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SNAP Spending Continued to Fall in 2016

Center on Budget and Policy Priorities - Tue, 10/18/2016 - 4:01pm

SNAP spending fell for the third straight year in fiscal year 2016, new Treasury Department data show.  This shows that SNAP (formerly food stamps) is working as designed: it expanded during the recession and its aftermath to meet increased need, and has fallen as the economy has improved.  

Categories: Benefits, Poverty

Medicaid Works: Medicaid Is an Essential Partner for Supportive Housing

Center on Budget and Policy Priorities - Tue, 10/18/2016 - 10:12am

This is the next in our “Medicaid Works” blog series, which aims to inform the debate over Medicaid’s future by providing the latest facts and figures on this essential and popular part of the nation’s health care system.

Categories: Benefits, Poverty

First Edition: October 18, 2016

Kaiser Health News - Tue, 10/18/2016 - 6:24am
Categories: Health Care

Are Blues’ Plans Benefitting Unfairly From Program To Offset Cost Of Sicker Patients?

Kaiser Health News - Tue, 10/18/2016 - 5:05am

Some health insurers say they’re paying too much to rival Blue Cross Blue Shield plans under a key pillar of the federal health law designed to compensate insurers that take on sicker and more expensive patients.

The critics’ chief complaint is that the Affordable Care Act’s risk-adjustment program unfairly rewards health plans — including Blue Shield of California — that have excess administrative costs and higher premiums. That comes at the expense of more efficient, lower-priced plans in the individual market, they say.

The Obama administration is considering changes to how these dollars are allocated in the state and federal exchanges, but critics say the proposed modifications don’t go far enough.

Molina Healthcare, a Long Beach-based insurer, covers about 600,000 people through exchanges in California, Florida and seven other states. The company’s chief executive, Dr. J. Mario Molina, said the flawed risk-adjustment program is hurting consumers by stifling competition and keeping rates artificially high.

Among insurers, “the rich get richer and the poor get poorer,” Molina said in an interview with California Healthline. “Across the board, the people benefiting from this are the Blues, so they are putting a lot of pressure on to keep the status quo. I think [the Obama administration] understands the issue, but they may lack the political will to change it.”

The Blue Cross Blue Shield Association, which represents 36 plans across the country, has warned Washington against rewriting the rules. Federal officials “should not heed the calls to make radical changes to the risk-adjustment model from a small, but vocal, minority of health plans that did poorly,” the industry association wrote to the Obama administration in a letter released in July.

This story also ran in CNN Money. It can be republished for free (details).

The risk-adjustment program doesn’t rely on government funds. Rather, insurers compensate each other for taking on sicker patients under a complex government formula.

It relies on risk scores assigned to enrollees based on their age, gender and diagnosed medical conditions. The calculation also uses the average statewide premium, which reflects plans’ administrative costs.

Health insurers big and small have said that methodology can hurt lower-priced plans and inflate what they owe.

Some of the new insurance co-ops created under the health law have sued the Obama administration, claiming that the program put them at a competitive disadvantage. The nation’s third-largest health insurer, Aetna Inc., also said “the current model rewards inefficient and expensive plans.” It isn’t involved in the pending litigation.

For the first two years of exchange enrollment, Florida Blue received the most from risk adjustment — $705 million — based on a state-by-state review nationwide. Blue Shield of California was second with $317 million, and a unit of UnitedHealthcare in New York was next at $127 million.

Overall, seven of the top 10 recipients for risk-adjustment dollars were Blues’ plans for 2014 and 2015, federal data show. Blue Cross Blue Shield plans are major players in most state insurance markets, so their strong performance on risk adjustment could be expected. However, a separate analysis by the Fitch Ratings agency found that some of these top recipients also have higher-than-average administrative expenses companywide.

Blue Shield of California called these complaints about risk adjustment “inaccurate.” It said the government formula is “completely independent” of a plan’s administrative costs and does not reward higher premiums.

In a statement, Florida Blue said its reimbursements were “based on the size of the state’s market, our market share and the risk profile of the people we attracted.”

Federal health officials have also defended their program, saying it’s working as intended to compensate insurers that enrolled sicker patients. They have proposed some changes, such as adding prescription drug data to the calculations for 2018.

“These changes will support issuers in serving the highest-cost enrollees while also seeking to make risk adjustment more predictable and more effective at spreading risk for all issuers,” Kevin Counihan, chief executive of the federal marketplace, wrote in an August blog post.

In addition to risk adjustment, there are two other mechanisms in the exchanges to cushion insurers from the cost of sicker enrollees. Reinsurance and a risk-corridor system offer further protection against high-cost claims or large financial losses. But those two programs were always meant to be temporary, and they expire at the end of this year. The risk-adjustment program is permanent, making it a bigger priority for policymakers and industry leaders.

“The heat on these risk-adjustment issues will really ramp up, and there’s a lot of pressure on the administration to make sure this is right,” said Sean Creighton, a senior vice president of risk adjustment at Verscend, a health care analytics company, and a former official at the Centers for Medicare & Medicaid Services. “These are large sums of money to be sloshing around.”

Creighton said the industry complaints warrant a closer look. He said it might make sense to drop the average statewide premium from the formula and focus more directly on a health plan’s medical claims. Some experts have suggested that the government could cap risk-adjustment payouts to a certain percentage of premiums to limit the financial strain on smaller plans.

Under the health law, insurers must spend at least 80 percent of customers’ premiums on medical care for individual policies. This rule helps limit what insurers can spend on administrative expenses and retain as profit.

Timothy Jost, a law professor at Washington and Lee University in Virginia and an expert on the Affordable Care Act, said some administrative expenses are worth counting in the risk-adjustment program because they’re tied to managing patients with diabetes and other chronic conditions.

“Administrative expenses do get factored in and some insurers think that rewards inefficient insurers,” Jost said. “But [U.S.] Health and Human Services has been skeptical of this argument.”

Steve Shivinsky, a spokesman for Blue Shield of California, said “risk adjustment recognizes that Blue Shield attracted sicker members than the market average. That is the primary driver behind the reimbursement.”

But the San Francisco-based insurer also has been open about its struggle with excess overhead. In a recent memo to employees, it conceded that, “we spend more on administrative costs than other comparable health plans.”

Blue Shield of California had the second highest expense ratio among Blues plans for the first nine months of 2015, according to Fitch Ratings. The California insurer spent 15.8 percent of its revenue on administrative expenses. The average for Blues plans nationwide was 10.6 percent. Florida Blue had an above-average expense ratio of 11.6 percent.

Molina said it paid $254 million into the government’s risk-adjustment pool, to be distributed to other insurers. The company said that amount could have been reduced by $44 million, or 17 percent, if it solely reflected medical costs.

“In every single market that we are in, a Blues plan is the No. 1 recipient,” Molina said. “That CEO [in Florida] should be sending me fruit baskets.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Categories: Health Care

7 Insurers Alleged To Use Skimpy Drug Coverage To Discourage HIV Patients

Kaiser Health News - Tue, 10/18/2016 - 5:00am

The health law prohibits insurers from discriminating against people with serious illnesses, but some marketplace plans sidestep that taboo by making the drugs that people with HIV need unavailable or unaffordable, complaints filed recently with the Department of Health and Human Services’ Office for Civil Rights allege. The effect may be to discourage people with HIV from buying a particular plan or getting the treatment they need, according to the complaint.

The complaints, brought by Harvard Law School’s Center for Health Law and Policy Innovation, charge that plans offered by seven insurers in eight states are discriminatory because they don’t cover drugs that are essential to the treatment of HIV or require high out-of-pocket spending by patients for covered drugs.

Insuring Your Health

KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.

To contact Michelle with a question or comment, click here.

The center filed complaints against Humana plans in six states: Alabama, Georgia, Illinois, Louisiana, Tennessee and Texas. Cigna plans were targeted in three states: Georgia, Tennessee and Texas. The group filed complaints against five other insurers: three in Pennsylvania, including Highmark, Independence Blue Cross and UPMC health plan; a complaint against Community Health Choice in Texas and a complaint against Anthem Blue Cross Blue Shield in Wisconsin.

“What’s most important to us is that there’s a robust enforcement mechanism around the promises … in the ACA and its regulations, especially the anti-discrimination provisions,” said Kevin Costello, director of litigation at the health law center.

Although the center’s focus is on HIV drugs, the complaints may help people with other chronic illnesses who may face similar hurdles on access to drugs, Costello said.

The HHS Office for Civil Rights investigates and enforces violations of civil rights and health information privacy. The Harvard center complaints were filed in September.

Federal rules prohibit marketplace plans from adopting benefit designs — such as coverage rules or reimbursement rates — that discriminate based on age, illness, race, gender or sexual orientation, among other things. But federal regulators have declined to define discriminatory plan design, noting that they will examine the facts on a case-by-case basis.

They’ve hinted, however, at some specifics in the regulations. They say, for example, that refusing to cover a single-tablet drug regimen, which is often associated with better compliance because a number of different drugs are combined in one pill, or placing most or all of the drugs that treat a specific condition in the highest cost tiers are examples of “potentially discriminatory practices.”

Working with local AIDS groups in several states, the Harvard center examined hundreds of silver-level plans sold on the marketplaces to gauge whether their formularies would allow access to six treatment regimens that are the current standard of care for treating people who are newly diagnosed with HIV. In addition, they looked at the plans’ cost-sharing requirements, Costello said.

They found, for example, that this year Anthem silver plans in Wisconsin cover only four of the 16 drugs or combination products that are recommended to meet the current standard of care, and they fail to cover any single-tablet regimens.  In Illinois, the center charged that Humana’s silver plans place 16 of the 24 most commonly prescribed HIV drugs in the highest cost-sharing tier, which requires patients to pay 50 percent of the cost. With estimated monthly costs ranging from $377 to $684 for different drug regimens, enrollees in the Illinois Humana plans would have to pony up between 8 and 14 percent of their average monthly income, according to the complaint.

“All Humana health insurance plans offered through the Health Insurance Marketplace fully comply with state and federal laws and regulations,” said Alex Kepnes, Humana’s director of corporate communications. He added, “Humana shares the concerns of HIV/AIDS organizations regarding the high cost of HIV/AIDS drugs and we are committed to working with them to lower prescription drug costs.”

Similarly, Anthem Public Relations Director Scott Larrivee said, “Anthem Blue Cross and Blue Shield is committed to providing all of our members with access to the care and services they need, including appropriate coverage of medications for the treatment of HIV/AIDS. Anthem Blue Cross and Blue Shield in Wisconsin covers more than a dozen medications for the treatment of HIV/AIDS and all required therapeutic drug categories are included on our formulary/drug list which is compliant with (marketplace) requirements.”

Cigna spokesman Mark Slitt said his company does not comment on pending legal matters.

The center’s work builds on an earlier discrimination complaint filed in 2014 with the Office for Civil Rights by two advocacy groups, the AIDS Institute and the National Health Law Program, against four Florida insurers that were selling marketplace plans. That complaint, against some of the same insurers highlighted by the Harvard center, charged that the insurers placed all the HIV drugs in the highest cost-sharing tier. The Florida insurance commissioner reached agreements with the four plans to move the HIV drugs to generic tiers and reduce cost sharing, and the same arrangement will continue in 2017, said Carl Schmid, deputy executive director of the AIDS Institute.

“We’ve been talking about these issues for years now,” Schmid said. “These things need to be addressed, and it could be through enforcement” by the Office for Civil Rights.

Marketplace coverage of drugs to treat HIV and other serious conditions have improved somewhat in recent years, according to research by Avalere Health, a consulting company. An analysis found that in the case of five classes of drugs that treat cancer, HIV and multiple sclerosis, fewer silver plans in 2016 placed all the drugs in the class in the top tier with the highest cost sharing or charged patients more than 40 percent of the cost for each drug in the class.

Speaking about HIV drugs, Caroline Pearson, a senior vice president at Avalere, said that while access and costs in marketplace plans are improving, they vary widely from plan to plan. Employer plans tend to offer better coverage, she said.

The new complaints may put more pressure on the Office for Civil Rights to address this issue, said Katie Keith, a steering committee member for Out2Enroll, a health insurance advocacy group for the lesbian, gay, bisexual and transgender community.

“It’s smart to do this in multiple states,” she said. “People are really pushing for more concrete guidance.”

Please visit to send comments or ideas for future topics for the Insuring Your Health column.

Categories: Health Care

New Shelving – Pic of the Week

In Custodia Legis - Mon, 10/17/2016 - 4:39pm

As I wrote last June, we have been installing new compact shelving in the smallest of the four quads which house the bulk of our collection.

Well, the new shelving is in and it looks great!

Not only does it look good, but the mechanics are much smoother than its aging counterparts, making the units move more easily.  With some of the older ranges, staff really felt all of the 1,000 or so volumes that they were moving.  Whereas the new units glide along as if they weigh just a few pounds.

So far we couldn’t be happier with our new shelving.

Categories: Research & Litigation

Staying Out Of The Closet In Old Age

Kaiser Health News - Mon, 10/17/2016 - 4:15pm

Partners Edwin Fisher, 86, and Patrick Mizelle, 64, moved to Rose Villa in Portland, Oregon, from from Georgia about three years ago. Fisher and Mizelle worried residents of senior living communities in Georgia wouldn’t accept their gay lifestyle. (Anna Gorman/KHN)

Patrick Mizelle and Edwin Fisher, who have been together for 37 years, were planning to grow old in their home state of Georgia.

But visits to senior living communities left them worried that after decades of living openly, marching in pride parades and raising money for gay causes, they wouldn’t feel as free in their later years. Fisher said the places all seemed very “churchy,” and the couple worried about evangelical people leaving Bibles on their doorstep or not accepting their lifestyle.

“I thought, ‘Have I come this far only to have to go back in the closet and pretend we are brothers?” said Mizelle. “We have always been out and we didn’t want to be stuck in a place where we couldn’t be.”

So three years ago, they moved across the country to Rose Villa, a hillside senior living complex just outside of Portland that actively reaches out to gay, lesbian and transgender seniors.

As openly gay and lesbian people age, they will increasingly rely on caregivers and move into assisted living communities and nursing homes. And while many rely on friends and partners, more are likely to be single and without adult children, according to research published by the National Institutes of Health.

Rose Villa Senior Living, located just outside of Portland, Oregon, has made a point of welcoming LGBT elders. The community, which offers independent and assisted living, also has a nursing home on site. (Anna Gorman/KHN)

But long-term care facilities frequently lack trained staff and policies to discourage discrimination, advocates and doctors said. That can lead to painful decisions for seniors about whether to hide their sexual orientation or face possible harassment by fellow elderly residents or caregivers with traditional views on sexuality and marriage.

This KHN story also ran on The Oregonian. It can be republished for free (details).

“It is a very serious challenge for many LGBT older people,” said Michael Adams, chief executive officer of SAGE, or Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders. “[They] really fought to create a world where people could be out and proud. … Now our LGBT pioneers are sharing residences with those who harbor the most bias against them.”

There are an estimated 1.5 million gay, lesbian and bisexual people over 65 living in the U.S. currently, and that number is expected to double by 2030, according to the organization, which runs a national resource center on LGBT aging.

Click to view slideshow.

Nationwide, advocacy groups are pushing to improve conditions and expand options for gay and lesbian seniors. Facilities for LGBT seniors have opened in Chicago, Philadelphia, San Francisco and elsewhere.

SAGE staff are also training providers at nursing homes and elsewhere to provide a more supportive environment for elderly gays and lesbians. That may mean asking different questions at intake, such as whether they have a partner rather than if they are married (even though they can get married, not all older couples have).  Or it could be a matter of educating other residents and offering activities specific to the LGBT community like gay-friendly movies or lectures.

Mizelle, 64, and Fisher, 86, said they found the support they hoped for at Rose Villa, where they live in a ground-floor cottage near the community garden and spend their time socializing with other residents, both gay and straight. They both exercise in the on-site gym and pool. Fisher bakes for a farmer’s market and Mizelle is participating in art classes. Fisher, who recently had a few small strokes, said they liked Rose Villa for another reason too: It provides in-home caregivers and has a nursing facility on site.

But many aging gays and lesbians — the generation that protested for gay rights at Stonewall, in state capitols and on the steps of the Supreme Court — may not be living in such welcoming environments. Only 20 percent of LGBT seniors in long-term care facilities said they were comfortable being open about their sexual orientation, according to a recent report by Justice in Aging, a national nonprofit legal advocacy organization.

Ed Dehag, 70, at the Triangle Square Apartments in Los Angeles, California, in August 2016. The retired floral designer moved into the building when his partner passed away and he couldn’t afford the rent on his old apartment by himself. (Heidi de Marco/KHN)

This summer, Lambda Legal, a gay advocacy group, filed a lawsuit against the Glen Saint Andrew Living Community, a senior residential facility in Niles, Illinois, for failing to protect a disabled lesbian woman from harassment, discrimination and violence. The resident, 68-year-old Marsha Wetzel, moved into the complex in 2014 after her partner of 30 years had died of cancer. Soon after, residents called her names and even physically assaulted her, according to the lawsuit.

“I don’t feel safe in my own home,” Wetzel said in a phone interview. “I am scared constantly. … What I am doing is about getting justice. I don’t want other LGBT seniors to go through what I’ve gone through.”

Karen Loewy, Wetzel’s attorney at Lambda Legal, said senior living facilities are “totally ill-prepared” for this population of openly gay elders. She said she hopes the case will not only stop the discrimination against Wetzel but will start a national conversation.

“LGBT seniors have the right to age with dignity and free from discrimination, and we want senior living facilities to know … that they have an obligation to protect it,” Loewy said.

A photo of Dehag’s partner sits on the dresser in his bedroom. Dehag moved into one of the apartments shortly after his partner passed away. (Heidi de Marco/KHN)

Spencer Maus, spokesman for Glen Saint Andrew, declined to comment specifically on the lawsuit but said in an email that the community “does not tolerate discrimination of any kind or under any circumstances.”

Many elderly gay and lesbian people have difficulty finding housing at all, according to a 2010 report by several advocacy organizations in partnership with the federal American Society on Aging. Another report in 2014 by the Equal Rights Center, a national nonprofit civil rights organization, revealed that the application process was more difficult and housing more expensive for gay and lesbian seniors.

Recognizing the need for more affordable housing, the Los Angeles Gay & Lesbian Elder Housing organization opened Triangle Square Apartments in 2007. In the building, the first of its kind, residents can get health and social services through the Los Angeles LGBT Center. The wait for apartments with the biggest subsidies is about five years.

Residents display rainbow flags outside their doors throughout the building. On a recent morning, fliers about falls, mental health, movie nights and meningitis vaccines were posted on a bulletin board near the elevator.

Lee Marquardt, 74, at the Triangle Square Apartments in Los Angeles, California, in August 2016. Marquardt moved into the apartment building two years ago. She said she didn’t want to spend her elder years hiding her true self as she had as a younger woman. (Heidi de Marco/KHN)

Ed Dehay, 80, moved into one of the apartments when they first opened. His partner had recently passed away and he couldn’t afford the rent on his old apartment by himself. “This was a godsend for me,” said Dehay, a retired floral designer who has covered every wall of his apartment with framed art.

His neighbor, 74-year-old Lee Marquardt, said she came out after raising three children, and didn’t want to spend her elder years hiding her true self as she had as a younger woman. Marquardt, a former truck driver who has high blood pressure and kidney disease, said she found a new family as soon as she moved into the apartment building two years ago.

“I was dishonest all the time before,” she said. “Now I am who I am and I don’t have to be quiet about it.”

Tanya Witt, resident services coordinator for the Los Angeles LGBT Center, said some of the Triangle Square residents are reluctant to have in-home caregivers — even in their current housing — because they worry they won’t be gay-friendly. Others say they won’t ever go into a nursing home, even if they have serious health needs.

Marquardt holds an old photograph of herself of when she was married. Marquardt, a former truck driver who has high blood pressure and kidney disease, came out after raising three children. (Heidi de Marco/KHN)

In addition to facing common health problems as they age, gay and lesbian seniors also may be dealing with additional stressors, isolation or depression, said Alexia Torke, an associate professor of medicine at Indiana University.

“LGBT older adults have specific needs in their health care,” she said. And caregivers “need to be aware.”

Lesbian, gay and bisexual elders are at higher risk of mental health problems and disabilities and have higher rates of smoking and excessive alcohol consumption. They are also more likely to delay health care, according to a report by The Williams Institute at UCLA School of Law. In addition, older gay men are disproportionately affected by some chronic diseases, including hypertension, according to research out of UCLA.

Torke said LGBT seniors are not strangers to nursing homes. The difference now is that there is a growing recognition of the need to make the homes safe and welcoming for them, she said.

The Los Angeles Gay and Lesbian Elder Housing organization opened Triangle Square Apartments in 2007. In the first of its kind building, residents can get health and social services through the Los Angeles LGBT Center.

At Rose Villa, CEO Vassar Byrd said she began working nearly a decade ago to make the community more open to gays after a lesbian couple told her that another facility had suggested they would be more welcome if they posed as sisters. Today, several gay, lesbian and transgender people — individually and in couples — are living there, Byrd said. Her staff has undergone training to help them better care for that population, and Byrd said she has spoken to other senior care providers around the nation about the issue.

Bill Cunitz and Lee Nolet, who began dating in 1976, didn’t come out as a couple until they moved to Rose Villa last year. Cunitz is an ordained minister and former head of a senior living community in Southern California. He said he didn’t want to be known as the “gay CEO.”

Nolet, a retired nurse and county health official, said it’s been “absolutely amazing” to find a place where they can be open— and where they know they will have accepting people who can take care of them if they get sick.

“After 40 years of being in the shadows … we introduce each other as partner,” Nolet said. “Everyone here knows we’re together.”

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

Categories: Health Care

Medicaid Spending and Enrollment Growth Expected to Slow Next Year

Center on Budget and Policy Priorities - Mon, 10/17/2016 - 2:58pm

Medicaid enrollment and spending growth is expected to slow again in state fiscal year 2017 as the initial effects of health reform’s Medicaid expansion taper off, the new Kaiser Family Foundation annual survey of state Medicaid directors finds.  While expansion states expect to spend slightly more of their own money on Medicaid next year due to the expansion, states knew that would be the case before they adopted the expansion.  Moreover, as

Categories: Benefits, Poverty

Scarcity Of Mental Health Care Means Patients — Especially Kids — Land In ER

Kaiser Health News - Mon, 10/17/2016 - 12:09pm

On any given day, pediatrician Lindsay Irvin estimates a quarter of her patients need psychiatric help. She sees teens who say they are suicidal, and elementary school children who suffer chest pains stemming from bullying anxiety.

Though she does her best, she doesn’t consider herself qualified to treat them at the level they need at her practice in San Antonio. She doesn’t have the training, she said, to figure which medications are best suited to treat their various mental health conditions. And she doesn’t have time. She’s juggling stomach ailments, vaccinations and ear aches.

But her daily experiences evidence the degree of unmet need for mental health treatment. “I see kids’ lives destroyed by not getting care,” she said.

Now, research abstracts presented Monday by the American College of Emergency Physicians offers insights into how frequently patients with mental health issues land in the emergency room — often because opportunities to intervene earlier are missed.

The researchers analyzed data compiled by the National Hospital Ambulatory Medical Care Survey, which tracked mental health visits to the emergency department between 2001 and 2011. The data tracks a national sample of patients who use hospital emergency and outpatient departments.

Use Our Content This KHN story can be republished for free (details).

Compared with patients who have physical illnesses, the researchers found that people with mental health conditions rely more on the emergency department, and are more likely to be admitted when they show up. They tend to stay longer, too. The researchers have not yet described down how the visits broke out by age. But anecdotally, children and older patients — “the extremes” — appear particularly affected, said Suzanne Lippert, a clinical assistant professor in emergency medicine at Stanford University, and lead author on the abstracts.

These findings underscore two concerns, Lippert said. They highlight potential consequences when patients can’t find good outpatient mental health care, and that, when psychiatric patients arrive in a crisis, there’s often no good place for them to continue treatment once the immediate issue has been addressed.

Medical patients can usually be sent home “because we know they’ll be evaluated by [their] doctor in one or two days,” Lippert said. But psychiatric patients don’t always have that option because of gaps in the mental health care system.

Young patients may be affected the most, said Steven Schlozman, an assistant professor of psychiatry at Harvard Medical School and associate director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital. He was not affiliated with the research.

“It’s a numbers game. Unless you live in a large urban area, you’re very unlikely to find a child psychiatrist,” Schlozman said. The emergency department, then, often is the only realistic venue for care.

Some numbers: About 6 percent of all emergency department patients — of all ages — had a psychiatric condition. More than 1 in 5 were admitted, compared with just over 13 percent of medical patients, and about 11 percent required transfer to another facility, compared with 1.4 percent. About 23 percent of mental health patients stayed in emergency care for longer than 6 hours, and about 1.3 percent for more than 24 hours — compared with 10 percent and half a percent of medical patients.

The most severely ill mental health patients were far more likely to spend extended periods of time in the ER. Bipolar disorder, depression, psychosis and having multiple conditions all tracked with stays longer than 24 hours.

These findings, the researchers write, highlight a “growing crisis.”

There is also a national shortage of inpatient psych beds, so patients have to wait longer in the ER, Lippert said. She’s seen them stay for over a week.

An online poll of emergency physicians released Oct. 17 offers evidence of how this plays out for young psychiatric patients. Of the 1,700 physicians responding, more than half (57 percent) reported increased wait times and boarding for children with mental health issues.

Plus, psychiatric patients can be harmed by long stays in cramped, overused emergency quarters, said Thomas Chun, an associate professor of emergency medicine and pediatrics at Brown University.

“We are the wrong site for these patients, and they have very important, very special needs. Our crazy, chaotic environment is not a good place for them,” said Chun, who was not affiliated with the abstracts.

Meanwhile, the young patients are least likely to get reliable care even after leaving. Whether they need regular follow-up with a psychiatrist, or a transfer to specialized facility, the resources often aren’t in place. The American Academy of Child and Adolescent Psychiatry estimates 8,300 such specialists practice in the country, while more than 15 million young patients need services.

“They’ll land in a pediatrician or family practice,” Irvin said. “I’m not trained to navigate the ins and outs of psychotropic meds,” she added, recalling difficulties she recently had finding a specialist who could prescribe the necessary medications and continue working with a suicidal teenage girl, who was one of her patients.

And children in crisis sometimes wait weeks for proper in-patient treatment, Chun said. That’s less common in his home state of Rhode Island which, he said, is “fairly resource-rich” in terms of psychiatric care — but he hears it often from colleagues in New York. Doctors will agree a child needs to be transferred, but no beds are available.

For children, the problem also doesn’t fall evenly. The resource squeeze is especially problematic for families with limited means, noted Alfiee Breland-Noble, an associate professor of psychiatry at Georgetown University Medical Center, who was not involved with the research. Cost, coupled with a stigma toward mental conditions, means low-income families are more likely to let a child’s ailment slide, until it reaches a crisis point.

That tracks with another finding: Emergency psychiatric patients were more likely to be uninsured than were physical health ones. About 22 percent of mental health patients lacked coverage, versus 15 percent for physical conditions — likely, Lippert said, in part because of the particular challenges the uninsured face in finding affordable psychiatry.

In San Antonio, just one visit to a child therapist can cost hundreds of dollars out of pocket, Irvin said. For her patients, the choice can be a week’s worth of groceries or seeing the doctor. Often, that means, “a kid will go neglected.”

By the time a child gets treatment, she added the mental condition can have produced physical ailments, too. It’s more expensive to treat, it’s bad medicine, and it’s avoidable, she said.

“These kids should never be in the emergency room,” she said. “They shouldn’t be waiting for 24 hours in a plastic chair.”

Categories: Health Care


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