[Hpn] Milwaukee, WI - Cuts spark crisis in mental health - Milwaukee Journal Sentinel - Dec 07, 2003

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Cuts spark crisis in mental health

Experts see treatment void, delays
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Meg Kissinger - Milwaukee Journal Sentinel - Dec 07, 2003

The elimination of a substantial number of hospital beds for
acutely ill psychiatric patients in Milwaukee County over the
past several months is creating a crisis in mental health care
here, doctors, nurses and health care administrators say.
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Quotable:
"I wonder if we won't see more suicides."
- Martha Rasmus, director of the Mental Health
Association in Milwaukee County
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With fewer places to go for treatment, many of the sickest
patients are ending up in jail or homeless shelters, where
they are unlikely to get any help, administrators at those
places say.

The county has cut the number of beds for patients with
acute mental illness by more than half over the past 10
years, with the notion that private hospitals would care for
such patients. Private hospitals have cut back, too.

But in the past two months, Aurora Sinai Medical Center
eliminated its 23-bed psychiatric ward. And St. Michael
Hospital, which continues to administer a 23-bed psychiatric
unit, stopped taking referrals of psychiatric patients who
were being detained by the county on an emergency basis.

That adds up to roughly 300 patients a year.

Sinai administrators said reimbursement by the government
for mental health care services was not enough to cover
their costs.

James Gresham, president of behavioral health
for Covenant Healthcare, which runs St. Michael, said the
decision to not take referrals from the county was both a
financial one and a concern that those patients did not mix
well with the hospital's current profile of patients.

Patients who are involuntarily detained are, by definition,
a danger to themselves or others.

"The ripple effect is huge here," said County Executive
Scott Walker.

"The decision to abandon these patients is not made in a
vacuum. We're seeing it trickle down all over the place."

He predicted that some patients would go to the emergency
rooms of private hospitals to receive care.

Kenneth Smail, a psychologist who contracts with the county
to evaluate criminal defendants on their ability to stand
trial, says he has seen a steady increase over the past few
years in the number of people in the jail who have
significant mental illness.

"Clearly, there is a link with the diminishing number of
services available," Smail said. "These people don't just go
away."

Likewise, directors of various homeless shelters throughout
Milwaukee County say they have seen a rise in the number of
homeless people who are chronically and persistently
mentally ill.

"We are seeing it getting worse," said Holly Gardenier,
executive director of the Guest House, a shelter that houses
76 men a night.

Stretched thin James Hill, the interim director of
behavioral health for Milwaukee County, acknowledges that
the county's in-patient mental health care system is
stretched seriously thin as a result of the recent cutbacks
by the two private hospitals.

"They can walk away, but we can't," he said. "We have a
mandate to take care of those people, and we will. But it is
creating a tremendous strain."

Hill and others say they worry that the money needed to
staff the in-patient wards at the county facility could
affect the quality of care at the county's community-based
mental health care facilities.

"You squeeze one place, it shows up someplace else," Hill
said.

Doctors and nurses report that it is now typical for 30 or
more patients to be housed in one of the county's
psychiatric wards built to serve 24 people.

With no staff added to accommodate the increase, patients
are having to wait longer to be treated and are routinely
dismissed before they would otherwise be in order to make
room for newer patients. The wait for out-patient services
is getting longer, too.

"It used to be that we would release a patient with an order
to go see another doctor the next day. Now, some of these
appointments are six or seven weeks down the road," said
Clarence Chou, medical director of the county's Child and
Adolescent Treatment Center who has worked there for more
than 20 years. "Sometimes, you just cross your fingers and
hope for the best."

Reimbursement worries Hill and others say the problem is
rooted in the federal government's Medicaid system, which
reimburses hospitals for the care of people without private
health insurance.

Typically, it costs between $600 and $800 a day to care for
a psychiatric patient in a hospital. Medicaid usually covers
75% of that, Hill said.

Further exacerbating the county's situation is a provision
in the Medicaid law that prohibits reimbursement for
patients between the ages of 21 and 64 who are treated at
free-standing psychiatric hospitals such as the county's
mental health complex in Wauwatosa.

So the county pays all of the cost of treating those
patients who do not have private health insurance. Many
people with chronic and acute mental illness do not have
insurance because they cannot work, Hill said.

Last year, the county spent more than $1 million for acute
in-patient care at the mental health complex, Walker said.

The cost is expected to be substantially higher because St.
Michael, which could get Medicaid reimbursement, is no
longer treating patients brought in on emergency detentions.

That cost will now fall to the county without any chance for
reimbursement for those patients without private
insurance.

"This is exactly a step backwards of what we need to do,"
Walker said. "We had been trying to work out a deal with St.
Michael to assume even more of a role in treating the
county's patients. We were even talking about having some of
our employees work over there. Once Aurora Sinai pulled out,
we had a bad feeling that St. Michael would follow. And they
did."

Gresham said St. Michael is working to expand its role in
treating psychiatric patients.

"The issue is not between the county and private non-profit
hospitals. It's between the county and the federal
government on this issue of reimbursement," he said.

The county has long had a philosophy of moving patients out
of the most restrictive setting into a community-based
program. That model is considered better therapeutically and
more cost-effective. Since 1993, the county has cut the
number of in-patient beds for acutely ill adults from 210 to
96.

The model made sense only if there were enough beds to care
for the small percentage of patients with mental illness who
require acute in-patient care, said Jon Gudeman, former
medical director at the Milwaukee County Mental Health
Complex and now director of the Center for Psychotherapy at
Columbia-St. Mary's, Columbia Campus, and a professor of
psychiatry and behavioral medicine at the Medical College of
Wisconsin. Gudeman helped design the current model.

But he is troubled with what he sees happening now.

"We have a crisis all right," he said. "The pendulum has
swung too far. We now have too few beds to effectively treat
the sickest of our patients."

Coordination called crucial Gudeman says there is a lack of
accountability in the public health care system.

"This is an extremely fragmented system, and, therefore, a
number of people are falling through the cracks," he said.

Hill, the interim administrator, agrees that there is not
enough coordination of services. "We need to do a much
better job coordinating with those who care for the
incarcerated with severe and persistent mental illness,"
Hill said.

Advocates for people with mental illness say they are
concerned about the crowding and the lack of adequate
hospital beds.

"I wonder if we won't see more suicides," said Martha
Rasmus, director of the Mental Health Association in
Milwaukee County.

Walker said he was trying to get together a team of
administrators from various health care organizations to try
to solve the crowding and a lack of services.

"This is a system-wide problem, and it is going to need a
system-wide solution," he said.

"We can't just turn our back on these people."

MEG KISSINGER mkissinger@journalsentinel.com
Milwaukee Journal Sentinel source page: http://tinyurl.com/y8v9
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