On the IMD exclusion and The Mental Health Reform Act of 2016

Lamar Alexander says he wants to have  a vote on the Senate mental health reform bill by the end of the spring.   The clock is ticking and much remains to be done.

Although the Alexander committee produced a bill that seemed to be a consensus Bill much remains to be settled on the Senate floor.   Although the bill is absent much of the most problematic stuff in the Murphy Bill major issues remain.

Chief among those is the IMD exclusion. Basically the IMD exclusion makes it illegal for federal Medicaid dollars to be used in free standing psychiatric hospitals with more than 16 beds. Eliminating the IMD exclusion the argument would address what its proponents say is a bed shortage as well as allowing people to be kept in the hospital a little bit longer. It is for most advocates the most remaining noxious proposal remaining in a bill largely shorn from an extremely noxious Murphy Bill.

Advocating effectively against it should be a key focus between now and the time the bill is brought to a vote.

There are a lot of points to consider and much that needs to be said :

1. This provision is not currently in the bill but several senators talked about the need for it and their intention to present it as an amendment on the floor. It is the big ticket item with a price tag of 40-80 billion dollars on it. They are tinkering with it and may just try to change it in some way to bring down the price tag. The price tag alone probably will defeat it. Not many big ticket items are going anywhere right now.

2. With the House Freedom Caucus in particular promising major problems with any budget it is worth remembering that big ticket mental health reform of any kind may be in trouble regardless of how many people like it. Right now the IMD exclusion piece is a major hurdle for Murphys Bill in the House.

3. If financial hurdles can’t be overcome at least in the Senate the IMD provision will be dropped if it puts passage of a larger Bill in jeopardy.

4. There are a lot of problems with this provision. Here is what I believe :

Psychiatric hospitals do not admit people because they can help them. They admit them because they can get paid for them. They don’t discharge them because something is settled or resolved. They discharge them because the people that pay will no longer pay. All hospitals have people whose only job is to translate problems into payable terms. If you make it easier for people to get in and easier for them to stay a long time you will have more people in for longer times. It’s a little like a mechanic. Psychiatric hospitals will find all the problems you are willing to pay for, for as long as you are willing to pay.

Proponents of this say this is intended as a boon for state hospitals. Yet the last article I read estimated this would bring an extra $5 billion in profits for for-profit mental health services. That is with a B. Any wonder that some of the organizations pushing this the hardest have the most to gain. For information about one major chain of for profit hospitals open the following link (http://interactives.dallasnews.com/2016/danger-in-the-psych-ward/)

If you change the narrative, if the bottom line standard of care becomes more hospitalization for more people for longer periods of time then you slowly move towards less focus on community care and eventually psychiatric hospitalization will create the very problem it is supposed to solve….more people doing worse and worse in the community.

Psychiatric hospitalization is an after the fact intervention. In Tennessee there is no voluntary state hospitalization. At best it is crisis stabilization not prevention or resolution and to my knowledge there is no data that suggests or proves that the stabilization of one crisis prevents the next one when the conditions that produce the crisis remain constant.

Tennessee over the last few years has developed an alternative to psychiatric hospitalization. They are called crisis stabilization units and for the first time this past year they had more admissions than state hospitals. They are small community based programs and most importantly they are voluntary. The maximum length of stay is 3 days and the emphasis is on getting people home and successful. In most of these units peer support specialists play a major role. The idea is that in some crisis situations another space is important but most importantly people having the ability to choose before things are out of control to get the help they need is essential. The data so far is positive. It costs far less than a state hospital bed and so far people that go there are not ending up in state hospitals.

Saying that something can happen and something will happen are not the same thing. In Tennessee it is unlikely that the state Medicaid program will fall all over itself in a state that no longer sees hospitalization as the first line of intervention to pay for more psychiatric hospitalization. A bill in Congress is not likely to change standards of medical necessity. And if somehow they are forced to pay based on past experience they will take that money from benefits in other areas. Even the fact that federal funds are used doesn’t do away with the need for the state portion. I don’t know about other states. In Tennessee even with the federal portion this would be called an unfunded mandate.

There are many more arguments but in my mind it boils down to this :

1. It carries an extraordinarily high price tag that just doesn’t match up to its supposed benefits.
2. If you wanted to pay that much money for an after the fact intervention think what might happen if you spent that money for crisis prevention.
3. There is no evidence I am aware of that says psychiatric hospitalization had any enduring benefits and plenty of evidence there are other more effective options.
4. There is no evidence I know of that extended psychiatric hospitalization is our should be the intervention of choice for people with diagnoses like schizophrenia or bipolar.
5. There are a lot of people who stand to make a lot of money off of this and they are pushing hard for it. If you open the door you will have a hard time keeping it from being opened further.
6. In time this changes the narrative and results in the perception that the biggest problem with the mental health system is that not enough people are locked up. Less and less people will seek any kind of help as it becomes more risky to seek help.
7. Psychiatric hospitals are not neutral medical events as recent news reports about the system in Florida for example make clear. There is a long track record of trauma, hurt, and victimization and to blindly give permission for more psychiatric hospitalization as the “compassionate” response is to be blind and call it sight.
8. Even with the federal portion it still imposes a financial burden on states that may cause them to have to shift funding from other things they think are more important.
9. Most state Medicaid systems are strapped financially. Even if you pass the law there is no promise that in the protection of their financial solvency they will really make this new policy fit within the bounds of their definition of medical necessity.
10. And finally what about those people without insurance which at least in Tennessee is a lot. How can you okay hospitalization for some and not for others and is that not just handing states a bill without asking them if they want to pay.

The argument for eliminating the IMD exclusion is one based on tragic anecdotes. It is time to look at a tragic reality and make changes that count for everybody.

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