A new Medicaid demonstration program slated to begin next year will pilot a solution to the problem of “psychiatric boarding,” which has plagued general hospitals for many years. An ambulance or police car delivers a psychiatric emergency patient to the local hospital. However, the hospital either doesn’t have a psychiatric unit or, if it does, all the beds are full. So the potentially suicidal person is “warehoused” on a gurney in the hospital emergency room or restrained in a trauma unit room. The patient may be there for days and never see a psychiatrist or get quality psychiatric care.
Much better care can be provided at an inpatient psychiatric hospital, but Medicaid will not pay for it. Medicaid will only cover the cost of emergency psychiatric care in a hospital emergency room or in a psychiatric unit of a general hospital. Under the institutions for mental disease (IMD) exclusion instituted in 1988, Medicaid will not pay for care in a private psychiatric hospital with more than 17 beds.
Michael Plopper, MD, Chief Medical Officer of Sharp Behavioral Services, said that psychiatric emergency patients who come into the emergency department of Grossmont Hospital in San Diego can stay there for 12 to 16 hours, maybe longer. Plopper, a psychiatrist, oversees the 45-bed psychiatric unit at Grossmont and the 149-bed Sharp Mesa Vista free-standing psychiatric hospital, also in San Diego.
The psychiatric emergency patient who is admitted to Grossmont is evaluated by a mental health professional (a non-psychiatrist). Medication is provided, but the patient is not stabilized. In essence, the patient is in transit as Grossmont decides the best facility for the patient to go to for stabilization. That could be the psychiatric ward at Grossmont, Mesa Vista, or another facility.
Plopper noted that Grossmont, like most general hospitals, has limited access to consultations from private practice psychiatrists in the community. “They are generally not interested in driving over because they probably won’t get paid,” he said. “We are able to manage the boarding issue because of our size, but it is an extremely common phenomenon and can be dangerous.”
In the best of all possible worlds, the Grossmont emergency department would send patients with psychiatric symptoms to the psychiatric unit or to Mesa Vista, with the latter having to eat the costs of the emergency care. But more often than not, there are no beds at Mesa Vista or the Grossmont psychiatric unit because San Diego County recently closed 2 long-term psychiatric facilities for financial reasons, resulting in fewer options. So both venues keep patients longer. That, in turn, means fewer beds at Mesa Vista and the Grossmont psychiatric unit. “That is true throughoåut the country to varying degrees,” explained Plopper. “Since the close of IMD facilities in the mid-1980s, there is no place to send very ill people.”
There have been a number of recent studies and journal publications that have underlined the dimensions of the psychiatric boarding problem. A report in the September 2010 issue of Health Affairs stated that “overcrowded US emergency rooms have become a place of last resort for psychiatric patients. Psychiatric boarding, defined as psychiatric patients waiting in hallways or other areas in the emergency department for inpatient beds, is a serious problem nationwide.”
Now the Centers for Medicare and Medicaid Services, with assistance from the Affordable Care Act (ACA), is taking a stab at assuaging the problem. Medicaid will fund a $75 million, 3-year demonstration program as authorized by the ACA to help care for Medicaid patients (aged 21 through 64 years) with psychiatric emergencies in private inpatient psychiatric facilities with 17 or more beds (ie, IMDs). These would be similar to Mesa Vista and the Peachford Hospital in Atlanta, a free-standing, 246-bed psychiatric hospital. The demonstration defines psychiatric emergencies as expressions of suicidal or homicidal thoughts or gestures resulting in a determination that the patient is dangerous to himself or to others. Demonstrations are due to begin in early 2012.
Matt Crouch, the CEO at Peachford—which employs 5 staff psychiatrists and uses 9 independent psychiatrists in the area in an attending role—said that although the hospital loses money on the stabilization of emergency Medicaid patients, the bigger problem is that the patient, once discharged, does not get the continuing care he or she needs. “That individual cannot be entered into a partial hospitalization program or receive outpatient care from us,” Crouch added. “He or she may be discharged to a local community mental health center, but their follow-up may not be as intensive as ours, and the result may not be as good. That is what concerns me the most, lack of access for Medicaid psychiatric emergency patients to a continuum of care.”