Private Equity Ownership of Psychiatric Hospitals Is Growing; Outcomes Still Unclear

The number of psychiatric hospitals owned by private equity (PE) firms increased from 42 in 2013 to 87 in 2021, according to a survey in JAMA Psychiatry. While PE-owned facilities were associated with lower staff-to-patient ratios, they performed better on some quality measures, including lower reported use of restraints and a higher rate of follow-up visits

Morgan C. Shields, Ph.D., of Brown University, and colleagues noted that PE firms acquire ownership of entities with the goal of increasing value for subsequent resale at a profit. “Maximization of short-term profits may not directly translate into higher quality of care for patients and could even undermine quality,” they wrote. “For example, PE firms may reduce staffing or shift responsibility to clinicians with less expertise, even if existing staffing configurations are associated with better patient outcomes.”

The researchers used industry data (Pitchbook and Irving Levin Associates Health Care M&A database) and online searches to create a database comparing 87 PE-owned and 530 non–PE-owned psychiatric hospitals in 2021. The combined sample encompassed all Medicare-participating freestanding psychiatric hospitals in the United States.

PE ownership was not evenly distributed over the United States; rather, the majority of firms were located in Southern states. In 2021, Texas, Louisiana, and Ohio had the highest number of hospitals owned by PE—19, 16, and nine, respectively. New Mexico had the highest proportion of hospitals (75%) owned by PE.

The researchers assessed quality measures at each hospital such as staffing levels, restraint and seclusion rates, readmission rates, and follow-up rates, among others. PE ownership was associated with fewer staff days per patient day among registered nurses (0.12 versus 0.15) and medical social workers (0.02 versus 0.04) compared with non–PE-owned hospitals. Yet, PE-owned hospitals reported fewer hours of restraint use (0.03 versus 0.24 hours per 1,000 patient hours), lower 30-day readmissions (19.40% versus 20.16%), and higher seven-day (29.34% versus 26.28%) and 30-day (52.92% v 49.08%) follow-up visits.

Shields and colleagues noted that “restraint and seclusion measures are crude and prone to both gaming and error, especially given their self-reported nature,” adding that “follow-up and readmission measures, while intended to reflect hospital performance, are also driven by differences in outpatient environments.”

The researchers said that a new patient experience measure added to CMS’ Inpatient Psychiatric Facility Quality Reporting program could be a more sensitive and meaningful measure of inpatient care quality.

For more information, see the Psychiatric News article “Private Equity’s Inroads Into Mental Health Bring Concern.”

(Image: Getty Images/iStock/Sumedha Lakmal)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on X, LinkedIn and Instagram!

Black Patients Having a Mental Health Crisis More Likely to Be Restrained, Sedated by EMS

Non-Hispanic Black individuals experiencing a mental health crisis are significantly more likely to be restrained or sedated by emergency medical service (EMS) personnel than are non-Hispanic White individuals, according to a report published yesterday in JAMA Open Network.

Diana Bongiorno, M.D., M.P.H., of Harvard Medical School, and colleagues noted that caring for patients with acute agitation is particularly challenging in the prehospital setting because EMS clinicians must consider safety on scene and within the enclosed space of an ambulance, often with limited resources. But, the researchers added, “Although restraints and/or sedation are needed in certain situations, there are notable risks associated with these interventions, including respiratory depression, hypoxia, physical trauma, and, rarely, cardiac arrest.”

The researchers used data from the 2021 ESO Data Collaborative—a database on EMS services—to analyze EMS encounters among patients ages 16 to 90 years having a behavioral health emergency from January 1 to December 31, 2021. The primary outcome was administration of any physical restraint and/or chemical sedation (defined as any antipsychotic medication, benzodiazepine, or ketamine).

The dataset included 661,307 encounters, of which 9.9% were with Hispanic patients, 20.2% non-Hispanic Black patients, 59.5% non-Hispanic White patients, 1.9% non-Hispanic other patients, and 8.6% patients of unknown race and ethnicity. Restraint and/or sedation was used in 7% (46,042) of the encounters.

After adjusting for demographic and community variables, non-Hispanic Black patients were 1.17 times more likely to experience any kind of restraint or sedation compared with non-Hispanic White patients; Black patients were also 1.31 times more likely to experience both restraint and sedation during an EMS encounter. Hispanic patients were 1.04 times as likely to experience physical restraint as non-Hispanic White patients but had no increased odds of chemical sedation or both restraint and sedation.

Bongiorno and colleagues said that future work should include investigation of EMS agency protocols for restraint or sedation use. “Our results also suggest a need for increased EMS training on behavioral health emergencies, and potentially consideration of expanded national prehospital education standards … that include de-escalation training,” they wrote.

For related information, see the Psychiatric News article “APA Resource Document Outlines Principles on Use of Seclusion, Restraint.”

(Image: Getty Images/iStock/Marco_Piunti)

---

Advocacy Alert: Protect SAMHSA Funding

The Substance Abuse and Mental Health Services Administration (SAMHSA) is potentially facing budget cuts as part of the Trump administration’s broader initiative to reduce government spending. The reported cuts could diminish oversight of the grant programs that support patients with severe mental illnesses, hamper efforts to improve 988 awareness, curtail the progress made on reducing overdose deaths, and reduce the ability to bring mental health resources to rural communities. Please urge Congress to protect SAMHSA and continue the successful bipartisan collaboration to address mental health, suicide prevention, and substance use care in our country.

Study Finds ‘Psychiatric Ambulance’ Provides Safe and Uncoercive Transport of Individuals in Crisis

Individuals having a mental health crisis who were transported to a hospital by a “psychiatric ambulance” required fewer restraints or other coercive measures compared with individuals transported by the police, according to a report in Psychiatric Services.

Though police are often responsible for transporting patients in crisis who may be agitated or aggressive, they “usually receive limited training in managing psychiatric disorders and in responding to individuals experiencing psychiatric symptoms or crises, which may increase the risk for preventable escalation and the use of restrictive measures,” wrote Jeroen Zoeteman, M.D., of the psychiatric emergency service in Amsterdam, and colleagues.

In 2014, Amsterdam introduced a psychiatric ambulance service as an alternative approach. The yellow-colored vehicle—operated by a trained driver and psychiatric nurse—was indistinguishable from the city’s typical ambulance, but the interior was stripped of visible medical equipment to create a tranquil environment. Individuals could be seated upright or lie on a stretcher, with soft Velcro fastening as a method of restraint if necessary. If needed, sedative medication could be administered.

Zoeteman and colleagues compared the use of restraints, incidents of aggression, and psychiatric hospitalization among 498 police transports in the four months prior to introduction of the ambulance and 655 psychiatric ambulance transports in the six months after introduction.

Among the individuals transported by ambulance, 86% had no restraints applied compared with 57% of those transported by police. The use of handcuffs was virtually absent among the ambulance group (less than 1%), while 42% of those transported by police were handcuffed. The occurrence of aggressive events was similarly low (2%) in both the ambulance and pre-ambulance groups.

The rates of hospital admission were similar between the two groups (36% vs. 33%), but significantly more admissions were voluntary in the ambulance group (39% vs. 27%).

The psychiatric ambulance is among several innovations—such as Crisis Intervention Teams (CIT) and the CAHOOTS (Crisis Assistance Helping Out On The Streets) program in Eugene, Ore.—designed to support police or relieve them of the burden of transporting agitated or possibly aggressive patients having a psychiatric emergency. The researchers noted that the CIT model in the U.S. has been successful at reducing the use of force or coercion, but CIT officers sometimes transport individuals to hospitals by police vehicle, which in many communities is accompanied by restraint with handcuffs.

“Thus, shifting to an ambulance system to transport persons in a mental health crisis could also improve care in communities in which the CIT model is active,” they wrote.

For more information see the Psychiatric News article “Street Crisis Teams in San Francisco Replace Police for 911 Psychiatric Calls.”

(Image: Getty Images/iStock/Jaap2)

---

Psychiatric News Seeks Contributions From Members

New Editor in Chief Adrian Preda, M.D., invites APA members to become involved in Psychiatric News by writing news or opinion articles on the topic of their choice or by applying for leadership positions to invite and curate articles from other members in new sections that include the areas of technology, sex and gender issues, advocacy, psychotherapy, integrated psychiatry and primary care, and consultation-liaison psychiatry. Interested? For more information, send an email to editor@psych.org.

Use of Seclusion, Restraint in Hospitals Drops, But Better Data Needed to Get Complete Picture

Rates of seclusion and restraint at American hospitals, including psychiatric hospitals, fell between 2013 and 2017, at least among those with the highest rates. For-profit hospitals appear to use seclusion and restraint much less than nonprofit and government-owned facilities, according to a report in Psychiatric Services in Advance.

But there continues to be enormous variability in the use of seclusion and restraint across hospitals. Moreover, reporting of data on seclusion and restraint use is marred by errors and lack of detail, including data on patient characteristics.

Public reporting of such data is intended to allow patients, families, and other stakeholders to compare hospitals and provides an incentive for hospitals to improve quality of care. “These benefits, however, can be realized only to the extent that the data collected and reported are accurate and complete,” wrote Vincent S. Staggs, Ph.D., of the University of Missouri-Kansas City.

He looked at rates of seclusion and restraint at 1,642 acute care and psychiatric facilities using the Centers for Medicare and Medicaid Services’ (CMS) Hospital Compare website. Staggs compared three types of hospitals—for-profit, nonprofit, and government-owned.

Among facilities with the highest rates of seclusion and restraint, those rates dropped by 18% to 32% between 2013 and 2017.

In 2017, two-thirds of hospitals reported seclusion rates of 0.09 hours or less per 1,000 patient-hours, and two-thirds reported restraint rates of 0.15 hours or less per 1,000 patient-hours. But 10% of hospitals reported rates roughly five times as high as these.

For-profit hospitals had markedly lower rates of seclusion and restraint than government and nonprofit hospitals.

Staggs found significant errors in the aggregated statistics, and a major conclusion of the study is the urgent need for more rigorous and detailed data. For instance, the data on Hospital Compare do not take into account patient-level data—such as severity of illness and other patient characteristics—that may help explain the differences in rates among hospitals.

Nor are there separate data on duration and on frequency of the use of seclusion and restraint. The statistic on “hours per 1,000 patient hours” currently reported by hospitals combines frequency and duration in such a way that obscures when a hospital may be outside the norm—either higher or lower—with regard to frequency and/or duration.

“As a potential resource for health care consumers, patient safety organizations, regulatory agencies, and researchers, these data deserve more attention and further development,” Staggs wrote. “[D]ata reporting to CMS should be made more rigorous and be expanded to include frequency of seclusion and restraint use and duration of seclusion and restraint episodes.”

(Image: beerkoff/istock.com)

---

Now in Psychiatric News

Psychiatric News continues to report news and information relevant to psychiatrists about the COVID-19 pandemic. We will highlight these articles for you as they become available online:

Leadership Has Critical Role to Protect Health Care Workers During COVID-19

Asian American Hate Incidents: A Co-occurring Epidemic During COVID-19

Don’t miss out! Learn when Psychiatric News posts new articles by signing up here.