PHYSICIAN ADVISING: Mental and Substance Use Disorders (MSUDs) + Inpatient Psychiatric Care Encounters

In day-to-day work as a Physician Advisor, we frequently encounter cases that are primarily due to, or influenced by, underlying Mental and Substance Use Disorders (MSUDs). These disorders are common in the United States, with over 55 million people aged 18 years and over suffering from mental and/or substance use disorders.

Consider statistics from the 2016 National Inpatient Sample (NIS) on inpatient stays involving MSUDs at community hospitals, compiled by the Healthcare Cost and Utilization Project (HCUP). Nearly 10 million inpatient stays had a principal (2.2 million) or secondary (7.7 million) MSUD diagnosis, totaling 28% of all inpatient stays. In addition, 1 in 8 of the 139 million (2017) ED visits are related to MSUDs.  

WHY IS MENTAL HEALTH AWARENESS IMPORTANT?

Those with behavioral disturbances, or substance abuse, are often considered our most challenging patients. We are all familiar with the instances of a patient languishing in the emergency department or a general medical unit, due to a lack of inpatient psychiatric beds. We have encountered patients with prolonged hospitalizations due to substance abuse complicating the clinical course (e.g. IV drug abuser with endocarditis). In addition, we encounter difficulties placing patients at an alternate level of care due to behavioral disturbances (yelling, punching) related to dementia. These and other scenarios, may lead to denials by payers, additional cost to the hospital, treatment of patients in the wrong setting, as well as other issues. Unfortunately, hospitals are increasingly dedicating ED space for patients awaiting transfer to psychiatric facilities.  

Whether working in the remote setting, or on-site, there are several key concepts that every Physician Advisor needs to understand. These include:

• Determining whether the principal reason for hospitalization is primarily a medical or psychiatric issue.
• Identifying the correct location for patient care, including outpatient, inpatient acute hospitalization, and acute inpatient psychiatric hospitalization.
• Recognizing when the determination involves the Medical Necessity of the initial hospitalization versus the continuation of an inpatient stay.
• Understanding how the presence of a MSUDS impacts the decision for hospitalization, the determination of inpatient vs. observation “status,” and the actual/predicted length of stay.
• Utilizing a consistent approach to the review and determination of cases involving MSUDs, including clear language in supporting the physician advisor determination.

On a more advanced level, the physician advisor should understand situations that are either unique to inpatient psychiatric care, or which are more commonly encountered in patients with MSUDS:

• Involuntary vs. voluntary admission.
• Active management v custodial care.
• Alternative levels of care for MSUDS, including intensive outpatient programs, and partial hospitalizations.
• CMS exempt vs. non-exempt IPP facilities.
• The UM regulatory differences between free-standing psychiatric hospitals, psychiatric units at acute care hospitals, and critical access hospitals.
• UM impact and regulations related to Transfers to/from IPP hospitals, medical care of the psychiatric patient, and “Interrupted stay” criteria.
• State level regulations impacting IPP facilities.

As we wrap up May and Mental Health National Awareness month it’s important to raise awareness for mental health and the challenges MSUDS patients face/pose when being admitted to the Emergency Department. As mentioned above, the importance of mental healthcare and understanding how it impacts not only the patient, but that it may lead to insurance denials by payers, additional cost to the hospital, treatment of patients in the wrong setting, amongst other issues is increasingly needing attention and remediation. Even though hospitals are dedicating more ED space for patients awaiting transfer to psychiatric facilities, the future for increasing mental health awareness and proactive tools looks bright with additional data transparency and FHIR connectivity coming into play so we can aid more connected, outpatient community solutions.  Emergency Department visits involving MSUDs – which are potentially preventable with adequately managed outpatient care – are 2x as likely to result in hospital admission compared with those not involving MSUDs. The importance of care for underlying MSUDs and comprehensive outpatient patient care is very apparent. Not only can it be costly for the hospital, but it’s costly to the patient as it can be unnecessary if they would have had adequate outpatient care. The National Alliance on Mental Illness (NAMI) offers education and more to help get proactive mental healthcare. Visit NAMI.org for more information.