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.

No Time to Heal

I sent an e-mail to one of my colleagues last night about a bill introduced in the state of Minnesota that would potentially allow managed care companies to replace inpatient psychiatrists with nonphysicians. She thought that was consistent with the managed-care model of high volume and low quality inpatient treatment. She also reminded me of the concept that inpatient units used to be a place where people came to heal. Over the years that I worked in inpatient settings it is apparent that severe psychiatric disorders take their toll and it takes a lot to recover.  Many people are admitted with acute hypertension, dehydration, malnutrition and weight loss, tachycardia, acute blood loss, and any number of stressful physical conditions in addition to their primary psychiatric diagnosis. At least half of the patients admitted to the acute psychiatric inpatient units have been using alcohol, cocaine, or other intoxicants that worsen their physiological state. In some cases such as catatonia, the psychiatric illness alone is life-threatening.  Before there were effective treatments some forms of catatonia had an 85% mortality rate.

Not too long ago when we had more functional inpatient treatment people had time to recover. It was not uncommon to see patients with bipolar disorder take at least 2 to 4 weeks to recover from an acute episode. Inpatient psychiatrists and nursing staffs were experts in supportive care and patience invariably left the hospital in much better condition than they came in.  That is no longer the case. Today the artificial pressure to make money restricts inpatient care to a number of days rather than weeks. That is well below the time frame that it takes for any of the known psychiatric medications to actually work. In the case of the patient with mental illness and substance abuse disorder, they may have only completed detoxification stage by the day of discharge. They leave the hospital in only slightly better shape than they came in.  In many cases, their families were trying to assist them prior to admission and they discovered they could not help.

I don't think that there should be any mistake that the current system is driven strictly by cash flow and the cash flow to psychiatry has always been limited. The business of managed care companies is not to give patients with severe psychiatric disorders the time they need to heal. The business of managed care companies is to make money and use any rationalization along the way to do that. Those currently include the idea that you should only be on an inpatient unit if you are acutely suicidal or aggressive.  The other consideration is that the inpatient atmosphere should not be designed with patient comfort in mind, because we all know that if is too comfortable - somebody might want to stay longer than the system wants them to.

George Dawson, MD