To:
From:
Subject:
Date:

Rosalind Adams, BuzzFeed
Isa Diaz
Universal Health Services response to your letter of Friday, November 18
November 23, 2016

Rosalind:
Thank you for providing an outline of your upcoming story and the opportunity to respond. It is
difficult to provide detailed responses to many of your contentions because much of your story
appears to focus on anecdotal accounts of unnamed former and/or current employees and
patients offering their personal perspectives. However, we do want to take the opportunity to
respond because we think it is important to set the record straight.
UHS has employed in excess of 100,000 people since 2010. While you claim to have spoken to
175 unidentified former and current UHS employees, it is difficult to respond to certain matters
without additional information on their identities, roles and circumstances of their tenure and
departure.
UHS’ record of providing high quality care is well demonstrated
Our record of quality care speaks for itself. All UHS subsidiary Behavioral Health (BH) facilities
are fully accredited by either The Joint Commission (TJC), a non-profit, independent
organization with a 60-year history of assessing and evaluating the clinical operations of
hospitals and health care facilities including Behavioral Health hospitals or the Council on the
Accreditation of Rehabilitation Facilities (CARF). TJC performs more than 20,000 assessments
annually on behalf of the federal government.
Over the past 4 years, 83 UHS facilities (including 69 in our BH division) have been designated
Top Performer on Key Quality Measures™. Over half of UHS’ eligible BH facilities received
this designation. TJC bestows such recognition to clinical facilities that “attain excellence on
accountability measure performance” because of evidence-based clinical processes that are
shown to be the best treatment for certain conditions. To obtain Top Performer status, a facility
must achieve performance of 95% or above on all accountability metrics. The aggregate number
and percentage of UHS facilities receiving Top Performer designations over the past 4 years far
exceeds (often by over 100%) our main competitors or comparable BH systems.
UHS’ BH facilities also greatly exceed the national average in HBIPS (Hospital-Based Inpatient
Psychiatric Services) core measure scores. HBIPS is an evidence based measurement of practices
at inpatient psychiatric hospitals that affect the course of a patient’s hospitalization and the
quality of care provided. An analysis of recently published 2014 (the most recent year available)
clinical data from CMS’ Hospital Compare site extrapolated from the Inpatient Psychiatric
Facility Quality Reporting Program (IPFQR) composed of over 1,500 behavioral health hospitals
across the U.S. reveals that 91.4% of UHS BH facilities outperformed the national average for all
7 primary clinical indicators.
Additionally, UHS’ patients consistently report high levels of patient satisfaction with the care
they receive at its affiliate facilities. In 2015, our patient satisfaction grand mean score – on a 1-5
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 scale – was 4.5 based on a 70% survey return rate (317,683 participants). UHS patient
satisfaction scores have increased annually over the past 7 years. In 2015, UHS BH facilities
treated almost 450,000 patients, amounting to over 5.8 million patient days.
Mental health facilities, patients and admissions processes require a careful understanding
of behavioral health medicine
It is important to understand that mental health facilities and the patients that we treat are unique,
and unlike traditional acute care hospitals or patients. Most of our patients are unable to make
the same judgements regarding clinical care and appropriateness of admission and discharge that
they might if undergoing other non-psychiatric medical treatment. Most of our patients arrive
via hospital emergency rooms, community agencies that serve as triage systems, or local law
enforcement.
Decisions regarding admission are made by an attending psychiatrist in consultation with
members of the clinical treatment team. There are three main criteria required for admission.
The first considers suicidality, whether someone is suicidal or at significant risk of harm to him
or herself. The second considers whether there is a significant indication that the patient may
harm someone else. The third concerns whether the individual is gravely disabled and/or unable
to care for him or herself. These are standard industry-wide admission criteria and are not unique
to UHS.
Your assertions about admission and retention of patients are contrary to the factual record and
UHS policies and practices, fail to account for the significant demand for mental health treatment
services, and ignore our clinical role in advocating for our patients to ensure that they receive
appropriate care in an environment where payors may attempt to limit or deny treatment.
All hospitals and particularly psychiatric facilities are highly regulated. They are regularly
inspected by federal and state agencies, required to undergo rigorous third party accreditation
evaluations, and must comply with a complex set of insurance/payor (whether commercial or
government) policies governing reimbursement and quality of services provided. Admitting
patients who do not meet clinical criteria for inpatient admission makes no sense as it would
result in both denials of reimbursement and regulatory citations alleging such conduct and
professional misconduct sanctions for the attending physician as admissions are made under their
medical licenses. No UHS affiliate BH facility has ever received a citation from a regulatory
authority alleging that any patient was inappropriately admitted due to failure to meet
appropriate clinical criteria.
Our intake process is clinically based and we strive to meet all EMTALA obligations
The material you forwarded focuses in part on the intake and admission processes at UHS BH
facilities, and again is based on anecdotal accounts. We strongly dispute these characterizations
of our intake procedures and your contentions regarding UHS’ EMTALA compliance record and
patient deflection practices.
First, UHS affiliate facilities work diligently to comply with all legal obligations under
EMTALA. To ensure compliance, facilities have established policies and procedures and
conduct ongoing comprehensive staff trainings on EMTALA and related topics. The assertion
that UHS affiliate facilities knowingly violate EMTALA obligations to deflect (i.e. “turn away’)
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 uninsured patients is categorically false. Over the past five years, UHS facilities have deflected,
for appropriate reasons, hundreds of thousands of both insured and uninsured patients who have
presented for potential admission. These patients were deflected for completely legitimate and
lawful reasons, including failure to meet clinical criteria for inpatient admission, bed availability,
license capacity and lack of expertise in treating particular medical etiologies.
If UHS had a practice or policy of deflecting uninsured patients, there would be hundreds if not
thousands of EMTALA citations. In reality, UHS BH facilities received an exceptionally small
number of citations over the past five years, particularly given the number and relative size of the
facilities when counted together. Many hospitals across the country encounter sporadic and
isolated episodes of EMTALA non-compliance due to the highly technical and detailed
requirements associated with the law and its regulations.
Second, these deflection numbers seriously undermine any contention that UHS facilities
regularly and routinely exceed capacity for economic reasons. As stated above, UHS has also
deflected hundreds of thousands of insured patients for a variety of legitimate reasons, including
failure to meet clinical criteria, lack of available beds, or limitations due to license capacity.
Data further shows that patients were denied for lacking the requisite acuity across numerous
facilities, even when the facilities were operating under budget.
Finally, the notes you sent similarly depict a needlessly negative view of UHS affiliate facilities’
daily “flash” meetings. These meetings are a widely used best practice to ensure that the entire
hospital team, including clinicians, administrators, and operational staff, are aware of current
matters relating to admissions, discharges, patient census, and support services. These meetings
enable the various teams to coordinate responsibilities so that the facility can continue to provide
patients with the highest level of care and comfort possible.
UHS facilities are staffed appropriately, regularly assessed and adjusted
All UHS facilities comply with state and federal regulations regarding staffing requirements,
including patient-staff ratios, training, and credentialing. (It should be noted that only a handful
of states require specific staffing ratios). UHS facility leaders base staffing decisions on the
clinical needs of patients, in accordance with all legal requirements and applicable state
mandates. UHS constantly assesses the multiple factors that go into staffing decisions, including
experience, type of patients, treatment environment and milieu to ensure that our facilities are
staffed at therapeutically appropriate levels at all times. As shared previously, staffing needs to
be responsive to patient needs and therefore is a fluid process. UHS categorically denies any
assertion that we deliberately and systemically understaff affiliate facilities. In fact, facilities
(including Old Vineyard) frequently went above budget to ensure adequate staffing, as reflected
in the employees-per-occupied-bed actual budget numbers. UHS facilities have consistently
received numerous quality of care accolades from independent bodies, which further undermines
claims that staffing was inadequate.
Additionally, UHS facilities employ rigorous hiring standards to ensure that only the most
qualified candidates are hired. For example, many facilities require two-round interviews for
line staff, pre-employment assessments, and extensive background checks.

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 Length of Stay (LOS) is a clinical determination and UHS’ average LOS did not exceed the
national average
Nationwide LOS data compiled by CMS and the National Association of Psychiatric Health
Systems (NAPHS) demonstrate that UHS facilities’ average LOS did not exceed the national
average in any measured patient segment, including children, adolescents, adults, and older
adults.
UHS also rejects any accusation that any of its affiliate hospitals improperly manipulate LOS to
increase financial performance. LOS is a common health care industry metric utilized by many
behavioral health facilities. Such metrics are used for internal operational purposes as well as
evaluation and management of patient care.
First, the top priority at all UHS facilities is providing appropriate care to our patients. Every
patient care decision is made with the goal of furthering the best interests of our patients; this
includes decisions regarding the amount of time a patient spends in treatment. Accordingly, such
decisions are made by the attending physician in consultation with the treatment team.
Second, in many states, initial and continuing stay decisions are made in conjunction with state
utilization management agents, outside case managers, and even courts, who review extensive
clinical materials and speak with treatment providers before rendering pre-authorization
decisions.
Finally, there are numerous instances of uninsured patients who have remained at UHS facilities
for extended periods of time, due to the clinical needs and best treatment for those individuals,
for which we have not been reimbursed. Over the past 5 years, UHS’ BH facilities provided over
$350 million in uncompensated care, including charity care. However, the economic realities of
our current healthcare system do not provide many patients with the resources to continue to
fund treatment post-EMTALA stabilization, even though that treatment would meet the criteria
of private or government payors if the patients had insurance coverage. This is an unfortunate
reality that we hope can be alleviated by greater access to health insurance or government
funding sources so that all patients can take advantage of the full treatment programs available at
UHS facilities or other community-based freestanding facilities.
Length of Stay: River Point Behavioral Health
As it has been for the other UHS facilities, patient safety has always been the top priority at
River Point. The desire to provide quality treatment and keep patients safe was the impetus
behind the treatment model instituted by Gayle Eckerd. Eckerd knew that medical research
shows that short stays are associated with high readmission and suicide rates, so she established a
10-day guideline with the goal of providing patients with the medically necessary care they
needed. This was not a one-size-fits-all requirement, but a general model of treatment planning
that was adjusted to the needs of individual patients.
Likewise, discussion of “days on the table” was about patient safety concerns. If the insurer had
reviewed a patient’s file and determined that the patient needed a certain number of days of care,
it was appropriate to evaluate—with the relevant physician and clinical team—whether
premature discharge was in the patient’s interest. The lists of patients, along with anticipated
discharge dates, were distributed in order to facilitate discussion about patient care—the patients’
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 criteria, their progress, and discharge planning, among other things. Exchange of information
regarding projected discharges, and the discussions the exchanges facilitated, were part of River
Point’s fulfillment of its government-mandated responsibility to review the appropriateness of
care provided and ensure proper discharge planning. There was discussion and debate between
the treatment team and physicians, but the physicians always exercised their independent
judgment and had the final say regarding patient care.
Moreover, River Point never released any patients—regardless of their ability to pay—until the
physicians felt that the patients were stable. This message was repeatedly emphasized by facility
management. In fact, there are numerous examples of River Point keeping “self-pay” patients
for many days until the medical staff was satisfied the patients were stable enough to leave.
Your outline also includes an anecdote about a patient who was treated at River Point in May
2016. You appear to think that this anecdote supports the idea that uninsured patients have been
forced out, and that this patient was arrested instead of properly discharged. You appear to be
relying solely on a police report. Out of respect for the patient’s privacy, we will not comment on
the specific patient’s file or specific situation.
However, we caution you that a police report obviously does not tell the full story of a mental
health patient’s experience. For example, you clearly do not know whether this patient had health
insurance. The fact that she had an assigned social worker, as you reference from the report,
should suggest to you that you need to do additional diligence before jumping to conclusions.
Social workers have been very much involved in discharge planning for patients at River Point.
You also do not appear to know the events that led up to this patient causing the disturbance at
the facility, such as what treatment the patient may have received prior to this incident, the
medical decisions made by her physicians, or any other non-UHS health care facilities previously
involved. You must realize that there are plenty of circumstances that can arise in this
environment that justify—even require—a call by the facility to the police. And the police here
obviously made a judgment about what was appropriate from a law enforcement perspective. We
suggest that it would be inappropriate for you to publish this as a purported example of
wrongdoing on River Point’s part without investigating all of the circumstances.
Length of Stay: Salt Lake Behavioral Health
Salt Lake Behavioral Health (“SLBH”) similarly makes discharge decisions with the input of a
patient’s entire treatment team, including the patient’s therapist, nurses, social worker, and
physician. However, the final authority to order a patient’s discharge resides with the physician.
Discharge is a particularly vulnerable point in the course of a patient’s treatment, and a welldesigned discharge plan is necessary to ensure the patient’s well-being after treatment. Because
the physicians who make final discharge decisions are not responsible for crafting discharge
plans, SLBH management does monitor discharges to ensure that an adequate discharge plan is
in place before discharge.
When SLBH patients have used up their pre-approved number of treatment days, but are not
clinically ready for discharge, SLBH continues to provide treatment regardless of financial status
until discharge criteria are met. Furthermore, under UHS management, SLBH has substantially
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 increased the proportion of unfunded and charity care that it provides, from less than 1% of
patients in 2012, under prior ownership, to over 7% in 2015.
UHS codes properly for suicidal ideation
We further reject the inaccurate conclusions regarding UHS’ suicidal ideation rates as they
compare to other companies, including Psychiatric Solutions, Inc. (PSI) prior to its acquisition by
UHS. Patients who present to a facility with suicidal ideation are admitted only after an
assessment, and upon receipt of a physician’s order. Further, the physician will then evaluate the
patient within 24 hours to independently determine and verify that the patient has genuine
suicidal ideation warranting continued inpatient admission. The insinuation that suicidal coding
implies greater diagnosis of suicidal ideation as compared to other facilities is inaccurate.
Coding for suicidal ideation is primarily a non-revenue producing co-morbidity. It is a coding
notation based upon evidence contained in medical records, as attested to by psychiatrists and
other medical staff. The notation is utilized for both diagnostic and patient care record-keeping
purposes. Given that the suicide rate in the United States has surged to the highest levels in
nearly 30 years (according to the National Center for Health Statistics), UHS believes that it is
critical to do all that we can do to both identify and treat patients exhibiting suicidal tendencies.
UHS is also subject to regular internal and independent external coding audits by third party
audit firms to ensure accuracy and compliance with all government healthcare programs. These
independent, external coding reviewers have never identified any improper assignment of the
suicidal ideation as a coding designation.
UHS cannot speak to the training, sophistication, or knowledge that other behavioral health
providers have in regard to coding such co-morbidities which may result in a lower coding rate
for such providers. We can confirm, however, that prior to the UHS’ acquisition of PSI, PSI
facilities tended not to code for suicidal ideation even though they diagnosed and treated patients
with suicidal ideation symptoms. (For the handful of PSI facilities that did code for suicidal
ideation, the rates remained fairly consistent after the UHS acquisition.) Further, former PSI
executives have confirmed that their level of diagnosis and treatment of patients with suicidal
ideation remained consistent following the UHS acquisition - only the use of the coding
designation increased, as a result of the training, experience, and expertise of UHS in this area.
This fact has also been confirmed by the independent, external auditors who reviewed this matter
closely at the time of the PSI acquisition and continue to do so today.
River Point Behavioral Health and the Florida Baker Act
Each state has a different legal mechanism for committing an individual into care if he or she is
determined to be at risk and disagrees with the recommendation for or is incapable of consenting
to treatment. The Florida Mental Health Act of 1971 (FL Statute 394.451-394.47891 (2009 rev.),
commonly known as the “Baker Act,” permits the involuntary examination and commitment of
individuals who meet certain criteria. As you are likely aware, a Baker Act petition can only take
place after two psychiatrists attest to the fact that the patient is a danger to him or herself or
others; these attestations are then included in a Baker Act petition that must be granted by a
judge. A facility cannot “Baker Act” a patient on its own; only qualified clinical personnel can
do so.
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 With regard to a particular line of inquiry you posed during our recent interview about River
Point Behavioral Health, you cited and shared statistics regarding the number of Baker Act
petitions that had been filed at River Point following the hiring of Gayle Eckerd as CEO of River
Point in 2009. We have since researched this issue more fully and wish to address some of your
assertions on this matter.
First, any claims that the Baker Act process was used improperly in any way at River Point are
completely unfounded, and UHS objects to these accusations. These assertions misapprehend the
law, the regulations implementing it, and the purpose and process of the Baker Act. For many
years, River Point has been a critical behavioral health resource for the Jacksonville community
because it has had the capacity, credentials, and expertise to admit and treat Baker Act patients,
often among the most severely in need of behavioral health treatment.
As for the increase in the number of Baker Act petitions at River Point beginning in
approximately 2009, the principal reasons were the facility’s shift to a different patient
population and River Point’s increased attention to demand for acute in-patient services,
including for Baker Act patients. Specifically, the State Inpatient Psychiatric Program (SIPP)
Adolescent unit was closed and new geriatric units were opened. The SIPP unit was a residential
treatment center composed entirely of adolescent patients who were voluntarily admitted, and
therefore did not involve Baker Act proceedings. Closing the SIPP unit and devoting greater
capacity to geriatric patients allowed River Point to take on a greater number of Baker Act
patients, including substantial numbers of geriatric patients who commonly have challenging
mental health issues requiring involuntary commitment, that flooded and overtaxed hospital
emergency rooms, nursing homes, and other health care facilities that simply were ill-equipped
to handle such patients (and not even Baker Act credentialed). These sources therefore
increasingly referred their Baker Act patients to River Point. Moreover, River Point was the
largest psychiatric facility in the Jacksonville area, comprising 38% of all the psychiatric beds in
2014. There were only five facilities treating Baker Act patients in this time period, with River
Point being the largest by two or three times. Also during this period, River Point developed a
stronger relationship with the Jacksonville Sheriff’s Office, which included training officers on
how to properly handle mental health patients. This strengthened relationship led officers to
bring more Baker Act patients to River Point.
The outline you sent also referenced a reduction in Baker Act petitions after the facility was
placed on a payment suspension in April 2014. In order to keep the facility open while under the
payment suspension (the merits of which we vigorously disputed), River Point decreased its
available beds from 93 to 40—a 57% drop. As a result, there were fewer beds available to treat
Baker Act patients. In addition, during this time period, Wekiva Springs completed an
expansion and began accepting Baker Act patients in 2013; Memorial Hospital of Jacksonville
added beds as well. The increase in Baker Act patient capacity in other facilities, coupled with
River Point’s decreased capacity, resulted in a drop in the number of Baker Act patients and,
correspondingly, the number of petitions filed.
Notwithstanding these factors, the percentage of Baker Act patients at River Point has remained
consistent since 2013 and actually increased for this year to date. In 2013, the percentage of
Baker Act patients comprising the total patients at River Point was 72%. For 2016 to date, that
percentage has increased to 77%.
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 Second, each state has a rigorous process for protecting patient rights. Regulators and inspectors
review claims that a patient is being held against his or her will when the patient and/or the
patient’s family feels as though their rights have been violated. UHS absolutely rejects any claim
that any of its facilities (including River Point) deliberately held a patient against his or her will
absent a legitimate clinical finding that such action was in the best interests of the patient and the
community.
In addition, River Point has consistently disputed and refuted the purported basis of the payment
suspension put in place by CMS in April 2014. We have submitted a detailed response to CMS
to the allegations presented supporting the suspension and believe that the suspension was
improvidently imposed.
Finally, your outline mentions River Point’s 2014 treatment of a specific Baker Act patient. You
state that you are relying on CMS records, which presumably you obtained through a FOIA
request. We do not know whether you have authorization from the patient to use his/her
information, but out of respect for the patient’s privacy, we will not comment on the specific
patient’s file or specific situation. If you obtain written authorization from the patient for us to
share the patient’s information with you to address the concerns in your outline, we would be
glad to do so.
In any event, we strongly suggest that you do additional diligence to ensure the accuracy of
whatever you publish because these difficult situations can often be misconstrued. For example,
we are aware of a CMS report addressing treatment of an anonymous Baker Act patient, which
we neither confirm nor deny is the patient you mention. That report notes that the patient in
question said he/she felt “hopeless.” However, the CMS report also states that the patient also
talked explicitly of suicide: before being admitted, he/she told a government agency hotline and
a separate law enforcement office (which deemed the matter so severe that they called on
someone specializing in hostage negotiation to speak with the patient) that he/she wanted to
“end[] it all,” that “life is not worth living,” and that he/she “would shoot [him/her]self.” For that
anonymous patient, the treating physician could and did explain to CMS auditors why the patient
was in the hospital: the physician noted that the patient was admitted and treated because he/she
had made “suicidal threats” to the government agency. River Point arranged for the patient to be
discharged to the government agency’s clinic, but only after his/her treating physician
determined that he/she was no longer a threat to himself/herself or others.
Salt Lake Behavioral Health admissions decisions are appropriate and clinically motivated
SLBH admits patients only when justified by clinical factors to ensure that patients who are not
medically appropriate for admission are not admitted. SLBH’s intake process begins with an
examination of a patient’s medical condition to ensure that admission criteria are met, followed
by a consultation with the potential patient’s insurer. SLBH furthermore does not provide
admissions-based financial incentives to either staff or doctors, including SLBH’s Admissions
Director.
SLBH takes involuntary commitment very seriously and uses its authority to involuntarily
commit a patient only when necessary to protect the safety of the patient or the public. When a
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 patient asks to leave against medical advice, SLBH first attempts to convince the patient to stay
of his or her own volition. If the patient continues to insist on leaving, an authorized medical
professional may order the patient to be involuntarily detained only if the patient would be a
danger to him or herself or to the public if discharged. When involuntarily committing a patient,
SLBH staff will explain to that patient the rules governing involuntary commitments. Such an
explanation is for the patient’s benefit, and is never given as a threat. It is possible, however,
that some patients may misinterpret the nature of the explanation, particularly if the patient is in
a mentally unstable state. SLBH does not use threats of any kind, including of involuntary
commitment, to force patients to stay against their will.
As always, please feel free to contact me if you have any questions.
Isa Diaz

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