NADD U.S. Policy Update (from the NADD Bulletin Volume X1 Number 6)

Complete listing

Adverse Impact of the Medicare Acute Psychiatric Inpatient PPS For Patients With Co-Occurring Developmental Disabilities and Mental Illness

Diane Jacobstein, Ph.D., William O'Brien, MSW, Joan B. Beasley, Ph.D., 

Ann D. Hurley, Ph.D., Terrence McNelis, MS, Robert Fletcher, DSW, Julia Pearce


Following is a brief outline developed by members of the NADD US Public Policy Committee and submitted to the DHSS Office on Disability on behalf of individuals with dual diagnosis:

·Concerns are growing across the country about the adverse impact of the new Medicare reimbursement formula for acute psychiatric inpatient stays on patients with co-occurring intellectual/developmental disabilities and psychiatric problems. 

·The current Medicare rates for acute inpatient psychiatric admissions do not account for the unique needs of people with co-occurring intellectual/developmental disabilities and mental illness, as they were based on cost estimates for patients without mental illness alone.

·Individuals who have both developmental disabilities and mental illness commonly have significant medical problems that must be considered in order to clarify the diagnosis and provide effective treatment. They may not be able to communicate about their symptoms.  Their care requires more time, an interdisciplinary approach and a much wider array of subspecialties than is needed for individuals with mental illness alone (including speech-language pathology, neurology, occupational therapy, urology, orthopedics, physical therapy, gastroenterology, behavior specialists) because of the developmental disability, medical co-morbidity and complexity of both. 

·There is not enough time allotted by current guidelines (generally about 8 days), so patients are being discharged before their needs are addressed (which is estimated to take an average of about 13-16 days for this target group).

·Communities are seeing these patients stuck in emergency rooms, sometimes for a week or more, although open "network" beds are available in acute psychiatric units. 

·Inadequate time to complete the process leads to readmissions for the same problem.  Recidivism under the new rates is on the rise for this population and individuals may also remain impaired for longer time. 

·Evidence shows that recidivism is reduced by a comprehensive approach that requires more resources up front. This population is estimated to cost approximately 35-40% more to treat appropriately in acute stabilization admissions. Since the most common reason for admission is severe aggression, a far more intensive staffing pattern is also required, in order to increase safety and reduce the need for chemical restraint. (This would not have been observable when Medicare reviewed the costs related to diagnosis.)

·Many general psychiatric units have been reluctant to admit these patients because they need such specialized care.  There are concerns that reduced rates will exacerbate this reluctance and reduce access, further increasing the disparity in services for people with developmental disabilities relative to people without disabilities if the current payment structure is not modified. In addition, there are concerns that dedicated specialty units that have proven to be very effective for those with severe co-occurring developmental and psychiatric disorders will be at risk.

·Medicaid managed care providers in some states have paid differential rates for this population with good results.

·The recent establishment of rates for inpatient stays is not the problem.  The concern is that the current rates and associated service expectations do not match the needs of individuals with mental illness and intellectual/developmental disabilities. There are specialized inpatient programs that may serve as a way to better inform policy makers. One example is the inpatient unit at UMASS Medical Center that serves the entire New England region. This program and others found in the US should be identified as pilots to help establish more appropriate rates for the population.



Charlot, L and Beasley, JB (2005) Specialized Inpatient Mental Health Care for People with Intellectual Disabilities. The Mental Health Aspects of Developmental Disabilities 8 (3) 100-103.

Lohrer, S; Greene, E.; Browning, C; & Lesser, M.S. (2002). Dual Diagnosis: Examination of Service use and length of Stay during psychiatric hospitalization Journal of Developmental Disabilities 14 (2) 143-158.

Lunsky, Y; Bradley, E.; Durbin, J.; Koegl, C.; Carninus, M & Goerinz, P. (2003) Dual Diagnosis in Provincial Psychiatric Hospitals: A Population- Based Study.  Ontario Mental Health Foundation Publisher, Ontario, Canada

O'Brien, W. (2007) Changing Environments of Inpatient Psychiatric Care for Individuals with Intellectual Disabilities. The Mental Health Aspects of Developmental Disabilities 10 (6) 99-106.

Xenitidis, K; Gratsa, A; Bouras, N; Hammond, R; Ditchfield, H; Holt; G.; Martin, J.; & Brooks, D. (2004) Psychiatric Inpatient care for adults with intellectual disabilities: generic or specialist units? Journal of Intellectual Disabilities Research 48 (1) 11-18.


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