Some Hospitals Call 911 to Save Their
By REED ABELSON
Published: April 2, 2007
Should a hospital be able to handle a medical
The answer may seem self-evident. But patients at
some hospitals may find the staff resorting to what
someone might do at home in a crisis: call 911 for
That happened recently in Texas, where a 44-year-old
man named Steve Spivey developed breathing problems
after spine surgery. No physician was working there
when the staff first recognized he was in trouble.
They phoned 911, and he was taken to a nearby
full-service hospital, where he was pronounced dead
a short time later.
The episode occurred at a small hospital that is
owned and run by doctors — one of roughly 140 such
hospitals around the country, with nearly two dozen
more under development, that are set up to
specialize in certain types of procedures like heart
surgery, back operations and hip replacements.
These hospitals have been assailed for
cherry-picking the most profitable procedures from
the nation’s 4,500 or so full-service hospitals.
Critics have argued that the doctors have a
financial incentive in sending patients to their own
facilities, even when those patients might be better
off having their surgery in regular hospitals.
But the Texas case, and others like it, have invited
new scrutiny from regulators and members of Congress
about these hospitals’ ability to care for patients
who suffer complications after their operations.
While some of these hospitals are large
sophisticated operations, like those hospitals
specializing in cardiac care, others are much more
modest. For example, small surgical hospitals may
not have separate emergency facilities or, as in the
Texas case, a doctor on site at all times during a
A similar case involved an 88-year-old woman two
years ago at a small doctor-owned hospital in
Portland, Ore., where the nurses called 911 after
she was given too much pain medicine following spine
surgery. She, too, later died.
As the number of doctor-owned surgical hospitals
grows, federal and state officials now acknowledge
that the government rules may be too vague about the
emergency abilities a hospital must have in place.
Regulators are particularly concerned about the very
small hospitals that focus on only a few kinds of
surgery but perform operations that frequently
require an overnight stay. While Medicare’s rules
currently say a hospital must “meet the emergency
needs of patients in accordance with acceptable
standards of practice,” the details are left largely
to the hospital’s discretion. Federal and state
officials say they are now reviewing the guidelines
to toughen the rules and make them more specific.
“We’re concerned about good quality of care in any
or all settings,” said Thomas E. Hamilton, who
oversees hospital certification for the federal
Centers for Medicare and Medicaid Services.
Medicare recently terminated its agreement with the
facility involved in the Texas case, West Texas
Hospital, a 14-bed hospital in Abilene that
performed procedures ranging from plastic surgery to
complex spine operations.
That is where Mr. Spivey had spine surgery.
Sometime during the night following his surgery, the
staff grew alarmed by his breathing difficulties and
called the surgeon back to the hospital.
Ill-equipped to handle a medical emergency, the West
Texas staff phoned 911, said Darrell Keith, the
lawyer who is representing Mr. Spivey’s family and
is still investigating what happened.
When the paramedics arrived, they inserted a
breathing tube before taking him to a nearby
full-service hospital where he was pronounced dead a
short time later.
“It is horrific that Steve Spivey had to sacrifice
his life in order to expose the problems associated
with physician-owned hospitals,” Mr. Keith said.
West Texas, citing patient privacy, said it could
not comment, although it defended the quality of its
After a review of the hospital following Mr.
Spivey’s death, federal officials decided last month
that the hospital could no longer continue treating
patients covered under the government’s Medicare
program. Although the chief executive of West Texas
Hospital defended its practices, he said it would
not appeal the government’s decision. The hospital
has since closed.
The doctors who set up the specialized hospitals
defend them by saying that by running the centers
themselves and concentrating only on certain
procedures, they can provide the best results for
“This is really about the physicians getting back in
control,” said Greg Weiss, chairman of USMD
Hospital, a small physician-owned hospital in
Arlington, Tex. USMD, which has 18 beds, has an
emergency department and a doctor present around the
clock, and is also building an intensive-care unit,
Mr. Weiss said.
Proponents of the specialty hospitals say the
Abilene and Portland cases are aberrations that
critics are exploiting to defend the turf of
full-service hospitals. They say they are able to
handle their patients’ medical emergencies, whether
or not they have emergency departments.
But some members of Congress are now pushing
Medicare to take a closer look at how such hospitals
“The problem with physician-owned specialty
hospitals is that decision-making is more likely to
be driven by financial interest rather than patient
interest,” said Senator Charles E. Grassley,
Republican of Iowa, who is a longtime critic of such
“You see it in the cherry-picking of patients, and
with policies that instruct hospital staff to call
911 for the local community hospital if emergency
care is needed,” said Mr. Grassley, a ranking member
of the Senate Committee on Finance, which oversees
Supporting his effort is the committee’s chairman,
Senator Max Baucus, Democrat of Montana, and
Representative Pete Stark, Democrat of California,
who leads the subcommittee on health for the House
Committee on Ways and Means.
Congress in 2003 temporarily banned new construction
of specialty hospitals over concern that they were
draining profit away from the full-service
hospitals. The moratorium ended in 2005. Congress
has asked for various reports on the issue,
including a comprehensive analysis last year by the
federal Department of Health and Human Services. The
number of these hospitals, around 100 at the time of
the moratorium, have steadily climbed to nearly 140
today, with more than two dozen under construction.
Mr. Hamilton, the Medicare official, says the agency
is now reviewing whether its rules need to spell out
exactly what emergency procedures a hospital is
required to have in place, and whether hospitals
must disclose any limitations to patients. Some
types of hospitals may merit greater attention and
oversight than others, depending on the nature of
the operations they perform, he said, and “size may
be a factor.”
Because some of the hospitals are so small, they may
not have the systems in place to handle an
“It almost assumes no one is going to get sick,”
said Dr. Mark V. Williams, a professor of medicine
at Emory University. Without a doctor on premises, a
nurse must call a physician for help if there is an
emergency, he said, but there is evidence that
nurses are often reluctant to do that.
According to Medicare’s review of state records,
West Texas Hospital had called 911 for an ambulance
15 times to transfer patients during medical
emergencies since it opened in May 2005.
The hospital says that some of those calls may have
involved routine transfers of patients to other
Some proponents of doctor-owned hospitals defend
calling 911. It is “by no means an uncommon
practice,” said Molly Gutierrez, executive director
of Physician Hospitals of America, which represents
many doctor-owned hospitals.
Although stabilizing a patient is essential for any
hospital, she said, hospitals of all kinds and sizes
frequently rely on emergency services to transport
patients to other medical centers.
But among full-service hospitals, such routine
transfers are carefully coordinated, according to
Carmela Coyle, senior vice president for policy with
the American Hospital Association, which represents
full-service medical centers.
“The difference is, a community hospital plans for
the unpredictable,” she said. Medicare does require
all hospitals to meet certain general standards,
relying on the states or an independent national
accrediting body called the Joint Commission to make
sure hospitals meet the requirements.
Beyond any changes Medicare might make, some states
are also contemplating new rules. Texas, for
example, is considering requiring any hospital in a
county with 100,000 or more residents to have a
doctor on the premises around the clock and to have
certain emergency medical equipment on hand. Indiana
and Kansas are also contemplating similar changes.