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"Mental" Issue Threatens Medical Care

By Bruce Mirken

June 2, 2000

[Note: Reporter Bruce Mirken investigated an attempt by the San Francisco Department of Public Health, against strong medical advice, to close a locked psychiatric ward for financial reasons. He found that the local problem was caused in part by irrational Federal, state, and private-insurance policies that determine healthcare decisions throughout the U.S., based on medieval philosophical ideas about a split between mind and body. Although this problem affects relatively few AIDS patients, we think it should be more widely understood, to help empower efforts to reform this country's dysfunctional healthcare reimbursement system.

[Readers should note that the central issue here is NOT the story which is often in the news, of refusal to reimburse treatment of mental illness on a par with physical illness. Instead, this problem concerns patients who do have a recognized physical brain disease -- whose treatment might be reimbursed routinely in other parts of the hospital, such as a neurology or general medical ward. But if they are treated in a psychiatric ward (which often has the facilities to deal appropriately with the behavioral problems resulting from their illness, when other hospital beds do not), then Federal coverage will only reimburse for certain psychiatric diagnoses, which not all these patients have -- and private insurers often follow the Federal lead. The result is serious pressure to close psychiatric hospital beds because they are used appropriately to deliver quality care. --JSJ]

Patients with AIDS Dementia Complex (ADC) or brain-related opportunistic infections such as progressive multifocal leukoencephalopathy (PML) may not get the most appropriate inpatient care -- or hospitals may be forced to care for them for free -- because of distinctions between medical and psychiatric diagnoses made by Medicare, Medicaid and private insurers. The same problem can occur with any brain disease or trauma that affects behavior, such as Alzheimer's disease or head injury.

This situation came to light as a result of an ongoing health department budget crisis in San Francisco. In order to balance his department's budget, health director Dr. Mitch Katz recently proposed closing 21 inpatient psychiatric beds at San Francisco General Hospital. He argued that the fact that Medi-Cal, California's Medicaid program, had "decertified" (i.e., declared that it wouldn't pay for) many of the patients treated in the unit meant that they did not truly need inpatient care. A compromise has since been worked out to spare the beds (although other budget issues remain), but the problem of reimbursement for dementia patients continues.

San Francisco General Hospital's inpatient psychiatric unit has several special-focus units designed to provide culturally competent care for people from various ethnic or cultural backgrounds, using specially trained staff. One of these units focuses on gay, lesbian, bisexual, transgender and HIV-positive patients and commonly treats patients with ADC or PML.

Dr. Mark Leary, assistant chief of psychiatry at San Francisco General, explains that the reimbursement issue occurs in cases of "what we call organic brain disease, which is some major medical process affecting the patient's brain" and which, "along with their medical effects also have behavioral effects." Behavior can be affected severely enough for the patient to "be gravely disabled or a danger to themselves or a danger to other people," necessitating inpatient psychiatric care. San Francisco General's 87-bed psychiatric unit typically cares for from two to five such individuals at any given moment.

These patients are often too erratic and dangerous to be treated in a general medicine ward. In addition to medical treatment, Leary says, they need care from staff trained and experienced in dealing with their behavioral issues. "If they were in a regular medical unit they would be in restraints most of the time."

But, he explains, "Medi-Cal and Medicare will pay for their hospitalization if they have certain psychiatric symptoms like delusions or hallucinations and certain kinds of depression. But if they don't have those particular symptoms but a more general kind of behavioral problem . . . Medi-Cal and Medicare won't pay for their psychiatric hospitalization, [even though] their behavioral disturbance requires them to be treated on a psychiatric unit."

At fault is what Leary calls "dichotomous, black-and-white thinking" that makes "the artificial distinction between 'psychiatric' illness like schizophrenia or manic depression and 'organic brain disease.'" Even if a patient suffers from both schizophrenia and ADC, "if Medi-Cal determines that their primary problem requiring hospitalization is the dementia, they won't pay." Although very few San Francisco General patients have private insurance, private insurers frequently follow the lead of government programs in such decisions.

After a week of inquiries, Medi-Cal informed us that it would take several weeks of research before they could answer our questions regarding their reimbursement policies. But Lourdes Maloney, acting associate regional administrator at the federal Health Care Financing Administration, confirmed that for Medicare to pay for psychiatric hospitalization the patient must have "a psychiatric principal diagnosis" listed in the American Psychiatric Association's Diagnostic and Statistical Manual or in the Mental Disorders chapter of the International Classification of Diseases. Even with such a diagnosis Medicare limits inpatient psychiatric care to 190 days, while no such time limit applies to medical hospitalization.

Dr. Marshall Forstein, chairman of the American Psychiatric Association's committee on AIDS and associate professor of Psychiatry at Harvard Medical School, agrees with Leary. The problem, he says, "speaks to the unfortunate and arbitrary distinction we make between disorders of the brain and disorders of the body." Forstein calls such distinctions between mental and physical illness "totally arbitrary. They're holdovers from an old view of the mind/body split. But we have studies now showing that in certain psychotic episodes, the brain reacts differently. How is that different than dementia?"

But these arbitrary distinctions, he adds, often "create a battlefield over who's going to pay for what." Because Medicaid is run by the states, the result is a patchwork of different rules. "State by state, Medicaid programs have taken different positions," Forstein says. "Sometimes the department of public health wants the department of mental health to pay for it, and vice versa. . . . Especially when it involves long-term care, everyone runs away."

ISSN # 1052-4207

Copyright 2000 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.

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