Regulations cost inpatient psychiatric facilities $1.7 billion

ROBERT KING  March 19, 2019

Inpatient psychiatric facilities across the country face $1.7 billion a year in compliance costs stemming from outdated regulations and inconsistent surveys from private and state agencies, according to a new industry report released Tuesday.

The biggest driver of regulatory costs for facilities is meeting requirements to lower ligature-risk points, which are areas where a patient can try to strangle themselves. Ligature-risk point regulatory compliance costs inpatient facilities nationwide an average $880 million a year, according to the National Association for Behavioral Health, which represents the facilities.

Some state regulators or accreditation services like the Joint Commission, which survey inpatient facilities, often demand major changes to psychiatric facilities because of ligature risk, and the surveyors' demands are often at odds with each other.

"There is a constant change in the interpretation of the regulations," NAHB President Mark Covall told Modern Healthcare in an interview. "Surveyors come in and they may cite a problem and then you have to make some significant retrofitting and subsequently six months later somebody else would come in and say you need to do something differently."

Manatt Health surveyed 62 inpatient facilities for the study, looking to pinpoint the top regulatory burdens they face and recommendations for change. It also examined data from the 2016 CMS hospital cost report to generate the approximate regulatory costs for facilities nationwide.

The NABH has been meeting with the CMS to create a national guidance for surveyors that would help foster more consistency for facilities.

Another high area of regulatory burden are called B-tags, which are standards for patient evaluations, medical records and staffing. Nationwide the B-tags cost psychiatric hospitals an estimated $622 million each year in compliance costs, the study said.

For example, two B-tags call for providers to comply with detailed requirements for comprehensive treatment plans and progress notes. The federal regulation calls for a provider to make progress notes at least weekly for the first two months of care and once thereafter, but many surveyors such as state regulators want to see daily progress notes that connect each therapeutic intervention back to the goals in the treatment plan, the report said.

"These requirements not only constrain clinician's professional judgment, but also impose immense documentation burdens that add little value," the report said.

The report recommends that the majority of B-tags be eliminated because they are outdated.

Facilities also must deal with greater requirements under the Emergency Medical Treatment and Labor Act, which calls for a hospital to screen all patients for emergency medical conditions and treat them. But the CMS and other regulators such as state or private agencies are now using the law to require psychiatric facilities with an emergency department to admit patients who were brought to the emergency department against their will, a reversal of a decades long practice.

The report, which estimates the compliance costs to be $209 million a year nationwide, charges that the new interpretations are not documented in any written guidance.

HHS' Office of Inspector General should step up enforcement of the statute and should not force facilities to take in patients admitted against their will.

"Regulators should not use the threat of (federal) sanctions to force all psychiatric facilities with an (emergency department) to accept involuntary admissions," the report said.

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