Institutional Best Practices for Treating Schizophrenia - Episode 5

Schizophrenia Burden

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A panel of experts in psychiatric treatment review the burden schizophrenia has on the health care system.

Peter Salgo, MD: Psychiatric care, inpatient care—you want to call it behavioral health, some people do, we can call it whatever you like—it is often viewed as a burden on the system by administrators. Now, I have not heard diabetes called a burden on the system, or heart disease, or cancer, but I have heard psychiatric illness, especially in the inpatient setting, referred to as a burden on the system. Why? Why is this nomenclature persistent? 

Rahn Bailey, MD, DFAPA: Let me jump in and take a couple of points here. First, to answer your question directly, I think, again, because of stigma and the misunderstanding of brain illness versus illness of other organs. Many in society, even those who are not physicians—legislators and politicians, what have you—see having a brain illness as something that really should not exist, until you get to be older, at an age where somebody may call you senile, then society accepts that you could have a brain illness. German psychiatrist, Emil Kraepelin called it dementia praecox; schizophrenia looked just like dementia, but at a 30- to 40-year age range, that is because we never got it across to society very well. There are the folks looking for a reasonable excuse to acknowledge that this really should not be the case, you should not be having these problems…and often that is what folks will say when you talk to a jury, they keep wondering, “Why would you do that?” Well, you did it because your brain was not working right. 

But if I have a second, I just want to support my good friend Henry, he is the lead person in our country now on this issue. But he is 100% right, we should use appropriate terminology and messaging. I am at a place now in California that just passed a law, the governor signed it, in 2023 nurse practitioners will have an unsupervised practice of psychiatry because we have lost the area of solo practice for ourselves. Psychiatry matters, we are not just behavioral practice any more than calling patients consumers when they’re patients. I think our audience should hear that for psychiatrists, this is a medical illness, or just like a stroke, Henry is right, and I think it’s key for us to appreciate that for other people, not us, who don’t use appropriate terminology, they use it to water down what we do. I support those considerations.

Peter Salgo, MD: I also think, based on what I am hearing, it is part of the entire stigma. You want to call it behavioral health as opposed to a psychiatric illness. You would not call a person who has a stroke somebody who needs, I cannot even invent a word for it. But you would say that is a neurologic problem. For schizophrenia, you would say it is a psychiatric problem.

Rahn Bailey, MD, DFAPA: Correct.

Peter Salgo, MD: I know that administrators are worried about slow bed turnover, the reimbursement for my psychiatric colleagues is always described as pathetically low, and it’s very resource intensive. All these things work against inpatient care, and the system works against getting adequate care to patients with schizophrenia, don’t you think?

Joe Avelino, RN, BSN, MHSA, CPHQ: Peter, can I add a further comment, because as the CEO here, in terms of burden, about the bed turnover. No. 1 is we are challenged here, particularly in Los Angeles, and Rahn can appreciate this as well, because there are not enough psychiatric services. Our emergency department is inundated. No. 2, with the COVID-19 pandemic, is the placement and challenges with the nursing homes. No. 3, we’ve had a couple of outbreaks in some of my units to the point that the Department of Health Care Services has closed down the department in my facility. At one time, 64 out of my 137 beds were closed by the Department of Health Care Services because of the outbreak. It is a tremendous challenge on top of, pre–COVID-19, we already have a shortage of behavioral health beds.

Peter Salgo, MD: For the first time I’m thinking about this, maybe it’s because I haven’t thought about it enough, but if so many of the patients with schizophrenic, when their medication levels drop, perhaps even go to 0, they wind up in jail, that’s expensive, right? That silo is big. If you’re going to pay for these patients, society is, they’re going to pay for them by taking care of them in the hospital, where the resources are therapeutic, or they’re going to pay for them by incarcerating them, where the resources really aren’t therapeutic, and they’re not going to get better nearly as quickly or as well. Isn’t this really just a choice society is making: jail versus inpatients, jail versus adequate therapy, and the cost is the cost? If you put all that cost together, it may come out the same, or it may favor inpatient psychiatric facilities, it might be cheaper, and it might be much better for the patient. Am I wrong about this?

Henry Nasrallah, MD: There’s no doubt. Joe can talk about this. This illness is best treated by physicians, nurses, and social workers, not by armed guards, and not to be housed with criminals, rapists, and felons. This is a tragedy. It is a travesty that has happened to our field when they shut all the state hospitals to save money, the politicians did that, and they are putting a lot of money into building prisons instead of building hospitals where patients can be taken. What do you think, Joe?

Joe Avelino, RN, BSN, MHSA, CPHQ: The challenge is when you look at it from reimbursement, not counting the clinical aspect, even when we deal with the Department of Mental Health, particularly with Medi-Cal [California’s Medicaid health care program], where they do not meet inpatient criteria, and whoever is looking at the so-called TARS, treatment authorization requests, we submit them; they say it “doesn’t meet inpatient criteria, could be managed in the outpatient setting.” These are nonclinical individuals making the decisions on the reimbursement, which is a challenge.

Henry Nasrallah, MD: Exactly.

Joe Avelino, RN, BSN, MHSA, CPHQ: This issue with the homeless population, where we deal with the homeless shelters here, where we even go as far as getting informed consent because the state attorney general, about 3, 4 years ago…indicating that we must have these protocols in place with the homeless population, making sure that they are giving informed consent to where they are being sent as well. Those homeless patients not having the resources as well is a challenge and working with the homeless shelter to make sure that if the patient does not comply, work with us here at College Medical Center, and get them readmitted or get them some help.

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