The bearded young man suffering a psychotic episode craned his neck to get a better view of his body before looking away in horror. “Something’s coming out of me,” he bellowed from the gurney where he lay in the emergency room at Wyckoff Heights Medical Center, an independent hospital in Brooklyn.
Nearby, a heavily muscled man in his 30s lay as still as a wax figure after Narcan had reversed his opioid overdose. Across the hallway, in the pediatric emergency room, a police officer was rocking a crying infant who had been left alone in a parked car.
Upstairs in the neonatal intensive care unit on the 11th floor, Diana Calderón, an Ecuadorean immigrant who crossed into the United States last year, would soon arrive for her daily visit to hold her two surviving triplets, born prematurely six weeks earlier. The third, Josiah, had lived just a day.
Some days her eyes fall on an empty incubator. That’s when Dr. Calixto Cazano, a neonatologist, murmurs a few words of solace in Spanish: “Luca, Zabdiel and Josiah were together in your womb.” His brothers would always feel Josiah’s presence, he tells her.
Wyckoff Hospital is considered low-performing by some metrics — including its damning one-star rating by the Centers for Medicare and Medicaid Services, which puts it in the bottom 7 percent of hospitals in the United States. But for many in a large swath of Brooklyn and Queens, it is the most convenient, or only, place to go for medical care, emergency or otherwise. Each year, some 110,000 New Yorkers — just over 1 percent of the city — are treated at Wyckoff or one of its clinics.
Wyckoff Hospital serves neighborhoods that are predominantly Black and Hispanic, and where there are few other choices for medical care.
Located in the predominantly Hispanic neighborhood of Bushwick, Wyckoff is one of about 10 independent hospitals across New York City that aren’t part of large health care systems and mainly care for poor patients. Many of them have been plagued by past mismanagement, labeled “failing hospitals” and long been considered for takeover or closure. Wyckoff is no different.
But now, the pandemic — and the racial health disparities it exposed and exacerbated — is fueling a reappraisal of these hospitals, even in Albany, where they were once seen as perennial money losers that the state had to prop up with huge payments each year.
In their neighborhoods, independent hospitals like Wyckoff are often the main providers of health care to many of the city’s most vulnerable residents. In this era of health care consolidation, there is broad consensus among state health officials that stand-alone community hospitals are outdated, especially in New York City. Yet they may well prove central to post-pandemic efforts to provide more preventive care and treatment for diabetes, hypertension and chronic diseases that drive racial health disparities. Outside of Wyckoff, doctors’ offices are scarce in Bushwick. The community around Wyckoff had about two primary care physicians per 10,000 residents in 2017. One stretch of Manhattan, running from the Lower East Side to Murray Hill, had more than 60 primary care doctors per 10,000 residents.
There is a growing recognition that if health disparities are going to be reduced, shoring up independent hospitals like Wyckoff may be central to that effort.
“No one else is trying in any visible manner,” said Wyckoff’s chief medical officer, Gustavo Del Toro, a lanky man in his 50s and the older brother of the actor Benicio Del Toro. He had worked at large hospital systems in Manhattan as a pediatric hematologist-oncologist before coming to Wyckoff to try to help turn it around.
The state has long supported independent hospitals in New York City that primarily serve lower-income patients, providing roughly $800 million a year in direct subsidies. Wyckoff receives more than $100 million — sometimes delivered at the last minute and grudgingly, hospital officials say. It has been enough to keep the hospital open, but often just barely.
This year, however, the administration of Gov. Kathy Hochul has budgeted about twice as much and has asked the federal government to give a boost to the Medicaid rates paid to hospitals that serve primarily low-income patients.
Vali Gache, the hospital’s chief financial officer, who regularly pleads the hospital’s case for more money in phone calls with state officials, has noticed a change in tone: “Two years ago nobody would listen to you. They would say, ‘You’re just one of these failing hospitals.’”
Nowhere else to go
At any given time, there are around 150 admitted patients at Wyckoff Hospital. who stay, on average, 4.6 days; another 40 or so occupy the emergency room. But amid this churn, one patient, in recent months, has been a constant: Rodolfo Parris.
Read More on the Coronavirus Pandemic
- Shifting Attitudes: Most offices, restaurants and schools are back to business as usual, but the coronavirus has not gone away.
- Long Covid: People who took the antiviral drug Paxlovid within a few days after being infected with the coronavirus were less likely to experience long Covid months later, a study found.
- Updated Boosters: New findings show that updated boosters by Pfizer and Moderna are better than their predecessors at increasing antibody levels against the most common version of the virus now circulating.
- Personality Changes: New research suggests that Covid’s disruption of social rituals and rites of passage have made people less extroverted, creative, agreeable and conscientious.
Back in March, Mr. Parris arrived by ambulance, unable to walk. A barber by trade, Mr. Parris, 53, was admitted with failing kidneys and festering leg ulcers.
His infections were treated, and his wounds began to heal. He should have been discharged a couple of weeks after he was admitted, but his apartment — a second-floor walk-up — was now inaccessible. Each stair was one too many.
Though he was a child when he emigrated to New York from Panama, he is without legal status in this country. That means that no skilled nursing home — where he might receive wound care and dialysis — has yet been willing to admit him. The government doesn’t typically reimburse nursing homes for care to undocumented immigrants.
So last summer, Mr. Parris spent his days in his hospital bed, reading the Bible, watching cop shows and telling visitors about better days, like when Christopher Wallace, the rapper known as Notorious B.I.G., used to come into his barbershop for a cut. Occasionally Mr. Parris would eye with fury the wheelchair that remained folded and untouched in the corner of the room. It was a gift from the hospital.
“They’re talking about discharging me and sending me out in a wheelchair,” he said recently. “I don’t got nobody to push me around.” Many hospitals have long-term boarders — patients like Mr. Parris, who have nowhere to go and are not easily discharged. They are a drag on the hospital’s bottom line, as insurance companies and Medicaid are reluctant to pay for visits that extend indefinitely. But Mr. Parris’s presence speaks to a role that these kinds of hospitals often play: housing a few patients whom no one else will take.
Big Manhattan hospitals also have these kinds of patients, but they offset the expense with a far greater number of profitable patients — those with commercial insurance or those needing cardiac or orthopedic surgery.
Wyckoff is not that kind of hospital.
Roughly speaking, New York City has three classes of hospitals.
There are the big academic medical centers, like NewYork-Presbyterian, Mount Sinai and NYU Langone, where the treatment you receive can depend on the insurance you have. They tend to be based in Manhattan.
There is also New York’s robust network of 11 public hospitals, jointly run by the city and state. They include Bellevue, where patients tend to be working class or poor, and no one is turned away.
Then there is a third category of hospitals, located in poor neighborhoods, which are often called “independent safety-net” hospitals. Some started as charity wards; St. Barnabas Hospital in the Bronx was founded in 1866 as “The Home for Incurables.” Others were built by booming ethnic communities like the Germans who in the 19th century transformed Bushwick into the brewery capital of the northeast. Wyckoff, once known as the German Hospital of Brooklyn, rebranded as Wyckoff Heights Hospital during World War I to deflect anti-German sentiment.
A century later, this hospital — a tiny player among the behemoth health care systems across the city — had one of the city’s first critically ill Covid-19 patients in March 2020: an 82-year-old immigrant from the Philippines.
The virus was still so new that Dr. Parvez Mir, an energetic, upbeat 67-year-old who runs the intensive care unit, went into the patient’s room to swab her nose enough times to collect samples to share with larger hospitals to help validate their laboratory tests.
The patient died on March 13, New York City’s first known Covid death. As the days passed, the hospital transformed into a labyrinth of plastic sheeting, as one makeshift Covid unit after another opened. Nearly 300 patients died at Wyckoff in that first wave.
The very communities that needed the most hospital beds had the fewest — the result of hospital closures. For decades, the state assumed that there were too many outer-borough hospitals and that the future lay in preventive medicine and outpatient procedures. For complex surgeries, it was thought, patients could go to Manhattan. In New York, the community hospital was deemed outdated. At the start of the pandemic, there were on average two hospital beds for every 1,000 residents of Brooklyn and Queens, compared with Manhattan’s five.
Those beds filled quickly as Covid patients streamed into emergency rooms. There weren’t enough nurses to look after them all, nor enough medicine to keep all the patients on ventilators — about 70 in Wyckoff at one point — adequately sedated, Dr. Mir said. When the medicine wore off, some patients emerged from their coma-like state and reflexively grabbed at the breathing tube down their throats.
“No one was looking at them, and they would self-extubate” — that is, pull out the tube — “and die,” said Dr. Mir, who at the height of the first wave lost 24 Covid patients in a single day.
The math doesn’t make sense
For much of the 20th century, hospitals like Wyckoff dotted the city. But more than 15 have closed since the turn of the century. Many of them were converted into condos. The same economic forces have kept Wyckoff on the perpetual brink of closure. On top of those pressures, though, were problems of Wyckoff’s own making.
For years, it had a well-deserved reputation for cronyism, subpar care and wasteful spending. (It once paid to insure the $160,000 Bentley of a hospital official.) The hospital took out a loan at 12 percent interest from a board member. According to news accounts, it paid bribes to a corrupt state assemblyman. And doctors remember other instances of petty corruption, such as requests for favors when they asked for admitting privileges.
In 2011, there was a change in leadership, and Ramón Rodriguez, a onetime lawyer for the indigent who had become state parole commissioner and was then leading a commission examining several troubled hospitals in Brooklyn, was installed as the chief executive of Wyckoff. “I saw criminality all over,” he said.
He fired 30 people. Some had no-show jobs, he said, and others were billing the hospital for malpractice insurance for their private practices.
Mr. Rodriguez coaxed doctors from big Manhattan hospitals who were attracted to the idea that there was more need for their skills in a poor neighborhood with few doctors, and he expanded the hospital’s community clinics. The dread that Wyckoff might close its doors at any moment started to fade. Still, Wyckoff is anticipating a shortfall of about $135 million this fiscal year. Even in this era of expanded insurance coverage, a hospital that primarily serves the poor is unlikely to make money.
At Wyckoff, just 14 percent of patients have private medical insurance, like employment-based coverage. At some Manhattan hospitals, about half the patients do. Private insurance companies typically pay hospitals much more than government-sponsored Medicare and Medicaid.
But the disparities run deeper. Because of its small size and low ranking, Wyckoff can’t charge private insurers anywhere near what the Manhattan giants do. Those hospitals are able to negotiate ever-increasing payments from insurance companies that need to keep the big hospitals in their network — or risk losing customers to other insurance plans. Wyckoff has no such leverage.
If a patient with employment-based health insurance came to Wyckoff severely ill with a respiratory infection, for instance, Wyckoff would receive on average 52 percent of what a Manhattan hospital would be paid, according to Manatt Health, a consulting firm that Wyckoff and several other safety-net hospitals hired.
Another analysis, by the union 32BJ, which represents cleaners, doormen and other service workers, found that the union’s health fund pays only $6,433 for a vaginal birth at Wyckoff but $11,101 at the city’s public hospital system, and more than $20,000 at major hospital systems including Mount Sinai, NYU Langone and Northwell.
A colonoscopy costs the union’s health fund $2,145 at Wyckoff; at most Manhattan hospitals it will pay two or three times as much.
At Wyckoff, slightly more than half the patients are covered by Medicaid, the government-funded insurance program for people with low incomes. Less than a third of hospital patients at some large systems, like NewYork-Presbyterian, have Medicaid. At the main Manhattan campus of NYU Langone, only about 18 percent of hospitalized patients had Medicaid, according to 2018 data.
Medicaid reimburses hospitals at far lower rates than other types of insurance, and the gap grows only wider each year. Wyckoff may receive just one-sixth as much treating a Medicaid patient as a top-ranked Manhattan hospital receives for treating an equally sick patient with private health insurance, according to Manatt.
As Mr. Rodriguez often repeats, the hospital loses money on most patients. “There are very few people who pay us more than our expenses for that visit,” he said. The lesson is clear: It’s impossible to run a safety-net hospital that doesn’t bleed money, he said. “The math doesn’t make sense.”
That math hasn’t made sense for some time. Since 2008, as bigger hospitals raised prices and medical inflation ticked up, the Medicaid reimbursement rates in New York State have gone up just 1 percent.
The disparity over the past three decades between Medicaid rates and what private insurance pays should be regarded as a form of redlining, Mr. Rodriguez said. The result, he said, is a racist, discriminatory practice that has left large areas of the city with few doctors and far less access to quality health care.
“There is a two-class system of health care, and it’s wrong,” Mr. Rodriguez said. “It’s pure disinvestment.”
‘Dr. Guberman saved my foot’
On a recent Friday afternoon, the patient bays in Wyckoff’s emergency room were all full. Another 10 or so patients lay on gurneys lined up, head to toe, like planes waiting for takeoff. In the last one sat a man with a vulture tattoo on his bald head and a jagged cut on his leg, which he had snagged on a rusty dumpster.
A young woman in abdominal pain groaned loudly as she dug the heel of her palm into her stomach.
Nearby Albert Feliciano smiled from his gurney. A resident examined his right foot, which was swollen, oozing and missing two toes.
When he had gone to another hospital, the doctor there had proposed amputation. So he called Wyckoff.
“Dr. Guberman saved my foot,” Mr. Feliciano said, gazing at it happily. “I love it here.”
In Bushwick, close to 13 percent of adults are diagnosed with diabetes, compared with 3 percent of adults in some of Manhattan’s wealthier neighborhoods. And in Bushwick, those with diabetes are far less likely to have the disease under control.
For many, the first step to doing so is a visit to Wyckoff’s diabetes clinic, close to the main hospital. One summer morning, Dr. Stella Ilyayeva dispensed advice at a fast clip as she saw six patients in one 40-minute stretch. “We drink only water,” she admonished as she left an exam room, finishing the thought across the hallway in the next patient’s room. “Nobody drinks juices.”
She chided patients for not refilling their diabetes medications. “Why’d you stop taking it, bad girl?” she said to a 59-year-old woman who looked away sheepishly. “Do you want dialysis? Amputation? Don’t curse my name later,” said Dr. Stella, as she is known in Bushwick.
The patient promised to take her medicine, but Dr. Stella was unconvinced, telling her to come back for another appointment within a month.
Mr. Rodriguez has a few ideas for the hospital’s future. His most ambitious plan is to sell the current site, in a rapidly gentrifying patch of Brooklyn, to developers and use the proceeds to build a smaller, modern high-rise hospital across the street on a parking lot.
If that doesn’t work, Mr. Rodriguez is hoping that a richer hospital system will absorb Wyckoff. For years, New York’s Health Department has been trying to push Wyckoff into an arranged marriage with Northwell Health, the state’s largest hospital system. Mr. Rodriguez hopes that if he can first persuade the state to invest more in Wyckoff — and in safety-net hospitals generally — Northwell might agree to not only absorb Wyckoff but also keep it open to the working class and poor.
But he and his colleagues are also wary. A large hospital system that absorbs Wyckoff will try to stem losses. One way to do that, Mr. Rodriguez said, is “by finding a way to see fewer Medicaid patients.”
Dr. Del Toro worries another institution would close down much of the hospital, until it was little more than an emergency room that sent patients onward to other institutions. “They’re not going to come here to provide,” he said. “They’re going to come here to extract, to suck away.”
In an interview, Michael Dowling, the chief executive of Northwell, noted that the gentrification and new development sweeping across Bushwick actually bodes well for the hospital.
“Wyckoff is going through some difficult times, but I do think Wyckoff has a future,” he said. Still, with Medicaid reimbursement rates so low, taking on a safety-net hospital could be a huge money loser for a larger, stable hospital system. “I’m not going to make a commitment at this point,” he said.
Nonetheless, Mr. Rodriguez has brought a new urgency to Wyckoff. In the past two years, the hospital received state approval to begin placing coronary stents, which means Wyckoff no longer sends every heart attack patient on a lengthy ambulance ride to Manhattan.
Wyckoff officials also talk of opening primary care doctors’ offices around the neighborhood and opening a large center devoted to diabetes care. Mr. Rodriguez hopes the hospital might one day expand its care capacity for stroke patients or receive a “trauma center” designation, which would allow it to treat gunshot victims. There is talk of renovating the maternity ward, adding showers to each room so new mothers needn’t line up, towels under their arms, to wait their turn at the shared stall.
For now, however, Wyckoff remains unable to pay all of its bills: It is currently tens of millions of dollars behind in bond payments.
“My biggest frustration is that no matter what we do, we remain a one-star institution,” said Dr. Del Toro.
“Knowing the people that work here, knowing what we do, it makes me feel like crying,” he added, as he teared up. “We haven’t been able to pull it off.”
Mr. Parris also has a feeling of dread about the future. More than 180 days after he was admitted with kidney failure, he was still living at the hospital, confined to a bed and engaged in a standoff with Wyckoff. One of these days, he knew, the hospital would force him to leave, and he was terrified.
When that happens, he fears he will become homeless.
As he grew more depressed this fall, Mr. Parris refused to talk to some of the hospital social workers about what lay ahead. And he had stopped participating in physical therapy. By then a fine layer of dust had begun to settle on the wheelchair in the corner.