(This article was provided by Kaiser Health News.)
Yolanda Solar has battled a life-threatening disease for more than three decades. The disease nearly killed her last summer and Solar, a 73-year-old grandmother, was rushed to the hospital by ambulance.
When Solar was discharged one week later, she received bad news: She would have to wait until March to see a doctor.
Waiting seven months for treatment would be unthinkable if Solar had cancer or heart disease. But Solar suffers from severe depression, and waiting that long for help is typical — and potentially dangerous.
Although San Antonio has earned widespread praise for its success in keeping people with mental illness out of jail, patients here routinely wait months to see psychiatrists, who are in short supply across the country. The number of available psychiatrists who specialize in the care of the elderly or children is even smaller.
Without routine medical care, patients like Solar, who tried to kill herself in August with an overdose of pills, can quickly deteriorate. Many return to the emergency room. Some don’t survive.
But Solar was luckier than most.
Emergency room (ER) staff made an appointment for her at a transitional care clinic at the University of Texas Health Science Center at San Antonio, which annually treats up to 1,500 patients with serious mental illness until they can find regular care. The clinic helps the mentally ill avoid winding up in the ER, where round-the-clock activity and confusion is ill-suited to the needs of patients who are already agitated, suicidal or psychotic.
Communities like San Antonio are increasingly focused on reducing emergency room use by people with mental illness. In addition to being chaotic, emergency rooms are among the most expensive places in the health system to get urgent care.
Patients like Solar end up in the ER because they can’t find care in the community, and emergency rooms can’t legally turn anyone away. The mentally ill can be stranded in the ER for hours, days or even weeks with minimal treatment, because doctors deem them too disabled to discharge, but can’t find them an inpatient psychiatric bed, which would allow patients to get more intensive care.
More than half of emergency room physicians said their local mental health system has gotten worse in the past year, according to a survey of 1,716 members of the American College of Emergency Physicians, released in October. Seventy-five percent of ER doctors said on their last shift, they saw at least one psychiatric patient who needed to be hospitalized.
“The emergency department becomes the de facto dumping ground for all mental health patients,” said Gillian Schmitz, a San Antonio emergency physician.
The number of ER patients with a mental illness grew from 4.4 million in 2002 to 6.8 million in 2011, an increase of 55 percent, according to a 2016 study in Health Affairs. About 836,000 Americans a year go to the emergency room after harming themselves, according to the Centers for Disease Control and Prevention. Nearly 43,000 Americans committed suicide in 2014 — more than are killed annually in car accidents.
The American College of Emergency Physicians devoted much of its annual meeting in October to patients with psychiatric crises.
Everyone suffers when people with mental illness are stuck in limbo in the ER, Schmitz said. Other patients face longer waits for care and hospitals lose money. That’s because insurers pay emergency rooms only for their initial encounter with a patient, but not for time spent waiting for an inpatient bed.
“Every hour we are holding a psych patient,” Schmitz said, “is lost revenue that hospitals could be earning on other medical patients.”
Solar’s story also shows the progress that people with mental illness can make when they receive prompt and comprehensive care. She has not returned to the ER since beginning treatment in August.
Hospital staff scheduled her appointment at the transitional care clinic through a web-based computer system before she left the hospital. Like most patients, Solar was seen within a few days.
Solar now meets regularly with a psychiatrist, who manages her medications, and a counselor to discuss her fears.
A therapist visits her at home to help organize her medications, which include pills for high blood pressure and cholesterol. The visits are paid for through a Medicaid pilot program, which allows staff to provide extra services for up to five patients who are considered “high utilizers” of health care, or patients who are particularly costly to insurers because of repeat trips to the hospital or ER, said Megan Fredrick, the clinic’s program manager.
Patients with serious mental illness, which can cause cognitive changes similar to dementia, often need help with day-to-day tasks, said psychologist Dawn Velligan, project director at the transitional care clinic. Therapists help patients set alarms that remind them when to take their medicines. They work with patients on calendars and organizational skills, so that clients don’t miss appointments.
Through a type of therapy called cognitive adaption training, clinic staff teach basic skills, such as how to shop for groceries or take the bus to a medical appointment, Velligan said.
Only 2.5 percent of psychiatric patients seen at the transitional care clinic return to the ER within three months, compared to 10 percent of patients who aren’t seen at the clinic, Fredrick said.
Without the clinic’s help, Solar said, she would probably have considered suicide again.
“Sometimes, I get pretty, pretty, pretty depressed,” said Solar, who was raised by an alcoholic father. Her depression began, Solar said, during an unhappy marriage.
Yet for years, Solar suffered in silence. The first time she saw a psychiatrist was after her August suicide attempt.
Nationwide, more than half of people with mental illness go without treatment, according to Mental Health America, an advocacy group. The reasons are complex. Many people with mental illness don’t realize they’re sick, or that treatment can help. Some patients lack transportation or money to pay for care. About 17 percent of people with a mental illness in the U.S. are uninsured, according to Mental Health America.
“For many of our elderly Hispanic patients, this is the first time they’ve seen a therapist,” Cynthia Sierra, a clinic counselor. “You’re raised not to talk about your problems with strangers … You can carry years of burdens and trauma.
For all its success, the transitional care clinic can’t help everyone.
With an annual budget of $3.5 million — provided by a variety of grants and a fund for Medicaid demonstration projects — the clinic sees just a fraction of those who need help.
“We constantly have to beg for money,” Velligan said.
Although the transitional clinic accepts patients covered by Medicare, Medicaid or private insurance, it can’t accept most uninsured patients.
Psychiatrist Harsh Trivedi describes the program as a “Band-Aid” that fails to address the larger problem of inadequate care for people with mental illness.
“Unfortunately, creating these programs doesn’t actually solve the real access issues,” said Trivedi, chair of the American Psychiatric Association’s council on healthcare systems and financing.
Trivedi notes that the national shortage of psychiatrists means that even well-insured patients often have to wait for care. Although the overall number of physicians increased 14 percent from 2003 to 2013, the number of psychiatrists fell by 10 percent when adjusted for population growth, according to a July study in Health Affairs.
That shortage is projected to worsen over the next decade as large numbers of psychiatrists reach retirement age, said Trivedi, who is also the president and CEO of Sheppard Pratt Health System in Maryland.
Many psychiatrists have stopped taking insurance because health plans pay them too little to sustain a practice, Trivedi said.
To really help more patients, the country needs to rebuild the mental health system, investing both in outpatient care, more hospitals beds and supportive services, Schmitz said. Instead, states have been steadily slashing mental health budgets for years.
“As a society, we’re OK with the fact that someone with depression isn’t able to get care,” Trivedi said. “That double standard allows some of our most vulnerable people to end up in harm’s way.”
Twelve years ago, Kathy Good and her husband, Dave, were looking forward to the adventures of retirement together – Dave was a district court judge; Kathy was a therapist and licensed social worker.
“Dave started having vision problems,” Kathy recalls. “He was having trouble reading jury instructions. He got new glasses; he had cataract surgery, all to no avail. Eventually it was determined by a neural ophthalmologist that he had something called the visual variant of Alzheimer’s disease.”
Alzheimer’s disease – he was 56 years old.
Suddenly, both of their lives changed dramatically. Kathy began plans to care for David in their home – she became a family caregiver. Caregivers are often thrust into their new roles unexpectedly, with no understanding of services available or how to navigate the systems they’ll encounter.
Kathy was fortunate; she had a background in social work and knew where to start. Using her professional know-how, she assembled what she called the “committee” (services that helped Dave remain independent at home). She considered herself very lucky to have had the means to create a support system for Dave – she knew a vast majority of family caregivers had no help at all. She carried the thought of those caregivers with her as Dave’s needs changed and she adapted to meet those needs for over a decade before he passed in May 2015.
Today, she is well-known in the Cedar Rapids community as a resource for family caregivers. This prompted Tim Charles, Mercy Medical Center-Cedar Rapids President and CEO, to call upon her for insights into an idea for a new program – a community-focused family caregivers center that would offer a wide range of services to improve the overall well-being of family members caring for a chronically ill loved one.
“The stress of caring for someone with a chronic condition like Alzheimer’s, diabetes, heart problems –all chronic diseases – can cause caregivers to be depressed and anxious, to develop their own chronic conditions,” Kathy states. “They may have weakened immune systems. They may be at risk for their own mental decline. That’s just a few of the major things that could happen to a family caregiver when they start having to live life for, in essence, two people.”
She jumped at the opportunity to help other caregivers.
Since 2014 she has dedicated hundreds of hours to research, workshops and networking to bring the idea of a family caregivers center to life. She has met with caregivers to talk about their needs and human service agencies to talk about their existing support systems, determining gaps in services and formulating a plan to bridge those gaps through the center, ensuring services are not duplicated.
The Family Caregivers Center of Mercy is the product of her work – a unique, first-in-the-state initiative that will be funded through generous gifts to the Mercy Foundation’s Family Caregivers Center Endowment. October 2015 kicked off the foundation’s fundraising efforts with the goal of raising $2.5 million to fully endow the center. A full endowment means the center can offer services at little-to-no cost to the caregiver – a critical need.
The innovative center will be one of the few in the nation (and the only one in Iowa) using a community-based model, meaning that no matter where a loved one receives care – home, assisted living or hospital – the caregiver can find support. Some components of the Family Caregivers Center of Mercy include respite care; therapeutic outlets of journaling, massage and art; along with a 24/7 care line to answer any kind of question the caregiver might have. A resource library will be available and education sessions will be held on a variety of topics. The center celebrated its opening in December 2015.
Encouraging doctors and nurses to wash their hands frequently has always been considered an easy and effective way to curb the spread of infection in hospitals and other health facilities.
But a new research letter published Monday in JAMA Internal Medicine points to another key group of people who aren’t always keeping their hands so clean and, it turns out, probably should: patients.
Researchers focused on inner-city Detroit and examined patients who went from hospitals to post-acute care facilities — places like rehabilitation centers, skilled-nursing facilities, hospice and long-term care hospitals. They found that almost one in four adults who left the hospital had on their hands a superbug: a virus, bacteria or another kind of microbe that resists multiple kinds of medicine. While in post-acute care, about 10 percent of patients picked up another superbug. Of those who had superbugs, 67 percent still had them upon being discharged, even if they hadn’t gotten sick.
These findings add to a growing body of research about hand hygiene and the patient’s role in infection transmission, and speak to an underlying problem with health care facilities — they can increase the odds of getting sick. The paper’s authors suggest it highlights a potential, so far underused strategy for addressing that concern: getting patients to wash their hands.
Conventional wisdom has long held that doctors and nurses — who go among sick patients — are most likely to transmit germs. As a result, few health care settings really make patient hand-washing a major priority, said Leah Binder, president of the Leapfrog Group, a nonprofit organization that grades hospitals on patient safety.
The paper, she said, “really requires an immediate response” from safety advocates.
“We have to revise hand hygiene policies to include patients. One of the main strategies on hand hygiene is to make it easy to wash hands,” she said. “Most hospitals have either sinks or dispensers near the door of every room, so that it’s very easy for a provider walking in to immediately wash their hands. Do we make it easy for patients to wash their hands? I doubt it.”
Beyond that kind of architectural change, signs should be visible around facilities to remind patients about hand washing, she said.
But just because patients are carriers of superbugs it doesn’t mean they will get sick, said Lona Mody, a professor of internal medicine at the University of Michigan-Ann Arbor, and the study’s corresponding author. There needs to be more research to measure the relationship between carrying germs and falling ill, she added.
If you have superbugs on your hands, though, you probably have them elsewhere too — in your skin or in your gut, said Louise Dembry, president of the Society for Healthcare Epidemiology of America and a professor of medicine, infectious diseases and epidemiology at Yale. Having them on your hands makes them easier to spread.
Plus, the patients in these kinds of facilities are, almost by definition, more vulnerable to infection, Binder said — they’ve just come out a hospital where they needed a high level of care.
“I find it not difficult to imagine” that a number of these patients will end up with serious infections, she said.
Spreading germs is also easier to do in post-acute settings, Dembry noted, since patients are more likely to interact with each other. Patients are encouraged to move around more and, as a result, more likely to touch medical equipment and furniture, among other things, which can spread the germs, Mody said. Overall, these circumstances increase the odds of transmitting germs and up the need for better hand-washing protocols.
Dembry added that hand washing can be only one part of any strategy to prevent infection. Medical tools and machines need to be kept clean. Culturally, patients should feel comfortable asking each other if they’ve washed — and steer clear if they might be infectious.
As health care facilities are increasingly evaluated on how well they care for patients, they should be rewarded for things like promoting clean hands, Mody said.
For instance, “if an institution has a program that enhances patient hand hygiene, the quality of that place should be considered higher,” she said.
The findings call for more research, Mody said, to see how widely they might apply. Researchers will want to examine how the settings examined here compare to transmission among patients within hospitals, she added, and study geographic regions other than inner-city Detroit — though she anticipated they might find similar results.
“This particular finding to us, from a public health standpoint has opened a whole new line of inquiry,” she said. Meanwhile, “From a policy perspective, we need to design and test the effectiveness of and implement novel programs that reinforce patient hand hygiene.”
But this time around, unlike three years ago when the court rejected a constitutional challenge to the law’s individual mandate, the case, King v. Burwell, focuses primarily on statutory interpretation.
The issue is whether section 36B means what it seems to say if read literally and in isolation from the rest of the law: that Affordable Care Act subsidies are available only to people “enrolled … through an exchange established by the state.”
And the different interpretations have proven dicey — so much so that each side in the case is having trouble explaining away the evidence supporting the contrary position.
Solicitor General Donald Verrilli and other defenders of the subsidies have failed to suggest any very plausible reason — other than sloppy draftsmanship, on which Verrilli has not much relied — why Congress said “established by the state” if it intended that subsidies also be available in the federally established exchange.
On the other hand, ACA opponents who read “established by the state” literally have produced little evidence that the law’s drafters deliberately and quietly planted in an obscure subclause the words that could become the seeds of the law’s destruction.
Plaintiffs in the case suggest that the drafters inserted these four words in order to pressure states to establish their own exchanges. But the legislative history offers scant evidence of this intent. And the three dozen states in question either failed to notice or disregarded it.
How these explanations sway the justices — or at least five of them — will determine whether the language drafted by Congress means that nearly 6.4 million low-and-middle-income people are not eligible for the overhaul’s tax subsidies because they live in a state that chose to rely on the federal government’s healthcare.gov, rather than establish its own online insurance marketplace. The subsidies make insurance affordable to many of the people who seek Obamacare coverage because they don’t get health coverage through their employers.
If the court rules that the subsidies are available only in states — mostly blue — that established their own exchanges, insurance markets in the other three dozen or so states might collapse. Unless Congress or the states reliant on healthcare.gov were to move fast to limit the damage, few people in those states would buy individual insurance. Those who did would likely have health problems and premiums would soar.
Many ACA opponents say that section 36B “means what it says,” as conservative Justice Antonin Scalia implied at the March 4 oral argument, even if the wording “may not be the statute [Congress] intended” and even assuming that it might “produce disastrous consequences.”
To the contrary, say Verrilli and other supporters, the law’s overall text, structure, design and history make clear that Congress intended to make subsidies available in all 50 states. They say the challengers’ interpretation would defeat the law’s purpose of making health insurance widely affordable. The Internal Revenue Service came to the same conclusion in an interpretive rule, to which Verrilli argued the justices should defer if in doubt.
As in 2012, the stakes in King v. Burwell are so high that Obama has made it clear that he would attack any decision that would cripple the health law as legally indefensible and politically motivated.
“[T]his should be an easy case,” Obama said June 8. “Frankly, it probably shouldn’t even have been taken up … based on a twisted interpretation of four words. … I’m optimistic that the Supreme Court will play it straight.” The next day, he added (without specific reference to the court) that “it seems so cynical to want to take health care away from millions of people.”
These shots across the court’s bow came even though Scalia and Justice Samuel Alito had strongly suggested during the argument that they would vote against the administration’s position.
Alito also suggested the possibility of delaying until 2016 the effective date of any decision against the administration. Such a delay, he said, would give the states and Congress time to avoid the disruption that would be caused if the court ruled the premium subsidies now available in the three-dozen states using healthcare.gov are illegal.
Justice Clarence Thomas, who was silent as usual during the arguments, is expected to vote with Scalia and Alito. The four liberal justices — Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor and Elena Kagan — seemed poised to line up with Obama. So the president will win if either Chief Justice John Roberts or Justice Anthony Kennedy sides with him.
While Kennedy’s vote is still up in the air, ACA supporters were cheered by his assertion to the lawyer challenging the subsidies that “there’s a serious constitutional problem if we adopt your argument.” Kennedy reasoned that the states are being unconstitutionally “coerced” if, as the challengers argue, the law requires them either to establish their own exchanges or see their residents disqualified from the subsidies.
The only way to avoid constitutional problems, suggested Kennedy, may be to resolve any ambiguities in Obama’s favor. This seemed inconsistent with the suggestions by Scalia, Alito and the challengers that the relevant language is free of ambiguity and without constitutional problems.
Roberts was sphinxlike during the argument in King v. Burwell. The case puts him in an unenviable position.
When Roberts stunned court-watchers by joining the four liberal justices and upholding the individual mandate in the 2012 decision, National Federation of Independent Business v. Sebelius, he was bitterly assailed by his usual allies — Kennedy, Scalia, Thomas and Alito — and was called a traitor by many other conservatives.
This barrage was intensified by a well-sourced news report that Roberts had initially voted to strike down the individual mandate and changed his mind — provoking a huge battle inside the court — after liberals led by Obama had preemptively denounced any decision to strike down the law as politically motivated, conservative “judicial activism.”
The conservative denunciations of Roberts will be even more bitter if he sides with Obama this time, too. On the other hand, if Roberts votes with the other four Republican appointees to gut the Democratic president’s signature accomplishment, it will feed the kind of attacks that the chief justice dreads on the Roberts court’s conservative majority as a bunch of robed politicians.
Looking to the future, a ruling against Obama could be extremely awkward politically for Republican members of Congress, presidential candidates and officials in the mostly red, affected states, even though it might be cheered (at least initially) by Republican voters.
In this scenario, the president and other Democrats would immediately demand that Republicans help them save the subsidies of millions of people at risk of losing their health insurance, by adopting new legislation.
Some Republicans say this would be an opportunity to extract compromises from Obama such as more choices for consumers – especially less expensive, less comprehensive health insurance options; the elimination of the mandate to buy insurance; or restrictions on medical malpractice lawsuits.
Others predict a humiliating and internally divisive Republican cave-in to avoid being blamed for the “disastrous consequences” that Justice Scalia hypothesized.
Whatever the outcome, the chief justice, in his tenth year on the Court, is in for a long, hot summer.