Transcript By the Numbers - University of Chicago Law School

By the Numbers
The Illinois Mental Health System
Prevalence of Mental Illnesses
• 1% of the population has schizophrenia—
130,000 people in Illinois
• 1 to2% of the population has bipolar affective
disorder—130,000 to 260,000 people in
Illinois
• 20% of the population will experience some
mental illness
Where are people with mental
illnesses?
• 1,400 state psychiatric hospital beds
• 4,000 private psychiatric hospital beds (psychiatric
units in general hospitals and free standing psychiatric
hospitals
• 12,000 persons with mental illnesses in nursing homes
(5000 in nursing homes dedicated to the treatment of
persons with mental illnesses—”IMDs”)
• 6,000 in state prisons
• 2,000 in county jails (at least 1,200 in Cook County Jail)
• TOTAL IN INSTITUTIONS (at any one time): 25,400
Historical Data on Hospitalization
• In 1950, 55,000 state psychiatric hospital beds
for a population of 7 million
– One bed for every 127 persons
• Today, 1,400 state psychiatric hospital beds for
a population of 13 million
– One bed for every 9,285 persons
• Treatment Advocacy Center study argues that
we need one bed for every 2,000 persons
Trend in Involuntary Commitments to
State Hospitals in Illinois
• Fiscal Year 1993
826
• 15,204 total admissions
• Fiscal Year 1999
317
• 9,788 total admissions
• Fiscal Year 2005
338
• 10,290 total admissions
• Fiscal Year 2008
283
• 10,837 total admissions
Hot issues in mental health law and
policy
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Integration of mental health services into health care
Mental health insurance parity (federal and state laws)
Should inpatient commitment be made easier?
How to insure continuity of care
Choice of funding streams for mental health services
Outpatient commitment
Mental health court diversion programs
Training of police (Crisis intervention teams)
Improving treatment for mentally ill offenders
• Mentally ill offenders in “supermax” (sensory deprivation) prisons
• Linking persons with mental illnesses leaving prisons to mental health
services
Causes of Deinstitutionalization
• Development of effective psychotropic medications
• Unionization of hospital employees drove up costs
• Creation of Medicaid program which excluded federal support for most
inpatient psychiatric care (“IMD exclusion”) but paid for some community
care
• General cost containment efforts from private insurance companies,
Medicare and Medicaid refused payments for lengthy inpatient stays for
any medical condition (for example, “drive-by labor and delivery”)
• Successful civil rights complaints about conditions of confinement in state
hospitals increased costs of inpatient care due to the need for more and
better-trained staff and other services
• Changes in treatment ideology
• Increased procedural protections provided in commitment hearings made
such hearings more difficult and expensive
• U.S. Supreme Court decision in O’Connor v. Donaldson, 522 U.S. 563
(1975) raised substantive standard for involuntary commitment
Trends in Commitment Law
• Prior to the 1970’s involuntary psychiatric hospitalization not considered
an issue of constitutional concern
• U.S. Supreme Court decision in Jackson v. Indiana, 406 U.S. 715 (1972)
announced that involuntary commitment to psychiatric hospital
constituted “a massive deprivation of liberty”
• U.S. Supreme Court decision in O’Connor v. Donaldson, 422 U.S. 563
(1975) prohibited involuntary commitment of persons “capable of living
safely in freedom” Court specifically held that mental illness alone cannot
be the basis for commitment.
• In the 1970s many states adopted higher standards for involuntary
commitment usually requiring that the respondent be dangerous to self or
others.
• In the 1990’s trend begins toward lowering the commitment standard.
• In 2008, Illinois dramatically lowers its commitment standard. Proof of
harm need not include proof that the harm occur “in the near future” or
that the harm be “physical” or “serious”
Barriers to Increasing the Amount of
Involuntary Commitment
• Lack of beds
• Commitment a low priority for state’s attorneys
(for whom prosecuting crimes is a higher priority)
• No funding (from Medicare, Medicaid, private
insurance or other sources) for the time of the
psychiatrist whose testimony is required by law
• Cost and time of transportation of patient to
court
Possible Results of Increasing the
Number of Person Committed to
Psychiatric Hospitals
• Creation of more (staffed) beds
• This is expensive
• This takes time--until accomplished, one or both of the
following will occur:
• Reduction in duration of confinement—speed
up the revolving door
• Overcrowding
The Fee for Service Model (traditional
insurance, Medicare and Medicaid)
• Payment for discrete services
• Payer determines
– That the patient is eligible
– That service is covered
– That the service provider is legally qualified to provide service
• Payer does not determine quality of service
– Payment even if provider commits malpractice
– Payment even if service results in death of patient
• Payer does not coordinate among service providers
• No one is responsible for outcomes
• Fee for service often does not work for chronic illnesses
such as schizophrenia