Volume XXXII - Number 19 - October 3, 1997

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Psychiatric hospitals and health systems are diversifying, providing a wider array of services for more patients with less intensive treatments at lower cost.

Those were among the principal findings in the 1997 Annual Survey Report of the National Association of Psychiatric Health Systems. The report is based on responses to the association’s annual survey from administrators of 239 psychiatric facilities owned and operated by NAPHS members.

"In an era of cost-containment and ratcheting down of dollars available for care, behavioral health providers have focused attention on developing treatment approaches that respond to payers’ increasing demands for shorter stays, lower costs, and expanded access to care," according to the NAPHS report. "Changes in the mix of services, the price of services, and the intensity of service are all part of this response. These changes have also been bolstered by a rapidly expanding science base, improved medications management, and the growing availability of nonhospital treatment settings. . . ."

The NAPHS survey did not report information about patient outcomes.

Steven S. Sharfstein, M.D., medical director and CEO of Sheppard-Pratt Health System, Baltimore, who has written extensively about system changes in care for the mentally ill, told Psychiatric News that the NAPHS report provides a "snapshot" of a field that is changing very rapidly and that varies from region to region.

Though the NAPHS report presents a picture of a field that appears to be thriving and adapting to change, Sharfstein cautioned that it is not clear whether specialty psychiatric hospitals will survive or whether psychiatric care ultimately will be integrated into primary care.

Sharfstein said it is also unclear how the most severely mentally ill have fared. "Many patients have done well with the expansion of less intensive treatments," he said. "But we still must provide good, high-intensity treatment for those patients that need it. . . ."

He added, "I know that some patients have been hurt."

Sharfstein was the coauthor, with Miles Quaytman, M.D., of a "clinical case conference" in the August American Journal of Psychiatry describing the difference in how a patient with severe borderline personality disorder would be treated in 1997, compared with 1987.

Diversified Services
Among the most important findings from the survey is that specialty psychiatric hospitals have diversified their services to include a range of behavioral health treatment settings.

In 1996 hospitalization remained a core service, representing 76 percent of all admissions.

Yet nearly 1 of every 4 admissions in 1996 was to a service other than inpatient hospitalization, compared with just 1 in 10 admissions in 1992.

The vast majority of survey respondents (91.6 percent) provided partial hospital services; two-thirds of respondents provided outpatient care (66.9 percent), and two-thirds provided residential treatment (66.1 percent), or both.

Lengths of hospital stay have dropped 1.7 percent from 1995 to 1996 to 11.5 days. At the same time, NAPHS members treated more patients than in 1995, according to the survey. In 1996, there were 476,155 inpatient admissions in 316 NAPHS member organizations. A typical hospital saw an average of 1,509 inpatients, an increase of 9.5 percent over 1995.

Ambulatory services are also seeing more patients, but for briefer stays, according to the survey.

The average number of outpatient admissions seen by a typical facility grew 20.5 percent, from an average of 1,021 admissions in 1995 to 1,231 admissions in 1996. Average partial hospital admissions increased 18.2 percent, going from an average of 362 in 1995 to 428 in 1996.

At the same time, the average number of visits per patient declined. A typical patient in 1996 had 13 partial hospital visits, compared with a typical patient in a partial hospital program in 1995, who had 17 visits.

A typical outpatient in 1996 averaged 8.7 outpatient visits, compared with a typical outpatient in 1995, who averaged 15.4 visits, or a typical outpatient in 1994, who averaged 23.5 visits.

The NAPHS survey also found that providers are increasingly focusing on community needs and assuming risk for the health populations.

A total of 30 respondents in 1997 were involved in at-risk arrangements, including capitation.

Partnerships between public programs and private health systems are also evolving, according to the survey. Eight contracts were in place among the responding NAPHS members with state psychiatric hospitals. Twelve respondents had arrangements to manage state mental health organizations; 30 respondents reported a total of 134 contracts with community public programs.

In addition, NAPHS members are providing more care for the Medicare and Medicaid populations. Together, these government programs accounted for 44.5 percent of all inpatient admissions in 1996, up from 40.7 percent in 1995.

Total expenses for behavioral health systems dropped by 13.8 percent, according to the survey.

The NAPHS survey report is available for $400 from the National Association of Psychiatric Health Systems, 1317 F Street, N.W., Suite 301, Washington, DC 20004-1105.