PROVIDENCE, R.I. (WPRI) — The top doctor at Eleanor Slater Hospital said Wednesday he’s concerned that dozens of people living in the state-run facility have been improperly counted as medical patients instead of psychiatric patients for years.
Chief Medical Officer Dr. Brian Daly, along with other hospital administrators, answered questions from state lawmakers for the first time since a report came out last month showing the publicly funded hospital system had far more psychiatric patients than a previous report showed in December.
Asked how the patient mix changed so suddenly — especially at a long-term acute care hospital where the average length of stay is more than a decade — Daly explained that several patients entered the hospital under one diagnosis that was subsequently never updated for billing purposes. As a result, patients who might have been admitted many years ago were already treated for their medical ailments, and are now living at the hospital primarily for psychiatric or behavioral care.
“I’m not suggesting that people before were not trying to do a good job,” Daly told members of the R.I. House Finance Subcommittee on Health and Human Services. “My concern is that it’s gone on for years and years and years.”
The distinction between medical and psychiatric diagnoses may seem academic, but for the hospital and state government it represents the difference between tens of millions of dollars in annual federal funding. It’s also at the root of many of the persistent problems that continue to plague the hospital system, which is made up of Zambarano in Burrillville and three more units in Cranston.
“It’s a bit of a quagmire,” said Rep. Deborah Ruggerio, D-Jamestown, who sits on the committee. “Facts and truth are absolutely paramount.”
Rhode Island stopped billing the U.S. Centers for Medicare and Medicaid Services in the fall of 2019 after state employees raised concerns that more than half of the people at the hospital were psychiatric patients. That ratio meant the hospital was out of compliance with a federal regulation known as the Institutions for Mental Disease (IMD) exclusion, which was designed to push states away from operating long-term psychiatric hospitals where people could become institutionalized.
Rhode Island has since been in an 18-month period of limbo that has cost more than $100 million in state revenue which would previously have been covered by the federal government. The primary driver of that expense is the fact that the annual cost of care at Eleanor Slater totals more than $500,000 per patient, according to a presentation by House Fiscal Office staff.
Last month, administrators at Eleanor Slater surprised observers when they reported 79% of their patients were classified as psychiatric — including 58% of the patients at Zambarano, which has traditionally been considered a facility that provides medical care.
“Most of the time the diagnosis didn’t change,” Daly said. “It was just inappropriately classified.”
Daly answered lawmakers’ questions alongside his chief of medical services, Dr. Andrew Stone, and the hospital’s former interim CEO, Jennifer White.
Daly also said they were helped by Richard Charest, who is Gov. Dan McKee’s pick to become the new director of the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH), which oversees Eleanor Slater. A retired longtime executive of Landmark Medical Center, Charest had already been privately consulting for Eleanor Slater since last fall, and his involvement has raised eyebrows among some critics.
“Rich Charest was one of the people involved with this,” Daly said.
Still, some lawmakers expressed skepticism about the officials’ explanation for the most recent Slater patient report.
After Stone spelled out why they determined some patients with dementia were psychiatric rather than medical — even though the federal government has indicated certain dementia patients don’t need to be classified that way for purposes of calculating the IMD exclusion — the subcommittee’s chairman, Cumberland Democrat Alex Marszalkowski, expressed some doubt.
“What I picked up on this was [it’s] splitting hairs,” Marszalkowski said.
Even the officials’ own boss, Health and Human Services Secretary Womazetta Jones, was quick to distance herself from the hospital administrators. (Jones is currently serving as interim director of BHDDH while Charest’s nomination is pending.)
Jones has had oversight of Eleanor Slater since before fall 2019, but said she would answer lawmakers’ questions in her capacity as health and human services secretary and the hospital’s regulator. She pointed to the state Medicaid office, which she also oversees and which is seeking to hire an outside firm to review the hospital’s patient mix and billing practices.
“I will not say that I will agree with Dr. Daly, or Dr. Stone, or Jenn White,” Jones said. “We want to be sure that whatever information we’re receiving is from a third party that has no stake in whether we get reimbursement or not.”
State Medicaid Director Ben Shaffer echoed that point, saying it is within his office’s regulatory authority and responsibility to hire a third-party consultant to review the patient mix.
“They could be exactly right,” Shaffer said about Slater doctors’ most recent patient breakdown. “We could also find the opposite and everything in between.”
In addition to the intense legislative scrutiny focused on Eleanor Slater in recent months, the hospital has been the focus of at least half a dozen outside reviews since 2019 — including at least three that are happening right now.
Separately, R.I. Attorney General Peter Neronha has launched his own investigation into the hospital, and the facility has been making headlines for its money woes, toxic workplace and subpar building conditions.
In his current budget proposal for fiscal year 2021-22, McKee allocated $65 million to build a new skilled-nursing-like facility at the Zambarano site to replace the current building. The governor has since said that plan is on hold pending the outcome of one of the state’s many ongoing reviews, though it is still called for in the budget documents currently being reviewed by lawmakers.
Several union groups, employees and mental health advocates testified during the five-plus-hour hearing, expressing frustration with the current state of affairs at the hospital. Many argued conditions haven’t improved and that workers are getting cut out of discussions about what’s going to happen next. There’s also widespread concerns that the state is continuing an effort to simply shutter the hospital, an idea reinforced Wednesday when The Boston Globe revealed the hospital sent ventilator patients’ medical information to an outside rehabilitation facility without notifying the patients or their families.
Jones and other state officials are adamant there are no current plans to close the hospital or any of its units. McKee has said repeatedly he expects to present his plan for the hospital’s future to the legislature before the current session ends, which typically happens by the end of June. Among the lawmakers at Wednesday’s hearing, several shared concerns from their constituents, and highlighted their own frustration with how long the issue of Eleanor Slater has dragged on.
“We want to establish guidelines so next year someone doesn’t come up here and say, ‘We’re out of compliance again,” Marszalkowski said. “This has been numerous hearings going over and over again.”