The Marin Health Care District held a special meeting on March 11. The focused was on plans to consolidate the acute care inpatient psychiatric units at Marin General Hospital (MGH) and Ross Hospital. Chair Diana Parnell noted that in 1995 the corporation leasing the hospital tried to close the MGH inpatient psychiatric unit, and the District Board addressed the issue very late. This time, she said, "The Board wanted to be ahead of the curve." The District leases MGH to a wholly-owned subsidiary of Sutter/CHS. The District Board returned to mental health as an agenda item at its March 18 meeting.
Following the national move to deinstitutionalize the mentally ill, Marin County had invested more money than required to open a wide range of community-based facilities and programs to provide care. Within the last ten years, this exemplary community system has been dismantled. In Marin, two inpatient acute care facilities remain, one at MGH and one at Ross. The concept of residential treatment largely has been discarded in favor of short-term acute care to stabilize. A few supervised group living facilities remain. Locally and nationally, the mentally ill today constitute a large subset of the homeless population and the inmate population in jails and prisons.
MGH Corporation and Ross Hospital began to discuss consolidation several years ago when the patient census in both facilities was low. Because of possible antitrust implications, Carr, McClellan, Ingersoll, Thompson & Horn, the law firm representing the two corporations, requested the Antitrust Division of the Department of Justice (DOJ) to review the possible consolidation. In February, the DOJ said the two corporations would be allowed to continue discussions to consolidate inpatient mental health services. A DOJ press release and correspondence dated February 11, 1997 to Carr, McClellan says the corporations propose to use MGH's stand-alone inpatient psychiatric facility near the main hospital to deliver the consolidated services, and to use Ross to provide management services. The DOJ letter states MGH "will increase the number of licensed, staffed beds at that facility from 17 to 34." Marin County Community Mental Health (CMH) had written a letter in support of the consolidation.
Ross is not eligible to provide the consolidated services to Medicaid-funded patients under age 65 because it does not have a license to provide general acute, inpatient care. MGH is eligible to care for County Medicaid-funded patients because it is appropriately licensed. In 1995, the County and MGH failed to reach agreement on fees to treat provide inpatient care to the mentally ill. At that time the County began sending psychiatric patients outside of Marin County. Sending acutely mentally ill patients out-of-county has been an ongoing concern in the Marin mental health community.
According to the DOJ, the corporations "have represented that the County's rates do not cover [MGH] costs of providing the consolidated services and that one goal of the proposed consolidation is to bring [MGH's] costs of treating County patients more in line with the County rates so [MGH] may once again treat these patients." (The DOJ press release and the accompanying letter are public information documents. Interested Marin residents can obtain them by email requests to [email protected] The DOJ website address is http://www.usdoj.gov.)
The strategy to bring inpatient costs in line will be addressed by having Ross manage treatment. MGH and CMH staff with whom we have spoken assert Ross caregivers are not unionized, receive lower pay, work under a leaner staffing pattern, are less likely to be registered nurses, are more likely to be unlicensed, and enjoy fewer worker protections.
The March 11 Forum
District Director Valerie Bergmann began the meeting by stating her objections to holding discussions on the proposed consolidation. The Board then convened in closed session to discuss potential litigation and reconvened at 7:30. When the meeting reconvened, Director Bergmann did not return.
According to Chair Diana Parnell, the March 11 meeting had been scheduled to provide an opportunity for the District Board and the community to get up to speed on the status of Marin County's acute inpatient psychiatric needs and services. Representatives were invited from various sectors caring for the mentally ill. John Martin and Dr. Scott Barshack, Medical Director of the Inpatient Psychiatric unit, represented MGH Corporation. Ross Hospital was represented by Judy House. Andy McCord represented the Alliance for the Mentally Ill (AMI). Psychiatrist Daniel Michael Beal and Psychiatric Nurse Michele Chouinard spoke as caregivers. Representatives from Marin CMH and the Sheriff's Department had been invited but were unable to attend. Following the presentations, the meeting was opened to questions from the audience.
Judy House of Ross described the background of the potential consolidation. She then reviewed their inpatient psychiatric statistics for 1992 through 1996. Due to aggressive marketing, they have experienced a large increase in the number of admissions this year. Average length of stay per admission has declined from 11 to 7.6 days during this period. Despite the increased number of admissions, the average daily census hovers around 12 because of the shorter length of stay. A copy of her handout can be obtained by calling the District Board.
John Martin said that if the census for the two facilities were added together, the average daily census would be less than 25 patients per day, and that MGH had an average length of stay of 9 days. He indicated a much more tentative understanding between the two corporations than details in the DOJ letter show. Martin stressed the need for the two entities to maintain confidentiality with respect to corporate information. He also reviewed 1996 utilization statistics. The inpatient unit had 593 admissions who stayed 5,340 days. Of these, 34% were Medicare patients, 34% Medical patients, 12% medically indigent, and 20% all others.
Dr. Barshack said the inpatient unit had no data regarding admissions from the crisis center of emergency department, but they guessed about 18%. Last year, 23 patients were discharged from the inpatient unit to facilities out of county, and 18% of patients were admitted more than 1 time. He stated there was a real logjam to get into residential support and locked facilities. He hoped some mechanism could be developed for Medical to pay for partial day programs.
Andy McCord stated that AMI had a strong preference for the acutely mentally ill to be served in-county. AMI is not interested in having psychiatric inpatients go through research intensive diagnostic workups. They hope the consolidation process will result in the development of specific policies with responsibilities delegated to administrators and discharge planners. AMI believes the psychiatric staff should meet industry standards with respect to the ratios of physicians and registered nurses to patients.
Dr. Beal is on the staff at Ross and MGH. According to him, Marin needs to increase the number of beds to treat people with severe psychiatric illness. He identified the need to obtain statistics describing how many patients are seen at the County Crisis Unit and then sent out-of-county for treatment. Dr. Beal said those least able to provide for themselves are unable to obtain a proper continuum of care when they are sent out of county. He identified the lack of facilities to adequately treat dually diagnosed mentally ill patients as an ongoing county problem for a long time. Dr. Beal felt there should be more county-wide planning for inpatient mental health services.
Michele Chouinard said CMH gave up evaluating MGH emergency room patients in 1992, and that those duties were taken over by a MGH social worker. Ms. Chouinard did not know how many patients were being evaluated, but said many more beds were needed to treat Marin patients in county. She observed that the Board of Supervisors had an item on their agenda to approve a contract with a Sonoma County facility.
In the absence of representatives from the Sheriff's Department, Ms. Chouinard was able to present data on the mentally ill in the County Jail. She said the jail had a census of 311 inmates, including 50 women, that 80 of those inmates had some psychiatric contact with the one mental health worker, and that 35 inmates were on psychiatric medications. She stated the jail had no mental health nurses, and that the one mental health worker was available only 8 hours per day to monitor the mentally ill inmates. She described patients in acute psychiatric episodes, breaking car windows, and being incarcerated for breaking the law. Ms. Chouinard observed that in prior years, patients in an acute state would have been brought to the inpatient units rather than being criminalized for their mental illness.
Director Linda Remy ended the planned portion of the evening by providing a comparative overview of service utilization at MGH from 1992 to 1995. She used statistics from the summary financial and utilization report submitted annually by MGH and every hospital in the state to OSHPD. She identified a pattern over time for MGH length of stay to be shorter than the statewide average and for the pattern of registered nurses per patient day and per discharge to be lower than the statewide average. She presented the same statistics for the inpatient psychiatric unit, but said she had no statewide inpatient psychiatric statistics for comparison. While length of stay was stable over time hospital-wide, it did vary over time as a function of payor within the psychiatric unit.
Audience comments following the meeting included a mother whose son had committed suicide at Ross while he was a psychiatric inpatient. Concerns were voiced that the two corporations would attempt to reduce the total number of inpatient psychiatric beds or reduce the quality of the caregivers following the consolidation.
The March 18 Monthly Board Meeting
As one of its final actions during the meeting, the Board approved a resolution in support of adequate psychiatric care to all members of the community. The resolution said that (1) the mental health unit at MGH should be fully and adequately staffed with appropriately trained personnel sufficient to care for the mental health needs and the safety of patients under care of the hospital, (2) that such staffing should be sufficient so as to provide law enforcement authorities with an alternative to incarceration in determining the placement of the mentally ill who come under their jurisdiction, (3) that inpatient mental health services should be available in Marin County to all district residents regardless of ability to pay.
Director Valerie Bergmann who attended this meeting, voted against the resolution, saying she was concerned that the Board was overly influenced by the "special interests" of the mentally ill.