Shortage of psychiatric hospital beds (IMD Exclusion) in Florida, Oklahoma, New Jersey and North Carolina

The Daily Oklahoman

October 6, 2000

OPED

‘No vacancy’ faces mentally ill

By Bruce Rheinstein, policy analyst, Treatment Advocacy Center

MANY people think that the era of closing large, state psychiatric hospitals and dumping the mentally ill on city streets is a thing of the past. Sadly, Oklahoma is proving them wrong and perpetuating the failure of deinstitutionalization and success of transinstitutionalization by downsizing Eastern State Hospital in Vinita.

Gravely ill Oklahomans, who were until recently provided appropriate psychiatric care, have now joined the hundreds of thousands of mentally ill Americans for whom deinstitutionalization has meant nothing more than a denial of treatment, abandonment to the streets and preventable imprisonment in jails and prisons. Patients are often discharged without a housing plan or place to go. According to Oklahoma’s Department of Mental Health and Substance Abuse Service, 33.8 percent of patients discharged from Eastern State were not in independent housing within six months of discharge. Ten percent of patients tracked by the Tulsa Institute of Behavioral Sciences seven months after downsizing Eastern State Hospital had spent an average of 32 days in jail.

The primary blame lies not in Oklahoma City, however, but in Washington and in a decades- old federal policy established when severe mental illness was not universally recognized as a biologically based brain disease.

Because their illness prevents them from obtaining private insurance through employment, many people with severe mental illness rely on Medicaid to pay for their treatment. For every dollar Oklahoma spends on Medicaid, the federal government reimburses more than 71 cents — unless the patient is between the ages of 21 and 65 and is receiving treatment in a psychiatric hospital or other “Institution for Mental Disease” (IMD). The IMD exclusion to Medicaid unfairly discriminates against patients solely on the basis of their diagnosed psychiatric disorder.

In order to shift the cost of treating the mentally ill to the federal government, Oklahoma and other states are emptying their psychiatric hospitals and providing “treatment” in general hospitals and community- based clinics. These are often ill equipped to handle their needs and quickly release them to the streets, where many fall through the cracks and receive sporadic treatment at best. Far too many receive little or no care whatsoever. This lack of treatment ultimately costs society more, not less. Studies have repeatedly shown that persons with severe mental illnesses don’t get better when treatment is withdrawn; they get worse.

We have lost most of our state psychiatric hospital beds nationally since 1965 due to the discriminatory nature of Medicaid. As a result, 1.4 million Americans with schizophrenia and manic-depression go without any treatment for their illness. People with severe mental illness are not to blame for their condition. Medical research has established that severe mental illnesses like schizophrenia and manic-depression are physical diseases of the brain. They are no more the fault of the sufferer than is Alzheimer’s disease, Parkinson’s disease or multiple sclerosis — yet society, or more specifically the federal government, does not accord them the same level of care.

Without early medical intervention, many of these individuals who would have been capable of living productive lives in the community become so sick that they are never able to function appropriately outside of an institution. But where do these ill citizens go when rampant psychiatric hospital downsizing creates a proliferation of “no vacancy” signs?

Rather than eliminating much-needed psychiatric hospital beds for the severely mentally ill, Oklahoma and the federal government must ensure the mentally ill receive the same basic level of health care as those who suffer from other debilitating illnesses. Closing hospitals and pushing the sick onto the streets and into jails and prisons is both inhumane and fiscally insane.

NEW JERSEY Star Ledger
February 26, 2007

State Must Offer More Options for Treating Mentally Ill

By Mary T. Zdanowicz

My sister lives in a facility with more than 700 people who are legally considered “dangerous to self, others or property”. That is what it takes to be committed to a psychiatric hospital in New Jersey.

Beth is a patient at Ancora Psychiatric Hospital. She was diagnosed with schizophrenia more than 20 years ago and she is among the most ill individuals with this terrible disease. Unlike about 90% of people with schizophrenia, medication doesn’t much help the worst of her symptoms.

Imagine a sweet, pretty 46-year-old woman who most days can’t hold a basic conversation. When I take her out on day visits, I have to hold her hand because she is apt to walk out into oncoming traffic. I can’t take her overnight anymore because she paces and if I dose off, she might wander off. At Ancora, she has 24-hour supervision, good nutrition, medical monitoring, and people who really care about her. Her caregivers have kept her safe for 9 years. Comparable care is nonexistent in the community – believe me, I have looked.

Most New Jersey citizens have no idea of the incredible service being performed every day by the staff of the state psychiatric hospitals. Nor do they realize the incredible duress that both staff and patients have been subjected to in recent years. Even a cursory examination reveals the real question: “How have the hospitals managed to avoid more tragedies?”

Follow the money. It isn’t necessary to even step foot in a state psychiatric hospital to see a state of emergency. Look at recent state budgets. My sister was transferred to Ancora when New Jersey closed the 750-bed Marlboro Psychiatric Hospital. At that time, there were 529 patients at Ancora with an anticipated maximum of 600. Today there are close to 750. That’s 150 more patients than the state planned for in facilities and staff when it closed its largest hospital in 1998. For years, New Jersey planned for fewer patients than it served. In FY 2005, the state budgeted for 651 patients at Ancora . . . but served 727.

Thus, it is easy to make hospitals the scapegoats. Yet while state hospital budgets have not even kept up with inflation over the last ten years, contracts with private community mental heath providers have increased 50% over inflation. Between 2001 and 2006, New Jersey poured $109 million into community service contracts specifically to reduce the population in state hospitals. It didn’t work. In fact, the hospital census increased 7% during that period. It appears that no matter how much money the state sinks into community mental health, it is the hospitals that continue caring for the most severely mentally ill.

Why isn’t the community appropriately serving this population? One difference is that hospitals can require patients to participate in treatment and take their medication. When they leave the hospital, the rules change. New Jersey is one of only 8 states in the country with no option for civil commitment in the community, known as assisted outpatient treatment.

That means that, unlike hospitals, community providers are able to pass on treating the sickest, and often most difficult patients, with the excuse that they can’t make a patient take their medication. And based on the position of their lobbyists, like the Mental Health Association of New Jersey and the New Jersey Psychiatric Rehabilitation Association, community mental health providers don’t want to do the tough work that psychiatric hospitals do.

They’ve eagerly accepted the money that Senator Richard Codey advocated for community mental health, but they actively oppose the Senator’s legislation, S-1093, that would allow community providers to do the one thing that keeps people from being hospitalized – ensure they stay in treatment and take medication.

New Jersey already closed one hospital and “reinvested” the money in the community. Yet the psychiatric hospitals are overcrowded because community mental health providers can’t – or won’t – do what is necessary to keep patients out of the hospital. Thus, tragedies among this very vulnerable population are inevitable both in and out of hospitals.

Blaming the hospitals is the easy way out, and allows the mental health community to again dodge blame for the crisis we are now facing. The community isn’t doing its part, and it is far past time to hold them accountable.

There are now more patients in fewer hospitals than ten years ago. Community mental health must step up and do more for hospital patients than just take their money. They can start by supporting and implementing S-1093.

Zdanowicz is executive director of the Treatment Advocacy Center (www.treatmentadvocacycenter.org), a national nonprofit dedicated to removing barriers to timely and effective treatment of severe mental illnesses.

The Raleigh News and Observer

April 2, 2000

OPED

Dix’s bind begins in Washington

By Mary Zdanowicz and Bruce Rheinstein

North Carolina’s mental health system is under increasing financial stress as the state struggles to provide care for those with severe mental illness. Cutbacks in mental health services have increased the strain on other parts of the system, including psychiatric hospitals.

At Dorothea Dix, Raleigh’s 500-bed state hospital, the lack of funding has resulted in serious nursing shortfalls on frequently overcrowded admissions wards. This funding-driven quality of care issue has jeopardized $41.5 million in federal funds the hospital receives.

[Following a federal inspection last week, officials said that if Dix can prove in coming months that it will cure its chronic staffing shortages and fix other problems, it will keep the federal aid. On Thursday, a state auditor’s report recommended reforms in the mental health system that include the eventual closing of Dix.]

The primary blame for the problems at Dorothea Dix lies not in Raleigh, however, but in Washington. Because their illness prevents them from obtaining private insurance through employment, many persons with severe mental illness rely on Medicaid to pay for their treatment. For every dollar North Carolina spends on Medicaid the federal government reimburses over 62 cents — unless the patient is between the ages of 21 and 65, suffering from a mental illness and treatment is in a psychiatric hospital or other “Institution for Mental Disease” (IMD).

The “IMD Exclusion” to Medicaid unfairly discriminates against patients solely on the basis of their diagnosed psychiatric disorder and prevents the state from recouping federal funds that could be used to help pay for improved nursing care in its hospitals.

States like North Carolina fill the funding gap created by the IMD Exclusion by relying on Medicaid’s “Disproportionate Share Hospitals” (DSH) payments for hospitals providing care to a “disproportionate share” of poor or indigent patients. But Congress and the president have trimmed North Carolina’s DSH payments by some $42 million per year between 1998 and 2002.

Not surprisingly, as North Carolina is forced to shoulder more of the burden of treating the mentally ill in hospitals, other treatment programs are downsized or terminated. This creates a greater burden on the hospitals as demand for services increases. Situations like those at Dorothea Dix will continue to result as the state attempts to do too much with too few dollars.

The IMD Exclusion created an incentive for North Carolina and other states to empty their psychiatric hospitals and provide “treatment” in general hospitals to save money. While care of the severely mentally ill in general hospitals costs as much as $300 per day more than in state psychiatric hospitals, it costs less to the state because treatment is reimbursable with federal Medicaid dollars. Largely as a result, North Carolina lost over 80 percent of its state psychiatric hospital beds by 1996.

Unfortunately, general hospitals are ill-equipped to provide long-term treatment for severe mental illnesses. And having fewer beds available to treat those who are acutely ill means that the psychiatrically ill are quickly released to the streets where many fall through the cracks and receive no treatment whatsoever. In the United States 40 percent of persons with severe mental illness are not receiving treatment for their illness. This lack of treatment ultimately costs society more, not less.

Today, a person in North Carolina with severe mental illness is nearly three times more likely to be behind bars than receiving treatment in a state psychiatric hospital. Based on national statistics, it’s estimated that there are at least 5,185 inmates in North Carolina’s jails and prisons who are mentally ill.

Nationwide, there are an estimated 150,000 to 200,000 mentally ill homeless, three times the number who are receiving treatment in state psychiatric hospitals.

Medical research has established that severe mental illnesses like schizophrenia and manic-depression are physical diseases of the brain.

They are no more the fault of the sufferer than is Alzheimer’s disease, Parkinson’s disease or multiple sclerosis — yet federal Medicaid does not accord them the same level of care.

By eliminating Medicaid discrimination against the severely mentally ill we can assure that enough funding for treatment in psychiatric hospitals is available to ensure that quality care is provided in those institutions for people who need it. Providing appropriate treatment is not only humane, it saves the taxpayer money.

The Orlando Sentinel

March 23, 2000

OPED

Florida’s mentally ill left out in the cold

By Mary Zdanowicz and Bruce Rheinstein,

Special to The Sentinel

Most people think that the era of closing large, state psychiatric hospitals and dumping the mentally ill on the streets is a thing of the past. Florida is proving them wrong by threatening to close another 350 hospital beds for its most severely mentally ill citizens.

The primary blame lies not in Tallahassee, however, but in Washington. Because their illness prevents them from obtaining private insurance through employment, many people with severe mental illness rely on Medicaid to pay for their treatment. For every dollar Florida spends on Medicaid, the federal government reimburses more than 56 cents — unless the patient is between the ages of 21 and 65 and treatment is in a psychiatric hospital or other “Institution for Mental Diseases” (IMD).

The IMD exclusion to Medicaid unfairly discriminates against patients solely on the basis of their diagnosed psychiatric disorder.

States such as Florida fill the financing gap created by the IMD exclusion by relying on Medicaid’s “Disproportionate Share Hospitals” (DSH) payments for hospitals providing care to a “disproportionate share” of poor or indigent patients. But Florida’s DSH payments have been trimmed some $47 million per year from 1998 to 2002. Rather than picking up the entire tab for state psychiatric hospital care, Florida is proposing to close 350 beds that are used to treat the most severely ill.

The IMD exclusion created an incentive for Florida and other states to empty their psychiatric hospitals and provide “treatment” in general hospitals to save money. Although care of the severely mentally ill in general hospitals costs as much as $300 per day more than in state psychiatric hospitals, it costs less to the state because treatment is reimbursable with federal Medicaid dollars.

Unfortunately, general hospitals are ill-equipped to provide long-term treatment for severe mental illnesses. And having fewer beds available to treat those who are acutely ill means that the psychiatrically ill are quickly released to the streets, where many fall through the cracks and receive no treatment whatsoever. This lack of treatment ultimately costs society more not less.

Today, a person in Florida with severe mental illness is five times more likely to be behind bars than receiving treatment in a state hospital. Based on national statistics, there are at least 15,870 inmates in Florida’s jails and prisons who are mentally ill. The Miami-Dade County jails alone hold nearly 1,000 mentally ill inmates. Many of these individuals are locked up because of behavior caused by their untreated illness.

There are an estimated 150,000 to 200,000 mentally ill homeless in the United States, three times the number who are receiving treatment in state psychiatric hospitals.

Medical research has established that severe mental illnesses such as schizophrenia and manic-depression are physical diseases of the brain. They are no more the fault of the sufferer than is Alzheimer’s disease, Parkinson’s disease or multiple sclerosis — yet federal Medicaid does not accord them the same level of care.

By eliminating Medicaid IMD exclusion’s discrimination against the severely mentally ill, we can assure that treatment in a psychiatric hospital will be available for those who need it. Providing appropriate treatment is not only humane, it saves the taxpayer money.