BRATTLEBORO — When talk turns to finances at the Brattleboro Retreat, the current buzzword is “stability.”
Administrators say they are implementing a two-pronged plan to improve the mental health and addiction hospital's short- and long-term financial outlook. The changes include a major overhaul in medical billing and an in-depth performance review of the Retreat's programs.
Retreat President and CEO Louis Josephson said the changes aren't driven by a dire financial crisis. Rather, Josephson said he's trying to build some breathing room into a budget that's been “too tight for comfort” for too long.
“I wouldn't say we're on shaky ground,” Josephson said. “But we have no cushion, and that's a big stressor on an organization.”
The Retreat's trustees recently approved a new, three-year strategic plan focused on four key areas - financial stability, clinical excellence, accountability, and the hospital's physical campus.
The plan was based on input from a variety of sources including staff, patients, community members, other health care providers and government officials. In the course of those discussions, Josephson said two top priorities emerged - clinical excellence and finances.
On the clinical side, the Retreat already has been working to adopt two new treatment programs designed to improve patient outcomes. Administrators also want to improve their use of electronic medical records and invest in new telepsychiatry services.
Finances are a somewhat thornier issue at the Retreat.
Room for improvement
Nearly two years ago, state officials confirmed that they were investigating allegations of financial malfeasance related to the Retreat's medical billing.
To date, that probe has produced no public results.
A state official in January said there was “only a single issue that's still under investigation,” but it's not clear whether the matter has progressed since then. In an Aug. 15 interview, Assistant Attorney General John Treadwell would say only that the case is still under review.
Josephson said he couldn't comment on the state probe. But he said it was clear when he came to the Retreat in early 2016 that the hospital needed to address its patient financial services operations.
While Josephson believes there's room for significant improvements in the state's health care reimbursement system, he acknowledges that the Retreat wasn't holding up its end of the bargain.
“We work really hard for what we're entitled to get paid, and we should collect every dollar that we're entitled to,” Josephson said. “But we've got to have a robust, in-house function to do that, and I admit that we had sort of taken our eye off the ball there.”
He added that, when it came to insurance billing, “we were literally not collecting hundreds of thousands of dollars ... that we should have collected.”
The short-term solution was to outsource the Retreat's billing office for the past year, which gave Retreat staff time to “reimagine the service,” Josephson said.
“Things were so broken that we couldn't fix it,” he said. “We just needed to pull the plug and restart.”
Staffers at the Retreat and the Department of Vermont Health Access have been working to get the hospital back on track. The department has waived its standard six-month filing deadline for Medicaid claims and allowed the Retreat to receive payment for older bills as long as the hospital continues to improve its billing operations, Deputy Commissioner Michael Costa said.
In fact, officials have been poring over past billing records “claim by claim,” Costa said. He sees the work as a partnership between the state and the Retreat.
“It is extremely labor intensive, but access is a really critical thing for us,” Costa said. “We want the Retreat to be getting paid what it's owed, because it's really important for our beneficiaries to have access [to Retreat services].”
'Infinitely better'
Within the next few months, Josephson said the Retreat will bring its billing functions back in-house and has been training staff for that transition. He's confident that the hospital is in an “infinitely better” position to deal with the complexities of medical reimbursement.
Costa also sounded optimistic: “They've got the right attitude and the right effort to get this done,” he said.
While medical billing is the Retreat's most pressing financial need, administrators also are taking a longer-term look at hospital operations.
“Our board has asked us to assess and look at all of our programs and their viability,” Josephson said. “Can we stay in every line of business? Frankly, I don't know.”
That doesn't necessarily mean that a money-losing program will be cut, Josephson said. But he believes administrators need to examine the sustainability of the Retreat's current operational setup.
For example, Josephson said he'd like to see more usage of an adult inpatient treatment program designed for lesbian, gay, bisexual, and transgender patients. Also, the Retreat is considering merging two adult units - known as Tyler 1 and Tyler 2 - in order to unite addiction and general psychiatric services.
The Retreat also is on the lookout for new programs with growth potential. One example is offering telepsychiatry services to hospital emergency rooms, with the goal of treating patients more quickly while also cutting down on the need for inpatient psychiatric services.
“We think it's a win-win for the state, for the emergency rooms, and could be a sustainable service for us,” Josephson said.
The Retreat is in the early phases of evaluating its programs. But Josephson is hoping that assessment, along with anticipated improvements in medical billing, can relieve some pressure on the hospital's approximately $70 million budget.
Through the first half of this year, “we've been spot-on budget. But spot-on budget means break-even,” Josephson said.
“Our goal is to kind of stabilize some things and build up a little bit of reserve so we can withstand the normal ups and downs that happen,” he said. “I think we'll be fine, honestly.”