Campaign for mental health parity continues
At the 14 December 2010 meeting of Physicians Organizing Committee’s (POC) Physicians Advocacy and Infor-mation Taskforce (PAITF), psychiatrists from the eastern San Francisco Bay Area (the East Bay), Akbar Gilani, M.D. and Thomas Powers, M.D. called for colleagues to join them in uniting with psychiatric nurses, psychologists and other health workers to condemn accelerating cuts in funding for mental health resources.
At the top of their agenda was the imminent closure of Eden Hospital’s 18-bed Inpatient Psychiatric Unit (IPU) in Castro Valley, California where Powers and Gilani admit patients. Both psychiatrists warned that the projected 2013 closure of this vital facility by hospital operator Sutter Health will result in severely adverse consequences for patients, practitioners, family members and the community.
POC members call for government to reverse cuts in mental health
Powers, Gilani and their fellow POC members further called for local and California state officials to not only reverse severe cuts in mental health resources and acute care psych beds, but to institute a comprehensive mental health system that meets medical and ethical criteria, as defined within POC members’ draft Statement of Principles.
Gilani pointed to the stark contrast between the rash of mental health ward closures in public and private hospitals and the burgeoning expansion of jail psychiatric facilities. The State of California recently broke ground on a 1,722-bed prison hospital in the City of Stockton for inmates with intermediate medical and mental healthcare needs. It will cost an estimated $906 million and include 432 intermediate-care mental health beds for inmates requiring comprehensive psychiatric and rehabilitative treatment, 43 beds for inmates requiring acute psychiatric care and 137 beds for inmates in psychiatric crisis. This is in addition to a 64-bed intermediate-care mental health facility in the state mental health hospital in Vacaville and a 45-bed mental health facility in the California Institute for Women in Corona.
“It’s unbelievable. That money should be used to care for patients in our communities, not for building prison psych units for the state to treat patients needing mental health treatment after they are locked up, usually because of untreated mental heath problems,” said Dr. Gilani.
Powers, the former director of the Department of Psychiatry at Eden Hospital, who was so busy at Eden’s Psych Unit that he had four patients left to see at 7:30pm on the night of the 14 December meeting and had to join in via teleconference, expressed his dismay that Sutter Health would pretend there was no need for the IPU. He called for an organizing campaign to reach all the psychiatrists, emergency physicians, nurses, patient advocacy groups and others in the East Bay most affected by the projected closure.
According to Powers, “As a result of continued psych facility losses, the mentally ill are being thrown into the prison system, onto the streets or ultimately dying as they fall victim to violence and neglect.
“The largest inpatient psychiatric population at this moment in the state of California happens to reside in the Los Angeles County Jail.”
Attendees at the December meeting universally condemned today’s status quo, in which mentally ill patients can be left to wait up to five days in emergency rooms before being admitted to a psychiatric inpatient facility.
POC Operations Manager Brian Tseng noted, “These cuts are wholly unjustified. Government tax breaks are feeding the coffers of the very same private hospital management chains notorious for their policy of eliminating mental health services.”
Powers’ and Gilani’s campaign to maintain an acute inpatient psychiatric unit for the Castro Valley area was endorsed by all attendees. Although they listed several potential replacement sites throughout the East Bay, they first requested POC’s help in reaching other members and potential members who would be allies in fighting to save the services before focusing on the details of where they should be provided or how many psych beds there should be.
Dr. Valerie Gruber, Ph.D., who helped draft the Statement of Principles, spoke about the need to organize allies in the community, including family members of the mentally ill, based on her experience battling to stop the dismantling of San Francisco’s mental health system.
Dr. Stanley Seifried, a POC member with over 44 years of experience as a psychiatrist in the Bay Area, and who was once in charge of Alameda County’s Community Behavioral Health Services, agreed to contact his colleagues to get involved in the campaign to save the Eden Psychiatric unit.
It took months of work, from an initial benefit intake with POC founding organizer Geoffrey Wilson and Tseng in June of 2010, followed by discussions with POC members at PAITF meetings between June and October, for Powers and Gilani to develop their strategy, starting with building a core grouping of POC members committed to doing the phoning, public speaking, meetings and letter writing necessary to prevent the closure of much needed acute inpatient psychiatric beds.
Powers and Gilani identified psychiatrists who admit patients to Eden Hospital’s IPU who had expressed the most concern about the loss of the facility as well as physicians at Eden and San Leandro Hospitals who frequently refer patients to the psychiatrists on staff at Eden for evaluation and treatment. This included emergency room physicians, hospitalists and those dealing with trauma. Powers and Gilani compiled lists of medical professionals to approach about taking a lead in promoting the need for the IPU. Meanwhile, POC member psychiatrists John Rouse, M.D. and Gil Villela, M.D. as well as psychologist Valerie Gruber, Ph.D., M.P.H. and Marvin Woodside, R.N. who have had extensive experience battling deep cuts in psychiatric services in San Francisco over the past decade, added their input regarding arenas to speak in and responsible government officials to hold accountable.
“Correctional Facilities” for the mentally ill
Gilani, in addition to serving as an attending physician at Eden’s Department of Psychiatry, is also a staff psychiatrist at the California Department of Corrections. At the June 16th meeting of the PAITF, he warned of further patient consequences as well as the dangers to mental health workers in overcrowded facilities, including correctional facilities where he has worked.
Several mental health professionals at the June PAITF meeting related their own first hand experiences of being attacked or witnessing their colleagues being injured when patient overcrowding destabilized care. Gilani’s concerns were reinforced by two separate incidents in October of 2010, in which two patients in Northern California — one at Napa State Mental Hospital and the other at Contra Costa County Jail — each killed a psychiatric nurse.
E. Fuller Torrey, M.D., a leading psychiatrist for the past 40 years gave a 24 July presentation at SF General Hospital’s Carr Auditorium, followed by a private reception held by POC member Rick Patel, M.D., a psychiatrist in San Francisco’s Psychiatric Emergency Services (PES) unit. Torrey, who founded the Arlington, Virginia-based Treatment Advocacy Center dedicated to eliminating legal and clinical obstacles to the treatment of severe mental illness, reported that over the past 35 years California has lost nearly 35,000 acute psych beds, and at present day there are about 35,000 Seriously Mentally Ill (SMI) people in the state’s prison system.
According to a 28 January 2010 presentation by Mark Leary, M.D., the deputy chief of SF General Hospital’s Psychiatry Department, these cuts have been very severe. Citywide, San Francisco had 223 acute psych beds in 2000. In 2006 there were 158, in 2008 it was down to 131, in 2009 it was 123 and in 2010 it was 81 — half of which belonged to SFGH. Leary noted that long-term care beds for the mentally ill in SF have seen a similar decline, dropping from 500 in 2007 to 327 in 2009.
In response to these extreme cuts in San Francisco, Drs. Rouse, Gruber, and nearly two dozen other psychiatrists, nurses and others in the mental health field formed the ad hoc Northern California Commission on Psychiatric Resources (NCCPR) in 2007 and developed a Statement of Principles as a rallying point for physicians, professional associations, nurses, patient advocacy groups, faith based congregations and business associations. They defined what psychiatric services need to be available in Northern California and demanded responsible government bodies be held accountable to develop a ways and means approach to implementing the plan for creating needed facilities instead of implementing another decade of draconian cuts.
Gilani stressed the need for physicians knowledgeable as to the medical consequences of the cuts to get out to the community through speaking engagements, literature tables and phone calls to churches, temples, universities and other key constituencies. “There is a tremendous lack of knowledge as to the vital role psychiatry plays and the real life crisis we are managing day in and day out,” he said.
POC member Paul Linde, M.D. a psychiatrist at San Francisco General Hospital’s PES unit, wrote Danger to Self, On the Front Line with an ER Psychiatrist in 2010 to highlight the conditions facing patients and practitioners in acute mental health settings. He sums up the untenable situation this way in his preface:
“PES is licensed by the state to hold and observe a maximum of 18 patients for up to 24 hours. In reality, from time to time we confine patients for two or three days, and our census sometimes jumps into the mid twenties. What else can we do with psychiatrically unstable patients who can’t be safely returned to the community and have nowhere else to go?
Sometimes all a doctor or nurse can do is to respond to behavioral emergencies in the moment: head banging; temper tantrums with the menace of violence; the monolithic man who breaks through his heavy metal seclusion room door; the woman who nearly bites her own finger off; the delirious, febrile, HIV positive man who cuts his wrist with a paper clip and spurts blood at the staff; the smearing of feces; the attempted hangings in the bathroom; the throwing of heavy plastic chairs…”
Dr. Villela, who works on the ward at SF General Hospital dedicated to treating SF County Jail inmates suffering from acute psychiatric problems, stressed the importance of contacting psychiatrists who work in the county jails as potential allies, stating, “If the Eden IPU closes, they will be hit with even more mentally ill patients who need treatment — not incarceration, handcuffs, mace and truncheons.” POC member, Jennifer Ardans, R.N. who works in Stanislaus County’s Behavioral Health & Recovery Services in Modesto, California, reported that they don’t even have such a jail ward in Modesto and police and parole officers have, at times, dropped patients off at her facility, who then end up wandering out of unlocked seclusion rooms or mixing with the general patient population. She said they recently had a man suffering from mental illness who was a convicted sex offender wander in wearing an electronic jail anklet monitor from the Sacramento jail, 70 miles away.
East Bay psychiatrist members Drs. Joseph Chan and Stanley Seifried offered to get in touch with psychiatrists in Alameda County’s John George Psychiatric Pavilion. According to Chan, “They are completely swamped and will not be able to handle the inflow of new patients from the closure of Eden’s IPU. There were regularly times when I was at John George and we would have to respond to 20 suicide calls a night.” According to Chan, the staff at John George have been very sensitive to the issue of overcrowding ever since Dr. Erlinda Ursua was beaten and strangled to death by a patient in 2003.
POC member Carole Rogers, R.N. who works at Alameda County’s Highland Hospital agreed to contact ER physicians there who are already severely backlogged with indigent and injured patients and will be negatively impacted by the addition of psychiatric emergency cases which they are neither set up to provide treatment for nor do they have treatment and stabilization facilities to transfer them to.
POC Membership Coordinator, Shane Kangas offered to provide training to Dr. Seifried in calling POC’s members in the East Bay as well as their own colleagues who work at Alta Bates and Summit hospitals, about how the elimination of Eden’s IPU will affect them and what they can do to promote the campaign among their colleagues.
Those with knowledge must speak out
At the 16 June PAITF meeting, Gilani encouraged members not to be intimidated by fear of retaliation. “The story must be told and the cuts must stop.” He related his own experience of receiving “anonymous complaints” after speaking at the 9 June meeting of the San Leandro Rotary club at the invitation of nurse Rogers, who is also an active fellow POC member, in the fight to save San Leandro Hospital (SLH). (For more see San Leandro article on page four). :
According to Dr. Gilani, he had highlighted the range of vital mental health needs he and his colleagues respond to on a daily basis that will no longer be available if Sutter Health is allowed to proceed with shutting the Eden psych unit. He used fictional patient names to convey real cases of suicidal Iraqi vets and that of a depressed elderly couple who had lost their home of many decades.
The very next day Dr. Gilani was informed by an EMC administrator that an “anonymous complaint” had been lodged against him for “violating patient confidentiality” and he would need to meet with George Bischalaney, Eden Hospital’s CEO. Gilani said he made it absolutely clear that he was unctuous in protecting patient confidentiality and had used pseudonyms. Gilani said he does not believe it was a coincidence that the CEO of San Leandro Hospital, a Sutter employee, was in the audience listening to his presentation.
Gilani said, “As a psychiatrist, I take patient confidentiality very seriously, but to see a hospital chain take a public presentation about the importance of a service they are planning to close and attempt to shoot the messenger with accusations that can lead to a State Medical Board investigation, shows a certain desperation.”
Acknowledging that even spurious accusations brought before the State Medical Board have ruined careers (See Spring 2010 New Diagnosis, “Appellate Court Decision on Behalf of HMO Imperils Physicians and Patients”), Gilani stood firm, “It is part of my ethical obligation as a physician to do what I can to make sure my patients have a facility to be treated in.”
Advocates meet with retaliation
POC members who have been advocating for their patients in the face of staffing cuts by their respective administrations have likewise met with resistance. Marvin Woodside, R.N., Ph.D., and Cynthia McCoy, R.N. both used to work at PES in SFGH but were fired shortly after testifying in arbitration hearings challenging the refusal of the San Francisco Department of Public Health (SFDPH) to live up to a year 2007 memorandum of understanding concerning staffing ratios in the acute care psychiatric unit. The contract required seven R.N.s for each day shift, seven for each swing shift, and five for each graveyard shift for the 18-bed unit. However, instead of the agreed upon figures, the SFDPH has been limiting the R.N.s to five, five and four respectively. Woodside attributes the severe beating he took from one of the patients in PES to these substandard staffing ratios.
Given the high acuity of the patients, the frequency of violent incidents and how having too many patients compromises the quality of care, Woodside and McCoy decided to speak at the hearing on behalf of their union. During a several month long arbitration process between their union and the SFDPH, which runs the county hospital, they were respectively accused of stealing medications and patient abuse. Both were fired and the SFDPH threatened to report them to the state nursing board if they did not accept their terminations quietly.
Sources of the problem identified
In developing their plan, Powers, Gilani and several Task Force members identified three major areas where profit was being extracted while services are being cut under the excuse of inadequate funds being available. These included:
1) The failure of the Office of Statewide Health Planning and Development (OSHPD) or other government agencies to exert jurisdiction over hospital chains that operate under a “free market” approach. These chains are free to choose what services to close and which to retain, with nothing stopping them from prioritizing money-making procedures to increase their profits. Crucial, but poorly reimbursed services such as psychiatry suffer — in some cases psychiatric patients are strapped to gurneys for days while awaiting transfer to a county facility. Instead, government agencies must ensure hospital chains have enough qualified mental health professionals to treat patients in a timely manner.
2) Mental health service reductions by “not-for-profit” institutions who pay no taxes yet do not provide commensurate services to merit those breaks and instead divert those patients to overcrowded county facilities.
“Many non-profit hospitals receive millions of dollars a year in tax breaks, yet divert uninsured or marginally insured patients who need psychiatric services to county facilities, thus not only failing to meet their charitable obligations to the public, but increasing the obligations on the part of the county,”
according to Valerie Gruber, Ph.D. “This includes Sutter Health’s elimination of the 32-bed inpatient psychiatry unit at St. Luke’s Hospital in San Francisco, the elimination of the geriatric psychiatry unit at Sutter’s Ralph K. Davies Hospital and the imminent closure of Eden Hospital’s psychiatric unit in Castro Valley, California.”
3) The failure of California’s Department of Managed Health Care or any other regulatory agency to stop private insurance companies and HMOs from collecting ever-escalating premiums while refusing to cover a broad range of psychiatric services. Eva Ihle, M.D., POC member psychiatrist at University of California San Francisco’s Langley Porter Psychiatric Hospital described how insurance companies will not authorize treatment for patients unless the diagnosis is confirmed, but then refuse to pay for the testing necessary to confirm the diagnosis.
POC members develop a Bay Area regional strategy
Powers felt these concerns could be best addressed through a pursuit of the Statement of Principles that POC members are using as the basis for their demands for a regional integrated mental health plan for Northern California.
After coming to agreement on the plan at the 1 December meeting of the PAITF, several members resolved to assist each other in their individual fights for patient care in the mental health field while joining Powers and Gilani in their campaign. Several agreed to circulate letters that mental health care workers throughout the Bay Area could sign on behalf of Dr. Powers and Dr. Gilani in their effort to maintain Eden Hospital’s psych unit in the East Bay. Dr. Seifried agreed to volunteer on phoning sessions to contact other POC members to apprise them of the situation and encourage them to get involved.
Other members agreed to refer their colleagues who are not yet affiliated with POC to join as members and add their voices. Still others have made themselves available for speaking engagements to universities, faith-based organizations, and other community groups in order to recruit more volunteers and support from the lay community.
According to Shane Kangas, POC’s Membership Coordinator “I have full confidence that where we stand up for patient care as an organization of medical professionals, we can win, if we are organized strongly enough. Organization is the key to survival. For all those who are interested, I strongly encourage you to call in to the office to offer your time and energy.” For more information, please call David at 415-434-9335.