03/25/2004 03:04 PM House HES
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+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES
STANDING COMMITTEE
March 25, 2004
3:04 p.m.
MEMBERS PRESENT
Representative Peggy Wilson, Chair
Representative Carl Gatto, Vice Chair
Representative John Coghill
Representative Paul Seaton
Representative Kelly Wolf
Representative Sharon Cissna
Representative Mary Kapsner
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
HOUSE BILL NO. 500
"An Act relating to medical review organizations; and providing
for an effective date."
- MOVED HB 500 OUT OF COMMITTEE
HOUSE BILL NO. 338
"An Act relating to attendance at public school; and providing
for an effective date."
- HEARD AND HELD
CS FOR SENATE BILL NO. 201(HES)
"An Act relating to home care and respite care; and providing
for an effective date."
- MOVED CSSB 201(HES) OUT OF COMMITTEE
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."
- HEARD AND HELD
PREVIOUS COMMITTEE ACTION
BILL: HB 500
SHORT TITLE: MEDICAL REVIEW ORGANIZATION
SPONSOR(S): REPRESENTATIVE(S) SAMUELS
02/16/04 (H) READ THE FIRST TIME - REFERRALS
02/16/04 (H) HES
03/25/04 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 338
SHORT TITLE: ENTRY INTO SCHOOL
SPONSOR(S): REPRESENTATIVE(S) MCGUIRE
01/12/04 (H) PREFILE RELEASED 1/2/04
01/12/04 (H) READ THE FIRST TIME - REFERRALS
01/12/04 (H) EDU, HES
02/17/04 (H) EDU AT 11:00 AM CAPITOL 124
02/17/04 (H) Moved CSHB 338(EDU) Out of Committee
02/17/04 (H) MINUTE(EDU)
02/18/04 (H) EDU RPT 6DP 1NR
02/18/04 (H) DP: WILSON, OGG, SEATON, GARA, KAPSNER,
02/18/04 (H) GATTO; NR: WOLF
02/18/04 (H) FIN REFERRAL ADDED AFTER HES
02/24/04 (H) CORRECTED RPT CS(EDU) 3DP 1NR
02/24/04 (H) DP: WILSON, KAPSNER, GATTO; NR: WOLF
03/02/04 (H) HES AT 3:00 PM CAPITOL 106
03/02/04 (H) Scheduled But Not Heard
03/25/04 (H) HES AT 3:00 PM CAPITOL 106
BILL: SB 201
SHORT TITLE: HOME & RESPITE CARE: CRIMINAL RECORDS
SPONSOR(S): JUDICIARY
04/28/03 (S) READ THE FIRST TIME - REFERRALS
04/28/03 (S) STA, HES
05/15/03 (S) STA AT 3:30 PM BELTZ 211
05/15/03 (S) -- Meeting Postponed to 5/17/03 --
05/17/03 (S) STA RPT 3DP
05/17/03 (S) DP: STEVENS G, COWDERY, DYSON
05/17/03 (S) STA AT 11:30 AM FAHRENKAMP 203
05/17/03 (S) Moved Out of Committee
05/17/03 (S) MINUTE(STA)
02/04/04 (S) HES AT 1:30 PM BUTROVICH 205
02/04/04 (S) Moved CSSB 201(HES) Out of Committee
02/04/04 (S) MINUTE(HES)
02/06/04 (S) HES RPT CS 3DP 1NR SAME TITLE
02/06/04 (S) DP: DYSON, GREEN, WILKEN; NR: GUESS
03/02/04 (S) TRANSMITTED TO (H)
03/02/04 (S) VERSION: CSSB 201(HES)
03/03/04 (H) READ THE FIRST TIME - REFERRALS
03/03/04 (H) STA, HES
03/23/04 (H) STA AT 8:00 AM CAPITOL 102
03/23/04 (H) Moved Out of Committee
03/23/04 (H) MINUTE(STA)
03/23/04 (H) HES AT 3:00 PM CAPITOL 106
03/23/04 (H) <Pending Referral>
03/24/04 (H) STA RPT 4DP 2NR
03/24/04 (H) DP: SEATON, HOLM, LYNN, WEYHRAUCH;
03/24/04 (H) NR: COGHILL, BERKOWITZ
03/25/04 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 535
SHORT TITLE: LIMIT STATE AID FOR MENTAL HEALTH CARE
SPONSOR(S): RULES BY REQUEST OF THE GOVERNOR
03/08/04 (H) READ THE FIRST TIME - REFERRALS
03/08/04 (H) HES, JUD, FIN
03/25/04 (H) HES AT 3:00 PM CAPITOL 106
WITNESS REGISTER
SARA NIELSEN, Staff
to Representative Ralph Samuels
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Testified on behalf of Representative
Samuels, sponsor of HB 500.
SANDY SEVERSON, Administrative Director
Quality Support Services
Providence Health System
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 500.
RYAN MAKINSTER, Staff
to Representative Lesil McGuire
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Testified on behalf of Representative
McGuire, sponsor of HB 338 and answered questions from the
committee.
BRIAN HOVE, Staff
to Senator Ralph Seekins
Senate Judiciary Committee
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented SB 201 on behalf of the Senate
Judiciary Standing Committee, sponsor, which is chaired by
Senator Seekins.
JERRY LUCKHAUPT, Attorney
Legislative Legal Counsel
Legislative Legal and Research Services
Legislative Affairs Agency
Juneau, Alaska
POSITION STATEMENT: Testified and answered questions pertaining
to SB 201.
KATHRYN MONFREDA, Chief
Criminal Records
Department of Public Safety
Anchorage, Alaska
POSITION STATEMENT: Testified on SB 201.
BILL HOGAN, Director
Division of Behavioral Health
Department of Health and Social Services
POSITION STATEMENT: Testified in support of HB 535 and answered
questions from the members.
JEANETTE GRASTO, Member
Alaska Mental Health Board
Fairbanks, Alaska
POSITION STATEMENT: Testified in opposition to HB 535.
VERNER STILLNER, M.D.
Psychiatrist
Bartlett Regional Hospital;
Legislative Representative
Alaska Psychiatric Association
Juneau, Alaska
POSITION STATEMENT: Testified in opposition to HB 535 and
answered questions from the members.
JEFF JESSEE, Executive Director
Alaska Mental Health Trust Authority
Juneau, Alaska
POSITION STATEMENT: Testified on HB 535 and answered questions
from the members.
SHARRON LOBAUGH, National Alliance for the Mentally Ill
Juneau, Alaska
POSITION STATEMENT: Testified on HB 535 and answered questions
from the members.
ROD BETIT, President
Alaska State Hospital and Nursing Home Association
Juneau, Alaska
POSITION STATEMENT: Testified in support of HB 535 and answered
questions from the members.
RICHARD RAINERY, Executive Director
Alaska Mental Health Board
Juneau, Alaska
POSITION STATEMENT: Testified on HB 535 and answered questions
from the members.
ACTION NARRATIVE
TAPE 04-22, SIDE A
Number 0001
CHAIR PEGGY WILSON called the House Health, Education and Social
Services Standing Committee meeting to order at 3:04 p.m.
Representatives Wilson, Wolf, Coghill, Seaton, Cissna, and
Kapsner were present at the call to order. Representative Gatto
arrived as the meeting was in progress.
HB 500-MEDICAL REVIEW ORGANIZATION
Number 0050
CHAIR WILSON announced that the first order of business would be
HOUSE BILL NO. 500, "An Act relating to medical review
organizations; and providing for an effective date."
Number 0102
SARA NIELSEN, Staff to Representative Ralph Samuels, Alaska
State Legislature, testified on behalf of Representative
Samuels, sponsor of HB 500. She told the members that this bill
adds the Joint Commission on Accreditation of Health Care
Organizations (JCAHO) to the narrow definition of a review
organization. She explained that the commission is an
independent not-for-profit organization that evaluates 16,000
health care organizations within the United States. The board
is comprised of physicians, nurses, and consumers, she added.
Ms. Nielsen said that JCAHO is the nation's oldest and largest
standards setting and accrediting body in the health care field,
having operated for more than four decades. She emphasized the
importance of including JCAHO in the review organization
definition because health care facilities that provide
information to the commission will have the assurance that
information will be treated as confidential. Its addition to
the statute will ultimately promote quality health care in
Alaska, she summarized.
Number 0213
SANDY SEVERSON, Administrative Director, Quality Support
Services, Providence Health System, testified in support of HB
500. She told the members that she believes this legislation is
necessary because JCAHO is the principal independent
organization that performs accreditation of hospitals and other
health care organizations throughout the United States.
Recently JCAHO redesigned its survey process from a tri-annual
survey to a policy of requiring hospitals and other health care
organizations to complete a mid-cycle periodic performance
review. The periodic performance review is a self-assessment of
compliance with all applicable standards, she said. If there
are areas that are found to be in non-compliance, the hospitals
and health care facilities are charged to develop plans of
action along with measures of success to demonstrate that the
identified problem areas have been resolved when JCAHO does an
on-site visit every three years, Ms. Severson explained.
Number 0322
MS. SEVERSON told the members that it was the intent of JCAHO
that all information developed through this process would be
shared directly with them. The American Hospital Association,
the American Society of Health Care Risk Management, and several
state hospital associations immediately identified this approach
as a significant risk management concern for health care
organizations, she explained. Ms. Severson pointed out that
depending on each state's statutes regarding confidentiality of
quality information, and what specifically entailed a quality
review organization, the information shared directly with JCAHO
could be deemed discoverable and used against the health care
facilities by any individual or entity requesting those results,
she said. This would waive health care organizations'
protection of the quality control data if the statutes do not
recognize JCAHO as a quality review organization.
Number 0441
MS. SEVERSON told the members that JCAHO met with concerned
health care organizations, the American Hospital Association,
and the American Society of Health Care Risk Management and
offered the health care organizations two additional options.
The first option suggested doing the self-assessment, but not
submitting it to JCAHO. The drawback of this is that the
organization would loose the ability to actively discuss the
details of the action plan with JCAHO and get feedback from
them. She explained that JCAHO takes data from participating
hospitals and publishes trends in patient safety and quality of
care so health care organizations can learn from each other. In
order for this to work effectively it is important that all the
health care organizations submit its data to them, she said.
MS. SEVERSON said that the second option is to choose to not do
the periodic performance review and instead do an on-site JCAHO
survey. The cost of additional surveys are charged to the
hospitals and will further inflate health care costs. She added
that surveys also take staff time away from patient care. Ms.
Severson told the members that Providence Health Systems does
not believe this option is the solution. She said that it has
completed the self-assessment process and has found it to be
very meaningful and educational for staff. Ms. Severson shared
that Providence Health Systems sought legal counsel to review
the Alaska statute as it pertains to public accessibility to
information reported through this process. She said its
attorneys reported that under current Alaska statutes JCAHO is
not considered a quality review organization; therefore, the
self-assessment information could be vulnerable to discovery
once it is submitted to JCAHO. She summarized that Providence
Health Systems is committed to evaluating and improving the
quality of health care in Alaska. It is important that this
legislation be enacted to protect the quality review
information, Ms. Severson stated.
Number 0566
REPRESENTATIVE COGHILL commented that he understands the benefit
of JCAHO. He said he believes current statute already addresses
this issue and asked for clarification that additional
protections are needed.
Number 0615
MS. NIELSEN replied that it is important to add the commission
to the statute to eliminate any uncertainty that it is not
included.
REPRESENTATIVE COGHILL asked if there are any other review teams
that should be included.
MS. NIELSEN responded that she is not aware of any; however, she
told the members that the sponsor would not be opposed to
including others who would want to be included in this bill.
Number 0722
REPRESENTATIVE SEATON moved to report HB 500, Version A, out of
committee with individual recommendations and the accompanying
fiscal notes. There being no objection, HB 500 was reported out
of the House Health, Education and Social Services Standing
Committee.
HB 338-ENTRY INTO SCHOOL
Number 0745
CHAIR WILSON announced that the next order of business would be
HOUSE BILL NO. 338, "An Act relating to attendance at public
school; and providing for an effective date."
[While no motion was made, Chair Wilson announced that version
S, 23-LS1258\S, Mischell, 3/4/04, was before the committee as
the working document.]
CHAIR WILSON told the members it is her intention to take
testimony today, but not move the bill from committee.
Number 0786
RYAN MAKINSTER, Staff to Representative Lesil McGuire, Alaska
State Legislature, testified on behalf of Representative
McGuire, sponsor of HB 338 and answered questions from the
committee. He told the committee that this bill accomplishes
two small but necessary things. First, it moves the date for
entry into kindergarten from August 15 to September 1. This
change would bring the entry date in line with most other
states. Mr. Makinster shared that there are approximately 35
states that have September 1 or later as the entry date for
kindergarten. It is important for Alaska because there are a
lot of people moving into the state, particularly military
families.
MR. MAKINSTER said a second benefit of this bill is that it
allows school boards to name an administrator to oversee this
process and to the review the applications for early entry into
kindergarten. Currently the statute provides that the school
board must review every single early entry request. This would
make the process much more efficient, he added.
Number 0886
REPRESENTATIVE WOLF asked how many other states allow early
entry into kindergarten.
MR. MAKINSTER replied that there are currently 35 states which
allow early entry into kindergarten. If this bill passes,
Alaska would be the 36th state. He explained that there are two
or three states which have August 15 or before as the cutoff for
entry into kindergarten and the rest of the states are later
than August 15. He commented that one state leaves the decision
entirely up to the parents.
REPRESENTATIVE WOLF questioned what dates other states use
beyond August 15th.
MR. MAKINSTER replied that there are 15 states that have entry
dates after September 1. The latest is California which has a
December 2 early entry date. The states before September 1
include Alaska which has August 15, Delaware which has August
31, Indiana which has July 1, and other states that do not
delegate a specific date, he said. Five states have dates
before Alaska, ten are optional, and the rest after September
1st, he summarized.
Number 0983
REPRESENTATIVE COGHILL asked what time of the year most schools
start in Alaska.
MR. MAKINSTER responded that most schools start [classes] after
September 1; however, the [actual] school year starts on July 1.
REPRESENTATIVE COGHILL commented that it has been his experience
that most of the schools start the third week in August which
would make the August 15 date more appropriate than the
September 1 date. He said he would like to know how the
districts determined the third week in August as an appropriate
time to start school.
MR. MAKINSTER replied that he has not looked at the start date.
Changing the start date will not change the mix of students very
much, he added. In a school district the size of Anchorage it
is estimated that this change will mean less than one-half
student per class.
REPRESENTATIVE COGHILL asked if there is a problem that would
merit the change of the current date.
MR. MAKINSTER said that he does not have a specific incident to
site, but that there is research in the members' packet which
reflects that starting students at an earlier age can be
beneficial. He added that the benefits may not be evident in
the first couple of years, but in the long run studies have
shown that by starting students at an earlier age the student
may progress at a faster rate of growth in the educational
system and end up being more involved with school at the high
school level.
REPRESENTATIVE COGHILL commented that he does not see how a two-
week difference is worth arguing over.
Number 1093
REPRESENTATIVE WOLF said he believes there are a lot of Head
Start programs in Alaska which would address early education.
MR. MAKINSTER replied that he has not looked into Head Start
programs. He emphasized that this bill would just align
Alaska's kindergarten starting date with that of the lower 48
states.
Number 1123
REPRESENTATIVE WOLF commented that the Head Start program starts
kids at the age of three and goes through five years of age. He
said he does not believe children are being harmed by the
current start date.
MR. MAKINSTER agreed with Representative Wolf, but pointed out
that not every school district has a Head Start program.
Number 1155
REPRESENTATIVE KAPSNER said she would like to comment on
Representative Coghill's earlier question about why school
districts start school in August. She explained that the Lower
Kuskokwim School District opts to start earlier in August so
they can get off earlier in May for spring hunting or get off
earlier for Russian Orthodox Christmas.
REPRESENTATIVE COGHILL commented Representative Kapsner makes a
good point.
Number 1195
REPRESENTATIVE SEATON asked how many students have birthdays
which fall between August 15 and September 1. He said he would
also like to know the number of students who have applied for
early entrance into kindergarten.
MR. MAKINSTER replied that he checked with the Anchorage School
District and still does not have an exact count, but it is
estimated that there would be less than one-half student per
class added to the system.
REPRESENTATIVE SEATON asked if that is per kindergarten
classroom.
MR. MAKINSTER responded that is correct.
Number 1245
CHAIR WILSON asked if the Department of Education and Early
Development has any opposition to this bill.
Number 1256
MR. MAKINSTER responded that the department actually has a
letter of support from the Anchorage School District on this
bill.
CHAIR WILSON announced that the HB 338 will be held in
committee.
SB 201-HOME & RESPITE CARE: CRIMINAL RECORDS
Number 1278
CHAIR WILSON announced that the next order of business would be
CS FOR SENATE BILL NO. 201(HES), "An Act relating to home care
and respite care; and providing for an effective date."
Number 1300
BRIAN HOVE, Staff to Senator Ralph Seekins, presented SB 201 on
behalf of the Senate Judiciary Standing Committee, which Senator
Seekins chairs. He explained that the bill was brought forward
in December 2002 by the revisor of statutes. He stated that a
law was passed that referred to a statute that had been
repealed; when the revisor of statutes reviewed the law, it was
determined that there were inconsistencies that needed to be
addressed. He said that SB 201 would clarify these
inconsistencies by replacing the repeal information with
criminal history record information permitted by Public Law
(P.L.) 105-277 and AS 12.62.
CHAIR WILSON remarked that SB 201 dealt with criminal statutes.
MR. HOVE used an example that respite care providers have to do
criminal background checks on employees to ensure that the
employees hadn't committed certain crimes.
Number 1442
REPRESENTATIVE COGHILL stated that three years ago, [the
legislature] was required by public law to pass laws for
vulnerable adults, and one of the requirements was to do
criminal background checks on employees [of respite care
providers]. He stated that during the formation of those laws,
[the legislators] had apparently skipped over a statute, or
referenced one that had previously been repealed. He stated
that one of his pet peeves is having the federal government
telling [the states] how to go about that. He stated it also
bothers him that [the state] has to reference this federal
requirement in statute. He said that he hasn't found a way
around the federal requirement, and that SB 201 would be
consistent with Alaska's vulnerable-adults law.
Number 1501
REPRESENTATIVE SEATON commented that he has previously heard SB
201 in the House State Affairs Standing Committee. He explained
that there were references to criminal justice information, and
SB 201 only refers to criminal history records so it included
information that shouldn't be acquired in a criminal background
check. He stated that he is comfortable with passing SB 201.
Number 1526
REPRESENTATIVE WOLF stated that he thought criminal background
checks were already required for respite care employees.
MR. HOVE said that it is required, but the law refers to a
section of the statute that no longer exists. He stated that
though it is required, there is nothing in statute that explains
how to do it.
Number 1609
JERRY LUCKHAUPT, Attorney, Legislative Legal Counsel,
Legislative Legal and Research Services, Legislative Affairs
Agency, affirmed Mr. Hove's statement. He further explained
that three or four years ago, a bill repealed the section of the
statute that explained how to perform these criminal background
checks. He stated that SB 201 was brought forth to reinstate
the section of statute that is needed, and to "clean up"
inconsistencies from the passage of the bill mentioned earlier.
He stated that the bill that changed all of this was not sent
through Legislative Legal and Research Services first, so the
agency could not assess the bill until after it was enacted into
law. He explained that Legislative Legal and Research Agency
found these inconsistencies two years ago, and referred it to
the Senate Judiciary Standing Committee.
Number 1644
REPRESENTATIVE CISSNA asked if it was a true mistake or if there
was a reason that the oversight happened.
MR. LUCKHAUPT responded that he felt it was a true mistake
because [the legislature] repealed Section 12.62.035 which was
the section referred to in order to perform criminal history
checks. The legislation that made this oversight was part of
the new criminal justice information act that was developed by a
governor's bill. He stated that the bill fixed a lot of things,
but overlooked these two chapters.
Number 1678
REPRESENTATIVE COGHILL asked for clarification on the scope of
the criminal history record involved in SB 201.
MR. LUCKHAUPT stated that there are various terms involved with
criminal history and criminal justice information that are
included in section 12.62. He stated that in that section,
criminal history is defined as past conviction information,
current offender information, and criminal identification
information. He said that those three things make up the
criminal history record. He explained that there is a broader
term, criminal justice information, that includes those three
things, as well as correctional treatment information, non-
conviction information, and information relating to a person who
has relocated.
Number 1750
REPRESENTATIVE COGHILL referred to hearing SB 201 in the House
State Affairs Standing Committee. He said that he recalled the
debate over what level to require employers to obtain of an
employee working for respite care providers, whether it should
be the criminal history record or criminal justice information.
He said that if he recalled correctly, it was determined that
the criminal history record was sufficient for hiring purposes.
MR. LUCKHAUPT replied that Representative Coghill is basically
correct. However, for some specific purposes such as mental
illness cases that requirement was broadened to include non-
conviction arrest information. He explained that along with the
state's requirement to conduct these background checks, there is
also a federal requirement. He stated that because these
statutes weren't in effect, the background checks might not have
been done. He commented that in order to resolve that problem,
the statutes need to be enacted to require the providers to
perform the background checks on employees.
Number 1877
REPRESENTATIVE COGHILL inferred that those reasons were why this
bill is separate from the revisor of statute's bill, stating
there are two very substantive issues; the criminal history
issue and assuming authority of public law into statute. He
asked Mr. Luckhaupt to provide some reassurance that if P.L.
105-277 is changed in the future that it isn't going to really
"mess up" the state's statutes.
Number 1909
MR. LUCKHAUPT responded that he understands the concern with
referring to other statutes. He stated that there have been
problems in the past where statutes were referred to and then
those statutes had been amended. He said that there were
certain ways that the legislature could handle this situation.
He said that [the legislature] could forbid people with a past
criminal record from working in respite care, or they could
leave that decision up to the employer. He commented that was
the reason this bill is separate from the revisor of statute's
bill. Mr. Luckhaupt said that there is a federal requirement
that mandates criminal background checks, and he doesn't think
that is going to change. He noted that if it did, Legislative
Legal and Research Services was there to identify that
significant changes have occurred. He stated that the
Department of Health and Social Services has many federal
statutes that it has to comply with at all times and it should
be watching for changes as well. Mr. Luckhaupt commented that
the legislature could be specific in what crimes need to be
required for review in order to get hired.
Number 2032
MR. LUCKHAUPT noted that many other states are referencing the
public law when creating their state statutes, and he believes
that referencing the public law is the easiest way to enact the
statute.
REPRESENTATIVE COGHILL asked if the public law did change,
whether it would require the state to make changes as well.
MR. LUCKHAUPT replied that if the public law changed, the
employers would still be required under state statute to perform
these background checks because of the language in the statute.
He told the committee that he tried to anticipate future changes
when drafting SB 201.
Number 2119
REPRESENTATIVE COGHILL shared that he asked that question
because he wanted it on the record that the bill was drafted so
that Alaska statutes would hold up in court of law if it was
ever challenged. He said that he wanted the state policy to
match the federal policy, but also be able to stand on its own.
Number 2157
KATHRYN MONFREDA, Chief, Criminal Records, Department of Public
Safety, stated that she really didn't have anything more to add.
She agreed that the statute had to be changed to make it
mandatory for a criminal background check.
Number 2163
REPRESENTATIVE COGHILL moved to report CSSB 201(HES) out of
committee with individual recommendations. There being no
objection, CSSB 201(HES) was reported from the House Health,
Education and Social Services Standing Committee.
HB 535-LIMIT STATE AID FOR MENTAL HEALTH CARE
Number 2200
CHAIR WILSON announced that the final 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 2225
BILL HOGAN, Director, Division of Behavioral Health, Department
of Health and Social Services, testified in support of HB 535
and answered questions from the members. He told the members
that HB 535 is designed to make changes in the existing statute
regarding diagnosis, evaluation, and treatment services. This
bill would give the Department of Health and Social Services
(DHSS) and the Division of Behavioral Health greater authority
to manage the program and services. Diagnosis, evaluation, and
treatment (DET) services are consider a critical component of
the community mental health and behavioral health system in
Alaska. The concept behind DET is to offer the opportunity for
individuals who may be experiencing a psychiatric emergency or
crisis and who meet the criteria for involuntary commitment, to
be stabilized in their home community, as close to their home
and family as possible.
Number 2250
CHAIR WILSON asked if she is correct in saying that he is
talking about individuals who would be harmful to themselves or
someone else.
MR. HOGAN responded that is correct. The criteria that would be
looked at is harmful to self, others, or unable to care for
themselves due to a mental illness.
MR. HOGAN explained that over the last several years the cost
for this program, which is primarily funded with general fund
dollars, has grown dramatically. The cost was approximately
$1.9 million in FY00 and has grown to over $3.3 million in FY03.
He said that the division has been receiving bills from the
various facilities, and reviewing the bills for services
provided several months after the fact. Mr. Hogan commented
that current statute says that bills need to be submitted to the
department for review within six months of the provision of
service. He explained that in many cases the department does
not even know that someone has been admitted to a facility and
that it will be liable for payment of the services. One
component of the bill creates a registration mechanism where
providers would be asked to notify the division within 24 hours
of admittance of an individual, the diagnosis, and reason for
admittance. Mr. Hogan emphasized that it is the division's
desire to work collaboratively with providers to better manage
care in these settings. The division would conduct a review on
the eighth day. He told the members that evaluation and
diagnosis services are provided between the third and seventh
day of admittance. Treatment services are actually provided
beyond seven days. It is for this reason it is important to
look at that service on the eighth day to ensure that the
individual needs to stay longer, he explained.
Number 2351
MR. HOGAN commented that one of the key aspects of the bill and
a concern which has been highlighted by the Alaska Mental Health
Board and the Alaska Mental Health Trust Authority, is the
notion of changing language from "shall" to "may". The current
language in statute has been interpreted as an entitlement. Mr.
Hogan clarified that there is not an official Attorney General's
opinion indicating that it is an entitlement; however, there
have been interpretations that it is an obligation on the part
of the state to pay for the service, whether or not the state
has sufficient funds. One of the aspects of this bill would be
to change the language to ["may" which would] make payment
discretionary.
MR. HOGAN told the members there is another critical aspect in
the bill. It provides for the department to actively work with
hospitals in the event that there are insufficient dollars and
look at modifying the rate of payment.
TAPE 04-22, SIDE B
Number 2359
MR. HOGAN emphasized that the division goes to great lengths to
ensure that the program is properly managed, and that there
would be adequate resources, but admitted that in a worst-case
scenario it may be necessary for an individual to go to the
Alaska Psychiatric Institute (API). He emphasized that is not
what the division intends to do, understands that the community
mental health system is critical, and wants to maintain the
integrity of that component and system. With increased costs
the DHSS believes it is important to have the authority to
better manage it, Mr. Hogan said.
MR. HOGAN pointed to the handout provided the committee on the
increase in costs, sites of service, and comparisons of daily
rates among providers of this service. He commented that the
primary providers are Fairbanks Memorial Hospital in Fairbanks
and Bartlett Hospital in Juneau. He explained that the
rationale for the increase in hospital costs, which has gone up
by about 100 percent since FY01 to FY03, is partially due to the
increase in the Medicaid rate which has gone up a little over 25
percent. Another reason is due to the number of people served
and the total occupancy between FY01 and FY03, Mr. Hogan
remarked.
Number 2304
CHAIR WILSON said that the committee will now take testimony
from others who have strong concerns about this bill and then
pose questions.
Number 2204
JEANETTE GRASTO, Member, Alaska Mental Health Board, testified
in opposition to HB 535. She told the members that she believes
this bill is taking the state backwards. In Fairbanks there is
such gratitude for the quality and capacity of the program in
the hospital's mental health unit. Before the hospital expanded
from 9 beds to 20 beds many people were going to jail until the
individuals could be transported to API. It was horrible, she
stated. The DET is a critical part of the community based
mental health services. Ms. Grasto commented that she agrees
with the utilization review and oversight of the program and
believes it to be an excellent idea. There is a major
philosophical change happening in this bill without any
discussion or participation by the stakeholders. That change is
the backing away from the principle of providing community based
services as close as possible to the consumer's home in the
least restrictive setting, she said. Ms. Grasto said that she
believes this change is discriminatory to the mentally ill in
particular. The Alaska Mental Health Board passed a resolution
urging the protection of adequate resources for vulnerable
Alaskans.
MS. GRASTO pointed out that API is being downsized as more
community-based services are being provided there is less need
for institutional care. She asked if the committee believes it
is appropriate to take away an indigent individual's civil
rights who cannot pay for his/her treatment.
Number 2108
VERNER STILLNER, M.D., Psychiatrist, Bartlett Regional Hospital;
Legislative Representative, Alaska Psychiatric Association,
testified in opposition to HB 535 and answered questions from
the members. He told the members that he believes HB 535 is a
threat to the involuntary treatment of the mentally ill in the
least restrictive environment, close to their homes, communities
of origin, and families.
DR. STILLNER said that historically speaking before statehood
and early statehood, Alaska sent all of the mentally ill to
Harborview which was in Portland, Oregon. Then API came into
being and was the only place an individual could be sent
involuntarily for treatment. Dr. Stillner shared that he served
as the director of the Division of Mental Health under the
Hammond administration. At that time there was an effort to get
hospitals to "buy into" the notion of regionalization, taking
individuals and evaluating them for 72 hours or even for 30-day
treatments. The hospitals asked where the money would come from
to do this, he said. There was no money available at the time.
However, through the DET program hospitals received the
assurance that it would be paid for 72-hour hospitalizations and
30-day commitments, he commented. Two facilities were developed
that could hold people behind locked doors, one in Fairbanks and
one in Juneau. After 30 days the individual would be
transferred to API if necessary, he explained. Dr. Stillner
stated that these two facilities brought about a regionalization
of treatment that did not exist before the program came into
being. In addition seven other hospitals now are able to do 72-
hour evaluations. When a judge, working in consultation with a
mental health professional, deems that some hospitalization
against an individual's will is necessary it can be done close
to home in nine different hospitals throughout Alaska, he
explained.
DR. STILLNER commented that he sees the mention of discretionary
funding as a threat to a hospital's motivation to take care of
these individuals. As many of the members in the room know many
of the mentally ill are not always very pleasantly received in
hospital settings. These individuals may be noisy, not well
dressed, bizarre, and may have a difficult time in the emergency
room. He emphasized that hospitals are providing care and are
currently being rewarded for that work.
DR. STILLNER told the members that he is not surprised that the
number of bed days has gone up. Under the conditions in which
the state operates there has been a tremendous reduction in the
community mental health funding. It is known that when
community funding is reduced the institutions become a greater
source for referrals, and that includes the correctional system
which he believes to be the new asylums or hospitals.
Number 2005
DR. STILLNER told the members that there are increasing numbers
of 30-day commitments. Bartlett sends very few people to API,
he added. The number that have required longer than a 30 day
commitment last year can be counted on one or two hands. He
summarized that the system is working with treatment being
offered close to home.
DR. STILLNER commented that another reason the number of beds
has gone up is that often when there is an individual ready to
go to API, it does not have a bed available and therefore it has
been necessary to keep people longer. There have been instances
where Bartlett has kept individuals up to 52 days because of the
problem with space or of the difficulty in transport services
between Bartlett and API, he said. Dr. Stillner summarized that
the issue of escalating cost of care over the last three years
is complicated.
Number 1961
DR. STILLNER pointed out that there is a problem when
hospitalizing someone against his/her wishes, taking away
his/her rights, and then asking the individual to pay for it.
He commented that he does not believe there is another
jurisdiction in the United States that asks an individual to pay
for an involuntary hospitalization. Hospitals won't take the
risk of being designated by the state as being a DET facility if
there is no assurance of payment. Dr. Stillner stated that the
way this bill reads, when the money runs out, the payment runs
out, and the patient will be sent to API. He underscored that
next year API will be downsizing from the current capacity from
85 beds to 72 beds. A greater reliance on the DET program will
then occur; and the individuals will either be sent to API or
into the correctional system for containment.
DR. STILLNER urged the members not to pass this bill until some
of these points are addressed.
Number 1893
REPRESENTATIVE CISSNA asked if the population in Juneau is
growing. Is the DET program similar to the emergency room (ER),
where people who have lost their insurance and have trouble end
up there, she asked.
Number 1851
DR. STILLNER replied that the Southeast population is not
growing and is static at around 90,000. He rephrased
Representative Cissna's question in asking why there is an
increase in utilization of the ER. Dr. Stillner replied that
the ER becomes the catch all for individuals. For example,
recently a young woman wanted to jump off the Juneau-Douglas
Bridge and the police took her to the ER. A mental health
clinician came in, evaluated her, called the judge with a
consultation with a psychiatrist, and advised that the woman
needed to be hospitalized involuntarily for 72 hours for
observation. It is a public health issue, he emphasized. It
protects the woman and others in some ways. Dr. Stillner said
that he sees this as a needed service. Sometimes individuals
come in from judges [orders], but often are brought into the ER
by an officer. An evaluation is done, the individual is deemed
a mentally ill person, harmful to self or others, or gravely
disabled. In summary, Dr. Stillner agreed that the ER is being
utilized more and expressed the belief that it is due to the
fact that the community mental health systems are not operating
as well.
REPRESENTATIVE CISSNA surmised that Dr. Stillner is saying that
[the increased use of the ER] is a warning sign that the
community mental health system needs to be working better.
DR. STILLNER responded that the DET is a very well designed
system, but it needs to work better. He told the members that
the monitoring of the days a hospital keeps an individual has
not been overseen very well. Speaking as a taxpayer that could
be improved, he said.
Number 1750
CHAIR WILSON commented that there were 65 clients served last
year and 57 this year [Summary of DES/T for FY00 to FY03].
However, last year the [average] number of days that clients
were hospitals was 6.6, but that number doubled this year, she
noted.
DR. STILLNER replied that is correct.
CHAIR WILSON asked if the patients' conditions were more
serious.
Number 1687
DR. STILLNER explained that API will not consider a transfer
until a patient has been hospitalized for 30 days. For example,
recently there was a woman who was admitted who was in her first
trimester [of pregnancy] and was diagnosed as psychotic,
mentally ill, and a danger to herself. It was not possible to
medicate her because of her pregnancy. A petition was made to
API and it took at least 10 days just to negotiate the transfer,
he said. There have been more 30-day treatment episodes this
past year. For example, one contributing factor is that
individuals who come to Bartlett from Ketchikan usually are
committed for a 30-day treatment. He clarified that this does
not mean an individual requires 30 days of treatment, but that
the individual can stay up to 30 days without discharge. If an
individual gets better then he/she could be discharged, but it
becomes more difficult to discharge individuals because of the
difficulty in getting follow-up care.
CHAIR WILSON asked if API has changed its policy from previous
years.
DR. STILLNER commented that he does not know if that is fair to
say, but agreed that API's numbers are up. In the case he sited
earlier, he said it took up to 10 days to get a woman
transferred to API when it was really our wish to have her
transferred immediately. It may have been a timing issue, and
not necessarily a change in API's policy. Dr. Stillner
explained that since Bartlett is a DET facility, API does not
want any transfers to be considered until 30 days of treatment
have been attempted in an effort to get individuals back into
his/her community.
Number 1608
CHAIR WILSON pointed out that there are significantly higher
numbers of days in treatment in Bartlett than other DES/T.
DR. STILLNER responded that it would be important to ask how
many are 30-day commitments.
CHAIR WILSON asked who treats patients that are transferred to
Bartlett.
DR. STILLNER replied that once Ketchikan commits someone through
the court system and sends the individual to Bartlett, the
Bartlett staff would treat the patient. He explained that
sending an individual back to Ketchikan is not always an easy
issue. There are housing, follow-up appointments, and treatment
issues that need to be addressed.
CHAIR WILSON commented that there are some snags in the system.
Number 1572
REPRESENTATIVE SEATON referred to the chart [Summary of DES/T
for FY00 to FY03] and noted that Ketchikan General Hospital had
a significant number of clients and days, yet in FY02 and FY03
the number went to zero. He asked if Dr. Stillner if he knows
if all of Ketchikan's patients were sent to Bartlett, which
would then account for the increased numbers at Bartlett.
DR. STILLNER commented that he was as puzzled as Representative
Seaton by the number in Ketchikan. He explained that Ketchikan
cannot do 30-day treatments there, only 72-hour evaluations.
Usually the patients will be transferred to Juneau. He
questioned why there would be a zero on the chart for FY02 and
FY03 unless the state has disallowed all payment of treatment
for [the 72 hour holds]. Dr. Stillner said he had heard a rumor
to that effect earlier. He referred that question to Mr. Hogan.
Ketchikan does send individuals up to Bartlett on the second or
third day of a 72-hour hold frequently, he stated.
Number 1476
JEFF JESSEE, Executive Director, Alaska Mental Health Trust
Authority, testified on HB 535 and answered questions from the
members. He spoke to aspects of the bill that the trust
supports, and commented that this program does need better
management by the department. This is a critical part of mental
health emergency services, and these are people who have been
identified as a danger to themselves or others. The Alaska
Mental Health Trust Authority is very supportive of the
management elements of this bill.
MR. JESSEE shared the history of mental health services in
Alaska. Individuals use to be sent to Morningside, then when
API was built, everyone was sent to API. It was determined that
there would be better results if individuals could be served
closer to their communities. Mr. Jessee pointed out that is the
reason the designated evaluation and treatment system (DET/S)
was developed. He emphasized that results are better and the
authority believes that the system should be expanded. The new
API has been built with a 54 to 72-bed capacity, which is
significantly smaller than the old facility. That was done
based upon the fact that the state had regional DETs in place.
The thought was that local services would be expanded, he added.
Number 1412
MR. JESSEE told the members that even Anchorage needs a DET, but
one has not be designated because API is there. Providence
[Health Systems] currently has a certificate of need [CON]
application to develop DET beds in Anchorage. If it is approved
it would allow for API to run at the 54 bed level which could
save about a unit of cost for API. The valley also needs DET
beds, he commented. It is a growing population and it will have
its share of mental health emergency needs. This is a core part
of the mental health system that needs to be supported, he said.
However, he agreed that it also needs to be managed. Mr. Jessee
emphasized that no one should be in these programs unless he/she
meets the commitment criteria and should not remain in it one
minute longer than is needed.
MR. JESSEE explained that the "rubbing point" from the Alaska
Mental Health Trust Authority's perspective is if the Department
of Health and Social Services finds that it is short on funds,
that the department would be authorized to pro-rate the
reimbursement to the hospitals. It would mean that the
department could basically reduce the reimbursement rate or
refuse to reimburse hospitals at all, he said. It would force
hospitals to absorb the costs as uncompensated care or for the
transport of individuals to API. Mr. Jessee pointed out that
since API has been downsized on the presumption that DET
services are out there, there could be a serious problem. Where
will patients be sent, he asked. As time passes and there is a
demand in need, how will it be met, he asked. The Alaska Mental
Health Trust Authority is very concerned. Some believe that
DETs are an entitlement. Mr. Jessee said that there could be an
argument that it is an entitlement for the hospitals to be
reimbursed for the services it delivers, but the fact remains
that the services are mandatory and not an option. This is not
only a public safety issue and a health issue, he reiterated.
Mr. Jessee commented that the problem could be pushed off onto
API, but that is not the view of the Alaska Mental Health Trust
Authority.
Number 1293
MR. JESSEE emphasized that no other community would take on DETs
if after making a significant capital expenditure and
operational commitment, it is found that the state may determine
at some point in the year that the reimbursement rate will be
slashed below the cost of care, or that the hospital will not be
able to keep the patients because the department will determine
that it will send the patients to API instead. Mr. Jessee told
the members that he is worried about what will happen to that
part of the emergency system if that part of the bill ends up
going through.
Number 1247
REPRESENTATIVE CISSNA expressed concern that API has decreased
in size, there is an increase in demand, and the movement of
kids out of the state continues. She said that this legislature
is saying that it wants the kids back in Alaska because it is
expensive, it is harder to integrate the kids back into the
community and their families if they aren't in Alaska. She
asked if the language in the bill he discussed impacts other
programs [with respect to kids].
MR. JESSEE commented that API is a very small part of the
adolescent treatment system. He said that the last time he
tracked the number of kids at API it was in the nine to ten
range. He said he believes API has a capacity to handle 12
kids, but said Mr. Hogan can provide the exact number. He
pointed out that with 426 kids out of state, API's 12 beds does
not make a material dent. Mr. Jessee pointed out that some of
the DET programs around the state do take kids. Mr. Jessee told
the members that the out of state placement issue isn't so much
about kids who are a danger to themselves and others at a
specific point in time, but are very seriously ill. These are
individuals who are actually committable at this point time. He
commented that the capacities the hospitals have to provide DETs
could be used to provide more emergency intervention with kids.
Mr. Jessee told the members that the biggest driver for sending
kids out of state is the continuum of care for children, not the
crisis emergency system. He added that Mr. Hogan may be able to
provide more specific information on that point.
Number 1083
REPRESENTATIVE CISSNA responded that the kids she worked with at
API were sent outside of Alaska because the state did not have
the services for them. She asked if it isn't possible that
indirectly there could be a snowball effect.
MR. JESSEE agreed with Representative Cissna. It is important
to look at the entire children's services continuum of care
because it is seriously under capacity to even start to deal
with the kids that are currently placed outside of Alaska. He
pointed out that it is not just a matter of building in-state
institutions like the ones out of state. There needs to be step
down services that start to move those kids back into their
communities and ultimately into their homes. It is a lot easier
if the kids are in state, working with in-state providers in
making that transition.
MR. JESSEE summarized that it is much easier to get individuals
who are in DETs back into the community and stabilized if the
individual is near family, community, and a treatment provider,
rather than shipping them to API. Shipping individuals to API
was done for 30 years before the DET system was developed, he
commented. Mr. Jessee said he understands the antipathy toward
what is viewed as an entitlement program, but a hospital can
provide the service and it has to be paid. He said he also
understands the budgetary and philosophical issue that this
presents. Mr. Jessee stated that he believes the solution is
better management of the program, not management of the program
through the budget. Budget management of critical mental health
care is a blunt instrument and not appropriate when dealing with
this population, he told the members.
Number 0960
SHARRON LOBAUGH, National Alliance for the Mentally Ill (NAMI),
testified on HB 535 and answered questions from the members.
She told the members that she wants to talk about the value and
need for the DETs from a personal point of view and the client's
point of view. Ms. Lobaugh shared that she has a 41-year-old
son who moved out of the house last year. He became ill at 15
years of age, and there was no place in Juneau to help him and
he was sent out of state for two and a half years. When he came
back things went pretty well for a while until he became more
and more ill. There were no community services at all at that
time, so she helped start community services by becoming
politically active through the Alaska Mental Health Board. The
community support programs and the DET facilities were a result
of those efforts. She emphasized that the mentally ill can get
well provided there is a lot of support in their community and
that includes close to home hospitalization.
MS. LOBAUGH pointed out that the alternatives are pretty bleak.
She posed a hypothetical example of an individual who lives in
Petersburg and who is experiencing stressful acting out. It
will be necessary for a police officer to escort the individual
to Ketchikan. The person will probably be chained and
handcuffed, then looked at for a while there by a doctor, then
chained and handcuffed and be transported to Juneau. The same
thing happens to the mentally ill if it is necessary to send the
person to API, she said. Ms. Lobaugh explained that the closer
the treatment is the less stigmatizing it is for the individual.
This treatment is very hard on [the mentally ill]. Many of
these people are living fairly normal lives today. Every now
and then there will be a problem and it will be necessary for
them to go to the hospital. Ms. Lobaugh emphasized that from a
family point of view it is very important to have treatment
options close to home. It is a great need. She told the
members that she was there when API was a 180-bed facility, that
is when her son spent two and a half years in API before there
were medications that were appropriate to enable him to come
home. It was very painful, she said. Because of the
medications that came out about 15 years ago her son has not
been back to API. He would not be recognized from any other
person who lives and works in the community. She emphasized
that mentally ill persons do get well.
Number 0784
MS. LOBAUGH said that she believes there are things in this bill
that would bother families. For example, the first episode that
usually occurs is when a person is a teenager. Sometimes it is
hard to distinguish teenage behavior and a mentally ill person.
Many times families do not have insurance because there never
has been parity for mental illness. She shared that her family
had a $50,000 lifetime cap. That went really fast. Just two 30
day intensive treatments in Seattle and the $50,000 cap was met.
She pointed out that some of the insurance policies do not
provide for any mental health care. Historically mental health
treatment has always been an entitlement program because that is
the way the mentally ill have been treated or discriminated
[against] because the mind has always been separated from the
body. Not until recently have people understood that mental
illness is like any other illness and it is deserving of the
same kind of equity. She emphasized the importance of moving
away from state hospitals and moving toward care in many
communities.
Number 0670
MS. LOBAUGH shared that she has a friend staying with her now
who was gravely ill and whose condition got increasingly worse
with his family situation. He was able to be admitted for 72
hours [which helped]. She explained that it is not just a
situation where the person is not taking their pills. It could
be that the medication is just not working. It takes a lot of
time to find the right mediation and dosage. The family's point
of view is that it is very important to keep evaluation and
treatment right in the community where the individual lives.
She commended the committee for trying to do that. Ms. Lobaugh
said that she has seen families go bankrupt trying to pay the
bills of their 17 year old when hospitalized. It seems unfair
in our society. She urged the members to think of this as an
entitlement because the state has always provided treatment for
those who are disabled, or a danger to themselves and others.
CHAIR WILSON asked if there was some specific part of the bill
Ms. Lobaugh wanted to address.
MS. LOBAUGH pointed to Section 5, page 4, lines [12 and 14]
which says:
(a) To receive assistance under this chapter, a
patient or a patient's legal representative must apply
in writing on a form provided by the department. A
patient must apply for assistance within 90 [180] days
after the date of admission to [DISCHARGE FROM] the
facility.
MS. LOBAUGH commented that she does not know of very many
mentally ill people who have legal representatives. It is not
provided very often. To require a patient to have that level of
sophistication is very difficult.
REPRESENTATIVE CISSNA pointed to page 2, lines [18 through 20],
where there is reference to a denial of financial assistance due
to the lack of appropriations as not appealable under AS
47.31.007.
MS. LOBAUGH thanked Representative Cissna for pointing that out.
Number 0457
REPRESENTATIVE SEATON referred the members to page 4, lines 17
through 20, where it covers Ms. Lobaugh's concern about
application for assistance. The language in this subsection
covers that notification issue as follows:
(b) A patient is considered to have applied for
assistance under (a) of this section if the evaluation
facility or designated treatment facility notifies the
department on a form provided by the department that
there is good cause to believe the patient would be
eligible for assistance under this chapter and
MS. LOBAUGH asked the members to defer this bill for about 25
years.
Number 0357
ROD BETIT, President, Alaska State Hospital and Nursing Home
Association (ASHNA), testified in support of HB 535 and answered
questions from the members. He told the members that he
believes HB 535 is intended to accomplish two primary goals.
The first, through Section 4, would introduce a 24-hour
reporting requirement for each admission to a community hospital
to facilitate co-management of the medical care of these
patients. It is ASHNA's belief that is a good policy. The
Department of Health and Social Services would be actively
participating in determining the appropriate length of stay at a
community hospital for each eligible patient. It would also
allow the department the option to order the transfer of a
patient to API for extended treatment where it will be more cost
effective, he commented. These decisions would be made by the
department as care treatment evolves, not after the fact. The
responsibility would rest with the department for any unintended
consequences from the discharge or transfer decisions. If the
bill implements the change in policy as he just highlighted, he
said ASHNA will support it. Mr. Betit told the members that it
appears to be an improvement in the process as long as there is
due notice to a community hospital when coverage is being
terminated, and the department determines that transfer to API
would be necessary. Under this arrangement the hospitals would
provide the care requested by the department for days prescribed
and in return receive reimbursement at the rates in effect at
the time care is given, he added. Mr. Betit admitted that this
will shift care away from some regional centers to a statewide
location [API], but patients will still receive care and
hospitals will receive reimbursement.
Number 0239
MR. BETIT told the members that the second provision of HB 535
is a little more concerning to ASHNA. That provision would
remove the entitlement provision for mental health services
which would allow the department the discretion to deny care to
otherwise eligible individuals for mental health services when
funding is exhausted. He commented that the department has said
both in this committee hearing and in the Senate Health,
Education and Social Services Standing Committee that situation
is not likely to happen if the department were more active in
managing the patients. It could still happen if more people
than expected required care or if the savings that the
department anticipates are unable to be achieved through more
aggressive management.
MR. BETIT stated that uncertainty on this point makes it more
difficult for ASHNA to support this part of the bill because
[even if funding is no longer there] community hospitals will
still be receiving those patients for holding and evaluation
since there is no where else to take them. It is not clear what
would become of the patients if care is denied, not because the
need for care is there, but because there is no money to pay for
it.
MR. BETIT reminded the members that he is talking about court
ordered involuntary placements with no other source of insurance
to pay for it. A community hospital could not simply discharge
that patient back into the community, nor could the hospital
expect to be compensated for treatment once the person's
treatment was completed. He told the members that this appears
to be a new unfunded mandate for community hospitals and those
who fund community hospitals as a result of this change in
policy.
MR. BETIT said ASHNA applauds the department's efforts to manage
programs more carefully in the face of very tight revenues.
However, ASHNA believes this must be done to ensure that there
are no unintended adverse financial consequences in already
strained community budgets, he said. Mr. Betit suggested that
before the committee advances the HB 535, ASHNA be given an
opportunity to work with the department on this bill and
hopefully come to an agreement on how these situations would
work if the department runs out of money.
Number 0066
REPRESENTATIVE CISSNA said that she believes the state needs to
do a better job of supporting the systems that are in place.
She asked Mr. Betit if these changes could jeopardize the
existence of some community hospitals.
MR. BETIT agreed that this bill could jeopardize the existence
of some community hospitals if it became a significant threat to
their financial viability.
TAPE 04-23, SIDE A
Number 0058
MR. BETIT added that he has a lot of personal experience with
the mental health system and ran the public mental health system
in Utah. He told the members that he has a sister who has a
very serious mental disorder. She is living independently now
with her two children because of what was done to the system in
Utah to get her out of the hospital and into the community. The
hospital piece is critical in the beginning, but it is essential
that the hospital not be the only place for an individual to go
to rescue an individual when he/she runs into trouble. It is
important to work with the mentally ill and follow-up [with care
as the individuals go back to the community]. Mr. Betit said
there are considerable things that could be done to strengthen
the system. He admitted the challenges are greater in Alaska
because the distances are greater, but the treatment of this
population is similar.
Number 0084
REPRESENTATIVE COGHILL commented that the legislature is caught
between the devil and the deep blue sea because of the state's
struggle with [funding]. He asked if ASHNA has seen any billing
difficulties presently.
Number 0150
MR. BETIT replied that he is not aware of any difficulties.
None have been brought to his attention at this time.
REPRESENTATIVE COGHILL said:
In allowing this discretion, given the numbers of
patients that is on the list of summaries of hospitals
only, we are talking probably somewhere around 500
patients, I would think throughout Alaska. If API
gets overloaded, and under this circumstance, would it
have any chilling effect to you on using the beds in
the regional areas if we put the "shall" in here.
MR. BETIT questioned inserting "shall" in [the bill]. In
response to Representative Coghill's clarification that "may"
would be inserted, not "shall". He responded that it would
[have a chilling effect] because the care would still have to be
given. This care would have to be provided without potential
reimbursement, he emphasized.
Number 0207
REPRESENTATIVE SEATON asked for clarification that these
involuntary commitments are to hospitals that are already
facilities established for these commitments.
MR. BETIT responded that there are nine facilities in the state
that could potentially take those placements for immediate
short-term care. He commented that any hospital is a potential
location for an individual to be dropped off by law enforcement
or courts if there is a crisis. There simply are not many good
places where an individual can be taken, even if it is not a
secure unit, to receive immediate medical care. The hospital
can rule out that there are not other things that might be going
on that might be causing that medical crisis. Then the hospital
begins the steps to get the patient to the closest place
possible to get him/her into the appropriate psychiatric
treatment. Mr. Betit said that hospitals are the first place
individuals go when there is a crisis.
REPRESENTATIVE SEATON asked if a court rules that an individual
must be involuntarily [committed] and there are no secure
facilities available, would the person would be held in jail.
Number 0331
MR. BETIT responded that he does not know the Alaska mental
health system well enough to answer that question, and suggested
that someone from the department would be better prepared to
respond.
Number 0350
CHAIR WILSON shared her experience as a nurse at the hospital in
Wrangell. She explained that there were times when a patient
was admitted, even though there were no secure facilities,
because the weather prevented the person from being transported.
In this event the hospital had to hire a person to attend the
individual 24 hours a day to ensure the individual would not
harm himself, herself, or anyone else. She reiterated that the
hospital must deal with the individual until transportation to a
secure facility is possible.
Number 0477
RICHARD RAINERY, Executive Director, Alaska Mental Health Board,
testified on HB 535 and answered questions from the members. He
told the members that many of the points that concern the board
have already been discussed. However, one point he did not hear
and wanted to make is that the DET program serves only indigent
individuals who have no other payment resources.
MR. RAINERY told the members that the Alaska Mental Health Board
supports the management tools provided in Sections 1, 4, and 5
of the bill. He said he believes these are appropriate. In
theory these tools could allow for more efficient use of the
program resources which should extend to allow the program to be
expanded to other communities and serve additional folks.
MR. RAINERY spoke to the philosophical differences the board has
with the department making the payment obligation discretionary.
The board believes that conflicts with several fundamental
principles which are articulated in Alaska Statutes under
47.36.55. Those principles have already been referred to in
earlier testimony. Services should be available as close to
home as possible and in the least restrictive setting, he said.
These principles were developed as part of a community consensus
process. Mr. Rainery commented that if the department plans to
move away from this consensus, as this bill does, it is hoped
that it will be done through a new community consensus process.
Number 0552
MR. RAINERY expressed the board's agreement with the governor
that the current fiscal situation is a problem. The board
distributed a resolution to all members of the legislature
supporting the development of a fiscal plan for the state that
does provide adequate resources for essential services that
protect the health of vulnerable Alaskans.
MR. RAINERY asked how many people, based on historical data and
trends, might end up being denied services if the bill were
adopted. He said he believes Mr. Hogan is speaking in good
faith when he says that it is not the department's intent that
anyone would be denied services. However, there is a fear that
could be the outcome, he said. The default referral, when a
local hospital opts not to take a particular patient because it
knows or fears that it will not be paid, is API. This will
include additional transportation costs and it will impact API's
budget and ability to provide other services. As has been noted
earlier, API is on the verge of being downsized, he added. Mr.
Rainery said he believes it is incongruous to restrict access to
the community service that most directly diverts folks from API
at a time when API's resources will be diverted. The board
believes that any savings developed from improved management of
the program should be put back into the program to allow more
folks to be served or to expand the program to other
communities, such as Anchorage or the valley.
MR. RAINERY pointed out that other than the one anomalous year
at Bartlett Hospital, the average time for individuals in DET
facilities in Fairbanks and Juneau is about 5 to 6 days. The
board does not believe this level of seriousness merits
consignment of those folks to API. He commented that API should
only be dealing with the most complex folks who are beyond the
capacity of local community hospitals to deal with. In summary,
the board agrees with the management tools the bill calls for,
but does not agree with converting the program to a
discretionary obligation on the part of the state.
Number 0785
REPRESENTATIVE CISSNA commented that she is aware of the long
process that has been undertaken to ensure cost savings and high
effectiveness. She asked Mr. Rainery if he believes this bill
would effect long-term costs.
MR. RAINERY responded that there are two sides to the issue.
The board's primary responsibility is to represent the best
interests of Alaskans with mental illness. The initial
determination was that the best interests were served by having
local services that are less restrictive than API. He said at
this point there is a lack of clarity of the long-term cost
implications. With API being downsized the possible increased
patient load is going to have an effect on its cost structure
and the other elements such as transportation. There are no
clear comparison between local costs and API costs, so it is
difficult to respond definitively to Representative Cissna's
question, he summarized.
REPRESENTATIVE CISSNA asked if other states that have
implemented community-based programs have demonstrated its cost
effectiveness.
MR. RAINERY asked for clarification that Representative Cissna
is talking about in-patient programs. In response to her
affirmative response, he said it is generally accepted wisdom
that in-patient programs are the most expensive. The issue with
local hospitals is two fold. It is a restrictive issue and from
a consumer's point of view, it is one of stigma. Going to API
involves a level of stigma that is not an issue when an
individual goes to a community hospital for care. Mr. Rainery
commented that there is a balancing act between the costs and
the appropriate way to treat a person. There are a variety of
options that have not been implemented. These involve more
intensive community-based services than are on the books now.
He noted that these are less expensive [options] than in-patient
options.
Number 0989
REPRESENTATIVE COGHILL commented that this is a tough issue
because this deals at the safety net level. He referred to
Section 3 which discusses eligibility for assistance and asked
if the board will step up to addressing the economic issue.
There needs to be shared resources by both the state and the
board. He asked Mr. Rainery if the board has discussed this.
Number 1055
MR. RAINERY replied that the board has not directly addressed
that issue. For twelve years, the API downsizing and
appropriate community system of care to support API has been the
board's number one priority. There have been many calculations
on what the fiscal arrangements need to be. Unfortunately, the
environment and administrations have changed over time so what
was viewed as the ideal arrangement of resources at one time is
something that the board must now reconsider. He agreed with
Representative Coghill that this is a safety net level of
resource.
REPRESENTATIVE COGHILL suggested that the bill be held for
another discussion on the safety net issue and the ability to
meet the needs of these individuals. He commented that the bill
needs to be amended and hopes the board will commit to working
on these issues.
MR. RAINERY replied that he does not endorse Ms. Lobaugh's
suggestion that the bill be held for 25 years. He does support
giving improved management tools to the department a chance to
work to see how that effects the expenditures under the program
for a year or two.
Number 1238
CHAIR WILSON asked Mr. Hogan to describe how the new process
would work. How is that different than the way it works now.
What happens when an event occurs on the weekend.
MR. HOGAN explained that the current process provides that the
hospital has up to six months after the provision of service to
submit a bill to us. He commented that at this time the
department does not even know if there is someone in a facility
receiving treatment. This bill would mandate that the hospital
notify the department within 24 hours to essentially register
the patient. This would begin the process of working
collaboratively with the hospital. Mr. Hogan said the
department plans to stipulate in administrative code that the
department would use First Health Services Corporation who
currently provides utilization review services for Medicaid
recipients with mental health problems. It is thought that the
department would use First Health Services Corporation as a
first step in addressing the weekend issue because the
department does not have staff available 24 hours per day, 7
days per week.
Number 1298
CHAIR WILSON asked if he believes API has enough beds so there
will not be a concern.
MR. HOGAN responded that there is agreement on the importance of
community-based services. This is a critical, essential service
to the system. The department will go to great lengths to
better manage the program to ensure that if at all possible the
service is available in communities throughout Alaska. In a
worse case scenario an individual would have to go to API.
There has been testimony that API is down sizing with only 72
beds. There have been times in the past when API has exceeded
its capacity and there will be times in the future it could
exceed capacity. That is not a desirable situation, he said.
CHAIR WILSON commented that in the past when there was not
enough money, the additional required funds were requested in a
supplemental [appropriations bill]. Why can't it continue to be
handled that way, she asked.
Number 1368
MR. HOGAN told the members that this approach has been discussed
with Commissioner Joel Gilbertson of the Department of Health
and Social Services. He has indicated that within the
department if there are programs or services where there might
be additional money that is not expended he is committed to
diverting those dollars to mental health services if it is at
all possible. Commissioner Gilbertson has said that if this is
not the case, at this point he is not willing to seek a
supplemental appropriation.
Number 1400
CHAIR WILSON announced that the bill will be held in committee
indefinitely. She commented that there is a policy decision
that needs to be made. The state does not like it when the
federal government issues unfunded mandates to the state. She
said she sees this as an unfunded mandate to community
hospitals. She believes the committee needs to move very
carefully because the state has a responsibility to these very
fragile people who need care.
CHAIR WILSON strongly suggested that the three different
entities [the hospitals, the Department of Health and Social
Services, and the Alaska Mental Health Board] work independently
to come up with some recommendations on this issue. After
working independently, she asked that they then get together to
see if some kind of agreement can be reached.
CHAIR WILSON stated that she also wants to know the procedure
that First Health will follow in the decision-making process.
She said her concern lies with the fact that First Health is not
the psychiatrist or the doctor that is involved with the
patient. Chair Wilson went on to say that she wants to know not
only how the three entities will be involved, but also how First
Health is involved.
CHAIR WILSON stated that she wants to feel comfortable with the
process. She explained that she can foresee that if there is
not great care given, there will be people who will fall through
the cracks. For example, there was an incident that occurred in
Anchorage not too long ago where a mother did something because
she did not have the correct medication. Chair Wilson
emphasized that she does not want to go home in May, and find
that something has happen without the knowledge that the
legislature did everything it could to make sure that what is
being done is the right thing. She summarized that she
understands that this will not be an easy task, but hopes that
this can be worked out.
Number 1559
REPRESENTATIVE SEATON said Denali Kid Care [eligibility] is set
at 175 percent of poverty. This bill allows for 185 percent of
poverty. He said he would like a discussion on these
differences and what the effect is.
ADJOURNMENT
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned at 5:08 p.m.
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