Hartford HealthCare’s bid to acquire Manchester Memorial and Rockville General hospitals would also give it full ownership of two ambulance services, potentially controlling one-third of Connecticut’s private ambulance providers.
Hartford HealthCare’s bid to acquire two Prospect Medical Holdings hospitals doesn’t just involve beds and emergency rooms — it could also expand the health system’s footprint in Connecticut’s emergency medical transport network.
Regulators approved HHC’s bid to purchase Manchester Memorial and Rockville General hospitals on Dec. 10, giving HHC full ownership of two additional ambulance providers, Aetna Ambulance Service Inc. and Ambulance Service of Manchester LLC (AMS).
That doubles the number of ground ambulance companies HHC controls and gives the system one-third of all privately owned or hospital-controlled ambulance services in the state.
HHC and Prospect each owned 50% stakes in both ambulance companies. Approval, according to the state, transfers Prospect’s shares to Hartford HealthCare, joining American Ambulance Service Inc. and Hunter’s Ambulance Service in HHC’s portfolio. (The system also owns the Life Star critical care helicopter service.)
Of the 18 ground ambulance services licensed in Connecticut, 12 are owned by hospitals or held privately.
Since the Prospect hospital deal was approve, HHC controls one-third of those 12 ambulance providers — prompting at least one observer to question whether the state’s second-largest health system could end up controlling too much of the market.
Approval not required
While the hospital purchase faces regulatory review and public scrutiny, the ambulance consolidation drew far less attention.
The Office of Health Strategy said ambulance ownership transfers are not subject to its review.
Separately, the state Department of Public Health regulates ambulance licensing in Connecticut, but its approval wasn’t required for the Prospect deal because the license holders remained the same. DPH reviews changes to the license itself, not changes in corporate ownership, according to an agency spokesperson.
Hartford HealthCare declined to comment for this story, citing a nondisclosure agreement with Prospect and ongoing discussions with state regulators.
Consolidation
Bob Holdsworth, founder of EMS consulting firm
The Holdsworth Group in Old Saybrook, said ambulance consolidation has accelerated in recent years.
Last month, Yale New Haven Health completed its acquisition of Nelson Ambulance and its affiliates — Access Ambulance Service, Connecticut Handivan and The Limo Group. Yale New Haven also owns ambulance services that cover Lawrence + Memorial Hospital in New London.
That deal leaves just two independently owned private ambulance providers in Connecticut: Empress EMS of New York, which serves Litchfield County, and American Medical Response.
Meantime, Hartford HealthCare acquired Hunter’s in 2021 and American Ambulance Services in Norwich in 2023.
“For years, the hospitals did not want any part of the ambulance business,” Holdsworth said. “They wanted to be independent from it, because there were concerns about Medicare self-referrals and those kinds of things.”
Now, hospitals want ambulances because “they need to move patients,” he said.
Limited staffed beds mean hospitals have to discharge patients to make room for new ones, but private ambulance operators typically prioritize 911 calls. That can clog emergency departments when hospitals are unable to move patients to rehab or other facilities due to a shortage of available ambulances, he said.
Owning ambulance services allows hospitals to control both 911 coverage and non-emergency transport, Holdsworth said. He added that ambulances are not a “cash cow,” because non-emergency trips are generally reimbursed at discounted Medicare and Medicaid rates.
“I don’t think any of the hospitals are looking at it as a significant revenue stream,” Holdsworth said.
Too big?
Holdsworth noted that when ambulance services change ownership, state law requires the new owner to continue serving the same communities. Ambulances cover primary service areas (PSAs), where a provider is designated as a community’s primary responder.
But consolidation could eventually shrink choices if a new owner seeks to exit certain PSAs, he warned.
“So the real risk with this for the municipalities going forward is lack of choice,” he said.
Another concern is a single provider controlling too large a region. That issue surfaced in the late 1990s, when the state sued American Medical Response after it grew significantly.
In 1999, then-Attorney General Richard Blumenthal sued AMR, claiming it controlled too vast an area of the state. The case was ultimately settled, with AMR required to divest 30 ambulance licenses and sell 20 ambulances at fair market value to competitors. AMR also agreed not to oppose any ambulance licensing applications filed by competitors for three years and paid $100,000 in attorneys’ fees and costs.
State Attorney General William Tong’s office did not respond to a request for comment on HHC potentially acquiring full shares of Aetna and AMS.
Editor's Note: This article was updated to reflect OHS approving the Prospect deal. The decision was issued Dec. 10.
