Govt. Waives Restrictions Allowing Psychiatric Wards In Hospitals To Admit Covid-19 Patients

Virginia Western State Hospital, state photo

(4-10-20) Notes about mental health and the Covid-19.

At the urging of lobbyists for hospital associations, the Trump Administration has announced that beds reserved for psychiatric patients in general hospitals and state mental hospitals can now be converted into beds for treating Covid-19 patients.

The authority to begin housing Covid-19 patients in beds previously reserved for psychiatric patients was authorized on March 30 and announced in a release by the Centers for Medicare & Medicaid Services which authorizes federal payments through the Medicare, Medicaid, and CHIP programs. CHIP is the Children’s Health Insurance Program (CHIP) that provides health coverage to eligible children.

Why would hospitals want to treat Covid-19 patients rather than psychiatric patients, especially since  advocates have been complaining for years about a lack of crisis care and longer care psychiatric beds?

One could argue that hospitals want to help flatten the curve by using every bed possible to combat the corona virus. That’s admirable. A less noble view is that psychiatric departments in hospitals are among the least profitable.  Time magazine recently reported that one uninsured Covid-19 patient was charged $34,927.43 for treatment in her hospital.

If general hospitals, eager to earn bucks off the pandemic, begin turning away individuals in the midst of a psychiatric crisis or sending them to state hospitals, there will be even more overcrowding and long waits for beds.

So where will psychiatric patients go if all of their beds are being filled with Covid-19 patients?

The same lobbyists who pushed for the 1135 CMS wavier that allows hospitals to convert their psychic beds are urging the White House to stop the enforcement of the IMD exclusion that prohibits federal funds from going to psychiatric treatment facilities larger than 16 beds. Lifting the IMD, which many advocates have urged for years, would allow larger psychiatric facilities.

Crisis Lines: Telephone crisis lines are being swamped during the pandemic. The Veterans Administration usually fields 40,000 calls per month. In March, that number topped 150,000. Other crisis call centers also are reporting a record breaking number of calls. The VA is studying a plan to begin offering psychiatric telehealth conferencing in convenient spots, such as Walmarts, to serve veterans in crisis.

White House Conference Call Encouraging Mental Health Workers: President Donald J. Trump, Melania Trump, Vice President Mike Pence, Karen Pence, HHS Secretary Alex Azar, Veterans Administration Secretary Robert Wilkie, and Assistant Secretary of Health and Human Services for Mental Health and Substance Use Dr. Elinore McCance Katz, spent a half hour on a conference call Thursday with 177 by-invitation-only listeners with varying ties to mental health.

Author D. J. Jaffe, Treatment Advocacy Center Executive Director John Snook, and Miami Dade Judge Steven Leifman were on the call, as was I.

The purpose of the call was to thank mental health workers who are risking their lives to serve individuals in need and to tout what the administration is doing to help Americans with opioid addictions and mental illnesses. The call was mostly a much needed pep talk and I am extremely grateful that the President took time to recognize the importance of mental health workers and mental health care.

As always is the case in Washington, conference calls with the White House are carefully scripted. Four individuals were allowed to ask questions that had been cleared beforehand. Those listening were not allowed to ask questions, which admittedly would have turned into a much longer and chaotic session.

Before the call, I asked a number of mental health experts to share recommendations they would make to the White House.  (These were personal requests by me and should not be seen as statements by any of the organizations that the experts represent.) I will forward these recommendations to the White House. I began by asking several of my colleagues on the Interdepartmental Serious Mental Illness Coordinating Committee that was created by Congress to advise SAMHSA. A top priority was more funding for telehealth.

Clayton Chau, M.D., Ph.D.,  Mind OC/Be Well OC 

Please advocate for the following:

  1. Development of a statewide mental health crisis number that is recognized by all wireless carriers as toll free and would not run up against a subscriber’s plan, especially for those who use prepaid cards.
  2. Strong message against any aggressive/violent act/statements that are anti-Asian Americans.
  3. Support, Personal Protection Equipment funding, directly to community mental health clinics as well as Federally Qualified Health Centers.
  4. Increase mental health funding to local jurisdictions in preparation for a decrease in tax funded programs by states and localities.

Conni Wells, Owner/Manager, Axis Group

  • DO NOT FORGET THE CHILDREN! There are children and youth in these homes with mental health issues that are unable to receive services and supports. Many received those services from school and schools have so many technical limitations.
  • Many of the families, who prior to this had figured out how to navigate the system of care, are unsure of how to access services that are new or provided differently. Case management is NOT happening.
  • Many of our families are struggling with anxiety and fears. Because they are secluded, they are not accessing treatment.

The technology capacity of schools needs to be raised. The Department of Education needs a TA Team to help schools troubleshoot issues.

Kids with IEPs should have interim IEP’s that outline how they will continue to receive the support services they were getting at school.

The President needs to do an update/press conference for kids. He could reassure them that we are working to protect their future, that this will be over, and that they are important to him. Advertise, promote, and spread the news. He would be the first President to talk to America’s children!

Remember…the unmet mental health needs of children will impact the adults in their family and THEIR mental health status.

Kenneth Minkoff, M.D., Zia Partners:

The increased flexibility in Medicaid/Medicare that has been rapidly promulgated during the COVID pandemic is impressive and deserves a lot of credit for provider agencies being able to continue services to those in need through increased connection through telehealth.   This increased flexibility demonstrates that many of the previous requirements might be now outmoded with current technology, particularly in relationship to the needs of individuals and families who have difficulty with transportation and socialization, and therefore should be maintained once the pandemic is over.

There should be a purposeful effort by Centers for Medicare and Medicaid Services to review with stakeholder input all regulations before they are reinstated, to see which ones are absolutely necessary for public health and safety, as well as protection from fraud and abuse. There should also be continuing effort to increase flexibility in requirements under Medicare, as we recommended in ISMICC, for not only expanding who can be covered providers, but expanding access to different levels of care under Medicare (analogous to what can be provided under Medicaid) including hospital and jail diversion interventions.

It would be helpful in a public health emergency to provide judges discretion to divert individuals who need treatment, who are charged with misdemeanors and non-violent felonies, and who would normally be incarcerated for competency restoration, to be sent to alternative settings for treatment, to suspend competency restoration, and to provide for Medicaid payment for diversion interventions. In addition to reducing unnecessary incarcerations, this approach would produce better results than meaningless competency restoration proceedings which often take longer than the sentence for the original crime, and which result in no ongoing treatment.

Elena Kravitz, Disability Rights New Jersey

It would seem to me that the mental health community has been doing pretty well for itself, as odd as that sounds in this desperate time of great additional need, there has been shifting gears as needed, and the offering of both peer support and direct services via telehealth. I would suggest that CMS approve voice only call reimbursement during the current emergency.
Provision of whatever is necessary for community mental health providers to keep people housed with services and be able to discharge people from institution that don’t really need that level of care: temporary housing in hotels or other sites that allow people to be separated.  Within psychiatric facilities – licensed medical health workers to provide services right now in institutions that normally see direct care staff without that experience or training.

Obviously, many ongoing challenges of the MH system have been exacerbated by this condition. State-by-state, there have likely been failures in justice diversion, hospital diversion/respite, community mobile services, supported housing, and overcrowding in hospitals. I hope that in the future, SAMHSA can be mandated to perform a post-mortem of our response to this disaster, and the block grant can be used to push on effective disaster planning.

Mary Giliberti, Mental Health America

There are two matters currently before the administration where they have authority to act and it would make a significant difference to people with mental health conditions.
First, the administration could allow Medicare reimbursement for mental health services by audio only telephone. The administration already determined that psychologists can bill for audio only assessments, but not for any subsequent therapy. There are many older people and people with mental illness who are not comfortable with video or have flip phones.
A second important issue has been raised by the National Association of Medicaid Directors in an April 6th letter. They urge CMS and OMB to allow states to make retainer payments to essential Medicaid providers during this crisis through 1115 waivers. They note that other vehicles such as small business loans will take too much time and providers are at risk of closing their doors now.
They specifically cite behavioral health providers as an example because Medicaid is a primary payer and plays a unique role for these organizations.

Allowing the state Medicaid programs to make retainer payments would ensure that people with the greatest needs have help now and when the crisis is over.

John Snook, Executive Director/ Attorney Treatment Advocacy Center

I am personally very focused on pre-trial competency restoration cases. We have a huge number of people sitting in jails waiting for a state hospital bed that often there longer than their sentence would be — we need solutions to get them out of jail into the community, but just releasing them with no warm handoffs, no strategy for housing, no ACT or AOT, etc is a problem for everyone as well.

From a mental health advocate:

I’ve been doing a literature review for a grant and have recently read how the 2008 economic recession was followed by increased suicides and multiple adverse events contributing to worsening mental illness; such as income loss, unemployment, and family disruption, etc…. In addition to economic barriers and disruptions, this pandemic has really impacted our mental healthcare system’s provision of care. In response to the pandemic, federal agencies have relaxed regulations on telehealth and telephonic services, and have made them more reimbursable.

That access to care has really helped with continuity of care for our patients. Much, although not all, of our patient population has access to devices for telehealth or telephonic connection, but data plans and connectivity are very limited. Funding available devices and connectivity would be hugely beneficial in ensuring continuity of care…Our patients have been available for almost all of their scheduled virtual appointments. So, I would highly recommend permanently removing federal regulatory barriers preventing the utilization and federal reimbursement (CMS) of tele-mental health services, and even adding texting options as a mental healthcare service. This would really allow flexibility to mental health care systems and to our patients.

Licensed Marital & Family Therapists, Licensed Professional Counselors, and Psychiatric Nurse Practitioners should be recognized as Medicare providers.This would expand the number of available mental health providers in rural areas. In many rural states, a large majority of  behavioral healthcare workforce is not able to be reimbursed by Medicare, but they are covered by state Medicaid and private insurance plans. That means patients must change providers or discontinue care when transitioning to Medicare coverage. Medicare standards being more burdensome than the private sector or many state Medicaid plans is an example of federal bureaucracy.

 Sherry Allen, co-founder and managing director at Allen Heritage Foundation, Nashville, Tennessee.

  • Access to telehealth sessions.  The cell phone and broadband desserts are real and more widespread than I think has gotten attention.  Especially if there are considerations for infrastructure expansion,  this is a critical need for folks to have access to mental health care, not only in these times, but that extends to what “after” looks like.  This also has implications for physical health telehealth and remote education.
  • Parity for counselors.  Again, in rural communities, mental health practitioners are few regardless of whether people access face to face or through virtual means.  It is especially concerning for seniors who rely solely on Medicare.  Seniors are experiencing increased isolation which contributes to depression, anxiety, fear, and confusion, all issues that can be addressed through telementalhealth. Grief is an issue for seniors in regular times, and especially true now. Licensed professional counselors still are not accepted for payment by Medicare.
  • Insurance networks.  I work with many youths whose parents work in Nashville, the closest metropolitan center.  Their family insurance is provided by the employer with networks of service providers in that metro center.  Practitioners in their rural home location are considered out-of-network and thus services are either not covered or are covered at a much lower rate.  This is a policy issue to consider with how segmented the current access process is when set up through the current insurance frameworks. As an aside, that is in part why my family started our foundation so that we could provide counseling for youth in this rural county at no cost to them or their families.

From a national housing expert:

For persons with serious behavioral health challenges primarily pre-dating the COVID-19 pandemic, comorbid mental health and physical health disorders is the rule rather than the exception so they are particularly vulnerable to suffering from and dying from COVID.

Mental Health America’s screening data from 2015-2019 highlights that 80% of respondents with COPD and 74% of those with diabetes also have a mental illness. Persons with these conditions, when infected with COVID have initially been found to more frequently need hospitalization or more commonly are found to pass away from the disease. The systems that serve them need to be strengthened to address their unique challenges. Strategies need to focus on supporting their recovery and integration in their local communities.  Institutional settings will only serve to spread the virus and keep the crisis ongoing.

Quickly and safely moving past COVID will require an investment in the social determinants of health including supportive housing. People experiencing homelessness by definition cannot shelter at home. CSH has seen nationwide a rush of states and localities, where people have been released from short term incarceration to address the likelihood of severe outbreaks in jails and prison and the criminal justice systems inability to implement social distancing.  These populations have more co-morbid physical and behavioral health conditions  and therefore will be more likely to be stricken with COVID and need more intensive care and resources to address.  The Social Determinants of Health Accelerator ACT is a small investment to address the needs for more system coordination.

System coordination is only as effective as its goals, evidence base and resources. The Corporation for Supportive Housing’s National Needs assessment for Supportive Housing estimates the need for 1.1 million residential units of supportive housing.  The fourth stimulus must include this type of investment in order to create these units and address the needs in the community to wipe out the COVID virus as soon as possible to ensure that communities are resilient and have the resources needed to address the pandemic.

D. J. Jaffe, author, advocate, blogger, who listened in on the call, forwarded an article entitled: Helping the Seriously Mentally Ill During The Pandemic, that he wrote recently for  The National Review. Here is a short excerpt:

First of all, on the federal level, the government should swiftly suspend Medicaid’s IMD (Institutes for Mental Disease) exclusion and its prison exclusion. Those provisions prevent states from using Medicaid funds to help seriously mentally ill adults who are in psychiatric hospitals and jails, on the grounds that they should be the state’s responsibility. These provisions cause states to empty psychiatric beds and withhold treatment from the incarcerated. This means that the seriously mentally ill who contract coronavirus will be sent to already overcrowded emergency rooms that are ill-equipped to serve them, instead of to specially equipped psychiatric hospitals. The prohibitions on using Medicaid for the incarcerated and hospitalized mentally ill should be waived during the pandemic so that they can be treated appropriately.

Most parents of the seriously mentally ill would love to have their children at home, but when the symptoms of the illness don’t prevent that, financial constraints often do. If a parent provides housing for a mentally ill loved one, he or she gets penalized: The child’s Supplemental Security Income (SSI) disability check is reduced by one-third, making it harder to contribute to the family’s food, clothing, and household expenses. The federal government should abolish this one-third-reduction rule during the pandemic, and preferably permanently, to let parents reduce the demands their children place on already overextended social services. In fact, while our lawmakers are increasing unemployment benefits and making them easier to access, they should also increase the amount of disability payments, because many social services that people with mental illness rely on, such as transportation, have shut down.

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About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.