Scope of Patient Dumping in Psychiatric Industry Cited
For immediate release: December 09, 1997
Boston, MA--Based on a national analysis of data from community health centers, hospitals and health care competition in various U.S. regions, Harvard researchers find that economically motivated transfers ("dumping") of psychiatric patients from hospitals to community mental health centers or state-run psychiatric hospitals were higher in areas with higher competition among hospitals, more for-profit hospitals and relatively smaller public sector in-patient capacity. Such transfers involved psychiatric patients who were non-emergency, medically stable individuals. A full two-thirds of hospitals included in the study were engaged in such transfers. The study is reported in the December issue of Health Services Research.
Anti-dumping legislation has been passed in some states to prevent such transfers but has typically extended only to medically unstable patients. The psychiatric patients described in this study are not protected by such legislation because they were non-emergency, and medically stable, patients. "We were interested in the potential impact of managed care and increased competition on the behavior of hospitals in terms of caring for a psychiatric patient population. This is an historically more vulnerable, and expensive, population to serve. Given cutbacks in public health hospitals and community health centers in recent years, we were interested in to what extent the scope of patient transfers to the community added to the public burden," comments Robert Dorwart, chief of psychiatry at Cambridge Hospital; Professor in the Department of Health Policy and Management, Harvard School of Public Health; and Professor of Psychiatry at Harvard Medical School.
While dumping as a phenomenon has been observed anecdotally in communities for some time, this is the first study to examine the interaction of the health care environment on hospital practices with regard to economically motivated transfers of psychiatric patients.
How is "dumping" accomplished? Hospitals may discourage an admission or, alternatively, discharge a patient after the high cost of care has become evident. The study finds that in areas with larger public capacity, dumping is increased. Investigators also find that the uninsured faced the most predictable barriers: the proportion of administrators who found it very difficult to find an admitting hospital increased fivefold for uninsured adolescents and twelvefold for the seriously mentally ill when compared to their insured counterparts. Strong hospital competition in a community appeared to have a striking, deleterious effect on admission of uninsured patients.
Previous studies suggest that private hospitals have a long history of transferring patients because the costs of care are high. The investigators cite additional contemporary pressures that could be expected to increase transfers: the increasing use of utilization review by insurance companies to contain costs; the use of the prospective system of payment by Medicare and other insurers such that hospitals are vigilant about exceeding the benchmarked average costs of care; reduced compensated care pools; and increased competition among hospitals in the managed care environment.
"Transfers disrupt continuity of care and creates a situation where patients are more likely to "fall through the cracks" of the treatment system," comments Dr. Dorwart. "The prospects for these patients is made worse in a public system that is receiving progressively less government support as time goes on. That access for the uninsured is severely impaired is no surprise. We need to take notice and do something about the impact of health system changes on some of the most vulnerable patients."
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