On a cool October evening in 2012, Samantha Trimble walked into the lobby of Millwood Hospital, a low-slung brick building on the side of a road in Arlington, Texas, seeking a free mental health assessment.
A few weeks earlier in the AP world history class Trimble taught, after a kid started acting childish, she put a diaper on his head — something she admits was a bad idea. When administrators heard about it, she was escorted off the property. Worried for her job and her ability as a single mother to support her daughter, she visited her doctor’s office in tears. A physician assistant asked if she wanted to talk to someone at Millwood.
Just after 8 p.m. that evening, a counselor at Millwood asked Trimble if she was having suicidal thoughts. With her pastor beside her for moral support, she replied, “Well, who hasn’t had suicidal thoughts?” She said she had no intention to kill herself but joked, “It’s Texas, it isn’t that hard to get a gun.” They all laughed, she recalled. She said she had no idea that the counselor characterized the line as a plan to commit suicide.
Nor did she know, she later testified in a deposition, that the dozen or so forms he gave her were anything other than standard doctor’s-office paperwork. She signed them and waited for her counseling session.
Rosalind Adams / BuzzFeed News
It was nearly 11 p.m. by the time a staff member walked her down a long hallway. She recalled being startled to see rooms that were filled not with desks but with beds.
A technician rifled through Trimble’s purse for sharp objects and then a nurse told her to strip down to her underwear. It was then, she said, that she realized the doors to the psychiatric ward had locked behind her.
Trimble, who has recently 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 identifying 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, What the fuck just happened?
Millwood Hospital is part of America’s largest psychiatric hospital chain, Universal Health Services, or UHS. Its more than 200 psychiatric facilities across the country admitted nearly 450,000 patients last year. The result was almost $7.5 billion in revenues from inpatient care last year and profit margins of around 30%. More than a third of the company’s overall revenue — from both medical hospitals and psychiatric facilities — comes from taxpayers through Medicare and Medicaid.
A yearlong BuzzFeed News investigation — based on interviews with 175 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 profits were achieved at the expense of patients.
Scores of employees from at least a dozen hospitals said those facilities tried to keep beds filled even at the expense of the safety of their staff or the rights of the patients they were locking up.
Current and former employees from at least 10 UHS hospitals in nine states said they were under pressure to fill beds by almost any method — which sometimes meant exaggerating people’s symptoms or twisting their words to make them seem suicidal — and to hold them until their insurance payments ran out.
A state-funded 2011 report on one Chicago hospital found “woefully inadequate” staffing levels, a “repeated and willful failure by UHS officials to ensure that their staff were properly trained,” and a pattern of admitting more patients than it had room for “in an effort to maximize financial profit.” Investigators also flagged broader concerns, citing “troubling reports suggesting a pattern of quality of care issues, harm to patients, or major healthcare fraud charges involving UHS-operating facilities in a dozen other states.”
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.
The company has 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.
UHS also disputed BuzzFeed 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” and “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 non-psychiatric medical treatment.” (Read the company’s statement here.)
The company “absolutely rejects” any claim that it held patients solely for financial gain. It disputed “the alleged findings and conclusions” in the Chicago report and said UHS hospitals have provided compassionate and high-quality care to millions of patients. Citing the approval of independent regulatory agencies, it said, “Every patient care decision is made with the goal of furthering the best interests of our patients.”
UHS “absolutely rejects” any claim that it held patients solely for financial gain.
After BuzzFeed News began reporting on UHS, the company purchased the domain name uhsthefacts.com. A person with direct knowledge of the matter said the site was intended to showcase stories of positive patient care to counter BuzzFeed News’ investigation.
Many current and former staff spoke to BuzzFeed News on condition of anonymity, often because they didn’t want to jeopardize future job options.
About 20 employees said UHS operates ethically and provides high-quality care. “I can honestly say in my hospital I never felt like people were being held long after they were due to be discharged,” said Bill Niles, who ran Roxbury Hospital in Pennsylvania for eight years.
“They wanted you to perform with the highest standards,” said Shari Baker, who ran Palmetto Behavioral Lowcountry Hospital in South Carolina until earlier this year. She called UHS “a very ethical organization.”
But scores of employees from at least a dozen UHS hospitals said those facilities tried to keep beds filled even at the expense of the safety of their staff or the rights of the patients they were locking up.
“YOUR JOB IS TO GET PATIENTS”
Millwood Hospital in Arlington, Texas, on Nov. 4, 2016.
Laura Buckman for BuzzFeed News
UHS was founded in 1979 by Alan Miller, who is still at the helm today as CEO and board chair. (Through a spokesperson, Miller declined repeated requests for an interview.) With thousands of patients getting pushed out of public hospitals, and with insurance companies willing to approve hospital stays of a month or more, the 1980s were a boom time for private psychiatric hospitals. But the industry soon got out of hand.
By the early 1990s, when UHS was still a relatively small player, several of the top hospital chains were facing state or federal investigations and a slew of lawsuits from patients. Meanwhile insurance companies tightened their policies, demanding shorter lengths of stay. Unable to sustain the profit margins that investors had grown accustomed to, the chains began to close or sell off hospitals. In many cases, UHS was the buyer.
Kyle Hilton for BuzzFeed News
Today UHS has more than two and a half times as many beds as its nearest competitor. But in its 211 US psychiatric facilities, the company’s name is almost nowhere to be 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 psychiatric hospitals can be found here.
UHS said the majority of its patients are either transferred from another hospital’s emergency room or dropped off by police who felt they might pose a threat to themselves or others.
The law requires psychiatric hospitals that receive federal money to screen all emergency 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 transferred elsewhere. But psychiatric patients — let alone people who have merely come 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, psychiatrists said. Clinicians should evaluate thoughts of suicide 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.
Still, this standard gives psychiatric hospitals wide leeway to confine patients to locked wards, an extraordinary power largely withheld 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 confidential assessment 24 hours a day, 7 days per week, please call.”
Staff members from across the country said such assessments were often not what they appeared to be.
When people called in to ask for help or inquire about services, internal documents and interviews show, UHS tracked what a former hospital administrator called each facility’s “conversion rate”: the percentage of callers who actually came in for psychiatric assessments, then the percentage of those people who became inpatients. “They keep track of our numbers as if we were car salesmen,” said Karen Ellis, a former counselor at Salt Lake Behavioral.
“The goal when you’re on the phone with someone is to always get them into the facility within 24 hours,” said a former admissions employee who worked at three UHS facilities in Texas. “And the reason for getting them 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 Lake Behavioral Health in Utah. “They think we’re going to diagnose them for anxiety or depression.” She added, “Our goal is to admit them to the hospital.”
Kyle Hilton for BuzzFeed News
UHS told BuzzFeed News it admitted patients based not on financial considerations but only on clinical need: “Decisions regarding admission are made by an attending psychiatrist in consultation with members of the clinical treatment team,” the company said in its statement. Asked about conversion rates, Roz Hudson, a senior vice president of UHS, said that while it’s standard in the industry to track various data points, “it’s not a number necessarily that the line staff are driven by.”
Former admissions and clinical staff told BuzzFeed 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.
“Your job is to get patients,” said a former clinician at Salt Lake Behavioral. “And you get them however you get them.”
Lauren Singer, who worked for six 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. “I would frequently get yelled at for overstepping my bounds and telling them too much about the evaluation process,” Singer said. A button behind the receptionist’s desk controlled the lock to the front door of the facility, and, she said, “If someone came in voluntarily, I wasn’t allowed to let them out of the door.”
In a statement to BuzzFeed News, Paul Sexton, who ran Highlands at the time, said, “I deny any claims that any patients were ever wrongfully held or detained at Highlands. However, patients are not allowed to leave during an assessment for the safety of the patient, the facility, and the community.” Sexton described that as standard practice across all kinds of psychiatric hospitals.
“Your job is to get patients. And you get them however you get them.”
But three leading organizations strongly contradicted that view. “Absent a reason to be concerned about safety, their own or others', a person who voluntarily presents for an assessment would be free to leave,” said Dr. Steven Hoge, chair of the American Psychiatric Association’s Council on Psychiatry 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 himself or others, “it’s not permissible to hold someone.” And Carly Moore Sfregola, a spokesperson for the American Hospital Association, wrote, “They get to leave at any time of their own free will unless someone gets a court order to involuntarily commit the patient.”
UHS’s view was supported by its industry organization, the National Association of Psychiatric Health Systems. At first, the group’s head of quality and regulatory affairs, Kathleen McCann, told BuzzFeed News something similar to what the other organizations said: People who walk in for an assessment “are absolutely and totally free to leave” unless they are clear threats to themselves or others. A few hours later, however, she emailed back to “clarify” the position of her organization, of which UHS is a member and whose board will soon be led by the head of UHS’s psychiatric division. (McCann said she informed UHS that she had spoken with BuzzFeed News, but declined to say when.) Patients seeking assessments cannot leave until hospital staff have deemed them safe, she wrote. “This may involve restricting their ability to leave the facility.”