Loss of services drives up mental illness costs

Hospital visits and costs associated with mental illness soared between 2009 and 2012 after the state substantially cut mental health services.

New statistics released Wednesday by Hawaii Health Information Corp. showed overall increases in emergency room visits, hospital admissions and charges statewide.

Total ER visits jumped 20 percent to 13,666 last year from 11,312 in 2009. What’s more, hospital admissions rose 14.3 percent to 4,040 from 3,535 in the same period, resulting in a significant growth in costs.

In 2012, emergency room charges and inpatient admissions related to mental illness totaled $98.3 million — 30 percent more than the $76.1 million spent in 2009. The data reflect only patients with a behavioral health problem as a primary diagnosis.

"Over those periods it looks like there’s been perhaps more intensive work needed in the ERs, and that’s being reflected in the higher costs," said Peter Sybinsky, HHIC president and chief executive officer. "That’s quite an increase over time." The HHIC collects, analyzes and disseminates health care information, its website declares.

The state Department of Health cut its mental health budget by $25 million in fiscal 2009. That resulted in reduced case management hours and crisis intervention programs. At the same time, the state Department of Human Services changed eligibility requirements for the population, resulting in fewer residents qualifying for services.

"When everything got cut back, they reduced categories so only people with psychosis could be served by the state. They eliminated post-traumatic stress disorder and major depression," said Marya Grambs, executive director of Mental Health America of Hawai‘i, a nonprofit education and advocacy organization. "It’s clearly a result of basically cutting off your nose to spite your face. The state said we’ve got to save money, so they cut off services to this very vulnerable population. As a result, because they get sicker, they end up using services that are far more expensive."

Further exacerbating access to care: Fewer psychiatrists willing to participate with the state’s Medicaid health insurance program, which covers most of the seriously mentally ill population, said Stephen Kemble, president of a physicians’ advocacy group, the Hawaii Medical Association.

Since Medicaid was converted to a more bureaucratic managed care program in 2009, doctors have stopped accepting new patients, he said. Meanwhile, enrollment in the Medicaid (QUEST) program rose 19 percent between 2009 and 2012.

"It’s become much more frustrating and difficult for psychiatrists to treat Medicaid patients because of burdensome managed care restrictions," he said. "They are having difficulties getting paid. It’s more hassles with prior authorization. A doctor can’t even write out a prescription and know that it’s going to be filled."

Of 180 psychiatrists in Hawaii, only about a third participate in Medicaid, he added.

The cuts have shrunk critical services for people like 57-year-old Scott Wall, who has been in the public mental health system for 45 years after being diagnosed with bipolar disorder at the age of 12.

Wall, who also is a board member of Mental Health America, said there are only three psychiatrists that he knows of on Oahu accepting Medicaid patients, and none on Hawaii island. In 2008 his unlimited case management services were reduced to 3.5 hours a month, he said.

Case managers are mental health specialists who monitor clients, ensuring they are taking their medications and are emotionally stable, in addition to helping with daily living activities.

"In my life it was not so bad (because) I’m a pretty functional guy," he said. "For other people, this has caused death."

The Health Department said it is restoring some of the services that were lost. The Medicaid program also is consolidating mental health patients under a single health plan responsible for linking them with psychiatrists.

"We started rebuilding our system from the serious cuts that happened, but there’s a lot more to do," said Mark Fridovich, administrator of the Department of Health’s adult mental health division. "Because our state’s economic circumstance has improved, we’re working with partners to strengthen a variety of programs."

That includes increasing crisis and case management services as well as partnering with organizations to address the needs of the homeless population. The Health Department also has launched a primary care behavioral health integration project with the Kalihi-Palama Health Center.

The HHIC data, which are not adjusted for inflation, were collected from hospitals across the state, except Tripler Army Medical Center. The research factors in conditions such as acute anxiety, childhood behavioral disorders, depression, schizophrenia, personality disorders and substance abuse. The information also includes military members, Medicaid/QUEST members, people on Medicare, the uninsured, patients with private insurance and self-payers.