RESEARCH WEEKLY: Hospitalization for Serious Mental Illness Among Most Frequent Inpatient Stays
By Elizabeth Sinclair Hancq
Inpatient care is a vital component of the full continuum of psychiatric care for individuals with serious mental illness who may need such intensive treatment in order to successfully stabilize. Much of long-term inpatient psychiatric care occurs in the remaining state psychiatric hospitals that exist in dwindling supplies across the United States. However, inpatient psychiatric care also occurs in community hospitals, general hospitals with psychiatric units that provide shorter-term treatment.
The Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality, U.S Department of Health and Human Services released a statistical brief last month on the most frequent principal diagnoses for inpatient stays in U.S. hospitals in 2018. Mental illness or substance use disorders were in the top five reasons for inpatient hospitalization for individuals in the youngest age groups under 45 years old.
HCUP calculated this data from the National Inpatient Sample, a nationwide database of inpatient stays in community hospitals that includes all payers, including private insurance, Medicare and Medicaid. The sample represents 95% of all hospital discharges in the United States
Deeper dive into the data
A deeper dive into the data reveals further insights into inpatient hospitalization for people with serious mental illness. Schizophrenia and other related psychotic disorders and depressive disorders were both in the top 20 of most frequent inpatient stays for all individuals, with Medicaid as the primary payer. In fact, Medicaid is the primary payer at a much higher rate for mental health reasons compared to physical health reasons. For example, more than 40% of all inpatient stays for schizophrenia were paid by Medicaid compared to 25% for diabetes-related hospitalization, the next highest diagnosis.
The mean cost per stay for inpatient stays for schizophrenia and related disorders was $9,300 per hospitalization. With almost 400,000 inpatient stays in community hospitals for schizophrenia in 2018, this amounts to an aggregate cost of $3.7 billion.
For men aged 18-44 years old, mental health or substance use disorders were three of the top five most frequent reasons for inpatient hospitalization with schizophrenia as first, depressive disorders as third and alcohol disorders as fifth. For women of the same age group, depressive disorders ranked second and bipolar disorder fourth as the most frequent diagnosis for inpatient hospitalization. In addition, depressive disorders were the top reason for inpatient hospitalization for women under 18.
Implications
The data presented in the statistical brief from HCUP have major policy implications. The Institution for Mental Disease (IMD) exclusion prohibits Medicaid funding for inpatient stays in psychiatric hospitals with more than 16 beds. In practice, this results in many longer-term hospital stays for individuals with serious mental illness that occurs in state psychiatric hospitals to not be Medicaid-reimbursable and much of those costs falling to the states. The HCUP data indicates that there is a disproportionate volume of Medicaid stays for mental health reasons in community hospitals, likely due to the high rates of Medicaid eligibility among this population as well as a consequence of the IMD exclusion not allowing Medicaid payment in psychiatric hospitals. The same data source from HCUP suggests that serious mental illness was the largest reason for hospital readmissions within 30 days of discharge in Medicaid patients, costing a combined $588 million in 2014, indicating individuals are not fully stabilized when discharged to the community.
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