When Profit-Making takes over Emergency Services, Tragedy can Follow

Sunday, June 26, 2016
(photo: Fairfax Media/Getty Images)

 

By Danielle Ivory, Ben Protess and Kitty Bennett, New York Times

 

A Tennessee woman slipped into a coma and died after an ambulance company took so long to assemble a crew that one worker had time for a cigarette break.

 

Paramedics in New York had to covertly swipe medical supplies from a hospital to restock their depleted ambulances after emergency runs.

 

A man in the suburban South watched a chimney fire burn his house to the ground as he waited for the fire department, which billed him anyway and then sued him for $15,000 when he did not pay.

 

In each of these cases, someone dialed 911 and Wall Street answered.

 

The business of driving ambulances and operating fire brigades represents just one facet of a profound shift on Wall Street and Main Street alike, a New York Times investigation has found. Since the 2008 financial crisis, private equity firms, the “corporate raiders” of an earlier era, have increasingly taken over a wide array of civic and financial services that are central to American life.

 

Today, people interact with private equity when they dial 911, pay their mortgage, play a round of golf or turn on the kitchen tap for a glass of water.

 

Private equity put a unique stamp on these businesses. Unlike other for-profit companies, which often have years of experience making a product or offering a service, private equity is primarily skilled in making money. And in many of these businesses, The Times found, private equity firms applied a sophisticated moneymaking playbook: a mix of cost cuts, price increases, lobbying and litigation.

 

In emergency care and firefighting, this approach creates a fundamental tension: the push to turn a profit while caring for people in their most vulnerable moments.

 

For governments and their citizens, the effects have often been dire. Under private equity ownership, some ambulance response times worsened, heart monitors failed and companies slid into bankruptcy, according to a Times examination of thousands of pages of internal documents and government records, as well as interviews with dozens of former employees. In at least two cases, lawsuits contend, poor service led to patient deaths.

 

Private equity gained new power and responsibility as a direct result of the 2008 crisis. As cities and towns nationwide struggled to pay for basics like public infrastructure and ambulance services, private equity stepped in. At the same time, as banks scaled back their mortgage operations after the crisis, private equity firms — which face lighter regulation than banks, and none of their rainy-day capital requirements — moved in there as well.

 

The power shift has happened with relatively little scrutiny, even as federal authorities have tightened rules for banks. Unlike banks, which take deposits and borrow from the government, private equity firms invest money from wealthy individuals and pension funds desperate for returns at a time of historically low interest rates.

 

Since the 2008 financial crisis, private equity firms have gone from managing $1 trillion to managing $4.3 trillion — more than the value of Germany’s gross domestic product — according to the advisory firm Triago. Retirement nest eggs are fueling the growth and sharing in private equity’s risks and returns: Nearly half of private equity’s invested assets come from pensions.

 

“There is private equity — a lot of it — and it’s happening everywhere,” said Vikram Pandit, a former Citigroup chief executive who is now head of the Orogen Group, which invests in financial businesses. Across the financial landscape, he said, “New champions will emerge.”

 

Warburg Pincus, Kohlberg Kravis Roberts & Company, and other major private equity firms have invested in emergency services, a business that routinely holds the lives of customers in its hands. While this represents one small corner of private equity, which traditionally used debt to seize underperforming companies, it captures the industry’s newfound pervasiveness.

 

K.K.R. — a firm memorialized in “Barbarians at the Gate,” a book that chronicled a defining 1980s Wall Street deal — also invested in public water services. Blackstone is now America’s largest landlord of rental houses. And in the mortgage industry, until recently the province of banks, the Fortress Investment Group controls a huge bill collector.

 

In many of the fields where private equity now operates, it has not necessarily performed better or worse than the banks and governments it replaced. In some cases it financed projects that others wouldn’t fund and provided crucial public services, including emergency care. And because these firms do not rely on the government for loans, and are much smaller than Wall Street banks, they pose far less risk to the broader economy.

 

“Over 11 million Americans work for private-equity-backed businesses, and millions more rely on private equity performance for their retirement security,” said James Maloney, a spokesman for the American Investment Council, the industry’s leading lobbying group. Private equity, Mr. Maloney said, helps “advance both our economic and societal well-being.”

 

But the Times investigation of emergency services shows that hasn’t always been the case.

 

Of the 12 ambulance companies recently owned by private equity, three filed for bankruptcy in the last three years, according to public filings and S&P Global Market Intelligence, a research service that tracks over 1,100 major ambulance companies in the United States. Those three companies had problems that predated private equity. But no other ambulance company tracked by the research firm filed for bankruptcy during that period.

 

The latest blowup came in February, when TransCare EMS, controlled by the firm Patriarch Partners, filed for bankruptcy, closing its doors forever. One day, cities and towns up and down the East Coast had TransCare services; the next, they didn’t.

 

“Private equity has, in this case, threatened public safety,” said Richard Thomas, the mayor of Mount Vernon, N.Y, which relied on TransCare. “It’s not the way to treat the public.”

 

Patriarch’s owner and founder, Lynn Tilton, said in a statement that she was “deeply saddened by the unfortunate circumstances that triggered the abrupt end to TransCare’s operations and the heartache it has caused for many of its devoted employees.” She noted that TransCare, like other ambulance companies, “faced the obstacles inherent to its business model.”

 

Rural/Metro, long one of the nation’s largest ambulance companies and one of the few operators of private fire departments, did a tour through bankruptcy, although it reorganized and stayed in business. One private equity investor took Rural/Metro into bankruptcy, and another helped get it out.

 

During that period, Rural/Metro’s response times slowed in certain towns and it instituted more aggressive billing practices across the board, records show. While under the control of Warburg, Rural/Metro once sent a $761 collections notice to an infant girl born in an ambulance.

 

“The matter may be reported to a national credit reporting agency,” the notice read, effectively threatening a baby with a bad credit report.

 

“Obviously there were problems with Rural/Metro,” said Ron Cunningham, a spokesman for Rural/Metro’s new parent company, Envision Healthcare, which is not a private equity firm. “We are continuing to hire paramedics and E.M.T.s and what you are seeing is that the response times are improving.”

 

In a statement, Warburg said it “invested in Rural/Metro with the objective of growing and strengthening the company’s business.”

 

“Despite several initiatives undertaken by the company’s board and management team,” the statement said, the “challenges Rural/Metro faced were too difficult to overcome.”

 

 

While private equity firms have always invested in a diverse array of companies, including hospitals and nursing homes, their movement into emergency services raises broader questions about the administering of public services. Cities and towns are required to offer citizens a free education, and they generally provide a police force, but almost everything else is fair game for privatization.

 

“We’re reaching new lows in the public safety services we will help provide, especially in very poor cities,” said Michelle Wilde Anderson, a law professor at Stanford University who specializes in state and local government. Private equity firms, she said, “are not philanthropists.”

 

The Collapse of a Company

 

A TransCare ambulance pulled into a hospital parking lot in Westchester County. Employees in windbreakers, “EMS” emblazoned on the backs, hopped out and headed for the emergency room door.

 

They were there not to bring in a patient or sign paperwork, but to go “E.R. shopping”: swiping supplies to replenish critical items TransCare could not afford to replace in its ambulances.

 

After an ambulance finishes a run, hospital staff members often restock medications as a courtesy. But TransCare emergency workers described pressure from supervisors to go further and raid supply carts, sometimes without the hospital’s blessing. On occasion, one TransCare worker would act as lookout while “the other one would just be grabbing stuff,” said Emanuel Almodovar, a former employee.

 

Chez Valenta, an 11-year veteran of TransCare, said employees often had no choice. Medications in the ambulances were expired and supplies were depleted.

 

“There’s only a couple of things that terrify paramedics,” Ms. Valenta said. “Being without your critical medications is one of them. I make no apologies.”

 

The supply shortage — and the extreme measures taken to address it — was just one warning sign of TransCare’s demise. In February, it became official: Employees received an email from a supervisor declaring, “We are being told to cease operations immediately.”

 

TransCare’s unraveling, told through internal documents and interviews with former employees, provides a case study in private equity’s ambulance experiment. The company’s implosion followed the bankruptcies of two other ambulance companies owned by private equity, Rural/Metro and First Med.

 

It wasn’t supposed to be this way. Private equity investors swept into the ambulance business with high hopes.

 

“Tremendous growth potential,” Warburg Pincus said in a statement in 2011 when it bought Rural/Metro with plans to acquire rival ambulance services and improve bill collection.

 

Other firms bet that fragile towns would outsource emergency care. And, the thinking went, President Obama’s health care overhaul would insure millions more people, providing new paying customers.

 

But many newly insured Americans turned out to be on Medicaid, according to the Kaiser Family Foundation. Medicaid restricts some of the most aggressive billing tactics.

 

“It didn’t quite play out like they had hoped,” said Mike Ward, executive director of the National EMS Management Association.

 

So some private equity firms fell back on a time-tested moneymaking strategy: slashing costs. The case of TransCare shows the perils of that approach.

 

In 2003, Patriarch helped rescue TransCare, which had previously been owned by other private equity investors, from another bankruptcy. For years the company, which once had 2,000 employees, showed signs of improvement, with ample resources and high morale.

 

Patriarch’s owner, Ms. Tilton, liked to put a friendly face on private equity, shunning the stereotype of Wall Street raiders out to strip companies of valuable assets or flip them for a quick profit. Ms. Tilton starred in a reality television show, “Diva of Distressed,” and has famously said, “It’s only men I strip and flip.”

 

The TransCare mess was a mere blip for Patriarch, which manages a sprawling portfolio of more than 70 companies, including the mapmaker Rand McNally.

 

And Ms. Tilton, who said she “worked tirelessly” to try to save the company, attributed TransCare’s collapse to problems beyond Patriarch’s control. The business requires costly investment in medical gear, she said. “With limited free cash flow, any disruptions in the business can cause unsustainable deterioration.”

 

Yet Ms. Tilton was very much in charge of TransCare as it crumbled. She was the sole owner of the Patriarch Partners fund that had a controlling stake in TransCare. And although she never held an executive or management role, she was TransCare’s sole board member — a situation almost unheard-of in corporate America. Only 3 percent of private companies have two or fewer board members, according to survey data from the National Association of Corporate Directors, which called a one-person board “likely a recipe for governance failure.”

 

Former TransCare employees described pressure to cut costs and increase billing as the company weakened in recent years. Patients were transported unnecessarily in ambulances, they said.

 

And ambulances regularly broke down. On the day TransCare filed for bankruptcy, more than 30 percent of the company’s vehicles were out of service, some for hundreds of days, according to internal documents.

 

“We drove buses on the 911 unit where the brakes didn’t work properly,” said Rayshma Raghunath, a former TransCare employee, referring to her ambulance. She started feeling uneasy during the Ebola scare in 2014, when she said workers had trouble getting enough sanitary wipes to disinfect their ambulances.

 

Caitlin Cannizzaro, another former employee, said that even starting the ambulances became tough. One morning, it took four hours to get some running, she said. “You really had to become a MacGyver in the field.”

 

By early 2015, the company had racked up health department violations for failed ambulance inspections, internal documents show. Employees spotted bedbugs in the Brooklyn dispatch center. Suppliers refused to provide drugs or repair ambulances because of unpaid bills.

 

“We were constantly having problems with the heart monitors,” said Mr. Almodovar, the former emergency medical technician. “It started getting scary. The last thing we want is for a patient to die on us because the equipment is failing.”

 

By February 2015, shortages became critical. According to meeting minutes reviewed by The Times, TransCare executives discussed how their New York locations would be “unable to make it through the weekend with current medical supplies.”

 

Supervisors regularly paid for supplies out of their own pockets and hoped for reimbursement, emails show. Some workers said the ambulances carried expired medications. Others went “E.R. shopping.”

 

In March 2015, a new problem emerged: Some TransCare employees did not get paid on time. Then in July, it happened again.

 

When it looked like payroll might be delayed another time, TransCare sent sample questions and answers to managers, “to help you communicate” with frustrated employees. It read in part:

 

Q. When will we be paid?

 

A. We do not know.

 

In the first few days of 2016, the trouble accelerated. Eviction warnings had piled up. High levels of carbon monoxide in the Brooklyn office sent at least one employee to the hospital, according to medical records.

 

The company lost a major customer, the city of New Rochelle, N.Y. Less than 48 hours later, employees learned the chief executive had stepped down — the third in four years to leave.

 

“Recent events have been a wake-up call,” the chief operating officer wrote to the staff to announce the chief executive’s departure. The note signed off, “Here’s to a great future together!”

 

A month later, the company filed for bankruptcy, leaving a mess for cities and employees alike. Workers rushed to the company’s offices in Brooklyn to collect their final paychecks. Worried the checks might bounce, some piled into emergency vehicles and raced to a 24-hour check-cashing store.

 

James Bradley, deputy commissioner of public safety in White Plains, blamed Patriarch for TransCare’s woes. “That’s where the problems lie,” he said.

 

The city of Mount Vernon, another former customer in New York, hired a new private company at a cost to taxpayers, and is developing its own ambulance operation within its fire department. In New York City, where TransCare had operated 27 ambulances, the fire department paid its own ambulance workers overtime to fill the void.

 

“I am highly upset with Patriarch. They lied to us,” said Jay Robbins, a former director of operations at TransCare who was at ground zero after the Sept. 11, 2001, attacks.

 

“I told my employees to come in and work, and now they won’t be getting paid,” he said soon after the bankruptcy, his voice shaking.

 

The bankruptcy also disrupted litigation pending against the company, including a malpractice case that raises questions about TransCare’s training procedures.

 

During an Aerosmith concert at Madison Square Garden in 2012, Robert Albrecht, a 52-year-old businessman with a wife and three children, suddenly collapsed.

 

TransCare arrived within minutes — it was stationed in the building. But a paramedic mistakenly inserted a breathing tube into Mr. Albrecht’s esophagus, medical records and the lawsuit show, pumping air into his stomach instead of his lungs. He was pronounced dead minutes later.

 

The case was scheduled for preliminary settlement talks, according to the family’s lawyer, Jonathan C. Reiter, when TransCare went under. Today Mr. Albrecht’s widow is a creditor in the bankruptcy, in line with medical suppliers and unpaid workers.

 

Measuring the Toll on Patient Care

 

In Loudon County, Tenn., another ambulance company was unnerving local officials.

 

After 11 years of relying on Rural/Metro, the Tennessee county wanted to part ways in 2014. So it sent letters to the company outlining grievances: Rural/Metro employees slept through an emergency call. A Rural/Metro driver refused to transport a dead body because it would “stink up” his ambulance. Another Rural/Metro worker, who later said she offered to respond to an emergency even though she was off duty, had enough time to smoke a cigarette while the company scrambled to assemble a full crew. The patient later died.

 

In the year since private equity had led the company into bankruptcy, Rural/Metro had endangered “the health and welfare” of its citizens, Loudon County said in a letter to the company. It was, as the letter put it, “a complete system failure.”

 

Data on the quality of an ambulance company’s performance is scarce at the national level and difficult to compare town-to-town or company-to-company. A basic metric — how often ambulances are late — is often defined differently, if it is measured at all.

 

Still, data can show how one company changes over time, and a Times analysis of data obtained under freedom of information laws from five of Rural/Metro’s major markets suggests that service in four areas suffered under private equity ownership. The Times examined where Rural/Metro operated exclusively, in or near cities.

 

In one town, response times surged; in another, penalties skyrocketed. In a third, county officials time and again received a dreaded alert: no available ambulances.

 

The first private equity investor to back Rural/Metro was Warburg Pincus. It was just one investment for a firm that manages roughly $40 billion.

 

But the 2011 takeover was the sort of acquisition that tarred private equity firms in the public mind as corporate raiders out to make a fast dollar. Warburg financed its roughly $730 million purchase by adding more than $500 million in debt to Rural/Metro’s balance sheet — a deep hole to climb out of.

 

Initially, Warburg invested in the company and its ambulances. Rural/Metro acquired two ambulance companies, helping increase capital spending by 20 percent and payroll by 15 percent in 2012. But the deals added to overall debt, contributing to cutbacks that potentially affected patient care.

 

Some ambulances weren’t promptly restocked, employees said. In Arizona, the company’s home state, it shelved a program that gave raises to senior staff. It also slashed pensions there.

 

“It was a train wreck,” said Aaron Chamney, a former Rural/Metro fire captain who said he was dismissed a month into Warburg’s ownership after he was injured on the job.

 

The financial results were also a mess. Rural/Metro, which operates ambulances in 20 states, told investors it would book higher revenue than it ultimately did, leading bondholders to sue Warburg for fraud, a case that continues. Warburg denies the accusations.

 

As Warburg’s investment spiraled toward bankruptcy, service suffered.

 

In Arizona, just days before the August 2013 bankruptcy, the health department wrote to Rural/Metro demanding data on its 911 response times. Rural/Metro was failing to respond on time, state records show.

 

Tacoma, Wash., waived almost all of Rural/Metro’s fines for lateness in 2012 because the company was meeting overall standards. Then, however, performance collapsed. Rural/Metro paid fines for nine straight months. In the first half of 2013, average monthly penalties, both waived and not, nearly quintupled from the same period a year earlier.

 

“Throughout our ownership of Rural/Metro, Warburg Pincus always supported a high standard of customer care and the best possible results for all of the company’s stakeholders,” the firm said in a statement, citing “increased spending to improve operations and processes, increased capital investment and strategic acquisitions.”

 

But as Warburg’s investment was crumbling, something interesting happened: Other investors saw an opportunity and snapped up Rural/Metro’s bonds. This is a classic strategy in which Wall Street firms hunt for investments (in this case, distressed debt), expecting them to bounce back.

 

But Rural/Metro didn’t recover. It filed for bankruptcy.

 

Suddenly those bondholders had a choice: revive the company, or lose their money. The biggest bondholder was Oaktree Capital Management, an investment manager that specializes in distressed bonds and private equity deals. Oaktree invested $88 million in loans and stock, helping wipe out Warburg’s stake in the company. By January 2014, Oaktree was the single largest shareholder in Rural/Metro.

 

But Oaktree, which owned nearly 40 percent of Rural/Metro, did not halt the slide. In Rochester, monthly penalties averaged $58,950 in the first half of 2015, during Oaktree’s tenure, more than double the average during the first half of 2013, when Warburg owned the company.

 

In July 2014, the Mesa, Ariz., fire chief formally complained about Rural/Metro’s “unprecedented reduction of ambulances, which in turn delayed patient care.” The fire chief of the Superstition Fire and Medical District, in Apache Junction, Ariz., accused Rural/Metro of appearing “more focused on cutting corners and canceling contracts than quality of care.”

 

In Aurora, Colo., Rural/Metro awarded medals of valor to some employees for responding to the 2012 movie theater shooting. But the city issued increasing penalties to the company, on an average basis, for late responses and other problems after the bankruptcy. Last year, during Oaktree’s tenure, Aurora chose to award its contract to a different ambulance company.

 

In a statement, Oaktree said Rural/Metro’s board was unaware of “any contracts that the company lost due to deficient response times or supplies.”

 

“The board’s foremost focus was patient safety,” Oaktree said, adding that it “never contemplated any expense cuts that would have affected response time or patient care.”

 

Not everyone was displeased with Rural/Metro. In Wheat Ridge, Colo., the company has been considered compliant since 2011. When Rural/Metro suffered delays, “There were always reasonable explanations,” said Daniel Brennan, chief of police.

 

Similarly, San Diego considered Rural/Metro compliant under Warburg’s and Oaktree’s ownership. However, the city’s records show that it excused several hundred late responses over the last five years for circumstances like bursts of emergency calls.

 

Officials in Knox County, Tenn., said they started worrying in April 2015 when Rural/Metro alerted them twice that it had no ambulances available for emergencies, forcing them to rely on other providers. That is known as a “level zero,” and it had happened only once before in recent years. In 2015, the county penalized Rural/Metro $110,000 for level-zeros.

 

Rural/Metro also must tell the county if three or fewer ambulances are available. During the second half of 2015, it notified the county of such shortages an average of 106 times per month — quadruple the average of the same period in 2013.

 

“What we’ve been told is that their challenge is around staffing,” said Dr. Martha Buchanan, director of the county’s health department. She cited the bankruptcy and a new law requiring more worker certifications, making hiring tougher.

 

Rural/Metro also reported increased lateness, defined as taking 10 minutes or longer to reach an emergency. In the second half of 2015, Rural/Metro was late, on average, about 9.4 percent of the time, up from 6.8 percent two years earlier. Though the company still met overall standards, the county said Rural/Metro “had increased difficulty in doing so.”

 

Since Envision took over Rural/Metro in late 2015, replacing private equity, the company has shown signs of improvement, Knox County officials said. It has purchased new ambulances and raised salaries.

 

In neighboring Loudon County, officials noticed response time problems after the bankruptcy, when Oaktree was the largest shareholder. The final straw came after an early-morning 911 call in August 2014. Donna Maher, 81, couldn’t breathe.

 

“They’re coming as quick as they can,” the 911 operator promised.

 

But Rural/Metro’s ambulance had not yet left the station. Surveillance video showed an emergency worker standing beside her ambulance, smoking a cigarette.

 

Ms. Maher eventually reached the hospital, but died 10 days later. Later that year, Loudon County negotiated an early exit from its Rural/Metro contract. And the ambulance worker, Cortney Bryson, was fired.

 

Ms. Bryson sued Rural/Metro for wrongful termination, saying the company was “covering up improper scheduling, staffing and response criteria” in a way that “could have been shown to be a direct factor in the death of a citizen.”

 

In an interview, Ms. Bryson said she had worked two 24-hour shifts back-to-back before the call about Ms. Maher came in. Ms. Bryson was technically off the clock, she said, but a replacement hadn’t yet arrived.

 

Ms. Bryson said that she offered to go with another colleague, but that they needed permission because the colleague lacked full credentials. While waiting, she smoked.

 

Jennifer Estes, the 911 center director, says it is difficult to link a delayed ambulance to a death. But this case, she said, “leaves some room for someone to wonder, ‘Could the extra time have made a difference?’”

 

Dispatching Medics, Then Big Bills

 

After private equity took over Rural/Metro, new posters appeared on the walls of ambulance and fire stations, featuring a caricature of a uniformed employee delivering a mandate: Get a signature.

 

In other words, get patients to sign documents that can be used to bill them.

 

“Almost always, if the patient is alert, they will be able to sign,” he says.

 

And if the patient can’t sign? Then go to a family member, or a nurse. “They’ll sign — because I don’t give up.”

 

The posters — just one element of Rural/Metro’s aggressive billing practices while owned by private equity — promoted “Do the Write Thing,” a policy instructing employees to document every detail of a patient’s treatment. It paired with another initiative, the “Care to Cash” checklist, also instituted during Warburg’s tenure.

 

Warburg Pincus said it was not aware of those specific initiatives.

 

The policies, Rural/Metro said, would help patients by ensuring that bills were accurate. But employees complained that the process distracted them from caregiving and put them in the awkward position of seeking signatures from ill or medicated patients.

 

Do the Write Thing “didn’t sit well with the firefighters,” said Nico Latini, who has worked at Rural/Metro for a decade. “We operate under a high level of integrity and we do the right thing every day — with an R, not a W.”

 

In the four years that private equity led Rural/Metro, the company was fighting for financial survival. It raised its prices, but patients couldn’t afford those bigger bills.

 

Against that backdrop, the company intensified its collection efforts. And when people didn’t pay, Rural/Metro took them to court.

 

After Warburg left the company, Rural/Metro eliminated Care to Cash and Do the Write Thing. But even under its new non-private equity owner, it still sues to collect some unpaid bills from fire and ambulance customers. Rural/Metro’s new owner said it “will continue to utilize the legal system to pursue payment when appropriate,” but added that it first asks “customers who need assistance to work with us to develop a payment plan that meets their needs.”

 

Rural/Metro’s fire departments sell homeowners an annual subscription for fire protection, often ranging from $100 to $500, depending on the property. If a nonsubscriber suffers a fire, Rural/Metro will still answer the call, unlike some other private departments. But then it sends a bill well above the subscription price.

 

Even before private equity took over, the company sued to collect fire bills. Under private equity, this practice flourished.

 

The Times examined court filings in the areas where Rural/Metro operates fire departments and identified dozens of lawsuits filed since 2011, when private equity took over. In these lawsuits, which are unheard-of at tax-funded public fire departments, the company pursued unpaid bills ranging from a few hundred dollars to $59,000.

 

In Knoxville, Tenn., Lester Day faced one of those lawsuits. When his chimney caught fire in March 2013, he dialed 911.

 

When firefighters arrived almost an hour later, 911 records indicate, the house had been reduced to ashes. That didn’t stop Rural/Metro from charging Mr. Day for their response and then placing a $15,000 lien on his home, which he had since rebuilt.

 

“Now I’m having to sell everything we’ve got,” Mr. Day said in an interview. “It ain’t right.”

 

Rural/Metro also filed hundreds of lawsuits against ambulance patients in the same time period, including claims against families of people who died.

 

Public providers are generally less aggressive than private ones, and some opt not to sue at all. The New York Fire Department said it sends letters to ambulance patients but stops short of suing.

 

And yet, patients may not always have the chance to ride in a government ambulance. Private companies now represent about 25 percent of all ambulance providers, according to the National Association of State EMS Officials.

 

Rural/Metro’s community fire service, which operates in Arizona, Oregon and Tennessee, is one of the nation’s few private fire departments. Only 4 percent of Americans rely on a private fire service. Rural/Metro mainly serves unincorporated areas without public fire departments, where often there is no government contract or public oversight.

 

The Times spoke with more than a dozen people who had been sued by the company after fires on their property. Many homeowners in Rural/Metro’s jurisdiction did not realize they had to pay for fire protection separately, on top of their taxes. Some thought the subscription fee was unwarranted.

 

“I thought the fire department was paid out of taxes,” said Alice Addie, who lives with her husband, LaVern, in Mesa, Ariz. In 2013, Rural/Metro filed a roughly $7,000 lawsuit against the Addies after their mobile home caught fire.

 

Mr. Addie, a Navy veteran, at first disputed the charges, storming into his local Rural/Metro fire department to question the suit.

 

Ultimately, the company allowed the Addies to pay off their bill in monthly installments.

 

But in the backyard of his home, in the shadow of the rugged mountains of Maricopa County, he explained how they were still struggling with that debt.

 

“We just eat two meals a day instead of three,” he said.

 

Jessica Silver-Greenberg, Alain Delaquérière, Peter Eavis and Nancy Sharkey contributed reporting.

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