RICHMOND, Va. — In late July, Norman Otey was rushed by ambulance to Richmond Neighborhood Hospital. The 63-year-old was doubled over in ache and babbling incoherently. Blood assessments steered septic shock, a grave emergency that required the assets and experience of an intensive care unit.

However Richmond Neighborhood, a struggling hospital in a predominantly Black neighborhood, had closed its I.C.U. in 2017.

It took a number of hours for Mr. Otey to be transported to a different hospital, in keeping with his sister, Linda Jones-Smith. He deteriorated on the way in which there, and later died of sepsis. Two individuals who cared for Mr. Otey stated the delay had more than likely contributed to his loss of life.

“He ought to have been capable of go to the hospital and get the therapy he wanted,” Ms. Jones-Smith stated. “He ought to have been saved.”

Ringed by public housing initiatives, Richmond Neighborhood consists of little greater than a strapped emergency room and a psychiatric ward. It doesn’t have kidney or lung specialists, or a maternity ward. Its magnetic resonance imaging machine incessantly breaks, and was out of service for seven weeks this summer season, stated two medical staff on the hospital, who requested anonymity as a result of they nonetheless work there. Normal instruments like an otoscope, a tool used to examine the ear canal, are sometimes laborious to return by.

But the hollowed-out hospital — owned by Bon Secours Mercy Well being, one of many largest nonprofit well being care chains within the nation — has the best revenue margins of any hospital in Virginia, producing as a lot as $100 million a 12 months, in keeping with the hospital’s monetary information.

The key to its success lies with a federal program that enables clinics in impoverished neighborhoods to purchase prescribed drugs at steep reductions, cost insurers full value and pocket the distinction. The overwhelming majority of Richmond Neighborhood’s income come from this system, stated two former executives who had been conversant in the hospital’s funds and requested anonymity as a result of they nonetheless work within the well being care business.

The drug program was created with the intention that hospitals would reinvest the windfalls into their amenities, bettering take care of poor sufferers. However Bon Secours, based by Roman Catholic nuns greater than a century in the past, has been slashing companies at Richmond Neighborhood whereas investing within the metropolis’s wealthier, white neighborhoods, in keeping with greater than 20 former executives, medical doctors and nurses.

“Bon Secours was principally laundering cash by this poor hospital to its rich outposts,” stated Dr. Lucas English, who labored in Richmond Neighborhood’s emergency division till 2018. “It was all about income.”

Greater than half of all hospitals in america are arrange as nonprofits, a designation that enables them to make cash however keep away from paying taxes. Though Bon Secours has taken a monetary hit this 12 months like many different hospital techniques, the chain made practically $1 billion in revenue final 12 months at its 50 hospitals in america and Eire and was sitting on greater than $9 billion in money reserves. It avoids at the very least $440 million in federal, state and native taxes yearly that it could in any other case should pay, in keeping with an evaluation by the Lown Institute, a nonpartisan assume tank.

In alternate for the tax breaks, the Inside Income Service requires nonprofit hospitals to supply a profit to their communities. However an investigation by The New York Occasions discovered that lots of the nation’s largest nonprofit hospital techniques have drifted removed from their charitable roots. The hospitals function like for-profit firms, fixating on income targets and expansions into prosperous suburbs.

Many of those hospitals have for years slashed staffing ranges, leaving them unprepared for a flood of severely ailing Covid-19 sufferers. Others, borrowing tips from enterprise consultants, have educated workers to squeeze funds from poor sufferers who needs to be eligible without spending a dime care.

In a press release, a spokeswoman for Bon Secours Mercy Well being stated the hospital system had spent practically $10 million on enhancements to Richmond Neighborhood Hospital since 2013, together with opening a pharmacy and renovating the cafeteria, emergency division and different areas. The chain additionally invested practically $9 million since 2018 within the neighborhood surrounding the hospital, she stated.

Bon Secours’s chief govt, John M. Starcher Jr., made about $6 million in 2020, in keeping with the newest tax filings.

“Our mission is obvious — to increase the compassionate ministry of Jesus by bettering the well being and well-being of our communities and produce good assist to these in want, particularly people who find themselves poor, dying and underserved,” the spokeswoman, Maureen Richmond, stated. Bon Secours didn’t touch upon Mr. Otey’s case.

In interviews, medical doctors, nurses and former executives stated the hospital had been given quick shrift, and pointed to a decade-old improvement take care of the town of Richmond as one other instance.

In 2012, the town agreed to lease land to Bon Secours at far beneath market worth on the situation that the chain broaden Richmond Neighborhood’s amenities. As a substitute, Bon Secours targeted on constructing a luxurious house and workplace complicated. The hospital system waited a decade to construct the promised medical workplaces subsequent to Richmond Neighborhood, breaking floor solely this 12 months.

‘Glorified Emergency Room’

For Dr. Richard Jackson, 69, an inner drugs specialist whose household has been caring for sufferers on this metropolis for greater than a century, strolling the principally empty halls of Richmond Neighborhood Hospital is a painful reminder of what has been misplaced.

The hospital was based in 1907 by Black medical doctors who weren’t allowed to work on the white hospitals throughout city. Within the Nineteen Thirties, Dr. Jackson’s grandfather, Dr. Isaiah Jackson, mortgaged his home to assist pay for an growth of the hospital. His father, additionally a physician, would take his kids to the hospital’s fund-raising telethons.

In 1980, Richmond Neighborhood moved to its present web site within the East Finish neighborhood, the place there was no different hospital. The modest constructing didn’t have an emergency room or a maternity ward. However along with the intensive care unit, it had specialists in most cancers in addition to coronary heart and lung illness. Dr. Jackson recruited lots of them from Howard College, the place he had attended medical college.

However within the Nineties, the altering well being care business threatened the hospital’s survival. Massive insurance coverage firms started requiring prospects to make use of particular networks of hospitals and medical doctors, in a bid to stress suppliers to decrease their charges. Unbiased establishments like Neighborhood — as it’s recognized within the neighborhood — couldn’t compete with bigger chains, and the hospital struggled to draw sufferers.

The medical doctors, who owned the hospital as a part of a for-profit partnership, offered it to Bon Secours in 1995.

Bon Secours was one of many dominant gamers in Richmond, with main medical facilities all through the town. It initially invested within the hospital, opening the emergency division, in keeping with a historical past of Richmond Neighborhood by Cassandra Newby-Alexander at Norfolk State College.

However because the years handed, Bon Secours started stripping the hospital’s companies, together with the I.C.U. The unit had solely 5 beds, however medical doctors regarded it as the guts of the hospital, the place to supply essential take care of the sickest sufferers and people recovering from main surgical procedure.

Eradicating the I.C.U. “actually takes the meat and potatoes out of being a hospital,” Dr. Jackson stated. “It’s a glorified emergency room.”

With the I.C.U. closed, the hospital’s two lung specialists had nowhere to deal with critically ailing sufferers. They retired, and Bon Secours didn’t exchange them. A crew of cardiologists left just a few years later. Different specialists, together with gastrointestinal medical doctors and neurologists who had been a part of Bon Secours’s broader community, not often handled sufferers at Richmond Neighborhood.

Medical doctors and nurses stated that once they had protested the closure of the I.C.U. and different cuts, Bon Secours argued that sufferers may nonetheless obtain care on the chain’s different hospitals.

However that promise was undermined by the arrival of the coronavirus, which disproportionately affected Black and low-income residents within the East Finish. Within the census tract that features Richmond Neighborhood Hospital, the Covid loss of life fee has been 81 % increased than the town’s general fee, in keeping with information offered by the Virginia Division of Well being.

In the summertime of 2021, because the Delta variant surged by the town, a girl within the emergency room with Covid declined and wanted an I.C.U. with a ventilator, in keeping with three folks concerned in her case.

For hours, the workers couldn’t get her to a different hospital. Finally, she was transferred to Memorial Regional Medical Heart, additionally owned by Bon Secours, however died after arriving. Her loss of life left some who had cared for her at Neighborhood questioning if she would have survived had she proven up at a distinct hospital.

Bon Secours declined to touch upon whether or not the hospital’s lack of an I.C.U. contributed to the Covid loss of life toll.

The pandemic exacerbated an issue that medical doctors and nurses stated they’d lengthy confronted — getting sufferers entry to different hospitals within the Bon Secours system.

The East Finish is dwelling to Richmond’s largest Black inhabitants and, regardless of current curiosity from actual property traders, lacks some primary companies. In 2019, it bought its first grocery store.

In a number of the neighborhoods surrounding the hospital, greater than half the households should not have a automotive, in keeping with analysis executed by Virginia Commonwealth College. The general public bus path to St. Mary’s, a big Bon Secours facility within the northwest a part of the town, takes greater than an hour. There is no such thing as a public transportation from the East Finish to Memorial Regional, 9 miles away.

“It turned unattainable for me to ship folks to the superior coronary heart valve clinic at St. Mary’s,” stated Dr. Michael Kelly, a heart specialist who labored at Richmond Neighborhood till Bon Secours scaled again the specialty service in 2019. He stated he had pushed some sufferers to the clinic in his personal automotive.

Richmond Neighborhood has the texture of an urgent-care clinic, with a small ready room and a tan brick facade. The distinction with Bon Secours’s close by hospitals is hanging.

On the chain’s St. Francis Medical Heart, an Italianate-style compound in a suburb 18 miles from Neighborhood, golf carts shuttle sufferers from the foyer entrance, previous a marble fountain, to their automobiles.

In December, Bon Secours kicked off a $108 million development mission at St. Francis to broaden its I.C.U. and maternity ward. Not lengthy earlier than that, Bon Secours broke floor on a free-standing emergency room that might be an extension of St. Francis in suburban Chesterfield County. The information launch boasted that it could supply CT, M.R.I. and ultrasound imaging.

Dr. Samuel Hunter, 81, who labored for greater than 4 many years as a pathologist at Richmond Neighborhood till he left in Might, stated the disparity reminded him of his childhood in segregated Florida, the place Black kids like him realized from textbooks that white college students had already used.

“I do know what it feels wish to have secondhand issues,” he stated.

A Profitable Drug Program

When Bon Secours purchased Richmond Neighborhood, the hospital served predominantly poor sufferers who had been both uninsured or lined by Medicaid, which reimburses hospitals at decrease charges than personal insurance coverage does. However Bon Secours turned the hospital’s poverty into an asset.

The group seized on a federal program created within the Nineties to present a monetary increase to nonprofit hospitals and clinics that serve low-income communities. This system, known as 340B after the part of the federal legislation that approved it, permits hospitals to purchase medicine from producers at a reduction — roughly half the common gross sales value. The hospitals are then allowed to cost sufferers’ insurers a a lot increased value for a similar medicine.

The idea behind the legislation was that nonprofit hospitals would make investments the financial savings of their communities. However the 340B program got here with few guidelines. Hospitals didn’t should disclose how a lot cash they constituted of gross sales of the discounted medicine. And so they weren’t required to make use of the revenues to assist the underserved sufferers who certified them for this system within the first place.

In 2019, greater than 2,500 nonprofit and government-owned hospitals participated in this system, or greater than half of all hospitals within the nation, in keeping with the unbiased Medicare Cost Advisory Fee.

Beginning within the mid-2000s, huge hospital chains discovered how one can supercharge this system. The fundamental concept: Construct clinics in wealthier neighborhoods, the place sufferers with beneficiant personal insurance coverage may obtain costly medicine, however on paper make the clinics extensions of poor hospitals to make the most of 340B.

Since 2013, Bon Secours has opened 9 such satellite tv for pc clinics in wealthier elements of the Richmond space, in keeping with federal data. Although the outposts are miles from Richmond Neighborhood, they’re legally structured as subsidiaries of the hospital, which entitles them to purchase medicine on the discounted fee.

The Bon Secours Most cancers Institute at St. Mary’s, for instance, administers most cancers medicine to sufferers in an workplace suite on the tree-lined campus of St. Mary’s Hospital.

Because of 340B, Richmond Neighborhood Hospital should buy a vial of Keytruda, a most cancers drug, on the discounted value of $3,444, in keeping with an estimate by Sara Tabatabai, a former researcher at Memorial Sloan Kettering Most cancers Heart.

However the hospital expenses the personal insurer Blue Cross Blue Defend greater than seven instances that value — $25,425, in keeping with a value record that hospitals are required to publish. That’s practically $22,000 revenue on a single vial. Adults want two vials per therapy course.

The best way hospitals use the 340B program is “nakedly capitalizing on applications which can be supposed to assist poor folks,” stated Dr. Peter B. Bach, a biotechnology govt and researcher whose work has proven that hospitals collaborating within the 340B program have more and more opened clinics in wealthier areas because the mid-2000s.

Bon Secours didn’t disclose how a lot cash it earned by this system, however stated the funds “assist us tackle well being disparities whereas offering group assist and outreach.” It stated it had offered practically $18 million in free care to poor sufferers at Richmond Neighborhood Hospital since 2018. In 2020, the hospital offered $3.8 million in free care to low-income sufferers, or about 2.6 % of its whole bills, barely above the nationwide common.

The federal company that oversees the 340B program, the Well being Sources and Providers Administration, stated that hospitals and clinics had been repeatedly audited, and that the Biden administration had proposed requiring them to report how they spent income generated by this system. Such a change would require congressional approval.

In 2020, the newest 12 months for which information is on the market, Richmond Neighborhood Hospital — together with its satellite tv for pc workplaces — had a revenue margin of practically 44 %, the best within the state, in keeping with an evaluation by Virginia Well being Info, a nonprofit group that collects monetary information from hospitals.

That 12 months, the hospital introduced in additional than $110 million in income, after bills and losses had been deducted, in keeping with Virginia Well being Info. In line with two former Bon Secours executives conversant in the hospital’s monetary operations, the overwhelming majority of Richmond Neighborhood’s revenue since 2013 has come from the 340B program.

Bon Secours’s different hospitals haven’t executed as properly. St. Mary’s, thought-about probably the most prestigious Bon Secours facility in Richmond, introduced in $83 million in 2020.

‘Unabashedly Revenue-Oriented’

On a sunny October day in Richmond in 2012, two cheerleaders for Washington’s Nationwide Soccer League crew smiled for cameras as they gripped a big signal between them.

“Bon Secours Coaching Heart,” learn the signal, which mixed the Bon Secours fleur-de-lis emblem with a bust of a Native American, the soccer crew’s emblem on the time.

The crew, Bon Secours and the State of Virginia had been unveiling a significant financial deal that might carry $40 million to Richmond, add 200 jobs and preserve the Washington crew — now often called the Commanders — within the state for summer season coaching.

The deal had three important elements. Bon Secours would get naming rights and assist the crew construct a coaching camp and medical workplaces on loads subsequent to Richmond’s science museum.

Town would lease Bon Secours a main piece of actual property that the chain had lengthy coveted for $5,000 a 12 months. The parcel was on the town’s west facet, subsequent to St. Mary’s, the place Bon Secours needed to construct medical workplaces and a nursing college.

Lastly, the nonprofit’s executives promised metropolis leaders that they might construct a 25,000-square-foot medical workplace constructing subsequent to Richmond Neighborhood Hospital. Bon Secours additionally stated it could rent 75 native staff and construct a health middle.

“It’s going to be a fast timetable, however I believe we will accomplish it,” the mayor on the time, Dwight C. Jones, stated on the information convention.

As we speak, bodily remedy and medical doctors’ workplaces overlook the soccer discipline on the coaching middle.

On the west facet of Richmond, Bon Secours dropped its plans to construct a nursing college. As a substitute, it labored with an actual property developer to construct luxurious flats on the positioning, and delayed its plans to construct medical workplaces. Residents at The Crest at Westhampton Commons, a part of the $73 million mission, can swim in a saltwater pool and work out on communal Peloton bicycles. On the bottom flooring, an upscale Mexican restaurant serves cucumber jalapeño margaritas and a Drybar provides salon blowouts.

The land subsequent to Richmond Neighborhood Hospital, in contrast, remained inactive till February of this 12 months, when Bon Secours broke floor on the complicated.

Former executives on the chain stated a sequence of administration modifications in Bon Secours’s Richmond area, coupled with a change in mayoral administrations, had distracted consideration from the mission. And a merger with an Ohio hospital chain in 2018 accelerated the push for increased revenues, in keeping with former directors and medical doctors.

“There was a significant shift from being mission-oriented to being unashamedly, unabashedly profit-oriented,” stated Dr. Jones, the previous mayor who helped dealer the unique deal.

Bon Secours stated that since 2018, it had spent greater than $19 million supporting organizations and initiatives all through metropolitan Richmond, together with greater than $8 million on native companies and charities within the East Finish. The work close to Richmond Neighborhood Hospital is projected to be completed by the top of this 12 months. Hospital executives have stated they plan to accommodate psychological well being, hospice and different companies there.

Catastrophe Medication

For years, medical doctors and nurses at Richmond Neighborhood have usually felt as in the event that they had been engaged on a battlefield, doing their finest with severely restricted provides and amenities.

Kristen Schnurman, who started her profession as a doctor assistant at Bon Secours in 2014 and left in 2019, stated she had as soon as confided in a physician that she was not studying correct medical care.

“He stated to me — and this can all the time keep on with me — ‘You’re not studying drugs, you’re studying catastrophe drugs,’” she stated.

In the summertime of 2016, with temperatures hovering previous 90 levels, the hospital’s air-conditioning went out for a number of weeks, making it hotter inside than out on the road.

When requested concerning the air-conditioning and lack of primary provides at Richmond Neighborhood, Bon Secours declined to remark. Ms. Richmond, the Bon Secours spokeswoman, stated it could exchange the M.R.I. machine as a part of a $5.3 million capital enchancment plan.

Dr. Kelly, the heart specialist, stopped treating sufferers on the hospital in 2019. However there may be one man’s story that haunts him.

The person, who was in his 50s, arrived on the emergency room exhibiting indicators of a coronary heart assault. To forestall everlasting harm, the person wanted to be swiftly catheterized, a process that might insert a balloon into his blocked artery and drive it open.

Bon Secours didn’t have the instruments for the catheterization, so Dr. Kelly organized for the affected person to be transferred shortly to Memorial Regional.

However Memorial couldn’t assure a mattress can be prepared, Dr. Kelly stated. So the affected person waited for a number of hours within the Neighborhood emergency room. “All we may do was watch it occur,” Dr. Kelly recalled.

The affected person survived, he stated, however the delay broken his coronary heart. For the remainder of his life, the person might be in danger for excessive fatigue and dangerously low blood stress, Dr. Kelly stated.

Each time that Bon Secours took away a service from Neighborhood, executives gave medical doctors the identical justification: Sufferers had been simply an ambulance trip away from hospitals within the broader system.

However Dr. Kelly and different medical doctors stated many sufferers had wound up like the person with the guts assault. “We very, fairly often had been caught for a lot of hours with sufferers who completely wanted superior care,” Dr. Kelly stated.

Different sufferers confronted a distinct drawback: Specialists who noticed sufferers at different Bon Secours places wouldn’t journey to the hospital.

This spring, Doris Scarborough, 79, went to Richmond Neighborhood to have her toe partly amputated. Poor circulation had turned the toe black and gangrenous. She stated her podiatrist had informed her that she would lose a few of her toe, however was prone to preserve her leg if she had a normal process often called revascularization.

Richmond Neighborhood didn’t supply this process. Ms. Scarborough needed to have it executed on the specialist’s workplace, and it took greater than two weeks to get an appointment. Weeks after the process, Ms. Scarborough misplaced her complete toe.

Dr. Foluso Fakorede, a heart specialist and an skilled on racial disparities in amputation, stated many individuals in poor, nonwhite communities confronted comparable delays in getting the process. “I’m not shocked by what’s transpired with this affected person in any respect,” he stated.

As a result of Ms. Scarborough doesn’t drive, her nephew should take day without work work each time she visits the vascular surgeon, whose workplace is 10 miles from her dwelling. Richmond Neighborhood would have been a five-minute stroll. Bon Secours didn’t touch upon her case.

“They’ve good medical doctors over there,” Ms. Scarborough stated of the neighborhood hospital. “However there does should be extra amenities and companies over there for our group, for us.”

Susan C. Beachy contributed analysis.