serve large numbers of Medicaid and Medicare patients in increasingly untenable positions. It has not helped that New York State’s $54 billion Medicaid system is the nation’s largest, making it particularly vulnerable to shrinking federal budgets. In 2009, the Health and Hospitals Corporation, which operates the city’s public hospitals and clinics, including Woodhull Medical Center, Kings County and Coney Island hospitals in Brooklyn, announced spending reductions of $105 million and the elimination of 400 jobs across its five-borough system.

And whereas a number of private practice physicians stopped taking on new Medicaid patients as a result of falling reimbursements, hospitals have to treat everyone, regardless of ability to pay.

Physician affiliations are vital to a hospital's health. (Arman Dzidzovic/The Observer)

Physician affiliations are vital to a hospital’s health. (Arman Dzidzovic/The Observer)

As more private practices have stopped taking on Medicaid patients over the years, they have flocked to emergency rooms, adding to the burden of hospitals located in neighborhoods with a dearth of primary care providers—something one-third of Brooklynites lack, according to the state report. Coupled with a high incidence of chronic conditions like obesity, diabetes and asthma, many in the borough end up relying on hospitals for treatment that could be more efficiently and cheaply delivered outside of a hospital.

“Brooklyn healthcare has traditionally been very hospital-centric and because we have many, many low to middle income patients, it’s more difficult to find the dollars to build brand new outpatient sites,” said Dr. Richard Becker, the president and CEO of Brooklyn Hospital. “Brooklyn as a borough has not been able to keep up.”

Even when Brooklyn hospitals manage to draw in patients with private insurance, they generally receive less payment per procedure because unlike the Bronx or Manhattan, where most hospitals are either part of large networks or considered “centers of excellence,” i.e. NYU Langone Medical Center, Mt. Sinai Hospital or New York-Presbyterian, which can negotiate far better rates, Brooklyn is a borough of independent hospitals.

“Small hospitals can’t compete with the bigger players; they often end up getting the Medicaid rate or less from insurers,” said one expert.

Stephen Berger, the chairman of a private equity firm and primary author of the state’s 2011 report on Brooklyn hospitals, put it more bluntly: “If it’s not a hospital the consumer demands, you pay them a shitty rate.”

In Brooklyn, healthcare has been extremely fragmented, with hospitals historically operating like fiefdoms, competing for clients to fill their empty beds rather than working collaboratively to create the kinds of outpatient networks that are essential to their eventual survival. (To be sure, there has also been mismanagement, some of it nefarious—in recent years, as Wyckoff Heights Medical Center was defaulting on bonds and begging the state for money, the Times reported that its chief executive was driving to work in a $160,000 Bentley and billing the hospital for $500 dinners at La Grenouille.)

Mr. Berger’s 2011 report identified six Brooklyn hospitals—Brookdale, Brooklyn, Interfaith, Kingsbrook Jewish Medical Center, LICH and Wyckoff Heights—that it strongly recommended merge into networks for the sake of stability, as they “do not have a business model and sufficient margins to remain viable and provide high-quality care to their communities as currently structured.” To this day, all six remain independent institutions, though some have formed affiliations with larger institutions.

“Brooklyn has nothing. It has no core, no center, just a series of weak hospitals, too many beds and a crappy primary care system,” said Mr. Berger. “There are some good hospitals, like Maimonides, but it’s not big enough or strong enough to be a core. And most of the hospitals there see their role as: ‘we will survive if we’re the last one standing.’ ”

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LICH closed this May, leaving only its emergency room open.

LICH closed this May, leaving only its emergency room open.

In May of this year, after 16 months of fierce legal battles and political protests that featured the dramatic arrest of then mayoral-candidate Bill de Blasio, LICH shut down everything except for its emergency department, which it agreed to keep open as part of a legal settlement. The financial losses associated with LICH—some $500 million—have been so great that SUNY says it has destabilized SUNY Downstate, the academic medical center in Brooklyn of which LICH was a part.

The hospital had been hemorrhaging money long before SUNY took it over from Continuum Partners in 2011, a move that even at the time was widely considered to be ill-advised given the magnitude of the changes needed to turn LICH around.

“We had an aggressive business model that anticipated we could retain Brooklynites at the site—the data at the time suggested that 20 percent left the borough for care—and that didn’t happen,” said Lora Lefebvre, SUNY’s associate vice chancellor for health affairs. “At the same the whole healthcare model changed from inpatient to outpatient,” she said, referencing the state health department’s plan to cut “avoidable” hospital admissions by 25 percent in the next five years.

LICH’s reputation, which had long been slipping as the hospital lost money, fell even further after SUNY took over, causing nearby doctors to drop their affiliations and stop referring patients there, which caused the hospital to lose even more money. The fact that LICH was being avoided by anyone with the means to go elsewhere quickly became an open secret and the hospital’s patient base increasingly shifted to underserved residents in Red Hook without other options.

“I wouldn’t have even sent my dog to LICH,” said an administrator at another Brooklyn hospital.

One Brooklyn Heights father, who asked to be identified only by his first name, Henry, said that when he grew up in the neighborhood, “LICH is where you would go. But it’s just been a steady decline over the last 35 years.”

“My pediatrician used to be affiliated with them,” he continued, “but at a certain point, he told us not to go there anymore. Now if my son had a broken arm or needed stitches, we would probably go to NYU.”

Another local father, Josh Gitlin, said he had taken his son to LICH several times over the years. Now that it was closed, he said he’d guessed they’d go to Brooklyn Hospital downtown if there were a real emergency. But even residents inclined to seek care in their home borough were often sent to Manhattan hospitals by their doctors—Mr. Gitlin said that when his newborn daughter was suffering from jaundice, the pediatrician instructed them to go to Weill Cornell.

The difficulty of keeping affluent Brooklynites in the borough for medical care is illustrated by many Brooklyn mothers’ preference for delivering their babies in Manhattan. Though Maimonides in Borough Park still delivers more than any other hospital in the state, 8,500 babies a year, a New York Times analysis found that between 1998 and 2008, each of the hospitals in Brooklyn’s “brownstone belt” lost maternity patients from their neighborhoods at the same time that four prominent Manhattan medical centers saw births for Brooklyn mothers rise more than 31 percent.

Maternity care, the Times noted, is considered highly important by hospitals as “once a woman has a happy birthing experience, her loyalty to that hospital for herself and her family may be cemented for life.”

The challenges of running a hospital at the LICH site are such that during two request-for-proposal processes only one of the nine bidders, Brooklyn Health Partners, proposed a full-service hospital, and SUNY cut off negotiations with BHP after deeming the organization unable to pull it off, despite the obvious demand for high-quality care in the neighborhood.

“I walked away from this experience with the conviction that a new full-service hospital was viable,” said Larry English, BHP’s general counsel. “I live on the island of Manhattan and one thing I’m convinced of is that powerful Manhattan would never tolerate the lack of healthcare that Brooklyn has. I have children and if my child got sick I wouldn’t want to hop the bridges and tunnels to Manhattan. But every year, you have tens of thousands of people doing that, bypassing Brooklyn hospitals. Well, I can’t believe they’d want to do that.”

Gabrielle Birkner, an editor and mother who lives in Clinton Hill, said being able to get to the hospital fast was a huge part of her decision to deliver her two children at Methodist in Park Slope. “I guess there aren’t the same bragging rights as giving birth, say, at the hospital where Beyoncé had Blue Ivy. But then again, you’re not up against a rush-hour commute across the Brooklyn Bridge and up the FDR while in labor. For me, that was no small thing.”

Viable or not, none of the other LICH bidders were willing to venture a full-service hospital in Cobble Hill; a $240 million deal is now pending with the Fortis Property Group and its partners, NYU Langone and Lutheran. It will bring a free-standing emergency room with a complement of clinics to the site, along with luxury condos (a component of all nine proposals).

Even Mr. de Blasio, who made saving the hospital a central tenet of his mayoral campaign, has since bowed to the exigencies of LICH’s situation.

Mr. de Blasio has repeatedly declared the hospital “saved” and praised the Fortis proposal, which will ultimately result in a set-up very similar to the one he criticized last summer at the former St. Vincent’s site, where just last week Manhattan’s first free-standing emergency room opened in the O’Toole building on Seventh Avenue, soon to be followed by clinics and an ambulatory surgery center.

The mayor’s liberal allies, meanwhile, have continued to rail against the deal. “While this agreement includes some healthcare services, it falls far short of a full-service hospital. And it does not resume immediate ambulance service, nor require an independent community needs assessment,” State Senator Daniel Squadron, Assemblywoman Joan Millman, City Councilmen Brad Lander, Steve Levin and Carlos Menchaca wrote in a joint statement.

Interfaith, in Bed-Stuy, is considered a safety net hospital. The state intervened to stop its closure.

Interfaith, in Bed-Stuy, is considered a safety net hospital. The state intervened to stop its closure.

The demise of LICH, though it has garnered the most media attention, is not even the borough’s most worrisome. The closure of Interfaith, which seemed imminent after the hospital declared bankruptcy in 2012, would have been far worse. Interfaith is located in Bed-Stuy, which has an underserved population of approximately 160,000, as well as 14 percent of Brooklyn’s inpatient psychiatric beds, according to a report put out by the public advocate’s office under Bill de Blasio. (The 2005 closure of nearby St. Mary’s, the borough’s last Catholic hospital, left Interfaith the only hospital in the vast and vastly poor swath of the borough.) So the state intervened, promising funding through 2015 while Interfaith, which just emerged from bankruptcy, restructures.

“It is morally indefensible to allow Brooklyn to continue on the trajectory its on. And it can’t—a lot of these hospitals are going to collapse,” Mr. Berger said. “While I think we have too many beds, you don’t want collapse, you don’t want chaotic change.”

Last week, the state announced that Brookdale, Interfaith and Kingsbrook will also get tens of millions of dollars of federal Medicaid waiver money—receiving $53.4 million, $36.8 million and $23.5 million, respectively—given with strict requirements that hospitals reduce in-patient services and hospitalizations while increasing outpatient care and collaboration with other institutions.

Of course, preventative health is not a panacea, cautioned Alan Sager, a professor at Boston University School of Public Health, especially in a place like New York, whose elderly population is expected to rise from 1 million to 1.3 million in 2030.

And given the daunting challenges Brooklyn hospitals face, and the widespread intransigence to change thus far, is a massive transformation really possible?

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The remaking of the Bronx’s hospitals over the last several years is instructive here. Despite being the poorest of the boroughs, the Bronx has a healthcare system that numerous healthcare professionals and policy makers described in interviews as “excellent” and “world class.”

That the Bronx’s healthcare system should flourish while Brooklyn’s flails may seem counterintuitive. After all, the Bronx has lagged far behind the other boroughs’ economic growth, a world apart from the much-touted transformation of Brooklyn. As Adam Davidson reported in a 2012 New York Times article entitled “Why Can’t the Bronx Be More Like Brooklyn,” while the two boroughs had income parities in the early 1970s, today the average Brooklyn resident is now 23 percent richer than the average Bronxite.

But the Bronx not only has high-quality hospitals, but also has clinical, community and preventative care networks that dovetail with federal healthcare reform’s goals.

Montefiore, in the Bronx, is considered a world-class institution, despite facing many of the same challenges as Brooklyn hospitals.

Montefiore, in the Bronx, is considered a world-class institution, despite facing many of the same challenges as Brooklyn hospitals.

The reason why Brooklyn and the Bronx are different, experts say, is Montefiore Medical Center—the Bronx’s largest healthcare player by far, which owns seven different hospitals, a free-standing ER (the city’s first), numerous outpatient clinics, home healthcare agencies and recently announced it was taking on a significant share of governance and financial responsibility for its partner Albert Einstein College of Medicine at Yeshiva University. More fundamentally, though, Montefiore has been as far ahead of every major healthcare shift in the last two decades as Brooklyn hospitals have been behind them.

Crucially, it has spent the last several decades building a diverse healthcare delivery system that integrates hospital and primary care, a development that came about in large part because of the borough’s devastation in the 1970s and ’80s.

“Back then, Montefiore was much smaller, only a single hospital,” said Dr. Andrew Racine, Montefiore’s chief medical officer and a senior vice president. “But it became clear to us that the primary care system in the Bronx had disappeared. Many doctors had left and there was no network of people referring patients.” So Montefiore slowly started re-building the networks itself, and in the act of providing both primary and hospital care, found ways to reduce costs for treating Medicaid and Medicare patients, who account for 80 percent of the network’s clients. And Montefiore came to believe that the standard fee-for-service model wasn’t ideal for overall health outcomes, incentivizing sickness rather than wellness.

As Montefiore has grown, it has increasingly transitioned to a capitated model, in which it negotiates with the insurance company to receive a flat monthly free for each patient regardless of the services provided. Essentially, Montefiore assumes the risk, making money if the patient stays healthy and losing money if he or she doesn’t. The system, which is also used by the Mayo and Cleveland clinics, incentivizes Montefiore to keep the patient healthy. Montefiore is also the only hospital in New York to participate in the Pioneer ACO model for Medicare, which uses designated care managers to facilitate between multiple doctors and social service agencies, splitting any resulting savings between the government and Montefiore. Dr. Racine said that Montefiore wants to eventually transition all of its patients to the capitated model.

“It’s our belief that this transition from fee-for-service to risk management, it’s a train that’s only going in one direction,” said Dr. Racine. He added, however, that shared risk arrangements “require scale, spreading risk out over a vast majority” to be effective—Montefiore has about 300,000 people in the capitated model now, out of a total 500,000, and wants to grow its network to 1 million—and that it can take a long time to figure out how to make such a system profitable. “We lost money for years,” he said.

Even with Montefiore, the Bronx is still burdened by distressingly high asthma, obesity and diabetes rates “the highest health disparities in the state,” Bronx borough president Ruben Diaz Jr. told The Observer. But at least with Montefiore, health problems seem potentially ameliorable via education and outreach. “We’ve been ranked last in so many other ways, I’m happy that we’re not last in healthcare institutions,” he said.

Brooklyn, though spared from the collapse and devastation the Bronx experienced in the ’70s, was also deprived of the opportunities opened up by that destruction. While Montefiore responded to the lack of services in the borough by building a system that anticipated the demands of the changing healthcare landscape, thriving in the process, Brooklyn’s system remained just functional enough to hobble through the decades, becoming increasingly mired in the outmoded healthcare models of the past. And even the hospitals that have innovated find it difficult to compete with the stunning array of sophisticated academic medical centers across the river.

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Surgeons at Maimonides performing a trans-catheter aortic valve replacement. (Arman Dzidzovic/The Observer)

Surgeons at Maimonides performing a trans-catheter aortic valve replacement. (Arman Dzidzovic/The Observer)

On a morning in early June, a large team of doctors and nurses crowded into a conference room at Maimonides to discuss the heart surgery they were about to perform. The patient, a 54-year-old Crown Heights woman, had severe aortic stenosis, a narrowing of the aortic valve, and had already suffered one heart attack. And though relatively young, complicating factors, namely hypertension and dialysis, made traditional open-heart surgery extremely risky.

The patient was scheduled to undergo a trans-catheter aortic valve replacement; a minimally invasive, cutting-edge procedure in which a new heart valve made of stainless steel and bovine pericardium is inserted via a catheter run through an incision in the groin. The procedure would be done in a hybrid operating room equipped with advanced digital imaging technology, which allows doctors to perform complicated cardiac maneuvers without opening a patient’s chest.

Doctors and nurses at Maimonides meet for a pre-surgical conference.

Doctors and nurses at Maimonides meet for a pre-surgical conference. (Arman Dzidzovic/The Observer.)

Just after 9 a.m., doctors made the first incision, a surprisingly small one that scarcely bled and the surgical team, led by Dr. Jacob Shani, chairman of cardiology, began the process of isolating the femoral artery to use as a conduit to the heart. Then a stent and temporary pacemaker were inserted into the heart through a catheter—in order to deploy the valve, doctors needed to reduce the patient’s blood pressure below 50, a feat that would be accomplished by accelerating her heartbeat. Finally, after about 90 minutes of meticulous preparation, including taking a  aortagram to determine the best angle to approach from, the valve insertion itself was so swift and smooth that an observer almost missed it in a moment of distraction.

The survival rate for patients with severe symptomatic aortic stenosis, Dr. Shani noted after the procedure, is far worse than most forms of cancer—within two years, 50 percent of patients without surgical interventions will die. But even though Maimonides is one of the few hospitals in the city capable of conducting minimally-invasive heart surgery, and consistently ranks in the top hospitals in the U.S. for patient outcomes and low mortality rates, it still struggles to attract affluent Brooklynites, who tend to reflexively believe that Manhattan is better.

“We suffer from location, location, location,” said Dr. Shani. “We’re in Borough Park, not Park Avenue.”

He went on to describe the case of a Brooklyn man who suffered a massive heart attack. Paramedics were going to take him to a Brooklyn hospital, “but I kept begging them to take me to NYU,” the man said in a promotional video for NYU. After arriving, the man was placed in a medically-induced coma, spent two months in the hospital and received a left-ventricular assist device, essentially an artificial heart. Eventually, he had a heart transplant.

“When you’re talking heart muscle, time matters,” Dr. Shani said. “By the time he gets there, his heart is pretty much destroyed, NYU has to do something heroic to save his life and he ends up on the list for a heart transplant. Now it’s all, ‘look what NYU has done.’ But if he came to us first, maybe he wouldn’t have needed the pump or the heart transplant. The perception among many people is that Manhattan is better, even though the data does not support them. It’s an uphill battle to get the word out.”

Healthcare experts praised not only Maimonides’ cardiac center, but also its broader policy decisions—over the last few years, the hospital has focused on partnering with community groups and sharing medical records with other healthcare facilities, taking big strides in improving long-term patient outcomes and moving in the direction that the Affordable Care Act and Medicaid waiver money will soon mandate all hospitals go.

Still, Maimonides is an independent hospital in an era of behemoths—and even a very good hospital, even in the company of several decent ones, does not a healthcare system for 2.5 million people make.

And yet, as intransigent as Brooklyn’s hospital dilemma may seem, change is imminent, though whether or not it will be beneficial remains to be seen. With funding changes tied to the Affordable Care Act and the federal Medicaid waiver, the borough’s hospitals will not be able to hold their decades-long pattern of slow deterioration, muddling along with shrinking budgets and decaying physical plants.

Maimonides recently opened a $5 million hybrid OR. (Arman Dzidzovic/The Observer)

Maimonides recently opened a $5 million hybrid OR. (Arman Dzidzovic/The Observer)

The federal government has made it explicitly clear that the Medicaid waiver, which will infuse $8 billion into New York’s struggling healthcare system over the next five years, cannot be used to prop up operations at failing hospitals. In order to receive the funding, hospitals will need to meet strict predetermined metrics aimed at reducing inpatient care and readmissions while forcing them to collaborate on the creation of clinical networks.

Kenneth Raske, head of the Greater New York Hospital Association, a trade group, called the waiver money “the single most important thing that had happened to communities in need for a long time.”

If used correctly, federal waiver dollars will allow hospitals to make the difficult transition from inpatient-centric systems to outpatient-centric ones; since September of last year, 10 new outpatient centers have opened in the borough, according to the Department of Health. But success is by no means guaranteed, or even likely for all hospitals, and for those that are already ailing, failure to embrace the reforms will mean almost certain collapse.

“It’s hard to shift all of a sudden to outpatient after being in a business that rewarded inpatient for so many years,” said an administrator. Nor is it clear, precisely, what demands will be placed on providers with the expansion of health insurance to populations that never had it before.

“We often assume that primary care will reduce the need for inpatient care, but that isn’t true at all. Sometimes primary care uncovers the need for inpatient care,” said professor Sager. “With all the hospitals that have closed in Brooklyn and Queens in the last 25 years, no other hospital should close without proof that it’s safe. In medicine we often say, first, do no harm, and if you’re going to subtract services you want to make sure they aren’t needed.”

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Brooklyn’s healthcare crisis may seem, in many ways, to be yet another tale of the two Brooklyns, in which residents of the rarified swath hugging Manhattan enjoy a lifestyle that is the envy of the world, while the rest of the borough struggles to maintain access to basic goods and services.

Though isn’t it a patient’s prerogative to seek the best care he or she can get? From a broader public health perspective, it might be ridiculous to have a person who needs stitches journeying across the city to hospitals that specialize in brain surgery or pediatric cancer, but then who wants to get stitches at a subpar hospital if he or she can help it?

“The quality of hospitals is such a big spectrum,” one top doctor told The Observer. “I live by a hospital now that I’d never go to; I’d never take my family there. Other people like having it there, it gives them a sense of comfort, but if they knew the reality, I don’t think they’d want to have any procedure done there. I would rather be in a place that doesn’t have a hospital than one that has a bad hospital.”

The problem with that premise is it assumes one will be conscious and capable of advocating for the best care, or at least in the company of someone who meets that description, which is not always the case in life-or-death scenarios. And even when it is, how many of us are really qualified to make the call between close but mediocre care and distant, top-of-the-line help?

Emergencies are, by nature, resistant to negotiation, nor is any community, even the most affluent, immune to the kind of emergencies where minutes make all the difference: traffic accidents, heart attacks, strokes, serious falls. It’s just as much a fantasy to assume that we will be able to dictate the terms of our emergency care as it is to assume we’ll never need it.

“In trauma situations, the faster you can get to a hospital, the better,” said Sam Mansour, the program director at Methodist’s EMS Institute. “At the scene, the paramedics are limited to 10 minutes to stabilize a patient. There’s the golden hour—a patient has to be in the operating room within an hour of the injury—after that the chances of recovery and survival go way down.” (Incidentally, most free-standing ERs, like the one that just opened at the former St. Vincent’s site, need to transport patients to full-service hospitals for surgery.)

An EMT must take patients to the hospital of their choice, provided it can treat them, but Mr. Mansour said that he would never recommend traveling from Brooklyn to Manhattan in an emergency.

“You jeopardize their safety when you go to Manhattan,” he said. 

Or as professor Sager put it, “If you have a heart attack at rush hour, you’re not getting across the bridge fast. Local hospitals are important even to the people who don’t plan to use them because, who knows, the hospital you save may be your own.”