Cover Story: Georgia’s broken mental-health system

Mental health, already a challenging issue for medical professionals, is made more difficult when funding is short and political leaders reject potential solutions. The burden then falls on public hospitals such as Grady Memorial Hospital. In an excerpt from A Spirit of Charity, a new book about Grady and the challenges public hospitals across the country face, veteran Atlanta journalist Mike King examines the heavy load doctors and medical workers must carry. — Thomas Wheatley

Her psychiatric social worker didn’t know why. It could have been lack of money or not having a way to get there, but Juanita’s mental stability seemed to hinge on a shopping trip to Target.

“I think she needs some bras,” a member of Grady Hospital’s Assertive Community Treatment team tells her colleagues as they go through, one by one, a long list of names staring at them on the whiteboard. “It’s made her increasingly anxious.” Another team member jumps in, volunteering to take Juanita to Target the next day. The team leader says he will find some money.

Next up is Peggy, who has temporarily stopped taking her antipsychotic medications. Peggy was at Grady’s ER two days ago with a urinary tract infection. She claimed the ER nurses told her that her medications probably caused her infection.

“I had to sit down with her and go over her discharge papers to show her that’s not what they were saying,” the psychiatric nurse presenting the case tells the team. Whoever sees Peggy next should follow up that she is taking both her psychiatric meds and the antibiotic she was prescribed for her infection.

Two down. The team has about fifty-eight names to go—all patients with similar stories revealing precarious control over their illnesses.

To an outside observer who agreed as a condition of attending the meeting not to use the real names of their clients, the Grady team’s ability to succeed with many of the patients seems equally precarious, especially given how fragmented and unresponsive the American health care system can be for the chronically mentally ill.

There are success stories, to be certain. The team cheers news of a new job for one of the patients, or a new, more stable living arrangement for another. Robert has reconciled with his brother, who says he’ll give him another chance. Rose got her old job back. Jackie’s estranged daughter has moved back to town, and she sees her once a week.

But even these patients are one unlucky break away from trouble. Something as random as an argument with a family member, a late Social Security check, an arrest for disorderly conduct, a frustrated municipal court judge who is tired of dealing with them can put them in jeopardy.

The team effort employed at Grady has been around for years. It was first successfully used in Wisconsin and based on a simple, but expensive premise: Chronic, severe mental illness requires more than short-term hospital stays, periodic outpatient group therapy, and daily medications. It involves frequent, supportive contact that ensures patients don’t get sidetracked by what most of us would consider minor setbacks, like needing to go shopping. Most importantly, patients must be willing to agree to frequent interventions in order to participate in the program.

Grady has three Assertive Community Treatment teams that meet every weekday. The goal for each team is to see patients at least three times a week. These encounters are designed to determine if the patients are taking the medications they need, keeping their appointments, having any luck at finding work, and living somewhere that doesn’t exacerbate their serious mental conditions.

Combined, the Grady teams have a patient load nearing two hundred—by far the largest of any program like it in Georgia. Funding for the program is heavily dependent on Medicaid, if the patients are eligible for coverage. Unfortunately, many aren’t. They could be, but Georgia won’t allow it. So the program stays permanently underfunded, forcing Grady to absorb a lot of the costs.

Ironically, the Grady program is handling an ever-increasing load because the state of Georgia has failed to provide the medical care these and thousands of patients like them need. Six years after promising a federal court it would fix serious safety and quality-of-care problems within the mental health system, the state has yet to fully make good on its pledge. And when the state system for caring for the poor and uninsured mentally ill essentially collapses, as it did in Georgia over the last ten years, it predictably falls on public hospitals and nonprofit charities, like Atlanta’s Mercy Care clinics to pick up the pieces.

More than 25 patients a day come to Grady’s ER with psychiatric symptoms as their primary diagnosis. The hospital’s inpatient behavioral health unit has almost tripled in size since 2012. It routinely has 80 percent occupancy and is often too full to take patients from the ER.

If there is one medical condition where public health policy has failed the poor and uninsured most, it is in mental health care. Despite numerous scandals and journalistic investigations over the years, public officials have rarely put forth efforts to comprehensively deal with it. Think of the last time a political campaign—any political campaign at any level—had a platform promising to fix mental health financing or services for the poor.

What little progress that has been made on the subject has been to de-stigmatize chronic depression, bipolar disorders, schizophrenia, addiction, substance abuse, and other conditions as something more than just bad behavior. But “mainstreaming” those disorders has largely been limited to patients who voluntarily submit to treatment and are covered by insurance when they need it.

Underlining the point, in the 1980s and 1990s, as mental-health advocates began to make headway in demanding insurance companies cover psychiatric conditions the same way they cover other health issues, there was a surge in for-profit and private psychiatric hospitals opening to accommodate the demand.

Usually covered treatment began with a hospital stay to reestablish a medication regimen, followed by outpatient visits for psychotherapy, counseling, and medication compliance. How long the hospital stay was and how long outpatient care lasted depended largely on what was allowed under the patient’s benefit plan. This is still largely the model used today for insured patients who need help coping with their illness.

But for the poor and uninsured, it is a much different world.

Private psychiatric hospitals and some acute-care hospitals with psychiatric beds may accept uninsured patients, often only to stabilize them and discharge them to their own care. But for the most part, these patients become the responsibility of the state mental health system, regional public health districts, the local public hospital, and, increasingly, the local jail and criminal justice system.

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“Behavioral health for the poor is one of our most serious challenges, not just from the standpoint of what works and what doesn’t, but because the numbers are overwhelming, and our system for paying for it has been cobbled together in crisis,” said Dr. Bruce Siegel, president and CEO of America’s Essential Hospitals, which represents most of the nation’s largest safety-net hospitals. “Many states have simply defaulted on public mental health services and expect our hospitals to take on the responsibility.”

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About 20 states, including Georgia, have refused to expand Medicaid coverage to residents who make too little to afford private insurance and too much to qualify for Medicaid under the very restrictive current income guidelines the state imposes on applicants. That effectively shuts out most of the uninsured mentally ill from the benefits of the new law. And it shifts much of the burden of paying for the care they inevitably need from the state onto public hospitals who have to treat them on an emergency basis. Even worse, it condemns them to the streets and, when they act out, to a judicial system that is ill-equipped to handle them.

The American Mental Health Counselors Association estimates that about 1 million Americans in need of mental health and substance abuse treatment did not receive it in 2014 because their states refused to expand Medicaid to cover them; more than 230,000 of these low-income and vulnerable patients reside in Georgia.

This dismal record of public support actually spans more than a century of public-policy indifference, stingy funding, unintended consequences, and fundamental misunderstanding of the nature of mental illness itself.

Unlike other chronic health conditions—such as heart disease, kidney disease, or even cancer, where symptoms are easy to diagnose and surgical treatment and medications can mitigate the impact of malfunctioning organs—chronic, serious bipolar disorders and schizophrenia manifest themselves in behavioral patterns that often are not easy to detect and even harder to control.

While there is no surgical procedure to deal with severe mental illness, fortunately there are drugs to control it. But treatment involves strict compliance and a supportive environment for those afflicted with the most serious forms of these illnesses. For many individuals, especially the poor, the supportive environment simply doesn’t exist and must be taken up by the public health system.

Grady CEO John Haupert said the cost of behavioral health services for hundreds of severely mentally ill patients is one of the biggest threats to the bottom line of the state’s largest safety-net provider. The high cost of services Grady must provide, especially to those patients who return time and again for inpatient care because they can’t take care of themselves, crowds out the hospital’s ability to provide care for poor and uninsured patients with other conditions.

Even if Georgia had agreed to the Medicaid expansion, Grady would still have been hard-pressed to provide the volume and intensity of services these patients need, Haupert said, because direct state funding for mental health services has been reduced across the board.

Nationally, per capita public health spending on mental health services by the states was roughly $120 in 2013. Georgia spent less than half of that, according to data compiled by the Kaiser Family Foundation. And the money we are spending is not being effectively used.

A large study of Illinois patients shows that those being treated by ACT teams (like the team at Grady) cost about $10,000 per patient per year—not much more than the cost of a single trip to the ER and a seven-day stay in the psychiatric unit. Many uninsured mentally ill patients cycle through Grady three or four times a year.

But care at the community level requires coordination and consistent funding, which is lacking in Georgia and many other states and localities. Instead, the states have attempted to shift the financial burden of public mental health funding—once almost exclusively their responsibility—to the federal government. Neither seems willing to accept the essential role of coordinating care for a vulnerable and difficult-to-treat segment of society.

And while there is no winner in this standoff between federal and state health officials, there is no question who is harmed the most. The losers can easily be found on the streets of major cities, in county jails, and in overcrowded public hospital psychiatric wards.

About half of the estimated 5,000 homeless people in Atlanta are thought to be mentally ill or addicted to drugs, alcohol, or both. Many of them would qualify for Medicaid if Georgia agreed to expansion. They rely instead on the street-level care they get from Mercy Care, the city’s largest provider of primary care services for the homeless. More than 90 percent of the patients it sees do not have insurance.

At times, the demand is overwhelming, Mercy Care’s staff said.

That means Grady’s 13th-floor psych unit will stay crowded; the names on the community treatment team’s whiteboard will only grow; and county jails along with state prisons will continue to house mentally ill Americans lost in one of the nation’s worst public-health failures.