Individuals with severe mental illness, especially those who are untreated, are frequently stuck in a revolving door of hospitalization and incarceration. As a result, people with severe mental illness are overrepresented in our health, criminal justice and social safety net systems. Although they make up only 3.4% of the adult population, people with severe mental illness account for a disproportionate number of individuals interacting with law enforcement, incarcerated in our nation’s jails and prisons, entering emergency departments and experiencing homelessness.
The Office of Research and Public Affairs (ORPA) released a report in 2017 identifying the role and cost of serious mental illness in super utilization, the phenomenon of the frequent use of high-cost public services by a small population. The result,
A crisis in search of data: The revolving door of serious mental illness in super utilization, was a first-of-its-kind effort to systematically and comprehensively assess what has been published or reported on the human and economic costs of super utilization and severe mental illness.
The top takeaway from the research was that much of the necessary evidence to make informed policy decisions about super utilization is unknown or unknowable due to the fragmented and siloed way that data is collected in the United States. For example, rarely are public health department data connected to the criminal justice system, so knowing if the same people frequently showing up in emergency departments are the same people frequently resulting in 911 calls for law enforcement dispatch is near-impossible, let alone determining if those individuals also have a severe mental illness.
The ORPA report concluded that more and better data are needed on how people with severe mental illness interact with high-cost services, including research to understand what practices or interventions may reduce the human and economic impacts of the ‘revolving door.’
New research published in Psychiatric Services by authors from ICES Toronto, an independent non-profit health research company in Ontario, Canada, attempted to do just that. Although the results and findings are from Canada, which has different health and correctional policies than the United States, the overrepresentation of serious mental illness in public service systems are similar and the results can still inform how to improve practices to prevent super utilization here in the United States.
Health care costs of individuals with chronic psychosis
The ICES Toronto researchers sought to examine the total healthcare costs — including mental health care, hospitalizations and emergency department visits — of individuals with chronic psychotic disorders such as schizophrenia who have also been incarcerated. Previous research has indicated that people with schizophrenia who have interactions with the criminal justice system are less likely to be in treatment and are more likely to be hospitalized or use emergency services, indicating they likely also have higher health care costs.
The study authors analyzed data from the corrections and health care systems that were linked at the individual level, making this type of comparison possible. They compared individuals with schizophrenia who were incarcerated and those who were not and compared one-year total health care costs prior to the individual being incarcerated between the two groups.
The researchers found that people with schizophrenia who were incarcerated had more than 25% higher total health care costs in the year prior to incarceration ($15,728 vs. $11,588 in 2018 Canadian dollars). Women who were incarcerated had higher costs than men ($20,648 vs. $14,763), and women who were incarcerated had almost $9,000 more in healthcare costs than those who were not incarcerated.
The higher costs between the two groups were mostly driven by higher rates of psychiatric hospitalizations in the incarcerated group, as well as increased utilization of emergency department services, both of which are high-cost services compared to outpatient or preventative healthcare.
The authors conclude that interventions or policies that reduce criminal justice system involvement in individuals with schizophrenia can reduce general healthcare costs and that future research should examine cost-effective interventions for criminal justice system involved individuals with psychotic disorders. Additionally, considering the substantially higher costs for women who were incarcerated, sex-tailored approaches for individuals with schizophrenia who are involved in the criminal justice system are warranted.
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