Minnesota's Abandonment Of Severely Mentally Ill - Nearly Complete

For years I have been documenting the systematic dismantling of the public mental health system in the state of Minnesota.  A chronic unanswered question is how the midwest's most liberal state has come up with such a horrible system.  The most obvious answer is that the system is being run by people who do not have a clue about the treatment of mental illnesses.  A Governor's Task Force, convened a year ago has not put a dent into the further systematic deterioration.  This 30 year race to the bottom in terms of deterioration is why I was not surprised at all by the latest piece of bad news.

The Minneapolis Star Tribune published a story three days ago that St. Joseph’s Medical Center in Brainerd Minnesota stopped accepting patients who were being treated on an involuntary basis under civil commitment.  They cite an increased length of stay and safety issues. Both of these are valid concerns with people committed for treatment of a mental illness.  The system of hospital reimbursement put in place in the 1980s encourages rationing and absurdly short length of stays in inpatient psychiatric units.  People who have undergone civil commitment generally have more difficult to stabilize mental illnesses compounded by a lack of recognition that they have a problem.  Some of them are also violent and aggressive and those behaviors are directly attributable to the mental illness.  The article refers to an incident where one of these patients threw a wooden chair at a nurse and the next day six voluntary patients requested discharge.  This is a relatively mild incident compared to what is possible in acute inpatient settings trying to care for people with the most severe forms of mental illness.  The most important aspect of treating violent and aggressive patients is having an environment of highly trained people to work with them.

The reality of the situation is reflected by the balance of both acute care and public psychiatric hospital beds.  There are 145 hospitals in the state of Minnesota and 125 have 24 hour emergency departments. Thirty two of these hospitals have psychiatric units.  These community hospitals have a total of  1,124 inpatient mental health beds statewide. Nine hundred sixty of these beds are for adults, and 164 for children and adolescents.  On the public side, there are 194 public beds for patients with severe mental illnesses who are committed.  Only committed patients can be admitted to these beds.  According to the Treatment Advocacy Center states need about 50 beds for 100,000 people.  Minnesota has 3.5 per 100,000 public beds and 22.8 per 100,000 beds in community hospitals.  Notice that in a comparison to psychiatric beds in OECD nations, the national average in the US is 22 beds per 100,000.  The United States ranks 29 out of 34 countries ranked in terms of fewest psychiatric beds.  Beds in public hospitals are not equivalent to beds in community hospitals and the newspaper report highlights the differences.  Like most states Minnesota continues to lose beds largely because of mismanagement at the level of state government and what has been an implicit initiative to shut down the state hospitals system.

The bed situation is compounded by a number of factors besides the lack of beds.  There is inadequate housing for people disabled by severe mental illness and inadequate resources to help them live independently.  The average person is expected to come in and see a psychiatrist for a discussion of medication and whether or not their acute symptoms are in remission.  Treatment for combined severe mental illness and substance use disorders is practically non-existent.  The inpatient crisis got worse when legislators passed a very poorly thought out law allowing incarcerated mentally ill patients to be transferred to remaining state hospital beds as a priority over committed patients waiting for transfer in community hospitals. This was an initiative to correct the statistic that Minnesota incarcerates 1.2 people with severe mental illness for every 1 person that it hospitalizes. 

All of the usual commentators are appear in the article - the Commissioner of Human Services and an advocate.  The reader is told that everyone is troubled by this development and wringing their hands.      

Well I'm not.  The entire sequence of events has been observable and is totally predictable.

This is a system that has been severely rationed nearly to the point of near extinction by Minnesota lawmakers and bureaucrats.  It has been interfered with by advocates and in some cases by very bad hiring decisions of people who were supposed to correct the problem.  The only thing we have to show for 30 years of hand-wringing is a a non-existent system of care that does not start to pull resources together until after a person has gone through a civil commitment hearing.  Psychiatrists have been marginalized in the process in favor of administrators who come up with one bad idea after the next.  Managed care systems seem to only recognize dangerousness as an admission criteria to inpatient psychiatric units.  The impact of that bias on commitment frequency, damage to the physician-patient alliance, and damage to the inpatient milieu is probably significant but nobody is interested in studying it.

From the article, the problem is clearly solvable.  There are an estimated 4,000 patients a year who need these services and only 194 beds available to them.  They cannot be humanely treated in community hospital acute care units.  They can also not be humanely treated in group homes designed to be surrogate state hospital beds.  They receive the least humane treatment in jail. The solution is not to blame community hospitals who cannot treat the problem.  One of the issues not mentioned in the article is that the state hospitals have been so decimated - they also cannot treat the problem.  There are probably three community hospitals in Minnesota who have adequate staffing and professional resources to address this problem.  It is conceivable that many more of the remaining 28 community hospitals with psychiatric units will adopt similar policies if they can.  The administrative measure of saying that they can't do this is really not a solution because they really can't provide the necessary care.  The state should know this from their failed initiative to provide smaller local units for committed patients.  That initiative failed for the same reason that St. Joseph's Medical Center no longer accepts committed patients.  They cannot provide adequate care for severe mental illnesses especially when aggression and violence is involved. 

I have posted the solutions in the past and they are obvious. Today I just have three:

1.  Build facilities necessary for the humane treatment of people with severe mental illnesses. Staff these facilities adequately and develop continuity of care with local facilities  when patients are ready to be discharged.  Build these facilities as state-of-the-art facilities in metropolitan areas and not rural areas.  The time is past when people were sent away to the country with mental illness.  Modern mental hospitals need easy access to advanced diagnostic and treatment equipment as well as expertise that is only concentrated in large cities.

2.  Immediately stop arbitrary transfers from county jails to state hospitals, unless the incarcerated patients have been assessed by psychiatrists who agree that a state hospital setting is the best place for them to be. 

3.  Get out of the way of the people who were trained to work there and run them - psychiatrists, psychiatric nurses, and social workers.     


George Dawson, MD, DFAPA



References:

1:  Chris Serres. Brainerd hospital stops admitting patients with severe mental illnesses, citing state bottlenecks: Brainerd decision alarms officials, mental health advocates.  StarTribune November 1, 2017.

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.

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 

References:

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.

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



References:

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:

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.