Monday, November 2, 2015

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 years of Rationing

It is clear to me that Minnesota doesn't want to hear from any psychiatrists.  Psychiatrists in this state have been complaining about managed care, prior authorization of medications and hospital treatment, managed care medical necessity criteria and mismanagement of the state mental health systems by the State of Minnesota for as long as I have worked here and that is now 27 years.  All of that work at various levels has basically been ignored by the politicians and responsible bureaucrats in this state who are quite happy to address the problems of severe mental illness by progressive rationing at all levels.  That is their only response.  This march toward the managed care approach to mental health has been inexorable and has resulted in major problems with access and quality of care.

I have been writing in various formats about the problem of mismanaging acute care beds in Minnesota for at least 15 years.  What do I mean about mismanagement?  The problem started in the late 1980s when the state of Minnesota gave carte blanche to one of the local insurance companies to start denying alcohol and drug related admissions to inpatient psychiatric units.  Anyone with a sparse knowledge of addiction knows that about 70% of people with addictions have significant psychiatric morbidity and many are at much higher risk of aggression or suicide if intoxicated.  That was not enough of a deterrent to prevent this insurance company (with full collusion of the State) to start denying psychiatric admissions to anyone with an addiction or eventually to anyone with acute alcohol or drug intoxication.  The effects of those denials filtered through the entire acute care system and eventually intoxicated people were held in emergency departments until they were less intoxicated, sent to county detox units where they got no medical or psychiatric care, sent to jail, or discharged to the street.  In some cases people were discharged to the street with a bottle of benzodiazepines and expected to manage their own detoxification.  Many of those patients take the entire bottle the first day.  None of those pathways leads to sobriety or treatment of associated medical and psychiatric conditions and it is not an acceptable level of medical care.

Treatment of mental health conditions has fared no better.  At some point the vague concept of "dangerousness" became the only reason that a person with a severe mental illness could be hospitalized.  In some cases it was a "dangerous enough" standard.  In other words if you happened to have chronic suicidal ideation or self injurious behavior, the gatekeeper (who is usually an emergency department (ED) social worker) has to decide if you are dangerous enough to admit.  That combined with bed availability, other persons needing admission, the availability of psychiatrists to cover the beds, any associated intoxication states, and even the likelihood that a probate court would hold or commit the person led to a gauntlet that even outpatient psychiatrists could not negotiate.  Outpatient psychiatrists from the same clinic could not admit their outpatients to hospitals run by their colleagues.  That led to more and more psychiatrists advising patients and their families to just go the the ED and "let them sort it out."  The ED provides no psychiatric care - only a triage decision on admissions.  This quasi-system of care results in a large circulating pool of people who are never stable, at risk for incarceration or victimization, and who never receive standard care for their problems.

The unstated toll that this chaotic system takes is on the psychiatrists and nursing staff who work in it.  They are frequently the first ones to be blamed for a lack of beds and timely discharges.  A completely unrealistic bed situation becomes a psychiatrist not discharging people soon enough.  Psychiatrists and nursing staff end up treating the consequences of patients being held too long in hospitals that are not equipped to be long term care hospitals.  Patients and family members can become frustrated or irate as a result of this situation and the only people to blame are not the people who caused the problem in the first place.

The quasi-system of mental health care was well described by Karl Olsen, a Hennepin County Crisis Intervention nurse in the Star Tribune about three weeks ago.  He describes the backlog of patients in the ED and crisis centers due to a lack of psychiatric beds.  He describes the risk to both the patients and staff in this setting as well as the impossibility of trying to provide care that can only occur in a hospital setting in an emergency department or crisis unit.  But most of all, he describes the ongoing active discrimination against people with severe mental illnesses by insurance companies and the state.  A more recent article is written by a reporter interviewing a state bureaucrat who reports that the situation is "the worst I have seen it in 20 years."  How can representatives of the State get away with these remarks when the State of Minnesota is largely responsible for the problem?  The article describes the lack of beds in State hospital facilities as being the problem and the State has made no secret of the fact that they are closing down State Hospital facilities and until very recently planned to close the last facility.  This article goes on to conclude:

"Hennepin County Sheriff Rich Stanek was in Washington, D.C., Thursday, helping brief members of Congress about mental health issues and seeking additional funding for treatment beds in a state that has the 50th lowest rate of mental health beds for its population..."

It is truly a sad state of affairs when a county sheriff is advocating for treatment of the mentally ill in Congress.  On the other hand it is also a direct result of the opinions of psychiatrists being actively ignored in this state for decades.

We have seen the bottom of the managed care rabbit hole - and it is called Minnesota.  We take the prize with the lowest rate of psychiatric beds in the US.  There are only two groups of people in this State with any credibility when it comes to critiquing this failed system of care - psychiatrists and psychiatric nurses.  There is no politician or bureaucrat interested in proposed solutions - they are directly responsible for the 30 years of rationing that led to this problem.   One of the retorts by state officials has been: "What's your solution?".  It is time to acknowledge that this is little more than political rhetoric.  They have ignored the solutions including many that have been proposed right here on this blog.

Until the psychiatrists and psychiatric nurses are heard - expect continued deterioration in the treatment of mental disorders that we have witnessed here over the past 30 years.

George Dawson, MD, DFAPA


Jeremy Olsen.  Shortage of state psychiatric beds leaves local hospitals jammed.  Star Tribune. November 2, 2015.

Karl Olsen.  Minnesota's mental health system is in crisis.  Star Tribune.  October 16, 2015.


Supplementary 1:  The image used for this post is of Dexter Asylum attributed to Lawrence E. Tilley [Public domain], via Wikimedia Commons.  The original image was Photoshopped with a graphic pen filter.

Supplementary 2:  For a detailed post on some of what happened try this.

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