Thursday, August 11, 2016

News Flash From the StarTribune - Psychiatric Patients Have "Nowhere To Go"

Not to be outdone by the local television stations, the Minneapolis StarTribune came out with their own stunning analysis of the problems with psychiatric care in the state.  At least the opening line was stunning:

"Hundreds of Minnesotans with mental health problems are languishing in hospital psychiatric units for weeks, even months, because they have nowhere to go for less intensive care, according to a comprehensive study to be released this week. " 

Notice the expertise in this sentence - we now have a comprehensive study.  We have a comprehensive study of what every inpatient psychiatrist in the state of Minnesota has known for the past 30 years!  There is a lot behind this headline that is not included in the story.  For example, they left out the part that inpatient psychiatrists and social workers are routinely scapegoated by administrators and government officials for the problem.  The system is not blamed for patients staying in the hospital too long - the doctors are.  I had the opportunity to work with outstanding social workers when I was in this setting and at some point they have to quit.  One of my social work colleagues spent all day, calling over 30 facilities to try to get the patient discharged and she failed.  She failed for two reasons.  First, the infrastructure for accepting patients with chronic psychiatric disabilities has been rationed out of existence by state and county officials.  Second, the existing facilities do not want to accept people with psychiatric problems especially if they have had a history of aggression or suicidal behavior.  The next sentence makes even less sense:

"As a result, private hospitals are absorbing millions of dollars in unreimbursed costs, while patients who are well enough to be released are being deprived more appropriate care at a fraction of the cost."

The author here clearly does not know how state and county officials think.  There is an assumption that they want cost effective and appropriate care.  In my 23 years on an inpatient unit - there is no evidence that those motivations exist.   To any career long student of the system, it should be abundantly clear that all of these administrators and bureaucrats want free care.   Only the Orwellian rhetoric of managed care could spin free care into appropriate care.  I will elaborate on free care instead - how does that happen?  It basically happens in four ways:

1.  The patient is admitted to a psychiatric unit and is too disabled to be discharged to either the street, an apartment, or their original living situation .  The hospital needs to get the patient out in 6 days or less in order to make a profit on the limited payment they get for admissions or discharges (a DRG payment).  The patient is stranded for much longer.  The patient's care is essentially free at that point.  Not only that but if the county rations placement options - they don't spend any money on placements.

2.  The patient is admitted and ends up on a probate court hold or a civil commitment.  In this case they can be stranded for months waiting to get to a state hospital.  Insurance companies and the state do not pay for people in this situation.  The care again is for free.  

3.  Homeless psychiatric patients circulate in an out of the emergency department.  They come in because they are in distress.  They know that they need to verbalize serious problems in order to get admitted.  If not they are discharged back to the street only to appear in the emergency department at a later date.  There is a large circulating population of these patients who may get briefly admitted but never get stabilized.  Apart from the nominal emergency department fee - their care is free.  But of course they are really getting no care.  

4.  Up to 2/3 of people with substance use problems have psychiatric disorders.  Many of them will show up in the emergency department with various levels of symptomatology.  If they are intoxicated they will be sent to county detox facilities - where once again the care is free but it is not psychiatric care.  

These are well hidden secrets of modern psychiatric care.  First, psychiatrists have nothing to do with how the system is managed.  Second, the myth that care is expensive.  People would always ask me if they were being charged a mythical "$1,000/day" fee to be on a mental health unit.  I can assure anyone that when all of the discounts and free care is rolled into the meager reimbursement from insurance companies, the actual reimbursement is more like hotel rates without the hotel accommodations.

The article also discusses the differences between general medical surgical care and psychiatric care. The question is asked if cancer patients were stranded and could not get to tertiary cancer care - would it be as acceptable as the case for psychiatric care?  That question minimizes the scope of the problem.  The problem with the "bottlenecks" described in the article is that they are all a result of rationing of psychiatric services.  There is nobody rationing cardiology or oncology services.  Any middle aged person who goes into an emergency department with chest pain will get state of the art care for chest pain and have all of the necessary testing.  There are no similar services available for psychiatric illnesses.  As soon as a person is admitted the current goal is to get them stabilized and discharged as soon as possible.  The resources are so meager that people frequently do not get the care that they need, because it is rationed.   The article also points out that inpatient treatment at some level is little more than containment.  With administrators rather than clinical psychiatrists running the system, there is no longer an emphasis on a therapeutic environment.  In many cases the experience is sitting around in a facility with little to do, waiting to talk with a doctor about getting released.

So - don't believe what you read in the papers.  Nothing in this article is news.  The system of psychiatric care in the state of Minnesota is dysfunctional by design.  It has been designed by managers at all levels who routinely ignore what psychiatrists have to say and who don't want to spent an additional penny on psychiatric care.

That produces deficiencies at both ends of the spectrum - the people who need to be admitted for psychiatric care as well as the people who need to be discharged.  People with mental disorders should get the same level of care as people with medical and surgical disorders.  That will never happen as long as rationing psychiatric care is justified as being "cost effective".

George Dawson, MD, DFAPA 


Chris Serres.   Nowhere to go, psychiatric patients languish in Minnesota hospitals.  StarTribune August 10, 2016.

George Dawson.  News Flash From Channel 5:  "There is a shortage of psychiatrists."  Link

Supplementary 1:

Every now and then the news media comes up with a shocking story about the rationing of psychiatric services at least they are hyping it that way.   One of my favorites is on Greyhound Therapy and yes this also happens in Minnesota and probably every other state in the USA.  When it comes to rationing and denying care - nothing beats the cost of a bus ticket.

Supplementary 2:

For a look at how modern medical managers and bureaucrats running managed care organizations view psychiatric services - read this post on the Dog Quadrant.

Supplementary 3:

I posted two brief sentences and a link to this post on the page with this story on the StarTribune website.  It was deleted.  If you are reading this please direct anyone interested to this post of what is really happening with mental health and psychiatric care in the state of Minnesota and everywhere.

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