Tuesday, October 1, 2013

What JAMA Psychiatry Doesn't Know About Patient Dumping

JAMA Psychiatry recently posted commentary on a form of patient dumping that I described in a previous post as Greyhound therapy.  The authors' post an impressive chart of state mental health budget cuts and some of the associated problems.  Their solution to the problem "opening a dialogue among providers, funding agencies, and Congress" is a non solution that suggests a lack of appreciation for the details of the problems and how the system of care for people with serious mental illnesses has been systematically dismantled and is no longer capable of providing quality or innovative psychiatric care.  To illustrate my point consider the following 8 points:

1.  The myth of dangerousness is all encompassing.  At some point the government and the managed care industry wanted to make the rationale for admissions to psychiatric units as difficult as possible to ration inpatient psychiatric care.  The standard question is: "Is this person a danger to themselves or anyone else."  This bias has completely disrupted inpatient care.  We now have desperate people who should have been admitted who are lying about suicidal ideation in order to get admitted.  We have people who don't need to be admitted saying they are suicidal and getting admitted.  The point is that this criteria is irrelevant for a whole range of indications for inpatient treatment.  As an example, anyone with a familiy member who has severe mental illness recognizes that there are times when they are completely unable to function due to their illness.  Leaving that person at home to fend for themselves in that condition is not only a bad idea it is inhumane and yet they may not meet somebody's criteria for "dangerousness".

2.  Length of stay in all community based psychiatric units is based on DRG payments.  That means there is a set reimbursement for a diagnosis related stay independent of how long the patient is in the hospital.  As an example a psychosis DRG is one of the commonest DRGs and the last reliable figure I have is that it pays $4,500 per DRG.  That is set by the federal regulatory agency for Medicare reimbursement but practically every managed care and insurance company pays the same way either per admission or per discharge.  If the patient stays 5 days that is nearly the mythical "$1,000/day" that most people believe the hospital is reimbursed.  If the stay is 30 days that is $150/day and less that the cost of most board and care homes.  This is a strong financial incentive for the hospital to discharge the patient as soon as possible.

3.  Despite an emphasis on biological treatments in inpatient settings, there really are no biological treatments that work in the 5 days.  That is the length of stay most hospitals want their patients discharged in.  Most inpatient experts will tell you that severe mental illnesses (as opposed to crisis intervention) often require at least 2 - 4 weeks for stabilization.

4.  Available social service providers have no incentive to assist the hospital with placement irrespective of whether there is adequate housing or not.  The hospital is the least expensive place to house the patient, even if they are stable for discharge.

5.  The economic incentives result in a large patient population that circulates from homelessness to emergency departments to inpatient care.   These same incentives result in the patient being exposed to no single environment that results in their stabilization.  In fact providing thousands of dollars of discharge medications to people who will probably never take them is a massive inefficiency that creates an illusion that inpatient treatment has done something.  My personal conversations and correspondence with many outpatient psychiatrists confirms that most of them consider inpatient care to be a complete waste of time and they acknowledge that they have no good place to send their patients anymore for stabilization.

6.  The same managed care companies that denied hospital claims many years ago currently own the facilities.  They now have case managers essentially running their inpatient treatment and telling the physicians there when a patient must be discharged.  If the doctors working in that environment don't go along they can be forced out or placed in an uncomfortable enough position that they quit.  Managed care companies frequently have proprietary and arbitrary guidelines that dictate when people are discharged.  It is not a coincidence that the suggested lengths of stay are expected to maximize profits and have nothing to do with quality psychiatric care.

7.  Utilization reviewers still exist.  Their job is basically to argue with inpatient physicians and harass them enough so that they discharge the patient.  These physicians were supposed to be "peers" but in my experience talking with them over the years, it was apparent that I was not talking with anyone who had actually worked in an inpatient unit.  Their job was clearly to force me to get the person out of the hospital or play the trump card by denying payment and getting the hospital to force me to get the patient out.  You might ask yourself why they are necessary if their company is paying a fixed fee for inpatient care and I think that is a good question.

8.  The trivial reimbursement for inpatient care deincentivizes access to other assessment and treatment modalities that the patient may need such as specialty consultation, brain imaging, and electroencepaholgraphy.  Patients may be told to come back for outpatient appointments when the treating psychiatrist knows that patient will not return for the necessary appointments and will probably be readmitted soon with the exact same medical problem.

All of these issues combined are why people are discharged to the street or put on a bus.  You can see that the common theme here is actually the rationing of services by the government and managed care industry as well as psychiatry's inability to deliver the quality of care that psychiatrists are trained to provide in this restricted environment.  The suggested solutions in the authors article seem to be written by Joint Commission bureaucrats and will have little impact.

This is a problem that can be solved by psychiatrists but it has to start with a quality approach.  Inpatient specialty training in psychiatry with a focus on providing state of the art assessment and care is necessary.  It is an ideal place to begin to attend to the cognitive dimension of psychotic disorders and mood disorders.  Civil commitment laws need to be reformed with a focus on treatment rather than dangerousness.  There needs to be an appropriate hand-off from the hospital team to  a community team and a housing team.   It is the time to stop demanding "cost effective" treatment from a system that has been practically rationed into non-existence.  It is time to invest in quality to the point that patients with severe mental illness and their families can expect that there will be psychiatric services available as a resource on par with the cardiology services they expect for any middle aged person with chest pain.

George Dawson, MD, DFAPA

1.  Das S, Fromont SC, Prochaska JJ. Bus Therapy: A Problematic Practice in Psychiatry. JAMA Psychiatry. 2013 Sep 25. doi: 10.1001/jamapsychiatry.2013.2824.  [Epub ahead of print] PubMed PMID: 24068366.


  1. Dr. Dawson, thank you for again highlighting how many of the ills of our mental health "system" are directly attributable to the pernicious effects of managed care and its emphasis on profit maximization over quality care.

    I do have one question for you, related to the issue of psychiatrists not being able to deliver the quality of care that we are trained to provide. Given that many (perhaps most) psychiatric residents in recent years are training in hospitals where the length of stays grow ever shorter, do you feel that up and coming psychiatrists are still trained to provide quality care?

    1. As a former residency director, I can tell you that residents have seldom followed hospital patients long enough to see how antipsychotic and antidepressant medication actually work in a community or state hospital setting (Thank goodness for the VA). For instance, they will sometimes change the dose of an antidepressant if there is no response in a couple of days.

    2. That’s a great question.

      I met one of my former mentors in an airport a few years ago and told him I was moving on from inpatient work after 22 years. He said: “Wasn’t 3 months long enough?” I think his joke perfectly frames the inpatient setting. It is basically a dumping ground for everyone’s unresolved problems with severe mental illnesses. By everyone I mean the police, nursing homes, group homes, jails, detox units, any state facility that can cost shift the care of their patients to short term hospitals, and of course the administrators who run it. Everyone but the patients. Patients on an inpatient psychiatric unit should expect the same level of service they would get if they were admitted for assessment or treatment of a myocardial infarction and of course they don’t. Can anyone imagine a 60 year old with chest pain having to run that gauntlet is order to get medical care?

      The situation has gotten so far out of control that some inpatient units run with minimal input from psychiatry and certainly nothing like state of the art care. There are really a small and vanishing cadre of inpatient psychiatrists and probably some consultation liaison psychiatrists who can operate at the interface between the medically ill and severe mental illness and be comfortable. It is intensive work and appropriately done it requires meticulous attention to detail.

      Even then it is a position set up for burnout because I have seen inpatient docs scapegoated for problems on their units that are not under their control. An excellent example is arbitrary administrative initiatives to deal with violence and aggression – initiated by people with no psychiatric training and a lack of awareness of the ecology of aggression in inpatient settings.

      In order to rapidly scale up and deliver care on par with Cardiology services in may take networks of these docs collaborating and being available as a training and ongoing resource. It will also take physicians refusing to work in managed care environments where they are accountable to business people with no medical or psychiatric training. There is no such thing as “medical necessity.” When I hear that from a managed care company it comes down to what they think is “business necessity.”

      It would be good to see the APA step into the breach and support this position, but they have already endorsed a collaborative care model that is essentially managed care.

      So I guess this is a long winded way to get to the bottom line. I don’t consider any inpatient team that is focused on case managers’ decisions to get symptomatic and untreated patients discharged as soon as possible to be acceptable psychiatric training – period. Maybe they could invent a separate “behavioral health residency” where the trainees round with managed care case managers and decide on how fast they can discharge people. My guess is you could do it in 6 – 12 months because you don’t really need to know how to diagnoses and treat people with serious problems. I am sure that they could do recertification exams and everyone would think it was great.

  2. Another excellent post. Thanks.
    I ran an inpatient general psych unit from 2004-2006. I left for full time private practice in large part because it was so demoralizing to see the revolving door effect play out, essentially every day.
    And the biggest money-maker for my hospital was the dual diagnosis unit, because the majority of admitted patients sign out within one day, which keeps the average length of stay low.
    I couldn't fix it, and I couldn't stand it, so I left. But there's got to be a better way.

    1. Here is the suggested solution from a major health care management text that refers to a "portfolio analysis of hospital inpatient services". The "dogs" (eg. low market share, low growth rate) include psychiatry and pediatrics. The suggested management strategy is "...May be targets for contraction strategies. However in health care, some 'dog quadrant services' may be slated for maintenance of scope or even expansion because of community needs". I am sure there was a manager somewhere very happy to manage the revolving door rather than an actual length of stay where treatment occurs. (ref. Strategic Management of Health Care Organizations, 6th ed, p 254)

  3. George; Back in the late '90's I took a leave of absence when a family member was very ill. After his death, I tried to come back--almost a 3-year hiatus. What had happened in that interval left me appalled. Suddenly supposed "social workers" were talking to managed care and dictating what I could do and how long the patient could stay. Most of my former colleagues had left by then, and I couldn't continue in that farce. I was out of there in less than 2 months.

  4. Thanks for your observation. Part of the reason I started this blog was to encourage other psychiatrists to speak out about these abusive practices. The public has no idea that they are getting a business product rather than one determined by medical training. The farcical atmosphere you describe did not affect me until several years later - but within a short time it was the community standard. Just the idea that a business can determine the community standard for medical care based on whatever they want to do should illustrate the significance of the problem here. The public does not know that there are no protections from this and that the so-called health care system has been disconnected from medicine.

  5. do you know if medicare drg's are subject to mental health parity act?

    1. Fairly certain that all of the managed care rationing strategies will remain intact. All of the industry and government bureaucrats who write about it talk as though these tactics are legitimate. Managed care has been able to embed itself deep within the government and the health care industry. They actually think that DRG rationing and having penalties for the expected readmissions leads to quality outcomes.