Patient Dumping: Mental Healthcare Thrown under the Bus

Suspicions are arising about mental patients being bussed to other states in order to save local costs. This raises questions about mental healthcare provision in the US, and highlights some ethical and organizational problems within the system.

Recently, I came across an article from The Sacramento Bee that was updated and republished online. The article exposed a Las Vegas, Nevada psychiatric hospital’s practice of shipping patients via bus to other states. Now, this practice is not exactly unheard of. But it’s quite rare, and most often done with some very rational justifications. Indeed, officials at the hospital in question point to the fact that Las Vegas is a natural magnet for troubled souls looking to escape their problems, or for those who, in the throes of mania or other psychotic states, find temporary relief amid the bright lights and 24-hour action. So, it’s not unexpected that a place like Vegas might even have a higher than average number of mental patients, who ultimately would be best served by returning them to their home environments and the care of local service providers just as soon as they can be stabilized. But the hospital in question was found to have bused over 1500 patients in just a few years to various locations in every state in the union — an unusual number, even when you consider the uniqueness of the hospital’s locale. This fact raised suspicions about a possible pattern of ‘patient dumping.’

The hospital’s suspected pattern of behavior might never have come to light were it not for the fact that, in at least one case, the staff put a man on a bus without any medication or documentation, and sent him not to another hospital or pre-arranged place of residence, but simply to the bus terminal smack dab in the center of the city of Sacramento, California. His discharge notes reflect that he was only vaguely advised to get follow-up treatment with a doctor and to call 911 if necessary upon his arrival. The case raised some serious ethical red flags. Purchasing a bus ticket might be a lot less costly and complicated an intervention for a hospital than providing housing for and an array of clinical services to a person from out of state suffering from a serious mental illness, but it hardly constitutes a treatment plan. But, perhaps even more troubling than this one egregious example is the more widespread problem of how difficult it can be for a seriously mentally ill person to secure the resources they need within the country’s cash-strapped and organizationally-challenged mental health care system.

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It’s not that the US doesn’t spend a lot of money on mental health care. It does. In fact, it spends as much or more per capita than most advanced societies. And when it comes to securing outpatient care for relatively minor mental health issues, and procuring various psychiatric medications to cope with these issues, the picture is a whole lot different. Folks whose needs are not as pressing and who have good insurance are generally well cared for. And within that population is where the lion’s share of mental health spending occurs. But for the seriously mentally ill, gaining access to proper treatment and in the proper environment is an entirely different story. While they might not be routinely shipped to other locales by facilities not wanting to bear the burden or the costs of their treatment, the seriously mentally ill constitute the single group within the healthcare system most likely to be thrown under the proverbial bus.

A century or two ago, persons with serious mental illnesses had virtually no place to go except state-run institutions, where they often languished in fairly squalid conditions. Even those institutions, however, were a big step up from the dangerous and unhealthy conditions most mentally ill folks endured prior to the advent of state hospitals. But, following the development of powerful medications that could control the symptoms of serious mental illness, there was a massive medical and political push toward ‘deinstitutionalization.’ Several laws were passed to protect people’s liberties and to guard against seemingly unnecessary or unwarranted forced commitments. And mental health centers were established, as a more cost-effective means of providing services to the chronically mentally ill. But an unintended consequence of all of these actions was the meteoric rise of chronically mentally ill folks who lacked sufficient family and community support, and whose illnesses by nature made them prone to non-compliance with their medication and treatment regimens, who then became ‘homeless,’ living on the streets in conditions far worse than the stark confines of an institution. And to make matters worse, because funding was simultaneously drying up for mental health centers, especially in less populated areas, all too often, the seriously mentally ill literally had absolutely nowhere to go.

Investigations into the practices of southern Nevada’s mental healthcare system are now ongoing. It will be some time before a determination can be made about whether any facility regularly and deliberately engaged in a pattern of patient dumping. But the Nevada case has sparked some renewed interest in the state of mental healthcare. Every state faces some dilemmas with respect to the costs, inefficiencies, and inadequacies of their mental healthcare delivery systems. And few would argue that merely transporting patients to other states in the hopes that they have the resources to shoulder the burden is the real solution. But, fixing the problems in the mental healthcare system will take time, well-focused attention, and of course, money.

In the wake of the recent rash of violent acts by persons with serious mental disturbances who went unattended, the need for easily accessible and affordable mental health services — especially preventative services — could not be greater. But in the US, mental health has always been the healthcare system’s stepchild. So the only real question left is, how many tragedies will it take before there’s enough public pressure and political will to implement badly needed mental healthcare reform.

• public health
• society