Hospitals tell Senate committee Medicaid screening rules and CMH processes delay psychiatric care and increase ED boarding

LANSING — Hospital representatives told the Michigan Senate Committee on Health Policy on March 19 that a Medicaid-specific pre-admission screening process and uneven community mental health agency (CMH) practices are delaying inpatient and other behavioral health placements and leaving patients to board in emergency departments.

Lauren Lapine, senior director of legislative and public policy at the Michigan Health and Hospital Association (MHA), and Kyle Hoffmaster, director of patient access at Pine Rest Christian Mental Health Services, outlined data from an 18-month MHA study and provider experience that they said show systemic delays for Medicaid beneficiaries.

MHA findings presented to the committee included an estimate that "on any given day there are over 155 patients that are waiting in emergency departments across the state for access to critical behavioral health services," Lapine said. She described pediatric and geriatric patients as boarding for the longest periods and said Medicaid patients comprise the largest share of those waiting; her slides and remarks showed more than 8,000 Medicaid patients boarded in EDs over a calendar year compared with about 5,000 commercially insured patients based on the hospitals' sample data.

Lapine explained the current process for Medicaid beneficiaries differs from commercially insured patients because hospitals must involve a county community mental health agency (CMH) that represents the prepaid inpatient health plan. "If I'm a Medicaid beneficiary, the hospital psychiatrist can't independently determine I need inpatient care without the approval of a community mental health clinician simply because the CMH ... must decide whether or not they are willing to pay for my services," she said. The MHA told the committee that pre-admission screening by a CMH is contractually required to be completed within three hours for Medicaid patients, but hospitals report the 3-hour timeline is frequently not met.

Pine Rest's Hoffmaster described operational impacts and logistics. He said Pine Rest often has beds available but that the CMH pre-admission assessment or the requirement that some patients be routed through an ED prevents timely admission. "We are adding additional stress and cost to families to go to emergency department, and in many instances, are adding additional stress ... to the EMS system to unnecessarily transport a patient to an emergency department," he testified, then urged allowing clinically qualified hospital personnel to complete the pre-admission screening when the CMH cannot do so within the required time frame.

Committee members asked about specific issues raised by the presenters, including variability among CMHs, weekend response practices and the qualifications of CMH staff who perform pre-admission screenings. Lapine and Hoffmaster said practices vary by CMH and by shift; they described situations where CMHs treat the three-hour window as starting when they retrieve a voicemail rather than when the patient first arrived in the ED. Hoffmaster told the committee CMH screeners are often bachelor's-level social workers, while ED staff often include physicians or master's-level clinicians, and providers said that mismatch can lead to disagreements about level of care.

What the record does not show

The presenters proposed policy changes and greater standardization but provided no proposed statutory language in the hearing record. The transcript does not include a formal committee vote on policy changes arising from this presentation; it was an informational presentation followed by questions.

Next steps

Presenters said they are eager to work with the legislature to streamline the pre-admission screening process for Medicaid behavioral health patients and to reduce ED boarding. Committee members expressed interest in state-level solutions and standardization; no formal committee action on those proposals is recorded in the transcript.