Psychiatrists’ Protest Raises Stakes on Unit’s Future

After months of stonewalling, Fletcher Allen Health Care executives in Burlington, Vt., agreed in October to sit down with opponents of their controversial plan for a new, segregated, inpatient psychiatric unit and look for viable alternatives.

At a meeting on November 7, however, representatives from a broad-based coalition, led by the Vermont Psychiatric Association (VPA), presented three options to keep the unit on the main campus of the state’s largest medical center. Hospital representatives reportedly balked at each of the alternative plans, citing concerns over appropriate size or cost, and suggested they may have to abandon psychiatric care altogether.

Fletcher Allen plans to relocate its inpatient psychiatric unit to a separate facility, known as the Fanny Allen Campus, three and a half miles from the main campus. This will make room for a nearly $200 million expansion featuring a state-of-the-art ambulatory care facility (ACF) (Psychiatric News, May 18). The building currently housing psychiatry must be demolished by late 2003 for the ACF project to stay on schedule, which would require ground breaking on the Fanny Allen replacement facility to occur no later than March of next year.

“Fletcher Allen is going through the motions of analyzing new options, but has made it clear that it does not think any of them will work,” said Anne Donahue, who attended the meeting. Donahue, a mental health advocate and editor of Counterpoint, a local patient advocacy newspaper, has worked extensively with the VPA-led coalition. “Fanny Allen is the only solution that Fletcher Allen executives intend to pursue to keep their outpatient center construction on schedule,” she told Psychiatric News.

Hospital executives have repeatedly said there simply is no space available for the psychiatric unit anywhere on the main campus. Indeed, when Fletcher Allen CEO Bill Boettcher testified before the Vermont House Health and Welfare Committee on August 10, he characterized the Fanny Allen location for the new unit as “not negotiable.”

In spite of these assertions, those same executives recently increased the total space planned for the ACF by some 35,000 square feet in a recent update filed with state regulators.

Fletcher Allen executives declined to be interviewed by Psychiatric News for this article.

APA’s Concerns

The VPA-led coalition fighting the hospital’s plan recently received strong support from APA and the American Civil Liberties Union (ACLU).

The ACLU’s move followed a letter by APA Medical Director Steven Mirin, M.D., to state regulators in which Mirin expressed APA’s “serious concerns.”

In a letter written in August to Susan Gretkowski, deputy commissioner of the Vermont Department of Banking, Insurance, Securities, and Health Care Administration (BISCHA), Mirin expressed APA’s concern that the hospital’s plan was a step backward in terms of quality of care.

“Separating psychiatry from the main hospital,” Mirin wrote, “would unnecessarily increase the need for patient transport [between the two campuses], with the attendant disruption of treatment, potential emotional trauma, and increased risk of injury to both patients and staff.”

Mirin also expressed APA’s concern with the proposed staffing pattern for the new mental health facility, in which the inpatient psychiatric unit’s 31 beds, in addition to other inpatient rehabilitation beds located on the remote campus, would be covered by a single family practice physician “on site” overnight and on weekends.

“Surely, a single family practitioner,” wrote Mirin, “should in no way be considered comparable medical care to a fully staffed general hospital in an acute medical emergency. In this regard, the present proposal would appear to represent a significant and disturbing reduction in patient safety and overall quality of care from the current situation.”

Mirin urged Gretkowski and the Public Oversight Committee of BISCHA “to carefully scrutinize this proposal and to defer any decision to declare the [hospital’s] application [for approval of the project] complete unless and until all information has been obtained concerning the many outstanding issues and concerns.”

Fletcher Allen executives responded to Mirin’s concerns by inviting him to visit Vermont and see firsthand the merits of the hospital’s proposal.

Gretkowski’s office stepped up its scrutiny of the hospital’s proposal after receiving Mirin’s letter. In the week following the letter, Gretkowski issued a list of more than 20 questions to Fletcher Allen, many of which directly addressed APA’s concerns.

Lease Complications

Other significant concerns have been raised as well. The Fanny Allen campus is owned by the Fanny Allen Corporation, which appears to be a wholly owned subsidiary of Covenant Health Systems. Covenant, in turn, as a “public juridic person,” is an entity of the Roman Catholic Church and reports directly to the Vatican. Direct ownership and management of the property have been difficult to pin down because of a number of “umbrella” and subsidiary corporations and foundations tied to Fanny Allen.

Several players in the controversy, including Gretkowski’s office, have repeatedly asked Fletcher Allen to spell out the church’s precise role in the ownership and management of the campus and whether church teachings would influence the scope of care offered on site.

After numerous requests by Gretkowski’s office and months of refusals by Fletcher Allen, the hospital turned over a copy of its lease agreement for use of space at Fanny Allen. The lease contains a clause that restricts activities on the campus to those sanctioned by the “Canon or other law of the Roman Catholic Church,” as well as any pertinent directives for Catholic health care facilities approved by the National Conference of Catholic Bishops and enforced by the Bishop of Burlington.

Several psychiatrists have voiced concern that they would not be able to counsel their patients regarding emergency contraception (for example, “the morning-after pill”) or other means of preventing pregnancy. Both Fletcher Allen and Covenant have denied that the church’s teachings on birth control would affect patient care, claiming that a psychiatrist’s counseling of a patient is protected by the doctor-patient privilege. Experts in interpretation of Canon law, however, have told the VPA-led coalition that such activities would clearly be restricted under the directives.

Contrary to these denials, one psychiatrist told Psychiatric News that he knows of two female patients seeking birth control or emergency contraception at Fanny Allen that were turned away from the existing walk-in clinic, having been told that they could not get “that kind of care here.” Fletcher Allen executives would not comment to Psychiatric News on these allegations.

It was concerns over possible religious restrictions that prompted the ACLU to become involved in the Fletcher Allen project.

“We are concerned that the legal arrangements between the two hospitals will incorporate the religion-based directives under which Fanny Allen operates,” Benson Scotch, executive director for ACLU in Vermont, told Donahue’s Counterpoint newspaper. “This could result in the loss of some critical, constitutionally protected health care functions. Health care services for women will be particularly at risk.”

Awaiting Final Answers

In an e-mail between hospital representatives and coalition members, hospital CEO Boettcher, in spite of his previous stance, gave the best indication that the hospital might be open to looking at options when he wrote, “If the discussion yields a workable location on the main campus, we will build [the psychiatric unit] there.”

The three options reviewed during the November 7 meeting identified ample space to keep psychiatry on the main campus, some of which was reserved for future development. Fletcher Allen representatives maintained that each of the alternatives did not offer enough contiguous space or was too costly under the currently approved budget.

The coalition, led by the VPA, had been cautiously optimistic. But following the meeting, members of the coalition are now gearing up for an even tougher fight.

During that meeting, hospital representatives were reminded by coalition members that the current building housing psychiatry, known as Smith, could not be demolished without a replacement facility available. If Smith is not torn down according to the current construction schedule, by November 2003, construction on Fletcher Allen’s overall “Renaissance Project”, including the ACF, could be significantly delayed. In order to have the Fanny Allen replacement unit ready for psychiatry to vacate the Smith building on time, Fletcher Allen must break ground on the Fanny Allen facility by the beginning of March 2002. That would require Gretkowski’s office to give approval to the project by the first week in December in order for the state’s Public Oversight Commission to review the project and give final approval.

Meg O’Donnell, a former state regulator hired by the hospital to manage the regulatory approval of the project, concluded the November 7 meeting by saying that if a workable solution could not be found to meet the March deadline to break ground at Fanny Allen, the hospital may have to rethink its involvement in psychiatric care altogether.

“We would hope that the state would not approve of Fletcher Allen’s abandoning psychiatric care,” Donahue told Psychiatric News. In addition, the Fletcher Allen facilities serve as the primary clinical site for the University of Vermont School of Medicine. “I would think that the University of Vermont would not approve an elimination either,” she added.

Information on Fletcher Allen Health Care’s Renaissance Project is posted on the Web at www.renaissanceproject1.net. ▪