Are health systems failing a moral test?
Tosa mental facility stuck in limbo
For more than a year, Milwaukee County has been searching for a health system willing to replace the outdated, understaffed hospital in Wauwatosa that provides care for many of the county’s most mentally ill patients — people with psychotic disorders, severe depression and complex bipolar disorders.
Not one of the three largest nonprofit health systems in Milwaukee County has stepped forward.
Only two out-of-state companies, both of them for-profit, have shown interest in operating a hospital to replace the one run by the county Behavioral Health Division.
One of them — Universal Health Services Inc., based in King of Prussia, Pa. — is being investigated by the federal government for fraud at 20 of its behavioral health hospitals in nine states, according to the company’s filings with the Securities and Exchange Commission.
The other — Correct Care Solutions, based in Nashville, Tenn. — focuses on providing medical and behavioral health care in prisons and jails. It runs only one behavioral health hospital, the South Florida State Hospital.
Working with a local
health system — either Aurora Health Care, Froedtert Health or Ascension — remains the first choice of the Behavioral Health Division and local mental health advocates.
“If I could wave my magic wand, that’s what should be done,” said Michael Lappen, administrator of the Behavioral Health Division. Others go further. “There is an ethical and moral responsibility for our health-care systems — which are nonprofit — to serve individuals with mental illness and not carve out this particular population,” said Barbara Beckert, director of the Milwaukee office of Disability Rights Wisconsin.
Children’s Hospital of Wisconsin is giving thought to taking over inpatient care for children and adolescents, according to sources. The hospital, which doesn’t provide inpatient care for behavioral health, declined to comment. But in a statement it said it “continues to evaluate how we could change and leverage our existing behavioral health programs.”
Beckert hopes an adult health system will do the same.
“They have a commitment to our community. They are connected to the local resources,” she said. “They provide outpatient (behavioral health) services. And they provide the whole gamut of health care services.”
Aurora Health Care, Froedtert Health and Ascension each declined to comment.
About 60 patients are hospitalized at the Mental Health Complex on a typical day, and its emergency department provides care to about 28 patients a day on average, or about 10,000 a year.
Its patients tend to be sicker, with higher percentages of them having depressive, bipolar and psychotic disorders, and a larger percentage are covered by Medicaid than the behavioral health patients admitted to other hospitals in Milwaukee County.
Nationally, almost 10 million adults — or about one in 25 — have reported having a serious mental illness that affects major life activities, according to the Peterson-Kaiser Health System Tracker.
People with severe behavioral health conditions also are more likely to develop medical problems, such as diabetes or heart disease.
“You have to treat the whole person,” Beckert said.
Aurora and Froedtert Health certainly appear to have the financial resources to take on the challenge.
Aurora’s operating income totaled $965.4 million in 2014 and 2015, and its operating profit margin averaged 10%. Its operating income was down in the first nine months of 2016 in large part because of a significant increase in salaries, wages and benefits, but it still was on track to top $300 million for the year.
Froedtert Health’s operating income totaled $293.5 million in its 2014 and 2015 fiscal years, and its operating profit margin averaged 7.5%. It also had $1.5 billion in reserves.
Ascension, which now includes the operations of Wheaton Franciscan Healthcare and Columbia St. Mary’s, is not as profitable as Aurora or Froedtert Health. It also is in the midst of integrating four health systems throughout the state and may be wary of taking on the additional challenge of providing care to the most complex behavioral health patients.
But it has room at its Wheaton Franciscan-St.
Joseph Campus, which would lower the cost of adding and operating a psychiatric unit in the hospital. Plus, the additional revenue from the unit could help lessen the hospital’s losses.
Aurora Sinai Medical Center, too, has excess space.
And Aurora plans to invest $40 million for a onethird stake in the Athletic Performance Research Center at Marquette University. The center will tie into Aurora Sinai Medical Center’s Sports Medicine Program.
Is that a more pressing community need than improving behavioral health care in Milwaukee County?
“Absolutely not,” said Peter Hoeffel, executive director of the National Alliance on Mental Illness (NAMI) Wisconsin. “We’ve got a mental health system that’s been fragmented and that’s been struggling for quite a long time.”
Froedtert Health would have to expand Froedtert Hospital if it were going to add a psychiatric unit. But the hospital has expanded several times in the past decade, most recently spending $140 million on the Froedtert & the Medical College of Wisconsin Center for Advanced Care.
It now plans to add four floors to that building at a projected cost of $43 million.
Froedtert Hospital also is the academic medical center of the Medical College of Wisconsin, which has psychiatrists on its faculty and a residency program for psychiatrists. Most academic medical centers in large urban areas provide inpatient behavioral health care, Beckert said.
“This could be an opportunity for Froedtert to re-examine their role, given their connection to the Medical College of Wisconsin,” she said.
Rogers Behavioral Health System, which has behavioral health hospitals in West Allis and Brown Deer, is another potential option. But it operates freestanding behavioral health hospitals, which because of a quirk in regulations cannot bill Medicaid.
Rogers opened its hospital in Brown Deer in 2015. And Aurora is spending $35 million to expand and renovate its freestanding Aurora Psychiatric Hospital in Wauwatosa. Both are examples of health systems responding to the need for behavioral health care in Milwaukee County.
They also have demonstrated that behavioral health can be profitable.
Aurora Psychiatric Hospital had a 12.4% profit margin in 2015, based on information filed with the Wisconsin Hospital Association. Rogers Memorial Hospital-West Allis had a 16.4% profit margin.
“There is totally money to be made,” said Héctor Cólon, the director of the Department of Health and Human Services for Milwaukee County. “It’s not a losing proposition.”
But both hospitals have a much larger percentage of patients covered by commercial insurance, which pays much higher rates than Medicaid, than the Behavioral Health Division’s hospital.
Columbia St. Mary’s Hospital-Milwaukee, Wheaton Franciscan Healthcare-St. Francis and Aurora St. Luke’s South Shore also have small psychiatric units.
But the hospitals — with the exception of Aurora Psychiatric Hospital — provide care only to patients diagnosed as “low to moderate” acuity, Cólon said.
Patients with severe behavioral health conditions are transferred to the Behavioral Health Division’s hospital in Wauwatosa.
About 20% of the patients admitted to its emergency department — about 2,000 a year, or five a day — are transferred from other hospitals.
The health systems have been able to rely on the county to care for the sickest patients, said Hoeffel of NAMI Wisconsin.
“It is a moral test for our community,” he said. “The private hospitals need to play a bigger role.”
The hospital at the Mental Health Complex is just one of an array of services provided by the Behavioral Health Division.
Since 2012, it has moved to provide more services in the community — a move praised by advocates and widely considered long overdue — with the hope of reducing the reliance on emergency services and preventing the need for people to be hospitalized.
It oversees roughly two dozen communitybased programs, ranging from mobile crisis teams to case management to resident and day treatment programs, and contracts with dozens of organizations, to provide care for thousands of patients — though the Behavioral Health Division couldn’t readily say how many people are in its programs.
By law, counties are responsible for people with behavioral health conditions and substanceuse disorders.
The tax levy in Milwaukee County that partly funds the Behavioral Health Division is budgeted at $57.4 million this year, down from $58.8 million in 2016 and $59.1 million in 2015.
The Behavioral Health Division can bill Medicaid for many of its services, and that revenue and the county levy account for about 60% of its funds. Medicare, state and federal grants, and commercial insurance account for most of the balance.
The hospital at the Mental Health Complex accounts for slightly more than a third of the Behavioral Health Division’s budget of $208 million for 2017. It also loses about $30 million a year.
That probably is a factor in the health systems’ wariness to take over responsibility for providing care for the hospital’s patients.
The county would need to continue to subsidize a hospital or psychiatric unit in an existing hospital that replaced the current hospital — and those payments could be an inviting target when future county administrations are looking for budget cuts.
Part of the hospital’s losses stem from the Mental Health Complex’s being more than half empty, Cólon said.
The hospital’s longterm care patients have been moved to community settings in recent years; that unit was shut down last year.
“Our utility costs are much larger than they would be in a more efficient facility,” Cólon said.
The hospital also is in limbo while the Behavioral Health Division’s board tries to find a company or organization willing to provide care to its patients or run a new hospital.
The hospital now caps its inpatient adult admissions at 48 to 54 patients because of chronic staffing shortages, said Lappen of the Behavioral Health Division. Some patients can be transferred to other hospitals. But only Aurora Psychiatric Hospital can take the sickest patients.
A total of 801 people were placed on the Behavioral Health Division hospital’s waiting list during the first six months of 2016 — more than the total number in 2014 and 2015 combined, according to a recent report by the Legislative Audit Bureau.
The challenges in recruiting staff, however, are unlikely to lessen, given the uncertainty about the hospital.
“Let’s face it, if you are a psychiatric nurse and you don’t know the future of the place, why would you go there?” asked Hoeffel of NAMI Wisconsin. “It’s a really big challenge.”
The hospital at the Mental Health Complex won’t close until 2019 at the earliest. But Lappen acknowledged that the uncertainty is difficult to overcome.
“It’s killing us on a retention and recruitment side,” he said. “We are losing staff at a pretty high rate.”
The hospital has the equivalent of 57 full-time positions open.
Lappen, who became administrator in May, is praised by advocates such as Beckert and Hoeffel.
“He’s the person for the job,” Hoeffel said, “but he needs more help from the private hospitals here.”
The lack of interest by the adult health systems in Milwaukee County in replacing the Behavioral Health Division’s hospital became clear in June and was first reported by Wisconsin Health News.
Cólon declined to comment on whether there is still a chance that a local health system would agree to set up a psychiatric unit in one of its hospitals that could replace the Behavioral Health Division’s hospital.
But the Behavioral Health Division has hired the law firm of Reinhart Boerner Van Deuren to do due diligence on Universal Health Services and Correct Care Solutions — the two companies that have shown interest in bidding on the contract to replace the hospital.
Reinhart Boerner is expected to make its recommendation to the board in August, and the board is expected to make a decision in September.
The company or organization that wins the county contract presumably would hire the hospital’s current staff.
It isn’t clear what will happen if neither Universal Health Services nor Correct Care Solutions gets the contract.
Advocates such as Beckert, however, remain hopeful that one of the health systems in Milwaukee County will come forward with a proposal.
“They have the resources — not only the financial resources but also the infrastructure, the clinical expertise and the deep roots in our community to step up and really make a difference here,” Beckert said. “We really need their leadership in responding to this important need in our community.”