inpatient mental health community hospitals in crisis revised december 2005 executive summary the 27 community hospitals that provide acute inpatient mental health services in washington state are a vital component of the state s public mental health system they provide a combination of psychiatric and medical treatment unavailable at other facilities they are the front door to the mental health system for washington residents who are committed involuntarily unfortunately financial losses from inpatient mental health units are threatening the viability of their entire hospital inadequate hospital payments from the washington state department of social and health services and state underfunding of post-discharge residential treatment options will result in an estimated $34 million in community hospital losses on inpatient mental health during the 2005-2007 biennium between 2000 and 2005 similar losses have resulted in a 14 percent reduction in inpatient mental health bed capacity while
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introduction washington state s public mental health system is comprised of a complex network of state agencies law enforcement agencies courts regional support networks and most importantly mental health centers and state/community hospitals each of these entities plays an important role in delivering treatment for residents suffering from mental illness for the system to provide adequate appropriate and cost effective mental health care all of its constituent components must remain viable and function effectively if any one component falters the entire system is threatened patients health and the public s safety are placed in jeopardy the state s mental health system is currently facing a crisis parts of the system are struggling to survive and without immediate attention they could cease to function nowhere is this more the case than for community hospitals providing acute inpatient mental health services low hospital payments and inadequate post-discharge community resources are r
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community hospitals with inpatient mental health units 2005 hospital city staffed mental health beds hospitals certified to accept involuntary patients 16 children s hospital and regional medical center fairfax hospital harborview medical center lourdes counseling center northwest hospital peacehealth st john medical center puget sound behavioral health sacred heart medical center skagit valley hospital southwest washington medical center peacehealth st joseph hospital stevens healthcare united general hospital valley general hospital west seattle psychiatric hospital yakima valley memorial hospital total beds only 10 beds available to ita patients hospitals not certified to accept involuntary patients 11 auburn regional medical center harrison memorial hospital highline community hospital lake chelan community hospital overlake hospital medical center providence st peter hospital snoqualmie valley hospital st francis hospital st joseph medical center swedish medical center/providence
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community hospitals with inpatient mental health units 2005 source washington state hospital association while involuntary commitments comprise a large proportion of community hospitals patients they are not the only patients competing for this limited resource community hospitals also serve patients who voluntarily admit themselves but who are no less in need of treatment additionally as with medical services not all mental health patients are alike and not every community hospital can treat every mental health patient the severity of mental illness may vary or the patient may have medical complications requiring specialized care kidney dialysis for example consequently on any given day the number of beds available to the public mental health system will vary depending on the caseload of other patients unfortunately the number of community hospital beds available to admit acutely ill mental health patients is on the decline between 2000 and 2005 the number of beds decreased by 111 1
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community hospital inpatient mental health beds 2000-2005 inpatient mental health beds source washington state hospital association inpatient mental health financing for most community hospitals providing care to low income patients is a fundamental element of their mission hospitals are willing to contribute financially for the benefit of their communities and the social and economic well being of the state in order to continue serving their communities however hospitals must remain financially viable most experts agree that a hospital should maintain at least a five percent operating margin to keep up with advances in medical technology and to maintain and improve its facilities unfortunately payments for inpatient mental health services not only provide no operating margin but in most cases they fall well short of covering even the cost of providing treatment the washington state hospital association wsha surveyed community hospitals asking them for financial information by payer fo
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of the 17 reporting hospitals 16 reported losses in their inpatient mental health units ranging from $35,000 to more than $6 million in 2003 on average responding community hospitals lost $155 for every day of inpatient mental health treatment provided inadequate payments by the washington state department of social and health services are a major contributor to these losses the department pays hospitals for mental health care under the federally-matched medicaid program as well as the state-only psychiatric indigent inpatient program formerly the medically indigent program and the general assistance unemployable program together these programs comprise 40 percent of the inpatient mental health units total gross revenues in contrast these programs make up only 16 percent of all washington hospitals total gross revenues considering all departments hospital revenue by payer all hospital departments inpatient mental health source washington state hospital association while not all of th
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that place a low priority on mental health services allow little room for cost shifting insurance policies that arbitrarily limit payment for inpatient mental health services also limit hospitals ability to shift costs for freestanding psychiatric community hospitals there has been increased federal oversight of medicaid eligibility for patients admitted to institutions of mental disease a federal designation this has resulted in a dramatic reduction in disproportionate share hospital funds a key source of revenue to offset uncompensated care no industry can sustain such losses community hospitals have kept the doors of their inpatient mental health units open by subsidizing them with revenue from other health services as payers continue to reduce hospital payment rates and as hospitals care for the ever-growing number of residents without health insurance hospitals find they no longer have the margins from other departments with which to support inpatient mental health services com
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logjams at both doors inadequate payment for inpatient mental health services is only part albeit a major part of the negative impact of the public mental health system on hospitals the inability to transition patients through the continuum of mental health care in a timely and appropriate manner affects all hospitals those with inpatient mental health units and those without entering the system patients suffering mental health crises and in need of assistance from the public mental health system are identified in a variety of settings individuals arrested for crimes ranging from misdemeanors to felonies can be evaluated in city or county jails patients presenting to clinics with myriad symptoms may be found to have underlying mental illness as their most immediate treatment need in addition hospital emergency rooms have become the providers of last resort for mental health care along with many other health services whatever the setting when a county designated mental health profesiona
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in the summer of 2004 the first time ever harborview medical center in seattle twice went on divert status it temporarily could not admit patients to its emergency room because there was simply no room some hospitals will board mental health patients in beds on their medical/surgical floors while this relieves pressure in the emergency room it takes away capacity for medical/surgical patients and the mental health patient still goes untreated in extreme cases the state mental health division has certified single beds in emergency rooms or on medical/surgical floors as eligible for involuntarily committed patients despite the absence of staff psychiatrists trained nursing staff or appropriately secure facilities such situations pose serious clinical safety and liability concerns for hospitals their staffs and their patients post-discharge treatment as difficult as it is getting mental health patients into treatment at community hospitals appropriate and timely discharge is as great a p
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that patients who require continued inpatient treatment are referred to eastern or western state hospitals for 90-day or longer commitments other patients who may no longer require inpatient treatment but continue to need ongoing care are discharged to residential treatment facilities washington state officials have made a conscious decision to reduce inpatient bed capacity at eastern and western state hospitals on the premise that care can be provided more cost effectively in community residential settings since 2001 150 beds have been eliminated at western state hospital and 30 have been eliminated at eastern state hospital while such a shift from state hospitals to community residential care may be clinically and financially justifiable the state has failed to fund development of residential treatment options adequately to support its philosophy a 2002 study by the public consulting group a boston-based consulting firm revealed a severe shortage of appropriate community residential
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conclusion community hospitals exist to serve their communities they are committed to providing access to all patients and to providing their fair share of the health care safety net the state must do its part as well and with respect to mental health it has failed to meet its obligations inadequate payments to hospitals closure of state hospital beds lack of investment in residential treatment capacity increased involuntary commitments single bed certifications these all leave hospitals bearing a disproportionate share of the public mental health burden even closing inpatient mental health units cannot fully relieve hospitals of this burden as long as emergency rooms remain open hospitals are obligated to admit patients and protect them from injuring themselves or others unfortunately emergency rooms are not equipped to provide mental health treatment nor can community outpatient residential or freestanding evaluation and treatment facilities provide all of the care both mental and ph
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for more information contact randy revelle vice president policy and public affairs washington state hospital association 206 216-2515 randyr@wsha.org washington state hospital association 300 elliott avenue west suite 300 seattle wa 98119-4118 phone 206 281-7211 fax 206 283 6122 www.wsha.org
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