In a recent issue of the NAMI Westside-LA newsletter, I wrote an editorial about the revolving door policy of many psychiatric wards. NAMI members know that it is usually difficult to get a relative placed on a 72-hour hold. If your relative is mentally unstable and would benefit from hospitalization, and doesn’t want to hospitalize himself, he or she needs to demonstrate that they are a danger to themselves or others, or are gravely disabled (i.e., unable to care for themselves), when the police or the psychiatric mobile response team responds to your call for help. If your relative is able to hold it together for minutes, long enough to satisfy inquiries of authorities, nothing will be done. Often concerned caregivers have to call several times in order for the responding police and/or mental health workers to see the full, florid illness at work.
Once someone is taken to the hospital, s/he is all too often released before there is any improvement in his condition. Some people refuse medication; others are medicated and yet remain psychotic. It’s not uncommon for a person who is clearly psychotic to be deemed by the hospital to no longer meet the criteria to remain in the hospital, i.e., no longer gravely disabled or a danger to themselves or others. The frequency with which this occurs led me to wonder whether there was a financial incentive to turn over psych beds, whether hospitals earned more from new admissions than they did from the same patient remaining in the hospital until their condition actually improved.
Now Cedars Sinai Medical Center has decided to close its psychiatric unit completely. They will use these beds for other purposes. This is part of a disturbing trend: California has gone from roughly 8,500 acute in-patient psychiatric beds, to 6500 in the last 15 years, according to the California Hospital Association.
The question is why? The need clearly hasn’t diminished. So why are psychiatric beds so much less valuable than beds of another sort? I know nothing about the economics of hospitals, but I posed this question to someone who does, a psychiatrist who was able to explain the economics to me. And the answer was stunningly simple.
Hospitals, he said, make money from tests. You come into the emergency room with any ailment, and you can’t get out without, at the very least, a battery of blood tests. At a minimum. Maybe you’ll get a PT scan, a CT scan, an x-ray, an MRI. And then, if you’re admitted, you’re sure to have a number of other tests. Blood tests daily. Other, more sophisticated tests.
But if you come into the emergency room in a psychotic state no one needs to test your blood—and often no one can corral you long enough to do so even if they’d wanted to. If you have a mental illness, there is little the hospital can do for you but give you medication—if you’ll consent to take it—and wait for the medication to take effect.
So, since no tests are necessary, less money is made. And since a hospital can make more money giving that same bed to someone with a pain in his stomach, his back, his arm, his leg, his foot, his hand, his head, why should a hospital “waste” a bed on an under-tested psych patient?
It makes economic sense, but what is the logical end to this? Do we abolish psych wards? Then what? The emergency response teams won’t even come out to our homes unless there is a bed in a psych ward available, in case our relative may need it.
So now, when our relatives are in need of involuntary holds because they are violent, are we supposed to wait until they commit actual crimes, and then call the police? Have we as a society decided that our relatives aren’t worth what it would cost to put them in a hospital until they are stabilized? That it is expedient to put them instead in jail?
And doesn’t that make mental illness–de facto–a crime?
Who knew that insurance companies, by their reimbursement policies, could essentially make laws?
Who thinks that’s a good idea?