Financial Aspects of Court-Ordered Evaluations

In 1971 Wexler and Scoville (1) published a landmark article in which they reviewed the administration of psychiatric justice in Arizona. The article was influential in restructuring the Arizona state system. Nevertheless, involuntary psychiatric evaluations continue to involve extensive legal work, psychiatric assessment, and hospital care. Bureaucratic procedures and the failure or inability to use viable alternatives serve to prolong the evaluation process and contribute significantly to high costs for health care. Thus court-ordered evaluation is an expensive and time-consuming endeavor.

Arizona law mandates that evaluations take place within 72 hours: "A person being evaluated on an inpatient basis in an evaluation agency shall be released within seventy-two hours, excluding weekends and holidays, from the time that he is hospitalized pursuant to a court order for evaluation, unless the person makes application for further care and treatment on a voluntary basis or unless a petition for court-ordered treatment has been filed" (2). In addition, "at least seventy-two hours before the court conducts the hearing on the petition for court-ordered treatment, a copy of the petition and affidavits in support thereof and the notice of the hearing shall be served upon the patient" (3).

In an ideal situation, the entire process could be completed in four or five days—one or two days for evaluation combined with the mandatory 72 hours for due process. We used a retrospective design to examine the costs of conducting court-ordered evaluations during calendar year 1999 according to Arizona law.

Methods

The study sample comprised all patients who were admitted to the psychiatry department of the Maricopa Medical Center in Phoenix, Arizona, during calendar year 1999 who received a court-ordered evaluation and treatment. This center is the only institution that conducts court-ordered evaluations in Maricopa County.

Total charges per hospital stay were readily available, but the charges were not itemized on a day-by-day basis. Thus we calculated the average cost per court-ordered evaluation by prorating total charges per stay by the number of days from admission to the court hearing. The average cost per day was calculated by dividing the cost per court-ordered evaluation by the number of days from admission to the court hearing. For the purpose of this study, the duration of each patient's court-ordered evaluation was defined as the number of days spent in the hospital from admission through court hearing. We used SPSS to conduct the analyses.

Results

Complete data were available for 998 patients—549 men and 449 women. The mean±SD age of the patients was 41.3±15.6 years. Most were Caucasian (729 patients, or 73 percent); 124 (12 percent) were Hispanic, 105 (10 percent) were African American, 12 (1 percent) were Native American, and 12 (1 percent) were Asian. Sixteen patients (2 percent) had other racial backgrounds. Collectively the patients were hospitalized for a total of 11,928 court-ordered-evaluation days, or a mean of 11.95±2.52 days per patient before the court hearing. The mean cost per court-ordered evaluation was $8,236±$2,201, and the mean cost per day was $686±$86.

Discussion

Both the duration and the cost of court-ordered evaluations were greater than expected. Several factors may have contributed to the prolonged duration of court-ordered evaluations. Most admissions for court-ordered evaluations take place on an emergency basis. They occur at all times of the day and on all days of the week, depending on the urgency of the situation and the condition of the patient. The psychiatry department of the Maricopa Medical Center is the only facility in Maricopa County that can legally hold a patient against his or her will for the purpose of conducting a court-ordered evaluation. The availability of a locked holding facility would make it possible to keep patients in a safe environment pending the evaluation, thus reducing unnecessary hospitalization time and costs.

Typically, evaluations for patients who are admitted to the psychiatry department on Thursdays or Fridays are completed the following Tuesday or Wednesday, and the court hearings take place 72 hours later. A government holiday on a Monday further prolongs the evaluation, which raises the question of whether evaluations should be conducted on weekends and completed in less than 72 hours if possible as a means of reducing costs. State law does not preclude a psychiatrist from completing a court-ordered evaluation on weekends or holidays and does not require that evaluations take the full 72 hours allotted.

The fact that court hearings are not available on weekends or holidays also delays discharge and treatment, thus increasing inpatient costs. The usual practice is for the court to hear four or five cases a day. The average daily cost of a court session, including direct and indirect costs but excluding the cost of the county clerk and public defenders, is $3,158 (personal communication, Dyer R, Feb 8, 2000). The number of inpatient days that could by saved by completing eight to ten court-ordered evaluations on a weekend, at $686 per patient per day, would more than offset the cost of providing court and psychiatric services on weekends.

Another alternative for reducing costs would be to house patients in a facility that provides a lower level of care while evaluations are being performed. The evaluating physician could determine the appropriateness of this option at the time of initial contact. Eligible patients could be placed in settings in which most of the supervision is provided by psychiatric technicians rather than physicians and nurses. Such an approach would reduce physician charges, nursing charges, and hospital bed costs. Of course, this less intensive setting would not be appropriate for all patients; some patients may be dangerous or medically compromised. Thus it would be most cost-effective to place patients in the least acute setting possible. Arizona law provides for alternative plans, stating that "the admitting officer may notify a screening agency and seek its assistance or guidance in developing alternatives to involuntary confinement" (4).

In the only related research we identified—a 1987 study of Oregon's civil commitment process—the average detention was 15 days long and cost $1,800 (5), compared with our finding of 11.95 days at a cost of $8,234 in Arizona. The Oregon study identified several major areas that influenced costs, including commitment procedures, the performance of individual mental health professionals, and screening procedures. Aside from the difference in the periods studied, a substantial difference between the two systems is the fact that Oregon places considerable emphasis on screening. A more efficient screening system in Arizona might prevent many people from ever beginning the court-ordered-evaluation process, thus reducing total expenditures for court-ordered evaluations. As noted by the authors of the Oregon study, many different facets of the commitment process must be scrutinized in order to promote efficiency and reduce costs.

Conclusions

We found that 11,928 court-ordered-evaluation days were required to conduct 998 court-ordered evaluations in Maricopa County, Arizona, in 1999. Under a more efficient system, the same 998 evaluations could be completed in 4,990 days (five days per evaluation), a difference of 6,938 days. At $686 a day, this difference translates to $4.8 million that could be saved and reappropriated to areas such as medication, housing, and outpatient care for persons with mental illness in Arizona.

Dr. Goldberg is with the department of psychiatry and Dr. Bay is with the department of academic affairs at the Maricopa Medical Center in Phoenix, Arizona. Dr. Kazim is with the department of psychiatry at Rhode Island Hospital and Brown University Medical School in Providence. Send correspondence to Dr. Goldberg at 4132 East Pinchot Avenue, Phoenix, Arizona 85018 (e-mail, [email protected]).