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The emergency room problem Obamacare won't solve

Jonathan Torgovnik/Getty Images News

Psychiatric patients are crowding emergency departments and exacerbating wait times across the nation. This is a problem that has long plagued hospitals, and it's about to get worse.

Emergency rooms are ill-suited to treat psychiatric patients, but they often serve as the first point of access to care. And increasingly, ERs don't have the space to handle these cases: 84 percent of emergency physicians report that psychiatric patients are "boarded" in their emergency departments, according to a new survey. Among those who reported boarding, 91 percent said that it had resulted in violent behavior by distressed psychiatric patients, distracted staff, or bed shortages.

"People having a mental health crisis seek care in emergency departments because other parts of the health care system have failed them," says Alex Rosenau, president of the American College of Emergency Physicians (ACEP), which conducted the study.

When a psychiatric patient enters an emergency room, they may need to be admitted to the hospital to receive needed care, but that doesn't mean there is a bed available for them in the appropriate department. That leaves the psychiatric patient waiting in the emergency room until they can be transferred — hospitals refer to this as "boarding" — which increases pressure on staff and reduces the emergency department's capacity to serve other patients.

Historically, this problem has been driven by the closure of psychiatric facilities and diminished state funding for mental health services. Between 1955 and 1997, total state spending on mental health fell 30 percent, a period during which most health spending grew rapidly.

These problems are likely to get worse, unless hospitals find new ways to adapt. Experts expect that emergency room visits will increase — not decrease — as the Affordable Care Act is implemented.

Studies have shown that patients are more likely to visit the emergency room — even for non-urgent problems — when they're insured because they're less likely to face catastrophic medical bills afterward. Lower-income patients are particularly likely to visit the emergency department, and much of the expansion of health coverage will be among this population.

Hospitals struggle to strike the right balance between encouraging appropriate use of care and discouraging use of the emergency department when it might actually be necessary. "We don't want to impose any barriers on people going to the emergency room," said Hans House, a clinical professor at the Iowa University Carver College of Medicine. "We don't want people to be afraid to go to the ER."

The problem is that Obamacare extends coverage to millions of Americans who were previously uninsured, and the size of emergency departments can't grow swiftly enough to accommodate the new patient population expected in the next few years.

The Affordable Care Act attempts to address psychiatric boarders on the payment side. The health reform law has made funding available for reimbursement of emergency psychiatric care in Medicaid; the public program does not usually cover these services.

The new payments are more of a band-aid than a cure, though. They don't solve the capacity problems, and with psychiatric boarding, it isn't just about available space. "We know that a lack of psychiatrists available and staffing patient beds is a barrier," House said. "That's a personnel issue."

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