Regulation, profit motive challenge ability to treat patients
This is the fourth piece in a four-part series about teen mental health. In the first article, we discussed the increase in teen mental health complaints during 2020; the second piece covered the rising incidence of teen suicide attempts prior to the pandemic. The third article investigated the problematic link between antidepressants and suicidal ideation. This final piece covers the financial incentives for medical facilities to max out their available space and staff without buffers for times of crisis.
Over the past 18 months, children and adults have seen increased rates of mental illness, including depression. National media have reported that some children and teens experiencing mental health crises have been “boarded” for days or even weeks in hospitals. However, the Lehigh Valley may be in a better position than many regions nationwide to cope with mental illness surges.
In June 2021, Boston NPR affiliate WBUR profiled a teen named Melinda who stayed at a Boston-area hospital for weeks after telling her mother she wanted to kill herself. Melinda spent days on a gurney in a hospital hallway, according to WBUR, separated by a curtain from gurneys bearing other teens in crisis, because the psychiatric care unit was full. The WBUR reporter noted that “all the child psychiatric beds in Massachusetts and some neighboring states [were] also full.” It took 17 days for Melinda to be placed at a nearby hospital that had added capacity for pediatric psychiatric care during the coronavirus-related crisis. The full WBUR report is available online (https://www.npr.org/sections/health-shots/2021/06/23/1005530668/kids-mental-health-crisis-suicide-teens-er-treatment-boarding).
The fact that this lamentable situation occurred in Massachusetts is not a coincidence. According to the Mercatus Center, a policy think tank at George Mason University, Massachusetts-like more than half of U.S. states-has “certificate-of-need” (CON) laws governing healthcare capacity. These laws require hospitals and other healthcare providers to apply for permission from a state regulator before expanding capacity; this means that mental health facilities, ICUs, and drug rehabilitation centers cannot add beds without getting the state’s OK.
The CON program, created in New York in 1964, has the stated intent of reducing competition, to increase hospital profitability. Hospitals in CON states are meant to subsidize care for people who are unable to pay, using the increased profits that result from deliberately constrained capacity.
Researchers at the Mercatus Center raised the alarm about the impact CON laws had on ICU capacity in the early days of the coronavirus pandemic. In an April 29, 2020, article, “Raising the Bar: ICU Beds and Certificates of Need,” Matthew D. Mitchell and colleagues argued that “flattening the curve” was only one part of crisis management, and that increasing hospitals’ capacity to treat patients was a crucial-but largely ignored-part of the equation.
“Certificate-of-need laws may contribute to diminished healthcare capacity,” they wrote, “and their elimination can help raise the bar so that the nation is ready for the next healthcare crisis.”
The CON approval process is costly (to the tune of hundreds of thousands of dollars), time-consuming, and allows a healthcare provider’s competitors to challenge the provider’s application for expanded capacity. CON states include Massachusetts, New York, New Jersey, and every state south of Pennsylvania and east of the Mississippi River. The impact on patient care during a crisis can be significant. CON states have about 99 fewer hospital beds per 100,000 population than non-CON states, and CON states that regulate acute hospital beds have 131 fewer beds per 100,000 people. These are the kinds of numbers that can affect a hospital’s ability to serve patients during sharp increases in need, be it the need for ICU beds during an infectious disease epidemic, or the need for pediatric psychiatric care during a time of rising teen depression and suicidality.
But Pennsylvania is not a CON state. Hospitals in the Lehigh Valley do not have to justify expansion decisions to a government regulator, nor do inpatient mental health treatment facilities. To the extent a capacity problem exists in Pennsylvania, it is the result of hospitals’ own internal management strategies.
Available data on mental health quality measures for Lehigh Valley hospitals are limited to those collected as part of the Center for Medicare and Medicaid Services (CMS) Hospital Inpatient Quality Reporting Program. The data point most relevant to the issue of “boarding” teen mental health patients in hospital hallways is that of “Median Time from ED [Emergency Department] Arrival to ED Departure for Discharged ED Patients-Psychiatric/Mental Health Patients.” This data does not include wait times for admitted patients to be given a bed in a psychiatric ward of the hospital; however, it does capture how long non-admitted patients wait to be either treated and discharged or discharged and transferred to another facility.
According to CMS data from the fourth quarter of 2019, the length of time in the emergency department for mental health patients was:
Lehigh Valley Hospital (Cedar Crest): 339 minutes
Lehigh Valley Hospital (Muhlenberg): 444 minutes
St. Luke’s Hospital (Anderson Campus): 213 minutes
St. Luke’s Hospital (Fountain Hill): 304 minutes
St. Luke’s Hospital (formerly Easton Hospital): 201 minutes
St. Luke’s Hospital (formerly Sacred Heart Hospital, Allentown): 175 minutes
Pennsylvania had a statewide average mental health emergency department wait time of 238 minutes; the national average was 208 minutes. As a point of comparison, the average wait time in Massachusetts in the fourth quarter of 2019 was 329 minutes. CMS data from 2020 are not yet available.