Legislature(2003 - 2004)
04/27/2004 03:11 PM House HES
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* first hearing in first committee of referral
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HB 535-LIMIT STATE AID FOR MENTAL HEALTH CARE CHAIR WILSON announced that the next order of business would be HOUSE BILL NO. 535, "An Act relating to liability for expenses of placement in certain mental health facilities; relating to the mental health treatment assistance program; and providing for an effective date." Number 2066 BILL HOGAN, Director, Division of Behavioral Health, Department of Health and Social Services, testified on HB 535 and answered questions from the committee. He explained that the bill relates to statutes which requires the state to cover the costs of diagnosis and treatment services for individuals who are financially eligible, and who need to be involuntarily committed to non-state operated hospitals. Mr. Hogan told the committee that the costs of both the services and transportation expenses have increased dramatically over the last four years. The intent of HB 535 is to clarify that the costs incurred will only be covered up to the amount appropriated by the legislature. The bill also requires hospitals to notify the department within 24 hours of admission of a potentially eligible individual. This would allow the department to assist in a timely and appropriate discharge to a community-based program, and also ensure that the funding is actually decreasing between fiscal year 04 and 05. The bill does give the department the capability of containing costs on an annual basis, he added. Mr. Hogan reiterated that this bill limits the state's responsibility to funds appropriated by the legislature. MR. HOGAN told the committee that there are currently 10 sites that can provide mental health care throughout the state. The two most prominent sites are at Bartlett Regional Hospital and Fairbanks Memorial Hospital. There are smaller sites, usually comprised of one or two beds, in Palmer, Ketchikan, Cordova, Homer, Valdez, Sitka, Bethel, and Kodiak, he said. MR. HOGAN reminded the members that the last time the bill was heard before the committee Chair Wilson directed the department to work with the various stakeholders including the Alaska Mental Health Trust Authority, the Alaska Mental Health Board, and the Alaska State Hospital and Nursing Home Association to come up with an agreement as to what the language in the bill should ultimately look like. The group agreed to a number of modifications to the bill, he said. He told the members that version H of HB 535 includes language in Section 2 of the bill, lines 28 through 30, which stipulates that the department will assist hospital-based facilities in moving individuals from its hospitals when there are no longer dollars available to pay for diagnosis, evaluation, and treatment (DET) services. It is not the department's intent to have hospitals bare the burden of having individuals in their facility without having appropriate compensation, he explained. In these circumstances, it would be the department's intent to have these individuals moved to Alaska Psychiatric Institute (API) if individuals are still involuntarily committed. However, if the individual no longer meets the involuntary commitment criteria the department will work to find alternatives in the community, Mr. Hogan said. MR. HOGAN told the members that Section 2 is still the "sticking point" in general. The stipulation that the state would only pay for the program up to the level of appropriation by the legislature is the primary point of disagreement by the stakeholders, he stated. Number 2188 CHAIR WILSON commented that the mental health community has been working hard to downsize API and find ways for patients to stay in their communities. Because of the lack of funding and cost- containing measures it appears there will be more individuals going to API, she added. Chair Wilson said she sees this as a philosophical tug-of-war. Number 2300 RICHARD RAINERY, Executive Director, Alaska Mental Health Board, testified on HB 535 and answered questions from the members. He said that as an advocate for Alaska's mentally ill he has real discomfort with Section 2 of the bill. There has been a process that has gone on over a dozen years in designing a system that diverts individuals from API, he explained. Mr. Rainery said he believes this system will threaten that progress. He noted that while the members are aware of the fact that the new API has been downsized, they may not be aware of the fact that it has been designed to be a national model. It will be a very different facility therapeutically speaking. The old API was a converted medical/surgical hospital. The new API will be a state of the art psychiatric facility with one and two patient rooms. When the new API goes over census the therapy will be altered substantially, he said. Mr. Rainery reminded the members that this is in addition to the fact that these individuals will be removed from their home communities. Number 2361 CHAIR WILSON asked Mr. Rainery to tell the committee what happens when a patient is removed from his/her community because he/she has been harmful to himself or herself or someone else. For example, what would happen to an individual living in Wrangell that has to be sent to API, she asked. MR. RAINERY responded that under normal circumstances an individual in Wrangell would be transported to Bartlett Regional Hospital. If there was a scenario where Bartlett could not accept the patient, then the person would be escorted by a security service, often in handcuffs on public transportation. TAPE 04-37, SIDE B Number 2365 MR. RAINERY commented that has been an issue at the top of radar screen for quite a while, because it is a very demeaning and stigmatizing experience. Not only is the individual taken away from his/her home and family, but dehumanized in the process, he added. The individual is treated in a separate environment and then sent back to his/her home community where the reentry situation is complicated. REPRESENTATIVE CISSNA asked if there have been studies on the outcomes of different treatment options. MR. RAINERY replied that he could not cite any studies. In some parts of the mental health community it is accepted wisdom that it is always a problem to have an individual taken out of his/her home community and treated in an institution. It does not matter whether it is in Anchorage or Colorado, the reentry to the community is difficult. At least when a person is treated at Bartlett Memorial Hospital mental health unit or Fairbanks Memorial Hospital mental health unit the individual's family is there and able to interact with the individual on a daily basis. Additionally, the people who will be working with the individual as he/she goes back to the community are there and able to work with the individual, he added. Number 2268 CHAIR WILSON commented that she tried to imagine herself in the place of an individual who was seen by people she knows being transported in handcuffs. That would be very embarrassing. MR. RAINERY told the committee that very thing has happened to members of the Alaska Mental Health Board while they were members. REPRESENTATIVE SEATON posed a hypothetical question where an individual from Wrangell were to be transported to either Bartlett Regional Hospital or a state of the art facility at API, would the outcome be the same. Are the treatment programs the same at both facilities, he asked. MR. RAINERY responded that there are definitely not the same programs available at Bartlett Regional Hospital as that at API. He explained that API is a specialty hospital. If the committee were to look at the mental health system as a pyramid, API would be considered the very apex. Local hospital treatments are for a maximum of 30 days, but most patients are only there for 6 to 8 days, he commented. A course of treatment at API could be months long, although most are not there for months. CHAIR WILSON pointed out that the Alaska Mental Health Board still prefers that individuals be treated at local hospital. MR. RAINERY agreed that is correct. Most people admitted to local hospitals do not need to go to a specialty hospital like API, he said. Number 2179 JEFF JESSEE, Executive Director, Alaska Mental Health Trust Authority, testified on HB 535 and answered questions from the members. He told the members that the problem with this bill is in Section 2 which allows the department to stop paying for DET when the state has reached the end of the appropriation. There are other parts of the bill that the Alaska Mental Health Trust Authority supports, such as those provisions which gives the department more management tools to bring the program under some active management. MR. JESSEE pointed to the provision that the commissioner and the governor have decided that in this particular arena if there is a cost overrun on DETs, a supplemental appropriation is not an option. Either the money must be found elsewhere in the budget or the state will stop paying, he said. Mr. Jessee noted that there is intent language in the bill testifying to the state's good intentions to try to find other funding. He said he does not doubt their sincerity in these efforts, but there are a lot of discussions going on in the state in determining what constitutes essential services. This is one of those things the state absolutely has to do, he stated. By definition all people who have been found to be a danger to themselves or others and are in the care and custody of the commissioner, who then designates the different facilities to provide these services. The administration is asking the committee to make a policy decision. He said he believes the question is who will bare the burden if a shortfall in funding for this program occurs. Mr. Jessee asked if it will be the department who will have to ask for a supplemental, the local hospitals who could be asked provide uncompensated care, or the beneficiaries who have to bare the stigma of being transported in handcuffs to API. He shared that during territorial days patients were sent to Oregon. For many people in the outlying portions of Alaska, being sent to Anchorage is about the same as being sent to Oregon, he commented. Mr. Jessee said the policy call is pretty straightforward, and if approved would mean partially dismantling the mental health system by transporting people to API. In closing, he commented that he does not believe the cost of transporting individuals to API has been included in the fiscal note. Number 2043 REPRESENTATIVE SEATON moved to adopt CSHB 535, 23-GH2080\H, Mischel, 4/26/04, as the working document. There being no objection, CSHB 535, version H was before the House Health, Education and Social Services Standing Committee. Number 1971 ROD BETIT, President, Alaska State Hospital and Nursing Home Association, testified in support of HB 535 and answered questions from the members. He told the members he believes this is a good bill in its present form and appreciated the time that was given to work through the details of it. Mr. Betit explained that he supports the bill because there is a $1 million hole in the department's budget that the legislature has not said will go away; the commissioner has stated that he will not seek a supplemental [appropriation]; and the department is seeking additional funding through disproportionate share hospital funding (DSH) that may help to fill that hole. He told the members that some people are concerned about Section 2 of the bill, however, if the department has a funding shortfall and cannot make up the $1 million, the commissioner must balance his budget. It will be necessary to act, and something akin to Section 2 will happen if there is not enough money. If this occurs there will be statutory language directing the commissioner to move these unfunded patients from community hospitals to API, he said. While the patient will be transported under embarrassing conditions, he/she will receive excellent care, and the community hospitals will not end up with an unfunded mandate that it cannot afford, he added. Mr. Betit commented that there will still be costs to local hospitals in that patients must be stabilized before being transported, but at least there is the expectation that cost will be minimized. If there is an overflow that API cannot handle, then he said he believes there will be tremendous pressure to divert money from other areas or ask for a supplemental. Mr. Betit acknowledged that this arrangement is not ideal for patients, families, or community hospitals that have made a philosophical and financial commitment to the DET program, but the future is muddier without this bill. He summarized that if there were enough money, this bill would not even be on the table, and asked that the members move this bill out of committee. Number 1898 REPRESENTATIVE COGHILL agreed with Mr. Betit's comment that when there is not enough money there needs to be a plan of action. He shared a personal experience where he escorted an individual to a treatment facility. It was not possible to get the person into the hospital so he/she was required to stay in jail for a day and a half. It was very difficult, he said. When the money is not there to pay for care, this is probably the best way to handle the problem. Representative Coghill commented that the average stay is between three to four days, so there will likely not be a huge number of individuals transported to API. He said he would be comfortable moving the bill. REPRESENTATIVE CISSNA asked how many people will be transported to API. MR. HOGAN responded in FY03 there were 244 individuals served statewide, 178 in Fairbanks, 57 in Bartlett, 8 Mt. Edgecumbe, and 1 in Kodiak. The great majority are served at Fairbanks [Memorial Hospital] and Bartlett [Regional Hospital]. He commented that Representative Coghill made a good point, in that it is the department's intention to stabilize individuals as quickly as possible. In a worse case scenario if the department had no money there could be approximately 240 individuals impacted by this change in law, he said. Mr. Hogan commented that he believes the number would actually be much smaller than that. Probably the number would be closer to 40 or 50 individuals. REPRESENTATIVE CISSNA shared that she has been involved in the mental health field for many years and has seen great strides in deinstitutionalization of individuals. She commented that there is a systemic problem. Many of these individuals could have been identified at a much earlier point thereby eliminating or minimizing the need to be hospitalized, she added. Are these services being cut, Representative Cissna asked. MR. HOGAN responded that he is a firm believer in community- based mental health services and has spent the last 25 to 30 years of his life working in that area. He said he understands that there needs to be a solid comprehensive community-based mental health system to make things work. Mr. Hogan acknowledged that there are some reductions in community-based services and prevention services. These were difficult decisions, he added. Mr. Hogan said that he has tried to maintain the integrity of the system that's been built while recognizing the current fiscal realities that face the state. Number 1995 The committee took an at-ease from 4:18 p.m. to 4:20 p.m. Number 1586 REPRESENTATIVE COGHILL moved to report CSHB 535, 23-GH2080\H, Mischel, 4/26/04, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 535(HES) was reported out of House Health, Education and Social Services Standing Committee. REPRESENTATIVE SEATON said for the record that he supports funding these obligations, but believes the state will be better off statutorily setting up a process in the event the state runs out of money, rather than leaving it to the department to do it. CHAIR WILSON commented that there are two further committees of referral including the House Judiciary Standing Committee and House Finance Committee.
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