Mind Over Money At Providence Hospital, Unique Services Can’t Pay for Themselves

Dr. Les Smith tells of a 6-year-old who arrived at Providence Behavioral Health Hospital with no ability to trust. That’s not surprising, considering that his parents disciplined him and his siblings by cutting off digits.

Behavioral health problems emerge from multiple causes: genetics, substance abuse, and in many disturbing cases — often involving children — horrible trauma. “We can do things here that nobody else can do,” said Smith, the chief medical officer at the Holyoke-based facility. “When you ask yourself who takes cases like this, who do you think of? It’s us.”

As Providence awaits word on a hoped-for influx of $5 million in emergency state funding — a critical transfusion for the hospital to remain open — officials there spoke to The Healthcare News about the niche Providence fills in Western Mass., and why no one else would be able to fill it.

“One thing that makes it unique is the scope of what we do. We’re different than any other facility in Western Mass.,” said Gerri Cote, director of Clinical Services. “Many other hospitals have a small psychiatric unit, but with 126 beds and a variety of services, we have the capacity for a continuum of care. That’s significant.”

However, low reimbursement rates from public and private payers have created a difficult financial situation at Providence. “If the payment for 20 behavioral-health beds in an acute-care hospital doesn’t cover the costs, the hospital can absorb the losses in other ways,” Cote said. “For us, that problem grows exponentially.”

The issue of Medicaid reimbursements for behavioral health has been taken up at the state level, said Mark Fulco, vice president of Strategy and Marketing for the Sisters of Providence Health System, which oversees the hospital.

But Providence can’t wait for incremental change, which is why it has applied for the $5 million from the state’s distressed hospitals fund.

At press time, it was not a done deal, but considering the role Providence plays — some of its services are unique to Western Mass. — officials are optimistic that funding will arrive, Fulco said. For one thing, he noted avowed support from several state legislators who represent the region.

“But we haven’t heard any official date yet,” he said, “which is cause for some concern because we’re in a deficit-spending situation, and every day that goes by without notice as to where we stand, we’re a little deeper in the hole.”

Acting on a Mission

Smith said the hospital’s mission makes it important to stay out of that hole.

“We do use the term ‘mission’ around here, and in our case we really mean it,” he said. “Behavioral health has not fared well in general in terms of funding, yet our mission hasn’t changed. We make sure we get an adequate amount of treatment done on patients before we discharge them. Despite pressure from payer sources, we go further than most in treating people, and when they are discharged, we work hard to get them the benefits they’re entitled to.”

This is more than basic compassion, although that’s an important value, Smith noted. By making sure patients are adequately treated while at Providence and provided with follow-up resources afterward, the hospital has forged a reputation in behavioral health for very low rate of rehospitalization — which not only impacts a region’s public health in a positive way, but also reduces medical costs for everyone.

“When we take people, we don’t just wave at them as they pass through, put them on medications, and send them out the door,” Smith said. “These people require real coordination of care with community agencies and a marshaling of resources. And despite taking care of a very difficult group, our recidivism numbers remain low — and that’s not us saying that; it’s tracked by payers.

“Again, that all plays into the continuity of treatment,” he continued. “It takes time to do what we do, and it costs us. We need to have somebody acknowledge that the community can’t do without us, and someone has to compensate us.”

Take the child psychology unit, for example, which includes 24 beds and treats children age 5 to 18 with mental illnesses, behavioral problems, and histories of abuse trauma. It’s the only child and adolescent inpatient unit west of Route 128.

“So that’s all of Western Mass., from the Berkshires to Worcester,” Cote said. “Our 24 beds are full most of the time.” Diagnoses run the gamut from post-traumatic stress disorder — a common response to physical or sexual abuse — to early signs of schizophrenia and psychotic disorders.

“We’ve also seen the substance abuse issue moving down in age and rearing its head earlier than before. We’re seeing it more in adolescent kids, acting as a co-occurring disease [alongside another condition], and we try to treat it all.

“More than 50{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the children who come here are in the custody of the state,” Cote added, “so there’s a whole socioeconomic, generational piece to this. A lot of kids are growing up in poverty, without parents, they’re exposed to crime and abuse, and many are wards of the state.”

Smith said that national data strongly suggests that children and adolescents with untreated psychological issues don’t just get better on their own; he noted that the nation’s largest provider of behavioral health services is the Los Angeles County Jail.

“These folks are going to be heard from again,” he said. “They don’t go away, and if you don’t treat them, they’re going to cost your community in a different way.”

Nowhere to Go

Without a facility like Providence, said Cote, many troubled children who live in Western Mass. wind up having to go to Boston for treatment, which can pose hardships for their parents or the guardians involved in their care.

“That’s assuming that Boston would absorb them, which is highly questionable,” Smith said, referring to current strains on capacity in Eastern Mass.

The children’s unit is only one aspect to the care offered at Providence, however. The inpatient detox unit offers 30 beds and averages more than 2,000 admissions per year. In addition, the hospital runs two methadone clinics, in Springfield and Holyoke, that serve more than 800 patients daily who are trying to kick heroin — more than the other two regional methadone clinics combined, Teehan said.

The hospital’s older adult unit, with 16 beds, is the only psychiatric unit in Western Mass. that specializes in treating the elderly. Meanwhile, the adult psychology unit, with 34 beds, is where the hospital sees some of its most difficult cases.

“That unit takes on a much more disturbed population than any other hospital psych unit,” said Tim Teehan, director of Nursing.

Smith said that, while every hospital likes to say it treats the toughest cases, Providence has a legitimate claim.

“Why are so many violent patients being held in emergency departments? What does that say about what’s going on in those facilities?” Cote added. “It says they’re not equipped for those patients; they’re struggling with restraint issues, and they’re sending these patients to Providence. We do see the hardest patients — more chronically mentally ill, violent, uninsured.”

In addition, she noted, typically, more than 20{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the hospital’s patients are homeless.

“Then there are significant public health issues,” Smith said. “When people are addicted to heroin, with that comes the spreading of HIV and hepatitis [through needles]. And there’s also a whole criminal issue that speaks to public safety.”

Beyond that, Teehan noted that pancreatitis and a host of other health problems follow in the wake of alcoholism, one way in which substance abusers put added stresses and costs on a region’s conventional health care system.

Long-term View

All of these arguments for Providence’s existence — low recidivism, impact on public health and public safety — go back to short-term versus long-term thinking, Smith said. So do the benefits Providence offers to area colleges. Each year, UMass, American International College, Elms College, and Holyoke Community College send a total of 70 to 100 students to the hospital for clinical rotations in behavioral health and social work fields.

“That has a significant impact on these students being able to finish their curriculum,” Teehan said. “They see everything as they rotate through the units.”

“We offer the kind of training where people can see a wider range of issues in a shorter period of time than anywhere else, in terms of the breadth of psychopathology,” Smith agreed.

And since Northampton State Hospital closed, Smith said, “we’re the only region in the state without a state hospital. This group of patients who end up in our hospital, other regions manage in state hospitals, and there should be some acknowledgement of that.

Specifically, “the state’s laying out money for state employees and facilities in other places that they don’t have to pay out here,” he said. “We should be paid some differential rate to care for a group the state would have to manage in a different way if we didn’t exist.”

Right now, existence is the key word. With the legislative support Fulco believes Providence Hospital enjoys — he named state Sen. Gale Candaras and state Rep. Thomas Petrolati among the hospital’s allies — he expects the doors to remain open well into the future.

“Our delegation from Western Mass. has really led the charge,” he said. “With the uniqueness of our services and the impact we have on our communities, we’ve really grabbed people’s attention.”

With so much at stake, however — not just for the hospital but for the region as a whole — no one is getting too excited just yet.