San Diego — Christy Scheck, on March 6, 1992, a Friday evening, walked into a bathroom in Southwood Psychiatric Center's Residential Treatment Center in Chula Vista (now called Bayview and under new management). Thirteen-year-old Scheck had been a patient at Southwood, a for-profit psychiatric facility, since early November 1991. Christy slipped off the sash from her bathrobe and hanged herself. She died, without regaining consciousness, two days later in Children's Hospital's intensive care unit.

Christy's parents, Robert and Merry Scheck, in March 1994 brought suit against Southwood Psychiatric Institute and its corporate owner, National Medical Enterprises. Also named were a series of defendants, including Christy's psychiatrist at Southwood and a number of workers employed at Southwood. The Schecks' suit alleged that the defendants engaged in insurance fraud, "crafted diagnoses to meet patients' insurance coverage," failed to properly train staff, used unlicensed staff in positions for which regulations required licensed workers, decreased patient-staff ratios to unsafe levels, and awarded bounties to employees as incentives to acquire and keep patients longer than their condition warranted. There were more charges - fraud, breach of contract, medical malpractice, and finally, wrongful death. In July 1994, days before going to trial in San Diego County Superior Court, Scheck vs. Southwood was settled in mediation in favor of the Schecks.

David R. Olmos, writing in the Los Angeles Times, described Southwood's out-of-court settlement with the Schecks as "an extraordinary admission of corporate responsibility." Olmos added, "It is the first admission of responsibility in any of the nearly 150 lawsuits alleging physical mistreatment and abuse of patients that NME [National Medical Enterprises] has faced since the late 1980s. The Santa MonicaPbased hospital firm has settled about 75 percent of those cases but had never admitted responsibility." Olmos also noted that in June 1994, just previous to their settlement with the Schecks, "NME settled a federal fraud investigation of its psychiatric and substance abuse hospitals by paying $379 million in fines and restitution."

Now, Leon Bing, the Pasadena-based author of two previous books that focus on teenagers, Do or Die and Smoke, has written about what happened to Christy Scheck and why. Billed as "a tragic story of what happens when a medical care system cares more about profit than medicine," A Wrongful Death: One Child's Fatal Encounter with Public Health and Private Greed (Villard Books) mixes the Schecks' story with investigation of for-profit psychiatric institutions whose patients are primarily adolescent. If you are a parent, grandparent, aunt or uncle, if you are a teenager, A Wrongful Death is a book you should read and study.

The gist of Ms. Bing's book is this: when the Schecks, at the recommendation of their family therapist, entered Christy in Southwood, "They had no idea that the hospital's CEO had instituted an unlawful system to extract extraordinary levels of profits. Insurance policies were processed to maximize reimbursements; the staff held 'chart parties' to ensure that patients' records would reflect a need for continued treatment; psychiatrists' hours were drastically reduced; and families were shut out of decision-making processes. Tragically, this non-care led Christy to an overdose of medication that resulted in hallucinations. She wrongly accused her father of sexual abuse, and ultimately Christy committed suicide."

Further, writes Ms. Bing, the Schecks, when they brought Christy to Southwood, had no idea that the hospital "was one of a chain of 76 hospitals spread over 24 states. The chain was known as Psychiatric Institutes of America (PIA), and its corporate parent was National Medical Enterprises (NME), a $4 billion company. [The Schecks were] unaware that another pia facility, Colonial Hills Hospital in San Antonio, Texas, was at the eye of a controversy that had culminated, two months earlier, with the Texas attorney general filing suit against PIA, alleging fraudulent conduct."

On the afternoon that Ms. Bing and I talked, I said that 20 years ago placing a troubled teenager in a psychiatric hospital or residential treatment center was something about which one never heard.

She agreed. "Twenty and 30 years ago, if kids acted out and it was really extreme behavior, a boy might be sent to forestry camp or military school and a girl to boarding school. It had to be a pretty extreme case for a teenager to be sent even to therapy, let alone to a private psychiatric hospital. If the family couldn't afford any of this, then they just dealt with the kid as best they could.

"But now because most health insurance covers this hospitalization, kids are more likely to be sent away to a treatment center. I can't think of any other reason than this availability of insurance money. The world is certainly more violent, kids are facing more problems - gangs, sexual experimentation can kill them. There are a million more reasons why this is not as gentle a time as it was two and three decades ago.

"However, if we were interviewing a journalist in 1945, we would probably hear similar statements. 'The times are so violent.' In the 1920s, you might have been told, 'Kids don't have manners anymore, and they're running around in roadsters.' I think each generation has had similar complaints about young people. So that all I can figure is that the reason so many kids are sent into residential hospitals is because the insurance pays the freight."

Because Robert Scheck was a retired career Navy man, CHAMPUS was the Schecks' health insurer. "CHAMPUS," Bing writes, "stands for Civilian Health and Medical Program of the Uniformed Services, a federal health insurance program that covers both active and retired military personnel and their families. CHAMPUS mental-health benefits include 30 days annually of inpatient care for adults, 45 days for children, and 150 days for adolescents in residential treatment centers. Additional days are authorized when deemed necessary.... Bob Scheck was not on active duty, so his champus benefits would cover 80 percent of Christy's hospital fees. If Scheck had been on active duty, CHAMPUS would have paid the full amount."

As Ms. Bing interviewed persons knowledgeable about medical insurance providers and their relationship to psychiatric hospitals, she learned that teenagers whose parents are covered by CHAMPUS are considered particularly desirable by hospital marketers assigned to "gets heads in the beds." She quotes from an interview with a past employee of Southwood.

"Every morning we'd start the day off with an intake meeting in which we'd review marketing contacts, incoming calls, evaluations, and admissions from the previous day. And we'd look at the discharge calendar, to see who was getting out, and we'd look to see what patients would be left and what their coverage was. The reimbursement rate was different for each company (the payor), and the payor mix was determined by which patients were covered by what policy. CHAMPUS, which paid approximately $1000-per-day for every CHAMPUS patient, was at the top of the list. MediCal, at about $350 per day, was at the bottom. All other coverage - Medicare, Aetna, and so on - was in between."

Ms. Bing's informant explained that on at least one occasion while he was at Southwood, a MediCal patient was dismissed before she was ready in order to make room for a patient whose parents could afford the $1000-per day fee. "That," he told Ms. Bing, "is human damage perpetrated for a $600-a-day difference in bed rate. That's a real story, and that's only one of them. Over a payor mix." I noted that Ms. Bing's book makes clear that many of these teen psychiatric care facilities send the patient home when his or her insurance runs out. Ms. Bing said that she had heard of only a few cases "where a kid is kept on a pro bono basis."

Ms. Bing first became interested in for-profit psychiatric hospitals in 1985 when she worked in the adult and adolescent unit in a for-profit hospital in the San Fernando Valley. Her title there was "Mental Health Technician." The title, she said, makes the work sound more glamorous than it is. "In actual fact what you do is make sure patients get their meals, get to school, get to group sessions, 12-step meetings. You also are available to search rooms, and you're kind of like a guard."

After Ms. Bing finished Smoke, she decided to write about the for-profit psychiatric hospitals. For 18 months, she interviewed teenagers who had been placed in psychiatric facilities.

I asked if she found that many teenagers she interviewed really did not belong in psychiatric institutions.

"I pretty much knew that when I worked at the facility in 1985. Some did and some didn't. And the ones who didn't said, 'I don't belong here.' My only advice to them could be and was, 'It doesn't matter. This is their ride and you're on it.' So what I told kids at that hospital was, 'Listen, whether or not you belong here is beside the point; what you have to learn to do is tell them what they want to hear. That's the only way out of here. You have to learn, in other words, to kiss a little butt.' I did not say, 'When your insurance runs out, you'll be out.' "

Ms. Bing came to the Christy Scheck story through David Olmos's Los Angeles Times story about the Scheck vs. Southwood settlement. Bing subsequently spent many months interviewing the Schecks, their friends and neighbors, Christy's teachers and therapist, the Schecks' lawyers and various ex-employees of the now-defunct Southwood. National Medical Enterprises executives consistently refused to speak with Ms. Bing. I asked Ms. Bing what she suggests parents do when considering placing their child in a psychiatric facility.

"I would certainly make sure that I investigated the facility thoroughly and sat down for a face-to-face with anyone who would be coming in contact with my child. I would find out who owns that facility, who is the parent company, what is their history, have there been any federal fines or awards for malpractice. All of that is in the public domain. All this, of course, is a lot of work. At a crisis point, it's often difficult to stop and do this work. But, it's your kid."

The Schecks, she added, "were too frightened by Christy's behavior and too concerned. And, remember, their therapist had recommended Southwood."

I asked if a therapist's recommendation would be sufficient for Ms. Bing.

"Would that be enough for me? Not now it wouldn't. And frankly, it wouldn't have been enough for me in 1985 when I was working in such a facility. But then I was there, I was seeing what was going on. If I had not worked in that facility, I don't know. It would probably have been enough for me. Parents get scared. They feel they're at a crisis point, and they could well be. When you're in a crisis point, if blood is pouring out of a gash, and someone says, 'Let's tie up that wound and you won't bleed to death,' you're perhaps not going to investigate. You're likely to turn that kid over to almost anyone with credentials. I don't say this in a pejorative sense. Someone says, 'I can help you.' Parents hope that's what will happen. If they're lucky, they get the right kind of help. If they're not, as in the case of Christy Scheck, they don't. I hope this book will make parents think two and three times and do that arduous legwork."