Elements of a successful short-stay inpatient psychiatric service

In 1989 Johns Hopkins Hospital modified the Meyer 3 short-stay psychiatric service, which has allowed the hospital to comply with state requirements to control inpatient costs and has increased revenues. Strategies and organizational changes that were implemented to reduce length of stay include use of a screening tool by the admitting physician to ensure appropriate referrals to the service, modification of morning and afternoon rounds and strengthening of linkages with the psychiatric emergency department and outpatient services to enhance communication, replacement of inexperienced first-year residents in the emergency department with senior residents on 24-hour call who are closely supervised by short-stay service staff, and enhanced training for service nurses. Patients who are functionally disabled and who need assistance in activities of daily living have longer stays. Patients with substance use disorders are now referred to an ultra-short-stay unit.

[Duration of treatment and case cost in different inpatient psychiatric facilities in Berlin]

In this study length of stay and costs per case were examined in three different types of psychiatric hospitals: Psychiatric departments in general hospitals and psychiatric hospitals each liable to provide in-patient care for a defined catchment area, and psychiatric departments in general hospitals without such liability. Data basis were all hospital treated cases in Berlin West that are covered by general insurance. Length of stay and costs differed significantly depending on the type of psychiatric hospital as well as on diagnoses, way of referral and age of patients. Psychiatric departments with catchment area have the shortest length of stay and lowest costs per case. This is independent of age, gender, way of referral and diagnosis of the patients. Influence of each factor is quantified.

Brief psychiatric hospitalization: preliminary experience with an urban short-stay unit

OBJECTIVE

To present data from the recently implemented psychiatric short-stay units (SSUs) in metro Halifax. There are few data describing SSUs and factors associated with successful outcome.

METHODS

A 4-month retrospective chart review of 124 patients.

RESULTS

Patients tended to be single, unemployed young adults, with a past history of psychiatric admission. Most patients were admitted voluntarily. There was an equal sex ratio. Mean length of stay for all patients was 2.5 days. Adjustment disorder was the diagnosis most responsible for admission.

CONCLUSION

Many psychiatric inpatients may benefit from brief hospitalization. Brief hospitalization results in reduced health care costs.

General hospital psychiatry and the new behavioral health care delivery system

Mental health care delivery has undergone substantial changes in recent years. This article reviews the evolution of managed care in the mental health care field and outlines managed behavioral health care techniques used in providing access to high-quality, cost-effective care. The expansion of general hospital psychiatry over the last 25 years is also reviewed. Current strengths of general hospital psychiatry which make it well positioned for an expanded role in behavioral health care delivery are examined. Recommendations are made for further improvements in the clinical, administrative, and financial aspects of general hospital psychiatry care delivery to prepare it for the integrated behavioral health care systems of tomorrow.

General hospital psychiatry and the ethics of managed care

Managed care programs come in many stripes, and the field is evolving with bewildering rapidity. In order to be effective advocates and critics, clinicians need a vision of ethical managed care practice, to use as a standard for judgment and quality improvement. This paper presents four principles that I believe capture the essential stance of an ethical clinician in managed care. The central challenge for creating ethical managed care systems is integrating stewardship (communitarian) and fiduciary (patient centered) values. Because general hospital psychiatrists treat individual patients in a "communal" (institutional) setting in which issues of resource use stand out with great clarity, they will play a central role in developing ethical guidelines for managed care practice. This paper considers issues in general hospital psychiatric practice--determining hospital length of stay, deciding how much suicidal risk is tolerable in a treatment plan, and the problems that arise when patients prefer valid but less cost-effective treatments--as examples of the kinds of questions a clinically relevant set of ethics must address.

Wagons ho: forward on the managed care trail

This paper describes the impact of managed care on an academic medical center department of psychiatry. Like the pioneers before us, academic medical centers have often traveled wilderness paths, training new generations of psychiatrists and providing research about and new understandings of psychiatric illness; under assault from powerful competitive forces, we have all too often circled the wagons in an attempt to survive what we perceive as an onslaught. We describe the ways in which our academic medical center department of psychiatry has responded to managed care forces, in particular, the impact of managed care on residency training, inpatient services, outpatient psychotherapeutic and psychopharmacological care, and faculty morale. We describe how we have worked closely with our medical colleagues, formed new committees, and initiated forays into capitated arrangements. Despite difficult external circumstances, we have been able to survive, regroup, provide leadership, and continue with renewed purpose.

The future of consultation-liaison psychiatry and medical-psychiatric units in the era of managed care

There has been increasing recognition and documentation of the impact of psychiatric problems on the outcome and cost of medical care. Because consultation-liaison psychiatrists have the expertise to address the psychiatric aspects of medical illness, this group should be in a strong position to facilitate integration of medical and psychiatric services in managed care delivery systems. Although consultation-liaison psychiatry (CLP) has documented its ability to shorten inpatient medical lengths of stay for some disorders, a greater challenge exists in developing comprehensive systems to identify and care for patients with mental health problems in primary care settings. This paper reviews the fiscal and programmatic implications for managed medical care systems of findings from outcome-based C-L research. The future role of CLP and combined medical-psychiatric units in an era of managed care is also discussed.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); mental health services--DoD. Final rule

This final rule is to reform CHAMPUS quality of care standards and reimbursement methods for inpatient mental health services. The rule updates existing standards for residential treatment centers (RTCs) and establishes new standards for approval as CHAMPUS-authorized providers for substance use disorder rehabilitation facilities (SUDRFs) and partial hospitalization programs (PHPs); implements recommendations of the Comptroller General of the United States that DoD establish cost-based reimbursement methods for psychiatric hospitals and residential treatment facilities; adopts another Comptroller General recommendation that DoD remove the current incentive for the use of inpatient mental health care; and eliminates payments to residential treatment centers for days in which the patient is on a leave of absence.

Mental health's contribution to the financial performance of a utilization management program

Analysis of a national utilization management program covering approximately 3.4 million individuals from 1989 through June 1993 indicates that while only 6% of all hospitalizations were for a primary psychiatric or substance abuse diagnosis, over 44% of the program savings are accounted for by concurrent mental health utilization management. The cost of performing mental health utilization management is significantly greater than the cost of providing medical, surgical, and maternity management, but returns on investments are significantly greater for psychiatric and substance abuse than for these other diagnostic areas. Implications for health care reform inclusion of full mental health benefits are discussed.

[The use of services, the effect of compensation and the costs of a panic disorder]

BACKGROUND

The use of general health care services by psychiatric patients has decreased drastically following correct diagnosis. This phenomenon, called offset effect, allows the use of inefficient health care services to be evaluated and contributes to the estimation of the relative impact of the disorder in addition to the estimation of the benefits of the training campaigns and/or the implementation of services. The aim of this study was to evaluate the offset effect and the costs of the panic disorder (PD) in a natural environment.

METHODS

The clinical data and the use of health care services over 12 months prior to diagnosis and 12 months following diagnosis were collected. Clinical evaluation of 61 patients with PD included a standard interview (SCID-UP), scales of general functioning, improvement, severity of the symptoms and the level of disability. The number of work days missed was also reported.

RESULTS

The sociodemographic features, clinical evolution and the rate of response to treatment were comparable to those referred in other studies performed in a natural medium. The direct costs of treatment of AP were 1,795,000 pesetas (1,547,000-1,889,000) higher during the year following the first psychiatric consultation, mainly due to the costs of the visits to the psychiatrist and the medication. On the contrary, the indirect costs were 5,435,000 pesetas less during this period.

CONCLUSIONS

In this study on the treatment of patients with the panic disorder a strong offset effect (94%) was found being much greater than that described for general psychiatric disorders. Adequate psychiatric treatment induces in the next 12 months an increase in the cost due psychiatric consultation and medication, however reduces the total costs when absenteeism is taken into account.

[New responsibilities via the health care structural law concerning inpatient treatment]

The new Health Care Structural Law (GSG) brings about changes in e.g. medical care in hospitals, the consequences of which are of utmost significance. New forms of payment challenge hospitals to take into account in the hospital management the various forms of payment, to define new programmes of hospital performance and the realise competitive aspects while maintaining the quality of medical care. For the first time ever the new system of nursing fees focuses on the performance of the hospital instead of on its costs. The GSG induces a need to act in various areas of medical care in hospitals: The nursing staff regulation and the psychiatry staff ordinance require a procedure that leads to feasible results in contract negotiations, planning decisions and budget negotiations. In the model project in accordance with section 275a SGB V the necessity of the stay in hospital will be examined to verify that ambulant medical care takes precedence over medical care in hospital. The implementation of section 301 SGB V "Hospitals" is to guarantee a correct accounting with hospitals and is intended to enable the statutory health insurance institutions to perform their task as established by law to examine the necessity and duration of patient's stay in hospital. The evaluation and implementation of these tasks require solutions that do not focus on the individual case but lead to a systematic approach. Future examination procedures have to take the local conditions into account. The contents of the examinations must be standardised to facilitate a comparison on a regional and national level.

Benefits of distinct part psychiatric or rehabilitation units

Distinct part psychiatric or rehabilitation units may help produce a positive financial margin for a hospital by transforming unused capacity into a revenue-generating enterprise and securing cost-based reimbursement from Medicare.

Quality of care for depressed elderly pre-post prospective payment system: differences in response across treatment settings

We evaluated the quality of care for depressed elderly patients (n = 2,746) hospitalized in general medical hospitals (n = 297) before or after implementation of Medicare's Prospective Payment System, focusing on whether the response to time period differed for hospitals that in the post-PPS period had no psychiatric unit, an exempt psychiatric unit, or a nonexempt unit, and by ward placement within hospitals with psychiatric units. Quality of care increased over time, and for most measures of quality of care the level of improvement did not differ significantly across different types of hospitals or by ward placement. The intensity of use of therapeutic services, such as rehabilitation, occupation, or recreation therapy, increased over time, particularly in nonexempt psychiatric units and hospitals without psychiatric units, such that these locations caught up some over time in the level of use of these services to the level for exempt psychiatric units. Several outcomes of care improved over time, and the degree of improvement in the rate of inpatient medical and psychiatric complications and other outcomes was significantly greater for psychiatric units that were exempt post-PPS than for nonexempt treatment locations.

Medical psychiatry units and the roles of the inpatient psychiatric service in the general hospital

The medical-psychiatric unit concept has been the most important influence in the development of general hospital inpatient psychiatry in the last decade. This concept and style of unit organization is reviewed in the context of the history of general hospital inpatient psychiatry. It is suggested that elements of the medical-psychiatry unit model will become more important in the organization of general hospital psychiatric units. Modifications of the medical psychiatry unit concept are suggested to take into account the heterogeneity of many general hospital inpatient services. Implications of these factors are discussed in the context of unit design, models of staff organization, and the formation of networks of care.

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); fiscal year 1994 updates--Office of the Secretary, DoD. Notice of updated mental health per diem rates

This notice provides for the updating of hospital-specific per diem rates for high volume providers and regional per diem rates for low volume providers; the updated cap per diem for high volume providers; and the beneficiary per diem cost-share amount for low volume providers to be used for FY 1994 under the CHAMPUS Mental Health Per Diem Payment System.

A "facilitated" model of inpatient psychiatric care

The authors describe a model for an effective partnership between a large health maintenance organization and a fee-for-service acute inpatient psychiatric unit. They present data from five years of experience with the model on a unit serving a catchment area of one million plan members. The model, which is based on "facilitated" care rather than managed care, emphasizes crisis intervention and a strong medical orientation. The HMO contracted with seven psychiatrists to provide treatment and helped develop a value system shared by the physicians and hospital staff. A clinician represented the HMO on the unit and played a key decision-making role in patient care. A total of 4,945 patients were admitted over five years. Costs per admission were reduced 47 percent during this period; the readmission rate was 16.9 percent. Implementation of the model resulted in the delivery of high-quality cost-effective care.

A comprehensive payment model for short- and long-stay psychiatric patients

In this article, a payment model is developed for a hospital system with both acute- and chronic-stay psychiatric patients. "Transition pricing" provides a balance between the incentives of an episode-based system and the necessity of per diem long-term payments. Payment is dependent on two new psychiatric resident classification systems for short- and long-term stays. Data on per diem cost of inpatient care, by day of stay, was computed from a sample of 2,968 patients from 100 psychiatric units in 51 Department of Veterans Affairs (VA) Medical Centers. Using a 9-month cohort of all VA psychiatric discharges nationwide (79,337 with non-chronic stays), profits and losses were simulated.

Who should receive high-cost mental health treatment and for how long?

The use of some recently developed and promising mental health treatments is likely to be restricted by their high cost. Cost-effectiveness studies, however, suggest that high treatment costs may be offset by associated reductions in inpatient service use. In view of the considerable variation in the cost of inpatient treatment for the mentally ill, it may be cost-efficient to use high-cost treatments for frequent hospital users but not for others. To illustrate this principle, we examine 9-year trends in inpatient costs incurred by schizophrenia patients discharged from Department of Veterans' Affairs medical centers across the country in fiscal year (FY) 1982. Even in the absence of specific intervention, average inpatient costs in this sample fell 49 percent, from $7,368 per patient in FY 1983 to $3,770 per patient in FY 1990, reducing the potential for inpatient cost offsets over time. Sensitivity analyses of potential inpatient cost offsets were conducted using a range estimate both for the cost of treatment and for resulting reductions in inpatient expense. Assuming effectiveness in a middle range, high-cost intervention was projected to be cost-neutral for the 25 percent of the sample with the highest rates of baseline hospital use for a duration of 1-3 years. Although our specific model had low predictive power, the projection of cost offsets in large mental health systems deserves further examination and may prove to be one useful criterion, in addition to clinical effectiveness, for selecting patients to receive expensive treatment.

The emergence of clinical psychology departments in Australian teaching hospitals

Over recent years, clinical psychological services have diversified within the health sector, leading to a breakdown in the traditional nexus between clinical psychology and psychiatry, and to the emergence of the interdisciplinary field of behavioral medicine. From their earlier limited role as providers of psychometric assessments in educational and psychiatric hospital settings, clinical psychologists now provide a wide range of therapeutic services and research skills to general hospitals, universities, community health centres, and the private sector. This evolving trend has significant implications for the future structure and direction of clinical practices in clinical psychology, psychiatry and medicine.

Developing a level III/IV medical/psychiatry unit. Establishing a basis, design of the unit, and physician responsibility

This article is part of a series defining the administrative, logistical, and funding issues necessary for the establishment of a medical/psychiatry unit. It emphasizes the experience of individuals who have developed such units and is offered in an attempt to prevent duplication of costly mistakes. Administrative issues, factors affecting the physical design of the unit, requirements for medical coverage and medical and psychiatric programmatic support, and the ethical issues encountered in managing such a unit are discussed.

A risk-based prospective payment system that integrates patient, hospital and national costs

We suggest that a desirable form for prospective payment for inpatient care is hospital average cost plus a linear combination of individual patient and national average cost. When the coefficients are chosen to minimize mean squared error loss between payment and costs, the payment has efficiency and access incentives. The coefficient multiplying patient costs is a hospital specific measure of financial risk of the patient. Access is promoted since providers receive higher reimbursements for risky, high cost patients. Historical cost data can be used to obtain estimates of payment parameters. The method is applied to Medicare data on psychiatric inpatients.

Managing Medicare reimbursement on medical-psychiatry units

Many general hospitals are confronting issues of financial strain precipitated to a large extent by Medicare payment reductions. The viability of psychiatry programs within general hospitals more than ever depends upon some demonstration of their financial as well as clinical contribution. The aim of this study is to review some of the basic parameters governing Part A (hospital) Medicare reimbursement of DRG-exempt general hospital psychiatry units and to provide options for improving their financial viability. There are a number of specific mechanisms involved in managing Medicare cost and reimbursement. Establishing a system for gatekeeping is important because significant control of payor mix and length of stay resides with the unit gatekeeper. Establishing liaison for short-stay patients with nursing home papers is important because Medicare pays on a target cost per discharge. The identification of short-stay patients is financially very favorable, and often critical to balance the unavoidable longer-stay patients. This paper also discusses how medical-psychiatric units can interface most effectively with medical-surgical units. Finally, there is some discussion of the need to develop pre- and postadmission outpatient medical-psychiatric programs. The financial aspects of medical-psychiatry care, if not the increasing scrutiny of managed care, will force further development of such outpatient programs.

Have general hospitals become chronic care institutions for the mentally ill?

OBJECTIVE

Dramatic increases in lengths of stay for general hospital psychiatric patients in New York City in recent years have raised speculation that general hospitals are assuming a large responsibility for care of the chronically mentally ill. This study examines changes in utilization patterns and patient characteristics to assess whether such a trend is occurring.

METHOD

The authors obtained discharge abstract data for all New York City general hospital adult psychiatric patients in 1985 and 1988 as well as utilization data from the public general hospital system for 1977-1989. Three measures of chronicity were chosen: hospital stays longer than 60 days, discharges to long-term care, and three or more admissions per year. Data on psychiatric diagnoses and comorbid diagnoses for chronically ill patients were also reviewed.

RESULTS

The mean length of stay of psychiatric patients in general hospitals has increased substantially in recent years and nearly tripled in the public hospitals during 1977-1989. Between 1985 and 1988, citywide increases were due largely to a growing proportion of patients with very long stays. Patients with stays longer than 60 days accounted for 35% of all inpatient days in 1988, compared with 27% in 1985. Patients with chronic illness accounted for half of all days in 1988, compared with 38% in 1985.

CONCLUSIONS

Although many factors have contributed to these trends, the leading cause has been reimbursement policies favoring short-term inpatient care. Improving accountability for community treatment programs will be the key to redirecting funding priorities and creating more appropriate alternatives for the chronically mentally ill.

Access to insurance and length of psychiatric stay among adolescents and young adults discharged from general hospitals

This study examines the characteristics of over 100,000 young people hospitalized in short-term, general hospitals throughout the United States between 1986 and 1988 for psychiatric and substance abuse diagnoses. Adolescent patients (ages 13-17) are compared with young adults (ages 18-22) in terms of demographic characteristics, diagnosis, source of payment, and length of stay. The study focuses on the relationship between the patients' access to private insurance and length of stay.

Hospital financial performance under the prospective payment system by type of admission: psychiatric versus medical/surgical

We performed detailed simulations of DRG-based payments to general hospitals for treatment of nonexempt psychiatric and medical/surgical patients under Medicare's prospective payment system (PPS). We then compared these results to calculated costs for the same patients. Hospitals without specialized psychiatric units tend to fare better financially on their psychiatric than on their medical/surgical caseloads, although the levels of gain for these two types of patients are correlated. Hospitals with nonexempt psychiatric units generally have similar rates of gain on psychiatric and medical/surgical patients. Comparing psychiatric treatment in "scatter-bed" sites with that provided in nonexempt units, the higher rate of gain under PPS for treatment in scatter beds results largely from shorter lengths of stay. We discuss hospital behavior and the relationships between treatment of psychiatric illness under DRG-based payment and its treatment in exempt psychiatric units, which are excluded from DRG-based payment.

Development of a medical-psychiatric program within the private sector. Potential problems and strategies for their resolution

Recent reports regarding the development of combined medical-psychiatric units have primarily involved units operated under the auspices of academic medical centers. Almost no published information is available regarding the fiscal, administrative, or clinical feasibility of operating such programs within the context of the private community hospital setting. This article outlines the organization and development of such a private unit and discusses the various medical, administrative, political, and financial considerations that must be evaluated in planning for the successful operation of medical-psychiatric units within the private sector.

Patterns of service use and costs in model day hospital-in programs in Boston and Tucson

Patterns of service use and costs in two similar model day hospital-inn programs for psychiatric patients in publicly funded hospitals in Boston and Tucson are compared. Implementation of the programs resulted in cost savings at both sites, although mean annual costs per patient were much lower in Tucson than in Boston. Compared with patients at the Boston site, patients in Tucson had more admissions but shorter stays and fewer days in the program during a 12-month follow-up period. Site-specific differences in the programs, in local practice patterns, and in state mental health funding levels may have influenced cost differences.

Cost-effectiveness index (CEI): a tool to help evaluate mental health programs

A method for evaluating the cost-effectiveness of mental health programs is presented. The method takes into account the profile of mental health services a patient receives, the frequency of each service and the relative costs of each service in relation to the change in a patient's clinical condition between entrance into and release from a treatment program. It can also be used to assess change over a specified time period. An example compares the cost-effectiveness index (CEI) for similar cohorts of schizophrenia patients treated in two 24-hour acute care psychiatric systems. The CEI can use either actual dollar costs, if known, or a relative value scale associated with different services. Its utility and weaknesses are discussed. The CEI is designed to alert management to differences in the relative cost-effectiveness of programs serving populations of similar patients. Identification of such differences can contribute to improvement in program functioning.

The impact of DRG-based budgeting on inpatient psychiatric care in Veterans Administration medical centers

In 1985 the Veterans Administration (VA) implemented a prospective budgeting system for acute inpatient care based on diagnosis-related groups (DRGs). To assess the impact of this system on psychiatric care, this study reviewed data on all VA discharges for psychiatric or substance abuse disorders that occurred during the four years before and the four years after this system was implemented. During the four years following the implementation of DRG-based budgeting the number of annual discharges increased by 28.7% and the number of unique patients discharged increased by 15.5%. Average lengths of stay declined by 36.9% and total annual bed days of care per unique patient declined by 29.7%. These changes occurred in association with an 11.5% reduction in the total number of beds occupied by psychiatric patients, an 8.9% reduction in direct per diem expenditures for psychiatric care nationally, and a 32.7% decline in direct expenditures per episode, after adjustment is made for inflation. In spite of a continuing decline in the value of the available resources, largely due to the effect of inflation, prospective budgeting appears to have had a major impact on the pattern of inpatient psychiatric care in this large health care system.