An unexpected victory was awarded last month to the Vermont Psychiatric Association (VPA) and a large coalition of mental health clinicians, patients, and patient advocates led by the VPA when state regulators refused to back a proposal by Fletcher Allen Health Care in Burlington to segregate its inpatient psychiatric service from its main campus. Ultimately, the hospital withdrew its application for approval of the controversial project before state regulators could formally act on the panel’s recommendation.
Reaction from the members of the coalition was summed up by David Fassler, M.D., who serves on the executive committee of the VPA and is an APA trustee-at-large.
"It is a good day for mental health in Vermont!," Fassler told Psychiatric News.
Fassler is a child and adolescent psychiatrist in Burlington and a clinical associate professor of psychiatry at the University of Vermont College of Medicine (UVM) for which the Fletcher Allen facility is the primary clinical education site. Fassler was one of 12 Vermont psychiatrists who testified before the state regulatory panel. Their concerns were further supported by Stephen Bartels, M.D., M.S., an associate professor of psychiatry at Dartmouth and medical director for the State of New Hampshire Division of Behavioral Health, and Philip Muskin, M.D., a professor of clinical psychiatry at Columbia University and chief of consultation-liaison psychiatry at New York Presbyterian Hospital.
The dramatic reversal on the part of Fletcher Allen Health Care—a conglomerate made up of Fanny Allen Hospital, the Medical Center Hospital of Vermont, and the University of Vermont Medical Center—comes nearly two years after psychiatry faculty at UVM wrote a strongly worded memorandum to Fletcher Allen administrators opposing the plan to move the psychiatric inpatient unit off the hospital's main campus to the Fanny Allen campus, four miles away (Psychiatric News, May 18, 2001, and November 16, 2001).
The Fanny Allen campus has limited services available—it is primarily composed of a rehabilitation unit and an outpatient surgery center—and would have resulted in a dramatic reduction in the quality of patient care and compromised patient safety, according to the VPA coalition.
In addition, the coalition was concerned about the stigma associated with isolating psychiatric patients from the main hospital, as well as restrictions on what types of clinical services would be available at the Fanny Allen campus, which is leased by Fletcher Allen from a Catholic religious order based in Canada.
When the UVM faculty's concerns appeared to fall on deaf ears with Fletcher Allen administrators, they asked VPA for assistance a little over a year ago. VPA ultimately helped build a coalition of patients, patient advocacy groups, and interdisciplinary professional groups and even enlisted the aid of the Vermont chapter of the American Civil Liberties Union.
After more than 16 hours of often tense and impassioned testimony during a two-day public hearing, the Vermont Department of Banking, Insurance, Securities, and Health Care Administration’s Public Oversight Commission (POC) voted unanimously to recommend to Elizabeth Costle, the agency’s commissioner, that the hospital’s proposal be denied. Costle had till the end of June to issue a final decision; however, on May 15 Fletcher Allen Chief Executive Officer Bill Boettcher informed Costle in writing that the hospital was voluntarily scrapping the proposal.
Although Fletcher Allen officials were unavailable for an interview with Psychiatric News, Boettcher was quoted in a prepared statement as having said, "The POC voted its recommendation, and we're taking their lead."
Fletcher Allen administrators now say that the inpatient mental health service will be relocated within the main campus.
During the first day of testimony, on May 1, Fletcher Allen officials reiterated their long-held claim that within the hospital’s massive Renaissance Project—a $225 million campuswide renovation—there simply was no room to keep the psychiatric unit on the main campus, integrated with the rest of the medical and surgical services. Under the plan, the psychiatric unit was the only service to be moved from the campus. The officials have repeatedly described the $10.7 million Fanny Allen replacement unit as quiet and serene with good views of the surrounding mountains and ample space for patients to enjoy an outdoor exercise area.
The remainder of the testimony on May 1 and continued on May 8 centered on those opposing the Fletcher Allen plan.
"We do not need to walk outside to a serene and beautiful plot of grass with a spectacular view," Todd Centybear, executive director of the Howard Center for Human Services, told the POC commissioners. The Howard Center is Fletcher Allen’s primary partner in mental health services in the Burlington area. Centybear told the POC that what mental health patients need is integration and interaction with their community and the availability of education and growth during recovery.
Ken Libertoff, Ph.D., executive director of the Vermont Association for Mental Health, testified that although there are "more than a dozen reasons" for opposing the plan, he could summarize them by saying that the plan is "flawed in concept, flawed in policy, flawed in design, flawed in clinical assumptions, and flawed in its basic disrespect for Vermont values involving the need for parity, integration, and collaboration between and among all key stakeholders."
Fassler presented testimony on behalf of VPA and the faculty of UVM. He noted that for the last year, VPA was aware of a climate of threats of retaliation and intimidation from the Fletcher Allen administration, attempting to keep faculty members from speaking out against the hospital’s plan (Psychiatric News, May 18, 2001).
"No one denies that the Fletcher Allen proposal would be physically attractive with nice views," Fassler concluded, "but no amount of architecture can really make up for the insurmountable clinical and programmatic flaws inherent in this plan. We can and must do better for patients with psychiatric illness."
It was the dramatic appearance, however, of four senior psychiatry faculty members at the POC hearing that culminated in the commission’s unanimous vote against the hospital.
Richard Bernstein, M.D., director of inpatient services; Paul Newhouse, M.D., director of the Clinical Neuroscience Research Unit and the geriatric psychiatry service; Terry Rabinowitz, M.D., director of the consultation-liaison service; and G. Scott Waterman, M.D., director of medical student education, approached the witness table together. Fletcher Allen officials appeared to be taken by surprise, observers told Psychiatric News. (More information on the four psychiatrists, and APA’s reaction to their stand, will appear in the next issue.)
"News of our absence has been greatly exaggerated," Waterman began, paraphrasing Mark Twain.
Waterman noted that the faculty’s absence from the proceedings had been portrayed as either apathy or even support of the proposal, but cautioned that "if anyone were to infer that the physicians in our department are divided, unsure, or ambivalent" about the hospital’s plan, they would be mistaken.
"We have been and continue to be united in our view that approval of the hospital’s proposal would be a tragic error," Waterman testified, "with adverse consequences that span the clinical, educational, and training functions of our department and clinical service."
In light of the tremendous amount of opposition to the plan, Waterman asked the POC, "Can such an avalanche of highly informed opinion be ignored?"
Commission members appeared to be overwhelmed by the vehemence of the faculty’s opposition. One member asked the faculty, "Why were you silent until now?"
"Internally we weren’t the least bit silent," Waterman said. "Our voices were raised in the [UVM faculty] memorandum. They certainly weren’t listened to."
Commission member Glen Gershaneck praised the faculty for their willingness to come forward and testify publicly, when it could be "considered a risk to bite the hand that feeds them."
"I am perplexed and astonished and disgusted that it reached this point," he said.
Other witnesses also testified as to the perception that Fletcher Allen wasn’t listening, including Vermont State Rep. Tom Koch, who chairs the state House Health and Welfare Committee.
"What we have here is an 800-pound gorilla that has announced that it will sit where it damn well pleases," Koch declared. "This commission can smile while the gorilla is seated, or it can tell it to get up, go back to the planning stage, and come in with a proposal that will truly meet the needs of Vermonters who are in need of behavioral health services."
That is precisely what Fletcher Allen officials are now doing.
"In concert with the UVM College of Medicine, our psychiatric faculty, and the mental health community," Fletcher Allen CEO Boettcher said in his statement, "We are starting the work of developing an interim solution, as well as beginning the dialogue about the long-term permanent location for the inpatient psychiatric unit."
The coalition of advocates is remaining cautiously optimistic, however, noting that it will be difficult to work the unit back into the overall scheme of the mammoth Renaissance Project. The coalition had previously identified several options that Fletcher Allen was not willing to consider. Those options will now be reviewed, advocates suspected.
The two-year saga that some have come to refer to as "fighting the big bad Fanny," is certainly not over. But the diverse advocates making up the VPA-led coalition paused briefly to bask in their victory.
"I really do believe this is a watershed decision with national significance," Peter Youngbaer, executive director of the Vermont Coalition for Disability Rights, told Psychiatric News. "Vermont does indeed lead the way—once again. How can any psychiatric unit again be proposed in this country without the meaningful input of all affected stakeholders? This was very empowering for all involved, but only because we stood together."
Information on Fletcher Allen and its Renaissance Project is posted on the Web at www.fahc.org. ▪