Hospital, Doctors Must Come to an Agreement to Keep Mental Unit Open

By Patrick Brendel, Victoria Advocate, Texas

Mar. 26–Unless Gulf Bend Center comes to an agreement with psychiatrists at Citizens Medical Center and with the hospital, the only inpatient mental health unit in seven counties will close the first of May.

While no one seems to know exactly when the Evaluation and Stabilization Unit (also known as One South) came into existence, nurse Caroline is in her 40th year there. She believes that the ESU began a decade before that when Citizens opened its doors.

The crux of the disagreement between Gulf Bend and psychiatrists Robert Lyman and Gregory Creager lies in the deceptively simple phrase “payer of last resort.”

Gulf Bend, as the official community Mental Health and Mental Retardation Center, is designated by the state legislature as the “payer of last resort” for area patients suffering from mental health problems.

This means that Gulf Bend cannot use state funds to pay for treatment of patients who are covered by Medicaid or private insurance, said executive director Don Polzin and director of operations David Way.

Gulf Bend has a contract with Lyman and Creager that pays them $120 per hour to see patients staying in the ESU. The contract runs from Sept. 1 to Aug. 31 and is reviewed annually.

Lyman and Creager are also paid an unrelated per diem and a weekend rate to be on call.

Neither Creager nor Lyman are employees of Gulf Bend, although Lyman was employed as Gulf Bend’s medical director from 1990 until 2001 before going into private practice and switching to a contract basis with Gulf Bend. Creager’s contract with Gulf Bend started soon after.

One problem with the setup, Way said, is that, while Gulf Bend pays the doctors by the hour, Gulf Bend bills Medicaid and insurance companies and is reimbursed on a fee-for-service.

An insurance company determines reimbursement according to the particular service a doctor performs, whether it be an X-ray, injection or interview, not how much time the doctor spent doing it.

Not only does this uneven, ill-matching system of payments provide accounting difficulties for Gulf Bend, it also is illegal, Polzin and Way said.

Gulf Bend’s budget comes from a variety of private, nonprofit, local, state and federal sources, with a significant portion coming from state tax revenue. Once the money is deposited in Gulf Bend’s account it all becomes public money, Way said.

While Lyman and Creager are paid by Gulf Bend to see all the ESU patients, about 50 percent of them have Medicaid or private insurance, Way said.

Even though Gulf Bend is usually reimbursed promptly by the third-party payer, it is simply against the law for Gulf Bend, as the “payer of last resort,” to pay physicians to see patients who have mental health coverage, Way said.

Gulf Bend has notified the Texas Department of State Health and Human Services, which has acknowledged that Gulf Bend’s interpretation of the statute is correct and also has recognized Gulf Bend’s efforts toward compliance, Polzin said.

If Gulf Bend does not comply with state law, then it is probable that funding will be cut, Way said, and possible that the state will sue Gulf Bend.

Accordingly, in March, Gulf Bend offered Lyman and Creager a new contract that replaces the hourly fee with a fee-for-service rate that matches the rate a health care provider would bill Medicare. The psychiatrists would bill the insurance company or Medicaid directly.

This is unfavorable to the psychiatrists, who — by having Gulf Bend do the billing — haven’t had to employ additional staff and are not now responsible in case the third-party payer refuses to reimburse.

Not only were the psychiatrists less than pleased with the terms of the new contract, they were very disappointed with the method of delivery of the contract — by certified letter on March 10.

Lyman said he received two pieces of mail from Gulf Bend: one was the new contract, and one was a letter stating that if Lyman and Creager did not sign the new contract, Gulf Bend would exercise a clause allowing the termination of the contract in 30 days, or on April 9.

In response, Lyman and Creager announced their resignation from Citizens staff, effective April 8 — a move Citizens CEO David Brown called “playing a card that they’ve got,” and Polzin characterized as bending Gulf Bend “over the barrel.”

Way said Gulf Bend has been talking contract changes with the psychiatrists for several years, but they weren’t aware until last fall that the contracts were not in compliance with state law.Lyman and Creager must provide services to the ESU patients if they want to retain hospital privileges at Citizens, whether they are being compensated for their time by Gulf Bend or not, Brown said.

By resigning, they would renounce this responsibility and would leave the ESU without physician support.

Without a psychiatrist, there can be no inpatient psychiatric ward; therefore, Citizens would have to close the ESU, Brown said.

Besides Lyman and Creager, there are only two other psychiatrists in Victoria — James Dotter, who conducts outpatient services for Gulf Bend on a full-time basis, and George Constant, who, after decades, is beginning to wind down his practice.

This dearth of local psychiatrists (Corpus Christi has 21, by comparison, Lyman said) gives Lyman and Creager leverage with Gulf Bend.

Lyman and Creager said that the proposed contract from Gulf Bend will make Victoria an even less attractive place for young psychiatrists, who probably would not choose to work in a place where they would have to be on call all the time.

Way and Polzin said the shortage of psychiatrists is not Gulf Bend’s fault, and there is no reason why addressing the concern should be entirely up to Gulf Bend. Rather, the entire medical community, including non-profit and private organizations and individuals, should work together to address this need, Polzin said.

“If anyone understands the importance of inpatient units, we do,” Polzin said.

He added that, although it is not within Gulf Bend’s capabilities or responsibilities to pay the psychiatrists to treat all the ESU patients, the last thing Gulf Bend wants is for the ESU to close.

As a sign of progress, Gulf Bend notified the psychiatrists and Citizens that the ultimatum of April 9 has been pushed back to May 1 to allow time for constructive talks, Brown said Friday.

Way said, “The extension is an extension of the olive branch.”

A meeting between the boards of directors of Gulf Bend and Citizens is set for April 4, said Gary Burns, a Victoria county commissioner and Gulf Bend board member.

“I’m fairly encouraged that on the fourth, we can maybe get everyone together and work this out,” he said.

“I hope that something is worked out,” Lyman said.

Editor’s Note: Nurses with Citizens Medical Center’s Evaluation and Stability Unit and the Emergency department, and local law officers will give their perspective on the possible closing of the THE ESU unit. The story will appear in a future edition of the Advocate.

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