by Cezary Podkul

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It was a multibillion-dollar strike, so stealthy and precise that the only visible sign was a notice that suddenly vanished from a government website.

In August 2017, a federal agency with sweeping powers over the health care industry posted a notice informing insurance companies that they weren’t allowed to charge physicians a fee when the companies paid the doctors for their work. Six months later, that statement disappeared without explanation.

The vanishing notice was the result of a behind-the-scenes campaign by the insurance industry and its middlemen that has largely escaped public notice — but that has had massive financial consequences that have rippled through the health care universe. The insurers’ invisible victory has tightened the financial vise on doctors and hospitals, nurtured a thriving industry of middlemen and allowed health insurers to do something no other industry does: Take one last cut even as it pays its bills.

Insurers now routinely require doctors to kick back as much as 5% if they want to be paid electronically. Even when physicians ask to be paid by check, doctors say, insurers often resume the electronic payments — and the fees — against their wishes. Despite protests from doctors and hospitals, the insurers and their middlemen refuse to back down.

There are plenty of reasons doctors are furious with the insurance industry. Insurers have slashed their reimbursement rates, cost them patients by excluding them from their provider networks, and forced them to spend extra time seeking pre-authorizations for ever more procedures and battling denials of coverage.

Paying fees to get paid is the final blow for some. “All these additional fees are the reason why you see small practices folding up on a regular basis, or at least contributing to it,” said Dr. Terence Gray, an anesthesiologist in Scarborough, Maine. Some medical clinics told ProPublica they are seeking ways to raise their rates in response to the fees, which would pass the costs on to patients.

“It’s ridiculous,” said Karen Jackson, who until her retirement in March was a veteran senior official at the Centers for Medicare & Medicaid Services, the federal agency that posted, then unposted, the fee notice. Doctors, she said, shouldn’t have to pay fees to get paid.

But that’s precisely what’s happening. Almost 60% of medical practices said they were compelled to pay fees for electronic payment at least some of the time, according to a 2021 survey. And the frequency has increased since then, according to medical clinics. With more than $2 trillion in medical claims being paid electronically each year, these fees likely add up to billions of dollars annually.

Huge sums that could be spent on care are instead being siphoned off to insurers and middlemen. The fees can cost larger medical practices $1 million a year, according to an April poll by the Medical Group Management Association, which represents private medical practices. The figure sometimes runs even higher, according to a 2020 complaint to CMS from a senior executive of AdventHealth, which has 53 hospitals in nine states: “I have to pay $1.8M in expenses that I could use on PPE for our employees, or setting up testing sites, or providing charity care, or covering other community benefits.” Most clinics are smaller, and they estimated annual losses of $100,000 or less. Even that figure is more than enough to cover the salary of a registered nurse.

The shift from paper to electronic processing, which began in the early 2000s and accelerated after the Affordable Care Act went into effect, was intended to increase efficiency and save money. The story of how a cost-saving initiative ended up benefiting private insurers reveals a lot about what ails the U.S. medical system and why Americans pay more for health care than people in other developed countries. In this case, it took less than a decade for a new industry of middlemen, owned by private equity funds and giant conglomerates like UnitedHealth Group, to cash in.

How these players managed to create this lucrative niche has never previously been reported. And the story is coming to light in part because one doctor, initially incensed by the fees, and then baffled by CMS’ unexplained zigzags, decided to try to figure out what was going on. Dr. Alex Shteynshlyuger, a urologist who runs his own clinic in New York City, made it his mission to take on both the insurers and the federal bureaucracy. He began filing voluminous public records requests with CMS.

Dr. Alex Shteynshlyuger is on a crusade against payment processors’ fees, which he says threaten his practice. (DeSean McClinton-Holland for ProPublica)

What he discovered in internal emails and government documents, which he shared with ProPublica, was a picture sharply at odds with the image of CMS as a hugely powerful force in health care. The records showed, again and again, federal officials deferring not only to a single company, but to a single executive.

Over the past five years, CMS adopted that company’s positions on fees. Shteynshlyuger discovered that, when it comes to the issue he cares about, the most powerful decision-maker wasn’t a CMS official. It was the chief lobbyist for a middleman company called Zelis. And that man just happened to be a former CMS staffer who had authored a key federal rule on electronic payments.

For Shteynshlyuger, the intersection of medicine and money has a particular resonance. He was born in the Soviet Union, in what is now Ukraine, and his brother nearly died of pneumonia as an infant because doctors refused to administer an antibiotic. The doctors wanted his family to pay a “bribe,” according to Shteynshlyuger. His grandmother ended up finding a different doctor to pay off and his brother got the medicine. Shtenynshlyuger’s parents emigrated to the U.S. in 1991, when he was an adolescent, and they settled in Brooklyn’s Brighton Beach area.

Today, Shteynshlyuger sees the fees for electronic payment through a similar lens. He’s a gadfly, but one with a wry, sometimes humorous disposition and an intellectual bent. He studied biology and economics in college and is capable of both rage at perceived unfairness and dispassionate observations about health policy. The unjust fees, as he sees them, threaten his medical practice, which he designed to serve middle-class patients. He prices his services at a discount. “Low cost is what keeps me in the business,” he said.

As a result, administrative combat has become a big part of his life. Unmarried, Shteynshlyuger, 45, stays up into the wee hours, writing lengthy memos to regulators. One recent missive spanned 155 pages, including appendices.

This New Year’s, he joined his family for a week off at his parents’ condo near Miami. Shteynshlyuger arrived with a desktop computer, which he set up in one of the bedrooms alongside two monitors that he keeps at the condo. While his nieces and brother enjoyed the beach, Shteynshlyuger sat indoors, drafting a 38-page memo to aid in one of two lawsuits he has filed in an effort to pry documents out of CMS.

Shteynshlyuger’s accent, with its distinctive Brooklyn-Russian mix, is unmistakable in calls with customer service representatives at insurance companies and payment processors. (He recorded many of the calls and shared them with ProPublica.) The calls follow a similar pattern: Posing questions in the manner of a genial but persistent litigator, Shteynshlyuger asks why he’s being charged a fee.

Ultimately, he’s informed that there’s no way to have an electronic funds transfer, or EFT, sent straight to his bank account without paying a fee. When the calls get escalated, representatives sometimes offer to shave a tiny amount off the fees — charging, say, 2.1% rather than 2.5%, a proposal made on one recent call with Zelis — but rarely is he offered a free transfer.

Shteynshlyuger spends hours on the phone with payment processors like Zelis, fighting their attempts to impose fees on electronic payments. (DeSean McClinton-Holland for ProPublica)

A spokesperson for Zelis, the payment-processing company that Shteynshlyuger has tangled with most often, said the company refers requests for free electronic payments to the insurers, but recordings and transcripts of recent calls show that did not happen when Shteynshlyuger called.

Shteynshlyuger and other doctors say payment processors routinely sign them up for high-fee payment methods without their consent. A brochure for one payment company, Change Healthcare, boasted of automatically enrolling 100,000 doctors and hospitals in a plan to receive virtual credit cards and sharing some $8 million a year in revenues with the large insurer it was working for. (Virtual credit cards are a form of electronic payment in which a payer sends a string of numbers that are typed into a credit card reader to generate a one-time payment. Fees for VCCs run as high as 5% versus a typical 2.5% for other kinds of electronic payments.)

Payment processors often boost insurers’ revenues by sharing the fees from virtual credit cards. One processor, VPay, says in its marketing materials that insurers can “make money on every virtual card transaction.” In response to questions from ProPublica, UnitedHealth, which owns Change and VPay, asserted that its services help medical clinics streamline recordkeeping, reduce administrative burdens and accelerate payments.

Zelis and other payment processors say they offer value in return for their fees: Doctors can sign up to receive reimbursements from hundreds of insurers through a single payment processor, and they can also get services that help match up electronic payments and receipts. Zelis asserted in a statement that its services remove “many of the obstacles that keep providers from efficiently initiating, receiving, and benefitting from electronic payments.” Zelis and other companies insist that it’s easy to opt out of their services, but Shteynshlyuger and other doctors say otherwise.

Virtual credit cards come with fees as high as 5%. (Courtesy of Dr. Terence Gray. Redacted by ProPublica)

When Shtyenshlyuger embarked on his mission of fighting the fees in 2017, his first step was research. He quickly came across an article from the American Medical Association that said the law was on his side.

Shteynshlyuger then approached the companies. He emailed senior executives of Zelis and VPay, asserting that the fees violated CMS rules. The companies denied breaking any rules and wouldn’t budge on the fees.

So Shteynshlyuger started filing complaints with CMS. The responses he received struck him as curious. CMS itself usually didn’t offer an opinion. Instead, it forwarded letters from a Zelis executive named Matthew Albright, who answered Shteynshlyuger’s complaints on at least five occasions. (The agency said this passive approach is part of its “informal” complaint resolution process.)

When Shteynshlyuger pressed a CMS official to articulate the agency’s position after it passed along Albright’s answer, the official wrote that the agency receives the “identical legal response” from Zelis to all such complaints. She added: “They believe that, according to their interpretation of the regulation, they are compliant.”

Shteynshlyuger was flummoxed. Who was Matthew Albright? A quick Google search revealed that Albright had once worked for CMS. That only piqued Shteynshlyuger’s interest. Had Albright been involved in the removal of the CMS notice prohibiting fees?

To Albright, the 2010 passage of the Affordable Care Act was a historic event of a magnitude akin to the moon landing. Then a policymaker with Washington state’s Health Care Authority, Albright was awed by the importance of the looming rewrite of U.S. health care rules. He felt he had to be part of it. “This is the Apollo 11 for regulators,” he recalled thinking, in an interview with ProPublica. “I’ve got to get to D.C. and write regulations.”

Matthew Albright, now chief legislative affairs officer at Zelis, made a series of explanatory videos in his days at the Centers for Medicare & Medicaid Services. (Screenshot via YouTube)

Now 55, Albright had unusual training for his new role. Instead of following the typical path through law school, he had studied sacred texts, first at the Pontifical University of St. Thomas Aquinas in Rome and later at Harvard University, where he earned a master’s degree in divinity. Those studies, Albright said, fostered what he called a “scholastic fascination with words and how they’re used to tell people what to do,” whether those words are in the Ten Commandments or the Code of Federal Regulations.

Articulate and cheerful, today Albright can still sound more like a divinity professor than a lobbyist when he describes his current job as studying laws and rules. “Hermeneutics,” he said, “it’s just like Bible study, right? Breaking it down into its understandable parts. And then, frankly, turning around and teaching it or turning around and explaining it in the vernacular, if you will. So I think that most of my job is looking at regulations and reading them and then explaining them to internal and external audiences.”

At CMS, Albright drafted a rule, published in 2012, that laid out standards for paying doctors via electronic funds transfers. The Affordable Care Act required all insurers to offer EFTs and encouraged doctors to accept them, and electronic payments quickly became the go-to method for handling medical claims. A CMS analysis predicted that eliminating the labor of manually processing paper checks and receipts would lead to savings of $3 billion to $4.5 billion over 10 years.

Albright became the agency’s point man on the issue. He looked every bit the government bureaucrat in a gray shirt and dark suit as he extolled the virtues of “administrative simplification” in earnest-but-stiff video segments that emulated a talk show. (Albright also created a personal YouTube channel when he taught a philosophy course. It had bite-sized explanations of, among other things, Kantian ethics — “do not use people” — and Ayn Rand’s philosophy — “selfishness is good.”)

Albright’s work at CMS, by his description, became a “turning point” for health care payments. The shift to electronic funds transfers facilitated the growth of an industry of payment processors. It also made Albright’s skill set very valuable. In 2014, he was recruited to the industry he previously regulated. Two years later, he landed at Zelis. The company had just been created via a merger of four businesses owned by Parthenon Capital, a private equity firm. Zelis is now co-owned by private equity giant Bain Capital and headed by a former Bain partner. (Parthenon declined to comment; Bain referred a request for comment to Zelis.)

Zelis, which once described itself as having a “regulatory-based business model,” touted Albright’s government resume when it hired him as vice president of legislative affairs. Albright said at the time he would “advocate for rational regulatory approaches.”

Rational regulatory approaches, from Zelis’ perspective, included the right to charge doctors for electronic payments. That was a crucial revenue stream for the company, but it could dry up if CMS enforced a rule prohibiting such fees. Who better than Albright, the man who had drafted rules on electronic payments, to help the company navigate the situation?

When Shteynshlyuger began to receive documents from CMS in response to his Freedom of Information Act requests, he was first struck by how deferential CMS officials seemed to be to Albright. In July 2019, for example, as Shteynshlyuger continued to complain about Zelis, a CMS official named Gladys Wheeler contacted Albright. “You may be familiar with Dr. Alex Shteynshlyuger,” Wheeler wrote. “To assist with resolution of the complaints, I have a few questions. Can I send the questions to you, or can you redirect me?” She added, “Just let me know the best approach. Thanks, and take care, Gladys.” (Wheeler did not respond to requests for comment.)

The tone of the conversations between Albright and CMS could be downright chummy. “Should we respond to it as per usual?” Albright asked in another July 2019 email about a new complaint filed by a doctor in Washington state. “Send the Zelis response for documentation purposes,” Wheeler responded in between banter that she and Albright exchanged about Chicago’s winter weather (bad) and architecture (great).

Shteynshlyuger was growing more frustrated. He didn’t understand why CMS had yanked the notice about the prohibition on fees from its website. If his months of effort couldn’t extract clear answers, how could other doctors with less inclination for bureaucratic battle figure out what to do?

What Shteynshlyuger didn’t know was that, less than two years earlier, a lobbying campaign had begun behind the scenes at CMS. The documents that he eventually obtained would provide a rare, nearly day-by-day glimpse into how one lobbyist — Albright — managed to bend the agency to his will with an artful combination of cajoling, argument and legal threats.

On Aug. 11, 2017, CMS’ website had posted the notice that EFT fees were prohibited. Such notices, presented in the form of answers to frequently asked questions, are meant to explain the agency’s complex rules in plain language. CMS based the notice on a rule from 2000 that banned fees in excess of normal telecommunication costs (such as, say, the tiny fractions of a penny to cover the cost of an email) that a doctor would incur if they were receiving the bill “directly” from an insurer.

The notice triggered an immediate protest from Zelis, according to emails and an internal CMS memo. Albright had “multiple conversations” with CMS staff and demanded that the agency revise the notice.

The nub of Albright’s argument was that CMS’ 2000 rule prohibited insurers from charging excessive fees for “direct” transactions. But, he argued, the rule was meant to apply to insurers dealing with doctors. Albright represented payment processors who work for insurers; those weren’t direct transactions between insurers and doctors. Thus, he argued, the fee prohibition couldn’t apply to EFT payments.

CMS, which took months or longer to respond to Shteynshlyuger, quickly complied with Albright’s request and removed the fee notice on Aug. 14, 2017, only three days after it was posted.

CMS published an updated notice in late September 2017. But the agency stood firm on the key point: The new document stated that insurers and payment processors “should not charge providers communications fees” for EFTs.

Shortly after the revised notice went up, Albright emailed the director of the CMS division that issued it. “Hope the kids have settled into the school year okay,” he began. He then asked for “our day in court to educate” the agency. He suggested that Zelis was preparing to escalate its complaints but offered to “work through this without causing too much noise.”

Two days before Thanksgiving, Albright confronted Christine Gerhardt, then deputy director of the CMS division that issued the fee notice. In a phone call, Albright demanded that CMS revise the document again, according to Gerhardt’s summary of the call. Gerhardt refused. Albright began debating her on the legal differences between the explainer and the regulation that it summarized.

The following week, Albright pressed harder, asking Gerhardt whether the prohibition on fees was enforceable. He told Gerhardt that if she did not answer, that itself would be an answer. It would, Albright said, “give me a sense of what steps need to be taken next” to challenge the agency’s notice. Gerhardt, who is now retired, said she assured him that the agency wasn’t implementing a new rule; only clarifying existing rules. Albright was pushing hard, but at that point, Gerhardt hadn’t bent.

Then, in January 2018, Zelis brought in the lawyers. A firm called Nixon Peabody wrote to CMS, demanding that the agency “withdraw or correct the offending language” in its notice. Nixon Peabody argued that the fee prohibition wasn’t a restatement of existing rules but that it amounted to a new rule that should have been issued via the formal rulemaking process. Nixon Peabody threatened to sue if CMS didn’t comply with Zelis’ demand. (Nixon Peabody did not reply to a request for comment.)

The legal threat set off a scramble within CMS. “Let’s just take it down,” Gerhardt wrote in a Feb. 9, 2018, email to colleagues. Her division not only removed the notice saying that fees were prohibited but also went so far as to institute a moratorium on any new notices. CMS was essentially depriving all medical providers of guidance on these issues because one company had complained.

The response puzzled even some within CMS. “What was the basis for withdrawal if the request was from a single entity and potentially harms providers?” Jackson, then CMS deputy chief of operations, wrote in an email.

Albright, his goal accomplished, sought to soothe Gerhardt and two of her colleagues. “I know I butted heads with all three of you,” he wrote a few weeks later. Albright offered to meet to explain why Zelis is not “one of the bad guys in this area.” (Zelis did not address detailed questions about Albright’s interactions with CMS.)

In March 2018, after Zelis complained and CMS removed a notice saying that payments to doctors couldn’t carry fees, Albright emailed three key agency staffers to patch things up. (Email exchange provided by Alex Shteynshlyuger)

CMS told ProPublica in a statement that it reversed its position because it concluded that it had no legal authority to “flat-out prohibit fees.” The agency declined to comment on Shteynshlyuger’s complaints, but said it takes seriously any allegations of noncompliance with its rules. As for Zelis’ lobbying, CMS said it “receives feedback from a wide range of stakeholders on an ongoing basis. The information received helps the agency understand where guidance and clarification of existing policy may be needed.”

The American Medical Association and over 90 other physician groups have urged the Biden administration to reinstate guidance protecting doctors’ right to receive EFTs without fees. For its part, the massive Veterans Health Administration system has been refusing to pay the fees, which it has described as illegal in letters to Zelis and insurers.

So far the protests have had no visible effect. In fact, when CMS finally issued a new explainer that addressed fees in July 2022, more than four years after erasing the previous one, the agency made explicit what had previously been implicit: EFT fees are allowed.

Shteynshlyuger is continuing his lonely campaign. Two months after CMS stated that fees are OK, a Zelis customer service representative contacted him. Shteynshlyuger had just submitted his 80th complaint to CMS. Emails show the rep offered to help him get signed up for no-fee EFTs — but the offer only applied to payments from one of the more than 700 insurers and other payers that Zelis represents. Shteynshlyuger demurred, saying he did not want the issue resolved without CMS’ intervention because then other doctors could not get the same assistance. As often as not, Shteynshlyuger and other doctors are left with little recourse; many insist on being paid by paper check rather than allowing Zelis to take a cut.

In mid-December, Shteynshlyuger finally got the long-awaited replies to eight other complaints he had filed over the years. CMS dismissed all eight because Shteynshlyuger didn’t file them against insurers but instead against companies like Zelis, which CMS referred to as “business associates” of the insurers. CMS said it now believes its oversight extends only to insurers, not to their business associates. The phrasing may have been bureaucratic, but the news was dramatic: CMS had fully surrendered, giving up on regulating payment processors entirely.

Shteynshlyuger hasn’t filed a new document request yet to uncover whether Zelis or perhaps another company influenced that decision. He has his suspicions.

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This post was originally published on Articles and Investigations – ProPublica.

by Isabelle Taft, Mississippi Today, with data analysis by Agnel Philip, ProPublica, reporting by Mollie Simon, ProPublica

This article contains detailed descriptions of mental illness and suicide.

This article was produced for ProPublica’s Local Reporting Network in partnership with Mississippi Today. It was also co-published with Sun Herald, Northeast Mississippi Daily Journal and The Guardian. Sign up for Dispatches to get stories like this one as soon as they are published.

If you or someone you know needs help:

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When sheriff’s department staff in Mississippi’s Benton County took Jimmy Sons into custody several years ago, they followed their standard protocol for people charged with a crime: They took his mug shot, fingerprinted him, had him change into an orange jumpsuit and locked him up.

But Sons, who was then 20 years old, had not been charged with a crime. Earlier that day, his father, James Sons, had gone to a county office to ask that his youngest son be taken in for a mental evaluation and treatment. Jimmy Sons had threatened to hurt family members and himself, and his father had come across him sitting on his bed with a loaded shotgun.

On Sons’ booking form, in the spot where jailers usually record criminal charges, was a single word: “LUNACY.”

The booking form for Jimmy Sons, identifying his “offense” as “lunacy” (Obtained by Mississippi Today)

In every state, people who present a threat to themselves or others can be ordered to receive mental health treatment. Most states allow people with substance abuse problems to be ordered into treatment, too. The process is called civil commitment.

But Mississippi Today and ProPublica could not find any state other than Mississippi where people are routinely jailed without charges for days or weeks during that process.

What happened to Sons has occurred hundreds of times a year in the state.

The news organizations examined jail dockets from 19 Mississippi counties — about a quarter of the state’s 82 — that clearly marked bookings related to civil commitments. All told, people in those counties were jailed at least 2,000 times for civil commitments alone from 2019 to 2022. None had been charged with a crime.

Most were deemed to need psychiatric treatment; others were sent to substance abuse programs, according to county officials.

Since 2006, at least 13 people have died in Mississippi county jails as they awaited treatment for mental illness or substance abuse, Mississippi Today and ProPublica found. Nine of the 13 killed themselves. At least 10 hadn’t been charged with a crime.

A woman going through the civil commitment process, wearing a shirt labeling her a “convict,” is transported from her commitment hearing back to a county jail to await transportation to a state hospital in north Mississippi this spring. (Eric J. Shelton/Mississippi Today)

We shared our findings with disability rights advocates, mental health officials in other states and 10 national experts on civil commitment or mental health care in jails. They used words such as “horrifying,” “breaks my heart” and “speechless” when they learned how many people are jailed in Mississippi as they go through the civil commitment process.

Some said they didn’t see how it could be constitutional.

“If an ER is full, you don’t send people to jail,” said Megan Schuller, legal director of the Bazelon Center for Mental Health Law, a Washington, D.C.-based organization. “This is just outright discriminatory treatment in my view.”

Mississippi Today and ProPublica also interviewed 10 individuals who had been committed and jailed, as well as 20 family members.

Many of those people said they or their family members had been housed alongside criminal defendants. Nobody knew how long they would be there. They were often shackled when they left their cells. Some of them said they couldn’t access prescribed psychiatric medications or had minimal medical care as they experienced withdrawal from illegal drugs.

“It felt more criminal than, like, they were trying to help me,” said Richard Millwood, who was booked into the DeSoto County jail in 2020 following an attempted suicide. “I got the exact same treatment in there as I did when I was in jail facing charges. In fact worse, in my opinion, because at least when I was facing charges I could bond out.”

“I got the exact same treatment in there as I did when I was in jail facing charges. In fact worse, in my opinion, because at least when I was facing charges I could bond out.” — Richard Millwood, who was booked into jail following an attempted suicide

DeSoto County leadership, informed of Millwood’s statement, did not respond.

Millwood spent 35 days in jail before being admitted to a publicly funded rehab program 90 miles away.

Jimmy Sons didn’t receive a mental evaluation when he was booked into the Benton County jail in September 2015, according to documents in a lawsuit his father later filed. Less than 24 hours later, he was dead. Left alone in a cell without regular visits by jail staff, he had hanged himself.

He had been back in Mississippi for just a few days, planning to join his dad in electrical work, said his mother, Juli Murray. He had set out from her home in Bradenton, Florida, so early in the morning that he didn’t say goodbye.

Murray remembers the phone call from Jimmy’s half-brother in which she learned her son was in jail. She didn’t understand why.

“If you do something wrong, that’s why you’re in jail,” she said. “Not if you’re not mentally well. Why would they put them in there?”

The Lesser Sin

When James Sons went to the clerk’s office in the tiny town of Ashland to file commitment paperwork for his son, he took the first step in Mississippi’s peculiar, antiquated system for mandating treatment for people with serious mental health problems.

Jimmy Sons at age 18 at his father’s home in Mississippi (Courtesy of John Sons)

It starts when someone — usually a family member, but it could be almost anyone — signs a form alleging that the person in question is “in need of treatment because the person is mentally ill under law and poses a likelihood of physical harm to themselves or others.”

James Sons filled out that form, listing why he was concerned: Jimmy’s guns, his threats, his talk of suicide.

Then a special master — an attorney appointed by a chancery judge to make commitment decisions — issued a “Writ to Take Custody.” It instructed sheriff’s deputies in Benton County, just south of the Tennessee border, to hold Jimmy Sons at the jail until he could be evaluated.

The sheriff’s office asked Sons to come in on an unrelated matter. When he showed up, Chief Deputy Joe Batts told him he needed a mental health evaluation. Batts tried to reassure Sons that the process would be as quick as possible and would end with him back home, according to Batts’ testimony in the lawsuit Sons’ father filed over his death.

Then Batts told Sons, “What we’re going to have to do now is take you back and book you.”

What he never told Sons, he later acknowledged in a deposition, was that the young man would have to wait in jail for days before he would see a mental health provider. The first screening required by law was four days away. If it concluded he needed further examination, he would be evaluated by two more medical professionals. Then the special master would decide whether to order him into treatment at a state psychiatric hospital.

The whole process should take seven to 10 days, according to the state Department of Mental Health. But sometimes it takes longer, the news organizations found. And if someone is ordered into treatment at their hearing, they generally have to wait for a bed, though the department says average wait times for state hospital beds after hearings have dropped dramatically in the last year.

While waiting for their hearing, people like Sons are supposed to receive treatment at a hospital or a short-term public mental health facility called a crisis stabilization unit. But state law does allow people to be jailed before their commitment hearing if there is “no reasonable alternative.” (The law is less clear about what’s allowed following a hearing.)

The Benton County Sheriff’s Department formerly housed the county jail where Jimmy Sons died, in Ashland, Mississippi. (Eric J. Shelton/Mississippi Today)

Mississippi Today and ProPublica spoke to dozens of officials across Mississippi involved in the commitment process: clerks who handle the paperwork, chancery judges and special masters who sign commitment orders, sheriffs who run the jails, deputies who drive people from jails to state hospitals, and the head of the state Department of Mental Health.

None of them thinks jail is the right place for people awaiting treatment for mental illness.

“We’re not a mental health hospital,” said Greg Pollan, president of the Mississippi Sheriffs’ Association and the sheriff of rural Calhoun County in the north of the state. “We’re not even a mental health Band-Aid station. That’s not what we do. So they should never, ever see the inside of my jail.”

Batts himself, who took Sons into custody in Benton County, said law enforcement officers across Mississippi “hate to detain people like that. But we’re told we have to do it.” He acknowledged that the facility “was substandard to begin with, not having the space and the adequate facilities to hold and monitor someone in that mental state — it just puts everybody in a bad situation.” And he said he thought the state could provide alternatives to jail.

Some counties jail most people going through the commitment process for mental illness, Mississippi Today and ProPublica found. Other counties reserve jail for people who are deemed violent or likely to hurt themselves. And at least a handful sometimes jail people committed for substance abuse — even though a 2021 opinion by the state’s attorney general says that isn’t allowed under state law.

This happens because until people are admitted to a state hospital, counties are responsible for covering the costs of the commitment process unless the state provides funding. If a crisis stabilization unit is full or turns someone away, the county must find an alternative, and it must foot the bill.

Counties can place patients in an ER or contract with a psychiatric hospital — and some do — but many officials balk at the cost. Many officials, particularly those in poor, rural counties, see jail as the only option.

“You have to put them somewhere to monitor them,” said Cindy Austin, chancery clerk in rural Smith County, located in central Mississippi. Chancery clerks are responsible for finding beds for people going through the commitment process. “It’s not that anybody wants to hold them in jail, it’s just we have no hospital here to hold them in.”

Timothy Gowan, an attorney who adjudicated commitments in Noxubee County from 1999 to late 2020, said people going through the commitment process there generally were jailed if they were determined to be violent and their family didn’t want them at home.

According to the Noxubee County jail docket, people going through the civil commitment process with no criminal charges were booked into the jail about 50 times from 2019 to 2022. Ten stays lasted at least 30 days. The longest was 82 days.

“Putting a sick person in a jail is a sin,” Gowan said. “But it’s the lesser of somebody getting killed.”

Some counties rarely hold people in jail — sometimes because a sheriff, chancery judge or other official has taken a stand against it. Rural Neshoba County in central Mississippi pays Alliance, a psychiatric hospital in Meridian, to house patients.

“We’re not a mental health hospital. We’re not even a mental health Band-Aid station. That’s not what we do. So they should never, ever see the inside of my jail.” — Greg Pollan, president of the Mississippi Sheriffs’ Association and sheriff of Calhoun County

The practice isn’t confined to poor, rural counties. DeSoto County, a populous, relatively wealthy county near Memphis, jailed people without charges about 500 times over four years, the most of any of the counties analyzed by Mississippi Today and ProPublica. The median jail stay there was about nine days; the longest was 106.

The state and county recently set aside money to build a crisis stabilization unit — currently, the nearest one is about 40 miles away — but the county and the local community mental health center haven’t decided on a location, said County Supervisor Mark Gardner.

Some county officials say that keeping people out of jail during the process requires the state to step up. State Rep. Jansen Owen, a Republican from Pearl River County in southern Mississippi who represents people during the commitment process, said he believes counties that spend “millions of dollars on fairgrounds and ballparks” could find alternatives to jail. But he also sees a need for more state-funded facilities.

“You can’t just throw it on the counties,” he said. “It’s a state prerogative. And them being held in the jail, I think, is a result of the state kicking the can down the road to the counties.”

Wendy Bailey, head of the state Department of Mental Health, said it’s “unacceptable” to jail people simply because they may need behavioral health treatment. Department staff have met with chancery clerks around the state to urge them to steer families away from commitment proceedings and toward outpatient services offered by community mental health centers whenever possible.

The Department of Mental Health says it prioritizes people waiting in jail when making admissions to state hospitals. The state has expanded the number of crisis unit beds from 128 in 2018 to 180 today, with plans to add more. And it has increased funding for local services in recent years in an effort to reduce commitments.

But Bailey said the department has no authority to force counties to change course, nor legal responsibility for people going through the commitment process until a judge orders them into treatment at a state psychiatric hospital.

Locked In the “Lunacy Zone”

Willie McNeese’s problems started after he came home to Shuqualak, Mississippi, a town of about 400 people and a lumber mill, in 2007. He had spent a decade in prison starting at age 17.

He found the changes that had taken place — bigger highways, cellphones — overwhelming, said his sister, Cassandra McNeese. He was eventually diagnosed with bipolar disorder.

“It’s like a switch — highs and lows,” said Willie McNeese, now 43. “I might have a whole lot of laughter going on, trying to make the next person laugh. Then my day going down, I be depressed and worried about situations that nobody can change but God.”

McNeese has been involuntarily committed in Noxubee County 10 times since 2008 and has been jailed during at least eight of them, one for more than a month in 2019 according to court records and the jail docket. During his most recent commitment starting in March 2022, McNeese was held in jail for a total of 58 days in two stints before eventually going to a state psychiatric hospital.

Cassandra McNeese, left, and her mother, Yvonne A. McNeese, in Shuqualak, Mississippi. Cassandra’s brother, Willie McNeese, has been held in jail during civil commitment proceedings at least eight times since 2008. Cassandra McNeese said Noxubee County officials told her jail was the only place they had for him to wait. ”This is who you trust to take care of things,” she said. ”That’s all you have to rely on.” (Eric J. Shelton/Mississippi Today)

From 2019 to 2022, about 1,200 civil commitment jail stays in the 19 counties analyzed by Mississippi Today and ProPublica lasted longer than three days. That’s about how long it can take for people to start to experience withdrawal from a lack of psychiatric medications, which jails don’t always provide. About 130 stays lasted more than 30 days.

McNeese said he spent much of his time in jail last year standing near the door of his cell, what jail staff called the “Lunacy Zone,” screaming to be allowed to take a shower. A jailer tased him to quiet him down, and his clothes were taken from him. For a period, his mattress was taken, too.

“It’s a way of punishment,” he said. “They don’t handle it like the hospital. If you have a problem in the hospital they’ll come with a shot or something, but they don’t take your clothes or take your mattress or lock your door on you or nothing like that.”

McNeese said he had inconsistent access to medication and received none during his first stay in 2022, which lasted 25 days.

The Noxubee County Sheriff’s Department did not respond to questions about McNeese’s allegations.

Staff from Community Counseling, the community mental health center where McNeese had regular appointments, could have provided him with medication, but McNeese said no one from the center came to visit him in jail. A therapist at Community Counseling said staff go to the jail only when they’re called, usually when there’s a problem jail staff can’t handle. Rayfield Evins Jr., the organization’s executive director, said when he recently worked in Noxubee, deputies brought people from the jail to his facility for medication and treatment.

“If you have a problem in the hospital they’ll come with a shot or something, but they don’t take your clothes or take your mattress or lock your door on you or nothing like that.” — Willie B. McNeese, jailed multiple times following a diagnosis for bipolar disorder

“If you have a problem in the hospital they’ll come with a shot or something, but they don’t take your clothes or take your mattress or lock your door on you or nothing like that.”

If you have a problem in the hospital they’ll come with a shot or something, but they don’t take your clothes or take your mattress or lock your door on you or nothing like that.”

Willie B. McNeese, jailed multiple times following a diagnosis for bipolar disorder

Mental health advocates in Mississippi and other people who have been jailed during the commitment process said the limited mental health treatment McNeese received is common.

Mental health care varies widely from jail to jail, and no state agency sets requirements for what care must be provided. Jails can refuse to distribute medications that are controlled substances, which includes anti-anxiety medications like Xanax. The state Department of Mental Health says counties should work with community mental health centers to provide treatment to people waiting in jail as they go through the commitment process.

But those facilities generally don’t have the resources to provide services in jails, said Greta Martin, litigation director for Disability Rights Mississippi.

Martin’s organization, one of those charged by Congress with advocating for people with disabilities in each state, investigates county jails when it receives complaints. “We are not seeing any indication that these individuals are getting any mental health treatment while they are being held in these county facilities,” she said.

Willie McNeese was incarcerated at the old jail in Noxubee County multiple times during civil commitment processes, including his first commitment in 2008. (Eric J. Shelton/Mississippi Today)

McNeese said those jail stays added physical discomfort and pain to the delusions that got him committed in the first place. “Then you get to the mental hospital — they have to straighten you all the way back over again,” he said.

Since being released from the state hospital last year, McNeese said, he has been doing well. He is now living in Cincinnati with his wife.

Scott Willoughby, the program director at South Mississippi State Hospital in Purvis, said it can be hard to earn patients’ trust when they arrive at the psychiatric hospital from jail.

At his facility, patients sleep two to a room in a hall decorated with photographs of nature scenes. Group counseling sessions are often held outside under a gazebo. In between, patients draw and paint during recreational therapy.

Willoughby has spoken with patients who had attempted suicide and were shocked to find themselves in jail as a result.

“People tend to associate jail with punishment, which is exactly the opposite of what a person needs when they’re in a mental health crisis,” he said. “Jail can be traumatic and stigmatizing.”

“I’m More Scared of Myself”

When Sons learned that he was going to be booked, he became anxious about being locked in a cell, Batts testified. So he was assigned to an area of the jail reserved for trusties — inmates who are allowed to work, sometimes outside the jail, while they serve their sentences.

On the afternoon of his first day in jail, Sons was sitting on his bed when a trusty named Donnie Richmond returned from work. Richmond said in a deposition that he asked a deputy who the new guy was.

“You better watch him,” Richmond recalled the deputy telling him. “He kind of off a little bit.”

Richmond offered Sons a cigarette and cookies and asked him why he was there. Sons took a cigarette and told Richmond the deputies had said he would hurt someone.

“He was like, ‘Man, I’m going to be honest with you,’” Richmond testified. “‘I ain’t going to hurt no one. I’m more scared of myself, of hurting myself.’”

Sons was not placed on suicide watch. The jail’s suicide prevention policy applied only to those who had attempted suicide in the jail, although attorneys for the jail officials in the lawsuit over his death said there was an unwritten policy to closely monitor people going through the commitment process.

An excerpt of the Benton County Sheriff’s Department’s suicide prevention policy at the time of Sons’ death (Obtained by Mississippi Today)

That evening, Sons told a jailer he was feeling anxious around the other men. He asked to be moved to a cell by himself.

A guard took him to a cinder block cell with no windows. There was no television and nothing to read. He was given a blanket.

A security camera in Sons’ cell was supposed to allow jail staff to watch him at all times. But jail officials said in depositions that no one noticed anything unusual the next morning.

At 11:28 a.m., Sons rose from his bunk bed, walked to the door and placed his ear near it. He went back to his bunk, fashioned a noose and tied it around his neck. He sat there for three minutes before hanging himself, according to a narrative of the video in court records.

He stopped moving just before 11:38 a.m. A trusty serving lunch peeked through a tray opening in the door 48 minutes later and saw his body.

The door of the Benton County Jail cell where Sons was held (Obtained by Mississippi Today)

Sons’ father sued Benton County, the sheriff and several of his employees over his death. The defendants denied in court filings that they were responsible, but the county’s insurance company eventually settled the case for an undisclosed sum. (All that’s publicly known is that the county paid a $25,000 policy deductible toward defense costs.)

Sheriff’s department staff said in depositions they had kept an eye on Sons, but they couldn’t watch the video feed constantly. Lawyers for the defendants said there was no evidence sheriff’s department employees knew someone could kill himself in the way Sons did.

Sheriff A. A. McMullen, who is no longer in office, acknowledged in a deposition that “any mental commitment is a suicide risk,” but he said he wasn’t sure it would have made a difference if Sons had been placed on suicide watch.

“You could write up the biggest policy in the world and you couldn’t prevent it. There’s no way. God knows, you know, it hurts us,” he said. “If they’re going to do it, they’re going to do it.”

McMullen couldn’t be reached for comment for this story.

In an interview, jail administrator Kristy O’Dell, who joined the department after Sons died, said the jail still holds two or three people going through the commitment process each month.

John S. Farese, an attorney for Benton County, told Mississippi Today and ProPublica that the county, like others, “does the best they can do with the resources they have to abide by the laws” regarding commitments. He said the sheriff and the county will try to adapt to any changes in the law “while still being mindful of our limited personnel and financial resources.” He declined to comment on the specifics of the Sons case, which he didn’t work on.

Murray, Sons’ mother, was at a grocery store around noon the day her son died. As she picked out a watermelon, she thought about him, a fitness buff who loved fruits and vegetables. A strange thought crossed her mind: “Jimmy’s never going to eat watermelon again.”

When she got home, she got the call that he was gone.

John Sons, Jimmy’s half-brother, wrote in a text to Mississippi Today and ProPublica that the family is left with “complete and total guilt for putting him in the prison and always the wonder if we would not have done that move, if he would be with us today.”

But Richmond, the trusty who briefly shared a cell with Sons, testified that it was jail staff who “messed up.”

“He hung himself,” Richmond said. “I say this. God forgive me if I’m wrong. We couldn’t have saved that man from killing himself, but we could have saved that man from hanging himself in that jail.”

How We Reported This Story

No one in Mississippi has ever comprehensively tracked the number of people jailed at any point during the civil commitment process, according to interviews with dozens of state and county officials.

Last year, the state Department of Mental Health released, for the first time, a tally of people who were admitted to a state hospital directly from jail following civil commitment proceedings. The department tracked 734 placements in fiscal year 2022. (Under a law that takes effect this year, every county must regularly report to the department data regarding how often people are held in jail both before and after their commitment hearings.)

But that figure understates the scope of commitments. It doesn’t include people who were sent places other than a state hospital for treatment or who were released without being treated, and it counts only the time people spent in jail after their hearings. People can be jailed for 12 days before a commitment hearing, or longer if a county doesn’t follow the law.

County jail dockets can provide a more comprehensive picture, so Mississippi Today and ProPublica requested them from 80 of Mississippi’s 82 counties. Seventeen counties provided dockets that clearly marked bookings related to civil commitments — with notes including “writ to take custody,” “mental writ” and “lunacy.” In two more counties, we reviewed dockets in person.

Many counties didn’t respond, said their records were available only on paper or declined to provide records. Some cited a 2007 opinion by the state attorney general that sheriffs may choose not to enter the names of people detained during civil commitment proceedings onto their jail dockets.

After cleaning and standardizing the data from the dockets, we counted the number of jail stays involving civil commitments in which the person was not booked for a criminal charge on the same day. (We ended up excluding about 750 civil commitments for that reason.) If the dockets provided booking and release dates, we calculated the duration of jail stays.

Our count of commitments includes those for both mental illness and substance abuse. None of the jail dockets specified which commitment process people were going through, although some county officials said they don’t jail people committed for substance abuse and haven’t for years.

State laws regarding commitment for mental illness and substance abuse are different, but in many counties they were handled similarly until late 2021. That’s when the Mississippi attorney general’s office said state law didn’t allow people going through the drug and alcohol commitment process to be jailed.

To identify deaths of individuals held in jail during the civil commitment process, we reviewed news articles and federal court records. We also reviewed nearly 90 investigations of jail deaths from the Mississippi Bureau of Investigation. Most of the deaths had not previously been publicly reported.

For our survey of practices in other states, we contacted agencies overseeing mental health and disability advocacy organizations in every state and Washington, D.C. We received responses from one or the other in every location, and we received responses from both in 33. We also searched for news reports of similar cases in other states.

Do you have a story to share about someone who went through the civil commitment process in Mississippi? Contact Isabelle Taft at itaft@mississippitoday.org or call her at 601-691-4756.

This post was originally published on Articles and Investigations – ProPublica.

by Ruth Talbot

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

“Nursing Home Inspect” makes it fast and easy to search thousands of recent government inspection reports, find information about specific nursing homes and discover new serious issues found by inspectors. Below are some tips to help you make the most of our database.

First, a little background.

Nursing homes receiving Medicare and Medicaid funding are subject to inspections to determine whether they are meeting requirements related to medical care, resident rights and safety. The facilities are inspected both routinely and when the government receives a complaint about a home. A nursing home’s failure to meet any of these requirements is called a “deficiency” and is documented in an inspection report.

These inspection reports and other nursing home data are compiled by the Centers for Medicare and Medicaid Services, which runs a site called Nursing Home Care Compare. Unlike the agency’s site, however, “Nursing Home Inspect” offers an advanced search function that allows you to search across all the reports at once. Also unlike CMS, our app allows searches by keywords, date ranges, states or territories, deficiency seriousness, report types and deficiency categories. So, for example, you can limit your search to finding any nursing home in Louisiana or Texas where inspectors documented serious deficiencies involving choking. Our app also provides summaries of the reports on each nursing home’s page to make them easier to digest.

As of today, the underlying database covers nearly 400,000 deficiencies from over 90,000 reports at over 15,000 homes. It is updated monthly to include new data and deficiencies. In addition to allowing you to search reports, the database also provides other information about nursing homes, including fines, whether the home is for-profit or nonprofit, staffing and capacity information, and COVID-19 vaccination information.

Understanding Inspection Reports

All deficiencies in a report have a seriousness score between A and L. These scores are assigned by government inspectors, not ProPublica. Scores are a combination of scope, or how widespread a problem is, and severity, or the level of harm inflicted. Broadly speaking, A is the least serious and L is the most serious. Letters J, K and L indicate residents were in “immediate jeopardy,” meaning they were at risk of serious injury, harm, impairment or death.

Inspection reports only focus on problems, not on whether residents get excellent care, so they should be used alongside other information such as staffing and ownership when assessing a home’s overall performance. Experts recommend that family members visit a home and see it for themselves before making decisions about where to place a loved one. Almost all nursing homes have been cited for some deficiencies, so citations are not necessarily an indication that a home is subpar.

On the flip side, the government isn’t aware of all problems in nursing homes, and some homes have not been inspected recently. If a home has not had a standard inspection in more than two years, it will have an “inspections delayed” flag at the top of its page. A home without recent reports may have undiscovered issues.

Find Homes Near You

ProPublica has redesigned its search experience to make finding nursing homes easier. When you type a word into search, it will auto-populate with relevant nursing homes, states and counties.

If you do not see the result you are looking for, you can narrow your search by choosing the type of result in the dropdown next to the search bar. For instance, if you are looking for a county, you can change the dropdown to “counties.”

If you do not see the search term you are looking for, you can select “Search all inspection reports and home names for …” or hit enter to view all results. Select the “homes” tab to see a list of homes with names that match your search. For instance, you can search for all homes with “view” in their name.

You can also go to a state, territory or county page and explore all homes in the area. For instance, if you are interested in homes near Chicago, you can go to the Cook County page or the Illinois state page. You can sort by lowest deficiency count or lowest total fines to find homes that haven’t been cited frequently.

Evaluating a Nursing Home

To make it easier to identify important characteristics of a home, a nursing home’s page may have one of several flags at the top. These show status indicators like whether the home is a “special focus facility,” meaning it has been cited by the government for having a history of serious quality issues; whether a home is behind on its inspections, meaning it hasn’t had a standard inspection in over two years; whether its staff vaccination rate is well below the state average; and whether the facility’s ownership has changed in the last 12 months.

Every page also has summary data about the home, including staffing levels, capacity information, and whether the home is for-profit or nonprofit.

If you’re looking for detailed information about a nursing home’s inspection history, there’s a section on each home’s page where you can review the last three inspection cycles (roughly 12-18 months each) and the last three years of complaint or infection reports.

Each report tells you the number of deficiencies found in the inspection, as well as the date of the report. To see more information about each deficiency, click the “read more” button to see the category, description and seriousness of each issue found.

Finding Recent Deficiencies

To make it easier to identify recent, serious problems in homes, ProPublica added a section for each state to highlight the most recent deficiencies that were categorized as putting residents in immediate jeopardy. These provide information on the type of deficiency and the home it occurred in, and they allow you to go to the report summary to view more information. Smaller states or states that are delayed on their inspections may not have any serious deficiencies in the last few months.

How to Do an Advanced Search

Our search engine looks through the narrative portion of the inspection reports — the part where inspectors describe conditions in the home and any deficiencies they have discovered. This is where you can find the most details about problems reported in a nursing home. Conducting an advanced search allows you to narrow down your results or combine multiple search parameters.

Text Search

Our search engine supports basic word stemming, meaning a search for the term elope will also produce results for elopes, eloping and so on. If you want to search for an exact term or phrase, put the words in quotation marks. For instance, if you want to search for medication, but not medicate or medicating, search for “medication”.

Advanced search also supports searching for multiple terms simultaneously. For example, if you want to search for reports that contain either theft or steal, you can enter theft OR steal and see results for deficiencies that contain either term. If you want to search for reports with both theft and steal in them, a search for theft AND steal will produce only deficiencies that contain both words.

You can also build more advanced queries. For example, (“theft” AND “steal”) OR rob will produce deficiencies reports that contain either both the words theft and steal exactly, or any version or the word rob (robbing, robbed, etc.).

Filters

The advanced search feature allows you to narrow your search by several criteria, including searching across multiple states, deficiency seriousness scores, deficiency categories and report types (standard reports, reports stemming from a complaint or infection reports) simultaneously.

Users can also search reports in a specific date range. For instance, if you are only interested in reports filed during the first six months of the COVID-19 pandemic, you can filter for reports dated between 3/11/2020 and 9/11/2020.

Term Tips

Inspectors may write up their reports differently. Try several search terms to be sure you’re getting the most complete results. For example, take a common problem like bedsores, which can develop if a resident is confined to bed and staff do not turn the person often enough.

Searching for the phrase “pressure sore” returns 2,318 reports. Searching for the word “bedsore” returns 84 results. Searching for the phrase “pressure ulcer” returns 14,018 results. But other words that also can return deficiencies related to bedsores include: decubitus, purulent and pus, as well as Stage III and Stage IV (phrases that describe the most serious and dangerous sores, but can also describe cancer progression). A search for “bedsore” OR “pressure sore” OR “decubitus” OR “purulent” OR “pus” or “pressure ulcer” returns 15,075 total results.

Some other searches that piqued our interest were: cigarette AND burn (found patients who were burned when allowed to smoke without supervision); conviction (found nursing home staff with criminal records); ignore OR mistreat OR rude (found residents who believed that staff had been unkind or neglectful).

A search for the words terminate OR suspend often produces results involving nursing home staff who were disciplined for alleged misconduct.

In the advanced search, you can also filter by deficiency categories such as “Quality of Life and Care Deficiencies” or “Freedom from Abuse, Neglect, and Exploitation Deficiencies.”

Understanding Search Results

When you search for a keyword, our app only returns the number of deficiencies that match the search criteria, not the overall number of deficiencies cited in each report. To count total deficiencies for a home or a specific report, you can visit the home’s page in “Nursing Home Inspect.”

Always read the reports and understand the terms in context by clicking on the PDF link in the search results. Some reports mention the words you’re searching in the text but they don’t describe a problem at the home. The word could be in a home’s policy statement or may describe past behavior.

The reports contain a lot of jargon and sometimes don’t make clear who is at fault for a problem. Don’t make assumptions. Verify information with the nursing home’s administrator.

Additional Information

Although the government is reporting nursing home deficiencies online, it does not report how each home plans to fix the problems. These “Plans of Correction” can be viewed at the nursing home or by submitting a Freedom of Information request to the government.

You can always view more information by going to CMS’ own website or downloading the raw data files.

Earlier reports or unredacted reports can be requested under the Freedom of Information Act.

If you write a story using this information, come across bugs or issues, or have ideas for improvements, please let us know!

Charles Ornstein contributed reporting.

This post was originally published on Articles and Investigations – ProPublica.

by Ruth Talbot

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

Join us for an upcoming live virtual event, “How to Use ProPublica’s Updated ‘Nursing Home Inspect’ Database.”

ProPublica has updated “Nursing Home Inspect,” our database that helps you find problems that inspectors identified in more than 15,000 U.S. nursing homes, to make it easier to search government reports and browse serious issues. We’ve added new data, a redesigned user interface and advanced search features.

We have expanded the database’s search capabilities, adding advanced search features that allow users to search reports in multiple states or territories, filter by type of inspection report, focus on inspections within a date range, and look specifically at reports with certain kinds of issues, also called “deficiencies.” These filters will allow journalists and others to quickly identify problematic homes in their searches, and will make it easier for curious researchers to ask advanced questions of the data.

Our new advanced text search features allow users to search for multiple terms simultaneously by separating terms using AND or OR or to search for exact phrases by putting terms in quotation marks. The search also allows users to search for a word like “elope” and automatically see results for other forms of the word, like “elopement” and “eloping.” For more information, please read our guide on how to use nursing home inspect.

To aid local journalists and others, we’ve added a section to each state or territory’s page highlighting serious deficiencies found in that location, allowing users to quickly identify homes that were recently cited for putting residents in immediate jeopardy. We’ve also added pages where you can see all nursing homes in a given county.

The database now also includes information on how many hours, on average, a registered nurse spends with residents and on nursing staff turnover, both of which experts say are indicators of the quality of care in a home. Pages for individual homes now show flags indicating whether the home’s ownership has changed in the last 12 months, whether the home is behind schedule on government inspections, and whether the staff’s COVID-19 vaccination rates are low relative to other homes.

In addition, we now have an expanded view of inspection reports that allows users to see detailed information about each deficiency, including its scope and severity, category and description.

ProPublica plans to continue enhancing “Nursing Home Inspect” with new data and features in the coming months. If you write a story using this new information, come across bugs or issues, or have ideas for improvements, please let us know!

This post was originally published on Articles and Investigations – ProPublica.

by Robin Fields

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

It’s one of the most crucial questions people have when deciding which health plan to choose: If my doctor orders a test or treatment, will my insurer refuse to pay for it?

After all, an insurance company that routinely rejects recommended care could damage both your health and your finances. The question becomes ever more pressing as many working Americans see their premiums rise as their benefits shrink.

Yet, how often insurance companies say no is a closely held secret. There’s nowhere that a consumer or an employer can go to look up all insurers’ denial rates — let alone whether a particular company is likely to decline to pay for procedures or drugs that its plans appear to cover.

The lack of transparency is especially galling because state and federal regulators have the power to fix it, but haven’t.

ProPublica, in collaboration with The Capitol Forum, has been examining the hidden world of insurance denials. A previous story detailed how one of the nation’s largest insurers flagged expensive claims for special scrutiny; a second story showed how a different top insurer used a computer program to bulk-deny claims for some common procedures with little or no review.

The findings revealed how little consumers know about the way their claims are reviewed — and denied — by the insurers they pay to cover their medical costs.

When ProPublica set out to find information on insurers’ denial rates, we hit a confounding series of roadblocks.

In 2010, federal regulators were granted expansive authority through the Affordable Care Act to require that insurers provide information on their denials. This data could have meant a sea change in transparency for consumers. But more than a decade later, the federal government has collected only a fraction of what it’s entitled to. And what information it has released, experts say, is so crude, inconsistent and confusing that it’s essentially meaningless.

The national group for state insurance commissioners gathers a more detailed, reliable trove of information. Yet, even though commissioners’ primary duty is to protect consumers, they withhold nearly all of these details from the public. ProPublica requested the data from every state’s insurance department, but none provided it.

Two states collect their own information on denials and make it public, but their data covers only a tiny subset of health plans serving a small number of people.

The minuscule amount of details available about denials robs consumers of a vital tool for comparing health plans.

“This is life and death for people: If your insurance won’t cover the care you need, you could die,” said Karen Pollitz, a senior fellow at the Kaiser Family Foundation who has written repeatedly about the issue. “It’s all knowable. It’s known to the insurers, but it is not known to us.”

The main trade groups for health insurance companies, AHIP (formerly known as America’s Health Insurance Plans) and the Blue Cross Blue Shield Association, say the industry supports transparency and complies with government disclosure requirements. Yet the groups have often argued against expanding this reporting, saying the burdens it would impose on insurance companies would outweigh the benefits for consumers.

“Denial rates are not directly comparable from one health plan to another and could lead consumers to make inaccurate conclusions on the robustness of the health plan,” Kelly Parsons, director of media relations for the Blue Cross Blue Shield Association, said in an email.

The trade groups stress that a substantial majority of patient claims are approved and that there can be good reasons — including errors and incomplete information from doctors — for some to be denied.

“More abstract data about percentages of claims that are approved or denied have no context and are not a reliable indicator of quality — it doesn’t address why a claim was or was not approved, what happened after the claim was not approved the first time, or how a patient or their doctor can help ensure a claim will be approved,” AHIP spokesperson Kristine Grow said in a written response to questions from ProPublica. “Americans deserve information and data that has relevance to their own personal health and circumstances.”

The limited government data available suggests that, overall, insurers deny between 10% and 20% of the claims they receive. Aggregate numbers, however, shed no light on how denial rates may vary from plan to plan or across types of medical services.

Some advocates say insurers have a good reason to dodge transparency. Refusing payment for medical care and drugs has become a staple of their business model, in part because they know customers appeal less than 1% of denials, said Wendell Potter, who oversaw Cigna’s communications team for more than a decade before leaving the industry in 2008 to become a consumer advocate.

“That’s money left on the table that the insurers keep,” he said.

At least one insurer disputes this. Potter’s former employer, Cigna, said in an email that his “unsubstantiated opinions” don’t reflect the company’s business model. In a separate written statement, Cigna said it passes on the money it saves “by lowering the cost of health care services and reducing wasteful spending” to the employers who hire it to administer their plans or insure their workers.

The few morsels insurers have served up on denials stand in stark contrast to the avalanche of information they’ve divulged in recent years on other fronts, often in response to government mandates. Starting last year, for example, insurers began disclosing the prices they’ve negotiated to pay medical providers for most services.

Experts say it’ll take similar mandates to make insurers cough up information on denials, in part because they fear plans with low denial rates would be a magnet for people who are already ailing.

“Health plans would never do that voluntarily, would give you what their claim denial rates are, because they don’t want to attract sicker people,” said Mila Kofman, who leads the District of Columbia’s Affordable Care Act exchange and previously served as Maine’s superintendent of insurance.

About 85% of people with insurance who responded to a recent Kaiser Family Foundation survey said they want regulators to compel insurers to disclose how often they deny claims. Pollitz, who co-authored a report on the survey, is a cancer survivor who vividly recalls her own experiences with insurance denials.

“Sometimes it would just make me cry when insurance would deny a claim,” she said. “It was like, ‘I can’t deal with this now, I’m throwing up, I just can’t deal with this.’”

Karen Pollitz, a senior fellow at the Kaiser Family Foundation, has written repeatedly about the lack of data on how often insurance companies deny claims. (Alyssa Schukar, special to ProPublica)

She should have been able to learn how her plan handled claims for cancer treatment compared with other insurers, she said.

“There could be much more accountability.”

In September 2009, amid a roiling national debate over health care, the California Nurses Association made a startling announcement: Three of the state’s six largest health insurers had each denied 30% or more of the claims submitted to them in the first half of the year.

California insurers instantly said the figures were misleading, inflated by claims submitted in error or for patients ineligible for coverage.

But beyond the unexpectedly high numbers, the real surprise was that the nurses association was able to figure out the plans’ denial rates at all, by using information researchers found on the California Department of Managed Health Care’s website.

At the time, no other state or federal regulatory agency was collecting or publishing details about how often private insurers denied claims, a 2009 report by the Center for American Progress found.

The Affordable Care Act, passed the following year, was a game changer when it came to policing insurers and pushing them to be more transparent.

The law took aim at insurers’ practice of excluding people with preexisting conditions, the most flagrant type of denial, and required companies offering plans on the marketplaces created under the law to disclose their prices and detail their benefits.

A less-noticed section of the law demanded transparency from a much broader group of insurers about how many claims they turned down, and it put the Department of Health and Human Services in charge of making this information public. The disclosure requirements applied not only to health plans sold on the new marketplaces but also to the employer plans that cover most Americans.

The law’s proponents in the Obama administration said they envisioned a flow of accurate, timely information that would empower consumers and help regulators spot problematic insurers or practices.

That’s not what happened.

The federal government didn’t start publishing data until 2017 and thus far has only demanded numbers for plans on the federal marketplace known as Healthcare.gov. About 12 million people get coverage from such plans — less than 10% of those with private insurance. Federal regulators say they eventually intend to compel health plans outside the Obamacare exchanges to release details about denials, but so far have made no move to do so.

Within the limited universe of Healthcare.gov, Kaiser Family Foundation’s analyses show that insurers, on average, deny almost 1 in 5 claims and that each year some reject more than 1 in 3.

But there are red flags that suggest insurers may not be reporting their figures consistently. Companies’ denial rates vary more than would be expected, ranging from as low as 2% to as high as almost 50%. Plans’ denial rates often fluctuate dramatically from year to year. A gold-level plan from Oscar Insurance Company of Florida rejected 66% of payment requests in 2020, then turned down just 7% in 2021. That insurer’s parent company, Oscar Health, was co-founded by Joshua Kushner, the younger brother of former President Donald Trump’s son-in-law Jared Kushner.

An Oscar Health spokesperson said in an email that the 2020 results weren’t a fair reflection of the company’s business “for a variety of reasons,” but wouldn’t say why. “We closely monitor our overall denial rates and they have remained comfortably below 20% over the last few years, including the 2020-2021 time period,” the spokesperson wrote.

Experts say they can’t tell if insurers with higher denial rates are counting differently or are genuinely more likely to leave customers without care or stuck with big bills.

“It’s not standardized, it’s not audited, it’s not really meaningful,” Peter Lee, the founding executive director of California’s state marketplace, said of the federal government’s information. Data, he added, “should be actionable. This is not by any means right now.”

Officials at the Centers for Medicare & Medicaid Services, which collects the denial numbers for the federal government, say they’re doing more to validate them and improve their quality. It’s notable, though, that the agency doesn’t use this data to scrutinize or take action against outliers.

“They’re not using it for anything,” Pollitz said.

Pollitz has co-authored four reports that call out the data’s shortcomings. An upshot of all of them: Much of what consumers would most want to know is missing.

The federal government provides numbers on insurers’ denials of claims for services from what the industry calls “in-network” medical providers, those who have contracts with the insurer. But it doesn’t include claims for care outside those networks. Patients often shoulder more costs for out-of-network services, ramping up the import of these denials.

In recent years, doctors and patients have complained bitterly that insurers are requiring them to get approval in advance for an increasing array of services, causing delays and, in some instances, harm. The government, however, hasn’t compelled insurers to reveal how many requests for prior authorization they get or what percent they deny.

These and other specifics — particularly about which procedures and treatments insurers reject most — would be necessary to turn the government’s data into a viable tool to help consumers choose health plans, said Eric Ellsworth, the director of health data strategy at Consumers’ Checkbook, which designs such tools.

A spokesperson for CMS said that, starting in plan year 2024, the agency will require insurers offering federal marketplace plans to submit a few more numbers, including on out-of-network claims, but there’s no timeline yet for much of what advocates say is necessary.

Another effort, launched by a different set of federal regulators, illustrates the resistance that government officials encounter when they consider demanding more.

The U.S. Department of Labor regulates upwards of 2 million health plans, including many in which employers pay directly for workers’ health care coverage rather than buying it from insurance companies. Roughly two-thirds of American workers with insurance depend on such plans, according to the Kaiser Family Foundation.

In July 2016, an arm of the Labor Department proposed rules requiring these plans to reveal a laundry list of never-before-disclosed information, including how many claims they turned down.

In addition, the agency said it was considering whether to demand the dollar amount of what the denied care cost, as well as a breakdown of the reasons why plans turned down claims or denied behavioral health services.

The disclosures were necessary to “remedy the current failure to collect data about a large sector of the health plan market,” as well as to satisfy mandates in the Affordable Care Act and provide critical information for agency oversight, a Labor Department factsheet said.

Trade groups for employers, including retailers and the construction industry, immediately pushed back.

The U.S. Chamber of Commerce said complying with the proposal would take an amount of work not justified by “the limited gains in transparency and enforcement ability.” The powerful business group made it sound like having to make the disclosures could spark insurance Armageddon: Employers might cut back benefits or “eliminate health and welfare benefits altogether.”

Trade groups for health insurance companies, which often act as administrators for employers that pay directly for workers’ health care, joined with business groups to blast the proposal. The Blue Cross Blue Shield Association called the mandated disclosures “burdensome and expensive.” AHIP questioned whether the Labor Department had the legal authority to collect the data and urged the agency to withdraw the idea “in its entirety.”

The proposal also drew opposition from another, less expected quarter: unions. Under some collective bargaining agreements, unions co-sponsor members’ health plans and would have been on the hook for the new reporting requirements, too. The AFL-CIO argued the requirements created a higher standard of disclosure for plans overseen by the Labor Department. To be fair and avoid confusion, the group said, the Labor Department should put its rules on ice until federal health regulators adopted equivalent ones for plans this proposal didn’t cover.

That left the transparency push without political champions on the left or the right, former Assistant Secretary of Labor Phyllis Borzi, who ran the part of the agency that tried to compel more disclosure, said in a recent interview.

“When you’re up against a united front from the industry, the business community and labor, it’s really hard to make a difference,” she said.

By the time the Labor Department stopped accepting feedback, Donald Trump had been elected president.

One trade association for large employers pointed out that the Affordable Care Act, which partly drove the new rules, was “a law that the incoming Administration and the incoming leadership of the 115th Congress have vowed to repeal, delay, dismantle, and otherwise not enforce.”

The law managed to survive the Trump administration, but the Labor Department’s transparency push didn’t. The agency withdrew its proposal in September 2019.

A Labor Department spokesperson said the Biden administration has no immediate plan to revive it.

Ultimately, it’s the National Association of Insurance Commissioners, a group for the top elected or appointed state insurance regulators, that has assembled the most robust details about insurance denials.

The association’s data encompasses more plans than the federal information, is more consistent and captures more specifics, including numbers of out-of-network denials, information about prior authorizations and denial rates for pharmacy claims. All states except New York and North Dakota participate.

Yet, consumers get almost no access. The commissioners’ association only publishes national aggregate statistics, keeping the rest of its cache secret.

When ProPublica requested the detailed data from each state’s insurance department, none would hand it over. More than 30 states said insurers had submitted the information under the authority commissioners are granted to examine insurers’ conduct. And under their states’ codes, they said, examination materials must be kept confidential.

The commissioners association said state insurance regulators use the information to compare companies, flag outliers and track trends.

Birny Birnbaum, a longtime insurance watchdog who serves on the group’s panel of consumer representatives, said the association’s approach reflects how state insurance regulators have been captured by the insurance industry’s demands for secrecy.

“Many seem to view their roles as protectors of industry information, as opposed to enforcers of public information laws,” Birnbaum said in an email.

Connecticut and Vermont compile their own figures and make them publicly accessible. Connecticut began reporting information on denials first, adding these numbers to its annual insurer report card in 2011.

Vermont demands more details, requiring insurers that cover more than 2,000 Vermonters to publicly release prior authorization and prescription drug information that is similar to what the state insurance commissioners collect. Perhaps most usefully, insurers have to separate claims denied because of administrative problems — many of which will be resubmitted and paid — from denials that have “member impact.” These involve services rejected on medical grounds or because they are contractually excluded.

Mike Fisher, Vermont’s state health care advocate, said there’s little indication consumers or employers are using the state’s information, but he still thinks the prospect of public scrutiny may have affected insurers’ practices. The most recent data shows Vermont plans had denial rates between 7.7% and 10.26%, considerably lower than the average for plans on Healthcare.gov.

“I suspect that’s not a coincidence,” Fisher said. “Shining a light on things helps.”

Despite persistent complaints from insurers that Vermont’s requirements are time-consuming and expensive, no insurers have left the state over it. “Certainly not,” said Sebastian Arduengo, who oversees the reporting for the Vermont Department of Financial Regulation.

In California, once considered the most transparent state, the Department of Managed Health Care in 2011 stopped requiring insurance carriers to specify how many claims they rejected.

A department spokesperson said in an email that the agency follows the requirements in state law, and the law doesn’t require health plans to disclose denials.

The state posts reports that flag some plans for failing to pay claims fairly and on time. Consumers can use those to calculate bare-bones denial rates for some insurers, but for others, you’d have to file a public records request to get the details needed to do the math.

Despite the struggles of the last 15 years, Pollitz hasn’t given up hope that one day there will be enough public information to rank insurers by their denial rates and compare how reliably they provide different services, from behavioral health to emergency care.

“There’s a name and shame function that is possible here,” she said. “It holds some real potential for getting plans to clean up their acts.”

Kirsten Berg contributed research. David Armstrong and Patrick Rucker contributed reporting.

This post was originally published on Articles and Investigations – ProPublica.

by Caroline Chen

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they’re published.

The organization that governs U.S. organ transplant policies voted unanimously on Monday to require that donors be tested for a parasitic disease called Chagas.

Last week, ProPublica reported on the death of Bob Naedele, a former police detective from Connecticut who died in 2018 after receiving an infected heart; his death could have been prevented if the donor had been tested for Chagas. The policy change comes after years of recommendations from experts for screening to prevent such deaths.

The new policy, passed by board members of the Organ Procurement and Transplantation Network, will require the groups that recover organs in the U.S. to test the blood of donors born in countries where Chagas disease is prevalent, including Mexico and 20 nations in South and Central America. To be implemented, the policy will need to be approved by the federal Office of Management and Budget.

“My family and I are elated hearing about the policy change,” said Cheryl Naedele, Bob’s wife. “Ensuring no heart recipient will ever have to suffer the ravages of Chagas has been our passion since Bob’s passing.”

Test results will not have to be provided to patients and their medical team before transplant. That means that patients potentially could find out after their transplant that they had received an infected organ — and not have a chance to weigh the risks of a worse outcome.

The Organ Procurement and Transplantation Network committee that drafted the proposal originally planned to require testing to be completed before a transplant. But “many commenters were concerned that the lack of availability of testing and time it takes to get test results could lead to” delays or wasted organs, spokesperson Anne Paschke said, so the committee removed the pre-transplant requirement.

Experts said that any testing requirement can still improve outcomes even if results arrive after a transplant because medical teams could begin treating an infection promptly, rather than discovering the disease after symptoms appear. Treatment for Chagas disease is available, but it’s not always successful in transplant recipients because their immune system needs to be suppressed so their body will not reject the new organ.

In Bob Naedele’s case, his diagnosis took weeks and came too late, after the parasite had invaded his nervous system and brain. He died seven months after what had initially appeared to be a successful transplant.

This post was originally published on Articles and Investigations – ProPublica.

by Max Blau, photography by Lucy Garrett for ProPublica

ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for Dispatches, a newsletter that spotlights wrongdoing around the country, to receive our stories in your inbox every week.

This story was produced in partnership with MLK50: Justice Through Journalism and co-published with the Commercial Appeal.

On a brisk morning in the winter of 2019, at a standing-room-only reception, a procession of speakers lavished praise on the surgeon who more than tripled the size of the liver transplant program at Methodist University Hospital in Memphis. The lifesaving doctor was receiving an honor often reserved for the dead: Methodist’s leaders announced that the hospital’s new state-of-the-art transplant center would be named for Dr. James Eason.

Eason seemed to have reached the summit of what was then a 25-year career. A decade earlier, he had performed one of the highest-profile liver surgeries in recent history: the transplant that extended the life of Apple co-founder Steve Jobs by more than two years. That operation earned Eason the gratitude of Jobs’ widow, who later donated a total of $40 million to the transplant center he helmed and the medical school where he worked as a professor. At age 58, Eason had become one of the country’s highest-paid transplant surgeons, earning $1.7 million a year, more than anyone at Methodist but the head of its nearly 13,000-employee, six-hospital health system.

But for all the lives the liver transplant program saved, the hospital’s leadership had growing concerns about the number of patients dying on Eason’s watch. During the five years before the renaming ceremony, those deaths had sparked investigations from the federal contractor that oversees transplant centers. They also prompted multiple health insurers to remove the liver program from their preferred networks, according to internal documents.

In 2018, following the most recent investigation, Methodist hired a consulting firm to audit the program. The audit, conducted by peers from other transplant centers, found that numerous errors had contributed to patient deaths — and that to reduce the rate of failed liver transplants, Methodist likely would have to perform fewer transplants overall. But according to the audit, that would be difficult. Staffers felt “powerless to make change due to the resistance of leadership,” who gave the employees the impression that “volume is king,” the audit said.

The audit concluded that “disruptive, disrespectful, non-collaborative individuals” had put the liver transplant program and its patients “in a constant state of risk.”

In December 2018, Methodist University Hospital President Roland Cruickshank wrote a letter to the federal contractor acknowledging the transplant program’s worrisome number of deaths. “The decline in our outcomes is of the utmost concern,” he wrote, “and is not taken lightly.” Weeks later, Cruickshank sat in the front row of the renaming ceremony and stepped up to unfurl a banner with the words “James D. Eason Transplant Institute.”

ProPublica and MLK50: Justice Through Journalism obtained an extraordinary cache of internal records that reveal Methodist leaders failed to comprehensively fix problems with the liver program before the renaming ceremony. The records include the independent audit, detailed internal reviews of patient deaths and the hospital’s correspondence with the federal contractor, a nonprofit called the United Network for Organ Sharing, or UNOS.

One of the documents was an internal analysis drafted at Eason’s behest. In part of the analysis, one of his most senior colleagues determined that between late 2014 and mid 2018, 25 deaths — more than half of the program’s 48 total fatalities — were preventable.

The analysis found that some liver recipients had died after their transplant as a result of “process/protocol issues.” It also found that a portion of patients “should not have been listed” for transplant due to preexisting medical conditions.

Along with the documents, interviews with families of nearly two dozen liver transplant recipients who died over the past decade show that, in some cases, Methodist staffers didn’t tell them about the extent of the problems that contributed to their loved ones’ deaths.

Terry Green, a retired Army noncommissioned officer who donated a portion of his liver to his identical twin brother, did not know that Eason’s team had, according to medical records and internal documents, failed to conduct enough testing to rule out the risks of cardiac and pulmonary complications before Eason himself performed the transplant. His brother died from cardiac arrest in the operating room.

Terry Green donated a portion of his liver to his identical twin brother, Jerry Green.

Stacy Roberts was unaware that, following her father’s transplant, Eason’s team had identified major problems with the donated liver it had placed inside him, issues it may have been able to identify with further screening, internal records show. Methodist had accepted the liver from another hospital, which had failed to spot that the organ bore the early signs of cirrhosis. Days later, after her father experienced serious complications, Methodist providers conducted their own biopsy, discovering the full extent of the damage to the organ. Her father died about a month after the surgery. Hospital records show that transplant program leaders later required surgeons to more rigorously review liver donations before accepting those organs for patients.

For years, Tiffany Garrigus was haunted by the memory of watching her 59-year-old father die just several hours after his transplant. Unbeknownst to Garrigus, a nurse had reported concerns about internal bleeding to the surgical fellow on shift and noted that the doctor failed to quickly alert the attending surgeon. The miscommunication delayed potentially lifesaving care. The independent auditors later determined that Methodist’s own review of Steve Garrigus’ death was a “missed opportunity” to prevent similar issues in the future.

“They screwed up,” Garrigus said after she learned about records that outlined Methodist’s treatment of her father. “No one was held accountable and nothing changed.”

Tiffany Garrigus visits the grave of her father, Steve Garrigus, in Union City, Tennessee.

Garrigus and five other families who spoke with ProPublica and MLK50 signed documents waiving their rights to privacy so Eason and Methodist could answer questions about their loved ones’ deaths. Eason and Methodist declined to address those questions. The hospital and Eason also did not answer specific questions about the dozens of deaths detailed in the investigations, the findings in the audit of the transplant program or the correspondence between the hospital and UNOS.

Spokespeople for Eason and the hospital asserted that ProPublica and MLK50 singled out patients with negative outcomes. Methodist spokesperson Tabrina Davis also said in a statement that the news organizations had “settled on a clear narrative, one which we believe is a misleading and inaccurate portrayal of the institute.” The statement went on to say that “the transplant institute is on a continuous journey of improvement, focused on providing the highest quality care for each patient.”

Eason turned down multiple requests to be interviewed for this story but responded to questions in writing at various points. In one statement, he said that he and his team at Methodist “tried to give every patient the opportunity for transplant.” He also said in that statement that while there were “2-3 unexpected deaths per year” between 2011 and 2018, “we also saved more than 100 lives each year, all of whom would have died without liver transplantation.” Eason’s lawyer, Elizabeth Sacksteder, said in a separate letter that “performing more transplants rather than fewer” and using “the best available organs rather than waiting for the perfect organ” are pivotal parts of Eason’s approach to running a liver transplant program.

Dr. James Eason discusses Methodist’s liver transplant program with the advisory board of the University of Tennessee Health Science Center’s College of Medicine in 2015. (via University of Tennessee Health Science Center’s Facebook)

For more than a decade, Methodist liver recipients had a greater-than-expected chance that their liver would not be functioning one year after transplant, a metric used by UNOS to assess transplant centers’ performance. Eason said in his statement that UNOS had overrelied on that metric without taking into account that programs like Methodist have accepted more high-risk patients who would otherwise die imminently. He added that Methodist has excelled at minimizing the extent to which patients die on the waitlist, a metric that is now part of how UNOS evaluates transplant programs.

“I would never choose to let a single high-risk patient die instead of giving that individual a good chance of living,” Eason said in another statement.

Eason, however, is no longer making those choices at Methodist. This past August — after years of investigations and years of Methodist leaders celebrating Eason’s accomplishments — hospital employees were unexpectedly pulled into a conference room at the transplant center. Standing at the front of the room, along with other top executives, was the head of the health system. He shared a brief message that caught employees off guard: Eason was no longer with the James D. Eason Transplant Institute.

Methodist’s Liver Transplant Outcomes Drew Scrutiny From Investigators

The United Network for Organ Sharing launched two investigations over the past decade after Methodist University Hospital’s liver transplant program performed worse than expected.

Note: Transplant centers report data about their performance to UNOS, which along with the Scientific Registry of Transplant Recipients examines whether the performance of transplant programs was worse than expected. To do so, UNOS analyzes the extent to which transplanted livers still functioned one year after a surgery. Each percentage is based on outcomes over the prior 30-month period. For still-functioning transplants performed in the last six months of the study period, the chance of a liver continuing to function one year after the surgery is modeled after the outcomes of previous transplants in the study period. The blue line shows the percentage of Methodist patients expected to have a functioning transplanted liver at one year, based on characteristics of the liver transplant program’s prior recipients and donors. The yellow and gray lines show the chance of a patient having a functioning transplanted liver at one year, modeled after real-world outcomes. (Source: The Scientific Registry of Transplant Recipients)

Before his arrival at Methodist, Eason led another transplant center that was investigated for its poor performance during his tenure.

In the winter of 1998, Eason left his post as head of a San Antonio military hospital’s transplant center to begin a new job. He now oversaw liver and kidney transplants at the Ochsner Foundation Hospital just outside New Orleans. Eason’s team increased the number of liver transplants Ochsner performed from 23 in 1998 to 76 in 2001. But the rapid growth was followed by higher rates of deaths within a year of transplant, according to data from the Scientific Registry of Transplant Recipients.

One of Eason’s colleagues, Dr. Ari Cohen, subsequently wrote in a presentation to a group of transplant experts that the rate of adult patients living for one year after their liver transplants at Ochsner became “significantly worse than expected” between July 2002 and December 2004.

In 2005, a UNOS committee began investigating the reasons behind poor outcomes at Ochsner, according to an article written by Ochsner doctors that was later published in the health system’s academic journal. The article described the liver transplant program’s culture prior to 2005 in a way that was similar to what Methodist’s audit would turn up years later: A “feeling of fear” had left employees “unable to freely express their views” about the program’s problems.

In response to the UNOS investigation, Ochsner put together a team that determined the transplant center’s leadership was one of the biggest problems contributing to the liver program’s poor patient outcomes.

UNOS spokesperson Anne Paschke said that the organization does not comment on specific investigations. Cohen, along with other Ochsner doctors who contributed to the article, did not respond to emails or phone calls. An Ochsner spokesperson declined to respond to ProPublica and MLK50’s questions or make anyone available for an interview. Eason declined to comment on the UNOS investigation or his former colleagues’ reflections on the program under his leadership. In his statement, he said that he came to Ochsner after the program had been “closed due to loss of leadership” and that the program “went from saving zero lives to saving more than 80 lives each year.”

Before the UNOS committee completed its investigation, Eason accepted an offer that would allow him to return to his home state of Tennessee — and provide an opportunity to take another small liver transplant program and grow it even more dramatically.

In the five years following Eason’s departure, his former colleagues addressed the problems, according to the journal article. They turned Ochsner’s liver program into one of the top performers in the South, according to health care ratings organizations.

When Methodist announced Eason’s hiring in 2006, Dr. Hosein Shokouh-Amiri was deeply concerned. The veteran Methodist surgeon said he had heard about the rapid expansion of Ochsner’s transplant program and was worried that a similar approach might lead to higher rates of failed liver transplants for Methodist patients.

Amiri was afraid that Eason would override clinical decisions that Amiri or his colleagues had determined were in the best interest of patients. And so he decided to leave the transplant program shortly after Eason arrived. Before Amiri’s final day at Methodist, Eason wanted to know if he would reconsider. Sitting in Eason’s office, Amiri asked if Eason would ever require a surgeon to accept a donated liver that the surgeon would rather decline because of poor quality. Amiri recalled that Eason wouldn’t answer at first. Amiri said that when he pressed for an answer, Eason told him that he would do so if he felt it was necessary.

Dr. Hosein Shokouh-Amiri, a former surgeon at Methodist, resigned because of concerns over how Eason might lead the liver transplant program.

As Amiri saw it, Eason’s track record of boosting volume would “bypass the moral and ethical standard we had promised” to Methodist patients.

“He wanted my approval,” Amiri said. “I resigned.”

Eason did not respond to questions about Amiri’s recollections and concerns. Eason’s spokesperson, Stefan Friedman, wrote in an email that Amiri left Methodist “to go to a program that performed only 11 transplants last year with higher deaths on the waitlist and lower one-year survival rates.” Amiri said that his liver transplant program had lower survival rates “because we took sicker patients.” Federal health data confirms that Amiri’s program accepted a higher percentage of patients at high risk of death from liver disease than Methodist.

During his early years in Memphis, Eason led the dramatic growth of Methodist’s liver transplant program. The year before he started, in 2005, Amiri and his colleagues had performed 34 liver transplants. Over the next three years, Eason’s team more than tripled the hospital’s annual number of liver transplants, replacing 117 organs in 2008. Methodist leaders celebrated this growth as a historic achievement — one that allowed the liver transplant program to serve more patients in a majority Black city that had a higher poverty rate than the national average. Eason’s lawyer said in a letter that the population of the Memphis region “disproportionately suffers from co-morbidities associated with poverty” that “heighten the inherent risks of liver transplant surgery.”

By performing 126 transplants in 2009, Methodist became one of America’s 10 largest liver transplant programs. As hospitals across the country expanded their transplant centers, they stood to profit from treating more patients suffering organ failure. According to a 2009 study published in Medical Care Research and Review, the average cost of a U.S. liver transplant and the subsequent days spent recovering in the hospital was about $163,000. Around that time, The Wall Street Journal reported that some hospitals charged nearly three times as much for the surgery. Friedman said in a statement that Eason did not receive additional compensation for performing more transplants, “nor was any aspect of his compensation based on such a metric.” Methodist did not respond to questions about the program’s finances.

The growth of Methodist’s program was fueled in part by a special agreement with federal health officials that allowed the program to obtain livers across the entire state of Tennessee and parts of Arkansas and Mississippi. As the program grew, it began attracting more patients from beyond the greater Memphis area. A central Ohio minister received a liver transplant at Methodist in 2009 after being rejected by three other programs. He lived for another 12 years. A mechanic from San Juan, Puerto Rico, who experienced liver failure received a transplant at Methodist in 2010; in an interview translated by his wife, Carlos Acevedo Martinez told ProPublica and MLK50 that he had no complications and was grateful “Methodist gave him life again.”

Near the end of his third year at Methodist, Eason was in touch with his friend George Riley, a Memphis native whose parents had been doctors at Methodist. Riley, a California lawyer, wanted to know if Eason might help his client. Steve Jobs faced a long wait to get a new liver in his home state of California. His wife, Laurene Powell Jobs, had learned that people could be simultaneously added to waitlists in multiple states. Since Jobs had a plane, he could fly to whichever transplant center was willing to accept him. Tennessee, it turned out, had a shorter waitlist.

One day in March 2009, before dawn, Eason waited for Jobs’ plane at the Memphis airport. “I went to meet him and escorted him to the hospital,” Eason later told WMC-TV. One of Jobs’ biographers, Walter Isaacson, wrote that Eason closely oversaw Jobs’ care after the transplant, assigned nurses solely to his recovery and “would even stop at the convenience store to get the energy drinks Jobs liked.” Jobs later recovered in a 5,784-square-foot mansion in Memphis that Riley purchased through a shell company, according to The Commercial Appeal.

Weeks after Jobs returned home that spring, news broke of his surgery. Media outlets including CNN and The New York Times published articles that explored whether Eason gave preferential treatment to the billionaire. The surgeon pushed back: Jobs was the sickest, most deserving patient on the day that liver became available, he said. Starting that summer, Eason lived on and off in the mansion — a perk he didn’t publicly disclose at the time. Two years later, in 2011, he bought the house from the shell company for $850,000, the same price the company paid for it in 2009. (Home sale prices in the greater Memphis area had fallen in the interim.) Eason did not respond to questions about living in or buying the home.

Eason speaks with a nurse in Methodist’s transplant ward on Aug. 18, 2009. (Lance Murphey/Bloomberg via Getty Images)

Around the time of Jobs’ transplant, Methodist’s liver recipients had a better estimated chance of their organs functioning at least one year after a transplant than the national average. But in the years after Jobs’ surgery, Eason’s liver transplant program began to struggle. The rate of failed liver transplants increased between July 2010 and December 2012. As a result, the UNOS committee that had scrutinized Ochsner’s performance under Eason opened an investigation in early 2014. The committee’s work is confidential, but ProPublica and MLK50 obtained records that described the investigation. (UNOS declined to confirm when the investigation ended.)

The UNOS committee, which is composed of several dozen transplant experts who volunteer to review their peers’ programs, can recommend the discipline of transplant centers for their poor performance. But the committee rarely punished programs. In fact, the committee was so toothless that in 2018 the then-CEO of UNOS likened the committee’s investigations to “putting your kids’ artwork up at home.”

“You value it because of how it was created rather than whether it’s well done,” the UNOS leader wrote of the investigative committee. “Only in this case, we persuade ourselves that it’s well done anyway.”

Though Eason now defends the program he led, he acknowledged in an April 2014 letter to the UNOS committee that Methodist’s outcomes “were not as expected.” He pledged to address the committee’s concerns.

According to internal documents from June 2014, Methodist was anticipating potential financial fallout from those poor outcomes. A Centers for Medicare & Medicaid Services official had informed Methodist that its liver transplant program was out of compliance with federal standards because it had “significantly lower than expected” outcomes and did not have an adequate policy for evaluating the reasons behind its failed liver transplants. The official warned that CMS would terminate the liver program’s participation in Medicare, which covered the costs for nearly a third of the liver transplants performed at Methodist, if it failed to correct those problems.

In its written plan outlining how it would fix the problems, Methodist told CMS that one way it would improve outcomes was through Eason encouraging a “higher scrutiny of patients” whose risks of complications outweighed the potential benefits of surgery. Methodist ultimately avoided termination from Medicare.

But records obtained by ProPublica and MLK50 show that Methodist kept accepting patients whose poor health increased the risk of complications after a transplant. Eason’s team soon approved for transplant a 356-pound woman with a BMI of 66 and a woman who struggled so much with drinking alcohol that she only stopped after getting sick from liver failure. The team also signed off on a patient for transplant in spite of the fact that she was septic the day before the surgery. All three died within a year after their transplants.

Dr. Satheesh Nair, one of Eason’s most senior colleagues, later determined in an analysis of patient deaths that Methodist should not have placed these patients on the transplant waitlist. Nair did not respond to questions. Eason did not comment on the findings of the analysis, but said that he asked for it to be done as part of his transplant program’s efforts to improve its quality of care.

Davis, the Methodist spokesperson, also declined to comment on Nair’s findings. She said in a statement that Methodist has turned away liver transplant candidates because they “do not meet the criteria to indicate they would have successful outcomes” after a transplant.

By the time Jerry Green arrived at Methodist in 2016, the 46-year-old minister from West Memphis, Arkansas, was experiencing symptoms of liver failure, including fatigue and jaundice. As Green underwent a battery of tests, the evaluation revealed potential signs of pulmonary hypertension, according to hospital records. That condition can increase the risk of death from a transplant.

Medical experts have written in journal articles that when a transplant candidate has signs of pulmonary hypertension, additional testing, including what’s known as a right heart catheterization, should be done to more precisely determine the risk of complications during or after a transplant. If the risk is too great, liver transplant programs can either reject the patient or postpone the surgery until the patient receives care to improve their health. But “no further assessments were made,” according to an internal analysis of Green’s treatment that the liver transplant program later conducted.

Methodist doctors calculated that Green had a strong chance of surviving for three months without a transplant. But that also meant he was unlikely to get a liver from a deceased donor because he would be low on the waitlist. According to hospital records obtained by ProPublica and MLK50, Eason encouraged Green to get a transplant immediately the only way he could: by finding a living donor. Green was reluctant. But when he gave in, he asked his twin brother, Terry. He agreed.

First image: Terry Green shares a photo of himself and Jerry with their mother. Second image: Terry and Jerry as babies.

In the summer of 2016, as the Green family packed inside Methodist to support the twins, a surgeon sliced open Terry’s abdomen. It was one of the first living liver donor transplants ever performed at Methodist. Once they started Jerry’s surgery, his pulmonary arterial pressure rose so much that surgeons considered halting the transplant. Methodist providers gave Jerry medication that lowered his pressure. According to an operative report from a surgical fellow, Eason “had extensive discussion with his family, where they strongly hoped to undergo the surgery with any possible measures.” (Jerry’s wife, Jacqueline Green, said that she was notified about the concerns over his pressure but did not have an in-depth discussion with Eason about the risks of proceeding with the surgery.) Eventually, surgeons began replacing his liver with a segment of Terry’s.

Once Terry woke up, Eason stopped by to check on his abdomen. The surgeon then shared the worst news of Terry’s life. Jerry’s heart had suddenly stopped. The staff tried to revive him in the operating room but could not pull him back from the brink of death. “His heart wasn’t strong enough,” Terry remembers Eason saying. “What we learned here will help others in the future.”

After the funeral, Jacqueline met with Eason to learn more about what went wrong. As Jacqueline asked questions about Jerry’s death, Eason said that the liver transplant was successful. “It was just his heart” that failed, she recalled Eason saying.

Jacqueline Green at home next to a burial flag for her husband, Jerry Green, who served in the Marines.

The following year, Methodist enacted several new policies designed to more rigorously test patients’ cardiac and pulmonary risks ahead of a liver transplant. In the program’s internal analysis, Nair later determined that Green’s death was preventable. Jacqueline said Eason never told her about that finding.

Not long after Jerry Green’s death, Eason and nearly two dozen colleagues gathered for a confidential meeting. A familiar problem that had dogged the program was now resurfacing.

Four years earlier, in December 2012, CMS had announced it would cut off a crucial part of Methodist’s organ supply from central and east Tennessee. Some transplant experts praised the decision because they felt Methodist had unfairly benefited from an old policy that provided access to more high-quality organs from a large geographic area. To avoid shrinking what had become the nation’s fourth-largest liver program, Methodist accepted more livers that posed a higher risk of complications for their recipients. Eason’s transplant quality director later wrote in a document responding to the UNOS committee’s investigation that the strategy was justified as the country faced a chronic organ shortage. As the quality director explained, the additional risk was in “balance against the risk of candidate death on the waitlist.”

At the confidential meeting, Eason and his staff focused on a case that exemplified the perils of such risk-taking. That July, Methodist had received a liver offer from a North Carolina hospital. The liver had belonged to a 34-year-old military veteran who had struggled for years with use of hard drugs and alcohol. The way that he died required that his liver be removed after his heartbeat stopped, known as a donation after circulatory death or DCD. Such donations involve an organ that has been deprived of sufficient oxygen between the time of death and the organ’s removal. As a result, these donations can elevate the risks of complications for a recipient. That year, about 6% of U.S. liver transplants involved DCD organs, according to data from the Scientific Registry of Transplant Recipients. The data also showed Eason’s team accepted DCD livers at a percentage nearly triple the national average.

The night that Methodist received the liver offer, one of Eason’s surgeons described the donor’s history to Eugene Willard, a 61-year-old grandfather who served as the mayor of his small town of Amagon, Arkansas. Willard wanted to reject the offer, according to his daughter, Stacy Roberts. Two weeks earlier, another Methodist doctor had determined Willard would be a “suitable candidate for liver transplantation providing he loses weight,” records show. That doctor had encouraged Willard to slim down to lower his risk of complications whenever the transplant did happen. But with the offer on the table that night, the surgeon urged Willard to accept the liver, his daughter recalled. “If you don’t do it, you’re going to die,” she remembered the surgeon saying. Willard followed the surgeon’s advice and agreed to accept the organ.

After Willard’s new liver showed signs of poor function, Methodist providers ordered another biopsy to better understand his complications. This time, they saw that the donated liver had so much scarring that the early stages of cirrhosis were present. He died about a month after the surgery.

At the confidential meeting, the team concluded that the North Carolina hospital’s biopsy of the donated liver “may have been inadequate.” Eason’s team responded by approving a policy change that required surgeons to more rigorously examine biopsies before accepting livers. Nair’s analysis later determined that Willard’s death was preventable, citing “donor selection” issues.

Data from the Scientific Registry of Transplant Recipients shows that Methodist continued to accept DCD livers in 2017 and 2018 at rates higher than twice the national average. Eason’s transplant quality director later explained in the response to UNOS that Methodist’s surgeons accepted more high-risk livers because they had “access to fewer local organs than the national rate,” leaving the program little other choice for saving patient lives. The quality director defended the practice as one that “represents our effort to provide care to an underresourced patient population.”

“Most have no other opportunity or hope of transplantation,” the quality director wrote.

Over the course of 2018, Methodist’s transplant center leaders were confronting a new round of scrutiny. After a period of improved patient outcomes following the UNOS committee’s investigation four years earlier, the liver transplant program’s failure rate had again worsened. As a result, the UNOS committee opened another investigation.

Methodist responded with a step intended to help its struggling program. It hired the transplant consulting firm Guidry & East to conduct an audit of its liver transplant program’s operations.

Five transplant experts — including doctors affiliated with medical schools at the University of California, San Francisco and Cornell University — traveled to Memphis in October 2018 for the two-day audit. They toured the center’s halls, interviewed employees and reviewed liver transplant records. The experts wrote a 35-page report, a final draft of which was obtained by ProPublica and MLK50, that identified a list of problems that they said contributed to patient deaths.

Excerpt from Guidry & East’s 2018 audit of Methodist’s liver transplant program (highlights added by ProPublica)

The audit stated that Eason’s program appeared to “maximize the number of transplants by disregarding flags” as to whether patients were suitable candidates for surgery and, according to one Methodist doctor, was “currently accepting less than ideal donor organs for transplantation.” It also determined that the program had failed to thoroughly review the causes of patient deaths in order to prevent repeat mistakes with future patients, a problem previously identified during federal inspections.

To better protect patients, Eason would need to improve its policies in a way that would limit surgeons from operating on patients unlikely to survive long after transplant, in addition to limiting the number of high-risk organs the program accepted, the experts’ audit determined.

The experts also flagged problems with the hospital’s oversight of its liver transplant program. The audit noted the stark “disconnect” between Eason’s team and hospital leadership. “There is a lack of transparency in what is reported,” the experts determined.

After the audit, Methodist University Hospital President Cruickshank pledged in a letter to the UNOS committee that senior hospital leadership would “work closely” with Eason’s team to adopt Guidry & East’s recommendations. Those changes, Cruickshank said, would “once again allow us to meet the UNOS requirements and our own expectations of exceptional outcomes.” (Cruickshank, who has since left Methodist, did not respond to multiple requests for comment.)

Eason at the transplant center renaming ceremony at Methodist University Hospital in 2019. (via Methodist Le Bonheur Healthcare’s Facebook)

In February 2019, less than two months after Cruickshank’s letter, Eason stood at the renaming ceremony before his supporters, including Laurene Powell Jobs, an internationally known philanthropist who has donated to a wide variety of causes. (Powell Jobs’ social impact organization Emerson Collective contributes to numerous media organizations, including ProPublica and MLK50, and owns a majority stake in The Atlantic. Through a spokesperson, Powell Jobs declined to comment about her support of Eason and Methodist.) In the halls of Methodist’s new $275 million nine-story tower, a portion of which would be home to the transplant center that had received her donation, Eason and Powell Jobs posed for a photo before a wood-paneled wall lettered with the surgeon’s name on it.

Later that month, Methodist received a letter from the chair of the UNOS committee overseeing the investigation, whose members had met to review the Guidry & East audit. The letter stated that “recent outcomes do not seem to be improving.”

In April 2019, as Methodist was about to welcome patients to its new transplant center, Eason wrote in a letter to the UNOS committee that the liver transplant program was headed in the right direction. To address the committee’s concerns, Eason presented a detailed plan that outlined how Methodist was overhauling policies within its liver transplant program. He attached newly written guidelines that directed the program to be more stringent in accepting high-risk patients and livers. He also noted that transplant leaders were routinely holding conferences where staffers more thoroughly reviewed cases with bad outcomes, openly discussed medical mistakes and identified ways to prevent repeat errors.

“We believe our team has made tremendous progress in improving the outcomes of our Liver Transplant Program,” Eason wrote.

Davis, the Methodist spokesperson, said in a statement that Methodist “considered every recommendation” from Guidry & East and enacted some of those policies “right away.” Neither Eason nor Nair responded to questions about the Guidry & East report.

After the new transplant center facility opened that spring, the liver program’s numbers did, in fact, begin to turn around. The program’s rates of failed liver transplants continually improved in 2019 and 2020. But they did not improve enough to clear the threshold that the UNOS committee typically required to close an investigation.

In 2021, UNOS rewrote the rules for investigating transplant programs. Ian Jamieson, then the chair of the investigative committee, said that judging programs on post-transplant outcomes alone had created a “disincentive to transplantation.” To remove that barrier, UNOS leaders decided, a program would have to have far worse rates of failed liver transplants before UNOS would automatically step in to investigate.

UNOS touted the policy as “a more holistic approach” to evaluating transplant programs, since the committee would now also consider the extent to which patients were dying on the waitlist. The changes were not universally praised: Critics worried that the policy would lead to fewer transplant programs being held accountable.

Around the time the new UNOS policy began to take effect last year, the committee ended its investigations into numerous transplant programs, including the liver transplant program at Methodist.

Eason and a spokesperson for Methodist said that the investigation was closed because the program’s outcomes had improved. (UNOS declined to comment on the reason.) Eason said in his statement to ProPublica and MLK50 that UNOS’ new policy was recognition that UNOS had been relying on a transplant metric that was “outdated and invalid.” He sees that decision as part of a broader shift in which federal transplant policy is falling more in line with his philosophy to offer transplants to as many people as possible.

With outcomes improving and policy shifting, Eason seemed poised to keep leading his team at the center that bore his name. But one morning this past August, Methodist transplant center employees were unexpectedly summoned into a meeting down the hall from where the renaming ceremony had taken place. For the prior week, Eason hadn’t made his usual rounds through the halls of the transplant center. His staff even had to postpone a living donor transplant because of his absence.

Once the seats were filled, Michael Ugwueke, the president and CEO of Methodist’s six-hospital health system, asked for everyone’s attention. He informed them that Eason was no longer with the transplant center. When staffers asked what happened, Methodist executives said they couldn’t provide any details. As part of the decision, the transplant center suspended conducting liver transplants for living donors.

Methodist and Eason declined to answer questions about his departure. Methodist has scrubbed many mentions of Eason from its website. In the six months following Eason’s departure, he remained employed as the director of the Transplant Research Institute at the University of Tennessee Health Science Center, the medical school affiliated with Methodist. In late February, he retired from his tenured position, according to emails obtained through an open records request. UTHSC spokesperson Peggy Reisser declined to comment on the retirement.

So far, no hospital has publicly announced that Eason will lead its transplant center. Medical board records show that he has obtained licenses in Ohio and Pennsylvania. When ProPublica and MLK50 asked about Eason’s departure and search for a new job, his lawyer, Sacksteder, responded in a letter on March 15 that he is a “highly respected” liver transplant surgeon whose name still graces the transplant center he had helmed.

Just a few weeks later, Methodist employees noticed something had changed at the hospital. Workers had removed several signs throughout the facility. The words “James D. Eason Transplant Institute” are no longer affixed to the front of the building.

A new sign simply reads: “Methodist Transplant Institute.”

First image: The exterior of Methodist, showing the James D. Eason Transplant Institute sign, on Feb. 17. Second image: The exterior of Methodist, without Eason’s name sign, on April 18. (Andrea Morales for MLK50) Tell Us About Your Experience With the Organ Transplant System

Wendi C. Thomas and Jacob Steimer, MLK50: Justice Through Journalism, and Mollie Simon, ProPublica, contributed reporting.

Design and development by Allen Tan.

This post was originally published on Articles and Investigations – ProPublica.