Hanover
That’s a question that remains without a full and satisfactory answer 18 days before the scheduled June 30 expiration of a contract under which Dartmouth College employs and supplies psychiatrists to the state’s main hospital for the mentally ill.
Although Dartmouth last week agreed to extend the current contract for four months, concerns remain about the welfare of the more than 150 patients, most of whom have been formally evaluated as posing a danger to themselves or others and who now live and receive care at New Hampshire Hospital, a state-owned and -operated facility in Concord.
Matt Davis, a NHH psychiatrist, described the situation as “potentially dangerous” and added: “It poses safety concerns for the staff here and the community at large.”
“The No. 1 worry is what if there are not enough psychiatrists to staff the hospital,” said Ken Norton, executive director of the New Hampshire affiliate of the National Alliance on Mental Illness, an advocacy group for patients and families. There are also concerns about the future quality of care at the hospital and about how changes may affect existing therapeutic and work relationships, he said.
The situation is a consequence of a sometimes controversial and painful restructuring by Dartmouth that began nearly a year ago to reduce growing deficits at its Geisel School of Medicine.
As part of the restructuring, Dartmouth prepared to remove from its payroll and operating budget hundreds of jobs in research and psychiatry and move them to Dartmouth-Hitchcock, the medical system affiliated with the college that has its own governance, management, operational and financial structure.
Included in the transfer was the five-year, $38 million contract under which Geisel employs the psychiatrists, who have faculty appointments, and some other professionals who work at NHH in Concord. The current five-year contract, which runs through June 30, was the latest in a series of deals that extended back to the late 1980s.
But the handoff has not gone as planned. The state has not yet awarded a new contract to D-H. And it appears that D-H may not yet have signed up the psychiatrists or other professionals it would need to deliver the contracted services.
New Hampshire Hospital, with 158 beds, is the anchor for a statewide system of health care services for an estimated 45,000 Granite State adults who suffer serious mental illness.
NHH is almost always full, with the only vacancies occurring in the “time lag between when a patient is discharged and a new patient is admitted,” said Jake Leon, a spokesman for the New Hampshire Health and Human Services Department.
Outside NHH, more patients need care. On Wednesday, 47 patients sat in hospital emergency rooms, jails and other facilities not designed to provide mental health care waiting for space to become available at the state hospital, he said.
There, uncertainty about how many psychiatric professionals will be available starting July 1 has put added pressures on caregivers. “A system that usually works under stress is under even more stress,” said Lisa Mistler, a psychiatrist at NHH.
In April, eight psychiatrists and four advance-practice psychiatric nurses refused to sign letters of intent to go to work for D-H, according to Davis. The medical center subsequently withdrew its offers of employment to those professionals. At least seven psychiatrists, including two in management, signed the letters, he said.
At issue, according to some of the affected psychiatrists, was D-H’s refusal to spell out the salaries, vacation, insurance, retirement plans and other terms it would offer its new employees. D-H officials, citing their pending bid, were not available last week to discuss their relations with the NHH psychiatrists.
The existing staff at first had “no reason to be cynical or skeptical” about D-H taking over as their employer, said Davis, a NHH psychiatrist who was a leader in a unionization drive by hospital professionals. They were told to expect a “seamless transition” and assured that “everybody would be kept whole,” he recalled.
But things changed in early March, according to documents filed with the National Labor Relations Board. On March 11, Alan Green, chair of the psychiatry department at Geisel, met with four NHH psychiatrists and asked them to commit to work for D-H if it should win the contract. “The four declined to sign the letters of intent on the ground that they do not know the terms and conditions of employment that they are being offered,” an NLRB official wrote.
A particular irritant, according to Davis, was the discovery that about half of the affected psychiatric professionals hadn’t worked the three years required to become vested and would lose the accumulated employer contributions to their retirement accounts. Some individuals stood to lose tens of thousands of dollars each, “People were really quite upset by that,” Davis said.
Meanwhile, the state of New Hampshire had issued a formal “request for proposals” for a three-year contract to provide “physician clinical and administrative services” at NHH. The Feb. 25 notice said the bidder must be an academic medical center or affiliated with one. That seemed to leave the field to Dartmouth-Hitchcock, which is affiliated with the college that is home to the state’s only medical school.
But the notice also said that a bidder must have letters of intent from qualified candidates for all 40 positions that needed to be filled. And the deadline to submit “technical and cost bids” was April 15.
That put the onus on D-H. It needed to show it had qualified candidates for the positions to be covered under the contract. So as the deadline approached for D-H to submit its bid, Green and three D-H executives traveled to Concord to meet with the psychiatrists and psychiatric nurses at NHH.
It quickly became clear that the purpose of the meeting was to get signed letters of intent, according to some psychiatrists who attended. Attendees were frustrated that the delegation didn’t answer questions about the salary ranges that D-H would offer and how its takeover would affect vacation calculations and unvested retirement contributions, they said.
D-H officials were not available to comment.
By the time of that meeting, some of the psychiatric professionals at NHH had submitted a petition to the NLRB seeking recognition of a union that would represent and bargain for 13 psychiatrists and four psychiatric nurse practitioners. That effort failed on April 21 when an NLRB official dismissed the unionization petition because the petitioners’ employer — Dartmouth — already had made clear that it was no longer going to employ them.
After the NLRB ruling, events escalated. On April 28, D-H set up a website, nhbehavioralhealth.org, that urged visitors to “imagine innovative behavioral health careers” and assured them “our recruiters would love to talk to you.” The site now lists jobs in the D-H system, including openings at NHH for a primary care doctor and an advanced-practice nurse and for faculty psychiatrist and child psychiatrist positions.
On the other side, Davis signed paperwork on May 4 that created a limited liability company called Psychiatric Professionals of New Hampshire. Nine days later, the company issued a memo saying that it had 18 letters of intent from qualified professionals, including 13 current staff members at NHH, and planned to submit its own bid for the NHH contract.
But right now, it seems there is no bidding process to submit to.
Meanwhile, both sides have talked tough. A May 13 statement from the psychiatrists’ company accused D-H of jeopardizing NHH’s future with “months of poor communication, disrespect, and tactics that can only be described as callous and bullying.”
In late May, in an interview on New Hampshire Public Radio, D-H General Counsel John Kacavas fired back: “We are not going to give a handful of people preferential treatment because they see this as a calculated opportunity to extract some sort of compensation benefit from us.”
The recent events have clouded what had been a bright spot — first-rate psychiatric care at NHH — in the often gloomy landscape of mental health care in New Hampshire.
“The quality of psychiatrists that work at New Hampshire Hospital is extremely high,” said Norton, the NAMI leader. The current professional staff at NHH has strong working relationships with patients including those who re-circulate into the hospital or are on conditional release to their families as well as with community mental health centers and peer support groups, he said.
Dartmouth’s role as supplier of psychiatric services at NHH began during a statewide reorganization of the mental health care system in the 1980s, according to Paul Gorman, a Dartmouth psychiatrist and former superintendent at NHH.
The state’s mental health care reform efforts during that decade aimed at downsizing NHH, which once housed thousands of patients, and improving community-based services. The state built a more modern and smaller hospital, but funding for community services lagged.
Before the reorganization, it had been difficult to find caregivers for NHH. “The state was not having a very successful time recruiting psychiatrists,” Gorman said.
Lingering problems at the hospital had also affected medical education, said Robert Drake, a Dartmouth psychiatrist who worked in mental health care at the state and local level. Prior to taking over clinical care at NHH, Dartmouth Medical School sent students to NHH but “the experience was probably pretty terrible,” he said.
Ultimately, handing over responsibility for the clinical program boosted recruitment and the quality of care at NHH, Gorman said.
New Hampshire has continued to set ambitious goals for mental health care but has come up short in providing the necessary funding. Most recently, the state missed some deadlines for implementing expanded community services called for in the 2014 settlement of a class action lawsuit by advocates. It has also scrambled to find the money to open a new 10-bed inpatient crisis ward at NHH that was completed last year but remains unused. That unit is now set to open July 5, Leon said.
The state missed an April 29 target to announce a new contract for psychiatric services at NHH. Dartmouth-Hitchcock was the only publicly identified bidder.
On June 7, HHS submitted to the governor and Executive Council a proposal for a four-month, $2.9 million extension of Dartmouth’s current contract, which would be assigned to D-H. The request cited “unanticipated contracting issues that arose well into the procurement process” but did not describe the issues or name D-H. The extension is on the agenda of the council’s Wednesday meeting.
Leon, the HHS spokesman, could not be reached for comment after the extension proposal was published.
Justin Anderson, a Dartmouth College spokesman, said, “the agreement reflects our work with the state of New Hampshire and Dartmouth-Hitchcock to ensure continuity of clinical service at New Hampshire Hospital.”
Rick Adams, a D-H spokesman, affirmed that the health system’s “intent is to fulfill the requirements of the RFP” but declined to say how many psychiatrists had been enlisted, saying that these were “personnel matters” and thus “confidential.”
D-H’s ability to sign up psychiatrists seems to be a key issue. In April, the labor relations board noted that D-H had a letter of intent from NHH’s current chief medical officer. In early May, the New Hampshire Union Leader quoted Green as saying that “more than a half dozen individuals” had accepted job offers. In late May, a D-H executive told New Hampshire Public Radio that D-H had signed up “the medical director, the assistant medical director and several of the providers.”
Davis said he believed D-H had signed up the two executives and five other psychiatrists. He did not sign a letter of intent and said that “it would be hard for me to envision a scenario” where he would still be working at NHH on July 1. That was the consensus of the dozen professionals who declined to sign the letters in April and had their employment offers withdrawn, Davis added.
Mistler, the NHH psychiatrist who supported the unionization effort but later signed the letter of intent, said it was unclear whether the contract extension would avert that crunch.
Meanwhile, those with psychiatric services to sell are in a strong market postition.
That was evident in early May, when Cheshire Medical Center, a D-H affiliate in Keene, announced plans to close its inpatient psychiatric unit due to “an inability to recruit permanent psychiatrists.” A unit with the capacity for 12 adults and six adolescents would be shuttered and 33 full- and part-time and contract employees let go for want of two full-time psychiatrists plus others to cover weekends and evenings, according to a news release from Cheshire.
“The shortage of psychiatrists is evident across the nation,” the release said, citing a study that found that three of five doctors in that specialty were more than 55 years old.
Filling vacancies at NHH is challenging, according to Davis. NHH staff psychiatrists work with the criminal justice system, the Attorney General’s Office, the governor’s office and community mental health centers, and frequently deal with legal issues related to involuntary commitments, orders to take medication and guardianships, he said. The learning curve for the legally and medically complex job can last from six months to a year, so replacing multiple psychiatrists quickly is “totally unrealistic,” he said.
Green, in an email, acknowledged a “crisis regarding the provision of psychiatric care for patients in the region” but did not comment on specific staffing issues related to the proposed contract.
Patients and families don’t want to get caught in the middle.
“NAMI’s hope is that the parties involved can come to some resolution as soon as possible,” said Norton, the advocate.
The alternative seems painful to some involved. “Where my heart breaks is for patients,” said Mistler. “I just want to make sure on July 1 we have enough folks.”
Rick Jurgens can be reached at 603-727-3229 or rjurgens@vnews.com.