FAHC, CVMC propose joint mental health facility

Editor’s note: Erin Hale, an intern with VTDigger.org, contributed to this story.

Vermont State Hospital. VTD/Josh Larkin

Vermont’s effort to build a new state mental health hospital in central Vermont has taken an unexpected and potentially money-saving twist.

Central Vermont Medical Center in Berlin and Fletcher Allen Health Care in Burlington have proposed jointly operating a new facility on the campus of CVMC, making it a national model for mental health treatment. The offer would dramatically alter Vermont’s proposal to build and run a state-owned facility, instead having it be under hospital auspices with a state contract.

The move could have huge fiscal benefits under federal rules and many treatment benefits as well, hospital officials said.

CVMC CEO Judy Tarr Tartaglia Monday confirmed that the two hospitals, which are affiliated together under Fletcher Allen Partners, have proposed creating “a center of psychiatric excellence as part of an academic medical center.”

By joining forces the two medical centers would provide a wealth of expertise and resources that comes from having two large hospital staffs, as well as access to residency programs and medical students from Fletcher Allen, which is a teaching hospital associated with the University of Vermont.

She said she and new Fletcher Allen CEO Dr. John Brumsted have had “extensive conversations” about the idea and said it would resolve a number of concerns raised by the mental health community, foremost that the 16-bed facility proposed by the state – dictated by a size limit for federal Medicaid reimbursement – is too small for the needs of northern Vermont.

“Our clinicians feel strongly that 16 beds in the north-central part of Vermont is simply not enough to take care of this population of patients,” she said. “I think it would be a mistake to build less than 25 beds,” she said.

That view is widely held among professionals at the state’s private hospitals and even Dr. Jay Batra, the medical director at the Vermont State Hospital, who testified before the Legislature that he felt a 48- to 50-bed hospital with four separate units was needed.

While still in a conceptual stage, the hospitals’ plan could help to resolve an agonizing legislative debate over how many acute care mental health beds to build in central Vermont, and potentially remove uncertainty about the loss of Medicaid funding for the patients it would serve. Representatives in the House approved a plan for 25 beds, and now the Senate is weighing a 16-bed option.

Tartaglia said the two hospitals have broached the idea with state Mental Health Commissioner Patrick Flood and administration officials, and the proposal remains a “concept and there would be a lot of details to be worked out.”

The Shumlin administration, however, insists that a 16-bed facility is best for the state and opposes the hospitals’ plan. Administration Secretary Jeb Spaulding said he and other administration officials had discussed it with the hospital officials last week and the governor immediately rejected the idea. “We think the state needs to be in control of its own destiny with a facility of last resort,” Spaulding said. “To put it on their license is not something we entertained for any more time than it took them to tell us about it.”

Vermont has been struggling with a crisis in mental health care since the Aug. 28-29 flood from Tropical Storm Irene caused the evacuation of the 54-bed Vermont State Hospital in Waterbury, eliminating the primary facility treating those in severe crisis. The administration of Gov. Peter Shumlin is pushing hard in the Legislature to enact a dramatic shift to community treatment and replacement of the 54-bed state hospital with 14 beds at the Brattleboro Retreat, six at the Rutland Regional Medical Center, and a state-operated 16-bed facility in central Vermont, plus four beds for those under court supervision at a future site.

While most aspects of the governor’s plan have drawn praise, a major tug-of-war has erupted over the 16-bed facility proposal. Since December, lawmakers heard extensive testimony from experts and top clinicians in Vermont that a 16-bed facility was too small for the patient needs of the entire northern part of the state, and that the size was flawed because it would not be big enough to attract and keep staff, provide training and meet the program needs of its patients.

The testimony had an impact, and as a result, the bill (H.630) that passed the Vermont House Feb. 3 with strong support called for a 25-bed hospital in central Vermont. Lawmakers in the Senate Health and Welfare Committee are now considering the same issue and facing pressure from the Shumlin administration to revert to the 16-bed plan.

The wrestling match is primarily about money, due to an arcane federal rule that denies Medicaid funding for any standalone mental health hospital over 16 beds. The 1965 provision sought to limit the expenditure of federal dollars brought about by construction of big new mental health hospitals, and also reflected a shift in treatment models from big facilities with several hundred beds.

Vermont has a waiver until 2013 that allows it to provide Medicaid dollars for mental health treatment, but uncertainty over its extension has underlies the debate in the Legislature. Spaulding warned the Senate Health and Welfare Committee last Friday that the jump to 25 beds could cost $9 million more in annual operating costs to the state if the Medicaid waiver is not extended.

Tartaglia said the two hospitals felt strongly after listening to psychiatric staff that something needed to be done about the federal rules “hangup” that is limiting the new facility to only 16 beds. She said having the new facility licensed under the hospitals was a “creative way” to address the situation, since the federal funding limit doesn’t doesn’t apply when mental health services are delivered as part of a much larger medical hospital.

Dr. Peter Thomashow, medical director of CVMC, said having the facility affiliated with a hospital has important benefits in providing medical as well as psychiatric care.

“We feel it’s very important to have the new psychiatric hospital near a general hospital,” Thomashow said.

Dr. Robert Pierattini, chair of psychiatry at Fletcher Allen, agreed, noting patients with mental health issues often have medical issues that have to be dealt with. “It’s critical from our point of view, that there be an immediate medical response, not simply a rescue squad,” Pierattini said.

Fletcher Allen would also be able to use the new hospital as a teaching hospital, according to Thomashow.

“Since Fletcher Allen is tertiary care and academic medical center for the state of Vermont, they could provide an academic affiliation, because we feel very strongly that we need a center of excellence where there could be teaching and resource,” he said.

Two sites are being considered near CVMC, the most likely on the corner of Berlin Street and Fisher Road adjacent to the medical complex, according to Thomashow. The other is about a mile distant on state-owned land in a wetland area behind the Berlin Regional Library.

State building officials have said it could take more than three years to build the new facility but Spaulding said Friday he “doesn’t subscribe” to that extended timeline.

Whatever the building’s size, it will need Act 250 approval and a certificate of need approval from Vermont regulators, though some lawmakers have suggested an exemption or shortened process for the hospital to speed its construction.

Insurance claims money and FEMA funds are expected to pay for around 90 percent of the cost of building the hospital, which is estimated very roughly at around $1 million per bed. Under H.630, the state is directed to permit and design a 25-bed facility, but funding and a final size decision are not expected to be made until the next legislative session when the new mental health system has taken shape and data on need is available.

It’s unclear what impact the hospitals’ proposal would have on the aggressive timeline for the bill’s passage, but the bill would need to be amended to reflect the proposal if it gains traction and legal and oversight issues addressed if the state decides to let the hospitals run the facility. It is also unclear how the plan could affect the jobs of the 240 state hospital employees who are now dispersed around the state.

Spaulding urged lawmakers to act quickly on the mental health bill, saying “it’s a very turbulent and at times dangerous situation out in the state of Vermont right now.” His comments were echoed earlier in the week in the Senate Institutions Committee by Dr. Isabelle Desjardins, medical director of Seneca Center and Inpatient Psychiatry, a Fletcher Allen affiliate. She testified that the number of patients turned away while seeking treatment at Fletcher Allen has increased from 12-15 to 30-40 a month since Irene struck, though the hospital has increased its capacity to 95 percent. Desjardins explained this has placed enormous stress on patients and doctors, and negatively affected treatment.

“We have seen shift in the kinds of referrals we get. The referrals we get are consistently for the treatment of patients who are in the most acute phase of their illness, who do not live in the hospital,” Desjardins said. Many of the symptoms exhibited by these patients include an acute suicide risk, extreme levels of agitation, severe impairment of perception of reality, and high levels of aggression, she said.

With the state hospital closed, patients needing acute care are being treated at Fletcher Allen, Brattleboro Retreat and Rutland Regional Medical Center, but that has displaced treatment beds for those needing less acute help as well.

Flood, the state’s mental health commissioner, could not be reached Monday to comment on the hospitals’ plan.

Editor’s note: This story was updated with a new response from Jeb Spaulding, Administration Secretary.