On March 23, as the coronavirus crisis was gaining momentum in New York, the state ordered hospitals to increase their capacity by at least fifty percent. Wealthy private hospitals started emptying out psychiatric units under the auspices of this effort. For these hospitals, it was a golden opportunity to enhance their bottom line. There would be no regulatory hurdles under the governor’s executive orders.
There are huge disparities in provider payments between physical and mental health. The inpatient rate for treating depressive neuroses is $4,429. By comparison, the cost for common cardiac care ranges from $28,000 to $86,000. Acute inpatient treatment of psychosis is $1,351 per bed per day; for a hip replacement, its $9,084.
We know that the need is enormous. More than 1.6 million New Yorkers live with serious psychological or mental distress. Twelve percent of all New Yorkers have experienced a substance use disorder.
Not enough services, beds or providers
For those in need of acute care, New York has only 52% of the inpatient beds needed to treat people with severe mental illness, according to the Treatment Advocacy Center, and that was pre-COVID. Since 2013, the state has lost over 40,000 inpatient behavioral health bed days available at NYS Article 28 hospitals, purportedly a move towards more and better outpatient services to help mitigate the need for inpatient care.
In an effort to ensure access to care, New York State and Federal laws were enacted over a decade ago requiring health insurance plans to cover mental health and substance use disorder treatment the same way they cover all other medical treatment, creating “parity” between the coverage of mental and physical illness. Realization of the promise of parity is impossible to achieve when disparities in reimbursement rates are allowed to persist and there simply are not enough services, beds or providers available. What good is having insurance coverage if there’s no place to get the needed care?
Balanced care model
As nurses, we understand the need for a balanced model of care to treat people with mental health problems. In balanced care, services are provided by RNs and other trained professionals in a variety of community settings, as close to the population being served as possible, mobile crisis intervention is available, and inpatient admissions can be arranged promptly when necessary. This model employs psychiatric-mental health nurses to utilize their essential skills — no de-skilling! — and to mentor novice nurses in this specialty, a model now in danger of being derailed by “COVID-19 surge plans”.
Pre-COVID, and without necessary outpatient services in place, private hospitals had already started shedding mental health services. In NYC, the burden of care fell on public hospitals. There was a 20% increase in mental health discharges in 2017 at NYC Health+Hospitals facilities, according to the NYC Independent Budget Office. Now many private behavioral health units, fully operational before COVID, remain shuttered or have transitioned to other types of care, guaranteeing an increase in new patients at already over-burdened public hospitals.
Under the COVID-19 cloak
Northwell, for one, had applied — pre-COVID — to close its behavioral health unit at Syosset, and was turned down. Now, under the cloak of COVID-19, the threatened closure is back on, a golden opportunity to add even more to the coffers of the biggest healthcare system in New York State, with net income of $671 million in 2019. Other hospitals have followed suit.
When “unprofitable” services are cut by wealthy private healthcare systems, public hospitals in NYC and safety nets downstate and upstate must fill this void. What exactly does that void look like?
“Just last weekend I was caring for 16 psych patients in the ER and 15 of them need in-patient care,” says Kevin Pantin, RN, a psychiatric-mental health nurse at Lincoln Medical Center, one of 11 public hospitals in NYC. “But we closed two in-patient psych units during the COVID surge and they have not been re-opened. So the 15 patients had to be sent elsewhere. They are making changes without giving us a full explanation. It is despairing. Our psych care is critical to the communities we serve.”
And when those services can’t meet the need? “Patients,” reported New Yorker magazine on April 23, “then go to transitional facilities, and those facilities began discharging patients sooner than planned — often sending them to residential programs or halfway houses, where they would be most at risk for the coronavirus infection, and in all cases sending them into the community at a terrifying time.”
Prison and jails
Worse case, patients end up on the street or in jail — guaranteed to exacerbate their illness. Prisons and jails have become the largest provider of mental health services in almost every state. Today, over 40% of the inmates at Rikers Island have been diagnosed with mental illness. Even judges are distraught: there are not enough residential treatment centers and outpatient settings available for much needed care.
“Are we going back to a homeless explosion?” asks NYSNA Board Member Seth Dressekie, NP, a psychiatric-mental nurse with 15 years of experience at Woodhull Hospital. Today he carries out mental health evaluations for NYC Department of Social Services. “The ER does not stabilize psych patients,” he explains. Seth fears that there are more discharges of people who need to be hospitalized. Many 911 calls for help with people in mental health crisis result in dispatching police. That must change for a number of reasons, he says, not the least of which can be the pitting of police against the seriously ill, a role for which law enforcement is not appropriate.
Quoting a mental health professional in April 23’s New Yorker: “The fact is the administrations, the business of medicine, is putting us — all of us — in harm’s way.” Is this where we want to leave the most vulnerable: In harm’s way?
We are calling on the following facilities to fully reopen their behavioral health units:
- Northwell Syosset
- New York-Presbyterian Methodist
- New York-Presbyterian Allen
- Health Alliance Hudson Valley