By MEG KISSINGER
mkissinger@journalsentinel.com
Last Updated: Dec. 7, 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.
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."
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."
