Mental Illness: Up Close and Personal
by Ashley Adams
Editor's Note: Ashley is the daughter of AHA vice president Don Adams and his wife, Judy

According to the American Heritage Dictionary, stigma is defined as "a mark or token of infamy (evil fame or reputation), disgrace, or reproach (disapproval of, criticism of, or disappointment in)." I suffer from several illnesses: anorexia nervosa, obsessive-compulsive disorder, and major depression often accompanied by suicidal ideation. Because of this, I also suffer from stigma.

Just as a person would not choose to have cancer, heart disease or diabetes, I didn't choose to have the illness I have. My illness began when I was seven years old and went unnoticed for many years, making early treatment and intervention impossible. I strongly support Mrs. Gore's plea for mental health education for parents and educators. Early treatment is critical.

When I was fourteen, it became evident that I was very ill and treatment began. Psychotherapy and medications were the first treatments of choice; however I became sicker and sicker. My doctors and family saw no other choice but to hospitalize me. I was sixteen when I first entered the hospital (five hundred miles away from family, friends and any semblance of normal life). My first hospital "career" lasted two and a half years and ended when the doctors sent me home, in their eyes a "hopeless" case. I weighed ten pounds less than I did when I entered the hospital and was obviously sicker than ever.

Imagine trying to return to the "real world" to live a "normal" life. Everyone else had gone on living theirs, but I had been locked up and had real difficulty trying to integrate back into society. People were scared of me, and those who weren't scared of me were angry with me. They couldn't believe all the trouble I was causing my family-all the money and all the pain. They didn't understand that I didn't want to be this way. I hated being sick. I was not choosing to feel the way I did, and in fact was suffering. No one knew how to react to me or how to talk to me or how to be around me. I was a scary, sick person.

After so much treatment for such an extended period of time-hospitalizations, countless medications, different doctors­ ­those suffering from other illnesses might be out of options or might choose to stop treatments that weren't helping. In surrendering to the illness, they are treated with dignity. Society deems them heroes for their valiant efforts and unyielding courage while fighting their disease. They die receiving respect and compassion from those around them. On the other hand, when a person with depression has exhausted treatment options and chooses to end their battle with the disease, he or she is frequently immortalized as a quitter. Quiet conversations of judgment echo throughout the weeks, months and years following their death. Stigma is perpetuated.

I currently live in Washington, D.C., and am a full-time employee at one of the nation's largest not-for-profit organizations. I have been out of the hospital for over 15 months, which is the longest I've been able to manage for many years. Those facts noted, I still suffer from the stigmas attached to mental illness. While there is no limit on the number of outpatient visits for illnesses classified as medical, my insurance company offers me a very limited number of outpatient visits per year for treatment of mental illness. As a person who requires extensive therapy, it is not difficult to figure that they stop paying about three months into the year. So, I have a choice to make. I can either stop treatment for my illness until the next calendar year begins, or I can attempt to find a way to pay. No one would put such limits on a person receiving treatment for cancer. It would be deemed a crime to ask someone to discontinue effective chemotherapy and wait to resume treatment when insurance benefits are again available the following calendar year. That is the dilemma I am faced with.

I continue to struggle with the impact my experiences have had on me, and the overwhelming fear I often feel­ ­fear that is also felt by others. The stigma associated with my experiences is unyielding. Coming from a remarkable deficit, I have made much progress and many changes, sometimes in ways visible only to me. However, I still have a long way to go. I am grateful that I finally found a therapist who is willing to work with me. She has not given up on me, and I don't believe she ever will.

I am choosing to continue on this long, arduous journey and encounter thousands of dollars of debt. I hope that in my lifetime, society will begin treating those suffering from mental illness with the same compassion and understanding as those suffering from other illnesses. It is time to see that just as those fighting cancer or heart disease are courageous and heroic, those of us fighting mental illness are to be recognized with the same recognition and compassion. We should be allowed to use all of our energy fighting our illnesses rather than also fighting the stigma attached to them.

Judy Adams, mother of Ashley, is president of Friends of Research in Psychiatry at UAMS in Little Rock. About her daughter’s article, Mrs. Adams shares these comments:
There are no words for me to echo Ashley's. Her story speaks for itself. What can we do to change how mental illness is viewed? How can we break through the stigma so that stories like Ashley's become things of the past? I struggled with these questions daily. I know that many answers lie in education. Hopefully someday, society will understand that mental illness has nothing to do with poor choices, moral weakness of lack of character or spirituality. It is a medical illness-a brain disorder-just as severe, insidious and deadly as cancer or heart disease, possibly even more so because of the stigma attached to it. It is my sincere hope that, as stories like Ashley's are told, they will bring compassion, understanding and healing to many.

AHA Takes Message To Washington

A group of Arkansas hospital representatives met February 1 with all six members of the state's congressional delegation, conveying the message that more relief from the 1997 Balanced Budget Act (BBA) is essential to the long-term survival of many hospitals in Arkansas. Arkansas Hospital Association (AHA) executives, hospital CEOs, and trustees met individually with Reps. Marion Berry, Vic Snyder, Asa Hutchinson, and Jay Dickey, then had lunch with Senators Tim Hutchinson and Blanche Lincoln.

Although Congress passed the Balanced Budget Refinement Act last November, restoring about $17 billion to Medicare spending, only about $9 billion is targeted toward hospital services. That won't be enough to offset the damage being done by the BBA, which was previously estimated to reduce hospital payments by $70 billion between 1998 and 2002. Actual reductions have been exceeding those estimates.

A new study by the Lewin Group shows nearly 60% of hospitals won't be able to cover the costs of treating Medicare patients by 2004.

In Arkansas, hospital profitability already suffers from those BBA reductions. Based on information found in AHA-member hospitals' audited financial reports, overall operating margins fell 55% between fiscal years 1998 and 1999. More than half the hospitals saw their total margins-including operating and non-operating income-decline. Hospitals having fewer than 100 beds are being hit especially hard. Fifty percent of those hospitals lost money on total income in fiscal 1999, and another 20% posted margins less than 1%.

The most urgent and helpful thing Congress could do to help is to pass legislation that would provide for reasonable Medicare payment updates to reflect the true cost of providing care. For fiscal years 1998, 1999, and 2000, hospital costs rose 8.2%, while Medicare hospital payments increased 1.6%.

Arkansas Hospital Association- Important Points About The BBA
(As Discussed with the Arkansas Congressional Delegation)

• The Balanced Budget Act of 1997 (BBA) cut Medicare spending for U.S. hospitals by more than $70 billion over a five-year period (1998-2002). That amounts to about 12% of the Medicare payments they would have otherwise received. In Arkansas, hospitals could lose as much as $1.25 billion over the period.
• The recent Balanced Budget Refinement Act of 1999 (BBRA) that was passed in November as part of the Omnibus Budget Act will restore about $17 billion in Medicare spending previously taken away by the BBA. About $9 billion of the total will go toward services provided by the nation's hospitals.
• Arkansas hospitals appreciate your support of the BBRA. But, the act didn't go far enough. For example, one large Arkansas hospital previously estimated the BBA would result in losses of $25 million. Provisions of the Balanced Budget Refinement Act will restore about $300,000 of that, or around 1%. Passing the BBRA doesn't mean Congress should walk away from other BBA-relief measures.
• Reports from some government agencies, like the Health Care Financing Administration and the Medicare Payment Advisory Commission, paint a rosy picture of hospitals' finances. You may hear from them that hospital operating margins are still healthy, despite the BBA. What you don't hear is those reports are mostly taken from pre-BBA data.
• In Arkansas, that is not the case. Over the last two weeks, the Arkansas Hospital Association has collected audited financial data from its member hospitals. The audited reports for their two most recently completed fiscal years show that operating margins in 65% of those facilities fell between fiscals 1998 and 1999.
• Aggregately, the margins fell 64% and were only 1.35% at the end of FY 1999.
• Thirty-two percent of the responding hospitals lost money when including operating and non-operating income and another 17% showed less than a 1% return.

• One of the most important steps would be to support legislation which provides for reasonable Medicare payment updates for hospitals that reflect the true costs of providing inpatient hospital care. Over fiscal years 1998, 1999 and 2000, hospital costs rose a total 8.2% while the PPS updates rose 1.6%. At the same time, we've just gone through a very costly Y2K transition. We see a doubling of pharmaceutical prices for new drugs; new, blood screening techniques that are being required will add 50% to the cost of a pint of blood; and congressionally-mandated changes for administrative simplification and patient record privacy standards will be expensive. Some believe that requirements related to the 1996 Health Insurance Portability and Accountability Act alone will cost up to twice what Y2K preparations did. If that weren't enough, hospitals are being forced to pay premium prices to attract and keep employees like nurses and pharmacists whose workforce numbers seem to shrink every year.
• We also need your help to pass a bill that would change the upcoming Medicare PPS for outpatient services to bring those payments closer to the actual cost of providing care.
• Support the Medicare Common Sense Hospital Payment Act. This bill to repeal the BBA's transfer provision will also help. Not only does the expansion of hospital transfers reduce inpatient payments for about 10% of Medicare inpatients-costing hospitals $1 billion annually-it also makes it almost impossible to coordinate patient care with other providers, such as home health agencies. It unfairly penalizes hospitals that have a shorter average length of stay than the national average because Medicare pays less for transferred patients who are actually in the hospital for shorter periods than might be expected for their particular diagnoses. And it puts hospitals at risk of violating the False Claims Act if a patient discharged from a hospital to his home is subsequently referred by a physician to a post acute provider for care without the hospital's knowledge.
• Support changes in Medicare policies on payment of graduate medical education costs. Those could include development of a GME trust fund, allowing GME payments to go directly to providers that incur the costs instead of payers and restoring indirect medical education funding to 6.5% for FY 2001 and beyond.
• Support a recommendation to HCFA that there be no further reduction in home health payments. The recent Balanced Budget Refinement Act delays the implementation of a 15% across-the-board reduction for home health until October 2001. With the coming prospective payment system for home health, the 15% reduction should be eliminated altogether.

Those are some of the things hospitals do need to come out of this session of Congress. But, there are also things they don't need. For example:

• Legislation to require worker safety standards to prevent needlestick injuries. The American Hospital Association and OSHA are already working closely on this issue.
• Laws to address the complex issue of reprocessed single-use medical devices. The FDA is already developing standards and will consult frontline caregivers and other experts for their input.
• Legislation on mandated nurse staffing ratios is also premature and unnecessary. Nurse staffing should be driven by patient needs and hospitals must have flexibility to put their nurses in the right place at the right time to meet those needs.

Medicare Hospital Advisory Group

The Arkansas Hospital Association (AHA) and representatives from the state's Medicare Part A fiscal intermediary (FI), Arkansas Blue Cross and Blue Shield (ABCBS), have worked together to establish a Medicare Hospital Advisory Group.

The purpose of the group is to serve as a forum to discuss problems related to Medicare. The AHA and ABCBS agreed that such a committee would help improve communication between hospitals and the FI. That could help solve many Medicare-related problems that arise and might deter others from occurring.

Seven hospital representatives will serve on the committee, one from each of the AHA's district councils. They are Judy Briggs, CFO, Crittenden Memorial Hospital (Northeast); Martha Carlson, CFO, Drew Memorial Hospital (Southeast); Stuart Hill, CFO, White County Medical Center (North Central); Jimmy Leopard, CEO, Medical Park Hospital (Southwest); Scott Peek, Administrator, Chambers Memorial Hospital (Arkansas Valley), and Chris Winters, CFO, Arkansas Heart Hospital (Metropolitan).

A new member from the Northwest District will be appointed to replace Joe Hammond, who resigned recently as administrator of the Eureka Springs Hospital.

The initial meeting of the Medicare Hospital Advisory Group was January 26. Plans are to meet periodically, once every three or four months. If you have topics or issues concerning Medicare that should be included on the agenda of this meeting, please contact Paul Cunningham at (501) 224-7878. Or send an email to pcunningham@arkhospitals.org.

CBO Expects Medicare Spending to Increase

Medicare spending will increase about 7% per year in this decade, the Congressional Budget Office (CBO) projected in late January. The steeper rise will end a period of slow growth that bottomed out in 1999 with a 1% decline, CBO said. It noted that slow enrollment growth, anti-fraud initiatives and the 1997 Balanced Budget Act spurred the 1999 decline. That downward trend will be reversed over the next 10 years because of several factors, mainly a projected 17% increase in enrollment in the Medicare Part A program and automatic updates to payments for providers. The projected average 7% growth in this decade, however, will be substantially less than the 11.1% annual growth seen between 1990 and 1995.

Arkansas Critical Access List Grows to Seven

Medical Center of Calico Rock and Dallas County Hospital in Fordyce became the most recent facilities in Arkansas to be certified as critical access hospitals by the Arkansas Department of Health. They join Eureka Springs Hospital, Dardanelle Hospital, North Logan Mercy Hospital (Paris), Mercy Hospital/Turner Memorial (Ozark), and Mercy Hospital of Scott County (Waldron) as certified critical access hospitals. Several others continue to evaluate the feasibility of converting to critical access status.

In a related item, the state's Critical Access Hospital Work Group met December 15 with Darlene Bainbridge, chief executive officer of a critical access hospital in Cuba, New York, to hear her perspective on quality and community issues involved in planning a conversion to critical access. Ms. Bainbridge shared numerous ideas on ways for small, rural hospitals to carve out a unique niche of services in today's rapidly changing healthcare environment.

The Health Department's Critical Access Hospital Steering Committee also met and agreed to establish a Quality Improvement Committee (QI) consisting of representatives of all parties with a role to play in critical access hospitals.

Initially, the group will include representation from the Arkansas Hospital Association; the Arkansas Department of Health; the Arkansas Foundation for Medical Care; two CEOs from critical access hospitals in the state; representatives from larger, sponsoring hospitals; the Medicare Fiscal Intermediary; managed care companies; rural physicians; and nurses.

Arkansas Hospital Trends

After remaining stable between 1996 and 1997, hospital spending in Arkansas jumped 8.4% last year, according to the most recent edition of the American Hospital Association's Hospital Statistics publication. That compares with an overall hospital cost increase nationally of about 4.2%.

Expenses in the state's hospitals grew 58% faster than net revenues, the amount of payments actually received for patient services. Those net patient revenues climbed 5.4% to $2.86 billion for the year.

One reason for the slower growth in net patient revenues was increased hospital write-offs, billed charges that were not paid by patients or payer organizations. In 1997, 45.9% of all hospital charges remained uncollectible. That rate increased to 48.8% in 1998.

While total hospital costs increased, there was some decline in utilization. In Arkansas, hospitals reported a total 358,068 admissions, a 3.3% increase over the 346,426 admissions in 1997. However, inpatient days fell about 1%, registering near 2.1 million in each year.

Hospital utilization across the country didn't fare much better. Overall admissions nationally rose less than 1% between 1997 and 1998, and inpatient days of care provided in hospitals remained relatively unchanged.

Visits by patients in Arkansas to hospital outpatient departments and emergency rooms, which increased 13% between 1995 and 1996, and fell to a modest 2.1% in 1997, posted a 0.2% decline in 1998.

One area where the state's hospitals reported significant increased utilization for the year was outpatient surgical procedures. Total outpatient surgeries grew from 143,322 in 1997 to 147,547 in 1998, a 3.4% increase. At the same time, the number of inpatient surgical procedures fell 13% to 98,224. Outpatient surgeries still accounted for more than 60% of all surgical procedures.