Mental Health System Inadequate for Patients

They’re going without treatment or medication for months at a time, waiting in a legal limbo until somebody finds a place for them. They’re reaching out to community centers for help, only to be denied the services they sorely need. They’re sick, suffering and stigmatized.

They’re Arkansas’ mentally ill, and they’re trapped in a vicious cycle of federal regulations, legal requirements and limited resources.

Ask anyone involved, and they will tell you that the state’s mental health system is at the boiling point, ready to bubble over into an unwieldy mess. Criminal defendants are languishing in county jails, unable to seek court-ordered mental evaluations or treatment at the State Hospital because of a shortage of beds and nurses. Community mental health centers are coping with huge slashes in Medicaid funding, in part due to recent state budget cuts and a new managed care system.

And private hospital officials are restructuring their psychiatric wards — or closing them altogether as Springdale’s Northwest Medical Center of Washington County did on April 22 — because they can’t afford the financial burden of caring for uninsured patients.

“The mental health system in the state of Arkansas is in shambles, frankly,” said Don Adams, vice president for the Arkansas Hospital Association. “The state has failed to step up and provide needed mental health services as a safety net to those who can’t get access to care any other way.”

State Rep. Jay Bradford, D-White Hall, calls the situation “a stick of dynamite with a real short fuse.” During the last legislative session, he ushered the passage of Act 1589, which mandates $11.5 million in state aid to treat the mentally ill. Unfortunately, the law has yet to be funded — a fact that led directly to a class-action lawsuit filed last summer by the Arkansas Chapter of the American Civil Liberties Union against law enforcement and State Hospital officials.

Arkansas’ Nightmare

The lawsuit, James Terry v. Richard Hill, was heard in December and ruled on May 6 by U.S. District Judge Stephen M. Reasoner in Little Rock. The suit is based on an Arkansas constitutional amendment requiring treatment for the mentally ill and represents all mentally ill inmates in Arkansas’ 75 county jails. These inmates aren’t convicts; they’re just waiting for one of the State Hospital’s beds to become available so that they can receive either a standard 30-day inpatient evaluation after an insanity plea or mental health treatment after a judge has declared them incompetent to stand trial.

Reasoner wrote that the state has “been deliberately indifferent to the needs of pretrial detainees [who] are ordered to receive mental health evaluations or treatment.” He added, “the length of wait experienced by inmates today is far beyond any constitutional boundary.”

Therefore, Reasoner ruled that the state’s practice of letting mentally ill criminal defendants waste away in county jails is unconstitutional and must be remedied. He ordered a June 10 hearing for the court to explore ways to improve the situation.

The initial plaintiff, James Terry, was held for almost a year in the Sebastian County jail without getting medication or treatment for a psychotic disorder. He was put in isolation several times, and guards used a ‘stun gun’ on him when he exhibited bizarre behavior. Another plaintiff, Scott County inmate Howard Erler, attempted suicide three times while living in a filthy cell. And Independence County prisoner Hugh Oyler bit off part of a deputy’s ear, tried to castrate himself and regularly threw his food into the toilet.

“Trying to treat these people is a nightmare,” said Chief Deputy Skipper Polk of the Pulaski County Sheriff’s Office. “Not only do they need meds, but you also need social workers working with them.”

Joe Quinn, spokesman for the Arkansas Department of Human Services, said the department is well aware of the State Hospital’s problems.

“The reality is, it’s a pretty straightforward issue,” he said. “We have a finite number of beds, and we have a constant backlog of people who need those beds.”

Finite indeed. In fact, Arkansas has fewer beds devoted to the mentally ill than almost every other state in the nation, said Kenny Whitlock, executive vice president of the state’s Mental Health Council.

‘Pushed to the Limit’

Although the State Hospital holds 186 beds, only 90 currently are being used. The problem? A chronic, severe nursing shortage, stemming in part from low wages, inadequate training and long overtime hours.

Reasoner pointed out in his ruling that the state hospital is actually licensed for 315 beds. A “licensed bed” means a bed that is staffed with nursing, psychiatric and psychology services. But, he added, the cost for one licensed bed per day is $400.

A February 2001 survey by the Center for Medicaid and Medicare Services found the vacancy rate for all nursing positions at the State Hospital was as high as 33 percent, with only 25 percent of the staff receiving some psychiatric training. One nurse told the surveyors: “We are pushed to the limit. We’re managing now, but it’s close to collapse.”

The survey further found that eight temporary nurses had made “serious and/or multiple medication errors” between April and December 2000. Although four of those nurses were fired, another 28 medication errors were reported in May 2000.

Richard Hill, the main defendant in the ACLU lawsuit and the director of the state’s Division of Mental Health Services, which oversees the State Hospital, testified in December that the nurses’ salaries had increased and that a new 16-bed unit was scheduled to open at the beginning of 2002.

Until then, the State Hospital is forced to place forensic patients in rooms with those who haven’t committed any crime but suffer from a mental illness. “It’s sometimes not a good mix,” hospital administrator Glenn Sago said, adding that they’ve seen increased violence because of this arrangement.

It didn’t help the hospital when computer problems interfered with about $700,000 in federal funding last year. The billing system crashed, and the subsequent six-month-long conversion to new software led to a slowdown in the facility’s ability to collect unpaid Medicare and Medicaid money.

Domino Effect

The state’s 15 community mental health centers once were able to help ease some of the State Hospital’s backlog by contracting with local hospitals, but that’s quickly becoming less of an option. In the mid-1990s, mental health center officials were given $7.5 million in state funds to admit their patients locally and keep them out of the State Hospital — a system that worked really well, said Jim Gregory, director of Benton’s Counseling Clinic Inc., given Arkansas’ rural nature.

But the state giveth, and the state taketh away; $5 million of those funds were abruptly withdrawn about six years ago and put toward other programs. Gregory said clinics like his continued paying local hospitals to admit their patients, even though they were no longer contractually obligated to do so.

“We kept trying to do what we could, as long as we could afford to do so, because we didn’t have any other options,” he said. “When you’ve got somebody that’s staring at you at two o’clock in the morning in the jail or in your local emergency room, and they don’t have a pay source, and you know they’re psychotic and that there’s a risk factor involved, you find it real difficult to not do what you’ve been doing.”

So the clinics continued eking out payments for local hospitalizations for a few more years until they were hit with another blow. The Department of Human Services changed the way Arkansas’ Medicaid funding is administered by putting it in the hands of a managed care company that requires prior authorization from a Nashville, Tenn.-based company. The limits to revenues and services were almost immediate. In the first year alone, community mental health centers saw a $6 million reduction in Medicaid funds.

Gregory said he’s avoided staff layoffs so far by not replacing departing employees, but other centers haven’t fared as well. Benton-based Birch Tree Communities, which has about 300 mentally ill patients in group homes and apartments across the state, has laid off more than 70 staff members, and CEO Tucker Steinmetz said the company is struggling to sustain its level of treatment.

Whitlock said Medicaid funding has decreased 40 percent in some centers, while the new system also requires significant increases in administrative costs.

“The result of this managed care decision has been to reduce the amount of funding for community mental health to the point that services we have come to expect cannot be continued in this environment,” he said.

The recently proposed cuts to Arkansas’ Medicaid budget may turn out to be the proverbial straw. “If those cuts to Medicaid go through as they are planned this April, there may be some mental health centers that won’t be here next year,” Gregory said. “I don’t know if we’re going to be one of them, but it certainly is frightening. We’ve never faced anything like what we’re facing now — ever.”

Neither have officials at private hospitals, who say they’re going broke treating the mentally ill.

Bearing the Burden

Three years ago, a private hospital’s unreimbursed costs for treating the mentally ill were so slight, they weren’t even worth tracking. Now, administrators in 14 hospitals report shouldering about $9 million in uncompensated care in 2000; and in the first six months of 2001, the burden was already more than $7 million. To make matters worse, federal regulations require hospitals to stabilize anyone appearing in the ER, including the mentally ill.

“If no beds are available at other institutions equipped to care for the mentally ill, then the hospital with the patient must keep him safe until he can be transferred,” Adams said. “This requires the hospital to expend enormous resources to keep the patient, the staff and the public safe while the mentally ill person is in their care.”

Adams said hospitals often must put the mentally ill person in an acute care bed and devote one-on-one care until he or she can be transferred.

“This is an enormously expensive way for the hospital to provide care for which there is no reimbursement,” he said. “It is literally breaking the financial backs of some hospitals.”

Freestanding clinics, some of which are affiliated with a hospital, also are in a bind. Neither Medicaid nor Medicare pays for hospitalization unless the care is for patients under the age of 21 or over the age of 65. It’s a regulation that’s causing many clinic administrators to consider shifting their emphasis to these age groups to capture Medicaid revenues and stay afloat.

Northwest Medical Center of Washington County ended inpatient psychiatric services in April at its 20-bed “Highland Hall” psychiatric ward. A subsidiary of publicly held Triad Hospitals Inc. of Dallas, the Springdale hospital cited the following reasons for discontinuing its mental health services:

• An increased severity in psychiatric-patient illness has resulted in violent situations involving Northwest Medical Center staff.

• An increased population of seriously ill patients is seeking care in Northwest Arkansas.

• 75 percent of the psychiatric inpatients at the hospital are uninsured or use Arkansas Medicaid.

Bill Bradley, Northwest Health’s CEO, said the hospital delayed the decision as long as possible. About 30 employees staffed “Highland Hall.”

“We hoped that the state would be able to muster resources to address the current system’s shortcomings,” Bradley said. “When it did not appear as though we would get any relief from being the only hospital in Northwest Arkansas to bear the financial responsibility for this service, and we started having staff injuries, we simply felt we could not continue to wait.”

Northwest Medical Center stated in the release that administrators would answer no further inquiry about the subject.

St. Bernards Behavioral Health in Jonesboro, a 60-bed unit owned by St. Bernards Healthcare, is definitely feeling the crunch. Administrator Andy DeYoung sent a letter to the governor’s office last summer warning that the facility could close, and “in its absence, mental health and substance abuse services will not be adequately provided to residents of Northeast Arkansas.”

With fewer beds and less public aid available, Tom Grunden, executive director of the Little Rock Community Mental Health Center, said it will become increasingly difficult to hospitalize the uninsured who need intervention.

“To do your outpatient effectively, you’ve got to have access to 24-hour care,” he said, “that’s the real crisis we’re looking at.”

Breaking Point

What’s the answer? Health care providers and Arkansas’ law enforcement officers support funding the $11.5 million legislation, but some aren’t as quick to jump on that bandwagon.

Adams blamed this on a “general lack of awareness,” maintaining that most people don’t understand the devastation mental illness can cause unless a family member or friend is afflicted. And, he added, insurance providers discriminate against those suffering from mental illness, with the best policies only covering half the cost of an extremely limited number of outpatient treatments.

“Insurance companies have no problems covering the full cost for treating someone with lung cancer from cigarette smoking, which is a self-inflicted illness,” he said. “Yet a person with severe depression is relegated to second-class treatment by insurance plans and government programs. The severely depressed person did not choose his illness, while the cigarette smoker did.”

Gregory and other community mental health center officials believe the answer is to go back and provide funds for local treatment.

“Even if you pump $10 million into the State Hospital, you’re still sending everybody to Little Rock, and that’s not cost-effective or efficient. And I don’t think it’s a real humane way to do it, either.”

At press time, Judge Reasoner was still reviewing written legal arguments filed on both sides of the ACLU lawsuit. If he decides the state is liable for mistreatment of the plaintiffs, the budget could be significantly affected — a fact that many believe is inevitable no matter what.

“If the state isn’t forced to fix something, I don’t think they’re going to fix it,” Gregory said. “They have to cough up the money somehow, some way, to take the burden off the hospitals and mental health centers. In order for everybody to survive and do at least an adequate job, the state’s got to step up to the plate.”

The situation won’t wait either, because hospitals will soon be forced to close their doors to the mentally ill. “Unless changes are made, people in direct need of help and treatment are going to be walking the streets and will be a danger to themselves, to others and to society,” Adams said.

Gregory agrees. “If you take any one of these issues by itself, maybe it doesn’t seem too overwhelming. But when you put them all together, it’s a powder keg, and, unfortunately, we have all the makings for it to blow up.”

(Editor’s Note: This article is reprinted, with updated information, from the Journal of the Arkansas Medical Society, a publication of Arkansas Business Publishing Group. Jeffrey Wood contributed to this report.)

Assessing Anxiety and Depression in Primary Care

Researchers estimated that 24 percent of adult Americans experience a mental illness during the course of a given year. About 2.6 percent of these suffer from a severe and persistent mental illness, such as schizophrenia, bipolar disorder or panic disorder. Anxiety and depression are much more prevalent, and a general practitioner can help spot — and treat — these illnesses.

Psychiatrists and counselors who see 40 patients per day could expect that eight will require support or treatment for anxiety or depression. Studies show that the recognition rates of mental illness greatly improve when doctors do one of the following:

• Adopt an empathetic style.

• Let the patient lead the interview.

• Ask direct, psychologically oriented questions early in the interview.

• Respond to nonverbal clues.

• Listen attentively.

• Tolerate silences.

• Maintain eye contact.

• Avoid closed-ended questions about psychical symptoms.

• Avoid interrupting the patient.

• Use screening tools, such as questionnaires.