Almost half of all psychiatric admissions to a 24-hour facility in the United States are made to a psychiatric unit in a general hospital. The number of psychiatric beds in general hospitals probably peaked in 1998, at 54,434 beds.
Since then, however, the decline of psychiatric beds has been steady. A 2006 survey of state mental health authorities, for example, reported that 80% of states have a shortage of psychiatric beds.
At the same time, one survey of emergency departments showed that mental health-related visits rose 75% from 1992 to 2003. Furthermore, it is thought that nurses in emergency departments spend twice as much time finding beds for psychiatric patients as they do for medical patients.
What explains these trends? Most experts point to an evolution in venues where inpatient services are provided. In 1970, about 80% of psychiatric beds were in state-and county-run mental hospitals.
But those closed throughout the 1970s. Until the late 1990s, private hospitals compensated for the loss of the government hospitals by opening psychiatric units because the reimbursement situation was favorable. However, that no longer appears to be the case, according to Dr. Benjamin Liptzin, who serves as chair of the department of psychiatry at Baystate Medical Center, Springfield, Mass., and is a professor of psychiatry at Tufts University, Boston.
From the peak in 1998, the number of psychiatric beds in general hospitals dropped to 40,000 in the year 2000, while admissions were increasing. It has been estimated that the number has dropped an additional 3% since 2003.
Reimbursement no longer favors psychiatric beds, Dr. Liptzin says.
In 1983, Medicare enacted the prospective payment system for hospitals, but psychiatric services were exempt because the costs and needs of psychiatric patients were deemed too unpredictable. Later, managed care cost-cutting hit the market, and in 2005 the Medicare exemption was rescinded. As a consequence, the number of beds in private and general hospitals is falling.
Dr. Liptzin believes that if nothing is done to reverse this trend, the future of psychiatric services in general hospitals will be in peril. CLINICAL PSYCHIATRY NEWS spoke with Dr. Liptzin about the situation.
CLINICAL PSYCHIATRY NEWS: What kinds of trends have you observed in the area of inpatient psychiatric services?
Dr. Liptzin: The beds in private and general hospitals increased dramatically with the availability of health insurance coverage and the decline of the public mental health system. The number had been going up during the 1990s and only more recently declined.
CPN: What factors explain this decline?
Dr. Liptzin: There are a couple of explanations. One is that length of stay has come down, so not as many beds are needed. But also, the reimbursement has become inadequate. In Massachusetts, for example, general hospitals are now being reimbursed for psychiatric services by Medicaid at 39% less than their costs.
CPN: Admissions and emergency department visits are going up. If length of stay is going down, how would you assess the need for beds?
Dr. Liptzin: I think the demand has gone down some, but the reason beds are being closed is largely economic.
CPN: You recently wrote a commentary titled, "The Future of Psychiatric Services in General Hospitals" (Am. …