COMMENTARY

Cedars-Sinai Nixing Psychiatric Services -- Now What?

Jeffrey A. Lieberman, MD

Disclosures

February 15, 2012

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Hello. This is Dr. Jeffrey Lieberman of Columbia University, speaking for Medscape. I would like to talk today about a topic we have been hearing a lot about lately: healthcare reform. For the past 2 decades, concern about rising healthcare costs in this country has been increasing. In the absence of any systematic, comprehensive, predetermined policy to reform the healthcare system or its financing, cost containment has largely been accomplished through the brute force of the marketplace using the blunt instrument of managed care.

Recently, I was in California giving grand rounds at University of California Los Angeles (UCLA) and found out about some developments in the Los Angeles area. Specifically, one of the major healthcare providers in that area, Cedars-Sinai Hospital, made a decision to close its Department of Psychiatry and substantially reduce and almost eliminate its psychiatric services. This decision was made by the hard realities of healthcare economics: How do you sustain a hospital in terms of the revenues that are generated for the various services that it provides? When one looks at it from the perspective of a hospital executive who is trying to make ends meet and justify expenditures based on revenues, it is clear that certain services are money losers. We have known this includes what are called the "cognitive specialties" -- those that are not procedure- or surgical-based specialties -- and none are more problematic in this respect than psychiatry and mental healthcare services. So, as a result, Cedars-Sinai made the decision to close their inpatient and ambulatory services that provide care for primary psychiatric disorders. The only services that the hospital would entertain continuing are those that provide psychiatric consultation to people who are being admitted to the hospital for medical, surgical, or nonpsychiatric medical problems. This decision makes sense from an economic standpoint, but it clearly backs away from the responsibility and missions of hospitals and healthcare systems to provide care to patients in terms of all of their needs, including their psychiatric and mental healthcare needs. Increasingly, however, this is a hard decision that hospitals are being forced to make in order to maintain their financial viability.

The unvarnished truth of the matter is that psychiatric services to patients with primary psychiatric illnesses (particularly the severe illnesses, mood disorders, psychotic disorders, dementia, and child psychiatric disorders) are hard-pressed to be financially viable and not lose money. As a result, hospitals increasingly need to make the choice between fulfilling their mission and being fiscally solvent, and those that need to be fiscally solvent will be closing services that provide primary psychiatric care to patients. This raises the question of where will these patients receive care? In Los Angeles, there is now a dearth of providers. The University of Southern California, Los Angeles County, the UCLA Neuropsychiatric Institute, and a smattering of community hospitals are continuing to provide care. If this type of decision-making becomes more prevalent, then the shortage of psychiatric hospital beds and services will become even more acute. This is happening in state mental health systems, which are also having to shrink their services because of declining budgets and state deficits that need to be covered. It complicates the problem even further.

It is ironic that we are just now seeing mental health parity and healthcare reform occurring in the context of the Patient Protection Affordable Care Act, but these developments may be too late to avoid the damage necessitated by decisions based on fiscal realities, and many patients will be left in the lurch as a result. We don't know how far this is going to go, and it may be harder for patients to find care than it previously would have been. This is all the more reason for us as a profession to become politically active and to advocate for the necessary access to care and reimbursement to enable psychiatric and mental health services to be provided in a way that meets standards of care and also is financially sustainable. I am hopeful that these legislative developments will not have come too late and that their implementation will begin to swing the tide backwards. For now, we are seeing an erosion of mental healthcare services and available psychiatric providers. It is often said that California leads the way in terms of national trends, and this may be the case in terms of psychiatry and mental healthcare as well. I hope that is not the case, but we will soon find out.

For today, this is Dr. Jeffrey Lieberman of Columbia University speaking to you on behalf of Medscape.

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