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Mental Health Enters Debate in N.H. Gubernatorial Race

  • Republican gubernatorial candidate Chris Sununu is seen at a news conference in front of the statehouse after winning his party's nomination Wednesday, Sept. 14, 2016, in Concord, N.H. (AP Photo/Jim Cole)

  • New Hampshire democratic gubernatorial candidate, Colin Van Ostern, listens to comments about affordable education from Dr. Alex Herzog, Vice President of Student Affairs at River Valley Community College in Claremont, N.H. on Tuesday, September 27, 2016. (Valley News - John Happel) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.



Valley News Staff Writer
Sunday, October 23, 2016

Lebanon — The inadequacy of mental health care in New Hampshire has emerged as an issue in the race for governor between two executive councilors, with Dartmouth-Hitchcock’s new contract to provide psychiatric services at New Hampshire Hospital serving as a lightning rod.

The heightened attention to mental health issues drew words of praise — of sort — from Ken Norton, the executive director of the National Alliance on Mental Illness’ New Hampshire affiliate.

“I think it’s great that the governor and Executive Council are asking probing questions about the problems with our mental health system,” he said. “I would hope to see them expand their questioning to go beyond the Dartmouth contract.”

An important question to ask, according to Norton: Why do so many people with mental illness wait for days in hospital emergency rooms for psychiatric care?

On Thursday, 33 adults and five children waited in hospital emergency rooms for beds to open in facilities equipped to give high-level care to people with serious mental illness, according to the state Health and Human Services Department.

As advocates and the public try to assess the state of mental health services in New Hampshire, emergency room waits — sometimes called boarding — offer a useful benchmark.

But there are others. A recent survey by the New Hampshire Community Behavioral Health Association, a group of community mental health centers, found nearly 200 unfilled jobs in the system.

Many providers say theirs is a network built on a weak financial foundation. They depend on funding from Medicaid, the state and federal program of health insurance for low-income people, but New Hampshire has set its reimbursement rates at very low levels, leaving caregivers perpetually financially strapped, they say.

And without a strong network of mental health centers, people who could progress toward care in their communities remain in the state hospital, so that those beds aren’t available to patients in crises.

Expanding community services was a key objective of a 2012 class action lawsuit filed by advocates for people with mental illness and joined by the U.S. Justice Department. But a court-appointed reviewer has found the state has so far failed to keep some important promises it made in the 2014 agreement that settled the case.

A Political Issue

All of which has barely surfaced in an election debate dominated by exchanges about D-H’s New Hampshire Hospital contract. That issue splashed into the political arena as it was considered by the Executive Council, which includes Chris Sununu, now the Republican candidate for governor, and Colin Van Ostern, his Democratic opponent.

Sununu was a critic of the D-H contract when it first came before the council. Yet both Sununu and Van Ostern voted “aye” in September when the council approved the $36.6 million, 32-month deal that made D-H the provider of psychiatric services at the state’s main facility for people with serious mental illness.

At the time of that vote, Sununu cited “continuity of care” as a reason for supporting the contract with D-H, which on July 1 had replaced Dartmouth College as the service provider at the state hospital.

Now he wants the deal rebid. What changed, Sununu said in an interview Friday, is D-H’s subsequent announcement of plans to lay off up to 460 workers. That “was incredibly disconcerting,” he said. The number of employees laid off, which was announced on Monday, turned out to be 84.

Looming layoffs at D-H “clearly would have come into play determining what steps to take, whether we should have delayed it a little more, whether we needed more clarification, more questions asked,” Sununu said. “But it was very intentionally kept from us.”

“That is not how you build a relationship with the state or between the state and a contractor,” Sununu said. “It needs to be open and transparent, and we simply have not had that kind of openness and transparency with Dartmouth-Hitchcock.”

Mike Barwell, a D-H spokesman, did not respond to Sununu’s comments, but instead emailed a general statement that D-H’s “commitment to psychiatric care is resolute.”

Ben Wexler-Waite, a Van Ostern spokesman, said the Democratic candidate would call for the contract to be pulled if D-H failed to provide the required number of staff with the specified qualifications.

The origins of the controversial contract trace back to the 1980s, when Dartmouth and its medical school stepped in to help New Hampshire as it pushed to improve mental health care and attract top professionals to work in its about-to-open state hospital.

“The state was not having a very successful time recruiting psychiatrists,” said Paul Gorman, a Dartmouth professor and former superintendent of New Hampshire Hospital.

So the psychiatry department at Dartmouth’s medical school took responsibility for providing treatment at New Hampshire Hospital, he said. That raised the level of care and helped with recruitment, he added.

The relationship lasted for decades. “Historically, the contract between Dartmouth and the state of New Hampshire has been a very bright light affecting the quality of mental health services in the state,” Norton said.

The state mental hospital’s relationship with Dartmouth helped it attract “talented career psychiatrists,” in part by adding an academic dimension to the work, he said.

“Many of the people coming through Dartmouth’s medical school and doing a residency stayed,” Norton said, influenced by role models who were effective and happy in their work. The result was “a really nice mix” of early, mid- and late-career psychiatrists.

But a recent push by Dartmouth to reduce deficits at its medical school gave rise to a restructuring plan that included the shift of hundreds of faculty and staff jobs to D-H, which has its own financial and governance structure. The psychiatry department, which employed at least 17 psychiatrists and advanced practice nurses at the state hospital, was included in the shift.

The transition stalled when about a dozen of the affected psychiatric professionals balked. They worried about how changing employers might affect them. Some were concerned that they might lose retirement benefits.

Dissatisfied with D-H’s answers, some of the affected professionals tried unsuccessfully to form and win recognition for a union. They also formed a company to bid against D-H for a contract.

The employee resistance prompted the Executive Council to put off its vote on a D-H deal to replace the Dartmouth deal, which was set to run out June 30. The previous deal was extended until Oct. 31. And finally, on Sept. 8, a deal with D-H was approved.

That left D-H Chief Executive James Weinstein visibly, and vocally, exasperated. “This is one of those situations that’s very frustrating because we have incredibly dedicated, truly wonderful people, working really, really hard on behalf of the citizens of New Hampshire and particularly those who most need mental health services and yet, that story doesn’t get told,” he told an in-house publication.

In fact, D-H was the only organization to submit a bid by the deadline, although the company formed by some state hospital doctors sought to have that deadline extended. Health and Human Services Commissioner Jeffrey Meyers rejected a unanimous suggestion by the Executive Council that the bidding be reopened.

So D-H came to the rescue, according to Weinstein: “The truth is, Dartmouth-Hitchcock took on the contract and the care when no one else would.”

Sununu said in an interview that he believes other bidders were interested.

A spokesman for MHM Services Inc., a Vienna, Va., provider identified by Sununu as a potential bidder, did not respond to a request for comment Friday. MHM provides some health care services in New Hampshire and Vermont prisons, according to its website.

In any case, it’s time to put the contract controversy in the rearview mirror, according to Suellen Griffin, chief executive of West Central Behavioral Health. “The governor and Executive Council passed it,” she said. “Let’s move along.”

West Central is a Lebanon-based mental health center with a website that notes its affiliation with the psychiatry department at Dartmouth’s Geisel School of Medicine. That department recently moved from Dartmouth to D-H.

The extended controversy isn’t getting at the issues needed to improve care, Griffin said: “There’s too much politics that’s involved in the decision-making versus what’s good for the system.”

With the current turmoil, she said, “it’s really hard to recruit good people because it looks like an unstable environment.”

At the Executive Council meeting where the D-H contract was approved, Sununu called for a review “of the entire mental health program of the state.”

In an interview, Sununu said a review is needed to “make sure that we are spending the dollars that we have in the most efficient way (and) that the community mental health centers have a viable agreement with ... the Medicaid contracting organizations, as well as with the state.”

“Then we can look at what additional funding needs to come in in order to provide those services at the highest level as required by the individual districts,” he added.

Sununu said he couldn’t say whether the Legislature would provide more dollars for mental health if needed: “I can tell you I would make it a top priority and I would work with the Legislature to ensure adequate funding to meet the requirements of the state.”

Van Ostern spokesman Wexler-Waite said his candidate knows the “need to improve the delivery of mental health services in New Hampshire, particularly given the state settlement (of the 2012 lawsuit) and clear correlation between opioid addiction and untreated mental illness.”

Van Ostern would be open to reviewing Medicaid reimbursement rates, Wexler-Waite said.

Vanostern.com, the official campaign website, notes Van Ostern’s support for efforts to “bring the state’s community mental health centers back into a prevention-focused payment model” and to integrate mental health and addiction care with primary care.

Van Ostern’s website also calls for an increase in the workforce at the state’s mental health and addiction treatment centers through “incentives,” easing of licensing standards, recruitment and education.

Contact Rick Jurgens at 603-727-3229 or rjurgens@vnews.com.