Mike Berens' three-part series, "Dangerous Bedfellows," began with the wrong question.
"I had seen that the cost of health care in jails was going way up, and a tip told me it was mostly psychotropic drugs," said the Chicago Tribune reporter. "So I wanted to find out how many mentally ill patients were in the jails."
Instead, he found the state taking mentally ill patients off the streets and out of the institutions and placing them into nursing homes. The reasoning: The state split the costs of care for nursing home patients with Medicaid. But, if the patient were placed in an institution, the state paid the full cost.
Using about a dozen federal and state databases, including the OSCAR nursing home database, Berens pieced together the skeleton of a dangerous and occasionally deadly practice. He found that nursing home owners openly searched for mentally ill patients and that the Department of Public Aid often turned a blind eye to nursing homes filled with non-elderly residents.
The series, published Sept. 27-29, 1998, resulted in a federal investigation of Medicaid fraud. The state responded by launching its own investigation. Illinois recently admitted that 17 of its nursing homes were actually being operated as mental institutions; all were then withdrawn from the Medicaid program.
Because of the series and the investigation that followed, many nursing homes will be relicensed to allow such patients, but staffs will be required to receive specialized service and rehabilitation training.
Violent histories
Berens found that many of the incoming mentally ill patients had histories of violence and needed intensive psychiatric care and drug therapies, neither of which nursing home employees were trained to handle.
"In 99 percent of the cases, the attacks — and the resulting injuries — were never reported to police. This lack of reporting is part of a major problem," Berens said. "I documented hundreds of incidents of attacks and injury from the state nursing home inspection reports."
Creating his own database of incidents, Berens found evidence of sexual and physical abuse of elderly patients and neglect of those who needed psychiatric care. In one case, he found a man whose behavior goals included keeping sexual fondling of other patients down to three times a week.
Department of Public Aid officials denied putting mental patients into nursing homes. In order to subvert a rule that Medicaid would pay only for patients in homes with more than 50 percent actual nursing home clients, psychiatric patients were sometimes reported as physically ill.
In one case, a woman whom state doctors had verified as mentally ill was re-classified in a nursing home as suffering from "cranial dermatitis," or bad dandruff, Berens said.
Underlying numbers
Much of the evidence Berens used in his series came from a Department of Public Health database, which included a patient-by-patient listing of about 1,200 nursing homes. DPH's state twin, the Department of Public Aid, was not so helpful.
"I would go to them with the numbers I had, showing that thousands of patients in nursing homes were mentally ill. And they would tell me I didn't understand the numbers and that I wasn't calculating the figures right," Berens said. "I've never had public officials just out-and-out lie to my face before."
Although the federal Medicaid cost report shows the owners of nursing home facilities, it only includes those who own more than five percent.
When Berens requested the same information from state sources, he was denied. After several months of wrangling with attorneys, the state relented. Berens then used the data to track down those owning less than 5 percent of the homes. "The whole thing was like an octopus network," he said.
It wasn't until Berens completed his investigative work that he finally stepped foot into the nursing homes themselves.
"The thing that helped me most was finding real advocates inside who helped guide me through the system. The series was a real melding of computer database technology and old-fashioned reporting."
Dawn Fallik can be reached by e-mail at dawn@nicar.org