Psych ER Fills Gap in Mental Health Care

Oct. 20, 2003 -- Another casualty of a health care system in crisis, mental health hospitals across the country face widespread cuts and closings that have shrunk inpatient care, clogged emergency facilities, and diluted the quality of care available to the growing legions of uninsured.

Yet an unlikely bright spot shines in one of Southside Chicago's toughest neighborhoods.

Englewood — plagued by poverty, wracked by crime, and, according to former district police commander Maurice Ford, home to the largest number of mentally ill in the state — has only one hospital. That hospital, St. Bernard, boasts a specialized psychiatric emergency room, newly built in 1996, and featured on Nightline Monday night.

While the majority of the nation's psychiatric emergencies are handled in general emergency rooms, separate psychiatric ERs give uninsured patients direct access to care. Federal legislation enacted in 1986 — EMTALA, the Emergency Medical Treatment and Active Labor Act — bans any emergency facility from turning an uninsured patient away.

According to Mark Tryba, director of mental health services at St. Bernard Hospital, having "a separate ER for pysch patients really affords them the respect and dignity that all patients are entitled to."

A general emergency room can be a chaotic place for the mentally ill, but a specialized facility can offer them privacy and security hard to come by in a general ER, Tryba says.

Intended as a "pit stop" or elaborate triage to sort and funnel patients into a psychiatric hospital or back out into the world, the psychiatric emergency room increasingly plays the role of primary caregiver — most often to the uninsured, or to admitted patients awaiting transfer to shrinking psychiatric inpatient units increasingly unable to accept them. The busiest psychiatric ERs treat more than 7,000 patients a year.

Deinstitutionalization and the Psychiatric ER

Roughly one-third of community hospitals surveyed by the American Hospital Association (AHA) in 2001 reported offering psychiatric emergency services.

According to Dr. Ron Manderscheid, chief of survey and analysis at the Center for Mental Health Services, "the large use of ERs by mentally ill persons has come about in the modern era of homeless mentally ill populations."

This group bulged in size, largely due to a deliberate process of "deinstitutionalization" first begun in the 1950s. A patient's best interest, mental health experts then agreed, was served not so much by long-term residential care, as by community outpatient treatment. As a result, the number of resident mental health patients in the U.S. dropped from 559,000 in 1955 to only 54,000 in 2000, Manderscheid reports.

But the community outpatient care system that mental health providers had hoped to build failed to blossom. A federal grant helped construct about 750 new community health centers between 1963 and 1978; but when the Reagan administration converted remaining funding into block grants to states, most opted to finance currently existing mental health centers, rather than build new ones. According to Manderscheid, the envisioned community mental health system "froze at that point in time."

The psychiatric ER stepped in to fill the gap in community mental health care. Variously described as a place patients choose over prison or a homeless shelter, or where social service agencies "dump" their toughest cases, the psychiatric ER can play a recurring role in a patient's behavioral pattern or disease cycle and is often the last line of defense for repeat patients known as "frequent fliers."

As deinstitutionalization continued, releasing many of the mentally ill to their hometowns, large numbers discovered they lacked families and communities willing or able to care for them. Now homeless, unemployed and uninsured, any health crisis brought them to the steps of the ER — the one place that cannot turn them away.

Insurance Inequities

The expense of providing free care to the uninsured at the ER is made worse by the fact that reimbursement rates for those who do have insurance fall far below rates paid to reimburse the treatment of other diseases. For example, the Medicare co-pay for mental health care is 50 percent, while it's only 20 percent for most other outpatient treatments.

This institutional bias against mental illness has persisted for 40 years, Manderscheid says. Insurance companies, reluctant to crack open a perceived Pandora's box, fear that mental health could become "a black hole for money."

The push for parity in mental health insurance has won political backers like Sen. Pete Domenici, R-N.M., whose daughter's mental illness has motivated him to stick with a long congressional fight for more equal reimbursement.

From Bloated Co-Pay to ER Clog

Reimbursement imbalances directly affect psychiatric emergency care, forcing inpatient units to often operate at a loss that can drive them out of business. In 1998, approximately 1,775 general hospitals had separate psychiatric inpatient units, offering a total of 54,434 beds. Just two years later, this had decreased 25 percent, to 40,809 beds in 1,325 hospitals, Manderscheid notes.

Between 1992 and 2000, closures furthermore caused a 29 percent drop in the number of state mental hospitals, and a 38 percent decline in the number of private psychiatric hospitals, according to the National Assocation of Psychiatric Health Systems (NAPHS).

This loss of beds leads to the related, Hydra-like boom in admissions at the jammed facilities that remain. In these places, psychiatric inpatient occupancy rates jumped nearly 20 percent between 1996 and 2001, the NAPHS says.

The patient overflow spawned by such cuts and closings can clog the ER indefinitely. Many psychiatric ERs suffer severe overcrowding, mirroring a broader trend in emergency medicine. Generally, 62 percent of hospitals and 90 percent of large hospitals surveyed by the American Hospital Association in 2000 reported being "at" or "over" operating capacity; one-third were forced at times to turn incoming ambulances away.

The average wait time for transfer to a psychiatric bed ranged from 2.2 to 4.7 hours — time elapsed after the patient's evaluation was completed and the transfer ordered.