SEATTLE — Dr. Mark Snowden and his staff at Harborview Medical Center routinely treat so many people with urgent psychiatric symptoms that they don’t have capacity to care for all of them. To help take some of those patients, Harborview staff have often called on a large psychiatric hospital in Tukwila called Cascade Behavioral Health Hospital.
“We used to be able to send anywhere from one to three patients a day” to Cascade, said Snowden, chief of psychiatry at Harborview. “It’s now less than that a week.”
Several months ago, Cascade Behavioral Health Hospital quietly stopped accepting nearly as many referrals as it used to. It was hard to tell why, but Snowden said he’d grown accustomed to not “falling on them as frequently.”
Then, in a move that shocked health care workers, families and elected officials alike, the 137-bed hospital announced in early June it intends to close for good.
Cascade is owned by Tennessee-based Acadia Healthcare and is one of the largest privately owned psychiatric facilities statewide. The hospital has a checkered patient and staff safety record, like many private psychiatric hospitals here. But since 2013, it has served as a lifeline for people who seek out treatment on their own, as well as those who are involuntarily committed to care.
Its anticipated closure in July will strip the county of about 13% of its involuntary psychiatric treatment beds, county estimates show.
The full picture of how a large haven for psychiatric care could get to this point is still unclear. But Cascade’s pending closure shows the tenuous status of a behavioral health system that state and local officials are desperately trying to bolster, and the risks of relying on for-profit companies to serve as that system’s underpinnings.
Such companies’ finances are opaque and their viability is subject to market forces. Yet they control the fate of nearly half of county beds dedicated to serving people who, by government mandate, don’t have a choice but to receive treatment. As of 2022, county data shows 49% of such involuntary treatment beds were located at for-profit facilities.
Cascade’s parent company Acadia watched its net income jump 8.5% during the first three months of the year compared to last year, according to its financial filings. But hospital officials refused to answer questions about Cascade’s specific financial situation or other stresses that precipitated the closure, so whether the hospital was sinking or swimming is still murky.
“A breadth of challenges created a situation where the long-term viability of the hospital was no longer sustainable,” a consultant hired by the company said.
Amid few details, some in the behavioral health community have described Cascade’s closure as an unfortunate event motivated in part by a prolonged standoff with the hospital’s labor union in 2021, which sowed deep tension between staff and management and led to the shuttering of some wards. Uncertainty driven by the pandemic and chronic workforce shortages may have also played a role.
Interviews with government bureaucrats and health care leaders, however, suggest Cascade’s decision followed warnings to state government about its finances at least a month and a half ago, raising questions about whether officials could have intervened before the closure. Indeed, officials in Gov. Jay Inslee’s office and two state agencies were told by top Acadia executives in a meeting on April 27 that the hospital was strained, several people interviewed for this article said.
“I can’t 100% confirm [closure] came up given that the meeting was some time ago. But I believe Cascade indicated closure would be possible without significant financial help,” said Amber Leaders, who attended the meeting and is senior policy adviser on behavioral health, aging, disability and poverty in the governor’s office.
In particular, the hospital requested the government raise the daily rate it pays for Medicaid inpatients to “an astronomical amount … that would have been far more than we pay anywhere else,” said Jason McGill, assistant director at Washington State Health Care Authority, which oversees the state’s Medicaid program. “We could not support that.”
Acadia said it would need about double the Medicaid rate it currently receives for each patient, according to emails between Acadia officials and governor’s office staff obtained by The Seattle Times. The hospital made its request at the tail end of a legislative session that was already jampacked with other mental health system proposals and budget lines. Too late, some say, for the government to take meaningful action and stave off Cascade’s woes.
Acadia and governor’s office staff corresponded several times leading up to the hospital’s closure announcement. Leaders inquired about whether the company qualified for new investments by the Legislature, though the answer turned out to be no. Acadia shared details about its difficulty serving so many patients held on involuntary treatment orders and said many were discharged to shelters or without timely referrals elsewhere because of backlogs in other corners of the system.
“What we think is happening is we are sending a set of chronically ill, underserved patients back into the system where they will continue to need care and/or have a higher risk of re-admission into a psychiatric inpatient setting,” Chelsea Hager, a consultant to Acadia, wrote on May 11.
Now, as the days tick down to Cascade’s closure, some are urgently sounding the alarm on how to save more than 100 beds that will soon disappear.
“I feel like every time I turn around, people are just kind of shrugging. Like, ‘Oh, yeah, this is really hard,’” said state Rep. Nicole Macri, D-Seattle, and deputy director for strategy at Downtown Emergency Service Center. “We owe families in this state and people living with serious behavioral health conditions, people going into behavioral health crises, a lot more than shrugs.”
“Doesn’t take long to crumble”
A few days after hearing the news about Cascade, a Seattle man named John began typing an email to a handful of state lawmakers. He was so upset, his hands shook.
John was thinking about his grandson.
The boy, who has mental health concerns, has been on a waitlist for care for multiple years. He’s waited for days in the emergency room for treatment, and had difficulty getting accepted into behavioral health facilities both inside and outside Washington’s borders.
“By allowing Cascade to close you have wiped out an option [for] the eventual care he will need,” wrote John, who asked to use his first name to protect his family’s privacy. “It is sickening.”
Cascade only serves adults, but John told The Seattle Times that without proper care he could “just see the future of where my grandson is going.”
King County, like many counties across Washington, consistently lacks enough psychiatric beds for those who need them. In March, for example, at least 481 people who were deemed to need involuntary treatment couldn’t get a bed at a psychiatric hospital or other specialized setting, state data shows. Instead, they were released or kept in a hospital ward under a so-called “single bed certification,” which allows hospitals to detain people with mental health concerns temporarily.
The lack of inpatient beds is one piece of an immensely fragmented mental health care system here. As the county’s population has grown over the past few decades, the number of places where people with mental illness can live or recover has halved. King County lacks a single walk-in crisis care center (though new property tax dollars are expected to add five such centers soon). Jails and emergency departments are often the front lines of care for people with substance use and psychiatric concerns.
Private for-profit hospitals like Cascade have helped fill in the gaps to some extent.
Over the past 11 years, the state has approved or expanded at least 10 private psychiatric hospitals, nearly all of which are for-profit.
These hospitals represent a massive public and private investment in behavioral health infrastructure and the workforce, though it hasn’t been enough to meet demand. Around the time Cascade opened, the state had only 637 psychiatric beds, documents show. But by 2019, new or expanded private psychiatric hospitals had won approval for an additional 850 beds.
This expansion coincided with a tripling of state payments to such private psychiatric hospitals, a Seattle Times investigation found in 2019. Hospitals’ parent companies have also injected millions into building or refurbishing such hospitals. When Cascade was first given the green light to open, for example, Acadia officials projected that they’d spend about $43 million to acquire and renovate the Tukwila campus that at the time was owned by Highline Medical Center, documents submitted to the Department of Health show.
The renovations included getting an elevator up and running, and a slew of upgrades to make the building safer for patients, said a former employee familiar with Cascade’s business who feared retribution for sharing information about the company’s internal operations.
But it was challenging to find and retain staff willing to work with what can often be a difficult patient population, the former employee said. Compared to other area hospitals, Cascade has historically served a higher percentage of the most vulnerable patients — those who were involuntarily committed and eligible for Medicaid — according to a 2019 report from the King County Auditor’s Office. In 2021, workers went on strike for more than three months following several violent incidents involving patients and staff. The Times investigation logged 65 assaults between 2016 and 2018, including some where the victim was knocked unconscious or broke a bone.
McGill, at HCA, said Cascade also witnessed significant turnover in its administrative staff. The hospital often didn’t have enough employees who knew how to properly submit patient claims for reimbursement. “You’ve got to do it right, and they just had trouble after trouble,” he said. The Cascade representative refuted this statement, saying that staffing has been “stable with very low overall turnover.”
Not being able to staff the hospital likely would keep it from filling its beds, which are an important source of revenue for the hospital, said the former employee.
“It’s millions of dollars that were invested in the community for the service and they’re choosing to shutter it,” he said. “What this demonstrates is, it doesn’t take long to crumble.”
No capacity
Less than two weeks after Cascade’s news hit, state and county officials were scrambling to ensure patients who take priority — those being treated involuntarily — could get transferred to other area hospitals.
But the network of inpatient beds was small even before Cascade’s move to close. “Where do you think those patients are going to go?” Macri asked.
Some are already getting referred to Harborview’s emergency department, Snowden said. “But again,” he added, “we don’t have any capacity.”
Cascade’s decision follows the shuttering of several smaller behavioral health providers over the past few years. The city’s largest LGBTQ+ behavioral health clinic, Seattle Counseling Services, closed in 2022, for instance, and Bellevue-based Cadence Child & Adolescent Therapy shut down this year.
Recent outpatient closures were significant, but Cascade’s closure feels “more momentous,” said Daniel Malone, executive director at DESC, since the hospital was a provider for so many people with serious psychiatric and substance use concerns.
It also raises big questions about the state’s reliance on often opaque, out-of-state, for-profit providers to handle patients with serious concerns, including those under government mandate for psychiatric or substance use care, he said.
“If that hospital was run by a local nonprofit provider, I think the warning signs would have been clearer to more people much earlier,” Malone said.
State records offer a glimpse, but not the whole picture, of the hospital’s finances. In its first few years, Cascade’s revenue grew on pace with what company executives had initially anticipated, DOH records show. By 2020, according to public records, the hospital generated over $100 million in patient revenue, 40% more than 2017; net revenue was $40.7 million and $34.7 million in those years, respectively, the Cascade representative said.
But what’s happened to the hospital since then is still elusive. Complete public records for 2021 and 2022 aren’t yet available.
What is clear: Acadia is making money. And it benefited from $81 million in federal relief dollars to offset pandemic-related losses, its financial filings show. The company, which owns an estimated 250 behavioral health facilities, is poised to expand, officials wrote in a recent report to investors: By year-end, they said, “we expect to add approximately 300 beds” at existing sites and open at least 10 new facilities. But it’s hard to tell how Cascade fits into the sunny outlook of its parent company.
One state agency said it might try to make use of the hospital. On Wednesday, a top official at the Washington State Department of Social and Health Services said the organization plans to tour the facility Friday; the beds, perhaps, could be repurposed to serve patients coming from jails.
The hard work now, Leaders acknowledged, includes facing the thornier questions raised by Cascade’s decision.
“Is this symbolic of something else, something larger going on that we need to try to remedy sooner rather than later?” Leaders said. “I don’t know that I have an answer for that today, but I think it’s the right question.”
