Abusing The System
I might as well make it three in a row. That is posts about mental health. Today I want to simply outline a problem. I do not know the solution. Before I state the problem, I want you to understand the nature of the problem. In school I had
systems theory drilled into my head. Basically what systems theory says is one thing influences another thing. Like dominoes, if you change one thing, other things are affected. If dad loses his job and becomes withdrawn, then mom worries, the kids don't get their allowance, they can't do things with their friends, the friends hang with other people and it keeps going out like ripples of water on a pond. If an alternator on an automobile breaks and stops charging the battery, the battery will eventually die. The car owner often diagnoses the problem as a bad battery only to find the new replacement battery dead in a day or two. A trip to the mechanic reveals the real problem. Therefore, in systems theory, it is important to find "the problem" and not focus on a symptom of the problem.
The problem I will attempt to explain today is many faceted. It is actually several problems interwoven. It is getting worse here in Louisiana and I suspect in other areas of the United States.
Problem:An individual presents at an emergency room saying they are suicidal and ask for help or someone is brought to an emergency room accused of being suicidal and the family / friends are asking that the individual get help. Often the individual is intoxicated or under the influence of drugs.
The ER doctor wanting to move people out of his department quickly writes a PEC (physicians emergency certificate), which is a 72 hour commitment. The social worker in the ER begins looking for a psych bed by calling psychiatric units.
EMTALA (emergency medical treatment and active labor act), is a set of federal laws regulating what obligations hospitals have toward patients who are in an emergency situation. These are the anti dumping laws. They make a lot more sense if you are talking about a pregnant woman or someone having a heart attack, but they make less sense as applied to psychiatric and substance abuse situations.
I work at a private psychiatric hospital. We participate in the Medicare program; therefore, we are bound by the EMTALA laws. So, if an emergency room calls us and says they have a patient in their facility and the doctor has written a PEC, we MUST accept that person regardless of their ability to pay.
In theory, this may sound fine, but in practice, it is a disaster. What is happening is individuals and families know they can solve their little crisis by going to an emergency room. The MD will PEC the individual to get rid of him and some psych hospital will have to sort things out without reimbursement. Then, because the person is in the hospital free, administrators (rightfully so) want them discharged ASAP. I often spend a lot of my time doing this, while paying customers are on the back burner.
If the hospital treats people without reimbursement enough, it will not have the money to pay me. Some units have closed already placing more of a burden on existing units. If things continue this way, I can see all of the psychiatric hospitals closing.
I can think of solutions, but it would involve regional cooperation between emergency rooms and psychiatric hospitals, including state mental health services. I do not even know where to start. Medical professionals talk about this problem all the time, but solutions usually involve one facility.
Everyone is afraid of being sued and this is a real concern. There is a large group of individuals who abuse the system. They go to an ER when they do not need to and wind up in a psych hospital when they do not need it. More often than not, some little 22 year old girl gets in a fight with her boyfriend, they breakup and she becomes suicidal. Her friends take her to the ER and she is transferred to a psych unit - maybe ours. Once in the system, it takes a few days and a lot of paperwork and expense to get out. It is all such a waste. A lot of work is generated for fear of regulator intervention or law suits.
I especially love cases of compulsive gamblers or crack heads that are "suicidal." Folks know all they have to do is walk into an ER and say they are suicidal. They will get a 3 to 5 day rest. They spend all of their money on drugs or gambling, but have no resources when it comes to paying medical bills.
Hospitals are often seen as unfeeling and callous, but they lose a lot of money treating people for free. If the trend continues, the hospitals will go bankrupt.
This problem concerns me and I do not quite know what to do. The problem is big and far-reaching.
Sometimes just writing helps me think to the next step. Maybe that will happen here. Being the optimist I am, I believe there is a way to improve this situation and I have not ruled out giving it a shot. Someone has got to do it, even if it is only in our region.
Until the next time
John Strain