The cover story in the newest issue of Texas Hospitals, published by the Texas Hospital Association, is headlined, "Nowhere Else to Go: Texas' Underfunded Mental Health System Shifts a Costly Burden to Emergency Rooms." This thorough and thoughtful story opens with a true incident that occurred at University Medical Center Brackenridge. With the permission of the magazine, the article is posted below:
By Carolyn Jones
On a busy weekday in Austin, a man stumbled into the emergency room at University Medical Center Brackenridge. He was having a heart attack. But before emergency physician Christopher Ziebell, M.D., could start treatment, a woman in the neighboring bed caused a disruption. She'd been in the hospital for hours, and her impatience suddenly led to violence. Until she could be secured, medics had to abandon their cardiac patient.
"He suffered when his care was diverted," Ziebell said.
The disruptive patient suffered, too, but from a mental rather than a physical illness. Although she shouldn't have been in the ER at all, she'd go on to wait more than 36 hours before a bed in a psychiatric unit became available. Unfortunately, she wasn't an outlier.
"Just this last weekend we were holding 10 psychiatric patients in the ER," said Ziebell, who serves as the emergency department medical director at UMC Brackenridge. "Because there aren't enough specialty beds available, the authorities bring them here."
Not only is this situation traumatic for the psychiatric patient, but also it takes scarce resources away from patients suffering medical emergencies. Having the mentally ill in ERs at all, Ziebell noted, is a sign that the mental health system has failed.
How the System Fails the Mentally Ill
So how did the system fail? In a study prepared for the Texas Conference of Urban Counties, national consulting firm Health Management Associates describes the public mental health system as a "series of safety nets," with community-based services being the most important layer of the net. Budget cuts, workforce shortages and patchy pathways of care render holes in that layer, causing patients to keep falling until a less-appropriate net catches them. In a reversal of the conditions conducive to mental wellness, the last layer of the net to catch patients often is the ER or the county jail.
Community-based services, which include medication, case management and therapies, also offer the most cost-effective care. Health Management Associates' research shows that the average cost per day of community-based care is $12, compared to $986 for an ER visit. Moreover, a headline-making study by the Integrated Care Collaboration and co-authored by Ziebell showed how nine patients using the ER over a six-year period cost $3 million to treat. Seven of those patients suffered from mental illness. Those seven patients had fallen - expensively - through the net. A Porous Public Mental Health System
Texas has the dubious honor of having the highest number of uninsured people in the United States and also ranks 50th in state spending on mental health care. Although the 82nd Texas Legislature voted for a minor increase in funding for behavioral health services, that figure won't keep pace with population growth or inflation.
When funding shrinks, so does the supply of mental health specialists. Medicaid reimbursement rates for mentally ill patients are so low that many doctors choose not to treat them at all. Meanwhile, as comprehensive care for the mentally ill becomes too costly, insurers react by making patients go through additional hoops to access benefits. A health care market that already struggles to handle unmet needs now also grapples with strong financial disincentives for mental health professionals to enter the field.
Accordingly, as of September 2011, 40 percent of Texas counties are federally designated as county-wide mental health professional shortage areas. Funding shortfalls and workforce constraints make it difficult for community mental health providers to keep pace with demand. Indeed, according to Health Management Associates, the number of state hospital beds in Texas has shrunk more than 30 percent in the last 17 years.
Although supply shrinks, demand continues to soar. The Texas Department of State Health Services estimates that in the last quarter of 2010, almost 10,000 people were on waiting lists for services at community mental health centers. Mild mental illness left untreated will eventually become so acute that law enforcement and urgent care providers become involved. In other words, if mental health patients fall through a hole in the safety net, they don't go away - they are just more likely to land in a squad car that brings them to an ER.
Nowhere to Go but Here
The squad car brings psychiatric patients to the ER because there is nowhere else to go. The Emergency Medical Treatment and Labor Act mandates hospital ERs to screen and stabilize every patient who comes through the door. This effectively means that ERs must accept patients regardless of whether the ER is the most appropriate setting for their care.
"In a busy ER, we turn a bed over about every two hours," Ziebell said. "If you have a patient occupying a bed for 48 hours or longer, you've effectively reduced your ER's capacity. Sometimes, waiting times for medical emergencies can be as long as six hours."
Accounting for the costs of mentally ill patients is a challenge for hospital executives. Keith Hopkins, FACHE, vice president of mental health services at DePaul Center in Waco, estimates that each year uncompensated care for the mentally ill equals 20-25 percent of DePaul's operating budget. DePaul, a division of Providence Healthcare Network, provides inpatient service for patients in psychiatric crises. DePaul collaborates with the Heart of Texas Region Mental Health Mental Retardation Center, the local mental health authority, which provides outpatient, mobile crises and respite care services to McLennan and the surrounding counties.
Half of DePaul's patients come from Providence's ER, 30 percent of whom are brought in by law enforcement authorities. DePaul also collaborates with Hillcrest Baptist Medical Center, a competing hospital, by offering psychiatric screenings in Hillcrest's ER. Hopkins explains that this improves the flow of care through the system and ensures that mentally ill patients receive the best care in the most appropriate setting.
"It's frustrating when our finances don't match the mission," said Hopkins, "but we're proud of our collaboration with Hillcrest."
Ziebell's health care system, the Seton Healthcare Family, also works with the greater community in trying to address the entire continuum of care. Among other initiatives, Seton has developed mobile crisis outreach, transitional care housing, wraparound counseling and assertive community treatment teams. Seton also is piloting a telemedicine program to harness the expertise of off-site psychiatrists in UMC Brackenridge's ER. The program's goal is to shorten patients' stays in psychiatric units by prescribing pharmacotherapy for them when they arrive at the ER. By enlisting specialists on the front end, Seton hopes to reduce congestion in its ERs. Seton is funding the program itself, an investment Ziebell hopes will be recouped.
"If we can redirect that $30,000 per month of uncompensated nursing time toward other patients who need it, then we'll have made a difference," Ziebell said.
Upfront investments and local collaborations aren't so easy if you're a community hospital in rural Texas. Otto Kaiser Memorial Hospital in Kenedy is an hour away from the nearest metropolitan area and, due to its location between San Antonio and the coast, a popular way station for the transient community. Nathan Tudor, chief executive officer of OKMH, said many patients come to the ER suffering from acute mental health problems, but the remoteness of the community means that OKMH can't offer a continuum of care appropriate for their needs.
"Many of them spend more than 24 hours in our ER, which has only six beds, as we try to find the best place for them to go," Tudor said. "We do the best we can, but it's not easy."
It's also not cheap. The vast majority of the mentally ill patients who use OKMH's ER are uninsured. Their uncompensated medical care costs about $120,000 per year, and Tudor feels strongly that there are better ways to provide care to this population. But this won't be easy for a county with no psychiatrists and with funding constraints made doubly severe due to the hospital's remoteness from other providers. It's clear that rural providers merit greater injections of funding, as well as greater flexibility to experiment with creative local solutions.
Additional big-picture challenges remain. Although the health care community as a whole works actively to find solutions, state-level changes may exacerbate the problem. State District Judge Orlinda Naranjo's forensic bed ruling in February, for example, requires the state to place individuals needing assessment to determine if they are competent to stand trial in a forensic bed within 21 days.
Also, the upcoming changes to Medicaid reimbursement rates for potentially preventable readmissions will have an impact. Many, if not most, readmissions are directly related to, or caused by, mental health or substance abuse issues. Policies like these will create a ripple effect across the system. Clearly, until capacity is created across the continuum of care, mentally ill patients will block beds in ERs while they wait for a more appropriate setting.
So what does the public mental health system need? Simply put, it needs financial investment - money to reimburse providers closer to their costs, money to make the field more enticing to mental health professionals, money to allow communities to care for their citizens at the most cost-effective location, and money to enable communities to design local solutions to local problems.
This also means addressing demand at the point of need rather than when a patient is in crisis. Some argue that money should follow patients as they cross boundaries, thus allowing providers to coordinate with agencies both upstream and downstream of the hospital. They'd also be able to shape a more holistic approach to mental wellness.
But until the state invests in mental health, the physically ill, the mentally ill and the Texas health care system as a whole will pay a heavy price.
Can the Waiver Help?
Both rural and urban providers may benefit from a new Medicaid program that is being implemented under a waiver granted by the federal government. The Texas Health Care Transformation and Quality Improvement Program will provide incentive payments to hospitals and local mental health authorities that meet specific goals to transform the health care delivery system.
The projects, for which incentive payments are available under the draft menu prepared by the Texas Health and Human Services Commission and in collaboration with a group of clinical champions, include several interventions aimed specifically at mental health. These include expanding access to mental health care, implementing or expanding telehealth services, integrating and co-locating physical and mental health care services, and establishing post-discharge support for mental health.
While these incentive payments may provide some
much-needed resources, the projects won't begin until November
2012 and funding won't flow until mid-2013. Additionally, these
funds must be earned by meeting progress markers and achieving
metrics, both of which may require local investment from
entities that are strapped for cash.