[HN Gopher] How a leading chain of psychiatric hospitals traps p...
___________________________________________________________________
How a leading chain of psychiatric hospitals traps patients
Author : howard941
Score : 177 points
Date : 2024-09-01 14:33 UTC (8 hours ago)
(HTM) web link (www.nytimes.com)
(TXT) w3m dump (www.nytimes.com)
| Traubenfuchs wrote:
| https://archive.is/n7NKM
| thayne wrote:
| A big problem is that people receiving psychiatric care often
| can't get justice in court. Who is the jury, or judge, more
| likely to believe, someone who needed psychiatric care, or a
| credentialed doctor?
|
| I know someone who was threatened with having their children
| taken away, and prison if they tried to leave the hospital, or
| stopped taking medication that was making them feel worse.
|
| But since it was just the doctor's word against theirs, they were
| told there was very little chance of winning in court.
| cj wrote:
| Agreed, to an extent.
|
| If this happening as frequently as the article suggests, and if
| Arcadia operates over 50 hospitals, you'd think there would be
| at least 1 law firm dedicated solely to prosecuting this
| specific hospital.
|
| Skip the class action BS, and run those "mesothelioma" type
| commercials. Then have a boilerplate structure for a lawsuit
| that you can repeat successfully, hire your own doctors as
| expert witnesses to refute the hospital, etc.
|
| If they are imprisoning people illegally, I imagine the
| settlements would be quite high per patient.
|
| > But since it was just the doctor's word against theirs
|
| When something is widespread and perpetrated by the same
| people, you have to establish a pattern of behavior to
| discredit the witness.
|
| The narrative could be pretty straight forward: the doctor was
| lying to the insurance company, and they're lying to the jury,
| too.
|
| Seems they already settled a couple suits, which could
| potentially be used to discredit the hospital as well.
|
| But again, you really need a specialized firm willing to take
| them down by taking on a bunch of similar cases to make it
| worthwhile to do all of the background/evidence/research to
| make a case.
|
| This is also the type of case that could get heavy PR / public
| support which the right law firms can leverage in their favor.
|
| ...or we embrace better regulation and trust the government to
| fix this. But the government also has a terrible track record
| when it comes to caring for the mentally ill.
| giantg2 wrote:
| The mesothelioma commercials only really became prevalent
| after suits were won and the firms knew they could get money
| just by adding more people to the class (or really getting
| them to collect).
| staticautomatic wrote:
| Meso class actions went away a long time ago. These days
| they're all individual suits, and on rare occasions, MDLs.
| giantg2 wrote:
| Yeah, but they're practically defacto wins as long as the
| same basic conditions are met.
| staticautomatic wrote:
| The individual meso cases? Lol no. At least some of the
| defendants nearly always settle but they're not remotely
| slam dunks for the plaintiffs if they make it to trial.
| ChrisMarshallNY wrote:
| _> If they are imprisoning people illegally, I imagine the
| settlements would be quite high per patient._
|
| That depends on whether or not anyone cares about the
| patient.
|
| Many, _many_ psych patients have basically been disowned by
| their families, they have no friends, and don 't have the
| ability to live on their own in society. Maybe the lawyers
| would care enough about them, if they could win a suit, but
| I'd not bet on that.
|
| I'd suspect that a huge number of homeless folks were ones
| that would have been "lifers" in mental hospitals. The
| enormous homeless problem in the US is actually relatively
| new. I remember when it was much, _much_ less of a problem
| (We have always had them, but nowhere near the scale we have
| them, now).
|
| We live in a nation, where it is easier for mentally ill
| people to get weapons, than help[0].
|
| That said, in MD, where I lived for a while, we had The
| Patuxent Institution[1]. It may still be around. Charming
| place. It inspired this movie[2].
|
| [0] https://www.npr.org/sections/shots-health-
| news/2024/08/24/nx...
|
| [1] https://en.wikipedia.org/wiki/Patuxent_Institution
|
| [2] https://www.imdb.com/title/tt0078043/
| watwut wrote:
| > Many, many psych patients have basically been disowned by
| their families, they have no friends, and don't have the
| ability to live on their own in society. Maybe the lawyers
| would care enough about them, if they could win a suit, but
| I'd not bet on that.
|
| What after winning the suit? I mean, if they dont have the
| ability to live on their own, what happens with them?
| ChrisMarshallNY wrote:
| The lawyers don't care. Neither does anyone else.
|
| They'll probably get cheated out of whatever winnings
| they get, and end up back on the street.
| giantg2 wrote:
| It gets more fundamental than this. These laws for involuntary
| commitment are civil laws and lack the protections of criminal
| court. The hearings can be ex parte, you don't have a right to
| an attorney, and proof is only what is more likely than not and
| not beyond a reasonable doubt. If you had a lawyer at the
| hearing and the proof required overcoming reasonable doubt,
| then there would be fewer abuses (one would hope anyways).
|
| These types of abuses happen with all the "institutional" civil
| laws - involuntary commitment, civil asset forfeiture,
| guardianship, red flag, and especially protection from abuse
| orders (weaponized in divorces fairly commonly). It will
| continue to increase as we, as a society, continue to favor
| quick and easy "fixes" to overcome the protections found on the
| criminal side.
| exe34 wrote:
| > Who is the jury, or judge, more likely to believe, someone
| who needed psychiatric care, or a credentialed doctor? > or
| stopped taking medication that was making them feel worse.
|
| This kind of thing used to scare me - once you're booked into
| the system, they can literally stab you with an injection to
| make you behave in whatever way they want to portray you in
| court. And that's just if they're outright malicious.
|
| Worse, they might instead be entirely earnest in their belief
| that you need to take that particular pill, that makes your
| misdiagnosed condition worse.
| Vampiero wrote:
| If you're so intent on suing for malpractice just record them
| against their will. If the court doesn't accept it then the
| media will
| awinter-py wrote:
| could create a system for getting an easy second opinion from a
| doctor outside the facility
|
| then its not patient vs doctor, it's doctor vs doctor
| spencerchubb wrote:
| Rare instance of good journalism. More people need to know about
| this company that commits heinous crimes
| antisthenes wrote:
| If we're talking about US healthcare, you can just point a
| finger to any one of those companies at random.
|
| Hospital chains, big pharma, insurance companies, retirement
| care.
|
| Think Sackler-family stuff. It's all designed to extract the
| maximum possible amount of money from the patient, while
| providing as little as possible.
| hn_version_0023 wrote:
| I'm beginning to think of the US healthcare system as a
| _cruel and unusual punishment_.
|
| I guess we're being punished for having the temerity to
| exist?
| falcolas wrote:
| No, we're left to suffer so we can keep coming back and
| handing them more profit. At least I can't think of a
| better reason for so many of the decisions our health
| "care" system makes.
| DangitBobby wrote:
| Apparently Acadia faced civil liabilities only, which is wild
| for kidnapping.
| ctxc wrote:
| Highly recommended movie watch:
|
| Unsane.
| ctxc wrote:
| Forgot to add the link - https://en.m.wikipedia.org/wiki/Unsane
| bookofjoe wrote:
| See also:
|
| 'One Flew Over The Cuckoo's Nest' (1975)
|
| https://www.youtube.com/watch?v=aTSz56rs_WE
| tomxor wrote:
| One Flew Over the Cuckoo's Nest
| jprete wrote:
| I've read that this movie is, at best, wildly out of date. I
| can't say for sure since I have no direct experience of the
| subject.
| hypercube33 wrote:
| Dark Waters Spotlight
| derbOac wrote:
| Prisons and psychiatric care provide compelling examples of the
| boundaries of for-profit models and why they might not always be
| the best solutions in an area. You can always argue -- reasonably
| I think -- that these cases represent anomalous bad apples but I
| think as long as that incentive structure is there it will pull
| for this kind of thing at some level, even it's not quite as
| extreme as this example. I think that profit incentives and lack
| of competition tend to distort healthcare across all sorts of
| specialties in much more subtle ways than what was going on at
| this hospital chain. When threats to personal autonomy start to
| become the consequence it seems to clarify some of the problems
| involved, but the same processes are at work in all sorts of
| areas.
| LadyCailin wrote:
| Well, yeah. Nobody _actually_ wants a true free market system,
| no matter how much libertarians and anarchocapitalists may
| scream that that's exactly what they want. If they got their
| way, the whole planet would become a dystopian nightmare, with
| no safety for anyone but the top handful richest people, and
| every single tragedy of the commons possible occurring,
| polluting the earth to the point of unusability. The only
| reason they claim to want it, is because of either greed,
| complete lack of empathy, or willful ignorance.
|
| The only possible way to have a society is to have regulations.
| left-struck wrote:
| Can confirm, as a libertarian I don't want a free market,
| it's more like I think the rights of people should be above
| the rights of companies, corporations and so on. Governments
| exist to protect the rights of the people and in this age, in
| developed countries, there is no greater infringement on
| those rights than by large businesses.
| briandear wrote:
| Free market healthcare means it gets cheaper. Go pay cash at
| a doctor or a surgeon -- it's dramatically less expensive.
| The idea of comprehensive health insurance has ruined
| healthcare. Insurance should be to protect against financial
| risk from an unforeseen loss -- a car crash should be
| insured, changing the oil should not. If car insurance
| covered tires and oil changes, car insurance would cost
| dramatically more.
| 1986 wrote:
| That's great if all you ever need to do is see a doctor,
| full stop. Getting, for example, an MRI is around $2k out
| of pocket. Just for one imaging! Most Americans can't come
| up with $500 for an unexpected expense. Comprehensive
| health insurance protects people from instantly going broke
| from everything in health care that isn't just seeing a
| primary care doctor.
|
| edit: Not defending insurers or our system at all, btw.
| Quite clear to me as ex-healthtech that a single payer
| system would solve many of our problems.
| delichon wrote:
| Most doctors agree that people in the throes of a psychological
| crisis must sometimes be detained against their will to stabilize
| them and prevent harm. These can be tough calls, balancing
| patients' safety with their civil rights.
|
| IMHO it's acceptable sometimes to balance others' safety with a
| patients' civil rights. But it's not acceptable to trump
| someone's civil rights with concerns about their own safety. That
| balance can certainly result in tragedy when people make horrible
| choices. But it preserves the concept of civil rights against the
| incompatible alternative of overruling them in the name of
| safety. We can't get the benefits of freedom by only allowing
| "good" choices, because those benefits flow largely from learning
| from the bad ones. We are very capable of collectively making bad
| choices (from slavery to lobotomies) and defining them as good.
| Civil rights are a way to counterbalance those.
| Gimpei wrote:
| I'm guessing you've never had to deal with a loved one in the
| throws of addiction or severe mental illness. We are not
| perfectly rational beings and sometimes we make very bad
| choices, especially when we suffer from a mental illness like
| addiction. If I had the choice between seeing a loved one
| temporarily institutionalized versus having them die of an
| overdose, I would take the former. It isn't ideal, but
| sometimes you have to choose the least awful thing.
| lazyasciiart wrote:
| What does "temporary institutionalization" look like in that
| choice? One of the highest risk periods for overdose is after
| leaving jail or rehab. Do you support proposals to reduce the
| risk of overdoses that don't rely on complete abstinence,
| such as drug test kits, safe injection rooms or even legal
| supply?
| bawolff wrote:
| While there is a place for such things, its hardly a
| replacement for rehab.
|
| We have all those for alcohol and yet alcoholism still
| causes massive problems.
| nradov wrote:
| I generally agree with you, but how far should we take this?
| Like if a loved one has been diagnosed with hyperlipidemia
| and makes the very bad choice of refusing to take their
| prescribed statins, should they be forcibly
| institutionalized? They are likely to die early, although it
| isn't an "imminent" threat.
| BurningFrog wrote:
| I'm as big a libertarian as anyone, and I see the logic and
| morality of this argument.
|
| Still, I can't be against violating people's rights by stopping
| them from suicide, and keeping them locked up for a while
| afterward. A close friend is alive because this.
| kayodelycaon wrote:
| > That balance can certainly result in tragedy when people make
| horrible choices.
|
| The thing is, someone may not be rational enough to make that
| choice. I've been suicidal in the past. Reasoning goes out the
| window and you can easily make a decision you never wanted to
| make. You simply can't choose to stay alive any longer.
|
| I've lost a friend because they couldn't hold out long enough
| for things to get better. They killed themselves because of a
| temporary situation they could have easily recovered from.
|
| I've saved a friend by preventing him from going down that
| route. It took over a year for him to be healthy. He doesn't
| want to die now.
|
| I'm always going to side with stopping people from suicide
| until they've had a chance to be mentally sound enough to make
| an informed decision.
|
| There have been people I've known who did make that decision
| and did so rationally. All of them had medical conditions they
| could never recover from without divine intervention. In their
| case, they wanted to spare themselves and others from a long,
| painful death. They should be able to make that choice.
| cwillu wrote:
| > I'm always going to side with stopping people from suicide
| until they've had a chance to be mentally sound enough to
| make an informed decision.
|
| The problem is that "mentally sound" is partially _defined_
| as not wanting to die. It doesn 't matter how stable and
| coherent you are, as long as you keep saying "on net, I don't
| feel like my life has been worth living and I would prefer to
| end it painlessly if I could", they will not let you out.
| Getting out is a process of learning the lies you need to
| tell the doctors and nurses.
| bawolff wrote:
| My understanding is that for many (not all) suicidal
| people, the time period of actually wanting to die can be
| remarkably short. Like on the order of 20 minutes, and then
| thought passes (at least for a little while)
| kayodelycaon wrote:
| If you mean at extreme risk of carrying through with a
| plan, that seems fairly accurate in my experience. I had
| a number of safety plans I'd use to remove myself from
| the means I'd use until I could get back to passively
| suicidal instead of actively suicidal.
| kayodelycaon wrote:
| The fact the current process isn't perfect doesn't change
| how I think things should work. Determining another
| person's mental state is difficult and you'll always run
| into problems.
|
| On a whole, more people ultimately wish to live afterwards
| than those who want to die. So any system is going to err
| on the side of caution.
|
| As I mentioned, there are situations in which a rational
| decision is easy to understand and verify. Our current
| system in the US does not allow for these cases.
| nullindividual wrote:
| > The problem is that "mentally sound" is partially defined
| as not wanting to die.
|
| Unless, of course, you have an illness that happens to be
| something _other_ than mental illness.
|
| Because pain and suffering can only come from physical
| ailments /s
| nullindividual wrote:
| Make assisted suicide for mental illness legal. There are
| plenty of treatment resistant or life-long illnesses that
| should qualify.
| WarOnPrivacy wrote:
| Helping clinically depressed people act on their most-awful
| impulses - this doesn't seem likely to yield whatever
| positive outcomes you're thinking of.
| sunshowers wrote:
| This fantasy libertarian nonsense doesn't fly in the real
| world. Check out how bad the MAID program has been in Canada.
| gmd63 wrote:
| It's sad that this information is behind a paywall. Not as a
| fault of the New York Times, they deserve money for this work.
|
| It's sad that the default freely available information spread
| around is that the chain of hospitals is a professional
| institution that's endorsed by the board of medicine. And knowing
| the truth costs money. Just as bringing these folks to justice
| costs money.
| gpvos wrote:
| It's a general problem: the good information is behind
| paywalls, so people only find bad information and start
| believing nonsense.
| watwut wrote:
| To be fair, the journalism was not historically free service.
| There was brief period where they tried to live by ads and use
| free articles to make people buy paper, but it did not worked.
| simonw wrote:
| This story is an incredible illustration of incentives gone
| wrong.
|
| The affordable care act mandated that insurance companies cover
| mental health. Psychiatric hospitals can charge insurers
| $2,200/day for holding patients who "pose an imminent threat to
| themselves or others".
|
| So now you get this:
|
| > Once Acadia gets patients in the door, it often tries to hold
| them until their insurance runs out.
|
| > Acadia goes to great lengths to convince insurers that the
| patients should stay as long as possible, often around five days.
|
| > To do that, Acadia needs to show that patients are unstable and
| require ongoing intensive care. Former Acadia executives and
| staff in 10 states said employees were coached to use certain
| buzzwords, like "combative," in patients' charts to make that
| case.
| archgoon wrote:
| This doesn't explain why the insurance companies don't have an
| incentive to fight back.
|
| If Acadia is engaged in insurance fraud, the insurance
| companies have every incentive to stop that.
| nickff wrote:
| Insurance company profits are capped as a percentage of
| expenses, so saving money means they make less money. There
| are bad incentives all over the place in healthcare
| regulations.
| gruez wrote:
| If you're referring to the minimum medical loss ratio
| provisions in the ACA, most insurance companies are above
| the minimum, which means any marginal fraud reduction is
| pure profit for them.
| sulandor wrote:
| unless there's a cut to be had
| loeg wrote:
| Why? Insurance providers have capped profit margins. The only
| way to grow their revenue is to grow covered expenses (and
| correspondingly, premiums).
| ericjmorey wrote:
| Insurance executives' pay is limited by a pool of money that
| is calculated as a % of total expenses. If expenses are
| higher due to this sort of fraud, have an incentive to ignore
| it to keep that pool of money available for compensation as
| large as possible.
| nradov wrote:
| For health plan executives the financial incentives run
| both ways. Most medical "insurance" companies no longer
| provide much insurance and primarily act as third-party
| administrators for self-insured employers. In the short
| term, health plans can make more profit by approving more
| claims. But in the long term they have to compete for the
| business of those group buyers and so they try to block
| waste/fraud/abuse that drives up customer costs.
| toast0 wrote:
| Health insurance companies aren't incentivised to fight this
| kind of thing.
|
| Clearly falls into mandatory coverage (if claims are
| accurate), so all companies are going to have to pay it.
| Raises costs. Insurance gets to have overhead (profit) based
| on claims paid.
|
| There's more incentive to deny marginal claims, because some
| insurance companies won't and then you may attract more
| customers with a lower price and maybe you get more money
| that way.
|
| Patients are unlikely to complain to insurance to tell them
| the treatment/confinement was unjustified... because the
| patient will then need to pay the bill.
| LordDragonfang wrote:
| > Patients are unlikely to complain to insurance to tell
| them the treatment/confinement was unjustified... because
| the patient will then need to pay the bill.
|
| Honestly, you buried the lede here. This is the horrifying
| and broken part. Under no circumstances should someone have
| to be afraid of paying for their _involuntary_ commitment.
| bobbylarrybobby wrote:
| Why wouldn't it be the hospital who has to pay?
| leo1smith wrote:
| I have worked in Mental Health for 20 years. These kinds of
| practices have been going on for decades. It did not start with
| the ACA.
| simonw wrote:
| Sure, it didn't start with the ACA, but this story implies
| that the ACA lead to a growth in this kind of bad behaviour:
|
| > Acadia was founded in 2005 by Reeve B. Waud, a financier,
| and grew slowly at first. But in 2011, the company went
| public and embarked on a major expansion.
|
| > The timing was ideal. Over the next several years, Acadia
| got a lift from Obamacare, which required insurers to cover
| mental health. Today Acadia has 54 inpatient psychiatric
| hospitals with a total of 5,900 beds.
|
| I'm not trying to imply that the ACA is bad here - just that
| the incentive provided by the requirement for insurance
| companies to cover this form of treatment inadvertently
| incentivized the kind of fraud described in the article.
|
| This is why legislation needs to be iterated on - to correct
| for unexpected consequences like this. Ideally the abuse
| described in this article would be prevented by further
| legislation - though there's always a chance that could open
| up further loopholes.
| mmaunder wrote:
| Consider the incentives for therapists.
| nradov wrote:
| Which incentives? Therapists can't make the official
| determination that a patient poses an imminent threat.
| BikeShuester wrote:
| Take note that all these victims were either employed or had
| insurance coverage. It's telling that they're not targeting the
| local homeless individual for 'care.' Which makes this more
| disgusting.
| nobody9999 wrote:
| >Take note that all these victims were either employed or had
| insurance coverage. It's telling that they're not targeting the
| local homeless individual for 'care.' Which makes this more
| disgusting.
|
| Apparently, "Medicaid is the single largest payer for mental
| health services in the United States"[0]
|
| That said, one will likely have to dig through quite a bit of
| data to determine, on a state-by-state basis, what the
| reimbursement rates are for inpatient psychiatric services. And
| they don't make it easy, either.
|
| For example, reimbursement rates for Texas[1], California[2]
| and New York[3] (chosen because they're large states which,
| together, make up a significant chunk of the US population) are
| available, but need to be parsed to figure out which specific
| code corresponds to daily reimbursement rates for psychiatric
| care.
|
| [0] https://www.medicaid.gov/medicaid/benefits/behavioral-
| health...
|
| [1] https://public.tmhp.com/feeschedules/Default.aspx
|
| [2] https://mcweb.apps.prd.cammis.medi-
| cal.ca.gov/rates?tab=rate...
|
| [3] https://omh.ny.gov/omhweb/medicaid_reimbursement/
|
| Edit: In case my point isn't obvious, I'm wondering aloud
| whether or not Medicaid (the US medical insurance program for
| those under 65 who can't afford to pay for insurance)
| reimbursement rates make it a target for similar shenanigans.
| While Medicaid is significantly _funded_ by the US Federal
| government (via block grants[4]), it 's administered (in vastly
| different ways) by each state, which set their own eligibility
| and reimbursement rates
|
| [4] https://en.wikipedia.org/wiki/Block_grant
| Spooky23 wrote:
| Unlike Medicare, which won't pay for poor performance,
| Medicaid pays for services rendered, period. If you're a
| shitty provider, there's a calculus for when to bill Medicaid
| for a lower, guaranteed payment vs Medicare.
|
| There's a wide variety of shenanigans at the provider,
| managed care and state/county level. A big part of the
| performative shipping of migrants and poor people to northern
| states is all about shifting Medicaid expenses.
|
| This happens often to mental patients, who often find
| themselves released from a police station or hospital, at a
| bus station with a ticket to NYC.
| nobody9999 wrote:
| >Unlike Medicare, which won't pay for poor performance,
| Medicaid pays for services rendered, period.
|
| I don't believe that's true. Do you have any evidence for
| this?
|
| I have _never_ heard of anyone challenging a Medicare
| reimbursement for "poor performance." In fact, billing
| codes often don't make a whole lot of sense, yet are
| approved without question just because the billing code
| exists.
|
| What's more, Medicare and Medicaid fraud are often
| perpetrated[0] by the same folks without and done in
| exactly the same way.
|
| [0] https://www.cnbc.com/2023/03/09/how-medicare-and-
| medicaid-fr...
| rKarpinski wrote:
| Do the patients ever use the phones from these facilities to call
| the local police departments about being held against their will
| without cause? At this scale seems like that should happen.
| jprete wrote:
| I'm not a psychiatrist, but it might be hard to tell them from
| the psychotics who can model the standard view of the world
| well enough, for long enough, to lie to the police about their
| condition.
|
| More practically, I doubt they get unsupervised phone calls.
| rKarpinski wrote:
| The only thing that should matter is if they are medically
| claiming the patient "poses an imminent threat to themselves
| or others", either they did the paperwork or they didn't.
|
| And these aren't one of occurrences, these are systematic
| abuses in the same communities that would come up over and
| over again - which is presumably why police raided their
| facility in Georgia.
|
| > More practically, I doubt they get unsupervised phone
| calls.
|
| Most facilities have communal phones that are available
| throughout the day for short periods of time.
| kelsey98765431 wrote:
| Phone access is typically restricted to a supervised call using
| the phone on the staff administrator's desk who can simply cut
| you off and glare at you with silent promises of retaliation if
| you don't say what they want you to say and what they agreed to
| let you say before they hand you the phone, all with their
| finger resting on the disconnect button the whole time.
|
| Unless you are not making them money, then they get you out of
| there asap and make calls on your behalf all day to other
| places to shuffle you around to.
| kelsey98765431 wrote:
| This is an industry wide practice for decades across every
| segment of the healthcare sector.
| geor9e wrote:
| I'm not anti-psychiatry per se, but I always keep in mind that
| every industry has perverse incentives to not lose their
| customers. Every once in a while, a professor or journalist
| checks themselves into a psychiatric hospital with some temporary
| fake symptoms, then behaves perfectly healthy, but are unable to
| escape without a lot of outside intervention. E.g.
| https://en.wikipedia.org/wiki/Ten_Days_in_a_Mad-House (1887),
| https://en.wikipedia.org/wiki/Rosenhan_experiment (1973) .
___________________________________________________________________
(page generated 2024-09-01 23:01 UTC)