Save Mental Health Services
The need for psychiatric and behavioral health services throughout New York is not disappearing, but inpatient mental health services are.
At the height of the COVID surge, many mental health and detox centers were converted to treat COVID, yet failed to re-open to serve people experiencing mental illness. A NYSNA informational flyer looks at declines in mental health services since the COVID-19 epidemic.
Need for Mental Health Services
More than 1.6 million New Yorkers are living with serious psychological or mental distress, according to a 2017 study conducted by USC’s Schaffer Center. When investigating Medicaid expansion data from 2014, these researchers found 1 in 5 new Medicaid enrollees used mental or behavioral health services after enrollment. 1 Despite attempts to increase access and availability of outpatient services, there are still few alternatives to the emergency department and inpatient hospital stay for patients in severe mental health crisis that need immediate access to care and medications. Our mental health system increasingly relies on nursing homes and sparsely regulated adult homes for the care of most mentally ill patients.
Hospitalization rates for New Yorkers with serious mental illness are higher than the national average. Overall, 4% of all New York state hospitalizations were for serious mental illness. The length of stay for serious mental illness is much longer on average than other hospital stays; for a serious diagnosis of schizophrenia, the stay is around 20 days. Yet the Treatment Advocacy Center’s research found that New York state only has 52% of the inpatient beds needed to treat severe mental illness in all populations (including prisoners) in the state.
Need for Inpatient Detox and Rehab Services
According to the New York State Department of Health (authors of the state Prevention Agenda), approximately 12% of people in New York have experienced a substance abuse disorder.2 Unlike with severe mental health crises, there are more alternatives to inpatient stays for substance abuse disorders. Residential rehabilitation is a popular alternative, but most of these facilities are not subject to reporting requirements that an Article 28, hospital-based detox or rehab unit is subject to. Therefore, much less is known about rehab and detox need and capacity. In 2019, all of NYC’s public hospitals closed their inpatient detox centers, claiming that treatment was better provided in the community.3
Inpatient Psych Capacity and Usage
In the post-Berger era of hospital consolidation, there has been a decrease of more than 40,000 inpatient psychiatric bed days available at NYS Article 28 hospitals since 2013. That is a decrease of 4% in just five years. Similarly, the number of beds that have been decertified between 2013 and 2018 stands at 390, a decrease of 12%. At the same time, total discharges are almost flat with a less than 1% decrease.These numbers do not include the New York state inpatient psychiatric hospitals, which were not regulated as Article 28 facilities, and therefore did not submit institutional cost reports. These hospitals represent about 32% of the state’s inpatient psychiatric capacity. These facilities have seen a 19% decrease in staffed beds per the Office of Mental Health’s “Transition Plan,” a plan to reduce inpatient psychiatric acre capacity.
As private non-profit hospitals shed mentally ill patients, the burden is being picked up by public hospitals. The NYC Independent Budget Office showed a 20% increase in mental health discharges at NYC Health+ Hospitals facilities during the five-year period of 2009 to 2014, while NYC’s voluntary non-profit hospitals' show a 5% decrease in discharges.4 In New York City, net patient service revenue per psychiatric discharge actually decreased in nominal dollars between 2013 and 2018 (whereas overall statewide, revenue from psychiatric discharges did increase slightly but not nearly the rate of medical inflation.5
Inpatient Detox and Rehab Capacity and Usage
While detox bed days have declined nearly 3% between 2013 and 2018, staffed rehabilitation beds have increased almost 33%, likely a result of the opioid epidemic. Still detox discharges increased nearly 1% and rehab discharges increased 25%.
COVID-19's Effect on Need for Mental and Behavioral Health Services
In the immediate aftermath of Hurricane Sandy, as many inpatient psychiatric centers, including NYC Health+Hospitals Bellevue and Coney Island were offline, the fall out for other hospitals with inpatient psychiatric beds was immediate and dramatic. Then Beth Israel Hospital reported a nearly 70% increase in inpatient mental health patients in the month immediately following the storm. Caseworkers lost track of patients, only to find them days later in unfamiliar hospitals being cared for by overwhelmed staff.6 During the COVID-19 crisis, there were no inpatient psychiatric departments open to pick up the need as every hospital scrambled to be able to accommodate the dead and dying of the epidemic. We still have no sense of what happened to the more than 2,000 inpatient psychiatric beds in New York City or their patients. We have no idea what outcomes were for patients in state regions with no mental health beds at all.
We are also just beginning to understand how COVID-19 and the related economic fallout will increase the need for inpatient mental health services. Nearly half of Americans reported mental health strain to the Kaiser Family Foundation.7 What we don’t know is the number of people who will present with severe mental health issues requiring hospitalization – either as a new manifestation or as a chronic condition, stable with outpatient care, but that has been exacerbated by an inability to access outpatient care during the pandemic.
Over the years, private hospitals have gotten rid of more psychiatric beds and services, putting an increasing burden on public hospitals and the correctional system. An estimated 12% of the state prison population has a serious mental health illness, about five times the amount of beds available. “The landscape of psychiatric care, especially inpatient psychiatric care, has been going through a transformational shift that is accelerating,” a 2020 study by NYSNA found.8 “Much of the provision of care is now deinstitutionalized, and specialty psychiatric hospitals are diminished in both stature and capacity.”
References
1 . “The Cost of Mental Illness: New York Facts and Figures,” Behavioral Health and Economics Network.
2. “Priority Area: Mental Health/Substance Abuse – Substance Abuse,” New York State Department of Health.
3. “Detox Units Closing at All 11 NYC-Run Hospitals,” The City.
4. “Are New York City Public Hospitals Becoming the Main Provider of Inpatient Services for the Mentally Ill,” New York City Independent Budget Office.
5. NYS Institutional Cost Reports
6. “Storm Weakened a Fragile System for Mental Care,” The New York Times.
7 . “The Implications of COVID-19 for Mental Health and Substance Use,” KFF Health News.
8. “A Crisis in Inpatient Psychiatric Services in New York State Hospitals,” NYSNA