The High Cost of Care

To the Editor: In the Economic Grand Rounds column of the December 1999 issue, Dr. Durrenberger and his coauthors (1) describe selecting four patients admitted to the long-term ward of a state hospital in Kentucky, using criteria that were not revealed, and then comparing the cost of their inpatient care to the cost of mental health care of 25 clients randomly selected from an outpatient program. The authors then used incomplete data on these inpatients to conclude that a system of involuntary outpatient commitment would save money for the state of Kentucky.

In none of the cases were there sufficient data to be able to separate the cost of psychiatric care from other medical expenses. Since the monthly inpatient costs for 80-year-old Mr. A were four times greater then the cost of providing inpatient care to 41-year-old Ms. C, nonpsychiatric care costs must surely have been involved, but they were not detailed. Nonpsychiatric medical costs for the comparison group were not provided. No information was given about the kind or intensity of outpatient services that were made available to these individuals following discharge.

Thanks to the Bellevue Outpatient Study (2), we now know that court orders alone do not improve treatment outcomes; the availability of comprehensive community-based services does. Two of the four people in this sample actually cost less to treat in the hospital than it would have cost to provide the most intensive outpatient treatment regimen the authors describe.

The real issue here may be that a substantial portion of the cost of care for outpatients is shifted to the federal Medicaid and Medicare programs. This shift means that community treatment under involuntary outpatient commitment would cost the state of Kentucky less money, a compelling argument to bureaucrats concerned with state budgets. From a human rights and social justice perspective, relying on court orders to enforce treatment compliance rather than creating a comprehensive system of care that people embrace voluntarily is reprehensible.