Myth vs. Fact
UHS wants to share the facts about our company and our facilities and specifically respond to myths in the public realm so that we can set the record straight.
UHS designs its patient intake process around financial considerations.
Each admission requires a medical order from a physician.
- The ultimate decision regarding whether to admit a patient to any UHS facility is made by the attending physician in consultation with members of the clinical team. Per regulations, all admissions require a physician’s medical order based only on the patient’s clinical presentation as a result of that physician’s independent examination and/or evaluation.
- Ability to pay (e.g. having insurance or not) is not a factor in making clinical decisions regarding the appropriateness of inpatient admission to any UHS BH hospital.
- Many of our physicians are not employed by the hospital.
- Three main criteria are required for an individual to be admitted to a psychiatric facility. The first is suicide — if someone is suicidal, or at significant risk of harm to themselves. The second is whether there is a significant risk that the patient may harm someone else, which is often referred to as homicidal. The third factor is whether the individual is gravely disabled and/or unable to care for themselves to the extent that their present psychiatric symptoms and diagnosis significantly interferes with their ability to undertake critical daily activities. These admission criteria are uniform across all psychiatric facilities and are not at all unique to UHS.
- The vast majority of patients who arrive at UHS BH facilities come directly from hospital emergency rooms, other medical providers, social service organizations, law enforcement or other service providers who have already determined that the patient is in immediate need of psychiatric care and treatment, including possible inpatient admission pending a medical order from the attending psychiatrist.
- Only a very small percentage (less than 1%) of our inpatient admissions result from patients who voluntarily presented to one of our facilities in the manner depicted in the article.
- In some circumstances, hospital administrators may be consulted by clinical staff to ensure that the facility has the appropriate staff and diagnostic resources to provide the highest level of care to the patient at the time of admission.
- UHS facilities have legal, ethical and moral obligations to treat all emergently presenting patients and we use our best efforts to comply with all applicable requirements.
- Outside of our Emergency Medical Treatment and Labor Act (EMTALA) obligations, UHS provides uncompensated and charity care to a significant number of uninsured patients annually with the same level of service provided to patients with insurance.
- We are proud that many of our doctors and facility leaders have stepped forward to provide testimonials to the quality care we provide.
UHS holds patients against their will / “Locks them In”.
UHS follows clinically-based industry protocols for assessments and admission.
- When an individual presents or is brought by law enforcement to an inpatient psychiatric facility, such an action indicates that the individual is in a potential state of serious distress requiring an assessment and possible inpatient hospitalization. If hospitalization is not required, treatment resources are provided to those individuals who receive an assessment.
- By law, psychiatric facilities have a legal, ethical, and moral obligation to conduct a proper assessment to determine the individual’s needs and to ensure the safety of the individual and the community.
- Unless there is a court order or good cause to believe that an individual is a threat to themselves or the community, a UHS facility will not hold someone against their will.
- Nearly all hospitals, particularly those treating psychiatric patients employ security measures to ensure the safety of the patients, staff and community. This includes areas of the hospital which are secured by locked doors and restricted access.
UHS puts profits over patient care and safety.
UHS facilities have a verified, decades-long record of clinical excellence.
- UHS’ overarching goal and focus is to provide the highest quality healthcare to our patients in a caring, safe and comfortable setting.
- UHS has a verified record of clinical excellence as established by independent third party verified, evidence based clinical performance criteria. In nearly all accountability metrics, UHS Behavioral Health (BH) facilities outperform the national averages and our competitors.
Our patient satisfaction scores from our behavioral health patients are high and have continued to increase in each of the past seven years.
- In addition to strong performance on evidence-based, industry wide clinical metrics, UHS’ patients consistently report high levels of satisfaction with the care they receive at our affiliate facilities. Last year, the patient satisfaction grand mean score – on a 1-5 scale – was 4.5. Our behavioral health facilities achieved a 70% survey return rate (317,683 participants).
UHS continually invests in programs, services and technology to enhance the patient experience.
- Every year, UHS invests millions of dollars in facility upgrades, safety improvements and new technology to improve the patient experience and promote the highest quality of care. In the past three years, UHS has invested more than $1 billion in its facilities.
UHS coding rates for Suicidal Ideation indicate excessive diagnosis of patients with Suicidal Ideation.
UHS codes appropriately for Suicidal Ideation.
- First, UHS categorically denies that its affiliates exaggerate symptoms or attempts to coerce patients to admitting to suicidal thoughts or plans in order to justify any admission.
- Notwithstanding any information provided to admissions personnel or others at any UHS behavioral facility upon intake or during assessment, a patient will only be admitted by a physician, the large majority of which are not employees of the facility or UHS. All admissions to any behavioral health facility (UHS or others) require a physician’s order based upon the patient’s clinical presentation.
- Based on UHS’ nearly 40 years of experience and consistent feedback from coders who joined UHS from other companies it is clear that many of our competitors (including companies we acquire) do not always provide the same level of training or require the requisite professional certifications for their coding staff. This situation often results in staff focusing only on revenue generating diagnoses rather than notating all co-morbidities.
- Coding for suicidal ideation has historically been non-revenue generating co-morbidity — meaning it does not get the hospital any more money. It is a clinical notation based upon the information contained in the patient’s medical records as attested by the physician and other clinical staff and utilized for diagnostic, recordkeeping and treatment purposes. Coding only takes place after a patient is discharged.
- Clinical treatment teams must consistently and accurately document all patient clinical symptoms and treatment protocols based on observation and clinical presentation and the coding teams must align their documentation and coding without regard to the revenue implications of any particular code.
- All coding staff at UHS behavioral health CMS-certified facilities are required to be certified as a Registered Health Information Administrator, Registered Health Information Technologist or Certified Coding Specialist.
- The reporter claims that after UHS acquired PSI the use of the Suicidal Ideation (SI) billing code “shot way up”. The reporter incorrectly attempts to correlate increased coding at former PSI facilities acquired in the UHS acquisition in late 2010 as evidence of this non-existent admission practice. This assumption is false.
- When UHS makes an acquisition, we require that coders become trained and certified to all applicable coding standards. PSI facilities prior to UHS’ acquisition, for the most part, did not code for suicidal ideation because it did not provide any additional revenue.
- There was no increase in the diagnosis or documentation of SI post-UHS acquisition — just more precise coding. In fact, in the small number of PSI facilities that were properly coding for SI prior to the UHS acquisition, the amount of such coding remained consistent after UHS’ acquisition.
- As indicative of this failed analysis, BuzzFeed’s charts purport to show that there that there was nearly zero instances of suicidal ideation coding prior to the UHS acquisition but then have huge increases after UHS acquires the facility.
- In order to accept the reporter’s theory, one would have to believe that these inpatient psychiatric facilities treated nearly zero suicidal patients during the 2 years prior to UHS’ acquisition. That is not only inaccurate but completely implausible considering that many if not a majority of patients admitted for inpatient psychiatric treatment, are diagnosed with suicidal ideation.
- The facts are that these facilities just did not code for PSI prior to the UHS acquisition because it did not have any financial benefit. We spoke with the CEOs and Health Information Directors (HIM) at some of these former PSI facilities and they each confirmed this fact. They further confirmed that the numbers of patients diagnosed and admitted with suicidal ideation did not increase or change after the acquisition by UHS — just the coding improved.
Deciphering Charts Provided by BuzzFeed
The documents provided by BuzzFeed show an implausible scenario that there were 0 incidents of suicidal ideation at these inpatient facilities. Many, if not a majority of patients admitted for inpatient psychiatric treatment, are diagnosed with suicidal ideation.
The charts represent suicidal ideation coding before and after UHS’ acquisition of PSI facilities in November, 2010. The red line denotes UHS’ acquisition of PSI facilities. The blue line indicates the number of claims submitted to CMS with suicidal ideation coding.
- The facts are that these facilities just did not code for SI prior to the UHS acquisition because it did not have any financial benefit. We spoke with the CEOs and Health Information Directors (HIM) at some of these former PSI facilities and they each confirmed this fact. They further confirmed that numbers of patients diagnosed and admitted with suicidal ideation did not increase or change after the acquisition by UHS — just the coding improved.
- Carey Carlock, the Chief Executive Officer at Riveredge Hospital in Chicago during its ownership by PSI and then following the acquisition by UHS stated the following: “Prior to UHS’ ownership, Riveredge did not code for suicidal ideation. After UHS took over, we began coding. Further, there was no increase in the number of patients we diagnosed and admitted for suicidal ideation after UHS acquired PSI as compared to the time the facility was owned by PSI. Our admissions and assessment practices remained the same.” *
- Riveredge’s HIM Director during its ownership by PSI and then following the acquisition by UHS confirmed this. She is the person responsible for coding at Riveredge and states the following: “Riveredge just did not code for “suicidal ideation” when we were owned by PSI as it was a non-revenue producing co-morbidity. After the UHS acquisition, we conducted a coding training including coding for SI. UHS was much more sophisticated and we did not really code correctly prior to UHS. The amount of notations in the records or diagnosis of SI was the same pre and post UHS. There was not a spike in documentation or diagnosis of SI post UHS acquisition — just a focus on coding what was in the records. In addition, the conversion rate from intake to admission was the same pre- and post- UHS acquisition.
- For several years, UHS has engaged a nationally recognized independent firm, nThrive, to audit and assess UHS’ coding as well train our coding staff on proper coding practices. Following UHS’ acquisition of PSI, nThrive conducted an assessment of PSI’s coding practices and specifically their coding for suicidal ideation. Below are some of their comments:
An Independent Auditor’s View of Coding
“nThrive began performing coding auditing for PSI locations following the UHS acquisition in 2011. nThrive found that coding practices observed at that time were insufficient to reflect the full clinical picture of the patient based on the documentation available. The foundational goal of accurate and complete coding is to reflect the full clinical picture of the patient. SI was documented throughout records reviewed; however, the coders were not assigning the code for the documented condition. Leading practice in the coding and auditing arena is to apply AHA Coding Clinic® guidelines while performing reviews. The analysis supported the recommendations made to add numerous codes, which included codes for suicidal ideation. Following the ongoing auditing and subsequent coder education processes, the coders’ overall accuracy and completeness in coding improved over time while adhering to AHA Coding Clinic guidelines.
nThrive has been serving as the external medical coding auditing company (doing business as Precyse Solutions, LLC) for the UHS Behavioral Health division since 2010. nThrive performs two to four coding audits per year for the majority of the Medicare certified UHS facilities… Coding recommendations made by nThrive are strictly based on provider documentation, the Cooperating Parties Official Coding Guidelines, and AHA Coding Clinic®.
nThrive can only speak to the quality and accuracy of the coding based on the documentation provided. A contributing factor to the increase of coding of suicidal ideation can be due to more accurate and complete coding through UHS’ on-going efforts to promote and support high quality and accuracy in coding. UHS’ efforts have included nThrive coding audits, formal educational webinars, and education through use of nThrive Education’s Precyse University modules.”
- Finally, there were a handful of PSI facilities that were regularly coding for suicidal ideation, a review of those charts prepared by BuzzFeed shows that the amount of coding remained fairly consistent after UHS’ acquisition of those facilities. Below is an example of one:
UHS manipulates a patient’s length of stay (LOS) to increase bottom line revenue.
UHS BH facilities’ average length of stay (ALOS) does need exist or is below the national average according to independent data compiled by CMS and the National Association of Psychiatric Health Systems.
- ALOS data from CMS/Healthcare Cost Report Information System (HCRIS), National Association of Psychiatric Health Systems and private firms with healthcare industry expertise reveal that UHS’ ALOS either did either did not exceed or was below the national average in all measured patient segments.
- HCRIS Data (2008-2013): UHS Facilities LOS is on the low end of the spectrum compared to average LOS and consistent with government and industry expected LOS.
- LOS did not increase after PSI acquisition and decreased after Ascend acquisition based upon HCRIS data
- All decisions regarding patient length of stay are made by the attending physician with input of the clinical treatment team based on patient progress toward treatment goals.
- UHS clinicians also take seriously their role as a patient advocate. Insurance companies in some markets approve lower number of days than are clinically appropriate to successfully treat a patient’s condition and avoid readmission. Research indicates that longer length of stay is associated with better clinical outcomes.
- Providing clinical care beyond stabilization is critical to a patient’s health and recovery. Transitioning to the next level of care safely is critical. Preparing a patient for safely stepping down to outpatient services is a key component to inpatient care. Outpatient networks are often overbooked and in some markets, two month waits are common, resulting in gaps in care.
- Numerous academic and clinical studies have demonstrated higher readmission and suicide rates have been associated with shorter LOS.
- Further, as stated above, decisions on patient’s discharge rest ultimately with the attending psychiatrist — not non-clinical facility personnel.
UHS admits patients improperly.
UHS’ admissions process is clinically based and physician supervised.
- It is important to understand that mental health facilities and the patients that we treat are unique, and unlike traditional acute care hospitals or patients. In reality, many of our patients are unable to make the same judgments regarding clinical care and appropriateness of admission and discharge that they might if undergoing other non-psychiatric medical treatment.
- The decision on whether to admit a potential patient is a clinically driven judgement requiring a physician’s order based on the patient’s unique medical condition and established diagnostic criteria.
- For someone to be admitted into a psychiatric facility there are three main criteria required. The first is suicidality — if someone is suicidal, or at significant risk of harm to themselves. The second is whether there is a significant risk that the patient may harm someone else, which is often referred to as homicidal. The third is whether the individual is gravely disabled and/or unable to care for themselves to the extent that their present psychiatric symptoms and diagnosis significantly interferes with their ability undertake critical daily activities. These admission criteria are uniform across all psychiatric facilities and are not unique to UHS.
- As a company and a community partner we have a legal, ethical and moral obligation to treat all emergently presenting patients and we use our best efforts to comply with all applicable requirements, including our responsibility under the Emergency Medical Treatment and Labor Act (EMTALA).
- The assertion that UHS affiliate facilities knowingly violate EMTALA obligations to deflect (i.e. “turn away’) uninsured patients is categorically false. Over the past five years, UHS facilities have deflected, for appropriate reasons, hundreds of thousands of both insured and uninsured patients who have presented for potential admission. These patients were deflected for completely legitimate and lawful reasons, including failure to meet clinical criteria for inpatient admission, bed availability, license capacity and lack of expertise in treating particular medical etiologies.
- If UHS had a practice or policy of deflecting uninsured patients, there would be hundreds if not thousands of EMTALA citations. In reality, UHS BH facilities received an exceptionally small number of citations over the past five years, particularly given the large number of affiliate facilities.
- No UHS affiliate BH facility has ever received a citation from a regulatory authority alleging that any patient was inappropriately admitted solely due to failure to meet established clinical criteria.
UHS understaffs its facilities.
UHS facilities are staffed appropriately, regularly assessed and adjusted as required.
- UHS categorically denies any assertion that its BH facilities are deliberately and systemically understaffed.
- UHS local facility leaders base staffing decisions on the clinical needs of patients, in full accordance with all legal requirements and any applicable state mandates. Local facility leaders constantly assess the multiple factors that go into staffing decisions, including staff experience, clinical condition of patients, patient demographics and treatment environment to ensure that our facilities are staffed at therapeutically appropriate levels.
- UHS facilities employ thorough hiring standards to ensure that appropriate candidates are hired. For example, many facilities require two-round interviews for line staff, pre-employment assessments, and all require extensive criminal background checks.
- Every UHS facility also conducts ongoing employee training addressing patient care issues. Specifically, all nursing staff and some clinical staff are trained in low-risk physical management techniques to utilize if a psychiatric crisis occurs. More importantly, we train all facility-level patient care staff to prioritize verbal de-escalation techniques to manage a potentially dangerous situation.
- Staffing protocols (including training) are among the many metrics evaluated by The Joint Commission when accrediting and assessing facilities.
- With respect to the survey citations associated with staffing issues, the majority of these situations involve isolated violations of the facility’s own policies as opposed to violations of statutory staffing requirements. Further, any staffing issues that are identified on any regulatory survey are given the most serious attention and immediately reviewed and remedied as appropriate. Many of these matters involved short term as opposed to systemic situations such as unexpected staff absences which did not result in any patient harm.
Patient stories are accurate.
The patient accounts depicted in the article are incomplete and are not an accurate picture of events.
- HIPPA and other federal and state privacy laws prevents us from commenting specifically about any patient encounters. Notwithstanding, UHS disputes the allegations and assertions made as well as the depictions of patient experiences referenced in the BuzzFeed story. A complete, objective review of the individual facts and circumstances of each patient account would demonstrate that the stories present a misleading, inaccurate or highly incomplete version of events.
- UHS requested that BuzzFeed obtain patient authorizations required by HIPAA so that we could use the patient’s medical information to refute the allegations and present the complete story. The reporter failed to obtain those authorizations but instead published the patient anecdotes without providing UHS the fair opportunity to respond in full.