Prisons and Emergency Rooms: Our New Medicaid Mental Health Care Providers?

Emergency rooms and jails are our mental health care providers for Medicaid recipients?

My best friend is an ER trauma nurse.  She told me that a majority of patients are mentally ill.  One man came in to the ER, screaming at the top of his lungs, “Get me my lilly pad!”  Apparently he believed that he was a frog.  While you may smile at the humorous notion of the lilly pad man, it is a sad tribute to the state of mental illness in North Carolina.  Why was he not getting the care he needed?

And here I  thought mental health care was so important. In light of recent events, I would venture to say that mental health is quickly becoming our nation’s most pressing issue.

First let me say, Boston…so tragic.  My prayers are with all families affected by the bombing.

So you would think with all the hoopla in the aftermath of the Boston bombing and other serious heinous acts (Connecticut) that our mental health system would be top priority.

Is there a correlation between poor mental health systems and violent crime? Yes.

Here are some studies:

  • The present study of public psychiatric beds in the United States suggests that 42 of the 50 states have less than half the minimum number of beds considered to be reasonable by knowledgeable experts. In 32 of the states, the shortage is critical or severe.
  •  A study in Ohio compared 122 patients with schizophrenia who had committed violent acts with 111 patients with schizophrenia who had not committed such acts. The violent patients had significantly more prominent symptoms and significantly less awareness of their illness. Friedman L, Hrouda D, Noffsinger S et. al. Psychometric relationships of insight in patients with schizophrenia who commit violent acts. Schizophrenia Research 2003;60:81.
  • A study of 961 young adults in New Zealand reported that individuals with schizophrenia and associated disorders were two-and-one-half times more likely than controls to have been violent in the past year. If the person was also a substance abuser, the incidence of violent behavior was even higher. Arseneault L, Moffitt TE, Caspi A et. al. Mental disorders and violence in a total birth cohort. Archives of General Psychiatry 2000;57:979–986.
  • A study of 63 inpatients with schizophrenia in Spain reported that the best predictors of violent behavior were being sicker (i.e., higher scores on symptom measures) and less insight into their illness. “The single variable that best predicted violence was insight into psychotic symptoms.” Arango C, Barba AC, Gonzalez-Salvador T et. al. Violence in schizophrenic inpatients: a prospective study. Schizophrenia Bulletin 1999;25:493–503.
  • A 10-year follow-up of 1,056 severely mentally ill patients discharged from mental hospitals in Sweden in 1986 reported that “of those who were 40 years old or younger at the time of discharge, nearly 40 percent had a criminal record as compared to less than 10 percent of the general public.” Furthermore, “the most frequently occurring crimes are violent crimes.” Belfrage H. A ten-year follow-up of criminality in Stockholm mental patients. British Journal of Criminology 1998;38:145–155.
  • A study of 331 individuals with severe mental illness in the United States reported that 17.8 percent “had engaged in serious violent acts that involved weapons or caused injury.” It also found that “substance abuse problems, medication noncompliance, and low insight into illness operate together to increase violence risk.” Swartz MS, Swanson JW, Hiday VA et. al. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. American Journal of Psychiatry 1998;155:226–231.

What about North Carolina? Where are our mentally ill? In jails? Hospitalized? Or receiving quality mental health care.

The study “More Mentally Ill Persons are in Jails and Prisons…” states, “Using 2004–2005 data not previously published, we found that in the United States there are now more than three times more seriously mentally ill persons in jails and prisons than in hospitals. Looked at by individual states, in North Dakota there are approximately an equal number of mentally ill persons in jails and prisons compared to hospitals. By contrast, Arizona and Nevada have almost ten times more mentally ill persons in jails and prisons than in hospitals. It is thus fact, not hyperbole, that America’s jails and prisons have become our new mental hospitals.”

Having a strong, competent, and easily accessible system to serve those people suffering from mental illness is key to so many things you would want in a society: (1) those suffering from mental illnesses would receive the quality health care so needed; (2) there would be less homeless; (3) there would be less violence (see above-referenced studies).

Now, since this is a Medicaid blog, I will obviously concentrate on the Medicaid population.

So what is North Carolina doing regarding the mental health system for Medicaid recipients?

With the implementation of the Managed Care Organizations (MCOs), the hiring of Recovery Audit Contractors (RACs) and the utter lack of supervision by the Division of Medical Assistance (DMA), the Medicaid mental health system is spiraling downward.

Medicaid recipients are not receiving the care needed because of the state’s, MCOs’ and RACs’ treatment of health care providers willing to accept Medicaid.

Here are some serious and real-life examples:

1. The MCOs are denying authorizations for more expensive mental health services.

In a certain county, a certain MCO is denying all ACTT services, stating the Medicaid recipients do not meet eligibility requirements. ACTT, or Assertive Community Treatment Team services.  ACTT is a 24-hour, 7 day/week service for the seriously mentally  ill. Since the MCO denied ACTT services in this certain county, despite medical necessity, 2 discharged ACTT recipients have committed crimes and become incarcerated. One discharged recipient attempted suicide. Two in jail; one in a hospital.  Thank you, new mental health care providers.

2. The RACs are causing quality health care providers who have never committed fraud to have their Medicaid contracts terminated based on paperwork nit-picking and causing Medicaid recipients to lose their provider.

One such provider serves teen-age boys suffering mental illnesses with violent tendencies. With its Medicaid contract terminated and the inability to pay its staff, those boys may soon be homeless and on their own. The consequences could be catastrophic. Jails and hospitals, I am sure.

What is DMA doing about the MCOs denying medically necessary services and the RACs terminating health care providers needlessly and erroneously?


DMA states that MCOs and RACs are independent contractors; therefore, DMA cannot supervise the MCOs and RACs. I say, “Hog-wash.” DMA cannot divorce itself the duties of managing Medicaid.

But, regardless, stop pointing fingers.  Who cares if its DMA’s fault that the teenage boys receiving residential Medicaid services will be homeless because the RACs erroneously and without due process terminated the provider’s contract? Just fix it. Period.

Stop the jails and emergency rooms from becoming North Carolina’s mental health care providers!

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on April 21, 2013, in Division of Medical Assistance, Federal Law, Health Care Providers and Services, Legal Analysis, MCO, Medicaid, Medicaid Appeals, Medicaid Audits, Medicaid Contracts, Mental Health, Mental Illness, NC DHHS, North Carolina, Termination of Medicaid Contract and tagged , , , , , , , , . Bookmark the permalink. 9 Comments.

  1. Laura Greenlee, PhD, NCC, LPCS

    Hello Knicole. Very well written, and good use of research. Having worked as a psychological specialist in a max security prison as well as a therapist in nursing homes in PA, I agree that many of our mentally ill are now housed in these facilities. The closing of many state hospitals across the country….with hopes that local communities will take care of these seriously mentally ill people has resulted in subpar care, or no care at all. I would also add that many of the Medicaid clients I know of are in and out of DSS with cases of alleged and founded neglect and abuse. I am quite concerned about the future of Medicaid in NC (as well as the country), but I will tell you that as a private provider, I have decided to give up my Medicaid clients in WNC, due to decreased reimbursement and increased paperwork. I feel bad about having to do this, but it was a business decision. I am open to get back on board if positive changes are made.

    Dr. Laura Greenlee
    Hendersonville, NC

    • Dr. Greeniee,

      Thanks for reading!! As for your decision to stop seeing Medicaid recipients, I cannot say I am surprised. But I am saddened. This is an increasing problem for Medicaid recipients. And it is a direct result of how the state treats provider who accept Medicaid.

      Hopefully we will make some positive changes!!


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