Should we not look before we leap…. The fallacy of lifting the IMD exclusion

I once saw someone stop breathing in a restraint.   I saw him turn gray and I thought he had died.   There was a RN involved in the restraint and he did CPR and he lived.   It was important to realize this was not an aberration.   Everything was done according to policy.   It was not the result of a “bad staff”  going off.   It was a tragic incident but it was done according to policy.   I heard him quietly say once “I can’t breathe.”  And that quick he was gone.  Thank God he didn’t die. 

Inpatient treatment programs can be and too often are dangerous to the people in them.   To my knowledge there is no organized structural way that exists to hold them accountable or even know what really happens.   Not only do we not know how much good they do we have no real idea how much harm is done. 

Congressional voices all seem to praising the lifting of the IMD exclusion.   According to many of them the most important part of the mental health “reform”  they are talking about is increasing the ability to put more people in psychiatric hospitals for a longer period of time.   Somehow the political acceptable truth has become we have so many homeless,  so many in jail because not enough of them spend enough time in psychiatric hospitals.   It is not because of poverty or racism or hunger or victimization or trauma or just miserable lives defined by overwhelming chronic injustice at every level of their lives.   It is for lack of the proper pills and adequate control over their poor decisions.   The victims of an inadequate often harmful system have been accused of breaking a system that many have experienced as making a  planned pervasive effort to break them….. always with the assurance it is for “their own good.”

There actually is a study by CMS that addresses the claims that more psychiatric hospitals are the panacea it is claimed to be:

HHS Study on Lifting IMD Exclusion Showed Little to No

Reduction in Admissions, ER Visits or Spending

NYAPRS  E- News  October 25, 2016


Several years ago, Congress required the US Department of Health and Human Services to look at whether lifting longstanding federal rules prohibiting Medicaid reimbursement to private psychiatric hospitals would improve outcomes and reduce costs.  

In response, HHS launched a Medicaid Emergency Psychiatric Services Demonstration (MEPD) between July 2012 and June 2015 in 11 states (Alabama, California, Connecticut, Illinois, Maine, Maryland, Missouri, North Carolina, Rhode Island, Washington, West Virginia and the District of Columbia) within 28 private psychiatric hospitals.  


 According to HHS, “the evaluation conducted a demonstration on the effects of providing Medicaid reimbursements to private psychiatric hospitals that treat beneficiaries ages 21 to 64 with psychiatric emergency medical conditions” (when an individual expressed suicidal or homicidal thoughts or gestures, or was judged to be a danger to him- or herself or others).”


The report was released last August. The results?


“Overall, we found little to no evidence of MEPD effects on inpatient admissions to IMDs or general hospital scatter beds; IMD or scatter bed lengths of stays; ER visits and ED boarding; discharge planning by participating IMDs; or the Medicaid share of IMD admissions of adults with psychiatric EMCs.


Available data suggest, however, that increased access of adult Medicaid beneficiaries to IMD inpatient care would likely come at a cost to the federal government.


Moreover, providing access to IMD services may not be able to address the numerous reasons other than inpatient bed searches that contribute to long stays of psychiatric patients in EDs.


Given the high cost of inpatient care relative to community-based care and major shortages in the availability of community-based care and psychiatric ED services across the country, future initiatives may wish to balance consideration of potential increases in funding for IMD and general hospital inpatient services within the context of amore comprehensive approach that considers distribution of new resources across all aspects of the system (inpatient, emergency, and ambulatory care).

Translation .. Whatever the problem there is no evidence psychiatric hospitalization is the magic pill.  It is about more,  much more than putting people in a hospital. 

People  stop using businesses they can’t trust.   The mental health system is no different. 

Some people are helped.   I know too many who have experienced the system as helpful to buy the idea it never works.   In some ways during a horrible time in my life it was helpful to me.   In Tennessee,  at least,  I  know many people who say that the exposure they got to peer support specialists  literally saved their lives.   “Somebody had been there and told me I was still a person and not a label and I could make it like they did.” 

Many people tell me it is just irrelevant.   I will always premember what one lady told me.   “I think my therapist meant well.   She was just horribly naive.   She thought it was about managing my symptoms.  I thought it was about finding a way to a better life.   She never understood the difference.   She had never been poor.   I don’t know she had ever been hurt.   She thought it was about getting well.   I thought it was about escaping hell. “

For many people I know it has been about the danger of those things that supposedly are supposed to make it better.   It is about medication that has made life hell.   It is about the thousand and one ways they are told that they don’t matter as much as other people,  that life will never hold much for them,  and that any problems they have with what is happening to them is a symptom of their illness and continuing need for treatment.   Many just want to have a real choice and feel like the system offers little. 

Many of the people I have met who feel the strongest have had one or more experiences in a hospital that have left them hurt in ways that those who want more hospitalization either understand or want to understand. 

I think there is a real chance they will pass a bill when Congress gets back from the election.   If nothing else to save face and show they are capable of doing something.   The simplest way to pass a bill will be for the Senate to cave and end up basically passing the Murphy Bill.  I wonder to how the elections will affect things.   If the Senate goes back to Democratic control Lamar Alexander will view this as a best chance effort and move heaven and earth to make something happen.   I  remember how mad he was when Harry Reid in a time of previous Democratic control would not let a mental health bill of his move before.  I would be astonished if he took a chance. 

If the faith that psychiatric hospitals are the answer to all things mental health becomes unquestioned political dogma as a result of all this much harm will have been done to many people. 

Everyone is exhausted physically and emotionally from this horrible election.   I know I  am.   The last thing anybody wants to do is talk more about politics.   The last vote in the House on Murphy was crushing proof of what an uphill battle this is. 

I hope it gets postponed till next year.   No one really knows.   I would like to see something like the accountability system talked about in the articles linked at the top of this post be talked about become part of any legislation. 

If you speak,  if you decide to voice your opinion tell them you a real evidence based approach.   The blind faith in psychiatric hospitalization is dangerous and unwarranted and there are many ruined and lost lives that attest to  it. 

I  hope these next couple of months bring some relief not just to you but to this country.  Consider what you wish to say and if you do decide speak loudly.   If nothing else this election has taught us that. 


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