By Alex Kacik and Caroline Hudson
Medical associations, patient advocates, public health organizations and health systems are asking for federal and state help to address the escalating number of mental health patients seeking care at hospital emergency departments.
Patients are being held in emergency departments for as long as months as they await psychiatric beds. Many outpatient referral partners have cut back or are struggling with staffing. The patient burden is straining ill-equipped hospitals, taxing already overburdened staff and delaying care.
The system is cracking in a demonstration of the mental healthcare safety net's systemic failings, the American College of Emergency Physicians and 30 other industry groups wrote in a letter sent to the White House on Wednesday. Absent short- and long-term regulatory and legislative fixes, mental healthcare will continue to decline amid rising COVID-19 cases, flu season and the respiratory syncytial virus outbreak, said Dr. Christopher Kang, president of the emergency doctors' organization.
“The system is at a breaking point. The mental health crisis is tantamount to the [COVID-19] public health emergency,” Kang said. “Everybody across the industry needs to come together. Otherwise, there will be irreparable harm.”
Health system executives and industry groups are lobbying for higher Medicaid reimbursement rates, relaxed medical malpractice laws and broader scope-of-practice laws, among other potential solutions.
“There is no single, magic bullet,” Kang said.
Health systems are scrambling to find workarounds as emergency department boarding times for mental health patients climb.
In Massachusetts, half of mental health patients arriving at emergency departments were there for at least 12 hours as of June, according to data from the commonwealth's Massachusetts Health Policy Commission and Center for Health Information and Analysis. That was up from 38% in January 2020.
“Being able to connect those patients to a setting more attuned for behavioral healthcare—which is not the emergency department—has been challenging,” said David Seltz, executive director of the commission. “We have growth in behavioral health beds in Massachusetts, which is great progress. The challenge, though, is being able to staff them.”
Many health systems are expanding inpatient psychiatric capacity to accommodate the surge of mental health patients coming to their emergency departments. But they are limited by a dearth of mental health professionals and a shrinking referral network of outpatient providers.
Massachusetts General Hospital in Boston, for instance, had to expand to accommodate the growing number of children and adults going to its emergency department for mental healthcare.The facility replaced its six-bed psychiatric unit with a 20-bed unit, but that is still often insufficient, executives said.
Northwell Health, a New Hyde Park, New York-based nonprofit system with 21 hospitals, has been trying to redirect patients to urgent care facilities with mental health providers on staff. Similar to other health systems, Northwell Health is integrating mental health services into primary care visits. CEO Michael Dowling said he is also trying to raise money for an adolescent mental health facility that would complement its children’s hospital.
“Our overall infrastructure in mental health is lacking. The capacity is lacking, the staffing is lacking, and that has to be a major focus for all of us,” Dowling said. “It is much worse now than it was. The adolescent piece is one area we are really focusing on.”
In Wisconsin, Children’s Wisconsin hospital in Milwaukee, Glendale-based Ascension Wisconsin, Froedtert Health of Milwaukee and Downers Grove, Illinois-based Advocate Aurora Health entered into a joint venture with Milwaukee County to open an $18 million psychiatric emergency facility in September.
Behavioral health services previously were less centralized. The county subsidized half the cost and each health system contributed 12.5%. The emergency department could potentially house up to about 25 adults and 10 children if pushed to capacity, said Joy Tapper, executive director at the Milwaukee Health Care Partnership, a public-private coalition that promotes healthcare access for low-income and underserved patients.
Tapper estimated the new facility can handle 8,000 to 10,000 patients a year. There are six licensed inpatient beds, she said, but they are used to stabilize patients and prepare them for transfers to other facilities.
The Milwaukee center, although more cost-efficient than hospital emergency departments, is already projecting a $12 million to $13 million annual operating loss because reimbursements for the majority-Medicaid population are not keeping up with the cost of care, Tapper said. Higher-acuity cases and staffing shortages add to the strain, she said.
“We are seeing significant capacity limitations in Milwaukee County and across our state for inpatient beds in general for both voluntary and involuntary patients,” Tapper said. “This mental health emergency center is one piece of a broader redesign plan...focused on prevention and early intervention in the community.”
Milwaukee County strives to grow its program for mobile crisis teams, which are deployed to de-escalate situations and connect patients to care before they reach emergency departments, Tapper said. The county wants to pair crisis teams with law enforcement, build more short-stay, behavioral health crisis resource centers, and embed crisis staff in walk-in clinics, she said.
Treating children with behavioral health issues adds challenges. Many of those patients don’t belong in emergency departments but have nowhere else to go. Families are overwhelmed.
More behavioral disturbances also occur when children get bored in facilities not designed for them, said Dr. James Rachal, medical director of behavioral health at Charlotte, North Carolina-based Atrium Health.
“If you’re depressed, have insurance, those people are actually able to find beds fairly easily,” Rachal said. “It’s the more complex behavioral patients and the ones without a payer source...[who] shouldn’t be in the emergency room. They should be in the community, but it’s just there’s no housing for them.”
The situation contributes to staff burnout and, in some cases, injuries. Providers are pushing for more respite beds or urgent care locations that can accommodate overnight stays.
Longer term, more group or foster homes are needed, plus better therapy services on the front end, Rachal said. Several years ago, Atrium Health launched a program to help young patients navigate their first psychotic breaks. Providers work with patients and their families to keep them working, in school and/or building social relationships, which is tough but doable with proper support, he said.
Health system executives and industry groups want regulators and lawmakers to consider easing regulations, incentivizing partnerships and expanding graduate medical education funding.
Federal tort legislation could be modified for certain circumstances to limit providers’ legal liability, Kang said. For instance, physician assistants may be exposed to legal risks as they evaluate mental health patients in waiting rooms, he said.
State regulators could support alternate behavioral health treatment sites, Kang said. “We need to find additional partners and promote sectors like social work."
Monument Health, a five-hospital system based in Rapid City, South Dakota, has a 54-bed behavioral health hospital that is practically full every day because it is one of the only facilities of its kind in its five-state region, CEO Paulette Davidson said.
The health system developed a public-private partnership with Pennington County, South Dakota, officials to build a 16-bed crisis stabilization unit. Law enforcement officers can bring someone in crisis to this facility, where they may remain for up to five nights, rather than to an emergency department.
“We're seeing more children, adolescents and adults seeking acute mental healthcare services in our emergency rooms, especially with the effects of the pandemic,” Davidson said. Roughly 1 in 4 patients come in with mental health issues, she said. The government should incentivize other public-private ventures, she said.
More medical students need to pursue mental health professions to meet the demand, executives said. Medicare pays teaching hospitals to offset resident training costs via graduate medical education funding. Typically, Medicare caps the number of residents it will finance per hospital based on how many residents it funded in 1996.
Medicare should remove those caps for mental health providers, said Marty Bonick, president and CEO of Ardent Health Services, a 30-hospital system based in Nashville. Tennessee. “Physician caps on graduate medical education programs need to be addressed,” he said.
Because Medicaid pays for most mental healthcare services, reimbursement rates need to increase, Dowling said. “We built a new psychiatric hospital a couple years ago, but the reimbursement doesn’t suffice so we have to cross-subsidize,” he said. “If there is going to be an answer for the mental health issue, we need to do something with Medicaid reimbursement.”