Bob Glover, executive director of the National Association of State Mental Health Program Directors, Alexandria, Va., which represents state psychiatric facilities, says the patient base as well as the funding for state psychiatric hospitals has declined dramatically since their heyday, in the 1950s and '60s.
In general, the number of psychiatric patients in inpatient settings has shrunk, Glover observes. “There's also been a general decline in general hospital inpatients and a decline in psychiatric beds at (Veterans Affairs) hospitals.”
The decline in state hospitals, however, has been particularly dramatic. To offer some perspective, Glover says 350 state hospitals housing nearly half a million patients existed more than 50 years ago. Today, about 235 hospitals remain and take care of only 50,000 patients.
The public mental-health system serves about 6.1 million patients a year. Only 4% of that population are being treated at a state facility, Glover says.
“As recent as 20 years ago, roughly two-thirds of public mental-health budgets went to state hospitals … today one-third is going to state hospitals and two-thirds are going to community-based services,” Glover says.
Glover estimates that state hospitals currently get $8 billion annually to support their services. The bottom line is states don't have the funds to keep them open, he says.
General hospitals are often the facilities that pick up the slack when a state hospital closes.
Debora Tanner, vice president and administrator of Riverside Behavioral Health Center, Hampton, Va., a 79-bed, not-for-profit facility of Riverside Health System, says her facility has been compensating for the fact that there will be fewer available beds at a nearby state mental hospital.
Several years ago, Eastern State Hospital, Williamsburg, Va., the region's state psychiatric hospital, closed 48 of its acute beds with a plan to close 90 by 2010 and then shift the access to communities in providing appropriate levels of acute care and increasing the availability of “temporary detention order,” or TDO, beds. TDOs are requested by healthcare professionals or law enforcement for individuals who are unstable and very aggressive who are in danger of harming themselves or others in the community. TDOs are obtained as a court order to hospitalize the person until they can be stabilized and granted a hearing to determine whether they should be discharged or committed to the hospital for a longer period of time.
With 90 fewer beds at the hospital, which currently has 401 beds, the commonwealth of Virginia would save approximately $2.6 million, but closing beds will require a plan to provide appropriate resources to the rest of the community in order to accommodate the shift, Tanner says.
Several economic forces have been at work to close state facilities, Fisher says, “although Medicaid has been the recent driving force in the last 20 years in trying to shift the focus of care to the general hospital.”
General hospitals have an advantage in that their mental-health units are reimbursable through a variety of private and public insurers, including Medicaid, according to Fisher's article. State hospitals by comparison cannot receive Medicaid payments under a specific regulation that prohibits Medicaid reimbursement in facilities with 16 or more beds and where more than half of the patients have a psychiatric illness.
“Thus, the financial burden of treatment in state hospitals, with a few exceptions, falls completely on the state,” Fisher says.
Many states began a big push to enroll as many mental-health-system clients as possible in Medicaid, and divert admissions to general hospitals, where Medicaid could be used. “This cost-shifting effort, which began in full force in the early 1990s, thus accelerated the decline in state hospital use,” Fisher says.
The bottom line is the demand for state hospitals isn't as high as it was 30 to 50 years ago, Fisher says. “In Massachusetts for example you have several state hospitals that have been around for 100 years and don't have many patients left in them,” which is why two of the hospitals—126-bed Worcester State Hospital and 220-bed Westborough State Hospital—are consolidating their patients into one location.
The reason for this is the healthcare system's growing ability to keep these patients in the community through case management and residential supports, “so reliance on inpatient care has been reduced,” Fisher says.