A study published today in Annals of Emergency Medicine reports lengthy waits for severely ill psychiatric patients in need of immediate hospitalization in the Boston area, due in part to time-consuming prior authorizations required by insurance companies.
Psychiatrists spent, on average, 38 minutes on the telephone getting authorization. In 10 percent of cases it took more than one hour to obtain insurance authorization; in one case authorization took five hours of psychiatrist time.
Mental health disorders are common, affecting nearly 1 in 4 adults annually, less than a third of whom receive psychiatric care. Better access to care might reduce the harms mental illness imposes on the mentally ill, their families and communities.
For the present study, over a three-month period, researchers tabulated how long psychiatric patients who were deemed in need of inpatient admission stayed in the emergency department (ED) prior to being hospitalized, and the amount of time that the ED psychiatrists spent obtaining authorization from the patient's insurer. A group of 11 psychiatric residents at Cambridge Health Alliance (CHA) working in the psychiatric ED with acutely ill psychiatric patients collected the data.
Most patients required hospitalization because they were suicidal or, in a few cases, homicidal.
Although obtaining insurance authorization delayed care and took clinicians away from other duties, only 1 of the 53 requests for authorization was denied. Median total time in the ED was 8.5 hours, with the shortest stay lasting 3 hours and the longest recorded stay lasting 20 hours.
These numbers don't include a handful of patients who boarded in the ED over the weekend while waiting for an inpatient bed to become available for them. They exclude uninsured patients and those with Medicare, which doesn't require prior authorization.
With approximately 1.6 million psychiatric admissions among people with private insurance nationwide each year, 38 minutes of phone time to obtain authorization translates into about 1 million hours of wasted psychiatrist time.
Lead author Dr. Amy Funkenstein, a child psychiatry fellow at Brown University, led the study while she was a psychiatric resident at CHA and Harvard Medical School. She said: "Society pays for inadequate psychiatric care; more than half of all prison inmates and a third of all homeless people are mentally ill. Massachusetts is considered a model for health reform, yet we found that seriously ill patients routinely spent hours stranded in the ED due to insurance bureaucracy. The hours psychiatrists spend obtaining those authorizations could be far better spent treating our patients."
Senior author Dr. J. Wesley Boyd, attending psychiatrist at CHA and assistant clinical professor of psychiatry at Harvard Medical School, commented: "Private insurers are obstructing care by requiring authorizations before a qualified psychiatrist can hospitalize a dangerously ill patient. With doctors, nurses and emergency departments already overburdened, adding a time consuming bureaucratic task that doesn't help patients is unconscionable.
"Insurers hope that clinicians will be so hassled by authorization procedures that they won't seek admission for their patients, saving insurance companies money," he said. "Placing profits ahead of the health of patients when mental illness makes them vulnerable is immoral. A single-payer Medicare-for-all health care system would represent a great leap forward for patients and providers alike."
More information: "Insurance Prior Authorization Approval Does Not Substantially Lengthen the Emergency Department Length of Stay for Patients with Psychiatric Conditions," Amy Funkenstein, M.D., Monica Malowney, B.A., and J. Wesley Boyd, M.D., Ph.D., Annals of Emergency Medicine, April 23, 2013.