Hospitals and Pine Rest tell Senate committee Medicaid process leaves behavioral health patients boarding in ERs

The Michigan Health and Hospital Association and Pine Rest Christian Mental Health Services told the Senate Committee on Health Policy on March 19 that procedural requirements for Medicaid behavioral health referrals are causing patients to board in emergency departments for extended periods.

Lauren Lapine, senior director of legislative and public policy at the Michigan Health and Hospital Association, told the committee that hospitals statewide reported more than 1,200,000 emergency department visits last year in which behavioral health was a reason for care and that on any given day about 155 patients were waiting in emergency departments for access to behavioral health services. Lapine said those figures are conservative because data came from roughly 70 hospitals that submitted weekly reports.

Lapine explained that commercially insured patients typically are assessed by hospital clinicians and, if inpatient care is needed, hospitals directly locate and transfer patients to available psychiatric beds. By contrast, Lapine said Medicaid beneficiaries require a pre-admission screening assessment by a community mental health agency (CMH) within three hours, and hospitals routinely report that CMHs fail to meet that timeframe. "We routinely hear from hospitals statewide ... that this assessment is not happening within that 3 hour time frame," she said.

The MHA witness said the difference in process contributes to longer waits for Medicaid patients: her data showed more than 8,000 Medicaid patients boarding in emergency departments over a calendar year versus about 5,000 commercially insured patients. Lapine told the committee that disagreements between hospital psychiatrists and CMH social workers about the appropriate level of care can prolong decisions and that the system's payment structure — in which CMHs act on behalf of prepaid inpatient health plans — requires CMH approval before hospitals can place a Medicaid patient.

Kyle Hoffmaster, director of patient access at Pine Rest Christian Mental Health Services, described repeated operational examples in which Pine Rest had beds available but could not receive a patient because the required CMH pre-admission screening had not been completed or because CMH required the patient to go to a hospital emergency department for the assessment. "We have had a bed available for a patient in need, and the pre-admission assessment from the CMH ... is a barrier to getting them here," Hoffmaster said. He said Pine Rest operates a walk-in behavioral urgent care and that some CMHs require patients to go to emergency departments even when Pine Rest clinicians can perform an assessment there.

Lawmakers asked questions during the presentation about weekend coverage and the qualifications of CMH screeners. Hoffmaster and Lapine said CMH staffing and processes are not standardized: some CMHs operate 24/7 and deploy mobile crisis teams, while others take voicemail and begin the three-hour clock only when staff return calls, prolonging patient stays in EDs over weekends. Committee members also raised concerns that CMH screeners are often bachelor's-level social workers and may overturn hospital psychiatrists' decisions about inpatient need.

Senators and witnesses discussed local crisis centers such as Common Ground in Oakland County that provide alternative 24-hour crisis services and short-term holds. Committee members and presenters emphasized that expanding access to crisis treatment sites, standardizing the pre-admission screening process and permitting clinically qualified hospital staff to perform the screening when CMHs cannot respond in the three-hour window could reduce ED boarding for Medicaid patients.

The committee did not take any votes on policy changes at this hearing; the presentation was informational and was followed by member questions.