Minnesota DB’s Success in Improving Access Not Duplicated Elsewhere

Support continues to build for the efforts of the Minnesota Psychiatric Society (MPS) to help resolve the crisis in access to inpatient care in its state.

The effort began in August 2002, when MPS President Kevin O’Connor, M.D., asked Eric Larson, M.D., chair of the mental health department at Park Nicollet Clinic, to head a task force that would assess the decrease in availability of inpatient/intensive outpatient treatment programs over the last 10 years, determine the causes of the shortage, describe the harm resulting from lack of access to services, and recommend steps to alleviate the crisis (Psychiatric News, September 20, 2002).

The task force issued the report “The Shortage of Psychiatrists and of Inpatient Psychiatric Bed Capacity” in September 2002.

MPS President-elect Karen Dickson, M.D., told Psychiatric News, “The most exciting new development is that the Minnesota Medical Association [MMA] will convene a work group to promote the ideas in the report. We’re delighted to have its support, which will multiply the effect of our own efforts.”

MMA also passed a resolution calling for meetings of insurance representatives, state officials, psychiatrists, and other physicians and plans to call on the governor to appoint a blue ribbon commission about the problems raised in the report. Dickson is a member of MMA’s board of directors.

Larson told Psychiatric News that HealthPartners, one of the state’s three major companies, had agreed to stop “really onerous aspects of case management.”

According to preliminary discussions, another company will offer parity in payment for psychiatrists and general practitioners for reimbursement of specific treatment codes. Previously, the company reimbursed psychiatrists at a lower rate than general practitioners.

The Minnesota Hospital and Healthcare Partnership, the trade association for the state’s hospitals, sent the report with a letter of endorsement to the state’s major insurance companies soon after it was published.

The crisis in access to inpatient care is accelerating in other sections of the country, however.

In Massachusetts, for example, as of November 1, 2002, the state stopped contributing to the cost of inpatient care for the approximately 200 uninsured Department of Mental Health (DMH) clients who are hospitalized each year with severe mental illness.

Private psychiatric hospitals had agreed to a “no reject” policy at a time when the state contributed to inpatient care for the uninsured and now will be legally obligated to absorb the costs of caring for those patients.

David Matteodo, executive director of the Massachusetts Association of Behavioral Health Systems, told Psychiatric News, “We lost 96 private beds last year and will lose another 150 public beds in 2003 with the closing of a state hospital and state inpatient units. The dam hasn’t burst yet, but it’s near the breaking point.”

He added that as of April 1, Massachusetts will eliminate Medicaid coverage for about 50,000 unemployed, low-income adults, which will expand the number of uninsured and place further financial strains on hospitals and other sources of health care.

In Virginia, 312 inpatient beds in state psychiatric hospitals closed in 2002, and 161 acute-care psychiatric beds in private hospitals closed in 2001 and 2002, according to a report in the November 7, 2002, Richmond Times-Dispatch.

The president-elect of the Psychiatric Society of Virginia, J. Gregory Fisher, M.D., told Psychiatric News that access to inpatient care for children and adolescents had become considerably more difficult during the last five years.

Fisher is a child and adolescent psychiatrist at Virginia Baptist Hospital in Lynchburg.

“If our unit is full, we might have to call six or seven hospitals to find a bed,” he said. “It’s a time-consuming process, and the child often is languishing in the emergency room while we get the approvals we need. Sometimes, the only available bed is at the other end of the state.”

Another psychiatrist at Virginia Baptist Hospital, Randall Scott, M.D., described a series of problems. “The workload has tripled in the last five years. The closest state hospital receives referrals from 13 community mental health centers. Because of the great demand for beds, state hospitals establish their own rules about whom they will accept. Western State Hospital, for example, will not take patients who have any form of insurance, including Medicaid.”

Scott said that patients are “sicker” when they arrive because of interrupted or no treatment. He added, “It’s a misconception to think that treating people in the community will eliminate the need for hospitals. There are patients who are visited twice a day by PACT teams and still need hospitalization periodically.”

APA President-elect Marcia Goin, M.D., told Psychiatric News that there are 230 psychiatric beds in the public sector in Los Angeles County, which has an estimated population of 10 million people. As many as 30 patients sometimes are housed in psychiatric emergency rooms that are licensed for eight patients.

Meanwhile, according to Goin, the Los Angeles County Jail houses 2,300 inmates who are taking psychotropic medication and 100 additional inmates who refuse to take such medication, although it has been prescribed.

Goin said, “These figures illustrate what has been called the criminalization of the mentally ill. When psychiatric beds and other mental health services are not available, people with serious mental illness go untreated and often self-medicate with illegal drugs. In their confused state, they commit crimes or engage in other activities that result in incarceration.”

Last November, she urged members of the President’s New Freedom Commission on Mental Health to consider the idea that dollars directed to the mental health system could result in savings for the criminal justice system (Psychiatric News, December 6, 2002).

“The recommendations in the commission’s final report, which will be released in May, could affect the mental health system for many years. I hope APA members will take advantage of the opportunity to let commission members know about problems of access in their states,” she said. (See contact information at the end of this article.)

These accounts are supported by data in the 2002 Annual Survey Report of the National Association of Psychiatric Health Systems (Original article: see box).

In related news, last month the Kaiser Commission on Medicaid and the Uninsured released the results of a survey in a report titled “State Fiscal Conditions and Health Coverage: How Are Budget Pressures Putting the Squeeze on Medicaid and SCHIP Programs?” It noted that 49 states and the District of Columbia were planning or had implemented cuts in Medicaid for Fiscal 2003. Thirty-two states reported making cuts twice.

Among the cuts are provider payment reductions (37 states), prescription drug cost controls (45 states), benefit reductions (25 states), increased copayments (17 states), and reductions in support for long-term care (17 states).

State budget shortfalls are expected to increase from $37.2 billion in Fiscal 2002 to $60 billion in Fiscal 2004, according to data presented at the press conference.

On January 9 seven senators introduced S 138, which would increase the federal medical assistance percentage for the Medicaid program by 2.45 percentage points for the last two calendar quarters of Fiscal 2003 and all of Fiscal 2004. The bill would also authorize the appropriation of $10 billion to provide states with temporary grants for fiscal relief.

The Bush administration has opposed any increase in the federal share of Medicaid, claiming that the federal government has fiscal problems of its own, according to the January 13 New York Times.

Numerous studies about Medicaid issues are posted at www.kaisernetwork.org under “HealthCast” and “Health Policy.” Comments can be posted at www.mentalhealthcommission.gov/comments.html. Goin would like to receive a copy of comments, which can be sent to her via e-mail at [email protected]. ▪