Private Hospitals Send Mentally Ill Packing To Public Care, Study Says

Under the cost-cutting pressure of competition and managed care, two-thirds of the nation’s private hospitals that are equipped to take in mentally ill patients dump them on financially strapped public hospitals and community services, says a study to be published on Wednesday in the journal Health Services Research.

In a nationwide analysis of such practices, the authors, Robert Dorwart, a professor of psychiatry at Harvard Medical School, and Mark Schlesinger, an economist at the Yale School of Medicine, say that hospitals sometimes reject mentally ill patients simply by denying admission to the great majority who have no other medical problem.

Dorwart and Schlesinger also report that hospitals discharge mental patients prematurely, either when their health insurance runs out or when the cost of their care exceeds the reimbursement that insurers pay hospitals.

And the report says hospitals are quickest to reject uninsured patients. Among adolescent psychiatric patients, for example, the researchers said it was five times harder for those without insurance to be admitted than for those with insurance.

Private, for-profit hospitals, the report says, appear to be the quickest to turn out the mentally ill, and the practice is most pronounced in communities where for-profit hospitals have provoked intense competition in health care. Competition for patients with managed-care health plans induces hospitals to reduce both their charges and durations of stay, and patients with severe mental conditions often require longer stays than others.

For decades, hospitals have turned away psychiatric patients they deemed difficult or expensive to treat. But economic constraints have tightened with the growth of managed-care organizations, their restraints on per-patient spending and their use of practices like utilization review to authorize and deny procedures for patients, the study says.

Dorwart and Schlesinger define such practices as “economically motivated transfers.” They say it is “one of the ways in which health-care providers can avoid unprofitable patients,” and add: “Dumping may have more deleterious effects than other denials of access. It potentially disrupts the continuity of care for patients at a time when they are most impaired.”

Moreover, the researchers say, “it increases the fiscal burdens on providers of last resort,” typically taxpayer-supported public hospitals and community mental health centers. States have been closing and shrinking psychiatric hospitals for years, they add, making it all the more difficult to accommodate the patients that general hospitals reject.

Larry Gage, president of the National Association of Public Hospitals, said that his members were seeing steadily increasing caseloads of all types of patients, including psychiatric, but that dumping was hard to spot. “Hospitals are very adept at covering up blatant dumping,” he said.

State and federal laws prohibit hospitals from rejecting psychiatric patients with unstable medical conditions, like a diabetic’s perilously high blood sugar count. But they do not apply to mentally ill patients who are medically stable. “There are essentially no protections for them,” Schlesinger said in an interview.