December 9, 2016 VIA ELECTRONIC TRANSMISSION The Honorable Daniel R. Levinson Inspector General U.S. Department of Health and Human Services 330 Independence Avenue SW Washington, DC 20201 Dear Inspector General Levinson, On December 7, 2016, BuzzFeed published an in-depth article summarizing the main findings of its yearlong investigation into the country’s largest psychiatric hospital chain, Universal Health Services’ (UHS), and allegations of pressuring patients into unnecessary admittance and prolonged hospitalizations, potentially defrauding the government via Medicare and Medicaid as a result. The alleged conduct raised in the article is particularly troubling and raises serious questions about UHS’ ability to properly care for its patients. Current and former employees interviewed by BuzzFeed noted that they were directed by management to hold patients in psychiatric wards until their insurance ran out in order to maximize profit. The investigation also notes that a state of Illinois report about one Chicago UHS hospital found that staffing levels were “woefully inadequate” and there was a “repeated and willful failure by UHS officials to ensure that their staff were properly trained” and that it engaged in a pattern of patient admission “in an effort to maximize financial profit.” Based on the report, it appears these issues spread to other UHS facilities and one patient reportedly even died from an apparent failure to properly diagnose and monitor him. The BuzzFeed article includes examples of patients being held against their will and supervisory employees instructing their subordinates to ensure that patients stay as long as possible to maximize profit. Further, the investigation found that UHS used the suicidal ideation code excessively to bill Medicare. This excessive use is more apparent in UHS’ purchase of Psychiatric Solutions Inc. – after the acquisition former PSI hospitals used the suicidal ideation code at a six-fold increase, according to the news report. The Honorable Daniel R. Levinson December 9, 2016 Page 2 of 2 The pattern of conduct described by the report paints a picture of greed and raises serious questions about patient safety. I understand there is a federal investigation under way. However, the level of your office’s involvement is unclear. Accordingly, by December 23, 2016, please detail what steps your office is taking to investigate UHS for its apparent abuses. Attached to my letter is a copy of the BuzzFeed article, for your reference. Sincerely, Charles E. Grassley Chairman Committee on the Judiciary BuzzFeeD Lock them in. Bill their insurer. Kick them out. How scores of employees and patients say America's largest chain turns patients into pro?ts. :1 iit?hsgurtcl Andras Id! int-w; Hmuntm On a cool October evening in you. Samantha: Trimhle walla-cl him the lobby {if Millu'riutl iltispilnl, at low-?slung hrirlt building [)11 the atria tifu mud in 'l'I-iLas, seeking a tire mental lil'E-Ill'l't zisseSsmt-iit. hm weeks unriitrr in the. AP world history class 'l'rimhle taught. alter a lilt?l started tit-lint; ritiltlish, Slit? put it diaper on his huntl snmethingslu- admits was e1 bad idea, lit-'hen atlntinistrutm?s heard about it, she mu} L'scm'tet! oil the property. Worried fur ltrt'jnh and her :ihiliti .is a single mother in stippnt't her daughter. she t'iHileci her ?utters in tears. assist-ant asked it' slit- wanted in In mint-unt- .11 .buzzt?ccd 3012016 - - lost after 8 that?(items a counselor at htilhvood'asked 'l-?rim hileiitshe was having I BuzzFeeo a heepastor- hestdeher for moral support. she-r9191. ted, -Wall. who hasn't had suicidal thoughts?" She ?d she had no intention to kill herself botjoked. [L?s Texas. it isn?t that hard to act a stun." The).r all laughed. she recalled. She said she had no idea that the counsetor characterized the line as a plan to comm Nor did she know. sl_ie_la_tt-_r testi?ed in a deposition. that the dozen or so forms he gave her tvere. anything other than standard paperwork. She signed them and waited for her counseling session. [t was nearly II p. m. by the time a staff .. member walkedher down a longhallway. Site recalled being startled to see rooms . i-tl?" we'r- that were ?lled not with deal-ts hut with - . WNW ?sf-fey; 4'4 beds. . I o' A technician ri?ed through 'l?rinihle's was? - purse for sharp objects and then a nurse I I. . told her to strip down to her underwear. It was then, she said. that she realized the doors to the ward had looked behind her. Trimhle. who has retently reached a settlement regarding. her hospitalization, recalled shaking with fear and "deep. shameful humiliation? as the nurse examined her body, noting the location of any identih-ing marks. ?All you can do," Trimble said, ?is stand there and let it happen." The nurse handed her a small cup of pills, and soon she was asleep. When she woke up early the next morning. she recalled thinking. l?tut Ma?a-Must happened? Millwood Hospital is part of .Junerit-a's largest p53. chiatrir hospital chain. Universal Health Services, or UHS. Its more than facilities. across the counter admitted uearh patients last tear. The result was almost $7.5 billion in itmatiept last year and pro?t margins of around 30%. More than a third of the company's overall revenue from both medical hospitals and facilities tf"_ gg?l'ront taxpayers through Medicare and Medicaid. Avearlong BuzaFeed News investigation based on interviews with 1325 current and former UHS staff, including 18 executives who ran UHS hospitals; more than 120 additional interviews with patients. government investigators. and other experts; and a cache of internal documents raises grave questions about the extent to which those pro?ts were achieved at the expense of patients. Current and former from at least to UHS lio5pitais in nine states said they were under ttl?CS tt pressure to ?ll beds by almost any method which (3111035663 fl'DI'? sometimes meantexaggerating people?s at least a dozen or twisting their words to make them seem suicidal h?sp I Said 121912016 1110?53 [Eitj?ii'j'li?g i a m" - tried to keep beds tilled even at the expense oftlte safer ol'their stal?for the rights BuzzFee A state-funded 2011 report on one Chicago hospital found ?opt-l Ll?ljt?titltuijtig" staf?ng levels, a ?repeated and willful failure in Lll-lh? officials in and a pattern of admitting more patients than it had room 0? the Patients for ?in an effort to maximize ?nancial pro?t." they Vii-Will? iOCh 111g Investigators also flagged broader concerns, citing Up. ?Lnauhling reports suggesting a 5&1;th of care issues, harm to patients, or major healthcare fraud chatges involving UH S?operat?lng facilities in a dozen other states." UHS is under federal investigation into whether the company committed Medicare fraud. The probe involves more than in to UHS hospitals. Three are being investigated criminally- including t'aciug .4chng ions that it routinely misused Florida's involuntary commitment law to lock in patients who did not need hospitalization. In March last year. the federal criminal investigation expanded to include UH as a corporate entity, the company li_Jit'i ingesting. The compa ny said it strongly disputes the allegations of civil or criminal fraud and is cooperating with the investigation. It has not been charged with any wrongdoing. Ll HS also disputed BuaaFeed News investigation. whose conclusions. it said, ?are contrary to the factual record and UHS policies and practices" and which ?appears to focus on anecdotal accounts" anti "personal perspectives." It added. "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 medical treatment." (Ilead the company's statement here.) The company ?absolutely rejects? any claim that it held patients solely for ?nancial gain. lt disputed ?the alleged ?ndings and conclusions" in the Chicago report and said hospitals have provided compassionate and high?quality care to millions of patients. Citing the approval of independent t'egulaton' agencies. it said, "Every patient care decision is made with the goal of furthering the best interests of our patients." After BuaaFeed News began reporting on LUIS. the UH "ti i330] Lllc? company purchased the domain name rt- cL- 5" [m A person with direct knowledge of L- a [h [1 held the matter said the site was intended to showcase Patienm Sole 1 f0!- stories of positive patient care to counter Btiszeed ?nancial gain. News' investigation. Many current and tanner staff spoke to BuzzFeed News on condition of anonymity. often they didn't want tojeopardize future joh options. About :10 employees said UHS operates ethically and provides high-quality care. ?i can honestly say in my hospital net-er felt like people were being held long after they were iBerngl 2f9/20] 6 luv In hc- said Bill Wilt-H, 12m Ruxbun Huapitul in [111' t'ighL BuzzFeeri - . . .. . .. H31 :51. wank-Cl you EU perform with the. hip,th said Shari Baker. who run I?nlmutlu thmim'ul [mu-munle litmpitztl in South Carolina until earlier thiH yum". culled HHS wry organization." Um ?ores ni'emplmetrs tram Ell lL-am .: derme IFHS l1U5pi1ul$HuEd ll?l?st' [rim] lu keep beds ?lled ever. {hr expt?nae nl? [he sari-U 01? their staff or the rights ml pulimuq ll] "1 n'm't? hurling, up. MILLWOOD H0 SplTi?K ITIIS 'le founder in by Alan Miller, ulna iu still at llL?llIl [why m: uml hoard (?Through spulmspel'sntl, Miller declined repent-ml for an inlenlewfl Wiih thousands uf gPtTing pushed nut 01? public hospilul?. am] with insurance wmmni?-R willing tn approve- 5133?s ml :1 month 01' inure. [he 19805 rrt' a time for private hospitals. But We industry sour: got out I'ngMl 139/2016 ?18 19905. when UHS was still a relatively small player. several of the top hospital?; i ?5 chains were facing state or federal int-'estigations and a stem of lawsuits from patients. Meanwhile insurance companies tightened their policies. demanding shorter of stay. Unable to sustain the pro?t margins that investors had grown accustomed to. the chains began to close or Sell off hospitals. In many eases. LTHS tit-?as the buyer. Today UHS has more than tit-'oand a half times as many beds as its nearest competitor. But in its 211 US facilities. the company?s name is almost nowhere to he found: one hospital's development director said including it in marketing materials was "forbidden." UHS said it does not brand its hospitals, because ?it believes strongly that all health care is local" and each hospital takes an individualized approach based on the needs of its community. A list of UHS hospitals can be found hen: UHS said the majority of its patients are either transferred from another hospital's emergency room or dropped off by police 1who felt they might pose a threat to themselves or others. The requires hospitals that receive federal money to screen all emergentn' patients to determine what care they need. If people require emergency treatment. hospitals must care for them. regardless of their ability to pay. until they are stable enough to be safely released or transfen'ed elsewhere. But patients let alone people who have merely eome to inquire about a hospital's services cannot legally be. held against their will unless they pose a clear threat to themselves or to others. Determining whether patients pose a true risk to themselves or others is hard. said. Clinicians should evaluate thoughts ofsuieide not in isolation. experts said. but together with a range of factors, including a recent change in the patient's mental state and whether the person has a plan to act on the thoughts. hospitals wide leeway to con?ne patients WHERE UHs ARE Still, this standard gives . to locked wards. an extraordinary pn?n'?r la rgely Wit It held from ordinary medical facilities. At some UHS hospitals, people come not because they're on the brink of suicide but because they have seen advertisements for free mental health assessments. ?Highlands can help,? the website for Highlands Behavioral Health in Littleton, Colorado, announces. "but only if you call. To speak with a caring professional or to schedule a free con?dential asaessment 24 hours a day, 3? days per week. please call." iBerngl 139120] 6 BUZZ FeeDasrr meiuhers from across the country said such assessments were often not what they appeared to be. [lt??pik? called in to ask for help or inquire about seniees, internal documents and iIilL'l". icws show. tracked what a fonner hospital administrator called each t'acility's "conversion rate": the percentage ol?cailers who actuaih came in for assessments, then the percentage otthose people who became. inpatients. ?They keep of our numbers as il?we were car salesmen." said Karen Ellis, a l?ormer counselor at Salt latte. Behrn'ioral. ?The goal when you're on the phone with someone is to always get them into the l?acility within 24 hours,? said a former admissions employee who worked at three 11-; facilities in 'l'exas. "And the reason for gettingthem into the facility is that once they stepped foot in. they are behind locked doors." ?People don't understand." said a former intake worker at Salt take Behavioral Health in Utah, ?They tliinlc we're going to diagnose them for anxiety or depression." She added. ?Our goal is to admit them to the hospital." tilts told Buml-?ced News it admitted patients based not on ?nancial consideral ions but only on clinical need: "Decisions regarding admission are made by an attending in consultation wit members ot'the clinical treatment team," the company said in its statement. Asked about conversion rates. Ros. Hudson. a senior rice president of said that while its standard in the industry to il?i?iL'ix various data points, ?it's not a number necessarily that the line statiaire drii'en by.? Former admissions and clinical stall told Bttaalieed News that most patients who arrived at their facilities did need treatment. But staff were under pressure to admit not just those people. but almost anyone who had insurance especially when there were open beds. ?Yourjob is to get patients." said a former clinician at Salt Lake Behavioral. "And you get them however you got them." Laureii Singer. who worked for sis months at the front desk of Colorado's Highlands Behavioral, said people who were waiting, in the lobby for an assessment would ask her what it would entail. would yelled at for orersreppinp ill} hounds and tollinptheni too much ahoul the eialuation process." Singer said. it tuition behind the rereptionist's desk controlled the lock to the from doorot' the facility. and. she said. "If someone came in yoluntariiy. i wasn't allowed to let them not of the door." in a statement to Rosalie-ed News. Paul Sexton, who ran Highlands at the time. said. ?i deny any claims that any patients were eyer wrongfully held or detained at Highlands. Hones er. patients are. not allowed to leave during an aesessment for the. safety of the patient. the facility. and the community." Sexton descnhed that as standard practice across all kinds dips}. cliiatrii' hospitals. iBerngl 12r?9f20 But three leadingorganiaations strongly a 5 it) that view. ?Absent a reason to be $331 pail ant s. A [1d concerned about safety, their own or others?. a on get than person who voluntarin presents for an assessment hnwewer you Um would be free to leave.? said Dr. Stew-n Hoge. chair a . -- ol' the American A?sociation?s Council on them. - and the Law. Ron Honberg. a senior policy adviser with the National Alliance on Mental Illness. said that without a court order or a concern that the person poses a threat to himselfor others. "it's not permissible to hold someone." And Carlv Moore Sfregola. a spokesperson for the American lilospital Association. '?Thcj. get to leave at any time of their own free will unless someone gets a court order to involuntarily commit the patient." view was supported by its industry organization. the National Association of Health Systems. At first. the group?s head of quality and regulatory affairs. Kathleen McCann. told BuzzFeed News something similar to what the other organisations said: People who walk in for an assessment ?are absolutely and totally free to lem'e'~ unless they are clear threats to themselves or others. A few hours later. however. she emailed bacl.? to "clarify" the position of her organization, of which UHS is a member and whose hoard 1will soon be led by the head of UHS's division. (Mt-Calm said she informed HS that she had Spoken with BuazFeed News. but declined to say when.) Patients seeking assessments cannot leave until hospital staff have deemed them safe. she ?role. "This may involve restricting their ability to team the. facility." New to the Boulder, Colorado. area. a you ng accountant named Allison called Centennial Peaks Hospital in June to inquire about outpatient treatment options. Having been diagnosed with bipolar disorder years ago. she wanted to line up support options. just in case. But she recalled being told on the phone that to learn about those options, she had to come in for an assessment. So on her way home from work. she drove to the hospital and sat down with a counselor. who recommended a live-week intensive outpatient program. she recalled. Allison (who asked to be identified only by her ?rst name to protect her privach said she told the counselor she didn?t need anything so structured. The counselor insisted on completing an evaluation now-av. she lecalled. Had she thought about suicide in the last 7?2 She had suffered a bout of depression earlier in the week and had been crying at work. the counselor wrote down. [lot she recalled explaining that such episodes were something she had learned to live with; iBj 12/920016 - - If.? ed Inedications; and than dark mouTts had_ as BuzzFeeo? - a tonyalways-did. Allisonevanremetnbemd tang-hing with?theeoumemr-during the? - ex?aluation. looking back, she said. "my whole demeanor would tell you l?m okay." In her medical record. the counselor ?She always goes Voluntarily to the hospital if her feelings ofSt" suicidal ideation, or thoughts of suicide ?are too great but says she is not to that point. She stated today has been a good day and that her meds are probably balancing out.? Nevertheless. the counselor told Allison they were going to hold her against her I-ler evaluation stated. ?Patient reported thoughts ofsuicidnl idealion within the last 72 hours, Littisshr was admin rd." Allison recalled being givenjust a moment to email her workplace and call her partner. who was expecting her home for dinner that to cning, before being escorted onto the unit. didn't even think that heng inpatient was even on the table." she told iiuzzi-"eed News. ?Iii would have known that. i wouldn?t llawgone in there.? HS said that out of respect for patient privacy. it could not comment on speci?c cases without a patient's written permission. an (i prodding about liven;r state has its own involuntan? commitment ui Ci de.? an law. which allows for patients to be held against get the PETS on 0 say: ?lt?s still on my mind.? their will if theyr are considered a threat to themselves or others. In Colorado, where Alison has held, the standard to hold someone. even for an initial examinationr is high: The threat must be considered ?inuui rein." meaning current. Expected to keep beds full. former admissions workers from three UHS hospitals said the}! learned how to turn even passing statements that people made do ring assessments into something that sounded dangerous. At Millwood. a former admissions counselor said she was told to ?play up the criteria" to get insurers to approve hospitalization. (After a patient was admitted. former clinical staff at Salt Lake Behavioral said. they were trained to "chart to the emphasizing the most troubling behavior to matte the person sound less stable.) Former intake workers said that suicidal ideation could justi?i almost any admission. it "was one of those go?to formulas." said Lacey Wilkinson, who worked in the admissions department at Because that's the way to make sure sleuthing gets paid for." With enough questions and prodding about suicide, DO you know 0f "we can get the person tosay. "It's still on my; mind.? problems at a hospital? Email DEMON. Texas- explained a therapist who performed assessments for University Behaiioral l-[ealth, a UHS hospital in One former clinician at Salt Lake Behavioral said intake assessments might start with the straightfom?ard question ?Have you ever thought 12f9/2016 - bout suicide?" than uni?vs on to the far more theti?cal ?if (05 had a Ian; how would BuzzFeed? ma . a you-do modi?ed?ass plani?? Allison said that's what happened to her. The counselor wrote that it'll) on pills" was "alums har plan.? but Allison told BuzzFeed News she mentioned pills during the assessment only to some of the La,th thoughts she ?amingos had not anything close to an actual plan. In fact. when she was discharged, the doctor ?During the initial two days ol? hospitalization it was clear that she had no intent or plan of wanting to harm herself." A Buzched News of Medicare claims shows that from at least 2009, mm hospitals steadily increased the frequency with which they described patients as experiencing suicidal ideation. By 2013, the code for suicidal ideation appeared in more than halfof all ofthc Medicare claims submitted by UHS hospitals. This is four and a half times the rate for all non~UHS hospitals. {BuzzFecd News obtained ?ve years of Medicare data from l'rol?uhhca, the nonprofit investigative news organization. and a full description of the data analysis is hcrc.) In the first full year after UHS bought about 100 hospitals from a competitor. Solutions Inc, or PSI. their use of the billing code for suicidal ideation in Medicare claims shot rising more than sixfold overall. In melr?b?ls to imitate,- UHS hospitals a refers to thoughts of I t' hospitals do. UHS buys PSI .i Nov. 2010 i iBerngl 12193201 6 mana er rfvho worked in billin at one of those hos ital-ssaid?t?hat after Lifts?bggiit it: I "g I p. sense - -'iwehad-to-adeEt-t? their-ways? wantatusto-bethorougla- - and build the severity level as much as we could.? She explained that merely being. depressed might not support admission. But. she said. "If you're suicidal, a threat to yourself. you're more acute and it would better support admission." Those UHS said. were simply evidence of more scmpuloos attention to proper coding, not of a higher propensin to diagnose suicidal ideation. Internal and external auditors. the com pany added. ?hare never identi?ed any improper assignment of the suicidal ideation as a coding designation." More. broadly. UHS said. none of its facilities have ?received a citation from a regulatory authority alleging that any patient was improperly admitted," Some former agreed with the company. "It's definitely a very census?driven atmosphere. but ifsomeone doesn't meet the criteria. ix'c'rc not going to admit them." said Alisha Powell. a former intake counseior at Highlands Behavioral in Colorado. Allison was released from Centennial Peaks on her third day. but her partner said she is still living with the effects. ?She?s going to be scared to death to ever walk into a facility like that again." he said. CORPORATE CULTURE Several people who ran HS hospitals said corporate bosses pushed them to cut their hospitaLs' staff further and further each year. regardless of the impact on employees safety or on their ability to care for the people being admitted. Each year. hospital administrators presented their budgets to a panel of corporate leaders. And each year. people who were involved with the process say. corporate execs offered the same prescription: Cut more staff. One former hospital head said that after she presented the. annual budget. the hel'iavioral division's chief ?nancial of?cer instructed her to cut nine nurses from the. staff in order to increase pro?ts. The executive resigned instead. wasn't going to fire a bunch of nurses [just hired.? 53'fi'tf'lr {Hid lJ?llEfli'S the executive told BuaaFeed News. She later ?Wch not {1 expiained. "It would have compromised the quality litrioril}? The Dime" priorin has the bottom line." 129/20 1 6 Internal financial reports reviewed by: Iittzxi?eed BuzzFeeo a New; show that in 20-14. one. LJHS facility projected a more than 50% profit. Even as the facility had increased revenues in the previous years, it had continued to cut staff. ?It was true greed," the person who ran that hospital said. A copy of the 2013 Executive compensation plan states that annual b?l?t?i were. ?designed to reward ?nancial performance in excess of budgeted expectations." Top hospital executives could make up of their annual salary based on their ?nancial performance. Only a modest sum in comparison, an additional got-ti of their llttut?lt?lul aunt-d. Could he added based on measu res of patient care. Hudson, the HHS senior vice presidem. said that structure did not unden'alue patient care. since all incentives are predicated on the ability nfthe hospital to maintain its accreditation. ?lfa facilitydoesn't maintain their level ot'quality. then the bonus plan is irrelevant." she said. But for one former hospital administrator, Iwho stayed ?ve years with the company and earned a large bonus UHS's message was clear: In this corporate culture. staff and patients "here. not a priority." he said. ?The priority was the bottom line. PATIENT CARE Carson Mangines was looking for help when he walked into Highlands Behavioral. The 22?year?old had been cutting himself and was addicted to opiates. After his admission. a doctor giggling a dose of fentanyl a opioid far more potent than heroin - every three days. for pain relief. His mother. Lianne. recalled that "could hardly even speak" 1irhen she talked to him a few days into his stay. One night. a nurse on the overnight shift mistakenly it not; that he was due for a new patch the tit.th dag. even though he hadjust had a dose that day. according to a lawsuit the family later brought. A colleague had already complained to administrators that the nurse was "hth?t-t yhiLrLing," or documenting things that she had not or done. the colleague later told local law enforcement. The nest day, after Mangines? second t?entanyl dose in tied: In: 5, a social worker wrote that the patient was "oti?et'medlealedi' and "almmt Ul. his Other stuff noted that he was falling aslgp and starring his words and that later he i omitcd up his medication. No one identi?ed these as signs of opioid overdose. iBerngl 12/9/2016 BUZZFeemhen engines took a broken pencil to his thigh in the shower that night. staff put him lr'tHAl' i a the_qt1iet rotln. They were supposed to check on him tn. on liminutos. His chart says he slenLtlutiush But by I1. in the morning. his body was in Lich inertia. He had been dead for hours. The dumps; suitlhc t'ltt'tl nt [mu-in. ?They killed an opiate addict with Opiates," said his mother. "It's unbelievable to me that could happen." According to a summary of ride.th from that night, staff members who were 319;;ng for breathing had only glanced in his room from the hallway. The angines family settled its wrongful death suit in October. UHS told BuaaFeed News the dose of fentanyl was ?appropriate for r. Mangines? and that according to an expert review. his death "was not the result of negligence on behalf of the facility." UHS did not respond to a request to make that review available. In statements to police. eight Highlands staff said they were inadequately trained or understaffed. Several inteniewed said it was their ?rst job out of school. or their ?rst in care. A nurse involved in Mangines? care told police she had just orient" training at the hospital. And the nurse who gave Mangines dose told police she had little experience and that she often had so many medications to distribute in such a shon amount of time it was inmossihle to check if each was being administered properly. A supenisor told police she. had gotten The position just a few months after she received her registered nurse's license. She said the hospital?s practice of moving new nut-Sea into management roles put patients at "litiggljisli" and that ?push much t1th [Lug rt- lining." It wasn't just Highlands. A rcnort singled out the unit for the most troubled patients at Millwood Hospital, which had just one mental health tech and two nurses. With numes busy updating charts. admitting patients, and passing out medication. only the tech was lett to check in on the. unit's 19 patients every 15 minutes. Staff inten'iewed said thong-aren't enoueh of them. Other UHS hospitals in _s and in Georgia, Florida, Louisiana. and Mississippi have been cited by federal regulators for poor staf?ng as well. UHS said most nfthe citations werejust for "isolated violations of the facility's own policies." Nancy Smith, who worked as a corporate director of clinical services until 2012, said the company ignored her repeated pleas about insuf?cient staffing levels. Her job required her to review patient charts in about a dozen hospitals in four states. She said she often became alarmed because doctors barely met with patients and the notes on charts didn?t match up with the observations of floor staff. She described the number of staff in the hospitals she sopervised as so low it was "almost criminal." [t was, she said. "so unsa fe." Yet, she said. her concerns Were ignored. 12f9f20] 6 BuzzFe-eo . - - -- I ?15 {nil-d; b-Li- - teenagets ho'trdingon-theehild'sunit, and kids "ever; hed ttlled There would on tl'Ekicl unit, we: 1; sleeping in the dap?oom on rubber mats." Palmer l-m ill?: ?Hi l- told ttuzai-?eed News. "And also in the seclusion rooms they would he sleep-hieI in there as well." hoarding on the Chi il? Hm] Seolnsion are meant to contain patients who 5 5 I cup ng have hemme dangerous. Aeeording to federal .. . . tlat' ts,the rooms are mean it the daytoom on i? ?3 i? ?1 .. and other patients. ?r?et staff at four other UHS rubber mats. facilities told BuzaFeed News that there, too, the. rooms were repurposed when the hUSpitals ran out of regular beds. Federal inspectors noted in 2014 that River Point hospital inJaeksonville. Florida. had more patients than hurls. They t?scut?erecl tin}! mattresses in a Closet and on the floors of some patient rooms. .t?t hospital oil?Leia! told regulators the arrangement has "ht-tit)! Elm-32:1; a l'll than Speaking for the company. the senior rice presidentI told BazaFeed News that when there are ?limited beds in the entire t?ommu nitjr." llS's "responsibility is to be responsive to the needs of the patients.? She. added, ?We're not abandoning the patient. we're. taking, care of the patient." In this environment both patients and employees said they often felt helpless. "You just hope there?s no type of crisis." said Diana Westriek. who worked as a tech at Old Vineyard Behavioral Health in North Carolina. ?I'm 5'2? 3 small female and was left a lot with 12 to 18 patients by mysall?." (Joe doctor who worked at Fairmount Hospital in Philadelphia said the culture of the hospital and the heavy patient loads were "eating my soul." ?That was the worst clinical experience that I had and I worked at a prison at one point," she said. At UHS, ?we were saying to loved ones that we?ll help them. and we didn't have nearly enough resou rues) WOULD LIKE TO GO ?When Trimble. the teacher who went to iIIwood Hospital for a free assessment, woke up the. next morning. she noticed a plastic hospital bracelet had been placed on her wrist. Still wearing her clothes from the previous day. she recalled, she walked toward the nursing station at the end of the hallway, passing one patient drooling, and another hitting iBerngl 1 21912016 1n the face. She had been admitted to intensn'e care, the unit tor The most-severe patients. would like to go home." she told a muse. She said she was not aware of it at the time. but one ofthe documents she had signed the previous night granted her cousin to be hospitalized. Now the nurse. said they couldn't release her without a doctor's permission. Hospital records show ?t at {3:05 that 'l't'imhlt? ?lled out it tribe lingtz. Texas rules say that within Four hours of tilting out that form. patients must be discharged. unless a physician ?nds cause to hold them against their will. A doctor instructed the [whitnl It was 4:30 in the afternoon by the time she met with that doctor. the ?rst one she had seen since she was admitted. At the meeting. 1which 'l?rimhie estimates lasted about 10 minutes. the doctor denied her request to go home. ?You've been converted to an involuntary commitment," Trimhle recalled being toid. Records Show that her treatment plan listed an estimated stay of ?re to Seven dog, in line with the ?ve days Tri 1311;] l_ ejad optioned. Tn'rnble called her mother to help get her out. Carolyn ?t?elehof?f drove down to the facility. but staff there refnwt-t! rt-lt-iiseTrimhle. So Velehoff salted the FBI: "th daughter has been kidnapped.? she said she told an agent, spokesman for the FBI of?ce in Etallas declined to comment on whether it has contacted.) On the afternoon of her third day at Millwood. Tn'rnble cal ted the local police. An of?cer came to investigate, but the hospital refused to produce am lLaperuuirlt to support Trimhle?s admission. A supen'isor told the officer "not to interi?erenhh n'wdicnl staff," the police report noted. "Based on of ?eer's training and experience, of?cer did not believe comp was danger to herself or others." the report stated, referring to Trimble. It also stated that the of?cer believed that themi?yitnl ?ms But after an hour and a halfat Millwood. even the police of?cer was unable to 1sin her release. KEEP THEM IN Two dozen current and former employees from 14 UHS facilities across the country told BilaaFeed News that the rule was: to keep patients until their insurance ran out in order to get the maximum payment. iBerngl 2i9/20 1 6 Three former heads of UHS hos itals said their dii'ision-al vice resident. Sharon BuzzFeeo it'otshamt repeated a mantra: Don't ieax?e-daya-on-the-tablet: . "tl' an insurance company gave you so many days, you were expected to keep the patient there that many days." said Rick who ran Austin lattes Hospital in Texas until 2014. [t was a ?common practice" that was openly discussed in regional conferences as well as phone calls with hospital execut heat. which Worshatn led. he said. Buckelen' added that he did not {Ollow this practice and that the operations he oyct'sau at his taeilit) were appropriate. Wot-sham said she and Florin-ten did not have regular discussions ?ahout days on the table. relating to Austin lattes." Employees of tJHi?i hospitals from Utah to said this message trickled down to staff and doctors through ?flash? meetings, the daily gatherings in which administrators ran through the list of patients in the hospital, discussing treatment and discharge. in its statcmerit. UIIS said it "rejects any t-iccusation? that any ofits hospitals improperly manipulated length nl?sta} "to increase ?nancial performance," it said ?discussion ot'Ilays on the tahle' was about patient safety concerns." if an insurer had determined that a patient needed a certain number of days. the company said, "it was appropriate to evaluate with the relevant physician and clinical team whether premature discharge was in the patient's interest." Karen .Iohnsont senior rice. president ot?riinicai sen-ices. praised flash meetings, describing them as an to "t?ltal-ie sure We're prepared to take care of each patient tt?ont a care pe rspert he and loolx at each discharge to make sure the patient has a t'iahle and manageable discharge plan so that they ran transition safely" hack to the. community Several former exec-attics who ran UHS hospitals agreed that flash meetings focused on medical care. ?i'et more than so executiyes and managers who attended those meetings in 12 states said their "l l' ttl'l purpose was also ?to how man days they in] have and to try to use up those days." as one former it rm it hospital head put it. (km L'Rtk?ulc?ti ill keep the patient there. Ihat many do} Two people who 1a'orlted at Highlands Behavioral in L'olumt?lo uhett Paul Sexton, then the head of the hospital, led the daily ?ash meetings, said he ran down the list demanding an explanation for each early discharge. "Why are. they going home? ?they still hay-e days left." one of the staffers recalled him saying. [Sexton told Buzzli'eeri News "the purpose ot'such discussions was clinical. Any ?nancial bene?t was secondary and only applied ifthe patient met clinical criteria") buzzt?eed 139/2016 After ?ash meetings. linspital managers such as Maria 'l?i ins at Salt Lalte Behavioral said BuzzFeeo - PP a the},- were expected to rises the rue-stage along to doctors. He said he chose an understated- approach. Referring to patients who still bad days left. he recalled saying. ?Second Floor" the hospital?s administrative offices ?wants me to see what we can do to get this patient to stay longer." For patients. the experience could be bewildering. even terrifying. ?It was pretty common to get women in the unit who were like. 'Why am here? I don?t need to be here,? recalled one former manager at Salt take Behavioral. ?We were just enoouraged to tail: them into stayng until as lon as insurance would cover.? She added. "Whatever manipulative strategies we Could use. we were encouraged to.? the patient was a mother, she said. employees might threaten to cail child protective sertices and have the patient's children removed from her care. UHS said the hospital "'does not more threats of any kind" to try to "force patients to stay against their will." At l-lighlands, a staff wrote to Worsham, the corporate divisional director. "1 am, in particular. deeva disturbed about the efforts to extend of stay." he wrote in a 2014 entail reviewed by BuaaFeed News. ?Doctors are publicly shamed by asking them to justify discharging a patient ?early' before the end of their insurance authorisation.? Two weeks later, Worsham responded by asking that PAYING speak the medical dtreetor oflus hospital about his MD "perspective." Worsham told BuzzFeed News site oversaw At Florida and Camomla hundreds of doctots and doesn't remember that particular hospitats in ?cent . . . 3 exchange. She denied ?any allegations that Clinical. decisions have ever been made. for purely financial purposesPATIENTS -- In a draft (tithe 2014 strategic plan, winch he THREE D-A?ji .. said was not presented to LlliS. Sexton described extending patient stays as a means to meet financial goals. Sexton proposed that the hospital "develop and implement a plan to increase average length ot?stav" as a means to meet financial goals. Other executives also told BuaaFeed News it was one of the strategies they used to meet their budgets. After UHS teamed that News had obtained a copy of this strategic plan, a lawyer on hehaltot the company demanded the return of it and any other internal documents. BuzaFeed News declined. Sexton Eater wrote in an email to Bantieed News that length of stay is a common ind ustry metric and +?any plans or efforts to increase length ot'stav at Higi'rlands never involved keeping patients beyond a 1 2/920 16 isrharge date as determined hi; the. tiltenttin He added that lie believed BuzzFee-ti1 - [1 U-l-lStvae an "ethical mamas}: :?it least the hospitals, Il'hltluijgij, lune been tritetl hy federal regulators [in R'itjl?iltm I'lglil in it illitml this lH said these t'ilutinns were pi?t'n?edtlt?al errurs that "do C(iJistittite iltlt?ti: ni In [mid patieltls ulm iln nut meet criteria ur tielzli' Humane." STAY Due. lmspiml acquired hj,? l'IlS River Point. in Jacksonville. {?nk Elli tippi'rmt'h T0 determining how 1011],: peuple he hospitalized: At the itiStt?Ltetiun tiltiui'ie l-Zelierd. the linspilztl's top executive. River l?nint It} (Lifts- the ?guideline? [or hair lung in keep patientS. Ten days is the length m'time for which will pay the full daily rate without requiring, the hospital to get approval. Ami uemrtling In eight current and former River (i buss: a ??go?ernrneotjaayrnents.? a - oi oi employees and it?westigative docunieEs. the hos ital's true oal win) maximize BuzzFeerl? Beyond the trauma of being con?ned against their will and the disruption to their lives and jobs One patients with chronic illnesses faced dire tfil consequences from this approach. Medicare grants new Shed only iil'iltintient 'cl iatri" trcatment . . . . r- 1-. I. in; as in "guideline" For how long to patients. the. course of a palient's entire life. So spending those days if they weren't actually needed to "taking away care that they're going to need later and they're not going to hat-e," said a former discharge planner at Highlands Behavioral. Ecl-zerd, who ran River Point until 2014. kept close track of the facility?s average length of stay, which was displayed on a board in the conference room where flash meetings were held. The higher the number climbed, current and former staff said, the happier Echerd seemed. [Erhard died suddenly that year.) "Flash meetings were basically to discuss why patients were leaxing hefore day to," said a former River Point manager. If the} left sooner, the manager continued. "you were questioned: 'W?hy were IJ'tey leaving?? Eolterd?s effort succeeded. In early 2009, the year she took over as CEO, just 37% of Medicare patients stayed for to days or more. By early 2010, the year UHS bought the hospital, that rate had to more than 70%. UHS kept Eckerd on to lead the facility, and the rate stayed high for years Asked about that increase, Johnson, the HHS senior rive pFeSident of clinical services. said that River Point was ?providing care that?s necessary for the patients." Now, however, ?lth-rut itnestigalurs are re thing Do You know 0f whether River Point achieved thosa numbers in part problems at a hospital? Email by abusing the courts to hold patients against their will. In response to questions about River Point?s operations. Hudson, who m?ersaw Eckerd, told News that all UHS's hospitals "have a responsibility to the safety of their communities? and "we do that very well at our hospitals and River Point does it Very well." ?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," UHS said in its statement to BuzzFeed News. It added that this was not a one-size-?ts-all requirement. An Unaniployed veteran. Michael Pruitt said he was feeling hopeless when he called a help line for team in March 2014. Police brought him to River Point under a Florida state law that allows authorities to send someone for an involuntary examination for up to ?2 hours. During his stay, federal regulators would visit River Point in response to an into allegations that the hospital was improperly holding people for to days in order to maximize insurance payments. 12/9/20 I 6 BUZZFethccording lathe hospital, Pruitt had told the. VA he was hatingthoughts ol' killirngqusell. When he arrived at River Point, however. records shon- he H?tti in; mpg; When those 7'2 hours were up. he expected to go home. But the hospital nould not release him. Instead. the hospital ?led a petition in court to hold him longer. Just ?lingI that petition gave the hospital the legal right to detain Pruitt until he had a court hearing. Those petitions are meant to be used only in extreme macs. But at River Point. three former therapists told BuzzFeed News, ?ling them became standard practice. "The rule of thumb is: Ifyou came in under at Baker Act. we're going to ?le a petition, and then we ?gure out what the days situation is" with the insurance company. one former therapist told News. ?It'they didn't have insurance they were discharged." But if they did hate coverage, the former therapists said. filing the petition would allow River Point to hold the patients in the hospital. and to keep the insuranCe money (timing. BuzzFeed News twill-sis of court records shows that in 2009. the year before UHS hought the hospital, it tiled 238 petitions forint'oluntan' commitment. Four years later, that number had grown to 1,362 an increase of more than 4:?096. UHS said ?any claims that the Baker Act process was used improperly in any way at River Point are completer unfounded." It attributed the increase in the number of petitions largely to increasing the number of beds for elderly patients, ?who commonly have challenging mental health issues requiring involuntary commitment." Therapists who ?led these petitions said the doctors gave little justification for holding the patient sometimes just a few words with almost no context. Public defenders who represent Baker Act patients noted this as well. The petitions ?led by River Point ?were often legally: insuf?cient and lacking in supporting documentation," said Stephanie Jaffe. a public defender in Duval County. Four days after Pruitt?s admission. the federal regulators who were looking into River Poi nt?s practices [t?jjfutiti his records. He told them he was being it?liti? ill. According to their report. his doctor could not explain why Pruitt needed to he involuntarily.- hospitalized. The documentation in his chart support his listed diagnosis. When asked about i?ruitt's diagnosis. the doctor told investigators that he still wasn?t sure. ?l'rnhabl; :1 ,rnomt disorder. I've only him a short bipolar affective disorder," the report quotas him as saying. to response to questions about his the doctor answered that his patient was "anew. irritable and miltth hosje." UHS told inspectors it held Pruitt to ensure that he was safe. The inspectors found that River Point had @?gt?l??bj evaluate Pruitt for discharge. and they told the hespital to correct its standards. In April 2014, because of the larger investigation that brought the inspectors to River Point in the ?rst place. the government Mtt?lld?il Medicare payments to River Point. UHS told BuzaFeed Newt's it has "consistently disputed and refuted the purported basis of 12/9/20 1 6 BUZZFeedhe Florida folloa-ed;ith assoc?ohm othtaicaii a ?*?pa?1neosa avg-{A_ . LET THEM IN In September of last year. Kevin Burns felt the urge to hurt himself again, .ltht two days before. he had been released lrom a UHS hospital. Suncoast Behavioral Health in Bradenton. Florida. But having battled schiaophrenia and depression for much ot?his 32 years. Burns knew the warning signs. he said the frightening and m'em'helming impulse to cut himself. So he walked back to Suncoast. The hospital liner, Fetusng even to let him in for an evaluation. something that many UHS hospitals. including Smmoast. advertise as a free service. The receptionist ca! let_l_trl,g- police. Burns walked behind the hospital to a nearby Walmart. where he bought a package of razors. Before the cashier had even handed him back his change. he popped the package open and made several _tLuiijl'LLEep entail: vat-1L . was begging for help. and that was the ?rst logical thing I could think of' to do." Burns told Buzali'eed News. li'lorida?s health care investigated Burns' case. The hospital told state investigators he had threatened to hurt staff a and that two employees later vowed to leave ifhe were allowed in. investigators ruled that the hos }i_tal_had i'iolatcii emergenci- treatment iah's. In the end. Suncoast {glniittL-djt had iolHled state. law. and the agency ?ned Stung. At Suncoast. said three former employees. admissions decisions were simple. If the person has insurance. why haven't they been admitted? it they don't have insurance. why are they st ill here? "We had people with medical needs that we could not meet.? said Painter. the former intake em ployee who worked at hospitals including Suncoast. There. she said. the hospital's leadership "would pressure us to accept them. jest because they?re paying customers.? (to the other hand ?It they couldn't pay, ship them out." In int?en'iews. staff from many,- hospitals con?rmed that despite these. goals, did accept uninsured patients, such as those dropped off by police or those who needed emergency treatment. Sta?' also said that clinical stat and doctors could advocate to keep some patients past the end of their insurance payments it' the need seemed great enough. hops/minor. buzz?ecdcom/ rosali ndadams/ 122?9f201 6 Buzz}eed3ut former encoutires said pushbackironi superiors For-admitting too?7 mm I. i a they all-didn't? hayea-payer?L?an insurance-plan "the nest day you'd get a call from your corporate regional person: ?Why are you admitting ?self?pay? payers?? said a hospital executive who left the company in 2014. ?If someone is self -pay it's well known that's a no-pay." Another former executiye. who ran a HS hospital for ?ve years, said the pressure came right from his corporate superiors: ?You were told to do things to eliminate uncompensated care. all the way down to basically lying and saying, that you didn?t have a bed." That happened at Suncoast too. Palmer said. Uninsured walk?in patients sometimes waited for hours in the lobby as intake workers looked Fer another facility to transfer them to, explaining that there was no bad araiiahle. Sometimes there really wasn't a bed available. Palmer said, but "sometimes it wouldn't be true.? A former Suncoast manager who is also a licensed nurse said she found the hospital?s management so unethical that she resigned. None of the Suncoast workers interyiewed knew about Burns? casespeci?cally, and ilcouldn't be insured people determined if insurance factored into the liespital's who did? '1 decision to lock him out. But in retiewing Burns" ?hum-S necd records. BuaaFeed News found something not . . mentionedintliestate'rinyesti revious getting 33 admitted." and "uninsured people not being time Burns was hospitalized. his Medicaid provider had declined to pay for eight of the 13 days. UHS said any assertion that its hospital turned away 1105-3le I [261] emergency patients in need ofcare ?is categorically t?i?i?lel'l SilULlid false." It said it provided more than $85 million of be. uncompensated care to patients across its division last year. HS had a practice or policy oi?de?ecting uninsured patients, there would be hundreds if not thousands" of citations fortiolating federal emergency treatment laws, it said. while in reality it has received only an ?exceptionally small number ol'citations? (WET the last ?ve years. But more than a dozen current and former employees also said that UHS pushed employed; to make sure that uninsured patients were discharged as quickly as possible or better yet, not admitted at all. Ellis. the counselor who worked in the admissions department at Salt Lake Behavioral Health. said the practice posed a dilemma: ?On the one hand. you have insured people who didn't always need treatment getting admitted. But the llipside is that you have uninsured people not being hospitalized when they should be." ?Peopledidn't get admitted became they met the criteria," she said. "There was always a financial consideration." 12f9i?20 6 the companv?s Florida has itals between 201: and sons. F596 ot'self- an?n atients BuzzFeeD - . . t_ . p; 3" were gnawir?i-mth-nlst mtheommercial insurance. (Other for-profit hospitals had a similar disparity, hut not?for- pro?ts showed almost no difference.) In California, ?imitamnterg Was found. Asked about this discrepancy. Jolmson said a patient's length of stay is based on their individual treatment plan. She disputed that a patient?s insurance was a factor and said a discharge is "a clinical decision: it?s not a business decision.? VISIBLY UPSET At itiillwood Hospital, where 'I?ri mhle. the AP history teacher. was held against her will, the police of?cer who answered her call had no success getting staff members to show him her records- Eventually he left. He in Luis rig-9511. that ?patient rights stated that comp" complainant, meaning Trimble ?could look at records but staff refused to show records to comp or officer. Comp was risiny upset." Trimhle saw her doctor again the next day. The doctor observed that 't?rimble. Was ?u rit Log down each and ererr word and :iskine about her rights.? behavior the doctor characterized as "very paranoid.? ttut in the diseha rge note, the doctor wrote that she had no reason to 1th Trimble against her will. hecause she was not suicidal ur homicidal. 'l?rimhle was released later that day. She has since sued the hospital for negligence and In court papers. UHS said 't?rimhle had been properly admitted and treated. based on physician orders. She says she fought hack after her release because began to realize what happened to me was wrong." she said. It was a shame and humiliation that I?ve never experienCed in my life." Last month. she agreed to settle the case. UHS won?t reveal the tones of the settlement. but the company maintains it did nothing wrong. Jeremy Singer-Vine and Kendall contributed darn anniysis to this story. ?ow-zbuzzfeedcomt?rosal 12/9f2016