Nevada Patient Busing

Civil rights commission looks at Nevada hospital’s busing of patients

James Flavy Coy Brown was released from a Nevada state psychiatric hospital in February 2013 with only three days medication and a one-way bus ticket to Sacramento where he knew no one. Photo taken April 4, 2013 in Sacramento.
James Flavy Coy Brown was released from a Nevada state psychiatric hospital in February 2013 with only three days medication and a one-way bus ticket to Sacramento where he knew no one. Photo taken April 4, 2013 in Sacramento.

James Flavy Coy Brown, a homeless and mentally ill man allegedly “dumped” by Nevada’s primary psychiatric hospital via Greyhound bus into Sacramento last year, on Friday became the national face of a problem that experts said is widespread and should be curtailed by federal authorities.

Brown’s story touched off a Sacramento Bee investigation into the Las Vegas hospital’s practice of routinely busing mentally ill patients to cities across the country. The saga was the centerpiece of a lengthy hearing before the U.S. Commission on Civil Rights in Washington, D.C., that explored the need for reforms of a federal law designed to protect patients from being discharged without proper treatment and planning.

“James Brown and others like him can no longer endure a disintegrating system of emergency mental health care,” said Staci Pratt, who spoke on behalf of the American Civil Liberties Union of Nevada.

Pratt presented a video in which Brown described his discharge from Rawson-Neal Psychiatric Hospital followed by a harrowing 15-hour bus journey to Sacramento, where he had no family or ties. He talked of wandering the streets, confused and delusional, and said he contemplated suicide before he found his way to UC Davis Medical Center.

The Bee’s inquiry found that Rawson-Neal discharged about 1,500 patients via Greyhound bus over a five-year period, many to cities where they had no treatment plans or arrangements for housing. Following the revelations, the facility announced it no longer would bus patients without chaperones. It since has lost its accreditation and faces lawsuits related to its discharge practices.

Pratt and nine other experts, including lawyers, doctors and advocates, testified at Friday’s hearing about the limitations of the Emergency Medical Treatment and Labor Act, or EMTALA, which requires hospitals that participate in the Medicare program to treat emergency medical conditions regardless of a person’s ability to pay.

The Centers for Medicare and Medicaid Services, which assesses hospitals for compliance with EMTALA, investigated Rawson-Neal following The Bee’s reports. The agency found the hospital had violated the law in 40 percent of cases reviewed because it failed to show that staffers had made basic arrangements for future care of those patients.

Southern Nevada Adult Mental Health Services has argued that Rawson-Neal is not subject to the act’s regulations because it has no emergency department. But Marilyn Dahl, representing the federal agency at the hearing, said psychiatric hospitals “may in fact meet the EMTALA definition.”

“We look at how a unit functions, rather than its label,” she said. A psychiatric hospital acts as an emergency department if it treats patients who are experiencing “acute, severe” psychiatric symptoms that pose a threat to patients or others, Dahl said.

Panelists at Friday’s hearing said that EMTALA needs to be strengthened and its mandates updated. The federal government, they said, fails to monitor whether hospitals are complying with the law; rather, it responds solely to complaints. Hospitals that violate the law rarely face severe penalties, they pointed out, leaving state regulators and civil litigators with the burden of holding facilities responsible for poor discharge practices.

“In three decades since EMTALA’s passage, the health care delivery system has changed dramatically,” said Katharine Van Tassel, an expert in medical law at the University of Akron School of Law. “But EMTALA has been left far behind.”

The system, Van Tassel said, “encourages discrimination against certain patients,” including the mentally ill and homeless, who are difficult to treat and frequently uninsured.

Panelists said budget cuts and closure of community mental health programs have left hospitals with few choices for helping people like Brown.

“Where the heck are we going to transfer them?” said Gina Greenwood, a lawyer for a national firm that represents hospitals. “I can assure you that if you address that problem you won’t be busing James to California anymore.”

Greenwood discouraged tougher laws, arguing that hospitals already are heavily regulated. She called for better training and education of doctors and first responders around mental illness. “I worry about people like James every day,” she said. “Our mental health system is in dire straits, dire crisis. But I caution against a heavy-handed regulatory scheme to fix problems.”

But Pratt said the federal government has a “core obligation” to protect the civil rights of mentally ill people. She and others called for an independent federal investigator to regularly evaluate discharge practices and hold hospitals accountable for violating them.

“It took the power of the media to bring attention to this matter,” she said. “Finally, there was a searching examination of discharge practices, and it found consistent failure.”

The independent, bipartisan civil rights commission, which is charged with advising the president and Congress, is scheduled to issue its report on the issue in late September.