DB Seeks Solution to State’s Shortage of Psychiatry Beds

The Minnesota Psychiatric Society (MPS) is tackling one of psychiatry’s most intractable problems.

In August MPS President Kevin O’Connor, M.D., consultant in psychiatry at the Mayo Clinic, asked Eric Larson, M.D., chair of the mental health department at Park Nicollet Clinic, to head a task force that would research the problem of a shortage of psychiatric hospital beds.

O’Connor told Psychiatric News, “There is no more important issue than access to care.”

Psychiatrists had become concerned because frequently they had to send patients in need of hospitalization by ambulance from the Twin Cities to smaller cities like Duluth or even out of state.

Emergency rooms are overwhelmed, and the number of psychiatrists willing to provide inpatient services is dwindling, said Larson.

According to a story in the August 12 Minneapolis Star Tribune, hospitals are losing money on psychiatric care. Data from the Minnesota Hospital and Healthcare Partnership show that in 2000 the average cost of treating a psychiatric patient in a hospital was $1,338, but health plans paid an average of only $678.

Larson told Psychiatric News, “At our first conference call, we acknowledged the complexity of the problem. We will begin a dialogue with hospital associations, state agencies, advocacy groups, and private payers such as employers and insurance companies.”

The first priorities of the task force will be to improve reimbursement and to decrease the long delays of inpatients waiting for a discharge placement, he said.

Minnesota is not alone in its struggle, although MPS might be the first state psychiatric society to initiate such a broad-based dialogue to address the problems caused by lack of access.

The November/December 2001 issue of the APA newsletter Psychiatric Practice and Managed Care offered accounts about shortages of psychiatric beds in 16 states that submitted reports.

Those accounts told of an inability to admit a patient unless he or she had been ordered to the state hospital by a criminal judge (Hawaii); assigning “sitters” to psychiatric patients who could find space only in medical wards (Maryland); and beds that are actually reclining chairs in the emergency room (Rhode Island).

APA Vice President Steven Sharfstein, M.D., told Psychiatric News, “The combination of managed-care-driven downsizing in the private sector with fiscal strangulation in the public sector is creating a national crisis for desperate patients and families who need hospital-level care.”

Sharfstein is president and chief executive officer of the nonprofit Sheppard Pratt Health System in Maryland.

Michael Hogan, Ph.D., chair of the President’s New Freedom Commission on Mental Health, identified the shortage of inpatient hospital and residential treatment as a “key issue” for the mental health system.

In a teleconference dialogue with members of the National Association of Psychiatric Health Systems (NAPHS), he said, “The erosion of [inpatient] care, especially at the more intense levels, has reached critical mass. But we haven’t figured out how to get our hands around the issue.”

Commission member Anil Godbole, M.D., president of NAPHS, added, “Behavioral health has never been a high-margin service. With consolidation, we are seeing diminished capacity and are now reaching a critical state.”

Godbole, who is also chair of the department of psychiatry at Advocate Illinois Masonic Medical Center, expanded on his remarks in an interview with Psychiatric News.

Costs are shifting from the public to the private sector, he said, with the closing of public mental hospitals. The number of psychiatric beds in public facilities declined from about 650,000 in 1960 to 57,000 in 2000. The most rapid decline has taken place during the last 10 years.

Since 1997, according to NAPHS data, admissions to private psychiatric hospitals and psychiatric units in general hospitals have increased by 3 percent to 4 percent annually.

However, Godbole quickly added, the dollars have not followed the patients. Neither Medicaid nor Medicare reimbursement covers the full cost of hospitalization. Medicare payments have not increased for inpatient hospitalization since 1992, and states are cutting Medicaid budgets.

“Psychiatric beds are the most vulnerable in the case of mergers and acquisitions,” he said. Hospital CEOs want to eliminate them because they are unprofitable.

A survey by the Illinois Hospital Association in 2001 showed that 50 percent of the responding hospitals were planning to cut the number of psychiatric beds.

The decreasing number of psychiatric beds results in overcrowded emergency rooms and a declining number of psychiatrists willing to treat patients under such adverse conditions, said Godbole.

“Reimbursement rates are key to solving the problem,” he argued.

Sharfstein agreed with that assessment. “Sheppard Pratt was able to survive and to continue providing inpatient care, in part, because we were able to negotiate a higher Medicaid payment,” he said.

Godbole said that the commission will be considering the problem through its committees on Medicaid and best practices.

The commission Web site at www.mentalhealthcommission.gov offers a section for public comment. ▪