Medicaid: States Fund Services for Adults in Institutions for Mental Disease Using a Variety of Strategies
Published: 2017-08-09T00:00:00

Fast Facts:
Federal and state Medicaid spending on behavioral health services—mental health and substance use treatments—is projected to be $71 billion in 2017.
However, some adults on Medicaid may have limited access to inpatient or residential behavioral health care because Medicaid generally doesn't cover services for adults in institutions for mental disease.
Officials in the 6 states we reviewed tried an average of 2 to 4 strategies to fund this care through Medicaid, such as
Applying for demonstration programs
Covering these services through Medicaid managed care plans
Relying on facilities that are too small to be considered "institutions"

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicaid is the largest source of national funding for behavioral health services—mental health and substance use services—with nearly $71 billion in projected 2017 spending. However, Medicaid excludes payments for beneficiaries aged 21-64 who are residents of IMDs. As a result, questions have been raised about adult Medicaid beneficiaries' access to services typically provided in IMDs—namely inpatient or residential behavioral health treatments.
GAO was asked to examine questions related to any potential effects of the IMD exclusion on adult beneficiaries. Among other things, this report describes (1) recent trends in the capacity of facilities that provide inpatient and residential behavioral health services; (2) how CMS policies related to the IMD exclusion have changed over time; and (3) how selected states finance IMD services for adult Medicaid beneficiaries. GAO examined federal laws, regulations, and guidance, interviewed officials in the Department of Health and Human Services (HHS), the department that includes CMS, and analyzed the most current data from three national HHS surveys. GAO also interviewed Medicaid officials in six states selected based on geography and use of options to provide care in IMDs for adult Medicaid beneficiaries. Additionally, GAO interviewed representatives of nine behavioral health facilities in the six states referred to GAO by state Medicaid officials and a hospital association. Selected states' and facilities' experiences are not generalizable. HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.
section_title: What GAO Found
paragraphs: Between 2010 and 2015, inpatient and residential behavioral health services capacity has gone up for adult mental health treatment and stayed about the same for substance use treatment. GAO found that for adult mental health treatment, inpatient and residential capacity increased from about 61 to 69 beds per 100,000 adults between 2010 and 2014. For adult substance use treatment, inpatient and residential capacity remained fairly constant between 2010 and 2015, increasing from 57 to about 58 beds per 100,000 adults. In both types of behavioral health services there was significant variation across states.
GAO also found that over time, the Centers for Medicare & Medicaid Services' (CMS)—the agency that oversees state Medicaid programs—changed policies to allow some states to finance care for adult Medicaid beneficiaries in institutions for mental disease (IMD), in certain circumstances. IMDs are generally facilities larger than 16 beds that primarily provide inpatient, residential, or other services to individuals with behavioral health conditions. These policy changes included the following:
Medicaid demonstrations. Beginning in 1993, CMS officials said they approved demonstrations in nine states, allowing federal funds to cover behavioral health services in IMDs; these demonstrations were largely phased out by 2009. In July 2015, CMS announced a demonstration that would allow states to use Medicaid funds to cover substance use services in IMDs. As of May 2017, CMS had approved these demonstrations in four states. CMS has also approved applications from some, but not all, states for demonstrations that allow states to pay for substance use or mental health services in IMDs.
Medicaid managed care. In May 2016, CMS issued a final rule that codified a policy, known as the “in lieu of” policy, under which managed care plans may provide alternative services or services in alternative settings, such as IMDs, under certain circumstances. In the rule, CMS set a 15-day per month limit on the number of days an adult beneficiary may receive behavioral health services in an IMD for which managed care plans will receive payment. According to CMS estimates, at least 17 states had likely been allowing such coverage before the rule was issued.
Even with multiple funding sources, selected states reported some problems with adult access to IMD services. While CMS does not collect national data on how states finance services for adults in IMDs, officials in six selected states GAO interviewed stated they used between two to four strategies to fund services for adults in IMDs in recent years, including under Medicaid managed care and demonstrations. State officials said that when their states were unable to use Medicaid funds to finance IMD services, they relied on other options, such as state-only funding, or providing services in smaller non-IMD facilities. Officials from each of the six states shared examples of access problems; for instance, one state reported long waits for inpatient mental health services. In addition, some facility officials said they regularly turned away patients and maintained waitlists.

section_title: Letter
paragraphs: Individuals enrolled in Medicaid experience a higher rate of behavioral  health conditions—mental health and substance use conditions—than  those with private insurance. Although Medicaid, a joint federal-state  program that finances health care coverage for low-income and medically  needy individuals, is the largest source of funding for behavioral health  services nationally, with spending projected to be nearly $71 billion in  2017, our prior work has shown that Medicaid beneficiaries may have  difficulty accessing services. Beginning in 1965 when the program was  enacted, Medicaid excluded federal payments for services provided to  most residents of institutions for mental disease (IMD)—generally  facilities larger than 16 beds that primarily provide inpatient, residential, or  other services to persons with behavioral health conditions. Today the  IMD exclusion applies only to adult Medicaid beneficiaries aged 21-64.  Little is known about how those beneficiaries access needed inpatient or  residential behavioral health care or how much the federal government  pays for these types of services.
Over the last several decades, changes in the delivery of behavioral  health treatments, which included reductions in the number of inpatient  beds, came about largely because of concerns about poor living  conditions in large institutions, advances in behavioral health treatment  options, including prescription drugs, and the rights of individuals to  receive care in the setting most integrated in the community. From 1990  to 2008, the number of adult inpatient mental health hospital beds and  residential beds decreased by 35 percent, dropping from 290,359 beds in  1990 to 188,951 beds in 2008. As the number of beds has decreased,  questions have been raised as to whether sufficient capacity for inpatient  and residential services exists. Additionally, the abuse of prescription  opioid pain relievers and illicit opioids, such as heroin, have contributed to  increasing numbers of overdose deaths in the United States and calls for  more substance use treatment.
Inpatient hospital services are more intensive than other types of services, with 24-hour  nursing care, and physicians and counselors available as needed. Residential services  are considered less intensive than inpatient hospitalization, with individual and group  activities provided in a structured 24-hour live-in facility with care provided by trained  counselors. States generally rely on medical necessity criteria to determine what level of  care is appropriate for individuals in need of behavioral health services such as the Level  of Care Utilization System or the criteria developed by the American Society of Addiction  Medicine.
The Centers for Medicare & Medicaid Services (CMS) is the federal  agency that oversees the Medicaid program within the Department of  Health and Human Services (HHS). The agency has stated that due to  the IMD exclusion, many Medicaid beneficiaries with acute mental health  conditions, such as those expressing suicidal or homicidal thoughts, are  diverted to general hospital emergency departments (ED), which often  lack the resources or expertise to care for these patients. Access to  behavioral health services, including inpatient hospital and residential  services, is important because of the harmful consequences of untreated  conditions.
While IMDs provide inpatient or residential behavioral health services,  these same types of services also may be provided in settings that do not  meet the definition of an IMD, such as a facility offering inpatient or  residential services with 16 beds or less. For purposes of this report, we  examine all facilities that provide inpatient and residential mental health  and substance use services, whether or not they are IMDs, as IMD  determinations are made on a facility-specific basis. Throughout the  report, we refer to inpatient and residential mental health and substance  use services as IMD-type services, even if the services are provided in a  facility that does not meet the standard definition of an IMD.
You asked us to provide information about IMD exclusion polices and  access for Medicaid beneficiaries to IMD services. This report describes  1.  trends, since 2010, in the capacity of facilities that provide IMD-type  2.  what is known about adult access to IMD-type services;  3.  how CMS policies related to the IMD exclusion have changed over  time; and  4.  how selected states finance services provided in IMDs for adult  Medicaid beneficiaries, and their perspectives on beneficiaries’  access to services.
To describe the trends in the capacity of facilities that provide IMD-type  services, since 2010, we obtained and analyzed the most recently  available data from two Substance Abuse and Mental Health Services  Administration (SAMHSA) surveys: the 2010 and 2014 National Mental  Health Services Survey (N-MHSS) and the 2010 and 2015 National  Survey of Substance Abuse Treatment Services (N-SSATS). Both  surveys are a census of facilities that provide either mental health  services or substance use services, respectively. Because IMD  designations are not limited to facilities that provide behavioral health  services, the survey does not include all facilities that are potentially  IMDs. SAMHSA tabulated data for us from N-MHSS and N-SSATS on the  facilities that provided inpatient and residential services, which was the  focus of our analysis. We analyzed SAMHSA’s data to assess the  capacity of facilities from both surveys. We ensured the reliability of the  N-MHSS and N-SSATS data used in this report by performing appropriate  electronic data checks, reviewing relevant documentation, and  interviewing SAMHSA officials knowledgeable about the data. We found  the data were sufficiently reliable for the purpose of our analyses. For  more information on the analysis of the N-MHSS and N-SSATS, see  appendix I.
To describe what is known about adult access to IMD-type services, we  conducted a literature search to identify original research that addressed  the topic. Specifically, we searched for relevant articles published from  January 2010 through October 2016 that addressed the need for, use of,  or access to inpatient or residential mental health or substance use  services, including articles that addressed indicators such as ED use and  length of stay. We also identified articles through searches of government  agency websites and through a bibliographic search based on relevant  articles already identified. We screened abstracts and articles and  excluded international research, research that included no data later than  2005, and research focused on children or elderly adults. The articles we  identified clustered around several key themes, including receipt of  services, self-reported unmet need, use of and length of stay in hospital  EDs, and inpatient readmissions. We focused our review on studies  based on national data, when available, and considered studies that were  more limited in scope when those were the only studies available, as was  the case for ED boarding studies. All estimates we present from the  relevant articles have margins of error at the 95 percent confidence level  of plus or minus 10 percent or less, unless otherwise noted. For details  on the literature review and a list of the articles selected, see appendix II.
To describe how CMS’s policies related to the IMD exclusion have  changed over time, we reviewed relevant federal regulations and  guidance provided to states related to the IMD exclusion. We also  interviewed CMS officials regarding the reasons for changes in policy.
To describe how states finance the type of behavioral health services  provided in IMDs for adult Medicaid beneficiaries, and states’  perspectives on beneficiaries’ access to such services, we spoke with  officials in six states: California, Maryland, Minnesota, Missouri, New  Jersey, and Washington. We selected these states based on geographic  distribution and use of four Medicaid options to provide funds for the care  of adult Medicaid beneficiaries in IMDs. In each state we interviewed  officials from the state Medicaid agency. In addition, we interviewed  representatives of nine behavioral health treatment facilities located within  our selected states that were referred to us by state Medicaid officials and  a hospital association. We also reviewed relevant federal laws, including  the Social Security Act, the Patient Protection and Affordable Care Act  (PPACA), as well as relevant federal regulations and guidance related to  the IMD exclusion. The experiences of the Medicaid officials in the  selected states and the representatives of the behavioral health treatment  facilities in the selected states are not generalizable to all facilities in the  states or to other states. In addition, when there were available data on  the use of specific Medicaid options by all states, we included such  information. To obtain contextual information about behavioral health  services under Medicaid, we interviewed representatives from behavioral  health professional and advocacy groups.
We conducted this performance audit from January 2016 to August 2017  in accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: CMS and states jointly finance and administer the Medicaid program,  which finances health care, including behavioral health services, for low- income individuals and families. In fiscal year 2016, Medicaid provided  health coverage to an estimated 72.2 million people and had $575.9  billion in estimated outlays, of which $363.4 billion was financed by the  federal government and $212.5 billion by the states. States have  flexibility within broad federal parameters for designing and implementing  their Medicaid programs. States must cover certain mandatory services,  including inpatient hospital, outpatient hospital, and physician services  and states may elect to cover additional optional services, such as  physical and occupational therapies for adults. States may deliver health  care services to certain Medicaid beneficiaries through fee-for-service  payments to participating providers or through Medicaid managed care,  through which states typically contract with Medicaid managed care plans  to provide a specific set of Medicaid-covered services to beneficiaries.  Under Medicaid managed care, states pay the plans a set amount per  beneficiary per month—referred to as capitation payments—to provide  those services. In addition, the Secretary of HHS may use discretion to  waive certain federal Medicaid requirements and allow costs not  otherwise eligible for federal funds for experimental, pilot, or other  demonstrations that are likely to assist in promoting Medicaid objectives.
subsections: section_title: Rates of Mental Health and Substance Use Conditions in Adult Medicaid Beneficiaries
paragraphs: Medicaid beneficiaries have higher rates of serious mental health  conditions than the general population. Serious mental health conditions  are defined as behavioral health conditions that substantially interfere  with, or limit one or more major life activities. Specifically, nearly 8 percent  of adults aged 22-64 enrolled in Medicaid reported having a serious  mental health condition compared to the nearly 4 percent of those with  another type of insurance and almost 5 percent of those who are  uninsured. (See fig. 1) Adult Medicaid beneficiaries had similar rates of  substance use conditions as those who were uninsured, 11 percent as  compared to 13 percent among the uninsured. The rate of substance use  conditions among those with another type of insurance was about 8  percent.
section_title: Medicaid IMD Exclusion
paragraphs: The Medicaid IMD exclusion, which we refer to as the “exclusion” for  purposes of this report, has been in effect since the program was  established in 1965. The exclusion prohibits federal payments to states  for services provided to most adult Medicaid beneficiaries who are  residents of IMDs, whether services are provided inside or outside the  IMD. Currently the exclusion applies only to Medicaid beneficiaries aged  21-64; the Social Security Act Amendments of 1965 and 1972 allowed  Medicaid beneficiaries age 65 and older and under age 21, respectively,  to receive services in IMDs. In addition to encouraging treatment in  small community-based group living arrangements, the exclusion was  intended to ensure that states, and not the federal government, are  primarily responsible for funding inpatient and residential behavioral  health services.
According to CMS officials, state Medicaid officials are responsible for  ensuring that they do not claim federal Medicaid payments for services  provided to IMD residents between the ages of 21 and 64, and for  applying the IMD statutory and regulatory requirements. Per the statutory  definition, an IMD is “a hospital, nursing facility, or other institution of  more than 16 beds that is primarily engaged in providing diagnosis,  treatment, or care of persons with mental diseases, including medical  attention, nursing care, and related services.” CMS’s guidance on how  to determine when the IMD exclusion applies is included in its State  Medicaid Manual, which contains criteria for determining whether a facility  is an IMD. Also, according to CMS officials, if needed, CMS is available to  provide technical assistance so states can make IMD determinations. The  State Medicaid Manual lays out IMD criteria that include an assessment of the type of licensure or accreditation the facility or  group of facilities holds; an assessment of the patient population; and whether the facility or group of facilities was established primarily for  the care and treatment of individuals with behavioral health  conditions.
Understanding which facilities are subject to the exclusion also requires  an understanding of what constitutes a “facility.” In determining if states  have applied the exclusion correctly, CMS also takes into consideration  whether a group of facilities has a common owner or governing body. If  one owner operates multiple facilities in a state and together the facilities  have more than 16 beds, the facilities jointly may qualify as an IMD and  would therefore be subject to the exclusion.
In 2015, Congress considered, but did not pass, legislation to fully lift the  IMD exclusion. The Congressional Budget Office (CBO) estimated that  this legislation would cost the federal government $40 to 60 billion over  10 years (2016-2025). CBO stated that its estimate was highly uncertain  and based on limited data. CBO officials said that they did not take into  account existing or recently available options states have to finance  Medicaid services for adult Medicaid IMD residents, such as Medicaid  disproportionate share hospital (DSH) payments to IMDs,  demonstrations, or care provided by managed care plans. They also did  not account for any offsets, such as those for potential decreases in ED  use, which could happen if the IMD exclusion were lifted.
section_title: Since 2010, Facility Capacity Nationwide Has Increased for Mental Health Treatment and Remained Constant for Substance Use Treatment, with Variation Across States
subsections: section_title: The Capacity of Mental Health Treatment Facilities Increased Nationally from 2010 to 2014, although There Was Significant Variation Across States
paragraphs: Capacity for inpatient or residential mental health services for the adult  population increased from 2010 to 2014, as measured by numbers of  facilities providing services, the number of beds designated for these  services, and the number of beds per 100,000 adults, according to N- MHSS data from those years. Between 2010 to 2014
The total number of mental health treatment facilities increased by  about 19 percent, from 2,888 to 3,427.
The number of beds designated for adult mental health inpatient or  residential services increased by 17 percent between April 30, 2010,  and April 30, 2014, from 119,527 to 139,885 beds.
By 2014, there were about equal numbers of facilities that provided either  inpatient or residential mental health services (see fig. 2). There was  greater growth in the number of mental health treatment facilities that  offered residential services than those facilities that offered inpatient  services. From 2010 to 2014, the number of facilities offering residential  mental health services increased by 33 percent, compared to an increase  of 7 percent in facilities offering inpatient mental health services. On  April 30, 2010, and April 30, 2014, more than two-thirds of residential  mental health treatment facilities had a bed utilization rate, the  percentage of a facility’s beds occupied on a given day of the year, of  more than 90 percent.
The national number of beds per 100,000 adults designated for mental  health inpatient or residential services increased from 61.1 to 69.5 from  2010 to 2014. The number of residential beds per 100,000 adults  increased from 2010 to 2014, but the number of inpatient beds decreased  slightly during the same time period, even though inpatient beds were  more common in both years. In 2010 the number of beds designated for  inpatient mental health services per 100,000 adults was 48.6 compared to  the rate of 12.5 beds per 100,000 adults designated for residential mental  health services. By 2014, inpatient beds had decreased to 47.9 per  100,000 adults and residential beds increased to 21.6 per 100,000 adults.
Significant variation exists in the number of beds designated for mental  health services per 100,000 adults across states, as illustrated in figure 3.  In 2014, for example, the number of beds per 100,000 adults was 43.8 in  Colorado, 73.5 in Maryland and 114.2 in Missouri. Significant change also  occurred during the time period within some states. For example, the  number of beds designated for mental health services per 100,000 adults  in Hawaii increased from 59.4 in 2010 to 107.6 in 2014, but the number of  mental health treatment facilities decreased by 1. Comparatively, the  number of beds designated for mental health services per 100,000 adults  in Wyoming decreased from 150.2 in 2010 to 100.5 in 2014, though the  number of facilities that provided inpatient services remained constant  and there was one additional facility that offered residential services.
Bed utilization for inpatient and residential mental health services  increased between 2010 and 2014. The percentage of inpatient mental  health treatment facilities with a bed utilization rate greater than 90  percent increased from nearly 34 to 41 percent in that time period. The  percentage of residential mental health treatment facilities with a bed  utilization rate greater than 90 percent increased from about 65 percent to  67 percent.
The overall capacity for mental health inpatient and residential services  may not have increased for Medicaid beneficiaries between 2010 and  2014. This is because we estimate that approximately one-quarter of the  inpatient and residential mental health treatment facilities may have been  IMDs in 2010, and this increased to about a third in 2014, and federal  Medicaid reimbursement for services provided by these facilities would be  unavailable for adult Medicaid patients of these facilities due to the IMD  exclusion. More information on the facilities that offered inpatient and  residential mental health services based on data from N-MHSS is in  appendix III.
section_title: The Capacity of Substance Use Treatment Facilities Did Not Change Significantly Between 2010 and 2015, but There Was Significant Variation Within and Among States
paragraphs: The capacity of facilities that offered inpatient or residential services for  adult substance use treatment had little change between 2010 and 2015,  according to the N-SSATs data.
The total number of facilities that offered services to adults decreased  slightly, about 2 percent, from 4,026 to 3,931.
More than 80 percent of the total inpatient or residential substance  use treatment facilities offered residential services in both years.
The total number of beds designated for inpatient or residential  substance use services increased by 4 percent between March 31,  2010, and March 31, 2015, from 115,336 to 119,600.
The number of beds designated for inpatient or residential substance use  services per 100,000 adults increased slightly, from 57 to 58.4 between  2010 and 2015. As a result of a larger number of substance use  treatment facilities offering residential services, as opposed to inpatient  services, in 2010, the number of beds designated for residential  substance use services per 100,000 adults nationwide was 50.7,  significantly higher than the 6.3 beds designated for inpatient substance  use services. In 2015, the number of residential beds per 100,000 adults  remained at 50.7 and there were 7.7 inpatient beds for every 100,000  adults. There was significant variation across states as shown in figure 4.  For example, in 2015 the number of beds per 100,000 adults was 28.7 in  Indiana, 50 in Tennessee, and 130.9 in Washington.
Bed utilization, the percentage of a facility’s beds occupied on a given day  of the year, for residential substance use treatment did not change  significantly from 2010 to 2015. In both years, about 56 percent of  residential substance use treatment facilities had a bed utilization rate  greater than 90 percent. Comparatively, the percentage of inpatient  substance use treatment facilities that had a bed utilization rate greater  than 90 percent increased from 40 percent in 2010 to 45 percent in 2015.
Access to substance use services was potentially limited for those with  Medicaid in both 2010 and 2015. Based on size and type of facility, we  estimated that nearly half of the inpatient and residential substance use  treatment facilities in 2010 and 2015 may have been IMDs, and thus  federal Medicaid funding would be unavailable for adult Medicaid  beneficiaries due to the IMD exclusion. More information and data from  N-SSATS on facilities that offered inpatient and residential substance use  services is in appendix IV.
section_title: Evidence Suggests Gaps in Adult Access to IMD-Type Services
subsections: section_title: National Surveys Identify Unmet Need for Behavioral Health Services, Which May Include IMD-Type Services
paragraphs: National health surveys conducted by HHS indicate that tens of millions of  U.S. adults, including more than 3 million adults with serious mental  health conditions, have behavioral health conditions but are not receiving  treatment. Although the surveys do not identify the level of care needed,  the findings generally suggest a large unmet need for treatment services  in the United States. For example, the most recent data from the National  Survey on Drug Use and Health (NSDUH) show that, in 2015, the  majority of adults with mental health conditions and/or who needed  substance use treatment did not receive services in the prior year. (See  fig. 5.)
Many adults with behavioral health conditions also reported they had  experienced an unmet need for services. According to the 2015 survey:
About one in five adults with any mental health condition–and almost  two in five adults with serious mental health conditions—reported that  they had needed mental health services, such as counseling, in the  prior year but did not receive the care they needed.
Fewer than one in ten adults who needed but did not receive  substance use services at a specialty facility perceived a need for  such services, and fewer than 3 percent made an effort to get them.
While services for these conditions are commonly delivered on an  outpatient rather than inpatient basis, inpatient or residential services of  the type provided in IMDs may be needed in some instances, particularly  for individuals with serious mental health conditions experiencing an  acute episode or for individuals with substance use conditions. It is not  known how much of the reported unmet need is for IMD-type services.
Findings from national surveys and other studies suggest that financial  factors, such as cost and lack of insurance coverage, are among the  primary barriers to receipt of behavioral health services, which could  include IMD-type services. For example, an analysis of 2011 NSDUH  data found that individuals with any mental health condition who had  private insurance were 1.63 times more likely than uninsured individuals  to have received services during the prior 12 months, and those with  Medicaid were 2.66 times more likely to have done so. Individuals with  any mental health condition who had either private insurance or Medicaid  were also less likely than uninsured individuals to report unmet need for  services. In our analysis of 2015 NSDUH data, we found that, among  adults ages 22 through 64 with any mental health condition, those with only Medicaid coverage were somewhat more likely than those with other  insurance coverage to report unmet need for services (26.4 percent  versus 19.8 percent). However, among those with serious mental health  conditions, the proportion of individuals reporting unmet need did not  differ significantly by insurance status.
section_title: Millions with Behavioral Health Conditions Obtained Care in Emergency Departments, and Some Evidence Shows They Had Longer Stays Than Some Other Patients
paragraphs: Individuals seeking care primarily for behavioral health conditions made  approximately 4.7 million visits to EDs in 2013, accounting for around 3 to  4 percent of all ED visits, according to the most recently published data  from the National Hospital Ambulatory Medical Care Survey (NHAMCS).  Many of these individuals turn to EDs for care because they lack access  to alternatives, including psychiatric facilities. However, care at the ED  may be less than optimal, as ED staff often lack the training, skills, and  resources to deal effectively with behavioral health conditions, and  patients may experience long waits for more appropriate care. Long stays  in the ED, particularly the portion of time spent waiting for an inpatient  bed—referred to as “boarding”—are widely regarded as symptomatic of  insufficient inpatient capacity, although other causes, such as inefficient  transitions between the ED and inpatient placement, are also cited in the  literature.
subsections: section_title: Overall ED Length of Stay
paragraphs: Multiple studies show that behavioral health patients experienced longer  overall stays in the ED than other patients or were more likely to have  long stays. For example:
An analysis based on 2008 NHAMCS data found that, controlling for  other variables including patient age and expected source of payment,  patients with behavioral health conditions were almost 5 times more  likely than other patients to remain in the ED 6 hours or longer.
An analysis based on 10 years of NHAMCS data (2002 through 2011)  found that whether adults with a primary behavioral health diagnosis  had longer ED stays—measured as the time from triage to departure  from the ED—depended on where they went from the ED. For  patients admitted to the hospital that housed the ED, mean length of  ED stay was about the same for patients with and without a primary  behavioral health diagnosis; but for those discharged, admitted for  observation, or transferred to another facility, mean length of stay was  longer for behavioral health patients in almost every year. In addition  to waiting longer for transfer—almost 3 hours longer in 2011— behavioral health patients were also transferred six times as often as  other patients. For those with the longest waits, differences were even  greater: At the ninetieth-percentile, ED lengths of stay for behavioral  health patients who were transferred were about 12 hours in 2011,  compared with about 7 hours for other patients who were  transferred.
section_title: ED Boarding
paragraphs: Direct evidence regarding the amount of time behavioral health patients  spend boarding—waiting for a bed after a decision had been made to  admit or transfer them, as opposed to total time in the ED—is limited, and  findings varied. The relatively few studies that isolated ED boarding time  for patients with behavioral health conditions were based on data from a  small number of mostly large hospitals, and only two of the studies  compared these patients’ boarding times with those of other patients.  Differences in the studies’ settings and methodologies, including in how  they identified behavioral health patients, may explain the widely varying  findings regarding mean or median ED boarding times for these patients,  which ranged from about 3 hours to more than 27 hours. We identified  two studies that compared boarding times for patients with behavioral  health conditions to boarding times for patients with other diagnoses. One  study found that patients who required inpatient care primarily for a  behavioral health condition waited significantly longer to be admitted or  transferred compared to patients with other conditions, while the other  study did not find a significant difference in boarding times for patients  whose chief complaint was a behavioral health condition compared to a  general symptoms category.
section_title: Hospital Readmission Rates Were Higher Among Individuals with Behavioral Health Diagnoses Compared with Some Other Diagnoses
paragraphs: Millions of individuals with behavioral health conditions have obtained  inpatient services, but higher-than-average hospital readmission rates for  patients with certain conditions could suggest unmet need for ongoing  services. Hospital readmission within 30 days of discharge is generally  seen as representing a negative clinical outcome for patients. While  readmission of patients with behavioral health conditions may reflect the  chronic, relapsing course of these conditions, other factors may also  contribute. According to a technical brief from HHS’s Agency for  Healthcare Research and Quality (AHRQ), these factors may include  insufficient inpatient care to stabilize the patient’s condition, inadequate  transition planning, and lack of access after discharge to outpatient  services or to short-term alternatives to rehospitalization, such as partial  hospitalization and crisis residential services.
An analysis of 2012 data from the State Inpatient Database readmissions  analysis file, part of a collection of health care databases sponsored by  AHRQ, found disproportionately high estimated 30-day readmission rates  among patients with the two most common behavioral health diagnoses  among hospitalized patients. Compared with patients admitted for a  non-behavioral-health condition, patients admitted for mood disorders  were more than twice as likely to be readmitted for the same principal  diagnosis within 30 days (9.0 vs. 3.8 percent), and patients admitted for  schizophrenia were more than four times as likely to be readmitted for the  same diagnosis (15.7 vs. 3.8 percent). This study also found that  patients with these conditions who were covered by Medicaid or Medicare  had higher 30-day readmission rates than privately insured or uninsured  patients.
Other studies have shown that some behavioral health conditions are a  common diagnosis or a contributing factor in repeat hospitalizations,  including among patients with Medicaid coverage. For example, another  study of Healthcare Cost and Utilization Project (HCUP) data found that  the two most common principal diagnoses for hospital stays among non- elderly Medicaid patients who had four or more stays in 2012 were mood  disorders and schizophrenia, while the sixth most common principal  diagnosis among these patients was alcohol-related conditions.
section_title: CMS’s IMD Policies Have Changed Over Time to Allow Payments in Certain Circumstances
paragraphs: Over time, CMS policies have changed to allow some states to finance  the provision of care for adult Medicaid beneficiaries in IMDs, in certain  circumstances. Nationally, the total amount of federal payments for IMD- type services for adult Medicaid beneficiaries is unknown. (See app. V for  a timeline of changes related to the Medicaid IMD exclusion.)
Section 1115 demonstrations. HHS has allowed states to pay for IMD  services in certain circumstances in Medicaid demonstrations, but HHS  has discretion over when to approve such coverage and has done so for  some but not all requesting states. Section 1115 of the Social Security  Act gives the Secretary of HHS authority to waive certain traditional  federal Medicaid requirements and allow costs that would not otherwise  be eligible for federal payments for demonstrations that, in the Secretary’s  view, are likely to promote Medicaid objectives. Under this authority, since  1993 HHS has approved demonstrations allowing certain states to  provide mental health services and substance use services in IMDs. The  demonstrations typically last 3 to 5 years, but can be renewed, and allow  federal payments for adult behavioral health services provided in IMDs.
According to CMS officials, beginning with Tennessee in 1993, HHS  approved section 1115 demonstrations in 9 states that allowed states to  pay for behavioral health services in IMDs. In addition to Tennessee,  CMS officials said that Arizona, Delaware, Maryland, Massachusetts,  New York, Oregon, Rhode Island, and Vermont also had approved  behavioral health demonstrations between 1993 and 2009. By 2009,  CMS officials said that the authority to pay for IMD costs in all of the  states was phased out, except in Massachusetts. CMS officials said the  demonstrations that were phased out were no longer considered  “innovative or experimental.” CMS officials also said that Massachusetts’s  2005 demonstration was renewed, most recently in November 2016,  because it was innovative and included behavioral health services  reforms.
In addition to Massachusetts’s demonstration, CMS has recently  approved applications from some, but not all states, for section 1115  demonstrations that allow states to pay for substance use or mental  health services provided in IMDs.
Substance use: In July 2015, CMS issued a state Medicaid Director  letter informing states that they may seek approval of section 1115  demonstrations to receive federal payments for demonstrations that  provided substance use services to adults in IMD settings as part of a  comprehensive initiative to reform states’ delivery of substance use  services. In the letter to states describing this opportunity, CMS said  the demonstrations would allow states to address the historical lack of  substance use treatment capacity, including inpatient and residential  treatment, particularly in light of the national opioid epidemic, improve  the quality of substance use services, and ensure Medicaid  beneficiary’s access to a full continuum of care for substance use  conditions. Specifically, the demonstration initiative allows federal  payments for short-term residential substance use treatment in IMDs,  limited to an average length of stay of 30 days. According to CMS  officials, as of May 4, 2017, California, Maryland, Massachusetts, and  Virginia had sought and received approval for substance use  demonstrations. CMS officials also said that they were working with  four other states in the process of applying for or obtaining such  approval for substance use demonstrations.
Mental health: CMS has approved some, but not all, demonstration  applications to provide mental health services in IMDs. For example,  although Maryland was approved to provide substance use treatment  services in IMDs under the substance use demonstration guidance  issued in July 2015, the state had applied at the same time to provide  mental health services in IMDs. According to Maryland Medicaid  officials, CMS denied this part of the request. However, in October  2016, CMS approved a section 1115 demonstration for Vermont that  allows the state to pay for acute inpatient mental health services  provided in an IMD, though the state is required to phase out that  coverage completely by December 31, 2025.
Medicaid managed care. Historically, Medicaid managed care plans had  the flexibility to provide covered services in alternate settings under  certain conditions, such as behavioral health services in IMDs. In May  2016, CMS issued a final rule designed to modernize its Medicaid  managed care regulations. The rule codified this policy, known as the “in  lieu of” policy, under which managed care plans may provide alternative  services or services in alternative settings, such as IMDs, in lieu of  covered services or settings if they are medically appropriate and a cost- effective substitute for covered services or settings. CMS set a 15-day  per month limit on the number of days a beneficiary may receive  behavioral health services in an IMD for which managed care plans will  receive payment. It is unknown how many states have allowed managed  care plans in their states to cover services provided in IMDs because  CMS does not currently collect such information. However, CMS  actuaries estimated that in 2010, 17 states were likely using the Medicaid  managed care in lieu of authority for services provided in IMDs, and  another 9 were potentially using the authority and that this change would  cost $66 million ($42 million federal; $24 million state) over 5 years (2016- 2020).
section_title: Selected States Use Multiple Approaches to Provide Inpatient and Residential Behavioral Health Services to Adult Medicaid Beneficiaries, and Reported Some Access Challenges
subsections: section_title: Selected States Use a Variety of Options to Provide Inpatient and Residential Behavioral Health Services to Adult Medicaid Beneficiaries, Including Medicaid and State Funds
paragraphs: While there are no national data on how states finance services provided  to adult Medicaid beneficiaries in IMDs, officials in our six selected states  told us they used or reported using between 2 to 4 approaches to provide  inpatient and residential behavioral health services to adult Medicaid  beneficiaries from 2012 to 2016 (see table 1). Most of these state  Medicaid officials said that when their states were unable to use Medicaid  funds to finance services in IMDs, they relied on other funding sources,  including state-only funding, or facility officials said they provided  uncompensated care.
Medicaid managed care “in lieu of” authority: Nationally, in fiscal year  2013, the most recent data available, nearly 54 percent of Medicaid  beneficiaries were enrolled in comprehensive managed care plans.  States with adults enrolled in managed care plans may opt to use the  Medicaid managed care “in lieu of” authority, and some states were  already doing so. Of our six selected states, officials in three states  (Minnesota, Missouri, and Washington) reported using the Medicaid  managed care “in lieu of” authority before the final rule became effective  in July 2016. Officials from these three states said their states used this  authority to pay managed care plans for individuals who were in an IMD  for more than the 15 days per month allowed by the new final rule. These  officials could not provide estimates of the amount spent on these  services because the plans received the same capitation payments  regardless of the services actually provided. These officials expressed  concerns about implementing the new rule, including increasing states’  costs for beneficiaries in need of IMD stays longer than the allowable 15  days per month because they would no longer be able to rely on Medicaid  managed care plans to cover longer IMD stays.
DSH: Federal law requires states to make DSH payments to offset  uncompensated care costs experienced by certain hospitals serving large  numbers of low-income uninsured and Medicaid patients and establishes  state-specific limits, or allotments, for this purpose. States are allowed,  within certain federal payment limits, to make these payments to mental  health treatment facilities, including IMDs. Within these limits, states  have broad flexibility in deciding how to allocate DSH payments among  eligible hospitals, including IMDs. CMS data showed that nationally,  states provided DSH payments to mental health treatment facilities,  including IMDs, totaling nearly $2.92 billion in fiscal year 2015 (see app.  VI for DSH payments to mental health treatment facilities by state).  Among our six selected states, DSH payments to mental health treatment  facilities in fiscal year 2015 ranged from $26,766 in California to nearly  $357.4 million in New Jersey. Officials from one Missouri IMD we spoke  with said that the facility is very dependent on DSH payments, which  make up about two-thirds of their operating costs.
Medicaid Emergency Psychiatric Demonstration (MEPD): The MEPD  allowed 11 states and the District of Columbia to reimburse certain private  IMDs for care provided to adult Medicaid beneficiaries to stabilize  emergency mental health conditions. PPACA authorized $75 million in  federal funds for the demonstration, which ran from July 1, 2012 to June  30, 2015, and total federal and state expenditures on IMD claims totaled  approximately $113 million by the end of the demonstration. A CMS  sponsored evaluation of the MEPD found little to no effect on ED  boarding or other measures of access for individuals with mental health  conditions; however, the researchers acknowledged that this finding may  have been attributable to data limitations. Following completion of the  MEPD, the Improving Access to Emergency Psychiatric Care Act of 2015  law was enacted, which included a provision to allow for possible  continuation and expansion of the MEPD through 2019, if the Secretary of  HHS and the Chief Actuary of CMS certified that the MEPD would not  increase program spending. In July 2016, CMS actuaries determined  that they could not make this certification based on the available data and  the MEPD ended in 2015 after 3 years, as required by PPACA.  Additionally, the 21st Century Cures Act, signed into law in December  2016, requires HHS to further study and produce a report on the MEPD  by December 2018.
Of our six selected states, four states participated in the MEPD:  California, Maryland, Missouri, and Washington. Washington Medicaid  officials said they withdrew from the MEPD early, in 2014, after the state  received approval to cover the costs of IMD services through managed  care. California officials said the two counties that participated in the  MEPD had positive experiences with the demonstration and one county  reported improved access to care, and reduced re-hospitalizations for  beneficiaries with psychiatric diagnoses. Officials from two of the states  expressed frustration and concern that CMS actuaries did not determine  that the demonstration would not increase program spending and, as a  result, the demonstration did not continue.
Despite the CMS actuaries’ determination, two state officials provided  data showing the average cost of a day in an IMD was less than the  average cost in a non-IMD. One state official told us that IMDs cost less to operate than a hospital since they do not have to purchase or maintain  equipment used in a typical hospital such as lab or surgical equipment.  For example, Missouri Medicaid officials provided data showing that in  2014, IMD daily rates were about 45 percent less than a non-IMD (see  Table 2). Likewise, Maryland Medicaid officials provided data showing  that in 2015, the IMD daily rate was about 24 percent less than the  average daily rate for two non-IMDs in the state.
Section 1115 substance use services demonstrations: CMS officials  said that nationally, as of May 4, 2017, 4 states have sought and received  approval for substance use services demonstrations (California,  Maryland, Massachusetts, and Virginia). CMS officials also said that, as  of April 20, 2017, 5 other states have applied for such demonstrations,  and a few states are in the preliminary stages of applying for substance  use services demonstrations.
Of our six selected states, California and Maryland had approved  substance use services demonstrations. California Medicaid officials told  us the substance use services demonstrations will allow participating  counties to offer beneficiaries substance use services in more settings,  providing a continuum of treatment options. According to CMS officials,  Minnesota, Missouri, New Jersey and Washington had not, as of April 13,  2017, applied for a demonstration, although the Minnesota Medicaid  agency had been directed by their state legislature to apply, New Jersey  officials said they have an application in progress, and Washington state  officials were still considering whether to apply.
Facilities with 16 or fewer beds: Another way states have avoided the  IMD exclusion is through the creation of 16-bed facilities that are eligible  for federal Medicaid payments due to their small size. While CMS officials  said they do not track national data on facilities that have 16 or fewer  beds, officials in each of our six selected states said they had such  facilities in their state and several state and facility officials said they  created inpatient 16-bed or smaller facilities specifically to obtain  Medicaid funding without triggering the IMD exclusion.
While 16-bed facilities are able to receive federal Medicaid payments for  the same services an IMD may provide, state and facility officials noted  challenges with facilities this size. Some state and facility officials noted  that facilities with 16 or fewer beds, as opposed to larger facilities, may  experience financial challenges because it costs more to offer the same  breadth of services to a smaller number of patients, or because smaller  facilities may not be able to offer certain services larger ones can. For  example, officials from one state said that costs per patient increased  when the state reduced the number of beds in its inpatient 24- to 40-bed  substance use treatment facilities to 16-bed facilities.
section_title: Selected States Reported Access Challenges, but Lacked Data on Extent of Problem
paragraphs: The six states we selected generally did not have data to document  access challenges for adult Medicaid beneficiaries seeking IMD-type  services, but state or facility officials from each of these selected states  shared examples of access problems. Although state officials often did  not characterize the prevalence of the problems, some facility officials we  spoke with said they regularly turned away patients, maintained waitlists,  and that enough demand existed to warrant expanding capacity. For  example:
California: Prior to California’s substance use services  demonstration, which was approved in December 2015, Medicaid  officials said that residential substance use treatment services were  not covered for Medicaid beneficiaries. Medicaid officials said that  residential substance use services would be available in counties that  chose to participate in the demonstration, but access to these  services would be difficult in counties that chose not to participate in  the demonstration. When beds are not available, an official at one  California facility said that they keep a waitlist and offer the next best  level of care available, typically outpatient care, until an appropriate  bed becomes available.
Maryland: Medicaid officials said that while they were not aware of  systematic access problems, they had heard anecdotally that some  hospitals had trouble finding beds for Medicaid beneficiaries outside  of EDs and other acute-care hospital settings. Officials also reported  that stays in acute-care hospital settings, which are covered by  Medicaid, may be longer than stays at lower levels of care in IMDs.
Minnesota: Medicaid officials said that it may be more difficult for  Medicaid beneficiaries with acute mental health needs to access  inpatient services than it is for beneficiaries seeking outpatient mental  health services.
Missouri: More than 61 percent of hospitals that responded to a  survey by the Missouri Hospital Association (38 of 62 hospitals)  reported boarding behavioral health patients in EDs during a specific  week in May 2016 and 76 percent of those boarded patients were  between the ages of 21 to 64. The survey data also showed that of  the hospitals that reported boarding behavioral health patients, 94.7  percent said that they boarded patients because they could not  identify a facility with a mental health bed that would accept the  patient. Other reasons reported for boarding included not having an  in-house mental health bed available (47.4 percent) and not having  access to appropriate transportation services (23.7 percent).
New Jersey: Medicaid officials said that accessing behavioral health  services can be challenging. For example, officials said there is a  problem with ED boarding in the state and there are oftentimes  waitlists for substance use services. Additionally, officials said it can  be difficult to qualify for a bed in a substance use treatment facility. To  address the shortage of inpatient treatment beds, in January 2017,  the governor announced plans to increase the number of beds  allowed for individuals with co-occurring mental health and substance  use conditions by almost 40 percent, adding 864 beds. Up to 5  percent of the new beds are to be available for Medicaid beneficiaries  and the uninsured population.
Washington: Medicaid officials said that there is not enough capacity  to meet the demand for services within the state even though over  100 additional beds opened statewide in 2014.Officials at two  Washington facilities reported turning away patients because of a lack  of available beds and patients were sometimes sent to geographically  distant treatment facilities. Officials at one 15-bed facility said that  demand would justify an expansion to 20 to 25 beds in their facility if it  were not for the IMD exclusion; these officials also noted that they  were in the process of building two new 16-bed treatment facilities.  Officials at another Washington facility said that they are building one  16-bed treatment facility and planning to build two additional treatment  facilities—each with 16 beds—to meet the demand.
section_title: Agency Comments
paragraphs: We provided a draft of this report to HHS for review. HHS provided  technical comments, which we incorporated as appropriate.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to our  requestor, the Secretary of the Department of Health and Human  Services, and other interested parties. The report is also available at no  charge on the GAO website at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or iritanik@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix VII.
section_title: Appendix I: Scope and Methodology for Data Analyses
subsections: section_title: Analyses of Facilities That Offered Mental Health and Substance Use Services
paragraphs: To analyze the capacity of facilities that offer mental health and  substance use services, we obtained data from two Substance Abuse  and Mental Health Services Administration (SAMHSA) surveys: the  National Mental Health Services Survey (N-MHSS) and the National  Survey of Substance Abuse Treatment Services (N-SSATS). To identify  recent trends, we obtained the 2010 and 2014 data for the N-MHSS and  the 2010 and 2015 data for the N-SSATS. The N-MHSS and the N- SSATS are both censuses of facilities offering mental health and  substance use services, respectively. Both surveys include data on the  number of beds available and facility characteristics, such as ownership  and type of facility, for inpatient and residential care. Due to our focus on  the implications of the IMD exclusion, SAMHSA provided us tabulated  data on the capacity and characteristics of facilities that offered services  to adults when possible, based on our specifications. Based on how  SAMHSA collects data, for the 2010 data we included facilities that  accepted adults aged 18 to 64, or if that information was missing, facilities  that had inpatient or residential clients aged 18 to 64. The 2014 data  included young adults aged 18 to 25 and adults aged 26 to 64 for  inpatient or residential mental health treatment. The 2010 substance use  treatment data excluded cases where the number of inpatient clients  equaled the number of inpatient clients under the age of 18 and the  number of residential clients equaled the number of residential clients  under the age of 18, or the facility did not offer inpatient services and did  not offer residential services. The 2015 substance use treatment analysis  also excluded cases where the number of inpatient clients equaled the  number of inpatient clients under the age of 18 and the number of  residential clients equaled the number of residential clients under the age  of 18 and the maximum age for males and females is 17, or the facility did  not offer inpatient services and did not offer residential services. We  excluded facilities which reported that their main function was to provide  services to children.
For the purposes of our review, we defined capacity as the number of  facilities that offered services, the number of beds for services offered,  number of beds per 100,000 adults, and the bed utilization rate, which is  the percentage of beds being used at a facility on a given day. To  determine the number of beds per 100,000 adults, both nationally and by  state, we obtained data from the U.S. Census Bureau. We used the U.S.  Census Bureau 2010 population data for adults 18 to 64 and the  population projections for 2014 and 2015. We calculated the number of  beds per 100,000 adults nationally, for each state, the District of  Columbia, and Puerto Rico using this data and the number of beds from  the N-MHSS and N-SSATS.
Additionally, we assessed the reliability of the data we obtained from  SAMHSA, including discussing the reliability of the data with SAMHSA  officials, reviewing relevant documentation, and comparing the data to  data from published sources. We determined that the data were  sufficiently reliable for the purposes of our reporting objectives.
section_title: Analysis of Adults That Obtained Mental Health or Substance Use Services, or Had an Unmet Need for Services
paragraphs: To analyze the prevalence of mental health and substance use conditions  for adults, including Medicaid beneficiaries, we analyzed data from  SAMHSA’s National Survey on Drug Use and Health (NSDUH) from  2015, the most recently available data. NSDUH is a representative  person-level survey that provides national use of alcohol and illicit drugs,  mental health status, and mental health and substance use treatment  utilization rates.
We restricted our analysis to adults aged 22 to 64. We focused on this  age group because the law excludes from coverage adults aged 21 to 64,  though there are certain circumstances in which the law provides  coverage of 21 year olds who receive care in IMDs, and because  Medicaid beneficiaries age 65 and older and under age 21 may receive  services in IMDs. We also analyzed our data by insurance type, focusing  on individuals enrolled in Medicaid only, other types of insurance, and the  uninsured population. We excluded individuals that had Medicaid in  combination with another type of insurance, such as Medicare or private  insurance. We analyzed these data by insurance status and by self- reported unmet need for mental health and substance use services, as  well as the reasons for the unmet need.
We assessed the reliability of the data we obtained from SAMHSA  including discussing the reliability of the data with SAMHSA officials,  reviewing relevant documentation, and comparing our analysis with data  from published sources. We determined that the data were sufficiently  reliable for the purposes of our reporting objectives.
section_title: Appendix II: Scope and Methodology for Literature Review
paragraphs: To describe what the literature shows regarding adult access to IMD-type  services, we conducted a literature search to identify original research  that addressed the topic. Specifically, we searched for articles published  from January 2010 through October 2016 that addressed the need for,  use of, or access to inpatient or residential mental health or substance  use services, including articles that addressed generally accepted access  indicators such as emergency department (ED) use and length of stay.  We conducted structured searches of various databases for relevant  peer-reviewed and industry journals, including ProQuest, MEDLINE,  SCOPUS, and PsycINFO. Key search terms included various  combinations of terms identifying the level of care under study (for  example, “residential,” “inpatient,” and “institution”); the conditions of  interest (for example, “mental health,” “psychiatric,” “substance abuse,”  and “substance use”); and the focus of our objective (for example,  “access,” “availability,” “capacity,” and “unmet need,” as well as potential  access indicators, such as “emergency department boarding,” “delay,”  and “wait list”).
We identified additional articles through a “snowballing” process,  including a bibliographic search based on relevant articles already  identified. All abstracts were screened by two analysts and any  differences reconciled through discussion. In screening, we sought to  identify original research articles that (1) focused on the U.S. non-elderly  adult population, (2) included at least some data from within the past 10  years (2006 or later), and (3) provided measures of the availability of  IMD-type services or of met or unmet need for such services. We  excluded articles that focused on services available only to certain  populations, such as services provided by the Veterans Administration or  the Indian Health Service. We identified additional articles through  searches of the websites of government agencies, including the  Substance Abuse and Mental Health Services Administration and the  Agency for Healthcare Research and Quality.
The articles we identified clustered around several key themes, including  receipt of services, self-reported unmet need, use of and length of stay in  hospital EDs, and inpatient readmissions. Two analysts screened each  article for methodological soundness. We focused our review on studies  based on national data, when available, and considered studies that were  more limited in scope when those were the only studies available, as was  the case for ED boarding studies. The key articles included in our review  are listed below. In reporting sample data, we considered the margin of  error (confidence intervals) around estimates. All estimates we present  have margins of error at the 95 percent confidence level or plus or minus  10 percent or less, unless otherwise noted. The articles included in our  literature review follow.
Center for Behavioral Health Statistics and Quality. Key substance use  and mental health indicators in the United States: Results from the 2015  National Survey on Drug Use and Health (Rockville, Md.: September  2016)
Ding, R., M. L McCarthy, J.S. Desmond, J.S. Lee, D. Aronsky, and S.L.  Zeger. “Characterizing Waiting Room Time, Treatment Time, and  Boarding Time in the Emergency Department Using Quantile  Regression.” Academic Emergency Medicine, Vol.17, No. 8 (2010).
Fee, C, H. Burstin, J. H. Maselli, R. Y. Hsia, “Association of Emergency  Department Length of Stay With Safety-Net Status.” JAMA, Vol. 307, No.  5 (Feb. 2012).
Heslin, K.C., A.Elixhauser, and C.A. Steiner, “Hospitalizations Involving  Mental and Substance Use Disorders Among Adults, 2012.” Healthcare  Cost and Utilization Project (HCUP) Statistical Brief #191, Agency for  Healthcare Research and Quality. Rockville, Md.: June 2015. ).
Heslin, K.C., and A.J. Weiss, “Hospital Readmissions Involving  Psychiatric Disorders, 2012.” HCUP Statistical Brief #189, Agency for  Healthcare Research and Quality. Rockville, Md: May 2015.
Jiang, H.J., M.L. Barrett, and M. Sheng. “Characteristics of Hospital Stays  for Nonelderly Medicaid Super-Utilizers, 2012.” HCUP Statistical Brief  #184. Agency for Healthcare Research and Quality. Rockville, Md.: Nov.  2014 .
Misek, R.K, A.E. DeBarba, A. Brill. “Predictors of Psychiatric Boarding in  the Emergency Department.” Western Journal of Emergency Medicine:,  vol. 16, no 1, Jan. 2015.
Nicks, B.A. and D.M. Manthey. “The Impact of Psychiatric Patient  Boarding in Emergency Departments.” Emergency Medicine International,  vol. 2012 (2012).
Nolan, J.M., C. Fee, B.A. Cooper, S.H. Rankin, and M.A. Blegen.  “Psychiatric Boarding Incidence, Duration, and Associated Factors in  United States Emergency Departments.” Journal of Emergency Nursing,  vol. 41, no. 1 (2015).
O’Neil, A.M., A.T. Sadosty, K.S. Pasupathy, C.Rossi, C.M. Lohse, and  R.L. Campbell, “Hours and Miles: Patient and Health System Implications  of Transfer for Psychiatric Bed Capacity,” Western Journal of Emergency  Medicine, Vol. 17, No. 6 (Nov. 2016).
Park-Lee, E., R.N. Lipari, S.L. Hedden, A.P. Copello and L.A. Kroutil.  “Receipt of Services for Substance Use and Mental Health Issues among  Adults: Results from the 2015 National Survey on Drug Use and Health.”  NSDUH Data Review (September 2016).
Pearlmutter, M.D., K.H. Dwyer, L.G. Burke, N. Rathglev, L. Maranda, and  G. Volturo. “Analysis of Emergency Department Length of Stay for Mental  Health Patients at Ten Massachusetts Emergency Departments.” Annals  of Emergency Medicine, in press, (published online Jan. 4, 2017,  accessed Jan. 6, 2017).
Rui, P., K. Kang, and M. Albert. “National Hospital Ambulatory Medical  Care Survey: 2013 Emergency Department Summary Tables.” National  Center for Health Statistics. Atlanta, Ga.: Dec. 2016  Simpson, S.A., J.M. Joesch, I. I. West, J Pasic, “Who’s Boarding in the  Psychiatric Emergency Service?” Western Journal of Emergency  Medicine, Vol. 15, No. 6 (Sept. 2014).
Stephens, R.J., S.E. White, M. Cudnik and E.S. Patterson. “Factors  Associated with Longer Length of Stay for Mental Health Emergency  Department Patients.” The Journal of Emergency Medicine, vol. 47, no. 4  (2014).
Walker, E.R., J.R. Cummings, J. M. Hockenberry, and B.G. Druss.  “Insurance Status, Use of Mental Health Services, and Unmet Need for  Mental Health Care in the United States.” Psychiatric Services, vol. 66,  no. 6 (2015).
Warren, M. B., R. L. Campbell, D. M. Nestler, K. S. Pasupathy, C. M.  Lohse, K. A. Koch, E. Schlechtinger, S. T. Schmidt, and G. J. Melin.  “Prolonged Length of Stay in ED Psychiatric Patients: A Multivariable  Predictive Model.” The American Journal of Emergency Medicine, Vol 34,  No. 2 (2016).
Zhu, J.M., A. Singhal, and R.Y. Hsia. “Emergency Department Length-of- Stay for Psychiatric Visits Was Significantly Longer Than for  Nonpsychiatric Visits, 2002-11.” Health Affairs, vol. 35, no. 9 (2016)
section_title: Appendix III: Information on Mental Health Inpatient and Residential Treatment Facilities
section_title: Appendix IV: Information on Substance Use Inpatient and Residential Treatment Facilities
section_title: Appendix V: Information on Changes Related to the Medicaid Institutions for Mental Disease (IMD) Exclusion
paragraphs: Appendix V: Information on Changes Related  to the Medicaid Institutions for Mental Disease  (IMD) Exclusion l88 Fed. Reg. 27, 498, 27,861 (May 6, 2016) (codified at 42 C.F.R. § 438.6(e)). The 21st Century  Cures Act requires HHS to conduct a study of IMD services provided by MMC plans under the MMC  final rule by December 2019. Pub. L. No. 114-255, §12002, 130 Stat. at 1272.  Pub. L. No. 114-255, §12003, 130 Stat. at 1273.
section_title: Appendix VI: Disproportionate Share Hospital Payments to Mental Health Treatment Facilities
section_title: Appendix VII: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Lori Achman, Assistant Director;  Dawn Nelson, Analyst-in-Charge; Nancy Fasciano; Ada Nwadugbo; and  Jessica L. Preston made key contributions to this report. Also contributing  were Jennie Apter; Sandra George; and Vikki Porter.