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Access to Mental Health Services Strained as Benefits Expand

 |  By jfellows@healthleadersmedia.com  
   February 27, 2014

On any given day, there are scores of psychiatric patients waiting in emergency departments for an inpatient bed. The strain on the healthcare system will worsen this year, as federal rules expanding behavioral health benefits come into play.

Federal rules for 2014 give Americans more access to behavioral health coverage, but providers' ability to meet what may be a pent up demand for services is questionable. That's because hospitals and health systems are already struggling to meet the needs of a growing number of patients with mental health diagnoses.

There is no shortage of examples that show the limits of mental healthcare in this country. On any given day, there are scores of psychiatric patients waiting in emergency departments for an inpatient bed. Known as boarding, the amount of time a psych patient waits in an ED varies across the country. In California, the average is 10 hours. In central Ohio, it's 19.

EDs are a common landing ground for psychiatric patients because over the last decade there has been a reduction of inpatient beds, psychiatrists, and state funding for mental health services.

California is one of the many states where the issue of psychiatric patients waiting in EDs is acute. Out of the state's 58 counties, says Sheree Kruckenberg, VP of behavioral services for the California Hospital Association (CHA), 26 have no psychiatric treatment facilities.

"Most counties have just washed their hands and are leaving it up to the hospital EDs to manage this population," says Kruckenberg.

"Our coastline in central California is doing quite well, and Los Angeles is doing quite well, but we've got some unique challenges in California," she says, citing a 2012 CHA study that showed a 47% increase in individuals presenting at the state's ED with a behavioral health diagnosis between 2006 and 2011.

The pressure on EDs to treat more and more psychiatric patients began almost a decade ago, but now, with the new mental health benefits granted to patients because of the Patient Protection and Affordable Care Act, access, or lack of access, is likely to become a heightened pain point this year.

Behavioral and mental health services are considered one of the 10 essential benefits that health insurance companies must offer in order to participate in the health insurance exchanges. As of this week, the Centers for Medicare & Medicaid Services announced that 4 million individuals had signed up for insurance on the exchanges nationwide.

Not much is known about this population yet, but since the exchanges were set up to insure people who didn't have access to insurance previously, it is a safe assumption that there will be an initial increase in utilization rates says Alan Whitters, MD, director of behavioral services at Mercy Medical Center in Cedar Rapids, Iowa.

"We know that patients who do have psychiatric disorders overuse the system," says Whitters. "What usually happens, due to liability concerns, is that ED physicians don't feel comfortable discharging a psychiatric patient. Someone says they're suicidal, they know the magic word to get into the hospital. Sometimes "three hots and a cot" does wonders."

For the psychiatric patients who are not overutilizers, Scott Zeller, MD, chief of psychiatric emergency services for the Alameda Health System in Alameda, CA, says too many organizations are not looking for alternatives to inpatient beds.

"It's the only area of medicine where the only solution for every [mental health] problem is admit to the hospital first and start treatment later," says Zeller. "It doesn't make any sense to me. It's as if you went to an ER having an asthma attack and they said, 'We're going to try to get you a hospital bed,' then finally they get you a hospital bed, and then start the inhaler treatment."

"It's the equivalent in psychiatry. Not nearly enough places are considering trying to do urgent treatment on arrival, seeing what they can do in those first 24 hours when so many patients can have their urgent symptoms relived."

Clarifications to the 2008 Mental Health Parity and Addiction Equity Act 2008 are also an additional component that could drive demand for more psychiatric care. Late last year, put more muscle behind the law, requiring doctors and insurers to treat mental illness the same as physical illness. This means services can get reimbursed easier, which could help meet the demand for psychiatric care, but it's too early to tell what the effect will be, says Zeller.

"It's a mixed bag," he says. "I don't think it's been established long enough yet that we have really been able to see if it is going to have a major effect; though even if you're getting a real solid reimbursement rate for psychiatric beds. If you've got a limited number of beds and you're not getting enough treatment in the emergency outpatient setting, it doesn't matter how good the reimbursement is unless you have a place for somebody to go."

And so starts the vicious and sometimes violent circle of psychiatric patients in the ED. After getting them out, where do they go? There are residential facilities, community homes, [and] psychiatric hospitals, but these are not the places where psych patients often end up, says Whitters.

"The pendulum has swung, and our society has determined that it's not okay to institutionalize people, but it is okay to put them in jail."

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Jacqueline Fellows is a contributing writer at HealthLeaders Media.

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