S.C. hospital to pay $1.3 million for not properly treating emergency psych patients

(Updated on July 6.)

AnMed Health in South Carolina has agreed to pay the largest-ever settlement in a case brought under the federal law requiring hospitals to stabilize and treat patients in emergency situations.

The not-for-profit, three-hospital AnMed system will pay nearly $1.3 million to settle federal allegations that in 2012 and 2013 it held patients with unstable psychiatric conditions in its emergency department without providing appropriate psychiatric treatment in 36 incidents. AnMed, based in Anderson, S.C., serves upstate South Carolina and northeast Georgia.

"Instead of being examined and treated by on-call psychiatrists, patients were involuntarily committed, treated by ED physicians and kept in AnMed's ED for days or weeks instead of being admitted to AnMed's psychiatric unit for stabilizing treatment," according to the settlement finalized on June 2 with the HHS Office of Inspector General.

The patients — most of whom were suicidal and/or homicidal and suffered from serious mental illness — were held in the ED from six to 38 days. In each of these incidents, AnMed had on-call psychiatrists and beds available in its psychiatric unit to evaluate and stabilize the patients. But it but did not provide examination or treatment by a psychiatrist, according to the settlement agreement.

The HHS OIG's office said that violated the section of the Emergency Medical Treatment and Labor Act requiring Medicare-participating hospitals with an ED to provide appropriate medical screening and treatment to stabilize the patient's condition.

AnMed did not admit to liability under the settlement deal. In a written statement, AnMed said it had been a longstanding policy of its behavioral health unit to accept only voluntarily admitted patients, while patients who were to be involuntarily admitted were held in the ED until they could be transported to the state mental hospital. The shortage of space in that facility often prolonged psychiatric patients' stays in the AnMed ED, the statement said.

But Sandra Sands, a senior attorney with the OIG who has been handling EMTALA cases since 1989, said in an interview that AnMed has engaged in significant corrective action, including expanding its psychiatric inpatient unit from 15 to 34 beds by the end of this year.

"That's one of the reasons why the penalty was not even higher," Sands said. "They were very cooperative with the OIG during the investigation, and it appears they did things that went beyond what was required."

AnMed said it launched a corrective plan in 2015 to make its own behavioral health unit appropriate for involuntarily committed patients, including adding more training for staff and security to protect other patients.

Hospitals across the country are struggling with the problem of having to hold psychiatric patients in their EDs for days or even weeks because of a shortage of available inpatient psychiatric beds. Mission Hospital in Asheville, N.C., recently discharged a particularly difficult-to-place patient after holding him in its ED for 19 months.

A study published in Health Affairs last year found a 55% jump nationally in ED visits related to mental health from 2002 to 2011, from 4.4 million to 6.8 million. Meanwhile, the number of inpatient psychiatric beds available nationally to serve these patients plummeted nearly 80% from the 1970s to 2010, from about 500,000 to 114,000.

But the AnMed situation was unusual because the hospital determined that the 35 patients cited in the OIG settlement were involuntary patients, and it had a longstanding policy of not admitting involuntary patients to its psychiatric unit.

AnMed's policy was that if a patient should be involuntarily committed and did not have financial resources, the attending physician could write an order for the local mental health center to evaluate the patient for commitment to the state mental health system after the patient is medically stable, according to the settlement.

"I haven't heard of this before and it's unconscionable," said Frankie Berger, director of advocacy at the Treatment Advocacy Center, an advocacy group that tracks the problem of psychiatric boarding in hospital EDs.

Berger said the policy sounded like "a convoluted method of triaging that this hospital system came up with to save expense and try to get around EMTALA so they can transfer these patients to a different system."

Sands agreed that it was unusual EMTALA case in that the hospital had available psych beds and on-call psychiatrists but didn't provide them for these emergency patients.

"I'm not sure we've ever had anything like that, where the hospital makes a distinction between who they treated and who they didn't treat," she said.

In 2013, AnMed's director of emergency services told Bloomberg News that the reason his system had to hold mentally ill patients for long periods in the ED was that state budget cuts had led to a severe shortage of available psychiatric inpatient beds.

Emergency physicians say they often see possible EMTALA violations by hospitals in handling seriously mentally ill patients. Dr. Marc Futernick, then-president of the California chapter of the American College of Emergency Physicians, told Modern Healthcare last year that his ED often holds psychiatric patients for many days because psychiatric units at many Los Angeles-area hospitals conduct financial screening and won't accept patients for stabilization who are uninsured or on Medicaid.