Universal Health Services (UHS), America’s largest psychiatric hospital provider, was skewered last week in an investigative journalism report by Rosalind Adams and published by BuzzFeed News. This wasn’t some hastily thrown together hit piece, but rather an in-depth look — talking with 175 current and former staffers at UHS hospitals and 120 additional interviews with patients, experts, and investigators into the claims brought against the company.
The report paints a picture of certain hospitals within the UHS system that seem to have significant problems and deficits. Worse yet, the company apparently has its head in the sand, denying any problems exist in its facilities, and spinning data that appears to show the company emphasizes money over patient care.
This report should act as a wake-up call for the entire inpatient psychiatric hospital industry.
This is a story we’ve heard before in the healthcare industry — one where certain hospitals prioritize profit over patient care. This new report from BuzzFeed News is the latest in-depth investigative piece of journalism that has delved into the problems at Universal Health Services (UHS). After the report was released, the price of the company’s publicly traded stock dropped nearly 12 percent. But this isn’t the first time UHS has been the target of investigative journalism and state investigations — see the end of this article for links to similar reports in recent years from across the nation.
UHS, which is based in King of Prussia, Pennsylvania, runs over 240 psychiatric, in-patient hospitals across the United States. These hospitals are, oddly enough, not branded with the UHS name (which is what you would typically find at a hospital chain treating medical diseases). Instead, they hide behind the folksy, local names of the individual hospitals themselves — names such as Millwood, Roxbury, Palmetto, Suncoast, and Highlands.1
UHS is a huge, for-profit corporation with nearly $9.7 billion in revenues resulting in over $600 million in annual profits. Not bad for people who are supposedly in the business of helping people with the most serious mental health issues get better.
UHS & Medicare Fraud
UHS seems to have some big problems looming on its horizon:
UHS is under federal investigation into whether the company committed Medicare fraud. The probe involves more than 1 in 10 UHS psychiatric hospitals. Three are being investigated criminally — including one facing allegations 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 UHS as a corporate entity, the company told investors.
That seems like a pretty significant issue, when 1 in 10 of your hospitals appears to be under investigation for Medicare fraud. And when an investigation expands to include the corporate parent of the hospitals it is investigating, that strongly suggests the investigation is turning up problematic practices that are potentially systematic (and not just affecting one or two outlier hospitals).
The fact that this is not the first time UHS has been investigated for issues in its hospitals is also suggestive, in my opinion, of a corporate culture that emphasizes profit over positive patient outcomes.
Suicidality Determined by Person with Conflict of Interest
One of the most significant problems for psychiatric hospitals is that the person making the determination as to whether or not to admit you is incentivized to err on the side of admitting you. The more people an intake professional admits, the more the hospital keeps its census up — and its profits rising. It’s a clear conflict of interest for these hospitals, yet they rarely even acknowledge this is a problem (that could be easily corrected).
Worse yet is that these intake coordinators or directors are usually not doctors, physicians, or psychologists. They may be a master’s-level individual who has only minimal training or understanding of severe mental illness and suicidality. Why do these hospitals employ lower-trained professionals for such a sensitive position? (Hint: It’s not because they are interested in providing the best, most-thorough patient assessment possible.)
In short, a poorly-qualified professional with a clear conflict of interest can readily relieve you of your protected civil rights and freedom in America, without you ever seeing a physician or psychologist. If you think I’m kidding, walk into any psychiatric hospital (especially in certain states, such as Texas) to see for yourself.2
Treatment Can be Lacking
One of the open secrets of many psychiatric hospitals is that during the day, treatment programming may be, ah… lacking. Patients rarely see an attending psychiatrist or psychologist, or if they do, it is only for a few minutes at a time. Instead, patients in many psychiatric hospitals spend their time in “activity therapy” groups, run by mental health “techs” who may have nothing more than a high school diploma.
”I’ve never been trained to run a group,” said a mental health technician at Havenwyck Hospital, “so those poor ladies leave my groups more confused than when they come in.”
Kevin Ball, a former tech, said he screened My So-Called Life during group sessions. “My degree was in parks and recreation,” he said, so “I was just as clueless as the kids.”
Mostly, patients “just sat around,” one former patient at Millwood recalled. You “spent most of your day in your room.”
I can vouch first-hand that this isn’t just a problem at UHS, but a problem across many psychiatric hospitals in the industry. There simply aren’t enough structured, therapeutic activities — led by actual mental health professionals who are well-trained — scheduled for most of the day for most patients. (While targeted, specific types of activity therapy might be beneficial for certain groups of patients, there is little research to suggest it is an effective therapeutic modality for nearly all inpatients at a psychiatric hospital.)
Money Makes the World Go Around
For-profit hospitals, as a group, have a profit-driven incentive to keep their uninsured patient populations low. And then to discharge uninsured patients as quickly as possible, compared to their paying patients. UHS is apparently no different:
At the company’s Florida hospitals between 2013 and 2015, 55% of self-paying patients were discharged within three days, compared with just 30% of patients with commercial insurance. (Other for-profit psychiatric hospitals had a similar disparity, but not-for-profits showed almost no difference.) In California, a similar pattern was found.
Asked about this discrepancy, a UHS representative said a patient’s length of stay is based on his or her individual treatment plan. The representative denied that a patient’s insurance is a factor and said a discharge is “a clinical decision; it’s not a business decision.”
Research shows those without insurance — the homeless and poor — tend to have worse prognosis and often present with more difficult, chronic disorders to treat. If these were purely clinical decisions, it would stand to reason that such patients would likely be admitted for similar or slightly longer periods of time as their paying counterparts. Yet that’s not what the data show. (Worse yet, a 2011 meta-analysis shows that, for clinical depression at least, psychological interventions administered in an inpatient setting have a minimal positive impact compared to a control group [Cuijpers et al., 2011].)
This audit of one of UHS’s facilities shows professionals copying and pasting parts of patient’s charts (time-saving laziness?), lack of training by staff, lack of oversight by appropriately trained professionals, and more. All of which paints a picture of a hospital appearing to not really giving much more than lip service to offering the highest level of patient care.
Psychiatric Hospitals: A Bad Reputation?
It’s no wonder that so many psychiatric inpatient facilities seem to have bad reputations. While one could argue this investigative report cherry-picked its data, highlighting some of the most egregious, anecdotal examples of problems at specific hospitals, there are data in the report that are hard to explain away so easily (like the above example of discharge rates among the uninsured).
There is a simple hierarchy at most psychiatric hospitals that starts with the owner or corporate finance people who demand certain ratios, metrics, and weekly goals be met (in terms of admissions, length of stay days, etc.). This bubbles down to the directors, head clinical staff (psychiatrists and psychologists), and intake personnel, because you’re not going to ignore the marching orders from the folks who sign your paycheck. Staffing levels are kept as low as allowed by regulations, which vary from state to state.3
Sadly, the staff who end up spending the most time with patients aren’t highly-trained, well-qualified psychiatrists, psychologists, and clinical social workers. They are the lowly paid “mental health techs,” folks who may have had little formal training and hold nothing more than a bachelor’s degree or high school diploma. These are the well-meaning, unsung heroes of inpatient psychiatric hospitals — staff who make running such hospitals even possible. These are the people most patients remember most, because they are the ones they spend the most time with.
This report should act as a wake-up call to all psychiatric hospitals in the U.S. to get their house in order. As patients become more educated, they’re learning that you’d better be offering the highest level of clinical assessment and care possible (with actual trained mental health professionals, not just mental health techs). Or the next investigation may be the one at your hospital.
For further information
Read the full BuzzFeed News investigation (long, but worth your time): Intake: Locked on the Psych Ward
Read UHS’s response: Myth vs Fact
Dallas Morning News 2016’s story: Danger in the psych ward
The Boston Globe’s 2013 story: National reviews of centers rare in mental health
Chicago Tribune’s 2015 story: Lawmakers urge faster action to protect youths at residential treatment sites
- From a marketing perspective, the only time I’ve found large companies refraining from branding on a national scale is in an effort to be able to distance themselves from a local affiliate or subsidiary that doesn’t perform well, gets into regulatory trouble, or has other significant issues. That way those local issues don’t affect the national brand. [↩]
- By the way, if the intake person gets you to acknowledge even an occasional or passing thought of suicide that happened years ago, some may write that up as “suicidal ideation.” Yes, it’s a great stretch of the truth, but it’ll be the intake professional’s word against yours. Guess who the hospital is going to listen to — even if you deny any active suicidal thoughts. And the police won’t be able to help you get out of the hospital, as the report makes clear. [↩]
- And whenever a hospital claims something about Joint Commission accreditation or accolades, know they are simply tooting their own horn with a paper tiger … The Joint Commission is, in my opinion, largely a paper-driven joke and one easily duped since they rarely do unannounced onsite visits. Does UHS have 90 percent of its hospitals winning a Joint Commission award, or some small minority? [↩]