A clogged mental-health system has left patients languishing in emergency rooms, awaiting a spot in a state psychiatric hospital.
Now the state is moving to reduce the number of those spots assigned to Pierce County patients.
By a certain kind of measurement, the county is a victim of its own success. The local mental-health network – the only one in the state that is run by a for-profit company, OptumHealth – has cut costs by moving patients out of Western State Hospital into other forms of treatment. The result is state government reducing Pierce County’s patient limit by nearly
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The change would free up space for patients from other areas, most of all King County. It moves Pierce County’s share of beds closer to its share of the state’s population, and closer to the number of beds it has actually been using.
Still, it has raised alarms for state lawmakers and health-care administrators in the area.
“I would say we need the beds,” said Tim Holmes, vice president of behavioral health for MultiCare, which operates Tacoma General Hospital. “In a way, it’s somewhat punitive to take away a resource from (an agency) that has been maybe more successful at coming up with creative options for how to serve people within the community.”
The change is set to take effect April 1 and involves patients detained by civil courts for long-term stays, and, in rare cases, patients who check themselves in voluntarily. It doesn’t affect suspects under the responsibilities of the criminal courts.
FORMULA DETERMINES BEDS
Every three years, the state Department of Social and Health Services divides up what is now 749 beds at Western in Lakewood and Eastern State Hospital near Spokane.
“There’s a formula in statute about allocation of state hospital beds, and we are obligated by statute to re-run that formula every three years,” Jane Beyer, who leads the Behavioral Health and Service Integration Administration at DSHS, told lawmakers last month.
First, the regional networks get a chance to negotiate an alternative. But Optum declined to participate because it knew it would see fewer beds no matter what happened, the agency said. Its King County counterpart said Optum wouldn’t have lost as many beds if it had negotiated.
Without a deal, DSHS took over, using its formula that takes into account population, prevalence of mental illness and use of the hospitals. It’s that third factor that Pierce County has dramatically reduced in recent years, both before and after its mental-health responsibilities were privatized.
In 2006, the county had an average of 163 patients at the hospital. In 2009, the year Optum took over from the county, it averaged 104. In 2012, it averaged just 97.
It has stayed well below its limit of 104 patients. But the April 1 change would shrink the county’s allotment to 94.
“It’s changing no matter what we say or do,” Optum Pierce Executive Director Cheri Dolezal said. “We already lobbied against it and it didn’t go anywhere – and I understand why.”
Every day they exceed their limits, regional support networks like Optum must pay a contractual penalty of $508.40 per patient.
Networks keep that penalty money if they stay under their limits. If they go over, half of the penalties go to the state hospitals. The other half goes to other regional support networks, which in the rest of the state are run by county governments.
Patient counts vary, and last week Pierce County sat right at its limit of 104 – mainly because of a growing number of patients being shifted from the hospital’s criminal-court side to its civil-court side, Dolezal said.
If it remained so high July 1, after the first quarter of a year under the new limit, Optum would pay a quarterly fine of more than $450,000.
“That’s going to cost us $2 million at the rate they’re going,” said Dolezal, who said she tried to seek a waiver of fines, to no avail.
In recent years, it has been King County paying the big fines, and Optum reaping the benefits.
Optum took in more than $380,000 in incentives between mid-2009 and mid-2012 for keeping patient counts low, according to DSHS.
King County’s number of patients have stayed steady even as the state hospitals have closed wards and counts have dropped in Pierce and some other regions, such as the one run by Thurston and Mason counties.
King paid more than $1 million in penalties in 2010, almost $500,000 in 2011 and roughly $200,000 in 2012, said Amnon Shoenfeld, director of King County mental health and substance abuse services.
It would have paid much more if other regional support networks had not agreed to essentially loan beds to King, Shoenfeld said.
“The nonprofit RSNs have been working to help each other, to keep each other from having to pay penalties,” he said. “It is a way we keep that state funding in the community, which is where it belongs.”
Optum does not loan beds, Shoenfeld said: “They get some of that money, and that is their bottom line. There’s their profit.”
WORSENING THE PROBLEM
Now Optum will have to reduce its use of Western further or face penalties.
That could have a cascading effect on the mental-health system, ultimately keeping more people waiting in community hospitals.
The limits taking effect April 1 apply to long-term commitments of more than 90 days. If Pierce County is over its limit, a patient from the county faces being wait-listed until the numbers fall, according to Western State Hospital.
That could in turn clog the short-term beds meant for evaluations. It’s a shortage of those beds that is driving the waits at community hospitals.
The lower limit could exacerbate the problem, said executives with MultiCare and Franciscan health systems, which together run most of the area’s hospitals.
Patients stay at Franciscan for an estimated three to four days on average, said Carla Trolia, director of inpatient mental health for Franciscan. Some patients have stayed as long as a full two-week evaluation period, she said, and in very rare cases longer.
Lakewood Sen. Mike Carrell, a Republican who leads the Senate committee on human services that oversees mental-health issues, said he would ask DSHS to hold off on its change until lawmakers go through their budget process.
And Tacoma Sen. Jeannie Darneille, the top minority Democrat on the committee, said she is “unbelievably concerned” about the state reduction.
DSHS says lawmakers can help the overall problem by putting money into a set of facilities created by the Legislature in 2005 but never funded. A measure to move ahead with the enhanced services facilities passed the Senate unanimously Thursday.
The facilities could take pressure off the hospitals by caring for patients who could be released from hospitals only if there were a place to put them that could care for their complex needs or deal with their disruptive tendencies, Beyer said.
Dolezal says the cut is coming because Optum has done such a good job keeping patients out of hospitals. Carrell agrees.
“I don’t believe we should be punishing parts of the system that show some great progress,” said Carrell, whose bill also includes a task force on mental health that he said would look at whether Pierce County privatization should be a model for other parts of the state.
Lawmakers who share Carrell’s concerns don’t all share his confidence in Optum, including Democrats such as Darneille and Sen. Nathan Schlicher, an emergency-room doctor at St. Joseph Medical Center in Tacoma who said he has a problem with a company making a profit while patients wait days for psychiatric treatment.
“I don’t think our company gets into this field to make money,” Dolezal counters. Other parts of the company are its profit centers, she said.
“We haven’t really given the A-plus rating, if you will, to OptumHealth and their program of services,” Darneille said. “Were their claims to be completely true, I think we would hear (fewer complaints) voiced by the jails and the emergency rooms.”
In some ways, the state is embracing the alternative model offered by Optum, even as hospital executives say they need both outpatient services and more hospital space.
DSHS is calling for more money to implement another never-funded law making it easier to detain patients. But instead of more beds at Western State, which the department originally sought in connection with the expansion, it is now seeking outpatient alternatives.
“The goal, essentially,” Beyer told lawmakers, “is to try to keep people in their communities, get them the intensive services that they need and avoid the cycle of institutionalization.”