Original Article

Changes in Proportions of Emergency Department Patients with Mental Illness Noted in the National Hospital Ambulatory Medical Care Survey, 2012–2015

Authors: La Vonne A. Downey, PhD, Amanda Hong MBA, Karina Herrera, BA


Objectives: The primary objective of this study was to determine whether there was a change in the rate and types of patients with psychiatric illnesses being seen in the emergency department (ED) from 2012 to 2015 using the National Ambulatory Care Survey. A secondary objective was to determine what if any changes occurred in the resources available to care for these patients.

Methods: Our study used 2012–2015 data from the National Hospital Ambulatory Medical Care Survey and the State Mental Health Agency Per Capita Mental Health Services Expenditures, and expenditures data from 2012–2015 to examine whether there was a significant change in the rate and type of mental illness ED visits. Additional data on the number of beds per region from the National Mental Health Services Survey, 2012–2015 were used. A t test was used to look for significant (P = 0.05) changes in the rate and types of patients, ED dispositions, ED reimbursement types, region and community level income, sex, age, state mental health funding, and psychiatric beds from 2012 to 2015.

Results: There was an 8% increase in the rate of patients who presented with a diagnosed mental health disorder (P = 0.03, 95% confidence interval [CI] 5.32–5.96) and substance use disorders (P = 0.03, 95% CI 0.564–0.122). The reimbursement for these visits did change (P = 0.01, 95% CI 0.245–0.685); however, there was no significant increase (P = 0.07, 95% CI−214 to 101) in state mental health budgets and the number of psychiatric and detox hospital beds from 2012 to 2015.

Conclusions: The rate and types of mental health patients coming to the ED are still on the rise. This is coupled with a lack of mental health infrastructure to address the needs and diagnoses that continue to be seen in the ED. States may need increased, targeted funding for mental health outside the increase in coverage via the Patient Protection and Affordable Care Act to slow the rate of mental health patients seen in the ED.
Posted in: Emergency & Disaster Medicine5 Mental Health3

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1. National Institute of Mental Health. Any mental illness. http://www.nimh.nih.gov/health/statistics/mental-illness.shtml. Accessed June 25, 2018.
2. National Institute of Mental Health. Serious mental illness. http://www.nimh.nih.gov/health/statistics/mental-illness.shtml. Accessed June 25, 2018.
3. National Institute of Mental Health. Prevalence of any mental disorder among adolescents. http://www.nimh.nih.gov/health/statistics/mental-illness.shtml. Accessed June 25, 2018.
4. National Institute of Mental Health. Schizophrenia. https://www.nimh.nih.gov/health/topics/schizophrenia/index.shtml. Accessed June 25, 2018.
5. National Institute of Mental Health. Bipolar disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. Accessed June 25, 2018.
6. National Institute of Mental Health. Depression. https://www.nimh.nih.gov/health/topics/depression/index.shtml. Accessed June 25, 2018.
7. National Institute of Mental Health. Anxiety disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml. Accessed June 25, 2018.
8. Substance Abuse and Mental Health Services Administration. Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.pdf. Accessed October 27, 2018.
9. Capp R, Kelly L, Ellis P, et al. Reasons for frequent emergency department use by Medicaid enrollees: a qualitative study. Acad Emerg Med 2016;23:476-481.
10. Capp R, Rosenthal MS, Desai MM, et al. Characteristics of Medicaid enrollees with frequent ED use. Am J Emerg Med 2013;31:1333-1337.
11. Raven MC, Billings JC, Goldfrank LR, et al. Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health 2009;86:230-241.
12. Henry J. Kaiser Family Foundation. Characteristics of frequent emergency department users. https://www.kff.org/health-costs/report/characteristics-of-frequent-emergency-department-users. Accessed June 25, 2018.
13. Kenney GM, Huntress M, Buettgens M, et al. State and local coverage changes under full implementation of the Affordable Care Act. https://www.kff.org/health-reform/report/state-and-local-coverage-changes-under-full-implementation-of-the-affordable-care-act. Accessed October 20, 2018.
14. Mechanic D. Seizing opportunities under the Affordable Care Act for transforming the mental and behavioral health system. Health Affairs 2012;31:376-382.
15. Beronio K, Glied S, Frank R. How the Affordable Care Act and Mental Health Parity and Addiction Equity Act greatly expand coverage of behavioral health care. J Behav Health Serv Res 2014;41:410-428.
16. Barry CL, Goldman H, Huskamp H. Federal parity in the evolving mental health and addiction care landscape. Health Aff (Millwood) 2016;35:1009-1016.
17. Office of the Assistant Secretary for Planning and Evaluation. Medicaid expansion impacts on insurance coverage and access to care. https://aspe.hhs.gov/pdf-report/medicaid-expansion-impacts-insurance-coverage-and-access-care. Published January 18, 2017. Accessed June 25, 2018.
18. Garfield RL, Zuvekas SH, Lave JR, et al. The impact of national health care reform on adults with severe mental disorders. Am J Psychiatry 2011;168:486-494.
19. Walker ER, Cummings JR, Hockenberry JM, et al. Insurance status, use of mental health services, and unmet need for mental health care in the United States. Psychiatr Serv 2015;66:578-584.
20. Weiss A, Barrett M, Heslin K, et al. Trends in emergency department visits involving mental and substance use disorders, 2006-2013: statistical brief #216. Healthcare Cost and Utilization Project Statistical Briefs. Rockville, MD:Agency for Healthcare Research and Quality;2016.
21. Tang N, Stein J, Hsia RY, et al. Trends and characteristics of US emergency department visits, 1997-2007. JAMA 2010;304:664-670.
22. Cummings JR, Wen H, Ko M, et al. Geography and the Medicaid mental health care infrastructure. JAMA Psychiatry 2013;70:1084-1090.
23. National Alliance on Mental Illness. State mental health cuts. https://www.nami.org/getattachment/About-NAMI/Publications/Reports/NAMIStateBudgetCrisis2011.pdf. Published March 2011. Accessed December 7, 2019.
24. Olluve M. Amid shortage of psychiatric beds, mentally ill face long waits for treatment. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/08/02/amid-shortage-of-psychiatric-beds-mentally-ill-face-long-waits-for-treatment. Published August 2, 2016. Accessed December 7, 2019.
25. National Center for Health Statistics, Centers for Disease Control and Prevention. Ambulatory health care data. 2012-2015. https://www.cdc.gov/nchs/ahcd/index.htm. Accessed May 25, 2018.
26. National Association of State Mental Health Program Directors Research Institute (NRI). State Mental Health Agency (SMHA) per capita mental health services expenditures. http://www.nri-incdata.org. Accessed May 15, 2018.