Diminished care, diminishing returns

From the Oregonian, July 27, 2003

Cutting mental health services to patients such as Douglas Bean has cost Oregon more money than it is saving

Douglas Bean was a quiet success story for the psychiatrists and others who struggled to treat him. After more than 30 years in and out of state hospitals, he was finally living on his own. His frequent visits to a Portland mental health agency cost about $2,000 a year.

Then in February, as Oregon grappled to balance its budget, the state stopped paying for that care.

Bean quickly fell apart and wound up in the emergency room of a Portland hospital, which later admitted him to its psychiatric unit. His weeklong stay cost taxpayers more than $7,000.

In the past five months, Oregon has dramatically reduced its spending on mental health, saving the cash-strapped state $21 million. But state officials say those savings are already evaporating as people such as Bean deteriorate and require much more expensive care. Many have landed in hospital psychiatric units and emergency rooms, where a few hours of care can cost as much as six months of outpatient treatment.

Officials at the Department of Human Services say the mounting costs could outstrip even the short-term benefits of the cuts.

“I don’t know when we will hit the point of paying more than we’ve saved,” DHS Director Jean Thorne said. “But it’s possible it will happen.”

Community mental health officials said they believe Oregon has already reached that point.

“I would be amazed if the state has saved anything,” said Leslie Ford, CEO of Cascadia Behavioral Healthcare in Portland, where Bean was treated until February.

State officials said they do not yet have precise figures for how much has been paid in mental health-related emergency room visits and additional inpatient psychiatric care. Hospitals have up to six months to submit data and some are thought to be absorbing a substantial portion of the additional costs.

To Ford and her colleagues at Cascadia, the anecdotal evidence is clear.

There is the woman who couldn’t afford her new $15 weekly co-payment for medications. She quickly became psychotic and wound up in the hospital for five days at a cost of more than $800 a day.

Another woman, Ford said, who lost her medication and counseling tried to commit suicide by jumping off a bridge. Her care had cost less than $2,000 annually. Now, the state will pay intensive care and rehabilitation costs of at least 50 times that.

Oregon’s cuts to mental health services run counter to national research that shows reducing medications, housing and counseling only increases costs borne by the mental health and criminal justice systems.

“We knew it would happen,” Ford said. “I’m surprised it happened this fast. It’s an eloquent demonstration that if you don’t pay for prevention, you’re going to pay for emergency.”

In April, the state surveyed hospitals across Oregon to try to gauge the impact.

Of 16 hospitals that responded, 13 reported an increase in the number of people seeking emergency psychiatric care since the budget cuts took effect.

Providence Medical Center in Portland, for example, has seen a 14 percent increase. Oregon Health & Science University reported a 25 percent to 30 percent jump.

Smaller emergency rooms in Baker City, Cottage Grove, Heppner and Springfield reported only slight increases but said they expect more soon.

“It will be a bloody nightmare,” the state survey quoted a worker at McKenzie-Willamette Hospital in Springfield as saying. “Hospitals are not set up to take this increase. People are receiving very expensive work-ups.”

Battling an illness for decades

Bean’s case illustrates the problem.

Throughout his 20s, 30s and 40s, Bean was ordered in and out of psychiatric hospitals in California and Oregon more than a dozen times. Electro-shock treatments all but destroyed his memory. His disease, bipolar disorder, took everything else.

In 1988, after he slammed his car into another vehicle and injured himself and two others, a court ordered Bean to take his medications and participate in a publicly funded mental health program.

The care he received at Cascadia Behavioral Healthcare in Portland was simple but effective: help deciphering his electric bill. Help so he could remember to take his medications. An occasional reminder of what year it was.

The years passed, and Bean, now 60, never committed another crime or returned to the hospital. Last year, he moved into his own apartment after more than a decade in a state-paid group home.

Bean’s Social Security disability income of $865 a month makes him ineligible for the Oregon Health Plan, the state’s insurance program for low-income people whose coverage is required by federal Medicaid law.

To pay for his prescription drugs, Bean’s case manager, Genevieve Moore, tried to sign him up for the state’s Medically Needy Program. The benefit covered more than 9,000 Oregonians who did not qualify for the health plan but had unusually high medication expenses.

The program was scrapped Feb. 1 — around the same time the Psychiatric Security Review Board turned him out of its group home and stopped paying for Bean’s therapy because he’d successfully served his probation on the 1988 traffic charge.

When told he would no longer receive services, even Bean, who has trouble remembering what pocket he keeps his wallet in, knew what lay ahead.

“So what? I’ll just get manic and depressed and spend the rest of my life in the state hospital,” he told Moore. “That’s a great life.”

After Bean was cut from services, Moore tried to keep him on track, even though she wasn’t paid to do so. She got him signed up for seven different free prescription samples — a temporary measure in which drug companies give “scholarships” to some patients — and checked on him by phone on her own time.

But without regular reminders of when to take his pills, as well as the daily routine of going to see Moore and his friends, his fellow clients at Cascadia, Bean became psychotic. In late June, an apartment maintenance worker found him naked, crawling in his own filth and crying that the world was ending.

At least some of Bean’s recent and future hospital costs will be paid by Medicare, the federal health plan for older and disabled people. But for many low-income Oregonians now forced to seek mental health care in hospitals, the burden falls fully on the state.

Hospital officials say many of those flooding their emergency rooms are enrolled in Oregon Health Plan Standard, which provides a lesser benefit for the working poor who earn too much to qualify for full health plan benefits.

On March 1, lawmakers dropped mental health coverage from that plan, but hospitalizations and emergency room visits were still covered. In other words, they no longer could be treated on the less expensive outpatient basis.

“Hospital units are packed with people because it’s the only mental health benefit people have, and it’s indefinite,” said Dr. Peter Davidson, chief clinical officer for Multnomah County’s Mental Health & Addiction Services Division.

“The more they get hospitalized, the more the state pays. What this means is that the disenrollment didn’t save any money, which of course, we all predicted.”

Lawmakers also put an end to retroactive health plan enrollments. In the past, if an uninsured patient showed up in an emergency room and was eligible for the health plan, the hospital could recoup its costs. Now hospitals must absorb those bills, which are eventually shifted onto commercial insurers and their policyholders.

Even cuts that appeared to be minimal — such as health plan co-payments for prescriptions — have boomeranged.

Two months ago, a local pharmacy turned away a Cascadia client who couldn’t afford a $15 co-pay on her anti-psychotic prescriptions.

“She got frustrated, so she just went without for two weeks,” said Dr. John Bischof, medical director at Cascadia and the woman’s psychiatrist. The woman, who suffers from bipolar disorder, became psychotic and was hospitalized for five days.

When put back on her medications, the woman was “immediately clearer, better,” Bischof said.

“The state paid for that to the tune of $5,000, solely because the pharmacy, as their representative, could not collect a savings of maybe $15 on her prescriptions,” Bischof said.

“The shortsightedness of that is outrageous. Not to mention the impact on this woman’s life.”

Caregiver’s fears become reality

The bulk of the service cuts, which have led to what mental health officials call the imminent collapse of the system, was made quickly during the past five months by legislators intent on balancing the budget.

Mental health workers across the state have lobbied lawmakers throughout the current session to restore some of what has been lost, not only to stave off skyrocketing costs, but also to save lives.

In February, Cascadia’s Ford testified before lawmakers and predicted — correctly — that without care, Bean would wind up in the hospital. She did not name him. Bean subsequently agreed to allow The Oregonian to make his case public.

Ford also told lawmakers the story of a woman in her 40s who last year had repeatedly plunged a knife into her chest and, on another occasion, barreled her car into oncoming traffic.

The woman had responded well to medication and counseling, but without care, “she will likely have contact with the criminal justice system again,” Ford said. “And one episode of booking costs as much as an average year of outpatient treatment.”

As it turned out, Ford’s prediction was too optimistic — for both the woman and the state’s bottom line.

In April, only two months after the woman lost her services, she became despondent and jumped off a freeway bridge.

She survived, but taxpayers now will pay at least $100,000 for her six weeks in the hospital, including two weeks in intensive care, and the year she will spend at a rehabilitation center.

Davidson said he at least has some hope for Multnomah County clients. In May, voters there approved a temporary income tax increase that will soon help restore some of the lost services.

“We’re going to put a whole bunch of folks back into regular services to try to stem this tide,” he said.

But most counties, many of which have been patching together their crisis programs with dwindling reserve funds, predict the worst is yet to come.

“If we don’t get money soon, you’ll see the real crash in the emergency rooms in the next few months,” said Gina Firman, executive director of the Association of Oregon Community Mental Health Programs.

It is unclear whether any funding will be restored to the 2003-05 budget to mental health programs by lawmakers grappling to close a $1 billion gap.

After his hospitalization last month, Bean moved in with his daughter in Eugene.

His medication scholarships could run out at any time, and Moore said she is worried. Bean’s illness, she says, comes on like a series of fires, each one harder to douse than the last.

“If anything happens,” a Cascadia psychiatrist told Bean’s daughter last week. “Take him to the emergency room.”