September 16, 2019 FROM: Bryon E. “BJ” Coleman Jr. CEO, North Tampa Behavioral Hospital (NTBH) TO: Neil Beedi, Investigative Reporter, Tampa Bay Times Subject: North Tampa Behavioral Hospital Follow-Up Response to Story Outline: Dear Neil, Thank you for offering NTBH the opportunity to provide additional important context, clarifications and corrections. As I stated in my earlier correspondence, I believe that your planned reportage provides a highly distorted and sensationalized portrayal that absolutely does not reflect NTBH’s overall record of providing much needed intensive behavioral health care services to needy patients across the greater Tampa community. Moreover, your recent story outline often unfortunately appears to rely on the anecdotes and opinions of a small and wholly non-representative sample of former patients, family members and in some cases, unscrupulous attorneys with potential personal and financial agendas. While I addressed many of your allegations and conclusions in my main written response last month, below I’ve provided some additional important information while ensuring adherence to all applicable patient privacy laws and our company’s code of ethics. Summaries of Isolated Patient / Family Member & Attorney Accounts: As we’ve stated repeatedly, NTBH is legally and ethically prohibited from providing details regarding specific patient encounters and allegations. However, many of the accounts and depictions provided in your story outline contain significant inaccuracies and critical missing context that if able to be fully disclosed, would provide a much different perspective than the overtly negative one you are currently choosing to pursue. Notwithstanding, your purported discussions with approximately 15 patients and family members out of over 17,000 total patients treated over 6 years should be placed in a more objective context. Moreover, and as more fully addressed below, several anecdotes appear to closely mirror unfounded allegations from plaintiff’s attorneys claiming to represent NTBH patients, some of whom have caused disturbances at the facility including threatening staff and soliciting patients. We also specifically refute anonymous claims and opinions ostensibly made by patients regarding the frequency of physician consultations and the overall quality of the clinical program. NTBH follows individualized, intensive and regimented treatment protocols which include both group and individual therapy sessions covering a wide range of evidence-based techniques. We also integrate exercise/activity, arts (e.g. music, meditation/deep breathing) and other education focused programs. Patients are also provided time for personal reflection and meditation which has been linked to positive outcomes. Nursing and other clinical staff conduct vital sign checks and medication managements for all applicable patients which are all overseen by the attending psychiatrists. Baker Act Allegations, Average Length of Stay (ALOS) & Financial Impacts: Your outline contains numerous misleading and incomplete allegations that I feel compelled to address. First, NTBH strongly rejects any claim that it deliberately or willfully holds patients against their will absent a legitimate, clinically based determination by a licensed psychiatrist that the decision is in the best interests of the patient and the community. Second, we likewise dispute the inaccurate contention that clinical decision-making regarding the appropriateness of extending Baker Act stays through either the BA-32 (i.e. 1 extending the initial 72-hour hold which you inaccurately characterize as a “loophole”) petition process or in some cases effectuating a transition to voluntary status is ever driven by financial motivations and/or any type of nefarious intent. This is absolutely not the case. Third, when describing the purported financial impacts of both voluntary and involuntary treatment, you misconstrue and largely ignore the important reality of medical necessity validation and audits from payors of all types. Far from being a “loophole” in state law, BA-32 petitions provide the opportunity for physicians to extend a hold if they believe that the patient’s clinical symptoms and presentation require continued inpatient care. This is the case whether or not the patient has insurance coverage or is indigent. As you likely know, as a long-time Baker Act and EMTALA receiving facility, NTBH is required to provide the same level of care to emergent patients whether or not there is any expectation of reimbursement. NTBH treats a significant number of indigent, uninsured patients. Moreover, even if the patient has insurance coverage, the mere act of two physicians filing a BA-32 petition does not equate to a decision from any payor that they will actually certify reimbursements to NTBH or that such an action by itself will satisfy established medical necessity criteria and reimbursement policies that are subject to stringent reviews and audits. As stated previously, patients suffering from serious psychiatric conditions do not always have the same ability to make rationale, objective decisions regarding their care in the same way as a patient in a traditional medical/surgical context. As for your comparisons between other hospitals in Pasco County, some important clarifications are necessary. As an initial matter, it’s important to understand that potential court hearings for BA-32 patients only occur once per week (NTBH’s day is Thursday). This schedule is set by the court and not by NTBH. The practical effect of the docket schedule often creates a situation where a determination is made that continuing care is clinically indicated, but given the timing of securing docket space, by the time the court date arrives (up to a week later and often longer than the ALOS), the patient’s condition may have improved to a point where safe discharge has already occurred, hence necessitating a withdrawal of the petition. In other cases, physicians work collaboratively with patients and their families to transition to voluntary status, knowing full well that doing so will permit the patient to request release if they so choose but also avoiding a time consuming and often stressful court appearance while continuing to receive the care they need. There are also uncommon situations where patients and their family members may have good faith disagreements with the clinical determinations of our psychiatrists or even disagreements amongst themselves where the family may push for discharge while the patient and clinicians believe that continued treatment is the best course of action. The overall point is that these decisions, while sometimes difficult, are clinical in nature and made in the best interests of the patient. Attached, we have updated the previously provided patient and financial data spreadsheet to break out ALOS between involuntary and voluntary (including generally longer-term service offerings such as SUD treatment, geriatric and military). As you can clearly see, ALOS among NTBH’s involuntary population is significantly lower than for voluntary, averaging 6.21 days between 2014 – July 2019. This is also lower than the statewide ALOS for all psychiatric hospitals between 2013-2017. Of note, in 2018-2019 NTBH’s ALOS among involuntary patients has decreased further to 5.9 and 5.2 days respectively. Notwithstanding, attempting to compare ALOS between facilities in one county to purportedly “validate” evidence of nefarious or improper practices (which do not exist) is a 2 very poor and largely inapplicable benchmark that ignores various important realities such as the acuities of the patient population (voluntary and involuntary), specific treatment programs, the hospital’s care approach (pure stabilization v. stabilization & treatment) and overall expertise. While I cannot speak to the dynamics at other hospitals either within our county or across the state, I can attest that NTBH adheres to a stabilization and treatment approach that emphasizes compassionate, evidence-based care in a therapeutic setting aligned to the best interests of the patient and community. Similarly, your insinuations regarding potential financial impacts of Baker Act (including “running up their bills” and “skirting the law”) are highly inaccurate, incomplete and needlessly inflammatory. As described above and in my prior written response, there are strict industry-wide clinical criteria governing admission to inpatient psychiatric treatment, whether voluntary or involuntary and without regard to whether the patient has insurance coverage. NTBH physicians follow this criteria for all patients including by conducting detailed ongoing assessments in full consultation with other members of the clinical team. For patients with insurance coverage (including both commercial and government[Medicare, Medicaid, Tricare]), reimbursement is subject to the payor’s medical necessity and coverage guidelines which include frequent and comprehensive review of the patient’s medical record and peer consultations with clinical staff. If a payor believes that inpatient care is not clinically appropriate, it will deny reimbursement to the facility regardless of whether the patient is subject to any Baker Act petition. Furthermore, your claims regarding the financial details (including mention of $1,500 per diems) of NTBH’s reimbursement are highly inaccurate and misleading. To illustrate, the actual average reimbursement rate for NTBH across all patients and payors (both private and public) is approximately $670 per patient, per diem which is consistent with reimbursement rates to other providers treating similar patient populations in the region. Likewise, and similar to ALOS, attempting to highlight operating margins (and cherrypicking individual years while doing so) to perpetuate a misleading narrative is equally problematic. Like all businesses including hospitals, operating margins can vary significantly depending on a wide number of factors including overall demand for services, reimbursement rates and network coverage, capital expenditures, staffing and occupancy costs and similar dynamics unrelated to patient care. Since NTBH’s founding (excluding the small portion of 2013 during our initial operations), our annual operating margins have ranged from - 15.6% to 15.1% with the average between 2014-2019 YTD being 4.4%, which is well below the 9% average of all Florida psychiatric facilities during the same period. Some years NTBH experienced higher operating margins (e.g. 2015, 2016, 2017 and some years (e.g. 2014, 2018 2019 YTD) it operated at a loss. To highlight a handful of years while completely ignoring longer term trends does not provide your readers with a complete picture of NTBH or the overall economic reality of health care providers in FL. Regulatory Citations – Baker Act & Non-Baker Act: As an initial matter, the handful of Baker Act AHCA survey reports referenced in your outline largely involved administrative record keeping citations related to the technical compliance process surrounding involuntary admissions and discharge procedural issues and not to any intentional or willful policy or practice by NTBH and/or its staff to inappropriately retain involuntary or voluntary patients not meeting established clinical admission and treatment 3 criteria. NTBH has never been subjected to any federal or state citation alleging or corroborating such practice which makes sense because no such practice has ever or will ever exist. As stated previously, the vast majority of NTBH’s AHCA, federal CMS and Joint Commission inspection surveys of NTBH result in clear determinations of substantial compliance with all licensure, accreditation and CMS Conditions of Participation. Many surveys (including those initiated from complaints) were found to be free of any deficiencies. Nevertheless, like nearly every other hospital in FL and across the entire country, NTBH is routinely subject to surveys which invariably include citations and recommendations for improvement which we take seriously. This is no different from hundreds of other hospitals and health systems that experience similar issues. Of note, there have been zero serious level AHCA or CMS regulatory findings at NTBH in the last 24 months as evidence by the lack of any conditional level or immediate jeopardy (i.e. deficiencies that can negatively impact a facility’s federal funding and ability to admit and treat patients). All citations in the past two years were standard level, indicating that the finding can be remediated through the submission of and acceptance of a formal plan of correction which were indeed timely submitted and fully accepted by AHCA after comprehensive resurveys. Moreover, many of the referenced citations involved administrative, relatively inconsequential matters such as website posting guidelines, documentation and written copies and other organizational matters not directly impacting patient care or clinical quality, all of which were fully resolved. We also reiterate our strong objection to your assertion that our employees are unqualified, undertrained or that they ever knowingly put patients in danger or denied them rights. As it relates to the issue of initiated or imposed regulatory fines, I would like to correct my previous statement. I was referring to the lack of any federal/CMS related fines or payment de-certifications as opposed to those initiated by AHCA, and I should have been more clear on this point. NTBH has indeed been subjected to a small number of mostly minor administrative AHCA monetary penalties regarding alleged deficiencies. In many of these rare instances, NTBH disputed the legal and technical appropriateness of the proposed fines but given the time consuming, costly nature of the appeal process, we elected to pay in order to focus on our central goal of providing excellent care to our patients. NTBH will continue to work hard to ensure the highest level of regulatory compliance and cooperation with all relevant stakeholders, including constant evaluation of our policies and procedures to build upon our already high level of clinical care. Family, Attorney Visitation Policies / Unscrupulous Attorney Harassment & Solicitation. Family members, close friends and in many cases, attorneys serve as vital resources and support structures for our patients during and after care at our hospital. This includes where appropriate, participation in family centered counseling sessions which can comprise important aspects of the overall treatment regime. In compliance with confidentiality laws and patients’ rights, we abide by our patients’ wishes regarding who they wish to see during their period of treatment in accordance with reasonable and customary protocols designed to ensure the overall safety and security of the family and maintaining a therapeutic 4 treatment environment. This includes working with the patient to create (and if needed update) a written approved visitor list. Similar to all intensive inpatient BH hospitals and in accordance with state guidelines, NTBH maintains regular designated visiting hours for patient-approved family and close friends which are scheduled around the structured treatment day. In some situations, visitors on the approved list could nonetheless be subject to physician approval where a visitor on the patient’s list may pose a legitimate harm to the patient or cause interference with their clinically indicated treatment plan. Patients also have access to actively working phones where they can place calls to family members, loved ones and attorneys. In situations where family members are unable to visit during the designated visiting hours, NTBH clinical and administrative staff work in good faith to accommodate visits outside of customary visiting hours subject to the patient’s personal wishes and so long as the visit doesn’t negatively impact patient privacy, facility safety/operations or risk of disruptions to the overall treatment environment. Visits with minor patients and with adult patients under legal guardianships require adherence to different protocols because of the guardianship and custody parameters. These situations often involve complex circumstances that can be challenging for the involved patient, their loved ones and the facility. As it relates to visits from attorneys with legitimate representation relationships, we generally provide as much leeway as possible again subject to customary safety and security procedures and patient wishes. Our protocols include checking all potential visitors against the approved visitor list. If the attorney is not on the visitor list but claims to have a right to see the patient, the attorney must provide valid documentary proof of a valid representation. Family members occasionally hire attorneys without the knowledge of the patient and sometimes against their express wishes. In fact, over the past year alone, NTBH experienced a number of troubling situations involving attorneys who came to the hospital, harassed staff, attempted to access patient care areas, and inappropriately solicited Baker Act patients. In one case, an adult patient’s mother and an attorney she hired tried forcibly to discharge the patient even though the patient repeatedly stated her desire to continue treatment due to suicidal ideations. Of note, another attorney claiming to represent several former NTBH patients has repeatedly lodged unfounded complaints and threats that bear remarkable similarity to your reportage summary, including perpetuating false and misleading allegations that NTBH inappropriately holds and “imprisons” patients (including Baker Act patients) who do not meet established clinical criteria. While NTBH continues to strongly dispute this attorney’s claims, we nonetheless continue to engage with her in good faith to demonstrate our ongoing commitment to sustained Baker Act compliance. I would respectfully request that you and your editors undertake diligent assessments regarding the credibility, motivations (financial or otherwise) and potential biases of all named and unnamed sources. Rare Serious Incidents In Context: As I’ve tried to reiterate, the handful of negative incidents you reference at NTBH comprise an infinitesimally small percentage of overall patient encounters. To again illustrate, since its founding our hospital has experienced approximately 75 serious level incidents over the course of 17,000+ inpatient admissions and 20,000 visits to our outpatient programs. This equates to a serious incident rate of 0.0044% of all inpatient admissions, a number that we 5 believe compares favorably to other BH providers treating equivalent patient populations in similar facility settings. 6 North Tampa Behavioral Health Data Collection Request - Tampa Bay Times Inquiry 2013 Admissions 158 Discharges 171 Patient Days 1,041 Self Pay % 35.0% OP Visits Involuntary Admissions % Involuntary N/A N/A Average Length of Stay (ALOS)- All patients 6.6 ALOS (Voluntary) ALOS ( Involuntary) 2014 2,010 2,027 13,083 3.7% 2,321 2015 2,878 2,883 19,856 4.8% 5,894 701 35% 1996 69% 6.5 6.9 6.94 7.15 6.06 6.73 Audited Financial Statements (Submitted to AHCA) Net Revenue 208,074.00 8,207,067.00 13,670,333.00 Net Income (1,677,100.00) (1,282,176.00) 1,645,292.00 Operating Margin -15.6% 12.0% StatewidePyschiatric SOURCE: AHCA Financial Data Dashboard Available at: https://www.floridahealthfinder.gov/researchers/studies-reports.a Hospitals Average Operating Margin per AHCA For Profit Not For Profit Average Length of Stay (ALOS) NTBH Charity Care 2017 - Present NTBH Bad Debt 2017 - Present % of Net Revenue -806.0% 7% 7% 10% 9% 10% 11% Statewide - Psychiatric Hospitals 8.70 8.00 7.70 2016 3,197 3,220 25,406 4.0% 3,871 2017 3,010 3,074 26,297 5.1% 3,274 2018 3,457 3,522 25,515 6.9% 3,469 2307 72% 2142 71% 2383 69% 2019-July YTD 2,047 2,074 14,258 8.1% 1,449 TOTALS & AVERAGES 16,757 16,971 125,456 9.7% 20,278 1485 11,014 73% 65% 7.9 8.7 7.4 7.0 7.3 11.36 13.67 10.33 10.81 10.04 6.40 6.66 5.90 5.52 6.21 17,455,021.00 18,271,320.00 17,349,207.00 8,996,355.00 2,642,409.00 2,546,698.00 954,192.00 (411,910.00) 15.1% 9% 10% 13.9% 5.5% -4.6% 4.4% 9% Not yet reported Not Yet Reported 9% Not yet reported Not Yet Reported 9% 9% 7.60 7.00 Not yet reported Not Yet Reported 7.80 $ 1,268,682.25 $ 765,352.00 $ 244,572.20 $ 1,107,649.23 $ 1,630,880.00 $ 1,434,376.00 6.9% 4.4% 2.7% *2013 excluded from average due to small patient census and first year operating loss status