Managing Care for the Acute Mentally Ill in California is Insane (Redux)

“California’s hospital emergency rooms are becoming increasingly crowded with mentally ill and often disruptive patients, partly the result of inadequate mental healthcare and sometimes injudiciously written ‘5150 holds.’  Acute care facilities lacking psychiatric beds sometimes have to hold these patients for days, at significant expense.  Medi-Cal reimbursement for psychiatric patients is inadequate; compensation for uninsured patients is all but non-existent.  The move toward involuntary outpatient treatment shows some promise, but its funding has often been uneven.  Chronically understaffed and underfunded rural counties are unlikely, if ever, to implement such comprehensive reforms.  Many medical providers consider it a single step in a gradual reform that may never completely occur.”

This was the opening paragraph of a white paper and blog I wrote on this subject seven years ago.  Sadly, the problem has only worsened since then, and it was then and now a vital nationwide public policy issue.

To be sure, the problem is not confined to hospitals serving densely populated urban communities, witness the plea of a nurse executive from a hospital in Santa Barbara who prodded me to write more about this issue.  It was, though, a letter published in Health Affairs from a CEO of small-town hospital in rural North Carolina that moved me to revisit this issue.

“I am challenged daily—as are my staff members—by the broken mental health services in our state,” the CEO says.  “Our emergency department has become by political default the local crisis center that is used to meet the socioeconomic demands of our times.  In our society today people with mental illness seem to live on an island, surrounded by an ocean of indifference.

“Since our hospital has no psychiatric inpatient unit, it is common to have three to five mental health patients waiting a week or more in an emergency department treatment room that is ten feet by ten feet.  The patients wait in shackles and chains for transport by the local sheriff to a state facility.”

“Many of these poor souls have lost their job, home, family, and pride.  Saddest of all, they have lost hope.  These neglected members of society are perpetually cycled from our emergency department to a psychiatric facility and back again.  Thirty to sixty days after leaving us, they return—usually because of noncompliance with their medications, which is related to their inability to afford the drugs or to understand the need for them.”

Here’s is the situation we’re in: 

Slightly more than 1 in 4 adults in the U.S. suffer from a diagnosable mental disorder in any given year.  Moreover, about 1 in 17 suffer from a serious mental illness, but a third or more of them receive little-to-no treatment except for when they are forcibly brought to our nation’s hospital emergency rooms because they have acted out in ways that deem these neglected souls to be a harmful threat to themselves or others.

Here are the solutions:

Medicaid payments must be increased to cover the actual cost for hospitalizing these poor souls who are forcibly brought into hospital emergency rooms for treatment of their mental disorders.  In California, hospitals receive slightly more than half of their actual costs for treating this population, resulting in the closure of more and more acute care psychiatric units.  This decline and any increase in capacity will happen if and only if payment for treating poor patients is increased.

Moreover, and perhaps most importantly, a legislator or legislators in California must step up to the plate and own this issue, much like the late state senators Lanterman and Petris of decades gone by did.  And I would suggest that a good place to start would be with a review of Laura’s Law that wasenacted 14 years ago but is in desperate need of a champion who will bridge the concerns of consumer advocates and providers of health care for the mentally ill.

I hasten to add that the enactment of federal Affordable Care Act in 2010 did little to address this problem, as the CEO from North Carolina went on to say, “These people have no guardian angel to provide them with person-centered care, and in the public arena they have no voice and no vote.  Our society’s treatment of them is unforgivable.” 

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