Thursday, May 17, 2007

15 or 16, but Not 17 – the Medicaid Numbers Game

Plug “16-bed” and “psychiatric” into Google and you will get over 26,000 results.

Hit on the first one and you’ll see that a full-time LPN is needed for the inpatient unit of a 16-bed psychiatric hospital in Muncie, Indiana. Delve further to find that a new 16-bed inpatient unit specifically dedicated to women’s mental health treatment opened in Westport, Connecticut last year. Also see that among the goals of an Arkansas provider is funding for four regional 16-bed adult inpatient facilities, one for each corner of the state. There will also be a link to a recent Associated Press story detailing that emergency rooms in New Orleans are flooded with psychiatric patients. One afternoon in one hospital, “18 of the emergency room's 23 beds held patients waiting for admission to a psychiatric ward.” A hospital spokesman commented that creating “a 16-bed psychiatric ward” would take months.

Doing the same search using “15-bed” yields a similar number (more than 20,000) and mix of items, but the results for “17-bed” are startling. There are only 681 results and most of them are links like those you sifted out in the other searches, ones where the two search terms appear to have only coincidentally been on the same page. You find out information like that there is a just-opened inpatient transitional medical care unit for patients in New Jersey with 17 beds. What 17-bed mental health care units there are mostly specialize in the care of children and adolescents or geriatric patients.

There are exceptions, such as a 17-bed medical/psychiatric unit attached to the University of Kentucky Hospital, but the conclusion is undeniable – there is a scarcity of 17-bed psychiatric facilities. The reason why, not surprisingly, comes from Capitol Hill.

The large majority of inpatient psychiatric care is paid for by either Medicaid and Medicare. The federal government reimburses states for a portion – typically one half or more – of the cost of the psychiatric care provided for people covered by these programs. When these governmental insurance programs where drafted and passed in 1965, care in “institutions for mental diseases" (IMD) was specifically excluded from Medicaid reimbursements to essentially force deinstitutionalization.

There are exceptions to this repayment prohibition; reimbursement is available for inpatient care rendered for minors and those over 65, in facilities where psychiatric treatment is given to less than half the patients, and in psychiatric hospitals of 16 patients or less. After forty years of operation, these artificial policy incentives have haphazardly sculpted the framework of inpatient mental health care – hundreds of hospitals have closed, juvenile care is largely unaffected, psychiatric patients have been increasingly mixed (albeit in a proportion less than 50%) into adult-care homes, and 17-bed psychiatric facilities are distinctly not en vogue.