The Shumlin administration Wednesday made it exceptionally clear that it opposes a game-changing idea to have a new 25-bed state mental health facility in central Vermont run by two big hospitals instead of by the state.
Yet lawmakers who listened to Secretary of Administration Jeb Spaulding didn’t seem ready to slam the door on the idea, which potentially could save a huge sum in annual operating costs by skirting a federal Medicaid funding restriction. It would also address strong concerns that the state’s proposed 16-bed facility is too small to meet needs in the northern part of the state.
Spaulding, while he praised the “spirit in which this proposal has been put forth” by Central Vermont Medical Center and Fletcher Allen Health Care in Burlington, left no word unturned in rejecting the idea, which he said could “derail” the urgent legislative process to create a new mental health system.
“We do not support the proposal and the reasons are pretty straightforward,” he told members of the Senate Health & Welfare Committee, which is considering a House-passed bill to revamp the state’s mental health system. He also said he was “very, very reluctant” to have the two hospitals run the facility.
Spaulding said not having at least one state-run acute care hospital to replace the flooded-out 54-bed Vermont State Hospital was a very bad idea, declaring that “to completely outsource to third-party vendors is very risky.”
The administration’s plan, most of which was adopted after lengthy debate in the House, called for 41 acute care beds to be geographically spread out among the Brattleboro Retreat, Rutland Regional Medical Center and a new state-built and state-run facility in Berlin next to CVMC, as well as five beds that would handle patients under court jurisdiction at a site to be determined.
Lawmakers in the House, after listening to extensive testimony from psychiatric experts and mental health administrators and advocates, bumped the Berlin facility from 16 to 25 beds but mostly backed the rest of the plan, including a major strengthening of regional community mental health services.
If the hospitals’ plan was adopted, it would mean all the acute care beds would be in private facilities under state contract. “It’s not wise to put all our eggs in the third-party basket,” said Spaulding. “It’s critical for the state to be in the driver’s seat on one of these facilities.”
He did not spell out why, but concerns have been expressed in House discussions that at least one acute care facility should be under state control to take the most disruptive, violent and difficult cases – essentially a place of last resort. There are also legal, access and privacy issues with private facilities, which the House bill wrestled with and addressed.
Another issue could be the fate of some 240 state employees who worked at the closed state hospital, who face a difficult employment situation. Many are dispersed around the state working at hospitals and other psychiatric facilities that are handling patients who would formerly have been in Waterbury. Presumably a state-owned hospital would provide at least some of them continued state employment.
Spaulding further warned that getting into discussion over the hospital’s proposal “would seriously disrupt the timeline we are on” to pass bill H.630 restructuring mental health, which is on a fast track as the state tries to address the crisis caused by loss of the 54 beds at Waterbury.
Spaulding said the administration was “anxious” to have the bill passed and said the hospitals’ plan was “not a productive discussion at this point.”
However, CVMC CEO Judy Tarr Tartaglia, who sat unruffled at Spaulding’s elbow and listened as he shot down the two hospitals’ idea, reiterated her strong belief that having the two hospitals operate the state facility would assure enough beds were built, save the state money in operating costs and provide “a huge opportunity to do it right.”
While stressing that she supports the administration’s overall revamp of mental health care and both sides have had amicable discussions, she said staff in both hospitals strongly felt at least 25 beds were needed. She said the offer to run them under hospital license was made to get around the federal Medicaid reimbursement limit to 16 beds and meet the need.
“All we want to do is help,” she said, joking she was not “a bed queen” out to build an empire. Under questioning she admitted some staff think even more than 25 beds are needed in northern Vermont, but said, “I think 25 is a number we could live with.”
Tartaglia noted that 70 percent of the state’s population lives in the northern part of the Vermont, yet the 14 beds proposed at Brattleboro Retreat and six at the Rutland hospital are all in the southern part of the state. She said “right-sizing” of the hospital was critical and 16 beds was not enough.
To punctuate that point, she told lawmakers that last weekend alone, Central Vermont Medical Center had enough patients that needed acute level I crisis care “that we could have filled the (16-bed) facility by half.”
Rutland and Fletcher Allen, which both have their own psychiatric wards, as well as Brattleboro Retreat have reported similar spikes in demand for crisis help as the state copes with a shortage of mental health crisis beds in the wake of the state hospital’s closure Aug. 29 from flooding.
Dr. Peter Tomashow, medical director at CVMC, said while the need for more beds was a “great concern,” the advantages of running the facility under the hospitals’ license go much further. He said the two hospitals want to establish a “flagship” facility that would use the alliance with Fletcher Allen and the resources that come from a teaching hospital allied with the University of Vermont medical school, to offer expert acute stabilization, care, treatment and medical care as well.
The Vermont State Employees Association said the hospitals were right in trying to get more beds built but it is opposed to having them operate the facility.
“It would be unprecedented to completely privatize the mental health system,” said Conor Casey, legislative director for VSEA.
“It’s a public policy issue. We think there needs to be some state control for people who are involuntarily committed,” he said, citing legal, privacy and jurisdictional concerns about how a contracted mental health hospital would work.
At the same time, Casey said the VSEA strongly supported the House’s decision to write the bill for 25 beds rather than 16, saying the hospitals were right in being concerned the Shumlin administration is beigh short-sighted.
“Almost every leading mental health professional in the state has said 25 beds is what we need,” he said.
Spaulding admitted at one point that the state’s rationale for the disputed 16-bed hospital was based on fiscal concerns, noting “for us dollars are finite.” “Probably there is no magic number (of beds),” he said. But he lobbied for the administration’s 16-bed proposal, saying action was needed now. He said when the new community mental health system was up and running and data was available, he was open to “taking a more deliberative and more considered look” at what the right size was.
The new facility is not expected to be built for two years or more, giving the state time to look at the issue next legislative session.
However members of the committee appeared interested in the hospitals’ proposal both because of the increased beds and the fact it assures a pot of federal financing for patient care. At the same time they had questions about what would happen to state hospital employees and the legal questions raised by outsourcing care.
Chairwoman Sen. Claire Ayer, D-Addison, asked Spaulding and Tartaglia if they were open to legislation that called for a range of beds in the proposed facility, such as 16 to 30, and taking up discussion in the future on the hospitals’ idea when Vermont has a better handle on its mental health reorganization and firm data on need.
That produced what was not exactly a Kumbaya moment. Tartaglia said she liked the idea. Spaulding paused awkwardly, and then said, “We’ll think about it.”
If the administration wins the tug of war and the Senate agrees to scale back to 16 beds, it could tie up the bill in a feisty conference committee between the two legislative bodies, said Rep. Anne Donahue, R-Northfield. Donahue was deeply involved in the debate over the size of the hospital and stressed the House bill passed by a huge 124-3 vote. She said pushing back to 16 beds would cause a big fight that would defeat efforts to get it passed quickly. She also said the hospitals’ idea had merit as an option to fund operation of a 25-bed facility.
“I do think the size is critical,” she said.
Democratic House Speaker Shap Smith said the Legislature hopes to have the bill out by Town Meeting Day.
This story was updated on Feb. 16 at 2:27 p.m. with comments from Conor Casey.
