The rise of managed care in psychiatric practice today is forcing psychiatrists to take a closer look at costs. The treatment of chronic illness in general consumes a disproportionately high share of health care expenses (1). In caring for people with chronic mental illness, a large proportion of resources may be consumed by a small number of difficult-to-treat patients through long or repeated hospitalizations, legal expenses, and damage to property.
Although it is difficult to accurately assess all of these costs, hospitalization costs can easily be figured. Knowledge of these costs can encourage clinicians to seek better outpatient alternatives for treating revolving-door patients. It is clear that noncompliance with medications is one of the top three reasons for rehospitalization in this population. Noncompliance, along with lack of insight and social problems accounts for as much as 80 percent of rehospitalizations of patients with chronic mental illness (2,3,4).
To provide clinicians with a better understanding of the high cost of treatment noncompliance, we examined hospitalization costs for four patients with a history of mania and noncompliance with medications. We present a brief case report for each patient and address issues such as outpatient commitment that may improve the care of chronic mentally ill patients who are noncompliant with treatment.
Eastern State Hospital is a 160-bed hospital in Lexington, Kentucky, that serves as the primary psychiatric hospital for a third of the state. Each year, about 1,250 patients account for the hospital's 1,600 admissions. The hospital has a long-term 30-bed unit for patients staying from several months to years.
During 1996, a total of 35 different patients were hospitalized on the long-term unit. Six had a history of mania diagnosed by the Structured Clinical Interview for DSM-IV (SCID). One of them was a patient with bipolar disorder who had unremitting mania and multiple medical problems, and one of them was a patient with schizoaffective disorder who suffered from a manic and a psychotic syndrome and experienced only a partial response to medications. The remaining four were patients with active mania who had a history of full response to treatment or whose residual symptoms when they were treatment compliant were minor enough to allow them to live in the community. However, due to lack of insight, all four had a history of noncompliance and lengthy hospitalizations.
To calculate the cost of hospitalization for these patients over six years, we obtained the per-diem fee used by the hospital to estimate expenses, which ranged from $210 in 1991 to $360 in 1996. This fee includes the costs of laboratory tests and medications but does not include physicians' fees. Because physicians' fees are calculated separately and differ for each patient, the hospital was not able to provide these data for our analysis. Also, three of the patients spent a significant time out of the hospital and received outpatient treatment for which cost data were not available. Thus the amounts reported are actually lower than the true costs of treatment for each of the patients.
Mr. A was an 80-year-old white man with a diagnosis of bipolar I disorder. He had a total of four hospitalizations at the Eastern State Hospital. Between 1991 and 1996, he was admitted twice to the hospital, staying a total of 2,179 days, or 99 percent of that time. He had a history of responding well to mood stabilizers but consistently refused medications. Both hospitalizations were due to medication noncompliance precipitating a manic episode. His one discharge was to a personal care home, where he stopped taking medications and had to be returned to the hospital in three weeks.
On a combination of divalproex sodium liquid and lithium, given with supervision, and with blood levels drawn every two weeks, after five years of hospitalization Mr. A's manic symptoms cleared completely for several months. In 1997 after he was sent home on convalescent leave, he stopped medications and returned because of relapse to mania. The total cost of his hospitalizations for the six years, excluding physicians' fees, was $544,668, an average cost of $7,565 a month.
Mr. B was a 73-year-old African-American man with a diagnosis of schizoaffective disorder, bipolar type. He was hospitalized a total of 13 times at Eastern State Hospital, and he had also been hospitalized at the Veterans Affairs hospital. Between 1991 and 1996, he was hospitalized five times at Eastern State Hospital, each time due to noncompliance leading to a manic episode. He spent 554 days in the hospital in during those six years, or 25 percent of the time.
With mood stabilizers and neuroleptic drugs, Mr. B's manic symptoms greatly improved. However, he continued to have chronic delusions. Hospital staff believed that he could live within a structured setting if he remained compliant with medications. In the hospital he agreed to take medications "to give a good example to other patients." But he adamantly refused to take medications, including those for medical problems, when he left the hospital. The total cost of his hospitalizations, excluding physicians' fees, was $172,834, an average cost of $2,400 a month.
Ms. C was a 41-year-old African-American woman with a diagnosis of bipolar I disorder. She was hospitalized a total of 18 times at Eastern State Hospital. She was also hospitalized in other medical facilities with short stays, but information about the costs of these stays was not available. Between 1991 and 1996, she had 11 hospitalizations at Eastern State Hospital, each due to noncompliance leading to manic episodes with paranoid symptoms.
Ms. C. showed a consistent pattern of rapid and complete response to mood stabilizers and neuroleptic drugs. After discharge, she stopped taking all medications, began to abuse alcohol, became manic, and returned to the hospital. She spent 15 percent of the previous six years in the hospital. The total cost of her hospitalizations, not including physicians' fees, was $100,470, an average cost of $1,395 a month.
Mr. D was a 46-year-old white man with a diagnosis of bipolar I disorder with mood incongruent features. He was hospitalized a total of 11 times at Eastern State Hospital. He was also hospitalized at other facilities in other states, but cost data for these hospitalizations were not available. Between 1991 and 1996, he was hospitalized three times at Eastern State Hospital, for a total of 1,206 days. He spent 55 percent of the those years in the hospital. When Mr. D was treatment compliant, he showed excellent response to mood stabilizers and neuroleptic medications. Each hospitalization was due to noncompliance leading to a manic break. The total cost of his hospitalizations, not including physicians' fees, was $364,400, an average cost of $5,061 a month.
The total cost of hospitalization for these four patients from 1991 to 1996 was $1,182,372, with a mean cost of $295,593 or $4,105 per patient per month. Again, these figures do not include physicians' fees or costs of outpatient treatment.
In 1996 a random sample of 25 patients with bipolar disorder was chosen from the mental heath center in the community where Eastern State Hospital is located. The cost of their outpatient treatment was found to be $1,267 per patient per year, or $106 per month, with a range from $8 to $538 per month. The latter cost was for a patient who received day treatment throughout the year. These figures include all clinical services, therapy, case management, evaluation, and medication management, and they exclude actual pharmacy costs and room and board.
In 1996 the cost of treating a patient in the supervised personal care home usually used by Eastern State Hospital was $27,546 per year, or $2,295 per month, including medication and room-and-board expenses. The personal care home typically uses the day treatment program for several patients. The maximum cost for outpatient treatment—that is, treatment at the personal care home combined with day treatment—was $2,833 per month.
Currently, the state of Kentucky is converting its Medicaid system to a managed care model. If patients such as the ones in this study are not taken into account when budgeting for care, the state could easily fall short. According to Chang and associates (5), the mental health managed care system in Tennessee failed due to underbudgeting, at $21.84 per enrollee per month regardless of an enrollee's mental health status. The proposed revised budget in Tennessee suggests $319.41 per enrollee per month for severely mentally ill patients.
The average cost for the four patients in this study was $4,105 per patient per month over the six years examined, a cost that did not include outpatient treatment between hospitalizations. Using the proposed figure from Tennessee, a neighboring and demographically similar state, the cost of hospitalization for each of the patients would consume the share budgeted for 13 enrollees. The amount budgeted for 52 patients would be needed for these four patients.
Quinlivan and colleagues (6) have shown that intensive outpatient treatment programs can significantly reduce the cost of care for patients with chronic mental illness. When noncompliance is an issue, relapse is common, and thus rehospitalization is necessary when no other means of care is available. Offering programs such as intensive outpatient treatment, community outreach, and home visits can help encourage compliance among chronic mentally ill patients. When these programs don't work, outpatient commitment laws should be considered.
The state of Kentucky does not currently allow for outpatient commitment except when patients sign an agreement during their inpatient commitment. This procedure allows patients to be discharged to the community with specific guidelines. Failure to adhere to these guidelines, such as keeping all scheduled appointments and maintaining therapeutic blood levels of medications, can result in readmission to the hospital. Unfortunately, patients such as the four described here, who do not believe they have mental illnesses or need psychiatric treatment, will not sign these agreements.
Over the six years examined, caring for the four patients in this study consumed a surprisingly large number of dollars due to hospitalization alone. With Kentucky Medicaid now converting to a capitation system of payment, the resources consumed by these patients must be taken into consideration when estimating a budget. Ideally, a change in the commitment laws in Kentucky to include outpatient commitment with forced treatment and allow for compliance monitoring by periodic measurement of blood levels of mood stabilizers would improve the situation for these patients.
The study was limited by the small sample size and the lack of availability of data on the number of patients with bipolar disorder in the catchment area and on the costs of outpatient treatment for the four patients. To examine the exact economic impact of noncompliance among patients with bipolar disorder, prospective studies are needed.
This study was made possible by the collaboration of the staff of the Gragg 2 unit at Eastern State Hospital and the director of the hospital, Daniel Luchtefeld, Ph.D.
When this work was done, Dr. Durrenberger was on a training rotation at the University of Kentucky (UK) Mental Health Research Center, where Dr. Rogers is associate director and Dr. de Leon is medical director. Dr. Durrenberger is now assistant professor of psychiatry at Marshall University School of Medicine in Huntington, West Virginia. Dr. Rogers is also clinical assistant professor at the UK College of Pharmacy, and Dr. de Leon is associate professor at the UK College of Medicine. Mr. Walker was formerly director of the Bluegrass East Comprehensive Care Center in Lexington and is assistant professor at the UK Center on Drug and Alcohol Research. Send correspondence to Dr. de Leon at the UK Mental Health Research Center at Eastern State Hospital, 627 West Fourth Street, Lexington, Kentucky 40508 (e-mail, email@example.com). A description of this sample was presented as a poster at the Institute on Psychiatric Services held October 24–28, 1997, in Washington, D.C. Steven S. Sharfstein, M.D., is editor of this column.