State agencies bused more than 1,500 mental health patients to almost every state in the contiguous United States.
James Flavy Coy Brown, a psychiatric patient diagnosed with schizophrenia, anxiety and depression, found himself at Rawson-Neal Psychiatric Hospital in Las Vegas in February 2013 after a bout of depression and suicidal thoughts forced him out of his group home. After three days there, the attending doctors informed Brown he was stable enough to leave — just not to Nevada.
“I said, ‘I don’t want to leave Nevada,'” Brown told ABC News. “He said, ‘California sounds like a really nice state. I think you’ll be happy there.'” Despite the fact that Brown has never been to Sacramento, Brown was given a one-way Greyhound bus ticket there, a ride to the local bus station, six bottles of Ensure nutrition shake and a three-day supply of his psychiatric medication. His “address on discharge” was listed as “Greyhound Bus Station to California,” and he was instructed to call 911 when he arrived in Sacramento, which would be the time his medication supply would run out.
Brown’s medical records, obtained by ABC News, indicate that Brown wished to be discharged to a group home in Las Vegas.
“If I don’t take my medicine, I get really confused and I start hearing voices in my head, and they tell me to, like, jump off a bridge or to do something to purposefully get arrested or go to prison or jail,” he said.
Upon arriving in Sacramento, Brown, instead of calling 911, walked in a confused stupor to the local police station, where he was taken to a homeless shelter. There, Brown suffered the trauma of psychiatric medication withdrawal.
Brown is far from alone in his suffering. Discovered through investigations by the Sacramento Bee, the Las Vegas Review-Journal and the Nevada Department of Health, Southern Nevada Adult Mental Health Services — a state agency — bused more than 1,500 mental health patients to almost every state in the contiguous United States, with California overwhelmingly the dumping spot of choice. Large populations of dumped patients ended up in Los Angeles, San Diego, Phoenix, Salt Lake City, Seattle, Denver and San Francisco.
The Rawson-Neal case is indicative of a growing national trend that includes denial of service charges at hospitals throughout the U.S. Cases such as the 2012 federal settlement with Hackley Hospital of Michigan, who denied treatment to an uninsured mother in labor, or the Duke University Health System settlement, in which Duke refused to accept the transfer of five unstable psychiatric patients, reflects the increasing role monetary considerations are playing in health care, despite the law.
In 2011, for example, it was reported that in St. Louis County, Missouri, elderly low-income African-Americans were expelled from their nursing homes after receiving hospital treatment. This occurred after a number of the nursing homes complained that the cost for care exceeded the patient’s Medicaid rate — in such cases, the nursing home had to swallow the difference. This left hundreds without adequate care.
“They will cite us for not taking these patients, when we will be losing money if we take them,” said Sheronda Brown, director of marketing at St. Louis’ Northview Village nursing home, when asked why her facility would turn away someone based on capability to pay. “We do it sometimes because we care. I tell people, ‘Don’t rush to judge the city nursing homes.’”
Passing the buck
San Francisco City Attorney Dennis Herrera has sent a letter to Nevada’s State Attorney General Catherine Cortez Masto informing her of his intent to sue concerning the 24 patients discovered so far to have been sent to his city. Of the 24, 20 needed emergency medical care shortly after arriving in San Francisco, and the city spent nearly $500,000 on medical care and housing for the patients.
Herrera accused the state of “inhumane and unacceptable” practices, including transporting the sick and incapable without escorts, not providing adequate medication or food and sending the patients away without making arrangements for them upon their arrivals.
“It’s my hope that our investigation and possible class action will send a strong message to public health facilities nationwide that there is a price to pay for such inhumane treatment in the future,” Herrera said in a statement.
“Patient dumping” is a felony under the federal government’s Emergency Medical Treatment and Labor Act, which requires most hospitals — specific government or special-purpose hospitals are excluded — to offer stabilizing treatment to any patient who presents for attention in an emergency medical condition, without consideration of ability to pay or convenience of the hospital. The fine for violation of EMTALA is $50,000 per violation in a major hospital, although federal regulators usually settle for less.
The definition of “emergency medical condition,” as defined by the statute: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in — placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, or with respect to a pregnant woman who is having contractions — that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or her unborn child.” This makes the categorizing of mental disorders as “emergency medical conditions” controversial.
However, hospitals are legally and morally obligated not to knowingly release a patient into a situation that immediately endangers the patient’s well-being. This situation is being seen as an indictment of Gov. Brian Sandoval’s (R – Nev.) cuts to mental health funding — which saw a 12 percent cut in 2011 and a reduction in the number of psychiatric beds. In response to this brewing scandal, Sandoval offered nearly $6.5 million in new funding to the state’s mental health programs, obtained due to a windfall tobacco settlement.
“In a state with high rates of severe depression and other serious mental illnesses — as well as suicides — a strong commitment is needed to restore and expand the mental health safety net,” said the 2009 National Alliance on Mental Illness report, which gave Nevada a grade of “D” for its mental health program. “Without one, Nevada will find its emergency rooms and criminal justice system overwhelmed — and costs being shifted to other sectorsof state and local government.”
Sandoval has since come forward to state that “disciplinary actions have been taken and a corrective plan of action was put in place” at Rawson-Neal, and that changes will be made to “provide additional oversight to ensure that discharge and transportation policies are followed correctly.”
Blaming Rawson-Neal, however, may be glossing over the issue. Nevada has the fifth-highest rate of suicide in the nation at 19 per every 100,000 people. 15.5 percent of all Nevada adults will be diagnosed as depressed in their lifetimes, with 11.6 percent being diagnosed as having anxiety. More than 8,000 patients go through Rawson-Neal each year, per the Nevada State Health Division. With stays in acute care ranging from a few days to a few months, and with the state on the line to pay for the care of uninsured patients at a rate of $850 per day, based on the 2011 average, the state has more than enough reason to seek “other remedies.”
In Nevada, a “Legal 2000” request can be issued by the police, social workers or health care staff to place a person in psychiatric observation for 72 hours to determine if the person is a threat to himself or others. On average, in Southern Nevada, about 50 persons are in emergency care per day under a “Legal 2000” request.
Nevada health officials have acknowledged that discharge procedures were not followed at Rawson-Neal and the hospital has been denied accreditation from the Joint Commission, a major quality assurance organization in the health care industry.
Herrera, however, in his complaint, argues that 10 of the 24 dumped patients came from Northern Nevada — including one man who came from facilities in Reno. The man in question, who is blind, deaf and mostly mute, was sent to San Francisco not once, but twice in the same year, after staying at the Renown Regional Medical Center and the West Hills Hospital in Reno, according to San Francisco Deputy City Attorney Kristine Poplawski.
“Northern Nevada Adult Mental Health Services has transported nine patients to California since April 2008,” Poplawski said. “The patients were transported by bus and Amtrak train. Two of these patients were sent to San Francisco by bus.”
In a statement, Renown stated that it “never sends a patient out of the hospital to another facility without his or her consent (or the consent of an authorized representative). In the case of mental health patients who do not have the capacity to make decisions on their own, we utilize resources in Northern Nevada for their continued care.”
The statement continued: “Although mental health resources are limited in Nevada and across the nation, we always use appropriate Nevada facilities for our mental health patients.”
Stewart Bybee, spokesman for Sandoval, said in an email to the Reno Gazette-Journal that “discharges from Northern Nevada Mental Health Services were included in the comprehensive discharge review requested by the governor. As such, the many policy improvements put in place after this review, such as the strengthening of discharge policies to ensure oversight and compliance, and a formalized chaperone policy have been instituted statewide including at the Northern Nevada facility.”
Bybee holds that the allegedly dumped Northern Nevada patients properly self-discharged and were previously residents of California prior to arriving in Nevada.
Nevada is not alone in patient-dumping. Recent allegations of patient dumping in California and Colorado highlight a trend of dumping in an environment where the act is hard to prove and is rarely prosecuted. Since the end of July, the U.S. Department of Health & Human Services have settled with seven hospitals on charges of patient dumping — and in light of continuously shrinking state budgets and mental health’s low priority in most states’ budgets — the trend is expected to continue.
“Federal and state investigators must do a better job of identifying violators of the law and enforcing the ban on patient dumping,” said Sara Rosenbaum, the Harold and Jane Hirsh professor of Health Law and Policy at George Washington University School of Public Health and Health Services. “If we do not start aggressively enforcing the law, millions of uninsured Americans will continue to get no care at all or incomplete care.”