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Psychiatrist, internist, and addiction medicine specialist Muhamad Aly Rifai discusses his article “The crisis in inpatient psychiatric care.” In this episode, Muhamad examines the growing dysfunction within the nation’s psychiatric hospital system, where patients in crisis are too often turned away or kept too long because of policy failures, financial pressures, and insurance algorithms that override clinical judgment. Drawing from two decades on the front lines, he describes the moral tension faced by psychiatrists navigating laws that punish both over- and under-admission, and insurers that cut coverage precisely when patients begin to improve. Muhamad calls for a new social contract for crisis care grounded in fairness, transparency, and dignity, where hospitals, insurers, and clinicians are all accountable to the patients they serve. Viewers will gain a clear and compassionate understanding of how reform can make psychiatric care humane, accessible, and just.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Muhamad Aly Rifai, psychiatrist, internist and addiction medicine specialist. Today’s KevinMD article is “The crisis in inpatient psychiatric care.” Muhamad, welcome back to the show.

Muhamad Aly Rifai: Thank you very much for having me to talk about the current issue about the crisis in inpatient psychiatric care here in the U.S. and propose some solutions for streamlining inpatient psychiatric care, and talk about my experience as an inpatient psychiatric provider for many years.

Kevin Pho: All right, so tell us about this crisis.

Muhamad Aly Rifai: In the U.S. as well as around the world, individuals who experience psychiatric emergencies, individuals who experience severe depression and suicidal ideation: thoughts about ending their lives or thoughts about not wanting to be around, as well as individuals who experience severe psychiatric emergencies that cause them to become a danger to others, end up being hospitalized psychiatrically.

Usually these emergencies happen when either the individual comes voluntarily to a hospital, to a hospital emergency room for psychiatric admission, or families notice the psychiatric and acute need of their loved one, whether they are becoming suicidal and verbalizing that they want to end their life or whether they’re becoming dangerous to others.

Sometimes even these individuals come to the attention of authorities, police, ambulances, or fire departments that end up bringing them to the hospital for inpatient psychiatric admissions. Around the country here in the U.S., the regulations and the laws about inpatient psychiatric admissions vary from state to state, but the majority of states mandate an inpatient psychiatric admission if somebody is exhibiting tendencies to harm themselves or harm others, as well as being unable to care for themselves.

We have a patchwork of laws, state laws around the country that also mandate involuntary psychiatric hospitalization if somebody is unable to care for themselves or if somebody is exhibiting thoughts about suicide or thoughts about harming somebody else, situations where an individual is hospitalized involuntarily to an inpatient psychiatric hospitalization.

We have seen over the last thirty years that there has been a significant decrease in our capacity in terms of inpatient psychiatric beds. Patients were being hospitalized less and less. This movement started even sixty years ago where the state hospital system was dismantled. We rarely now have state psychiatric hospitals in different states.

We are seeing that this tendency of hospitalizing individuals has somewhat gone by the wayside. Individuals are managed on an outpatient basis, but still some people will require inpatient psychiatric care. We have seen trends where that has decreased, and we’re seeing a lot of pressures in terms of whether to hospitalize somebody or not to hospitalize somebody. And I, as an inpatient psychiatric provider for many years, wrote about these pressures. These are societal pressures, these are insurance pressures, these are government pressures, and we as physicians who manage inpatient psychiatric services are between a rock and a hard place with managing these competing needs for patients, insurers, government, regulators, and society.

That is an untenable situation for us.

Kevin Pho: You mentioned that you, yourself, are caught in a situation as an inpatient psychiatrist. Talk to us about some of these decisions that pull you in multiple different directions from a practical standpoint, so we can really just see that in action.

Muhamad Aly Rifai: Sure. One situation is a scenario where a family brings a loved one who is experiencing a psychiatric emergency, whether they are experiencing thoughts about self-harm or they’re experiencing suicidal ideation, and the family is concerned about their loved one. But when the loved one is interviewed by the psychiatrist or by the emergency room staff, they disavow that notion that they’re having suicidal thoughts, while the family is concerned about them, that they have verbalized suicidal thoughts.

That creates such pressure. The family wants them hospitalized. The person feels that they’re OK to go home and that they’re safe. Sometimes the family resorts to doing a legal petition to see if they can keep their loved one because they’re concerned about their safety, while the person who is experiencing the symptom says, “I’m OK. I should be OK.” That’s usually a difficult situation.

I talked in the article also about families that feel that their loved one needs to be hospitalized, and the hospital evaluates the person and doesn’t see that they meet any criteria for hospitalization. A person may have verbalized suicidal thoughts but now they’re doing much, much better. I referenced in the article a piece by ProPublica which talks about how some patients that need to be hospitalized were not hospitalized and that the family wasn’t happy about that. The patient may or may not have had bad outcomes, but that hospitals turn away people who are in need of psychiatric hospitalization.

It’s usually an evaluation, and whether the person needs psychiatric hospitalization or not is related to laws and regulations.

I’ve also talked about a situation where government regulators, the Department of Justice, sanctioned a group of hospitals because the government says that they were hospitalizing people that did not need to be hospitalized or they were keeping them in the hospital longer than they needed to. That’s another part of the equation. The family wants you to hospitalize their loved one. The loved one may not want to be hospitalized. You end up caving to some of that pressure and you keep the person in the hospital, and then the government regulators come and say, “Well, this person didn’t need to be in the hospital. They should have been discharged sooner.”

You have significant pressure of no place for the person to go, or the family that is saying, “No, no, no, our loved one is still suicidal, still a danger to themselves. You shouldn’t be discharging them.” Then the government regulators, the Department of Justice, the payers come and they tell you, “No, no, no, no. You should have discharged this person earlier.”

These are all competing needs. Sometimes the patient’s best interest is not the top priority; sometimes it’s insurance payments, sometimes it’s family, sometimes it’s societal needs. That’s one of the difficult situations that we face on a daily basis.

Kevin Pho: When the government comes in and says this patient doesn’t need to be hospitalized, on what grounds do they base that decision?

Muhamad Aly Rifai: That’s a very good question. A variety of factors that they consider. Sometimes they just look at the diagnosis of why the person was hospitalized and they say, “Well, our data says artificial intelligence looked at large data sets and thinks that a good number of days for a person with this diagnosis is five to seven days. The person has been in the hospital for ten days now.” Individualized care is very important. Not everybody needs only five to seven days. Some people need ten days, some people nine days, some people fourteen days.

The government and insurers are utilizing AI to do a cookie-cutter care, a level of care. Other scenarios are if there are any complaints. If families are complaining, the government comes and basically does a statistical analysis and says, “OK, we think 30 percent of your admissions needed to leave sooner. That’s it. Pay us back.”

We see a variety of scenarios where the government is just arbitrarily asking or saying that these individuals don’t need inpatient psychiatric hospitalization. While on the ground, these individuals need significant psychiatric hospitalization, and sometimes that leads to difficult scenarios.

For example, for individuals who have Medicare, a facility may tell a patient, “Listen, we don’t have any criteria for us to keep you in the hospital.” An individual has the right to appeal to Medicare and say, “I don’t want to be discharged from the hospital, I think I need to stay in the hospital.” Then the person gets an opportunity for an appeal for Medicare to review the decision to discharge them.

There are some opportunities for individuals where they feel that they’re not getting appropriate care or they’re not getting enough care for them to appeal and ask the government to intervene on their behalf.

Kevin Pho: It sounds like this issue regarding the competing priorities is multifactorial. What are some reforms or fixes that you would suggest to alleviate some of this pressure on inpatient psychiatrists?

Muhamad Aly Rifai: What we need to do is enforce the existing laws that we have, and these laws involve: fairness as well as speed and providing appropriate care. We also have to protect patients. The patient is the number one priority, and what’s happening is that other competing needs: payers, family, society, other things are trumping the patient needs.

We need to also bring in transparency to utilization review because insurers as well as the government just have these arbitrary reasons to hospitalize or not hospitalize a person or discharge them, and there’s no transparency. We don’t know why the patient was hospitalized or why the patient was discharged.

We also need to invest and increase the inpatient psychiatric bed capability as well as what we call post-discharge capabilities, such as subacute units. These are units where the person is not per se in a psychiatric inpatient bed, but they’re at just a step-down level where they could receive some psychiatric care, but they’re not at the level of an inpatient psychiatric hospitalization.

We must also center on focusing on patient dignity and patient rights and ensure that we are doing right by our patients, because that’s not happening right now in this system where patients are just shuffled very, very quickly, and there are other competing needs that are not priorities in our care.

Kevin Pho: We’re talking to Muhamad Aly Rifai, psychiatrist, internist, and addiction medicine specialist. Today’s KevinMD article is “The crisis in inpatient psychiatric care.” Muhamad, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Muhamad Aly Rifai: This tension that we’re seeing in competing priorities for inpatient psychiatric care is real. Sometimes we turn people away. Some worry that if we turn people away, we may break the law. If we keep them longer, you may harm them. You may break other laws and invite government enforcement. Sometimes insurance companies will hide the coverage and the reason for hospitalization behind algorithms, and this robs patients from care that they need and that they have paid for.

We can replace this tension with a different tension. We can call for accountability and pair that with compassion, transparency, and support for patients as well as a scientific approach to patient care and inpatient psychiatric care that prioritizes patient needs and dignity to ensure that patients and their families continue to trust the system.

Kevin Pho: Muhamad, thank you again for sharing your perspective and insight. Thanks for coming back on the show.

Muhamad Aly Rifai: My pleasure. Thank you.