The Lunacy of Our Mental Health Policy

MEDICAID1-master675An institution for mental diseases (or, “IMD”) is defined as, “a hospital, nursing facility, or other institution that is primarily engaged in providing diagnosis, treatment, or care of persons with mental illness, including medical attention, nursing care, and related services” (42 U.S.C. §1396d(i)).

Last week the New York Times ran an article addressing the infamous Medicaid IMD exclusion: the culmination of state and federal policies dating back to the 19th century up to and including the Medicare Catastrophic Act of 1988, in which an IMD was infamously defined as a facility with more than 16 beds.

The apparent intent at that time was to promote small, community-based group living arrangements as an alternative to large institutions. But what has resulted is that Medicaid covers mental health treatment for a large percentage of people with Medicaid, but that coverage is excluded for inpatient treatment of adults aged 21 to 64 in any acute or long-term care institutions with 17 or more beds that are primarily engaged in providing treatment for mental illnesses. This is what is known as the Medicaid IMD exclusion.

Another indirect consequential reality of the IMD exclusion is what’s known as psychiatric boarding. The 1986 Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals participating in the Medicare program to provide a medical screening examination of any person presenting to its emergency department regardless of the ability to pay.  For psychiatric emergencies, an individual expressing suicidal or homicidal thoughts or gestures, if determined to be dangerous to themselves or others, the hospital must either provide treatment until their condition is stabilized – or transfer that person to an inpatient facility where the person can be treated until the condition is stabilized.

But there’s the rub: since so many individuals with mental illness (and addiction is considered a mental illness) are Medicaid patients there are very often limited alternatives for transfer.  Thus those patients tend to stay in emergency departments longer than necessary – an expensive consequence because of the cost intensive nature of ED’s. Communities work hard to develop informal diversion relationships to try and address the issues and challenges this creates: but their time could be better spent – like on improving patient care.

Section 2707 of the Affordable Care Act, Medicaid Emergency Psychiatric Demonstration, is a three-year pilot program that permits non-government psychiatric hospitals with more than 16 beds to receive Medicaid payment for providing EMTALA-related emergency services to Medicaid recipients aged 21 to 64 who have expressed suicidal or homicidal thoughts or gestures, and who are determined to be dangerous to themselves or others.

But this only addresses specifically-defined crises and will take a long time to be tested, evaluated and debated. It does not address the epidemical crisis we face as a nation with heroin addiction. So even though 26 states have willingly or unwillingly embraced Medicaid expansion under the ACA, many of the individuals needing inpatient treatment for addiction will be unable to receive that treatment.

A recent study published by researchers at the Boston Medical Center in the JAMA Internal Medicine Journal  reaffirmed the importance of combining inpatient and outpatient treat of heroin addiction. From the NYT article: for many suffering with heroin addiction, “there is an undeniable and essential need for residential treatment,” said Allen Sandusky, the South Suburban Council’s chief executive in Chicago.

Study after study has demonstrated that substance abuse treatment and rehabilitation is less expensive than incarceration as an alternative to addressing individual addiction and alcoholism. At the same time, economies of scale driving greater efficiency and lower program costs in facilities that allocate overhead over a larger number of beds is just economically intuitive.

When all these considerations are taken together with the skyrocketing costs associated with increasing crime and the burden being placed on community first responders as a direct result of the heroin epidemic it would seem like the biggest no-brainer in the history of earth is to legislatively repeal the IMD exclusion. Thus be to the ignominious wasteland that is Washington, DC.

At a time when communities across the country are scrambling to address a heroin epidemic that is literally destroying those communities and the families living there Congress is focused on a lawsuit against the president (the House) and an irrationally urgent need to reverse the Supreme Court’s innocuous Hobby Lobby decision (Senate). Shameful, truly shameful. Even more so than usual.


Photo credit: Armando L. Sanchez for The New York Times

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