Highlight on Alabama: Class action against state alleges inadequate prison mental health care

Focus on the issue of accessibility to quality mental health care has been growing in recent years, and the state of Alabama is facing intense scrutiny for the possible failure to treat mentally ill inmates. A federal trial began on December 5, 2016, in which dozens of inmates are expected to testify.

This trial is one part of a larger suit filed by the Southern Poverty Law Center (SPLC) in 2014 alleging that overall, medical care in the state’s prisons is below constitutional standards. Claims that the Department of Corrections (DOC) failed to accommodate prisoners with physical disabilities were previously settled, with the DOC agreeing to improve its facilities.

U.S. District Judge Myron Thompson granted class action status to the mental health portion of the case in November 2016,  noting that the failure to provide funding for staff creates an Eighth Amendment violation, even if this is caused by a lack of available money.

The claims currently being heard allege that the mental health care, provided through the contractor MHM Correctional Services, fails to provide enough providers to offer care, including psychiatrists, psychologists, and nurses. Additionally, the lack of security staff causes interruptions in care. This results in failing to identify mentally ill inmates and properly diagnose the severity of illness in those who are identified. These issues have led to a failure to prescribe medication, manage side effects, offer adequate counseling, and properly monitor and treat inmates who are suicidal and self harm.

According to a local news report, the first inmate witness had been in prison for six years and is currently at the Donaldson Correctional Facility. He testified that he had physical and mental illnesses and was prone to self harm, but he only sees mental health staff approximately every two months for sessions lasting about five or 10 minutes.

SPLC stated that other expected witnesses include a Dr. Kathryn Burns, a mental health expert who has inspected nine Alabama prisons and their mental health procedures.

This suit is not the only attention Alabama’s prisons are currently receiving. In October 2016, the Department of Justice began a statewide investigation into the conditions in Alabama’s prisons. This investigation is to focus on efforts to protect prisoners from abuse and excessive force at the hands of other prisoners or correctional offers, as well as the provision of sanitary, secure, and safe living conditions.

Fed big spender, as prescription drugs drive increases

U.S. health care spending in 2015 grew by 5.8 percent, reaching $3.2 trillion; on a per capita basis, spending on health care increased 5 percent to $9,990, according to researchers at the Office of the Actuary at CMS in a new National Health Expenditures report. As a result, the share of gross domestic product devoted to health care spending was 17.8 percent in 2015, up from 17.4 percent in 2014. CMS noted that although millions of people gained coverage in part to the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), per-enrollee spending growth in private health insurance and Medicare continued to be well below the average in the decade before passage of the ACA.

In 2015, the federal government accounted for the largest share of health care spending (29 percent), followed by households (28 percent), private businesses (20 percent), and state and local governments (17 percent). Hospital care accounted for the most spending based on type of service or product at 32 percent with physician and clinical services at 20 percent.

Retail prescription drug spending continued to grow faster than the overall spending growth, increasing 9 percent to $324.6 billion. Although the growth in 2015 was slower than the previous year, spending on prescription drugs still outpaced all other services in 2015.

Spending numbers 

Overall, private health insurance expenditures, which amounted to 33 percent of total health care spending, reached $1.1 trillion in 2015, and increased 7.2 percent in 2015. The faster rate of growth reflected increased enrollment in private health insurance associated with coverage expansions under the ACA, and a notable increase in the enrollment in employer-sponsored plans.

Medicare spending, which amounted to 20 percent of total health care spending, grew 4.5 percent to $646.2 billion in 2015, which was a slight deceleration from the 4.8 growth percent in 2014. The slightly slower growth in 2015 was largely attributable to slower growth in Medicare enrollment, which increased 2.7 percent to 54.3 million beneficiaries following 3.1 percent growth in 2014.

Medicaid spending, which accounts for 17 percent of total health care spending, slowed slightly in 2015 to 9.7 percent, but continued the growth that began in 2014 (11.6 percent). State and local Medicaid expenditures grew 4.9 percent while Federal Medicaid expenditures increased 12.6 percent in 2015. The latter increase was attributed to newly eligible enrollees under the ACA.

Out-of-pocket spending grew 2.6 percent in 2015 to $338.1 billion, slightly faster than the growth of 1.4 percent in 2014.

CMS updates its Medicare and Medicaid drug spending dashboards

As part of its effort to provide additional information on, and increase transparency in the cost of prescription drugs, CMS has updated both its Medicare and Medicaid drug spending dashboards to include information from 2015. According to a CMS press release, the medications presented as part of the 2015 Medicare Drug Spending Dashboard represents a very large proportion of Medicare spending, including 34 percent of all Part D spending and 69 percent of Part B drug spending, which was similar to the 2014 drug dashboard. A second, contemporaneous CMS press release notes that the medications presented as part of the 2015 Medicaid Drug Spending Dashboard represent approximately 41 percent of Medicaid covered outpatient drug spending in 2017.

Total program spending

For total program spending, the Medicare dashboard shows five drugs with the highest Part D and Part B drug spending, respectively, in 2015 compared to their spending in 2014. For example, the dashboard shows that Lantus (insulin) was a top-five drug in terms of costs in Medicare Part D between 2014 and 2015, as was Havroni, a new drug to treat Hepatitis C.

The Medicaid dashboard also shows the trend in total drug spending for the five drugs with the highest aggregate drug spending in 2015. Of the top five, Harvoni and Abilify (aripiprazole, a brand name anti-psychotic drug) had total drug spending greater than $2 billion in 2015, with annual total program spending for Abilify greater than $1.7 billion for each of the past five years. Also, spending for Lantus/Lantus Solostar (insulin glargine, a brand name diabetes drug) was $1.4 billion and spending for Vyvanse (lisdexamfetamine dimesylate, a brand name attention deficit hyperactivity disorder drug) and Humira/Humira pen (adalimumab, a brand name drug used for rheumatoid arthritis) was approximately $800 million each.

Highest total spending (Part D)

The Medicare dashboard shows that the five Part D drugs with highest total spending in 2015 were:

  • Spiriva (tiotropium bromide, a brand name chronic obstructive pulmonary disease treatment);
  • Advair Diskus (fluticasone/salmeterol, a brand name asthma and chronic obstructive pulmonary disease treatment);
  • Crestor (rosuvastatin calcium, a brand name cholesterol drug)
  • Lantus/Lantus Solostar (insulin glargine, a brand name diabetes drug); and
  • Harvoni (ledipasvir/sofosbuvir; a brand name Hepatitis C virus treatment).

Advair Diskus and Crestor were also among the top five drugs with the highest Part D spending in 2014, but Spiriva, Lantus, and Harvoni were not. Harvoni was introduced in October 2014 and in 2015 had just over $7 billion in spending. Sovaldi (sofosbuvir), another drug for treating Hepatitis C, had the highest spending in 2014, but was not among the top five drugs in 2015, with $1.3 billion in spending.

Highest total spending (Part B)

The Medicare dashboard shows the top five Part B drugs with highest total spending were:

  • Lucentis (ranibizumab, a brand name drug for wet age-related macular degeneration);
  • Remicade (infliximab, a brand name rheumatoid arthritis drug);
  • Neulasta (pegfilgrastim, a brand name white blood cell stimulator for use with cancer treatments);
  • Rituxan (rituximab, a brand name cancer treatment); and
  • Eylea (aflibercept, a brand name drug for wet age-related macular degeneration).

These were the same five drugs with the highest Part B spending in 2014. Each of these drugs contributed more than $1 billion in spending for the Medicare Part B program.

Unit cost

The Medicare dashboard lists the top five drugs with the largest increases in average cost per unit from 2014 to 2015 in the Part B and D programs. Glumetza (metformin HCl, a diabetes treatment) had the largest increase in cost per unit at over 380 percent and had total spending increases from $34.3 million to $153 million. All five of these Part D drugs had increases in cost per unit of more than 100 percent. Among Part B drugs, mitomycin (a generic chemotherapy agent), had the largest increase in average Part B cost per unit at 163 percent and had total spending increases from $5.9 million to $15.8 million. The other four Part B drugs had smaller, but still significant increases, approximately 25 to 40 percent.

The Medicaid dashboard shows the top five drugs with the largest increases in average cost per unit from 2014 to 2015. Ativan (lorazepam, a brand name drug used for anxiety) had the largest increase in cost per unit at 1,264 percent and a spending increase from $1.7 million to $5.3 million. All five of the drugs had increases in cost per unit of more than 400 percent.

High cost per prescription fill

The Medicaid dashboard shows the top five drugs selected for high costs per prescription fill (i.e., greater than or equal to $1,000) in 2015. Advate (antihemophilic factor [recombinant], a brand name hemophilia treatment) had an average cost per fill of $20,828 and was associated with total program spending of $354 million. In comparison, Prezista (darunavir ethanolate, a brand name HIV antiviral) had an average cost per fill of $1,259 and total program spending of $335 million. NovoSeven RT (coagulation factor VIIa [recombinant], a brand name hemophilia treatment) had the highest average cost per fill at $67,098 and $298 million in program spending.

Highlight on California: the price of privatizing psychiatric care

California may privatize a state mental health hospital as a cost saving measure. However, critics are worried that Correct Care Recovery Solutions, the selected contractor, will achieve cost savings through dangerous reductions in care quality. The California Mental Health Services Authority—the consortium of California county mental health agencies—is proposing a facility which would serve around 250 civilly-committed patients. Additional beds are needed due to a persistent and historically high need for the most dangerous and severe of the state’s mentally ill.

Backlog

The current network of state hospitals houses people who are charged with crimes but found mentally incompetent to stand trial or not guilty by reason of insanity. In June, the waiting list for hospital beds reached a five-year high of 700 individuals. The average wait time for an individual not found competent to stand trial is two months, but many are forced to wait several months.  Those patients found incompetent to stand trial who do not have access to a bed are forced to wait in county jails, typically in Los Angeles County.  In county jails, patients have access to basic mental health care but long-term psychiatric treatment is often delayed. Other patients, those who are civilly-committed, are housed in local psychiatric hospitals.

Costs

The costs are significant regardless of where patients are housed. It can cost between $600 and $1,300 a day to house civilly-committed patients in local psychiatric hospitals in Los Angeles County. When patients are eventually transferred to state hospitals, counties are still obligated to pay for the care provided to patients, and the state bills about $650 per patient, per day. In 2015, Los Angeles County, alone, spent $55 million on patient care in state mental health hospitals.

Correct Care

The contractor, Correct Care, says it can cut the state’s cost by 10 percent. However, the promise of cost savings through privatization has a complex history. The Department of Justice (DOJ) announced in August 2016 that it would end its use of private prisons noting that private facilities are both less safe and less effective than government run facilities. Soon after, the Obama Administration announced it would take steps to move away from the use of for-profit (private) immigration detention facilities. Privatization of state psychiatric facilities poses similar problems to those which led to the administration’s policy on prisons and immigration facilities.

Privatized State Hospitals: South Florida State Hospital

If California moves forward with its plan, the state will not be the first to privatize a state mental health hospital. The South Florida State Hospital was one of the first in the U.S. to be privatized.  The Florida hospital was managed by a division of GEO Group—a private prison contractor—until 2014, when Correct Care Solutions bought the unit. Following three deaths in the facility, in 2011, Florida’s Department of Children and Families investigated the hospital. In one of the deaths, a heavily medicated patient was found dead in a bathtub with water so hot the patient’s skin sloughed off his body. Investigators determined that Correct Care was addressing the problems. However, between 2011 and 2015, investigators verified 19 more claims that staff abused, neglected, or failed to properly supervise those in their care. Some of those instances of abuse and neglect included a technician throwing a patient to the ground and a patient jumping to his death from the eighth floor of a parking garage. Those opposed to privately run mental health institutions cite understaffing as a key cause of such abuse and neglect.

State-run hospitals

The state-run hospitals are not immune from criticism and instances of patient harm. In 2014, 3,500 patient-against-patient assaults were recorded in California. Metropolitan State Hospital in Norwalk admits the type of civil-commitments which would be transferred to the hypothetical Correct Care facility. Between 2011 and 2015, the California Department of Public Health investigators found at least 55 deficiencies at Metropolitan related to a patient’s harm, abuse, neglect, and restraint.

Access

There is no dispute that California requires additional mental health hospital beds. However, regardless of who will operate additional mental health facilities, lawmakers and stakeholders in California must be careful that the wellbeing of patients is not exchanged in a bargain for a lower rate.