OPINION | Why the Shirtless Man Shouting on the Street Isn't in the Hospital

by Bruce L. Davidson M.D., M.P.H.

Have you wondered why that ill-kempt shirtless man shouting on the street isn't in a hospital somewhere? If he were convulsing or sitting up clutching his chest instead, he would have been phoned in to Medic One and whisked away. But he's on his own since so many inpatient mental health facilities and beds were taken away nationwide when bad conditions were revealed during the 1970s.

A half-century later, the closures considered compassionate back then have evolved into a crisis. Are inpatient beds available? Absolutely. But in Seattle and elsewhere, private hospitals, nonprofits limiting their charity care, and for-profits aren't interested in those mentally ill patients on the street, especially not when multiple publicly owned and taxpayer-subsidized hospitals already abound in the same county. Why? Because these patients are poor, and their Medicaid insurance pays less to the hospital and professionals than Medicare and private insurance pay. Seattle-King County is fortunate to have four publicly owned and funded hospitals, two — Harborview and Valley-Renton — owned in King County, and University of Washington (UW) Medical Center and UW-Northwest owned by the state. All four are administered and staffed by UW Medicine, which the commercials during the Seattle Mariners broadcasts tell me is where research meets great health care. Those four hospitals file annual Medicare cost reports of their inpatient bed numbers and use. They claim 1,579 beds between them.

Reporting by The Seattle Times told us of an experimental church detox clinic in Centralia where the physician stated, "We're really not having much success." In King County, an urgent-care physician addiction specialist described his treatment attempts this way, "It's just kind of word-of-mouth and what's happening locally."

If you're thinking, "This isn't how childhood leukemia was cured, is it?", you're correct.

Just 122 of those 1,579 UW-administered beds are inpatient psychiatry beds — 8% of the total. And the mentally ill Medicaid-covered poor patients? Just 2% of the total, or around 37 patients on any given day. The other 6% — 85 psychiatry inpatients — pay insurance premiums. At UW Medical Center, the private-pay patients average 43-day stays, while the indigent Medicaid patients average 30-day stays. Why? Money. South King County must have zero mentally ill patients requiring inpatient psychiatric care, because UW Medicine's Valley-Renton, with 330 beds has no inpatient psychiatry ward at all! In the apparently needier north, UW-Northwest (206 beds, has a 27-bed psychiatry ward, but its Medicaid patients occupy just 0.7% of that hospital's annual bed-days.

Meanwhile, King County Executive Dow Constantine has repeatedly called attention to our behavioral health crisis. And there is a solution. Public hospitals learned to repurpose inpatient beds for COVID-19; why not for mental illness? Although rare patients with moderate-to-severe drug or alcohol addiction can detox as outpatients, many cannot, and doing so can be life-threatening. Then there are the chronically mentally ill with frequent decompensations, who, like those with fragile, frequently decompensated heart failure or lung disease, require frequent admissions for partial tune-ups. Why isn't UW Medicine making more inpatient beds for those mentally ill, and instead using just 2% of its 8% of psychiatric bed-days for Medicaid inpatients while leaving the rest on the street and competing with private hospitals for private-pay psychiatric inpatients? Why is "research meets clinical care" UW leaving the complex tuning of new narcotic antidotes to help detox complex new fentanyl syndromes to church clinics and urgent care centers?

The Seattle Times reported that King County mental health facilities refuse and turf away 25% of patients. Of that group, 30% are refused for "administrative (?!) or no-capacity" reasons, but a full 50% are refused due to medical issues — "…wounds, kidney dialysis, mobility problems" — and 20% for behavioral problems. These two classifications, often applied to the same patient, are routinely found in genuine county general hospitals elsewhere, where they are restrained initially if necessary, administered psychiatric medication intramuscularly, then intravenously, and their medical/surgical issues are then addressed while they are followed by the consultative liaison psychiatry service. Repairing such problems has been the rule in other public hospitals for many decades. Why do our four publicly-owned hospitals not make beds available for such typical patients?

"Follow the money" helps us figure this out. Inpatient hospital beds generate two bills: facility fees and professional fees. In most public hospitals, both go to support the whole operation. But not at UW Medicine, which operates a separate company, UW Physicians (aka Association of University Physicians), that uses the professional fees to pay bonuses to physician leadership, doubling and tripling (the former dean) their State-paid compensation to over $1 million annually for several. So a Harborview neurosurgeon earning $657,000 in his State paycheck collected another $430,000 from the private company, as well as $127,000 in "other compensation." Altogether, 831 UW Medicine leaders earn at least $100,000 each extra from this company that collects, then redistributes professional fees paid for subspecialty surgery and intensive care on mostly private insurance patients.

That public hospitals — with physician leaders earning handsome State salaries and State benefits and zero medical practice expenses — would take on-the-job medical billings laundered through a nonprofit as cash bonuses has stunned every person to whom I've shown the report linked above. Without public pressure, why in the world would they replace their favorite money-generating inpatients with that shirtless, mentally ill patient on the street? We must remind physician-leaders of their duty to use biomedical resources, inpatient beds, and expertise to develop methods leading to successful detox and medication for disordered brains. Physicians' priority-ordered missions include brain disease, and require using biomedicine to relieve body pain and breathlessness, prevent disability, and postpone death. Society must commit to handling the rest.

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The opinions, beliefs, and viewpoints expressed by the contributors on this website do not necessarily reflect the opinions, beliefs, and viewpoints of the Emerald or official policies of the Emerald.

Bruce L. Davidson, M.D., M.P.H., a board-certified physician, researcher, and public health physician, has served on local, state, and federal advisory boards, including a City Drugs and Alcohol Abuse Commission and State Health Facility Hearing Board.

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