Inpatient mental health care ends in county as Oaks closes

Seven Rivers officials say the hospital simply couldn't fill enough beds.

Published October 29, 2006

CRYSTAL RIVER - A decision by Seven Rivers Regional Medical Center to shutter its mental health facility has left Citrus County with no inpatient psychiatric services.

"Everything has closed," said Mary Lee Cubbison, director of the Centers formerly Marion-Citrus Mental Health in Lecanto. "There isn't one inpatient bed in the entire county."

Representatives from Seven Rivers said the decision to convert 16 beds dedicated to psychiatric services - known as "the Oaks" - to acute care beds was based on community needs.

"Because of advancements in outpatient care and medication, people don't need inpatient care as much anymore," said Dorothy Pernu, spokeswoman for Seven Rivers.

But mental health advocates say Florida faces a shortage of inpatient psychiatric beds. The state received the lowest score possible in terms of access to inpatient services, according to a recent study by the National Alliance on Mental Illness.

"There are about 3,000 more beds needed in the state," said Sue Homant, executive director for NAMI Florida. "My personal guess is the number is even higher than that."

While Seven Rivers maintains that the hospital simply couldn't fill the beds, mental health experts say the decision to abandon psychiatric services is often driven by finances.

"Psych services classically lose money," said Ken Duckworth, medical director for NAMI. "It's a silent crisis in America today."

Bed shortages weren't such a looming problem 15 to 20 years ago, said Mark Covall, executive director for the National Association of Psychiatric Health Systems.

"There was actually major growth in the late 1980s and early '90s," he said. "In some areas, there was even an oversupply."

He attributed the increase to two factors: excess capacity and the advantages of a cost-based Medicare reimbursement system.

But since that time, excess space at many hospitals has been swallowed up by population growth, and, in January 2005, Medicare changed its reimbursement system. Instead of reimbursing medical facilities based on actual costs, Medicare now offers a flat daily rate.

"The pendulum has swung in the other direction," Covall said.

The flat rate that any facility receives is based on an average for all of the mental health programs around the country. Though adjustments are made, Covall said the new system generally puts smaller psych programs at a disadvantage.

"Smaller units, because of economies of scale, are often paid less," he said. "Ten to 15 beds is hard to operate if you have a high Medicare population."

Not to mention that insurance coverage and reimbursement for psych services rarely measure up to those given for other medical conditions.

"As states have withdrawn their commitment to the mentally ill, private entities need to do it out of beneficence," Duckworth said. "But the reimbursement is poor."

For example, a hospital may get $4,000 a day for a cardiac patient and only $500 for a labor-intensive psych patient, he said.

Seven Rivers, a private hospital, launched the Oaks in 1991, during the boom in general hospital mental health units. Citrus Memorial Health System, the county's other hospital, has no beds reserved for psychiatric care.

"At that time, there was a definitive need for inpatient services," said Joyce Brancato, chief executive officer of Seven Rivers.

But because of advances in treatment, the hospital saw a gradual decline in the number of mentally ill patients needing hospitalization, she said.

Then, in 2000, Seven Rivers stopped accepting Baker Acted - involuntarily committed - patients.

The change affected both families of patients and the Citrus County Sheriff's Office. Patients who threaten suicide or homicide now have to be driven to the Centers in Ocala (the Lecanto office offers only outpatient services) or the Harbor Behavioral Health Care Institute in Spring Hill.

"It's definitely inconvenient," said sheriff's Lt. Buddy Grant. "We have to take them out of county and then stay out of county for at least an hour."

Even worse, Homant said, "you're driving around a person who is very sick. If someone was having a cardiac crisis, you wouldn't make them wait for treatment."

But Brancato said the hospital needed to stop accepting Baker Acted patients, no matter the downfalls, to improve the treatment environment.

"We were trying to combine both voluntary and involuntary patients," she said, "and it was difficult to care for both."

While Seven Rivers focused efforts on voluntary patients, the hospital saw the number of them dwindling, Brancato said.

At the same time, the demand for surgical beds went up.

"This was truly a decision made on the needs of the community," she said, pointing out that Seven Rivers provides several million dollars' worth of uncompensated care every year.

Cubbison said the Centers will likely pick up former Oaks patients - a service that she is sure the organization can provide, even if it's a bit of a struggle.

"The demands on our resources will be heavier," she said. "We're the last standing mental health facility."

Elena Lesley can be reached at 564-3627 or elesley@sptimes.com.