San Francisco Sues Nevada Over `Patient Dumping`

The state of Nevada and its primary psychiatric hospital "intentionally and wrongfully" foisted the cost of caring for indigent mentally ill people onto California cities and counties by issuing patients bus tickets out of town without making proper arrangements for their care, a lawsuit filed Tuesday in San Francisco charges.

San Francisco City Attorney Dennis Herrera filed the class-action lawsuit against Nevada, Rawson-Neal Psychiatric Hospital in Las Vegas and state mental health administrators, seeking reimbursement for the care of indigent patients he said the system "dumped" onto California in an effort to save money.

"What the defendants have been doing for years is horribly wrong on two levels," Herrera said in a written statement announcing the lawsuit. "It cruelly victimizes a defenseless population, and punishes jurisdictions for providing health and human services that others won't provide."

In addition to unspecified financial damages, the suit asks for a permanent injunction preventing Nevada from dispatching psychiatric patients to California unless they are residents of the destination city or county, are being sent to family members who have agreed to care for them, or are being sent to a medical facility where arrangements have been made for their treatment.

Mary Woods, spokeswoman for the Nevada Department of Health and Human Services, said Tuesday afternoon that her agency would have no immediate comment on the suit.

The action follows a formal demand Herrera issued last month to Nevada officials. He said he planned to take legal action within weeks unless the state reimbursed San Francisco $500,000 for care of patients he maintains were improperly bused to the city since 2008. Herrera said an investigation by his office had identified 24 patients who had been bused to San Francisco over the past five years, 20 of whom Herrera said required emergency treatment upon arrival.

Nevada's attorney general responded this week with a letter arguing that San Francisco had offered insufficient evidence to justify its claim. Records gathered by state health officials and given to Herrera "demonstrate that the policies are appropriate and that only proper discharges were made," reads the letter, sent Monday and signed by Chief Deputy Attorney General Linda Anderson.

Nevada's mental health system has been in the spotlight for months, following a Sacramento Bee report published earlier this year that found Rawson-Neal had bused 1,500 mentally ill patients out of Southern Nevada from July 2008 through early March 2013. About 500 were given one-way tickets to California.

The Bee undertook its investigation after one of those patients, James Flavy Coy Brown, turned up suicidal and confused at a Sacramento homeless services complex after a 15-hour bus ride from Las Vegas to the capital city. Brown said he knew no one in Sacramento and that Rawson-Neal doctors advised him to dial 911 once he arrived in the city.

Nevada health officials have acknowledged that they erred in shipping Brown to Sacramento without any arrangements for care. But they contend his case was an exception and that the vast majority of patients bused from Rawson-Neal had family or treatment waiting for them on the other end of their journeys.

They said many of the patients bused to their "home states" were vacationers who suffered breakdowns or abused drugs. A Herrera spokesman disputed that explanation.

"This is about Nevada's state-sanctioned practice of improperly transporting indigent psychiatric patients," said Matt Dorsey. "It's not about patients who travel voluntarily between Nevada and other states."

The lawsuit filed Tuesday charges that Nevada sent mentally ill people to California in a manner that placed patients, their fellow Greyhound passengers and residents of the places where they landed in peril.

"All of the patients were transported without escorts," and often without "adequate food, water and medication" to sustain them during lengthy bus trips. Because the hospital failed to make proper arrangements for their care, many of the patients "ended up on the streets of their destination cities without funds or means of support, shelter or medication," the suit reads.

Although Nevada is required by state law to care for its poor and indigent, it sent patients out of state "and avoided expending its own public resources" to provide for them, it says.

The state's aggressive busing practices coincide with funding cuts that slashed Nevada's mental health budget by 28 percent between 2009 and 2012. During the same period, the number of psychiatric patients bused from Rawson-Neal grew by 66 percent.

Since Brown's case became public, the hospital's discharge practices have been under scrutiny by an array of regulatory groups. Recently, Rawson-Neal lost its coveted accreditation with the private Joint Commission and remains under investigation by the U.S. Centers for Medicare and Medicaid Services, which has threatened to pull its Medicare reimbursements. In addition, Sacramento attorney Mark Merin has filed a class-action lawsuit on behalf of Brown and others, charging that Nevada's busing policies violated patients' constitutional rights.

The lawsuit filed Tuesday offers detailed information about several previously unpublicized cases that Herrera said illustrate improper practices by the Nevada system. In one, a homeless man with schizophrenia and a history of visits to Rawson-Neal was bused to San Francisco even though he "had no stable support system there," the suit says. Upon arrival, he received five days of crisis care.

After returning to Las Vegas, the man again wound up at the psychiatric hospital and got another bus ticket to San Francisco. Police brought him to San Francisco General Hospital after he "expressed thoughts of homicide and suicide," according to the suit.

Other patients shipped to the city from Nevada received public housing and cash assistance funded by San Francisco in addition to costly health care, the suit claims.

If successful, San Francisco's claim for reimbursement would establish a precedent for awarding restitution to cities and counties across California "able to demonstrate claims for damages" from improper transfers of patients from Nevada, Herrera said in his statement.

Lisa Ikemoto, a professor at UC Davis School of Law and a specialist in health care law, called the litigation very unusual. "I haven't seen anything like it," she said.

A judge first would have to certify the suit as a class action, said Ikemoto. To win in court, San Francisco would have to prove that Nevada intentionally "dumped" patients and the cost of caring for them onto the city, she said.

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