Economic Grand Rounds: The High Costs of Care for Four Patients With Mania Who Were Not Compliant 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.

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 protected]). 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.