National Trends in Inpatient Psychiatric Bed Supply, 2011 to 2023

Abstract

This cross-sectional study discusses trends in inpatient psychiatric bed supplies.

While most mental health care is delivered in outpatient settings, patients in crisis may require inpatient psychiatric care. In the US, patients receive this care in freestanding psychiatric hospitals and psychiatric units of general hospitals. However, there are ongoing concerns that demand for inpatient beds has outpaced supply. Psychiatric patients are disproportionately boarded in emergency departments,¹ and many general hospitals have closed psychiatric units.² Yet, there are signs of concurrently increasing for-profit activity, particularly expansions of large for-profit hospital chains.^3,4,5 While for-profit entry may alleviate access problems, it may also exacerbate concerns about safety and quality of care.^4,6 However, there is limited research on recent trends in psychiatric bed supply, including trends in large for-profit chains.

Methods

We combined 2011 to 2023 data from the Healthcare Cost Report Information System (HCRIS) and the American Hospital Association (AHA) Annual Survey. To identify freestanding psychiatric hospitals, we used HCRIS data supplemented by AHA data. We ascertained psychiatric beds in general hospitals from AHA data. We used HCRIS data to identify freestanding psychiatric hospitals that were members of large for-profit chains (systems with ≥15 psychiatric hospitals in 2023). The study was approved by Columbia University’s institutional review board and data were deidentified.

We first assessed changes in total bed supply, beds in freestanding psychiatric hospitals, and psychiatric beds in general hospitals. We grouped freestanding psychiatric hospitals by ownership type and decomposed the change in beds into net openings (from facilities opening and closing), net expansions (from changes in existing facilities), and net conversions (from facilities switching ownership types due to acquisitions).

Results

Total psychiatric bed capacity fell only slightly between 2011 and 2023 from 115 350 beds to 112 986 beds. However, the composition of beds shifted considerably, with shrinking capacity at general hospitals and growth of the freestanding hospital sector (Figure 1). Over this time, the share of beds at freestanding facilities rose from 65.3% (n = 75 285) to 74.4% (n = 84 102).

Figure 1. Psychiatric Beds at General Hospitals and Freestanding Psychiatric Hospitals, 2011 to 2023.

This figure depicts total psychiatric beds and separates the total into beds at freestanding psychiatric hospitals and psychiatric beds at general hospitals. Bed counts at freestanding psychiatric hospitals are sourced from the Healthcare Cost Report Information System (HCRIS) and supplemented by the American Hospital Association (AHA) for hospitals that did not appear in the HCRIS. Psychiatric bed counts are sourced from AHA data.

Among freestanding psychiatric hospitals, the increase was driven almost entirely by large for-profit chains. Bed supply in this group rose by 14 474 beds, from 11% (n = 8186) of all freestanding beds in 2011 to 27% (n = 22 660) in 2023. Growth was mostly due to the openings of new hospitals and acquisitions of existing facilities (Figure 2). Bed supply was stable among other for-profit and nonprofit hospitals, which represented 15% (n = 11 100) and 11% (n = 8166), respectively, of all freestanding beds in 2011, and 15% (n = 12 859) and 10% (n = 8082) in 2023. Government-owned beds decreased by 7333 due mostly to downsizing; government hospitals’ share of freestanding beds declined from 64% (n = 47 833) in 2011 to 48% (n = 40 501) in 2023.

Figure 2. Decomposition of Growth in Beds at Freestanding Psychiatric Hospitals 2011 to 2023, by Ownership.

This figure shows the sources of bed growth at freestanding psychiatric hospitals from 2011 to 2023. Each panel depicts bed growth for a different type of ownership. Net openings were defined as beds at facilities that opened during the period when fewer beds closed at that facility. Net expansions reflect the change in beds during the period when facilities stayed open during this time. Net conversions were defined as the beds at facilities that switched to the given ownership category and resulted in fewer beds at facilities that exited the ownership category.

Discussion

The decline in total bed capacity was driven by general hospitals and government-owned freestanding psychiatric facilities. Concurrent expansion of bed supply at freestanding facilities owned by large for-profit chains nearly offset that decline. Because government-owned facilities largely serve long-term patients, these results may imply an expansion of overall capacity for patients needing acute inpatient psychiatric care.

An earlier study showed increases in for-profit, chain-operated hospitals between 2011 and 2016.⁵ Our results show that growth in for-profit chains is ongoing and is not simply an artifact of the Affordable Care Act or federal mental health parity legislation. The supply of psychiatric beds is increasingly concentrated in large chains that have received media attention related to quality of care. Study limitations include the inability to measure scatter beds at general hospitals, possible inaccurate reporting of chain affiliations, and absence of information on the volume or quality of inpatient care.

The implications of these trends for quality of care merit rigorous study. Increasing the role of freestanding psychiatric hospitals may raise quality of care through specialization. However, given reports of safety concerns at large for-profit chains, our findings also underscore the need for research on the effects of growing corporatization of inpatient mental health care on patient outcomes.⁶

Supplement 1.

eMethods. Supplemental Methods Appendix

Supplement 2.

Data Sharing Statement