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Hidden Crisis: An occasional series

Psychiatric bed access worsens in pandemic

From the Hidden Crisis: Mental Health in Southern Minnesota series

Funding, staffing issues lead to decline across state

Mental health-Psychiatric beds

Matthew Gerlach has lost count of how many psychiatric units he’s been to in Minnesota.

The 37-year-old St. Peter resident has struggled with mental illness ever since he was diagnosed at 6 years old with attention deficit hyperactivity disorder. He went to his first psychiatric ward in Willmar as a 16-year-old suffering from major depression — just over 100 miles away, it was the closest facility with a juvenile ward and psychiatric beds available.

He stayed there for six months and graduated a year late from St. Peter High School.

“When I was up there, I wasn’t doing any schooling,” he said. “When I got back, it was a hard time and school was the last thing on my mind.”

Gerlach has coped with severe mental illness for the past 20 years. He’s checked himself into numerous psychiatric wards to treat his depression and suicidality, which has made him something of an expert on psychiatric units and treatment programs throughout Minnesota and North Dakota.

He can tell you which facilities are nice, which facilities offer you more access to services, and which facilities just stick you in a room.

Gerlach has the routine down. He goes to the emergency room at Mayo Clinic Health System in Mankato, asking for treatment. He waits for hours, sometimes overnight, in a small room in the ER as medical staff check what psychiatric beds are available throughout the state. He’s never had to wait more than a day or so, but he knows some people wait for days to get treatment.

“Then they take you in an ambulance up to whatever’s available,” he said. “It’s usually not close.”

Gerlach is among thousands of Minnesotans struggling with severe mental health illness who sometimes require inpatient psychiatric treatment. Yet an ongoing shortage of psychiatric beds throughout the state has put a strain on mental health services for area residents such as Gerlach.

Many beds are either constantly in use or are taken offline by mental health providers who can’t afford to keep them running. State and federal regulations make it difficult to add more beds in the system. And wait times to get into psychiatric treatment programs keep growing.

All the while, the ongoing COVID-19 pandemic is compounding the issue as more Minnesotans seek treatment for severe mental illness.

“It’s not happening just in Minnesota,” said Sue Abderholden, executive director of NAMI Minnesota. “It’s happening across the country. It’s happening across the world.”

Growing issues

Psychiatric bed access has been a problem for decades.

The number of psychiatric beds in the U.S. has fallen by 97% since 1995. That’s due in large part to the advent of Medicare and Medicaid in the 1960s, as the programs were created with a funding prohibition for psychiatric beds. Dubbed the Medicaid Institutes for Mental Diseases, or IMD, exclusion, the rule bars Medicaid reimbursement for most patients ages 21-64 in mental health and substance-use facilities with more than 16 beds.

The rule was designed to curtail asylums and mental institutions throughout the U.S. by shifting to more community-based treatment for mental health issues. Though care has advanced in the decades since, the rule has remained in place despite growing opposition from advocates, providers and lawmakers.

“Sixteen (beds) isn’t a clinical number,” Minnesota Senate Health and Human Services committee chair Sen. Michelle Benson said. “It’s an arbitrary number. We need to address that.”

Minnesota’s hospital moratorium rules, enacted in 1984, put a cap on the number of total licensed beds in the state. Fewer than 100 hospital beds were added over the next two decades until lawmakers created and passed an exemption process in 2004. Officials say Minnesota’s overall bed capacity has shrunk over time — licensed hospital beds have decreased by more than 1,000 since 1996.

Advocates say the moratorium rules continue to ensure the market for medical providers isn’t monopolized by a few large hospital chains, while critics say the moratorium makes adding more beds to psychiatric wards far too difficult.

“It’s a relatively onerous process,” said Lisa Dailey, executive director of the Virginia-based Treatment Advocacy Center. The nonprofit tracks psychiatric bed access and civil commitments at the state level across the U.S.

Though the state’s total hospital beds are down since 1996, more than 500 hospital beds have been added throughout Minnesota since 2004. The Minnesota Legislature approved another 50 beds for psychiatric treatment in the state during this year’s legislative session. Thirty of those beds will go to PrairieCare, a mental health group with offices around the state including Mankato.

PrairieCare’s 71-bed pediatric facility in Brooklyn Park will grow to 101 beds, which the provider’s CEO Todd Archbold said would likely be ready by 2023.

“We’re just doing our best to keep up with demand,” Archbold said.

PrairieCare got permission to open an inpatient psychiatric treatment facility for children more than a decade ago. The group’s Brooklyn Park facility opened in 2011 with 20 beds, then grew to 50 beds in 2015 and 71 beds in 2017.

Each time, PrairieCare’s facility hit maximum capacity in a matter of days.

“The very day we opened (in 2011), we had five admissions,” Archbold said.

Treatment varies

You’re having a mental health crisis.

Perhaps you’re struggling with depression, getting anxious or panicked by your job, your school, your friends, your family, maybe even your hobbies or social outings. Maybe you’re thinking about hurting yourself or others around you.

What do you do?

You’ll most likely do what Gerlach and a majority of Minnesotans in a similar situation do: Contact emergency services and end up in the hospital emergency room.

With few exceptions, the local ER is the starting place for most people seeking inpatient psychiatric services.

“About 90% of our admissions come from ERs, and that’s a scary experience, especially when it’s your child,” Archbold said.

Wait times can vary wildly based on bed availability. Hospitals and treatment facilities are bound by law to accept patients as soon as they’re presented, which means some psychiatric units will take a patient who showed up in the afternoon over a patient who came in the morning, depending on when a bed opens and when ER staff call to check.

As a result, the average wait times to get into a bed are only increasing — and it’s made worse by the pandemic.

The Minnesota Hospital Association reports mental health and substance use-related ER visits among patients of all ages went up by 77% across the state from 2010 to 2019. A recent report from the federal Centers for Disease Control and Prevention shows mental health-related emergency room visits increased by 31% in 2020 for U.S. adolescents ages 12-17. ER visits for children ages 5-11 increased by 24% compared to the previous year.

Experts say it’s more common for patients to wait several days, or even more than a week, to get into a psychiatric unit. Some experts say they’ve heard of patients waiting two weeks or more for Minnesota’s mental health services to unclog.

“At the beginning of the pandemic, people were nervous even going into the hospital,” Abderholden said. “That changed as this pandemic sprint turns into a marathon.”

After a trip to the emergency room, patients in a crisis will be transported to a psychiatric unit with an available bed. There, staff assess the patient and come up with a treatment plan.

Some psychiatric units offer more individual or group treatment options. Some have more chances to connect with nurses, mental health practitioners or other staff. Some units, however, make you feel as though you’re “treated like cattle,” Gerlach said.

“You just kind of sit there,” he said. “I’ve been to places that have had helpful groups during the day, and it seems like they’re actually trying to treat you instead of house you.”

Gerlach knows which treatment facilities he prefers. He thinks the nursing staff at Mayo Clinic Health System in Mankato is good but the place could be better, while facilities in Marshall and Albert Lea are helpful. He didn’t have a good experience with Hennepin County Medical Center, while Abbott Northwestern in the Twin Cities is probably the best psychiatric unit in the state — they give patients coffee during the day, and Gerlach likes his black.

“It’s comforting,” he said.

One patient’s reviews won’t make or break a psychiatric unit, however.

“I honestly have gotten complaints and kudos about every psychiatric unit in the state,” Abderholden said. “So much of it is about how the staff is delivering something, how they’re relating to a person. Sometimes you get along with someone better than another.”

The quality of care can vary depending on staff and facility resources. At Mayo Clinic Health System in Mankato, the psychiatric unit has 11 beds available — or at least it does when there isn’t a pandemic. The local hospital shuttered one bed as part of COVID-related safety regulations.

Dr. Vyoma Acharya, Mayo Clinic Health System in Mankato’s Psychiatry and Psychology department chair, said Mankato stands above other psychiatric units because there’s an in-house psychologist available for patients on top of the nurses, social workers and other mental health professionals.

“That is really unique to our unit,” she said.

Mental health doctor 2

Dr. Vyoma Acharya oversees the behavioral health unit at Mayo Clinic Health System in Mankato. Acharya is one of many experts and advocates who say more state support is needed to improve access to inpatient psychiatric care.

In addition, patients visit with internal medicine staff and participate in individual or group treatment.

Acharya said the Mankato unit may not offer coffee like Abbott Northwestern — the staff tries to limit caffeine for patients, though some do get decaf — but the facility does try to solidify support for patients through family or friends when appropriate, so patients have people to turn to when they leave.

“You might have been through a very stressful situation,” Acharya said. “It’s really difficult to navigate those things alone without having some support.”

Yet Mayo Clinic Health System in Mankato faces the same sort of issues other facilities do when it comes to treating patients: not enough funding support, not enough physical space, and sometimes not enough staff.

Mankato is one of the biggest hubs for inpatient psychiatric beds in southwest Minnesota, despite only having 11 beds. Mayo officials have discussed expanding the Mankato psychiatric unit to 14 beds in the past, but physical space limitations remain a problem.

Facility staff have discussed expanding outdoor therapeutic space. Still, local patients in crisis may not get to see those improvements.

“Most other beds you can go to a hospital and find one, you can even choose which hospital you go to,” Archbold said. “That’s not the case with psychiatric beds.”

‘A bed is not a bed is not a bed’

Despite decades of experience, solving the shortage of psychiatric beds in Minnesota is a difficult task made more complex by the rules and reimbursement systems in place.

Minnesota may have more than 16,000 licensed hospital beds, but that doesn’t mean they’re all available for psychiatric care. Hospitals are free to use bed space however they like, which means hospitals weigh psychiatric bed space against beds for surgery, emergency room care or other medical services.

Bed space is also divided based on patient needs. A certain number of beds is set aside for patients with autism, some for patients with substance use issues, eating disorders, or whether someone is voluntarily committed or ordered to do so through the court system. Those beds are further grouped based on their location in a private residential treatment facility, a private hospital setting, or a state hospital setting, among other things.

“A bed is not a bed is not a bed,” Archbold said. “Even if you have the right classification, those beds are reserved for other uses sometimes.”

For patients in crisis seeking help, there are about 1,000 beds in Minnesota available — just over 600 for adults, and 200 to 300 or more for children.

Even then, those beds may not be available. Just because a licensed bed is open doesn’t mean a facility has the staff to operate it.

Unused licensed beds MN 1021

“There’s always a shortage of providers, to be honest,” Acharya said. “I think it’s pretty difficult to keep psychiatrists, not just psychiatrists but psychiatric nurses.”

Providers and experts point to treatment costs as another major factor behind the psychiatric bed shortage. Mental health services aren’t reimbursed through insurance as well as other medical services; Archbold, Abderholden and other experts estimate mental health gets reimbursed at 80% of the rate other services are. As a result, facilities turn to state funding and reimbursement rates to keep open.

Smaller facilities can struggle with reimbursement for patients in need, forcing the provider to absorb more and more costs until it becomes too difficult to stay open or provide proper care.

Cambia Hills, a 60-bed intensive residential treatment center for children, opened last year in East Bethel after several years of planning but closed in June due to financial issues. State regulators also found the facility violated several patient care rules.

Another pediatric treatment facility in Duluth, The Hills Center, closed this past summer after more than a century in operation. Both facilities were run by the same group.

Hospital systems can absorb some of those extra costs because psychiatric units are only one part of the services they offer, but larger providers have been reluctant to operate too many licensed beds at a time for fear of losing money.

“Hospitals make their money by having high-profit making specialists doing procedures, potentially doing radiology and that kind of stuff,” said Dr. Michael Trangle, a senior fellow at the Health Partners Institute. “That’s how hospitals make their money. There’s really no rational reason that cardiology or neurosurgery or orthopedics should make more money than something that’s more cognitive.”

Aside from reimbursement issues, mental health providers seem to deal with insurance companies far more often than other medical services.

Trangle, who sits on several state and federal mental health-related advisory boards, used to be the medical director for behavioral health at Regions Hospital. He remembers a time when he and some co-workers did “back-of-the-napkin” calculations on how often staff at Regions dealt with insurance companies. For other medical staff, it could take about an hour each week to address insurance questions. For mental health staff, it could take about 10 hours.

That’s a common tale among mental health providers, experts say.

“When a child gets to a hospital for mental illness, we contact the insurance companies and set up care. We may have to call back every day thereafter to justify the ongoing need for care,” Archbold said. “You’re talking months of recovery, repair and treatment, and insurance companies will call us 24 hours later and ask how they’re doing.”

Justifying treatment to insurance companies can cause providers to discharge patients “quicker but sicker,” according to Dailey and advocates at the Treatment Advocacy Center.

“You’re seeing a decrease in the length of stay in hospitals, I think in part because of pressure from insurance to discharge people quicker,” Dailey said. “And then there’s an increase in readmissions.”

Mental health-Psychiatric beds 3

Matthew Gerlach (right) and his mother, Diane Gerlach, have become familiar with the lack of access to psychiatric beds and inpatient hospital treatment for mental health issues over the years.

Moving forward

Experts and policymakers say multiple things need to happen to solve the psychiatric bed shortage.

Some advocate for more mental health-based exemptions to Minnesota’s moratorium law, arguing the need for more beds is so great there’s little chance a monopoly on treatment options would happen.

Others say federal action is needed to end Medicaid’s exclusion of mental health treatment facility services. Minnesota could apply for exemptions to the Medicaid exclusion rule, though lawmakers say federal officials have soured on such requests in recent years.

Abderholden and other NAMI advocates say the state won’t be able to add beds and treatment facilities without more workers. They point out many large hospital systems have plenty of banked beds available — Children’s Minnesota plans to open a 22-bed unit next year using slots they already had licensed — but further growth requires more mental health professionals.

“We could dump a billion dollars into our mental health system right now and we wouldn’t have enough people to do the work,” Abderholden said.

Others want more synergy between mental health and medical providers, as many patients’ trips to the doctor also include a mental health component. The state Department of Human Services has run trials on similar proposals before, but reimbursement issues quashed hopes for those models.

Almost everyone agrees reimbursement rates need to be addressed.

“As solutions are sought, reimbursement for these services should be considered alongside other factors including market considerations and laws that make it more difficult to simply add more mental health beds,” the Minnesota Council of Health Plans said in a statement.

State Rep. Peter Fischer, the House DFL lead on mental health, said Democrats and Republicans are looking at ways to ease some of the burden behind Minnesota’s hospital moratorium law.

He pointed out PrairieCare and Regions both received permission to add beds without having to go before lawmakers this year, provided they go through the proper channels with the state Department of Health.

Democrats also are exploring whether the state should reclaim unused licenses for banked beds to distribute to other hospital systems that apply.

Senate Republicans have resisted that proposal, arguing it would cause the state to pick winners and losers in the marketplace and could lead to a few systems monopolizing unused bed licenses. Fischer argues the current system is already allowing some hospitals to hoard bed access in the state.

“People have to start asking the tougher questions toward the hospitals in that, why aren’t you adding more?” Fischer said.

Advocates are pushing for more treatment options outside of inpatient psychiatric beds — the more access to mental health care, the less need to treat severe mental illness.

State officials have tried to concentrate on outpatient, community-based services in recent years to help people before they’re in crisis. While some residential centers help in emergency situations — Horizon Homes runs the Mankato-based South Central Crisis Center’s 12-bed unit where people can stay for up to 10 days — there are few options for intermediate-level care.

Some providers are opening so-called EmPATH units — a kind of psychiatric emergency room care. EmPATH, or emergency psychiatric assessment, is not quite an emergency room wait and not quite a full psychiatric unit, but it allows hospitals more focus to address major mental health crises.

Only St. Cloud Hospital and M Fairview Health Southdale Hospital have opened EmPATH units in the state, while M Health Fairview University of Minnesota Medical Center has plans to open another.

Benson, the ranking Senate Republican on health and human services, said she’s willing to explore moratorium exemptions and more support for EmPATH units as the state grapples with an ongoing mental health public crisis. In addition, she’d like to see more attention on intermediate level care to alleviate access to psychiatric units.

Benson and Fischer agree it’s taken the state a long time to address psychiatric beds and other mental health issues because of the stigma surrounding mental health care.

“We are just getting to the point where people are willing to talk about mental health and people with disorders,” she said. “It’s been a long time since they started this work, but we’re just now as a society getting comfortable saying, ‘I suffer from depression and anxiety and other forms of mental illness.’”

Fischer said that reluctance is part of the reason why hospitals and facilities are underfunded in the first place.

“When we dismantled the old system of warehousing people, we never put a focus on putting a system to replace it, and that’s having big consequences,” he said.

That’s good news to advocates, who have long argued for more focus on mental health treatment.

“It’s not that there isn’t any way to fund this stuff, but there doesn’t seem to be a lot of willpower either,” Dailey said.

For people like Gerlach, more access and a better standard of care is key. Diane Gerlach, Matthew Gerlach’s mother, said she’s seen her son struggle in recent years as he often has to go far from the Mankato area to get treated. That makes it more difficult for Matthew’s family and friends to support him if they have to drive halfway across the state to visit.

At the same time, maintaining psychiatric beds remains a priority.

“When it’s been so many years, you see him so sick and he doesn’t always want to go in, when you finally get to that point it is just kind of a weight off of your shoulders,” Diane Gerlach said. “You know that they’re in a safe place and they’re going to get some help.”

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