July 28, 2016

Inside The Reporter’s Notebook: Register Reporter Describes Investigation Into Stranded Mentally Ill Patients

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Tony Leys, Des Moines Register

Tony Leys, Des Moines Register

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About Inside The Reporter’s Notebook:

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Read The Des Moines Register Story:

Mentally Ill Iowans Stranded For Months In Hospitals

Iowans with mental illness are being stranded at hospitals for months after being cleared for release, according to a recent Des Moines Register report.

Register health reporter Tony Leys, who wrote the story, uncovered one particularly striking example of a man who remained stuck in Broadlawns Medical Center’s psychiatric unit in Des Moines for a year and two months after he had been cleared.

The issue is a nuanced one, Leys explained in an interview with IowaWatch. Few residential care agencies are willing or able to take on the expense of caring for these patients who no longer need hospitalization but are not able to live on their own. However, once hospitalization is no longer considered medically necessary, many insurance programs cut off payment, meaning hospitals end up holding the bill for the expensive hospital stays of stranded patients.

The logjam adds to Iowa’s shortage of psychiatric hospital beds. If no beds are available, new patients struggling with psychiatric crises who are in need of hospitalization are turned away.

In the IowaWatch interview, Leys said he heard a comment that led to this story during his coverage of other health care issues. As a beat reporter churning out daily stories, Leys said he keeps his ear to the ground to uncover new information that can lead to larger investigative reports.

Thomas Nelson, IowaWatch: My first questions for you is, what attracted you to this story?

Tony Leys, Des Moines Register: Well, I cover health care for the Register (Des Moines Register) and I have for quite a while now and I had heard from staff members at Broadlawns (Medical Center in Des Moines) that they had a gentleman who’d been in their psych unit at that point for almost a year. They just were unable to find placement for him. This was an increasing problem, but this was an extreme example. I certainly had written in the past that the psych units in Iowa are always full and that sheriff’s deputies and ambulances are just constantly crisscrossing this state with people trying to find an open psych bed. And then to hear that a lot of those psych beds were filled by people who had been cleared to be released. That got me interested.

Nelson: Why is this story important to Iowans?

Tony Leys, Des Moines Register

Tony Leys, Des Moines Register

Leys: Well, if you have a loved one who has mental illness it’s obviously important because this could happen to them or could happen to you. It would not be acceptable for any other kind of ailment, for a cancer patient or a heart patient, to have to get stuck in a hospital for months at a time just because there was no alternative. And then for the tax payers, this is an incredibly expensive way to do it. No one disputes that it’s roughly double as expensive to do it this way as opposed to having them in a community setting and the tax payers end up footing that bill one way or the other.

Nelson: There were specific numbers cited in there: over $500,000 for keeping a patient at one time. (The patient stayed at Broadlawns for 16 months total.) How difficult was it for you to get those numbers?

Leys: Well the limitation in that case of that gentleman was they talk to me about it on the condition that I wouldn’t name him, which is unusual. We don’t usually grant that because we find it to be more compelling when we have an actual person with a name and their photo that people can relate to. But once I agreed to that and then I talked to the man’s father, who is his guardian, and then Broadlawns was wiling to give me estimates of how much this costs.

Nelson: What kind of legal and medical obstacles did you run into this, because that’s a major piece of the story, that you have a gentleman that has a mental illness and he’s not able to be named. Were there any other difficulties along that line, along those lines, that you ran into while doing this?

Leys: Well, that was a big one and it was worse in this case. I write about a lot of patients and they can sign waivers for me and then the providers can talk about it. In this case there was a legitimate question as to whether he would understand such a document, which I thought was a legitimate question. So that was the biggest hurdle and then one of the other hurdles is it’s a little hard to define who is a person who’s ready to leave. So the hospitals would give me sort of back of the envelope estimates. They would say, “Oh, a quarter of our beds on any given day probably are taken up who don’t really need to be there.” But it’s not a, there’s not a strict definition of who you’re talking about. So that was a challenge. I couldn’t get a specific number of how much this is costing the state each year.

Nelson: How big of a deal is mental illness in Iowa? The funding was cut and there are limited facilities now. What does that mean for Iowans now and what does that mean for investigative reporters who want to find out what’s going on and finding out the deeper meaning behind what’s going on with mental illness in Iowa?

Leys: There’s two sides to that story. One is that the there have been very deep cuts over the last ten or twenty years in the number of beds both in hospitals and in institutional care. In the state mental hospitals, they’ve closed two of the four and they’ve cut way back on the number of beds in the remaining ones. Also about half of what they used to call, they’re called residential care facilities, have closed in this state and those mainly are what used to be the old county homes. They’re closing left and right and that’s a big story. I’ve written about that too, and I think journalists should be paying attention to that. Those folks, a lot of them are being moved in to community settings, in apartments and private homes that they share with say three, or four, or five other people and there will be staff in that home and they go on more outings and they cook meals for themselves and for the most part, most people think that’s a very good idea. It’s being driven by federal regulations, Medicaid will no longer pay for a lot of institutional care because they’re trying to push states to put people into this more community setting. So for most people that’s a positive thing and so I don’t think when we talk about closings institutions we should just focus on the negative. There is a positive to it. I’ve written that story and I think others should too. The negative comes in that there’s still this subset of patients, who are so ill and have so many problems that they just can’t hack it in that kind of setting. So then the question becomes what do to with those folks and that’s who we’re talking about in this story. Those are the kind of people who are getting stuck in hospitals for months at a time, because there’s a lack of alternatives.

Nelson: Now there was also mention of I think about 348 people in the article that have been turned down for care in the Polk County facility. What does that mean for them and how also did you find, that’s a very specific number, how did you go about finding that, and do they keep records of whom they turned down and why?

Leys: They do. They could give me that because they weren’t telling me who those folks were, but, yeah, they keep track of that. It’s in the hospital’s interest to talk about that because they don’t what to do that. They gave me that number fairly easily. It’s a public hospital. It’s a public record. I think that private hospitals would be willing to do that too. Broadlawns is in the process of expanding their inpatient unit, which is very expensive and they have to justify that to the taxpayers. The taxpayers own that hospital. That’s part of the way they’re doing it. That number represents the people who needed to get into the hospital on an emergency basis and there wasn’t a bed for them. They’re often sent hundreds of miles away, by Sheriff’s deputies or by ambulance. That’s very expensive. A lot of those folks could be cared for here if the beds weren’t taken by people that don’t need to be there.

Nelson: What kind of follow-ups should be done for this story? What information is still out there that you think should be more present?

Leys: A big one on this is there’s new companies called managed care organizations who’ve taken over management of Iowa’s Medicaid program. Very controversial. It just started in April so it’s a little too soon to know how that’s all going to shake out. State officials who favor that and pushed it through say that those companies should be able to be more flexible and come up with creative ways to help these people, because they’re not gonna want to pay to keep them in the hospital. The skeptics doubt that’s going to be much help. They’re afraid that these for-profit companies are going to look for every possible alternative to not give these folks much care at all and that they’ll end up worse off. So I’m going to try to keep on eye on it and see how that shakes out. At this point it’s too soon to tell.

Nelson: How much time and energy did you end up having to put in to find out all of this information and be able to get the story out to the public?

Leys: I worked on it for several weeks. I actually had heard the initial tip several months ago. When I really buckled down it took me several weeks. I tend to be someone who does a lot of shorter daily stories and then I think of having a crockpot or a pot on the back burner where I have something bigger going. I try to do that at all times and so this was one of those. It was a crockpot story.

Nelson: Is that sort of how you go about it? When you get a tip, you get that story, and then you work on that while working also sort of just, just a daily story and then eventually you’re able to bring up a little bit of information after putting it on, doing that and doing the smaller ones?

Leys: I do. There are a few people who their whole job is: investigative journalist. I think that’s rarer and rarer. I think there’s more of us who are beat reporters. I’m a beat reporter. I think a lot of the best investigative pieces come from beats because the best stories are the ones where you’re telling people something they don’t already know and where you find out stuff that people don’t already know is by poking around. And that’s what beat reporters do. So I heard about this when I was talking to Broadlawns people about something else, and they’re like, they started bringing up, “Aw jeez we’ve had somebody in the unit who’s been they almost a year and we can’t find alternatives for him.”

Nelson: Now do you think that investigative journalism then is something that newspapers should have someone on staff to be an investigative journalist or do you think just having quality journalist doing their beats is the most ideal?

Leys: I see value in both. I do think if you’re gonna have people who are investigative journalist, which we do have, that they should have some specific lines of areas that they are looking into. What I don’t think is so valuable is having somebody who tries to do big think pieces. They’re like, “Well, let’s investigate subject X”. Without there being a specific news peg to it. And then they spend months and months pulling data, and because they put that much effort into it they feel like they have to write a big long investigation. Sometimes you get pieces, I think of them as book reports, that really don’t have much impact because they’re just nothing very surprising. They’re showing you a bunch of data that confirms whatever you already figured. That’s the danger.

Nelson: Do you have any specific examples of book reports that you’d be willing to sort of put out there?

Leys: Oh, I don’t want to pick on anybody and I’ve written them so I’m not casting stones. I live in glass house. I’ve written book reports before. Back in the day some of the old-timers called them thumbsuckers because people would sit around and suck their thumbs while they read them. I do think every story, every series ought to have a point. You have to know what that point is and it has to be something that people will be interested in and not have heard about before. If you don’t know what that one point is, then you got a problem. That’s a sign you might be writing a book report.

Nelson: You’re an investigative journalist but also sort of a beat journalist at the same time. When did you sort of make that turn to beat reporter to investigative?

Leys: I guess I don’t see there being such a clear distinction. I think all reporters should consider themselves investigative reporters. Even if you’re a sports reporter. You know some of the best sports reporting, some of the best feature reporting, is looking into something you heard about that sounded odd and so you dig. I don’t know that there’s such a clear distinction. I guess I mainly consider myself a beat reporter, but I want to tell people things they don’t already know and I want to tell people why something’s happening.

Nelson: What would you say are hallmarks of good journalism?

Leys: Somebody’s who’s very curious and wants to find out why things are. Also somebody who doesn’t see the world in black and white. I think the world’s a very complicated place and I think sometimes investigative journalism becomes too much of a black and white thing. They’re looking for black hats and white hats. I’ve always been of the opinion that there aren’t very many truly bad people in the world. There’s a few. There are people who do dumb things or things that could be done better and so we should investigate and write about it. I don’t think we need to portray every person who we disagree with as a bad person.

Nelson: There’s the phrase, “the devil’s in the details”, and I think, as I get older I find myself looking more at stories and everything going on around me as a more nuanced, more nuanced than it has been before. How important do you think that is to get that information out to the public when it comes to nuance? Do you think that’s the most, one of the most important parts of being a journalist?

Leys: Oh absolutely. You know this story specifically. There was a commenter on there who, I just kind of shook my head, who said, I was afraid to take on Governor Terry Branstad, and obviously this is all his fault, and why didn’t I say that, you know, it’s because the Register’s afraid. Well, we’ve criticized Terry Branstad plenty and I have too. The fact is some of these issues are because of decisions that have been made by his administration. Some of them are due to decisions made nationally. Some of it goes back, certainly, before he took office. You know a lot of it is unintended consequences of this move away from institutional care, which most people would say on the whole is a good thing. It’s just there’s this unintended consequence. So I think that’s a nuance. I think it’s important. If you just start writing about this as: it’s a clearly partisan issue and a bad person is at fault for this because they’re evil. Well that gets everybody’s backs up and it just turns in to a mud fight and nothing gets solved that way. And the fact is it’s not true. It’s more nuanced than that.

Nelson: And you also mentioned earlier that there are a lot of good things that have come from revamping mental health, how we deal with mental health in Iowa, and there’s both good and bad. Do you think it’s the job of a journalist to look into the bad though?

Leys: Sure. Sure, absolutely, of course it is and those are the stories that get more attention and I’m willing to, I want to do that. When they closed those two mental hospitals a year or so ago I tracked down what happened to some of the patients, including three who died shortly after they were transferred. These were very fragile, very ill people. It was very important for the public to know that. If it hadn’t been for journalists that would not have come out. So that’s very important. But I’ve done the stories about folks who have made this transition and who are living more in an apartment and I’ve quoted people who say “Wow, this is way better for me in my situation.” That’s an important story to do too. It tends to not get as much attention, but I think it’s important to do it so to try to help to understand the totality of what’s going on.

Nelson: How much academic knowledge do you think is necessary when you’re looking at a story, you’re grabbing data from studies? When you observe that data, do you say, “Well, they took the mean what they should’ve done is grab the medium.”

Leys: Well, you need to make sure you understand the data and you need to go over it with someone who understands it. I mean, I happen to have some background in data, that helps me a little bit. One thing I do a lot of is when I’m talking to experts, when they explain something in very technical ways, the phrase I use is, “Wait, tell me that again.” When you put it that way they’re going to tell it to you in more plain English. If they won’t, I’ll be really candid. I’ll be like, “Listen I need to boil this down, but I want it to be correct and I want it to be in a way that the general public will understand and that they will be interested in but it has to be right so you need to help me.”

I don’t show sources whole stories. We’re not allowed to do that here and I support that rule. I do send them paragraphs that are technical. “Is this correct?” And there’s often a back and forth because they want to put it in more academic language and I’m like, Yyeah, that’s not gonna fly, but how about this?”, and it’ll go back and forth. I do quite a bit of that.

Nelson: And do you think data might be a new source of, sort of, taking on a more investigative tone? Because you have places like fivethirtyeight and I know at IowaWatch, we have people that are taking on data and sort of taking a story from that while still doing get person on the street, getting interviews, sort of journalism. But do you think that, that push for data which seems new — though I don’t know how new it would actually is — is going to be maybe a new form of investigation?

Leys: It can be very good. We’ve all read some great data stories. I’ll go back to saying, it has to be something that people didn’t already know. You shouldn’t get a giant data set and tell yourself, “Wow, this is great. I’m gonna write a story about this data set.” You need to hold on a minute. You need to look through that data and look for things that are surprising. I mean stories should be surprising and if they’re not they’re not very good stories. So that would be my caution. So sure it’s great. A lot of this data is really interesting.

Nelson: Do you think that sometimes that’s the line of punditry in journalism when you have someone taking data that everyone clearly knew was right. “50, 60, 50 percent like cats 50 percent of people like dogs,” and then making observations about that. Do you think that’s the line of punditry versus, “Apparently, 30 percent of the population owns mice and 60 percent own hamsters,” or something along those lines?

Leys: I don’t know. You could write a straight story on data or you could use data to back up your opinion. It works either way. I’ll say the most interesting data story shows trends. A lot of times the snapshot ones are hard to know what to make of, but if you’ve got a chance over the years, like over the last ten years, twice as many Iowans have bought cats and dogs are becoming less popular than they used to be. That’s a way more interesting story and then get into the why, rather than just saying at this moment here’s how many Iowans own cats and here’s how many own dogs. In my area, a lot of the most interesting stories either do trend data or some of the most interesting ones I’ve seen are differences in practice by geographical area. I remember a story from a few years ago, that in some areas of Iowa women with early stage breast cancer were twice or three times as likely to get mastectomies as women in other parts of Iowa with the same diagnosis. And that’s a data-driven story based on Medicare data and it had to do with the practices of the surgeons in their area. Some surgeons were being way more aggressive. So if you happen to be a woman in this part of Iowa you’re twice as likely to have your breast removed for this diagnosis as other parts of Iowa. That’s an interesting story. If you just had the data for one county it’d be kind of hard to make, what to make of it, right?

Nelson: There’s also the, the statistician’s line, “Correlation does not imply causation,” as well, and do you think there’s sometimes any worry that by doing data journalism and when you find a trend sometimes you can associate the correlation does not imply the causation or do you think it’s the job of the journalist to go ahead and make a point to find the people that are able to communicate that in the article?

Leys: Sure. That’s the biggest problem with data is one thing does not prove the other and often times correlation goes both ways or the causation goes both ways. So yeah, that’s the biggest problem. You’ve gotta try to figure that out. You’ve got to own up to the limits of your data and you’ve got to own up to them right up front. You don’t bury that in some footnote.

Nelson: The best example I’ve ever heard, I had a professor at Iowa State University, Professor Urbatsch (Associate Professor Robert Urbatsch) tell me that, to explain that correlation does not imply causation, there is a correlation of intelligence toward height so the taller you are the more intelligent you are. But that stems to the fact that an infant and children are not as smart as adults and as you get taller and you get older and that’s where that trend comes, so by saying as you get taller you get smarter, makes that incorrect. Do you think there’s any, have you seen any examples in media of sort of “the taller you are the smarter you are?”

Leys: Sure. There’s a big one. Here’s example of one in my area healthcare. A lot of people in cancer treatment tout that five-year survival rates are increasing enormously and that’s great. Sounds great. It is great. But part of the reason for that is there’s a lot more people being diagnosed with cancer earlier than used to be. And some of those people might not have ever been diagnosed with cancer in the past. So if you’re diagnosing a lot of people earlier, a lot of them are going to live more than five years past their diagnosis, right? But the claims seem to be that we’ve gotten so much better at treating this. Well, that’s partly true but it’s partly just that diagnosis that way more people and a lot of those people you’re diagnosing earlier by definition, they’re going to live longer. So that’s a very misleading statistic and I see it get batted around a lot. That’s just an example. It’s kind of complicated to explain, but when you think about it makes a lot of sense.

Nelson: You’re looking for a story. You can find a lot of those statistics that are erroneous and a lot of what I have to do is when I’m looking for a story, at least for my editors, is sort of just being like, “Eh, that’s bull. I can’t really use that.” How much sorting of that do you usually do for your own articles, especially with health care because there’s so much data out there for health care that you can have eight tabs open on your computer and see eight different studies and they could all be the same ones, but they could all be maybe pointing to something different?

Leys: Right. There’s a lot of different things there. One is I’ve tried to get away from studies showing disease X in mice, because they’ve cured everything in mice. I know that’s an important step in research but it’s so far from curing them in mice to making a difference in humans that at some point is it even worth getting people all excited about curing cancer in mice? I’m amazed that there are any more mice that have cancer. That’s important and you also have to know your source, and where they’re publishing. My brother, who’s an academic, he’s had a quote he liked to cite that: “No idea is so stupid that can’t find a professor who believes it.”

Nelson: What do you for see as possible future possibilities for investigative journalists, because with the internet out there you can go and you can find any number of studies. I’m working on a story about the homeless right now and I can go on HUD websites and shelter websites and there are mountains and mountains of data that ten, fifteen years ago if I was looking for it I would have to go and go to where they are and then look specifically for their data. How much do that’s made a big change for journalism?

Leys: I think a lot of the best stories don’t start there. The best stories still start on the ground. They start with actual people and you’re hearing something very surprising that happened to somebody. And then you go look at the data to see what the patterns are. Those tend to be the best stories. What happens too often and, I’ve been guilty of this, is you get a story based on data, or some study, or some bill and then at the last minute at the back end you go find a quote real person unquote to illustrate the point and a lot of times their example doesn’t exactly fit but you kind of hammer on it to try to make it fit. So you write a short anecdotal lead with this person and you kind of have to twist it a little bit and then you get into this book report. The stories tend to be better when they go the other way. Like when I was writing about the closing of those mental hospitals I then went and got a bunch of data and talked to national experts about the trends, but it started with this event that was happening in Iowa. It didn’t start the other way around.

Nelson: O.K. then one final question for you, or at least unless this spurs another question, is what advice would you give journalists who are graduating, graduating in 2017, 2016 who are going out? What would you tell them, the prospective investigative journalist, the prospective beat journalist out there? What is the best thing they can do, and the best way for them to spend their time to try to be, to give the most quality news to the public?

Leys: I would say try to start out as a beat reporter, but a beat report who’s willing to investigate things. There’s so much going on that you can find out as a school board reporter, as a suburban reporter. I’ve heard a lot of young reporters wind up covering the suburbs to start with and I’ve heard some people poo-poo that and say they can’t wait to get off that beat. There’s so much going on out in the suburbs. That’s where all the growth is. There’s tons to dig into out there. You should have a good attitude about that. If you’re a sports reporter, you should be willing to look into it. I absolutely would encourage people to start out as beat reporters and I like being a beat reporter. I’ve been in this business for 28 years now and I have no desire to get off of being a beat reporter, because it’s such a fertile ground to find things to look into. Whereas if you have brainstorming sessions, I’ve always thought brainstorming sessions, they have their place, but sometimes they feel like séance where you’re trying to raise a great story idea from the middle of the table. Instead you should be out there talking to people and trying to find out what’s going on.

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