Legislature(2003 - 2004)
03/24/2004 01:44 PM Senate HES
| Audio | Topic |
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
SB 364-LIMIT STATE AID FOR MENTAL HEALTH CARE
MR. BILL HOGAN, Director, Division of Behavioral Health,
Department of Health & Social Services (DHSS), testified he was
answering questions that arose in HES committee meeting of March
22. He referred to the first question ["Questions on SB 364 from
3/22/04"] in committee packet, which was:
1. Fiscal note - how to manage 24-hour notification,
contract with First Health? What happens if there is
a lapse by the provider in the time to report?
He said the department's intent is to work with providers to
indicate there has been a change, and to educate providers on
the new registration requirements. The intent is not to
disallow payment because of not reporting within 24-hours; he
pointed out departmental implementation would be reasonable.
Regarding eligibility, there is no change, but rather a
clarification. When the patient is admitted, the department
will be seeking additional information regarding mental status
pertaining to being a danger to self or others, and to confirm
that status as the stay is retrospectively reviewed. The cost
to the division is anticipated to cost approximately $32,0000
annually, contracting with First Health to do these reviews.
There were potentially 275 reviews in the current fiscal year,
at $112 per review. This would also anticipate, in addition to
that initial review, reviews at the eighth day of admission.
The diagnoses evaluation piece runs up to 7 days. The eighth
day is when treatment begins so the reviews should be done on
the eighth day of admission; that would be approximately an
additional $7,000. The cost of doing the reviews would be about
$40,000 annually, based on current volume of admissions.
MR. HOGAN told members that Dr. Hopson was available to address
the second question.
SENATOR GRETCHEN GUESS asked, "Do we have a 24-hour line now?"
MR. HOGAN replied First Health Services Corporation is available
24 hours, seven days a week for Medicaid reviews. If a client
or consumer calls any of our offices, there is an after-hours
emergency, and if it is a mental health emergency, that person
is referred to the local provider. There is no mechanism in
place for departmental staff to take these calls 24 hours, seven
days a week.
MR. HOGAN continued with the third question:
3. Is there a liability issue if we order an
early discharge and someone is harmed due to that
early discharge?
He said the department is not seeking a prior authorization
process, but a retrospective review of the records with more
detail about the individual's mental status while in hospital
care. Additionally there will be fiscal discussions after
discharge. The retrospective review versus prior authorization
process will avoid most liability concerns and is only a
refinement in detail over the current process. This is not
anticipated to be a problem, he added.
MR. HOGAN continued with the next question:
4. What have other states one on this issue -
entitlement and permissive issue?
He deferred to the Department of Law to answer this question.
MS. STACIE KRALY, Assistant Attorney General, Human Services
Section, addressed the question of whether other states deal
with payments for local services as an entitlement or otherwise.
She responded she has been waiting for a response from other
states. She noted that Alaska is different from most other
states, and pointed out that in most other states - although
they have local facilities and contract for local services -
most are dealt with on an evaluation and stabilization basis,
and then immediately go to a state hospital. There is more of a
centralized provision of services in other states. Alaska is
set up so that many local facilities provide evaluation and
stabilization, and then regional facilities such as Bartlett or
Fairbanks, or API provide treatment services. Bearing in mind
that Alaska is different in terms of size and scope of services
is important. She said she was still gathering information to
answer this question, and it would be provided either through
the Chair or further testimony.
CHAIR DYSON referenced the entitlement language and asked if the
state or any other political subdivision must provide services
even if they were broke or if it meant taking funds from other
government services.
MS. KRALY replied this is the argument that would be made. In
the circumstance of a fiscal crises, where there was no money to
be paid, there are issues. If it's an entitlement program, the
government is obligated to make that payment.
CHAIR DYSON asked if political subdivisions have been sued
successfully for applying triage.
MS. KRALY said anecdotally, she is familiar with at least one
lawsuit filed in Juneau resulting from the inability of the
recipient at Bartlett to pay for his cost of care. That
litigation was resolved prior to trial. Subsequently, the case
was not filed, but there were overtures from attorneys in town
dealing with both Bartlett and consumers, seeking reimbursement
for payments they were unable to recover from folks who didn't
qualify for this program, or the program wasn't in place, or
didn't have third-party payor status. There is litigation on
this issue.
CHAIR DYSON said this wasn't exactly his question. He was
wondering if someone was refused services, or given reduced
services because of financial limitations. He questioned whether
this had been litigated.
MS. KRALY said she was not familiar with any cases that have
been brought, but it would be a conceivable cause of action.
CHAIR DYSON referred to folks receiving diagnostic services, and
asked if most were not self-payers.
MR. HOGAN confirmed this program was designed for indigents,
below 185 percent of poverty who do not have a third party
payor, including Medicaid.
CHAIR DYSON asked who pays for people who come - willingly or
unwillingly for diagnostic services.
MR. HOGAN reflected on his work in a mental health center, where
there was a sliding fee scale for all services provided. People
were expected to pay a little bit, he said.
CHAIR DYSON said if the department runs out of funds for this,
the question is, "Are they going to get the service needed, and
perhaps the presumption is there being attempt to recover cost
from the patient and their assets, so the person wouldn't be
denied the services."
CHAIR DYSON asked what happens to people who need services if
the department runs out of money and is committed to not having
a supplemental budget.
MR. HOGAN responded those individuals would have to go to API if
in-patient services were needed even though, ideally, the person
would be treated in his/her own community.
CHAIR DYSON said the default position is a more expensive one.
MR. HOGAN responded the cost at API is less expensive than
services provided at community hospitals. He said this was
answered on the second page of the handout.
CHAIR DYSON asked Ms. Kraly when she anticipated receiving an
answer to her questions.
MS. KRALY told him she hoped to receive an answer on how other
states deal with the payment issue by the end of this week or
the beginning of next week.
CHAIR DYSON said another question is liability involving
somebody bringing an action for not receiving services.
SENATOR LYDA GREEN clarified this wasn't the original question
for number three, and asked what the question was that she was
gathering information on.
MS. KRALY reiterated that Mr. Hogan had answered question number
three, and she was looking into question number four.
SENATOR GREEN asked if the question was, "How many other states
have this service as an entitlement?"
CHAIR DYSON said he asked, "How have other states handled it?
[Do] lots of them have permissive language that we are being
asked to move towards? And, what's happened with them, in terms
of cost and service to the client population?"
SENATOR GREEN asked for clarification of "permissive language."
CHAIR DYSON replied it's what's in the bill. It takes out the
entitlement language.
CHAIR DYSON asked about the companion bill.
MR. HOGAN told him HB 585 would be heard in House HES on
Thursday afternoon at 3:00 p.m.
CHAIR DYSON asked to be kept informed of its progress because of
the timing in the legislative session.
MR. HOGAN referred to the next question:
5. Wants to know what we will do if we run out of
appropriated funds. [The hand out version continues
with: We won't come back on a supplemental? Our
response of this language in other legislation is that
it is pretty much standard language in legislation on
benefits (i.e. Senior Care)]
He indicated on Monday the commissioner does not intend to ask
for a supplemental. He deferred to Ms. Jackson for further
explanation.
MS. KARLEEN JACKSON, Deputy Commissioner, DHSS, reiterated that
the objective is for no supplemental. They plan to handle the
departmental budget as one unit and do what happened this year
with a net zero supplemental within the department itself,
shifting funding as needed. If that is impossible, it's not
inconceivable that a supplemental would be necessary, but that's
not the goal.
CHAIR DYSON asked if, by inference, the goal includes that
people needing services wouldn't be turned away.
MS. JACKSOON confirmed the goal is to provide for the health and
well being of all Alaskans.
CHAIR DYSON commented SB 364 tightens up on the controls and
puts sideboards on it to get better control of costs, but not to
deny services.
MS. JACKSON concurred.
SENATOR GUESS asked, if the projection is wrong. Is the
administration's intent to take those funds out of other places
in the budget, or to deny payment to providers, or to have that
person end up at API?
MS. JACKSON responded the intent is, if there are areas within
the DHSS budget to move funds from one unit to another, that
would be done. The intention is to ensure people have services
they need, and to ensure there are cost containment boundaries
as much as possible. There are all sorts of "what if"
scenarios, but until the situations are dealt with, specific
responses aren't available. She reiterated the intent is to
provide for the health and well being of people, while
containing cost.
SENATOR GUESS asked, "The intent is not to refuse payment to a
provider because there's not enough money in that BRU to pay for
the services?"
MS. JACKSON said the whole purpose in doing this was to ensure
there is sufficient resource to meet the need in the best
possible way. The intent is not to harm providers or consumers.
SENATOR GUESS questions, "The intent is not to deny payments to
providers if you run out of money?"
MS. JACKSON confirmed that is correct.
MR. HOGAN continued on page 2, question number six:
6. Do we need to note in the bill that a medical
professional representing DHSS will be the one
deciding with the provider?
He said "deciding" refers to whether or not the person should
continue to stay within the facility. He said, as with previous
questions, these will be retrospective reviews. There is a 24-
hour review, and a review on the eighth day. If there is a
decision the person needs to leave the facility on that eighth
day, the intent is to include the medical director at API, in
the decision, and particularly in the appeal process if there is
a determination that the hospital feels the person should stay.
SENATOR GUESS asked if the administration's intent is to put
forth an amendment clarifying this, "although it's the intent of
this administration to ensure that that intent and that plan is
carried out in the future."
MR. HOGAN said he believes there is a willingness to do that.
SENATOR GREEN wondered if there was any conflict with interest,
with the named person.
MR. HOGAN replied a conflict was not anticipated.
SENATOR GREEN asked if, as a possible receiving facility, "Is
there enough of a wall, or a third person?"
MR. HOGAN said he understood there is no financial benefit to
the medical director at API, based on the number of admissions,
or people coming into the facility.
SENATOR GREEN noted this would be the facility of default, and
she wanted to be sure the program would be designed so that it's
a clean process and that no one could say, "Of course you wanted
the patient, etc." She said it wouldn't take long for it to be
full, with this process in place, and wanted to be sure this
wouldn't be misinterpreted.
MR. HOGAN said the intent is to manage API's census as best as
possible, and a concern is there would be too many people
seeking admission at API rather than not enough. He did not
anticipate this being a problem. He mentioned Dr. Hopson would
be available to answer questions about the evaluation process.
MR. HOGAN proceeding to question number seven:
7. How do costs compare between API and DET/S
[diagnosis, evaluation, treatment and stabilization]
facilities?
He referred to the hand out, listing the API daily rate as about
$670. The daily rates for the DET facilities range from about
$1,640 per day at Bartlett to as high as over $2,000 per day at
Mr. Edgecumbe and Bethel.
2:12 p.m.
SENATOR GUESS asked about comparing DET, DES, and API rates.
MR. HOGAN explained the API daily rate was the rate for all
patients, regardless of length of stay. If someone is there for
as little as 24 hours, that is factored in with individuals who
have been there for several years.
CHAIR DYSON thought the heart of the question was whether they
were there for diagnostic work.
SENATOR GUESS said she presumed API does more than DET and DES.
Given that, the local community's cost for DET and DES should be
compared to API's cost. She was interested in comparing similar
services, or "apples to apples."
MR. HOGAN said they could come up with those figures, that is,
looking at the same kinds of services at different facilities.
SENATOR GREEN asked about a third alternative. She asked what a
"community service would look like?"
MR. HOGAN responded the services provided in various hospitals
are in patient services, provided in the various communities.
The term, "community based service" connotes out of hospital,
for him, that is, not in the hospital.
SENATOR GREEN asked where out-of-hospital providers comes in for
someone who doesn't need to be at API, and depending on the
diagnoses and stabilization diagnoses is, "What is the next
lowest piece that comes after this? Because certainly these
aren't the only choices."
MR. HOGAN replied there is an array of services available in a
number of different communities. The next step down from
hospitalization would be what used to be called partial
hospitalization, or day treatment. It's possible for somebody
to participate three to four hours per day, obtaining individual
or group therapy or skills development, usually three or four
days per week. That would be the next intensive array of
services. If a person didn't need those, there might be the
more traditional hour of counseling. He said he could provide
the cost for that next array of services.
SENATOR GREEN asked if this was germane to this conversation.
MR. HOGAN said he wasn't sure, as this was not a 24-hour per
day, seven day per week service. The ideal is for the person to
be stabilized as quickly as possible, and then return to the
community with an array of behavioral health services.
SENATOR GREEN said the focus here was on the period of time
before they're stabilized.
MR. HOGAN confirmed the service refers to the period of time
that they're being stabilized, that is, to stabilize the
individual so he/she can return to his/her own community,
ideally with his/her own family.
MR. HOGAN then addressed the eighth question:
8. Do we know what the rate reduction might be, per
Section 7 of the bill?
He said as indicated on Monday, the department will work out
what that might look like, via regulation. There is also the
possibility of running out of funds, although they would go to
great lengths to ensure the basics of this service were still in
place, even if it meant looking at other programs within the
department.
SENATOR GUESS asked if there was a contradiction with the
statement of "we don't plan to refuse payment" and the
administration say, "no, it is not our intent to deal with
shortfalls in that way" and having this part of Section 7 which
says, "yes, we might reduce payments to providers if there is a
shortfall." She said she wanted clarification of the
administration's intent if there is a shortfall. Also, it seems
the intent of SB 364, regardless of the administration, is to
refuse payment - partial or full - to a provider.
MR. HOGAN responded the cost for providing DET services in a
hospital would be somewhat less than the cost to provide
services in an intensive care unit, or a medical surgical unit.
The Medicaid daily rate for services in a DET unit includes
costs from those other beds. This is the hospital daily rate.
The department has discussed looking at more closely determining
what it actually costs to provide the service in the DET unit
itself, which he thinks would be lower than an intensive care or
a medical surgical bed. That would be the methodology they
would like to move toward, to establish a lower rate for that
particular service provision.
SENATOR GUESS said this doesn't go to whether a negotiated rate
is DET or not and that you could even reduce the negotiated DET
if funds were short. Given that you can't refuse a patient, a
shortfall is passed on to everyone else paying at that hospital.
The intent is good, but since statues are around for long
periods of time, she questioned why the clause in Section 7 is
there if that isn't the intent of the administration.
MR. HOGAN responded the clause is in the bill because the
original intent was to manage cost better, and to ensure the
person still gets the necessary service. They would like the
authority to be able to negotiate a rate different than the
Medicaid rate, and this would do that, he said. He said he
would defer to the attorney general's office for advice
regarding whether it was necessary to include that clause.
SENATOR GUESS asked if the purpose of Section 7 is to allow the
department the authority to negotiate a different rate.
MR. HOGAN said it does give that authority, based on [indisc.]
shortfall.
SENATOR GUESS said she doesn't read it as a negotiation, but as
a percentage reduction, given the shortfall. So, the
flexibility wouldn't be there to say, "maybe Bartlett does cost
less but Fairbanks costs more, and we need to address these DET
rates."
CHAIR DYSON declared, "That line of reasoning raises my
hackles," and acknowledged he is somewhat familiar with cost
shifting that goes on in medical facilities. Alaska needs to be
careful that public dollars are not being used to pay for a
service, and the hospital is shifting cost from other services
and clients, onto the bills that are being paid for by public
dollars. He said he is very interested in what the department
is doing to ensure hospitals aren't doing this. He questioned
how to amend the bill to make sure the negotiated rate is
available for those who are self-payers, thereby allotting them
the same discount.
MR. HOGAN addressed the last question:
9. Explanation for cost increases over the last
several years.
He reported the hospital cost increased has 100 percent between
FY 01 and FY 03. A little over 25 percent of that increase is
due to the average daily Medicaid rate going up between FY 01
and FY 03. The other increase is in the total number of bed
days, again about a 25 percent increase.
CHAIR DYSON asked Dr. Hopson if the department's time
constraints were adequate to stabilize a patient to the point of
doing an accurate evaluation of the diagnoses. He asked what
the plan is when a patient is admitted.
DR. HOPSON from Alaska Psychiatric Institute testified via
teleconference. He said this would be different for every
patient and every treatment or evaluation center, and this would
affect the length of stay and length of treatment. Various
members of the team observe the patient, complete a psychiatric
evaluation, a past history, social history, substance abuse
history, observe them in response to the milieu to see if the
environment has a positive effect. Determine if medications are
required, and if so, to observe the response to the medication,
which could take 24, 48, or 72 hours. The first three days are
the most critical in determining whether someone will require a
length of stay longer than seven days.
CHAIR DYSON asked if some of the patients are there because they
didn't take prescribed medications and if they get back on
medication they usually stabilize in 24 to 72 hours.
Tape 04-14, SIDE B
DR HOPSON replied many patients are presenting for the first
time so there might be no history to reflect on so stabilization
might take longer. This means there wouldn't be a medication
history and other metabolic problems that are causing the
psychiatric presentation would have to be identified. These
people might end up staying longer than those that have been
there before.
Chronic patients are at the other end of the spectrum and have a
well established pattern. They might be resistant to treatment,
they might be off their medication, or their medication might
not be working any longer. These patients require very creative
treatment and may take longer to stabilize.
The short answer is that length of stay is specific to the
presentation. The retrospective review that's being discussed
would enable them to look at specific cases and observe
responses and then determine appropriateness.
CHAIR DYSON restated that patients with a history might be
stabilized more quickly. If a schizophrenic or bi-polar patient
came in and medication was indicated, he questioned whether they
could be stabilized in two or three days.
DR. HOPSON said they frequently take longer than that. A typical
scenario for three to four day stabilization would be someone
who had something happen in their lives to cause them to become
despondent or suicidal. They would be hospitalized for
evaluation and stabilization. They would be provided with
support opportunities in the community and they would receive
medication. Within 72 hours they are generally able to leave the
hospital. That population represents a number of the patients
that are under discussion, but there are a large number that
fall outside that category.
CHAIR DYSON said with that information in mind, are the time
limits for the diagnostic phase that the department is talking
about generally sufficient?
DR. HOPSON replied he thinks so.
CHAIR DYSON asked if this legislation provides ways for patients
to spend more time in the stabilization and diagnostic phase if
that's what they require.
DR. HOPSON replied, "Absolutely." It's common in the managed
care environment in other states, but it's new in Alaska. In the
managed care environment in the Lower 48, physicians are most
accustomed to working with managed care agencies and providers
to assure that patients receive the appropriate level of care.
SENATOR BETTYE DAVIS noted his qualification to speak to the
bill and asked what he thought about it.
DR. HOPSON replied the bill does provide for care for Alaskans
and also sets a precedence to begin to manage the care.
SENATOR DAVIS asked if he was saying that hospitals would have
no problem with the language in the bill.
DR. HOPSON said hospitals might have some concerns, but "if the
reviews are done in a collaborative manner with the physicians,
I think the overall intent is to provide improved quality of
care in the least restrictive setting possible. I think an
individual needs to stay in the hospital only as long as they
really need to stay in the hospital. Unfortunately, in some
communities without adequate community resources, that might
affect the new patient length of stay. This puts forth a sort of
process to kind of monitor that."
SENATOR DAVIS asked for his comments on Section 7 that talks
about working out a percentage payment if there isn't sufficient
money to pay for the services provided.
DR. HOPSON replied this is new to Alaska, but it's not new in
the scope of medicine.
SENATOR DAVIS said it's been suggested that he would be doing
evaluations and she wondered whether he felt he could do that
without help.
DR. HOPSON admitted that it "could very quickly snowball into
quite a process." He noted that he did previously state that as
medical director for the division, he thought he would evaluate
some of the retrospective reviews or consult with physicians in
some cases. However, at this point, he couldn't tell how large
that responsibility might be.
CHAIR DYSON asked Verner Stillner to come forward.
VERNER STILLNER testified on behalf of Bartlett Regional
Hospital. He stated the following:
I think this Senate Bill has tremendous implications
on the treatment of the involuntarily mentally ill
individuals of Alaska and therefore I would like to
put a couple of points forward to you.
First of all, there are seven facilities in the state
that are diagnostic evaluation facilities and there
are two outside of Anchorage that are diagnostic and
evaluation facilities. When you are a diagnostic
facility, you can take someone for 72 hours
involuntarily and then the disposition is either to
send to another hospital or if you are diagnostic,
evaluation and treatment facility, then you are able
to treat the individual up to 30 days. And the State
pays for this at the present time. The State
designates the hospital and the hospital provides the
treatment and most of the time - I can tell you I'm a
Bartlett employee, I'm a psychiatrist and a member of
the Alaska Psychiatric Association - their legislative
representative - and so therefore I look at this from
several standpoints here. Additionally, I used to have
Mr. Hogan's job back in the Hammond Administration in
'79 to '82. At that point we were having the history
of still sending all our mentally ill from Alaska to
Morningside outside of Portland Oregon. There was no
facility in Alaska. Then the API came into being and
we thought, well look, this is not a very good
regional approach. Why not bring treatment closer to
the patient's community of origin or the client's
community of origin. And we said, 'Let's get the
hospitals to do it.' And the hospitals said, 'Nothing
doing. Unless we are reimbursed for this service, we
will not provide this diagnostic evaluation or
treatment facility.'
We have evolved now where we have two treatment
facilities - diagnostic evaluation treatment
facilities - Fairbanks Memorial and Bartlett - and we
have seven evaluation facilities. I think this piece
of legislation would distort and perhaps dismantle
this regional approach to treatment because the way I
read this bill, when the money runs out - 'Good
intentions,' as my Spanish teacher used to tell me,
'pave the road to Hell.'
The legislation has a tremendous cutback in the
funding - $400,000 in its first year - which means
there are going to be fewer services provided. So that
the hospitals that are currently doing this - outside
of the API - are going to lose their motivation for
the treatment or the evaluation and treatment
facility. I think that is an unfortunate thing for the
mentally ill of Alaska because they are first of all,
involuntarily admitted.
DR. STILLNER related an anecdotal example to show that the
system is currently doing well. Patients are treated locally in
outpatient clinics and they are able to remain close to their
families and homes. SB 364, he said, has the potential to undo
this good approach.
The API is slated for downsizing in 2005 so when there is no
capacity there, the mentally ill will go to corrections. "When a
judge can't find any place to put them, then Lemon Creek
[Correctional Center] becomes an option for that individual and
then the Division of Corrections will end up paying for them,
but not treating them."
DR. STILLNER said the intentions are good here, but when you
take away an individuals freedom by involuntarily hospitalizing
them and then you make them pay for it, you're on soft ground
and thin ice legally and he would like to hear the attorney
general give an opinion on this.
In conclusion he said, "The system of designation, evaluation
and treatment facilities has allowed the treatment to become
closer to the community of origin for individuals and I fear
that this legislation with its attempt to cut the costs of
regional hospitalizations is going to shunt individuals to the
API, and when the API is full, to corrections. And therefore, I
would ask you to seriously consider the merits of this piece of
legislation."
SENATOR GREEN acknowledged she agrees with some of his
statements, but she wasn't sure about all of them. She asked
whether he opposes any kind of involuntary hospitalization.
DR STILLNER assured her he is very much in favor of it because
mentally ill individuals don't always realize that they're ill.
He emphasized that it's a wonderful vehicle for getting those
that need it into treatment. It's good for the community, the
family and the individual.
SENATOR GREEN stated that it doesn't necessarily follow that
someone who is committed involuntarily is unable to pay.
DR. STILLNER replied your insurance company is billed first and
the State is the last resort payment.
SENATOR GREEN suggested it's not wrong to try to get payment
from patients, but she's getting the impression that he's saying
it's wrong to try to get payment from individuals who are
involuntarily committed and she doesn't agree with that.
DR. STILLNER advised her that many of the individuals that are
committed for a 72 hour hold are indigent. If the hospital isn't
reimbursed for the stay then they'll be sent to Anchorage if the
transport services are available.
SENATOR GREEN questioned whether these individuals would be sent
to a correctional facility.
DR. STILLNER asked her where a judge would send an individual
for an evaluation.
SENATOR GREEN asked whether he was talking about incarceration.
DR. STILLNER said it's not incarceration, there's a holding area
at Lemon Creek and that's been used recently.
SENATOR GREEN stated that's not like going to prison. She
emphasized she doesn't want there to be the implication that
someone that can't pay would go to a correctional facility.
DR. STILLNER assured her there is no intention to sent mentally
ill individuals to a correctional facility, but that's where the
mentally ill would ultimately land if there were no safety net
treatment spectrum of services. "That's what increasingly is
happening and unfortunately [it's] throughout the nation, not
just Alaska, the correctional system is becoming the new
asylum."
CHAIR DYSON asked him to return on Monday when the bill would be
heard again. He called Sharron Lobaugh.
SHARRON LOBAUGH, NAMI Juneau representative, said she is a
founder of National Alliance of the Mentally Ill (NAMI) and has
been working in this area for about 30 years because her son
became ill at age 15. He is now 41 and moved into his own home
just last year. He's had a seriously difficult time and spent
three years at API. She said she doesn't want anyone else to
have to do that, which is why she has been to the Legislature
many times over many years. She said she's been working to get
designation and evaluation and treatment facilities close to
people's homes and to establish community support programs so
mentally ill people don't have to end up in API or on the
street.
It's been a long struggle to get to the state of the art that's
available now and she and others in the field don't want to see
it regress. SB 364 tends to regress, she said.
She pointed out that there is the issue of parity here because
there isn't good insurance for the mentally ill. This means that
if a family doesn't have insurance that covers mental illness
and if they're in the over 185 percent of poverty category, then
they'd have go into poverty to pay for their children's health
care. "Mental illness is a no fault illness," she emphasized,
and it's something that happens when individuals are on the cusp
of becoming an adult. These individuals aren't able to go on and
become income producing adults and frequently they aren't able
to qualify for Medicare until they've applied two or three
times.
There's no provision for appeal in this process and frequently
it does become a correctional issue. The mentally ill individual
may commit an infraction and if there is no other place to go,
they go to jail. "This is a big step backward and I would like
you to put this bill on hold for a long long time."
CHAIR DYSON asked if it's her position that State resources
should be used to take care of the mentally ill rather than have
families use up their resources to take care of a family member.
MS. LOBAUGH said in this kind of case she would have to say yes
because families can't get insurance to cover mental illness.
"If in the wisdom of the Legislature, you were able to get us a
parity bill so that you required insurance companies to cover
mental illness, then that might be a different story." Insurance
companies treat mental illness as though it isn't part of the
body, she said.
SENATOR GREEN asked whether any of the waivers provided
assistance to her son.
MS. LOBAUGH said yes. Her son has both a developmental
disability and a mental illness and fortunately he has a
Medicaid waiver "That has kept him out of hospital as well as
his medications," she said.
SENATOR GREEN said that's what a waiver is designed for.
MS. LOBAUGH pointed out that the bill caps a doctor's ability to
prescribe state of the art medication and that may affect her
son. He may lose the ability to have the best medication and the
consequences could be horrific.
3:00 pm
HAROLD STEPP stated he was speaking on behalf of the mentally
ill to say that the bill isn't very good. Under the bill,
respite would be good for just seven days and a lot of
medications don't work in that amount of time so "you're in the
same boat you were in before." He urged members to deal with
this problem now.
RICHARD RAINERY, executive director of AK Mental Health Board
(AMHB), said the board asked him to relay their position on SB
364. In general, the management tools are appropriate, he said,
and in some cases they're overdue. Utilization review is good
and is something everyone is trying to move toward as quickly as
possible. Other than that, the AMHB has philosophic differences
with the bill.
SB 364 allows mental health treatment to be a discretionary
service on the part of the State and that isn't in keeping with
the principles of AS 47.30.655, which says that services will be
available in the least restrictive venue possible. It also says
that services will be as close as possible to the community of
origin of an individual. Those same principles are mirrored in
the plan for the mental health system created by the board.
SENATOR GREEN asked for the statute again.
MR. RAINERY told her it's AS 47.30.655 and said the board
believes that making this a discretionary service backs away
from those principles.
CHAIR DYSON asked if he was saying that moving away from
entitlement language makes it discretionary.
MR. RAINERY said yes, the State should pay for these services.
He continued to say that the board agrees with the governor that
the current environment threatens certain essential services.
This is why the board is on record with the Legislature
supporting a fiscal plan that provides adequate resources to
protect the services that are essential to vulnerable Alaskans.
The points that make them question the bill include:
1. They don't have any idea how many individuals would be
denied services if the bill becomes law.
2. They don't know, but they surmise that if people aren't
served locally, they'll be served at API.
3. API is being downsized and a key to that is that there are
appropriate and adequate services across the state.
4. There are elements of DET that aren't yet in place and DET
in Anchorage is part of the downsizing plan. Could that
happen under this bill?
5. Other areas of the state would like to provide DET
services. Could that happen with this bill?
6. The provision of DET is an alternative to API and it was a
consensus decision by people interested in mental health in
Alaska. The board isn't opposed to changing previous
decisions, but with no clear vision of what the change
would bring they are hesitant.
7. The time that is spent in a DET facility averages about
five to six days. Under the downsize scenario at API, that
hospital would have to deal with the most complex
individuals that can't be handled at a local level. People
that just need hospitalization for five or six days
shouldn't be sent to API.
SHAWN ANDERSON testified that he is from Polaris House. He is a
father of three and is bipolar. He got out of the hospital less
than 24 hours ago and still feels vulnerable. He delayed going
for help, at least partially, because he was worried about what
it would cost. The consequences of SB 364 are scary to him and
many others are likely to look at it the same way.
JEFF JESSE, executive director of AK Mental Health Trust
Authority, said he would start by discussing the concept of
entitlement. He reminded members that they were talking about
people that health professionals have identified as a danger to
themselves or others. These aren't people the State can avoid
dealing with altogether. There's a lot of talk about which
services are essential and intervention for these people has to
be at the top of the list. This is a public safety issue, a
health issue, and often a life and death issue. "The question
isn't really the entitlement; we have to serve these people. The
question is how are we going to do it."
A number of years ago a policy decision was made. There's been a
progression from sending everyone to Morningside to sending them
all to API and now people are treated on a local/regional basis
as much as possible. Now only the people that need the longest-
term treatment end up at API. "That's why we elected to build an
API that's smaller than the one we have today and it's dependant
upon this designated evaluation treatment system that we're
still in the process of building around the state." Building a
54 bed API facility was predicated on the assumption that 18
beds of evaluation and treatment would be built in Anchorage.
That is still in process, he said.
He said they don't take issue with the cost estimate and they
agree that the program needs to be managed more closely.
However, he urged members to focus on the real problem of fixing
the rate.
In summary he said,
The bill gives the department management tools and
they would agree with those - time frames,
applications, approval - that sort of thing. In my
view, if you then also say, 'But you only have to
manage this program until you run out of money.' you
basically take away any incentive to manage. They can
sit back, spend the money and when the money's gone,
everybody else goes to API. I think you're better off
telling them that if you have a cost overrun you're
going to have to be accountable to the Legislature in
a supplemental. You need to manage this program; we'll
give you the tools to manage it, we'll give you the
tools to set the rates where they need to be, but we
need to be able to provide the service in the
communities where these people come from.
CHAIR DYSON said he thinks they agree and he and Senator Guess
tried to get on the record stating that people will get services
and facilities will get paid.
SENATOR GREEN noted she found several other references to
appropriations [AS 47.30.655] and it sounds as though it's being
applied to an additional section instead of it being a new
concept. She asked if that's correct.
MR. JESSE agreed, but made the point that introducing that kind
of uncertainty into the financing plan is the kiss of death. He
said, "One of the things I've learned in working with the Denali
Commission is business plans are gold and if you set up a system
where a facility cannot count on what the financing system is,
not only will you jeopardize the current providers who provide
service, but you can forget any expansion into Anchorage, Mat Su
or any other part of the state because no reasonable provider
would get into a business where their reimbursement is so
subject to the unpredictable management policies of the
department."
CHAIR DYSON added or the number or people that are served.
SENATOR GREEN asked if he would get back to the committee on the
question that relates to the 100 percent of hospital cost
increase between FY 01 and FY 03.
CHAIR DYSON stated that he would like to apologize for using the
term "nutty" in a previous discussion about mental health.
Directing his comments to those who had testified, he urged them
to get together with the committee members to make sure their
concerns were addressed.
CHAIR DYSON held SB 364 in committee.
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