Mental health patients forced to seek treatment outside Sonoma County
Maria Cepeda said she knows exactly how she will end her life. She won’t use pills as she has several times before. Her final attempt, she said, will be with a rope, and alcohol will buy her the courage.
“My last way, my final out, will be a hanging,” said Cepeda, who suffers from severe depression, bipolar disorder and post-traumatic stress. “And like I told my brother, there will be no more suicide attempts. There will be one more and I will succeed.”
For now, the 42-year-old Sebastopol resident, who lost both her best friend and her mother this year, said she’s holding on, keeping her “mental demons” at bay. When her world starts to go “black,” Cepeda said she still has the rationale to check herself into a local emergency room, with the hope of being admitted into an inpatient psychiatric facility.
For Cepeda and hundreds of other Sonoma County residents, that usually means waiting hours while hospital staff searches for a bed in a facility outside the county.
Because Cepeda’s health care is covered by Medi-Cal, the state’s Medicaid program for low-income residents, she essentially is ineligible to stay at Aurora Santa Rosa Hospital, the new for-profit private inpatient psychiatric hospital in west Santa Rosa. The Fulton Road facility, which opened last year, is located at the site of the psychiatric unit previously operated by Santa Rosa Memorial Hospital before being shut down in 2008.
A little-known federal rule that goes back to the creation of the Medicaid program in the mid-1960s tightly restricts the use of federal Medicaid matching funds to pay for care at “institutes of mental disease,” or IMDs, residential treatment facilities with more than 16 beds whose primary purpose is to serve those with mental illness.
Known as the IMD exclusion, the rule was established at a time when state-run mental institutions were receiving serious scrutiny and criticism for “warehousing” mental health patients. The rule reflected the federal government’s wish to stop funding such institutions.
Since then, the number of state-run mental health facilities has declined dramatically.
The IMD exclusion does not apply to inpatient psychiatric facilities that are tied to general acute care hospitals, such as the one operated by Marin General Hospital in Greenbrae. And it does not apply to people younger than 22 or older than 64.
However, the number of these hospital-affiliated units also has declined as hospitals close inpatient psychiatric facilities to reduce costs. Memorial Hospital shuttered its psychiatric unit - the county’s only remaining inpatient psychiatric hospital - in 2008 as part of a large cost-cutting plan.
Wide age range ineligible
At hospital-affiliated psychiatric units, Medi-Cal pays for about half the cost of a patient’s stay, and counties pay the other half.
But under the IMD rule, Medi-Cal will not pay for any care provided to patients ages 22 to 64 at freestanding psychiatric hospitals, like Aurora Santa Rosa Hospital, that are not tied to a general acute care hospital. As a result, these patients usually are sent out of Sonoma County to other facilities.
Seventy percent of the Sonoma County residents who were hospitalized last year for mental health treatment fall within this age group, said Michael Kennedy, the county’s mental health director.
“To not provide a psychiatric hospital benefit for this age group is discrimination,” Kennedy said.
During the 2013-14 fiscal year, the county’s mental health department hospitalized 894 local residents, Kennedy said. Some were covered by Medi-Cal, others had private insurance, and some had no insurance at all. The average daily cost at a psychiatric unit is about $1,000 to $1,200 per patient, Kennedy said. The county does not have the financial resources to send Medi-Cal patients to Aurora Santa Rosa Hospital unless the state insurance program picks up half of the cost.
Kennedy said that modern freestanding psychiatric units are nothing like the old state-run mental institutions the federal government began defunding decades ago.
“We are saying that they need to clarify that freestanding psychiatric hospitals are not IMDs,” he said.
Long waits, distances
Since 2005, Cepeda has checked herself into psychiatric units a half-dozen times, she said. She was able to stay at the Fulton Road facility when it was operated by Memorial. But since then, she’s had to go to facilities outside Sonoma County, to cities like Greenbrae, Fairfield, Sacramento and even as far as Modesto.
Cepeda said her “decompensation” process is familiar, and it starts with a gradual darkening of the world around her.