03/05/2020 03:00 PM House HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| Presentation: Addressing Gaps in the Crisis Psychiatric Response System | |
| HB86 | |
| HB183 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| += | HB 183 | TELECONFERENCED | |
| += | HB 86 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
March 5, 2020
3:06 p.m.
MEMBERS PRESENT
Representative Tiffany Zulkosky, Chair
Representative Ivy Spohnholz, Vice Chair
Representative Matt Claman
Representative Harriet Drummond (via teleconference)
Representative Geran Tarr
Representative Lance Pruitt
MEMBERS ABSENT
Representative Sharon Jackson
COMMITTEE CALENDAR
PRESENTATION: ADDRESSING GAPS IN THE CRISIS PSYCHIATRIC RESPONSE
SYSTEM
- HEARD
HOUSE BILL NO. 86
"An Act relating to a state-owned inpatient mental health
treatment hospital; and providing for an effective date."
- HEARD & HELD
HOUSE BILL NO. 183
"An Act relating to the duties of the Department of Health and
Social Services; relating to the duties of the Department of
Labor and Workforce Development; and relating to staffing and
wage standards for the Alaska Psychiatric Institute."
- HEARD & HELD
PREVIOUS COMMITTEE ACTION
BILL: HB 86
SHORT TITLE: MENTAL HEALTH HOSPITAL: CONTRACTS/BIDS
SPONSOR(s): REPRESENTATIVE(s) FIELDS
03/06/19 (H) READ THE FIRST TIME - REFERRALS
03/06/19 (H) HSS, L&C
03/26/19 (H) HSS AT 3:00 PM CAPITOL 106
03/26/19 (H) <Bill Hearing Rescheduled to 3/28/19>
03/28/19 (H) HSS AT 3:00 PM CAPITOL 106
03/28/19 (H) Heard & Held
03/28/19 (H) MINUTE(HSS)
03/03/20 (H) HSS AT 3:00 PM DAVIS 106
03/03/20 (H) -- MEETING CANCELED --
03/05/20 (H) HSS AT 3:00 PM DAVIS 106
BILL: HB 183
SHORT TITLE: ALASKA PSYCHIATRIC INSTITUTE
SPONSOR(s): REPRESENTATIVE(s) FIELDS
01/21/20 (H) PREFILE RELEASED 1/10/20
01/21/20 (H) READ THE FIRST TIME - REFERRALS
01/21/20 (H) HSS, L&C
03/03/20 (H) HSS AT 3:00 PM DAVIS 106
03/03/20 (H) -- MEETING CANCELED --
03/05/20 (H) HSS AT 3:00 PM DAVIS 106
WITNESS REGISTER
HEATHER CARPENTER, Health Care Policy Advisor
Office of the Commissioner
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Testified during the presentation on
addressing gaps in the crisis psychiatric response system.
STACIE KRALY, Chief Assistant Attorney General
Statewide Section Supervisor
Human Services Section
Civil Division (Juneau)
Department of Law
Juneau, Alaska
POSITION STATEMENT: Testified and answered questions during the
presentation on addressing gaps in the crisis psychiatric
response system.
ALBERT WALL, Deputy Commissioner
Office of the Commissioner
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Answered questions during the presentation
on addressing gaps in the crisis psychiatric response system.
REPRESENTATIVE ZACK FIELDS
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented a PowerPoint as the prime sponsor
of HB 86.
JAKE METCALFE, Executive Director
Alaska State Employees Association
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 86.
CLINTON LASLEY, Deputy Commissioner
Office of the Commissioner
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Answered questions during the discussion of
HB 86.
ALBERT WALL, Deputy Commissioner
Office of the Commissioner
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Answered questions during the discussion of
HB 86.
BESSE ODOM, Staff
Representative Zack Fields
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented the Sectional Analysis for the
proposed committee substitute for HB 86 on behalf of
Representative Fields, prime sponsor.
REPRESENTATIVE ZACK FIELDS
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: As prime sponsor, explained the proposed
committee substitute for HB 183.
BESSE ODOM, Staff
Representative Zack Fields
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented the Sectional Analysis of the
proposed committee substitute for HB 183 on behalf of
Representative Fields, prime sponsor.
MARK REGAN, Legal Director
Disability Law Center of Alaska
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of HB 183.
ACTION NARRATIVE
3:06:40 PM
CHAIR TIFFANY ZULKOSKY called the House Health and Social
Services Standing Committee meeting to order at 3:06 p.m.
Representatives Zulkosky, Spohnholz, Claman, and Drummond (via
teleconference) were present at the call to order.
Representatives Pruitt and Tarr arrived as the meeting was in
progress.
^PRESENTATION: ADDRESSING GAPS IN THE CRISIS PSYCHIATRIC
RESPONSE SYSTEM
PRESENTATION: ADDRESSING GAPS IN THE CRISIS PSYCHIATRIC RESPONSE
SYSTEM
[Contains discussion of HB 303, SB 238, and HB 304.]
3:07:21 PM
CHAIR ZULKOSKY announced that the first order of business would
be a presentation, "Addressing Gaps in the Crisis Psychiatric
Response System."
3:08:13 PM
HEATHER CARPENTER, Health Care Policy Advisor, Office of the
Commissioner, Department of Health and Social Services (DHSS),
relayed that there had been a high-visibility case which had
resulted in a report to the courts on January 21, "Addressing
Gaps in the Crisis Psychiatric Response System." She said Ms.
Kraly would share an overview and then she would share the DHSS
response and plan to implement the order by the judge.
3:08:59 PM
STACIE KRALY, Chief Assistant Attorney General, Statewide
Section Supervisor, Human Services Section, Civil Division
(Juneau), Department of Law, acknowledged that there had been "a
long-time crisis within the acute psychiatric care in the
Anchorage area." She reported that about a year and a half ago,
two lawsuits were filed: the Public Defender Agency filed a
claim for individuals that was predicated upon a writ of habeas
corpus; and the Disability Law Center of Alaska (DLC) filed a
lawsuit seeking injunctive relief so DHSS would not hold
individuals in correctional facilities longer than necessary
while waiting transportation to evaluation and stabilization
centers for proper mental health evaluations. She reported the
two cases were consolidated and the judge issued a 61-page
decision in late October 2019 granting the relief sought by DLC,
while the relief sought by the Public Defender Agency was left
open and not dismissed, even though the habeas corpus petitions
were moot because the individuals had been released from jail.
She added that there was still an open question before the court
for interim relief. The judge granted the injunction by DLC,
and his findings articulated that the State of Alaska must
develop a robust plan to meet these gaps in care and to meet the
challenges that were identified in his order, which was released
about six weeks after the decision by the court. She added that
the parties were in active negotiations for settlement.
3:12:04 PM
MS. CARPENTER highlighted parts of the 30-page report DHSS had
submitted [included in members' packets]. There had been many
hours worked with stakeholders, including the Alaska State
Hospital and Nursing Home Association (ASHNHA) and the two
designated evaluation and treatment facilities, Fairbanks
Memorial Hospital ("Fairbanks Memorial") and Bartlett Regional
Hospital ("Bartlett") in Juneau, she said. She added that there
had been work with Department of Corrections (DOC) and the
Alaska Mental Health Trust Authority (AMHTA). There had been
requests to "not break what was working" in the Fairbanks region
and in the Juneau region. She offered examples for both, which
included that individuals are not allowed at DOC facilities on
Title 47 holds. She stated that the plan had an Anchorage and
Southcentral Alaska focus due to the input of the stakeholders.
MS. CARPENTER talked about the extensive background of the plan,
including the history of the Alaska Psychiatric Institute (API),
the history of designated evaluation and stabilization and
designated evaluation and treatment (DES/DET) centers. She
noted the plan also included discussion of the efforts to study
the problem and efforts that were implemented, including the
1115 waiver and the efforts of Senate Bill 74 in 2016 to address
behavioral health gaps. She shared that the 90-day plan has a
stipulation that a statewide DES/DET coordinator will be hired
and work from the Office of the Commissioner in DHSS. This will
consolidate what is currently happening differently in each
district and done by the Department of Law to track the active
Title 47 individuals, to determine how long they are waiting for
beds, and to help connect them to open beds. She reminded the
committee that those beds could be at API or in any of the three
DET facilities, Fairbanks Memorial with 20 beds, Mat-Su Regional
Medical Center ("Mat-Su Regional") with 16 beds, and Bartlett
with 12 beds. She opined this consolidation would allow for
better response to the partners. She explained that the
individual in the Office of the Commissioner would have a
different relationship with providers; instead of working with a
paralegal, he/she would be working "with somebody who is more
health focused and very responsive."
3:15:31 PM
MS. KRALY, in response to Representative Spohnholz, explained
there were two contractual arrangements with providers. She
said a DES facility is a shorter-term facility, as in Bethel and
Ketchikan. Those facilities offer a robust mental health
evaluation to determine whether an individual meets the criteria
for a 30-day commitment, although people are generally only kept
in these facilities for seven days. She explained that DET is a
more robust system, as mentioned earlier, where individuals
could be committed for 30 days. She added that a commitment of
longer than 30 days is usually at API.
3:16:30 PM
MS. CARPENTER directed attention to the "Fiscal Summary for
Settlement" [included in members' packets] which included a
budget amendment submitted for fiscal year 2021 (FY 21) which
would be funded by Trust-authorized receipts as well as federal
funds for the DES/DET coordinator position. She relayed DHSS
also proposed to hire a statewide adult protective services
worker dedicated to discharge planning from hospitals and DOC to
appropriate placements for longer term care or connection with
family members. She shared an anecdote for the prioritization
of vulnerable individuals. She noted that this would be funded
by AMHTA along with federal funds.
3:18:18 PM
MS. CARPENTER reported that the judge had declared it was
necessary to identify procedures and mechanisms to evaluate
someone subject to an evaluation order who had waited for
admittance to a facility to determine whether that person still
met the evaluation criteria or could be transported to an
alternative facility. She shared, "This was a little bit of a
particular pain point for our partner hospitals; however, the
department has proposed our method of meeting this is that we
will use a provider agreement to hire a pool of mental health
professionals who can be dispatched to a non-DET facility to
reevaluate individuals who have been waiting ... over 48 hours
for admission into a longer-term facility." She noted DOC was
excited to have a mechanism to help with this need. She
reported that this would be funded in partnership with $300,000
from AMHTA and $300,000 from the general fund.
3:19:50 PM
REPRESENTATIVE TARR asked whether the pool of professionals was
an "on-call" group, and what type of services would be provided.
3:20:12 PM
MS. CARPENTER said that was exactly what had been envisioned.
3:20:30 PM
MS. CARPENTER moved on to report that DHSS would order the API
wait list by priority, with clinical factors in mind, rather
than chronologically. She reported that as the department had
been ordered to focus on the respondents at DOC facilities, DHSS
would partner with DOC to create a process for notification to
DHSS for Title 47 admissions before the court order was issued.
She stated the DES/DET coordinator would assist in finding
appropriate evaluation placements outside DOC and local jails.
She opined this would be a "pretty simple form for our partners"
at DOC; however, there was not an automatic mechanism to know
whether "they have somebody sitting in a DOC facility that has
been titled." She declared that it was the intention of DHSS to
meet the goals of the court for persons not charged with a crime
but suffering from acute psychiatric needs and waiting in a DOC
facility; however, DHSS could not guarantee this in all cases.
She offered the example that sometimes in Rural Alaska, the
local jail may be the only safe place to hold someone until
transportation could be arranged to a hub community or larger
city. She noted that Governor Mike Dunleavy had introduced
three bills to "help address that process": HB 303 and SB 238,
regarding involuntary commitment procedures; and HB 304,
regarding psychiatric examinations commitment and sanity for
criminal cases. In response to Representative Spohnholz, she
deferred to Deputy Commissioner Wall to describe the intent
behind the governor's bills.
3:23:17 PM
ALBERT WALL, Deputy Commissioner, Office of the Commissioner,
Department of Health and Social Services, in response to
Representative Spohnholz, explained that HB 303 and SB 238
addressed the two types of involuntary commitment to psychiatric
hospitals. One was a psychiatric commitment performed under
Title 12 for a criminal procedure, while the other was a
psychiatric commitment performed under Title 47 for a civil
procedure. He declared there had been longstanding issues on
both sides concerning who had custody of the patient and what
the procedure was for that commitment process. He explained
that Title 12, the criminal procedure, had a requirement in
statute that the evaluation be performed by two certified
forensic psychologists. He declared that the State of Alaska
had never been able to comply with the statute, as there were
only about 275 certified forensic psychologists in the nation,
and none in Alaska. He explained that the proposed bill was an
effort to make Alaska statute more in line with what other
states do.
3:24:53 PM
REPRESENTATIVE CLAMAN asked whether the current standard was for
both psychiatrists and psychologists.
3:25:00 PM
MR. WALL clarified, "That is correct." He explained that
although the statute allowed for either, even the psychiatrists
working at API or a similar facility may not feel qualified in
the area of forensics specifically and would disqualify
themselves.
REPRESENTATIVE CLAMAN asked whether the number of forensic
psychiatrists was even smaller.
MR. WALL expressed his agreement. He explained the proposed
bill dealing with the civil involuntary process was about the
"who and when" for the custody of a patient. He stated, as
there had been some unclear practice for when DHSS custody would
begin in the evaluation process, the proposed bill would clarify
that this would begin at the time the evaluation takes place.
The proposed bill would also clarify that DET should have the
full 72 hours for the evaluation process, as it often took this
much time for a patient in crisis to stabilize enough for an
effective evaluation.
3:27:25 PM
MS. CARPENTER continued with the presentation. She said DHSS
recognized that full implementation of the plan would require
the continuation of "several pieces," including forward movement
with hospital partners to make improvements to the entire
Behavioral Health system. The department plans to engage with
hospitals and other front line behavioral providers on best
practices and to ensure that tele-psychiatry is available. She
said hospitals requested that the department connect [API] to
the Emergency Department Information Exchange (EDIE) system so
that emergency room (ER) doctors can find prior medication
information for a patient. She added that DHSS would continue
to support a full continuum of care, including the new options
for crisis stabilization. She reported there was an extensive
list of these considerations on pages 21 and 22 of the plan.
She added that DHSS had recommended two changes to the Alaska
Court System for amendment of court forms.
3:28:52 PM
REPRESENTATIVE TARR asked whether the best practices would
include discussion about improvement for the grievance
procedures.
MS. CARPENTER replied, "Absolutely." She said DHSS was also
speaking with ASHNHA.
MS. CARPENTER suggested a modification for the two different
notifications of rate forms into one form, so the DES/DET
coordinator could encourage its use by the partners. She added
DHSS had also asked the Alaska Court System to change its form
for ordering an individual to be treated or placed at API or a
DET facility. She explained that currently, the judge had the
discretion to determine which facility, which she opined could
limit the options when attempting to quickly place a patient in
an available bed. She said DHSS was asking that this be a more
generic form, so the coordinator could find the most appropriate
placement in conjunction with the partners.
3:31:12 PM
CHAIR ZULKOSKY asked whether the DET facilities can have a
patient within their purview for up to 30 days.
MS. CARPENTER offered her understanding that the DET facilities
do take the 30-day commitments and would likely move a longer-
term patient to API.
CHAIR ZULKOSKY asked about the discharge and coordination
process for patients arriving from other parts of the state
after an extended stay at either API or another facility.
MS. CARPENTER explained that when an individual was admitted to
a DET facility with a Title 47, DHSS would ensure that the
transportation was paid. For example, Bartlett would often send
a hospital staff member as a travel companion with an individual
[in its Mental Health Unit] to ensure the patient was on the
final plane to his/her home community. She reported that the
Bartlett social worker would find out what the patient needed
upon discharge and would set up these items with the providers
in the patient's home community to make sure that the discharge
was successful. She noted that as often there was not
compensation for this extra work, DHSS had proposed funding
administrative grants for DES and DET, pointing out that this
was not compensated by Medicaid or the daily bed rate. She
reported that DHSS had proposed $125,000 for each DES facility
and $250,000 for each DET facility, which was detailed on the
included spread sheet [included in members' packets]. She added
that DHSS had also requested $375,000 for contingency money to
incentivize additional DES and DET providers.
CHAIR ZULKOSKY asked whether Bartlett had paid for the
referenced travel support through "financial collaboration with
the state."
MS. CARPENTER answered that the financial collaboration for the
transportation would be handled by the Division of Behavioral
Health, while the rest of the discharge planning was at the
expense of the individual providers.
CHAIR ZULKOSKY asked for the percent of Alaskans discharged from
a facility not into their home community.
MS. CARPENTER acknowledged that as there were a limited number
of facilities, there would be "a lot of out of region
placements."
3:36:26 PM
MS. CARPENTER reported that the plan included a commitment with
the partners for a timely implementation of the "Crisis Now"
model, which she had reviewed in Arizona. She reported on the
three legs of the plan: an improved statewide call center,
mobile crisis teams, and crisis stabilization with a full
continuum of care.
MS. CARPENTER declared that these were funded through the 1115
behavioral health waiver. She noted that there was a Medicaid
funding mechanism to fund the bulk of the services. She
reported that DHSS recognized that successful implementation of
the plan required several appropriation item requests through
the Alaska State Legislature. She stated that money had been
requested through a judgement and claims line in the
supplemental budget for crisis placement provider agreements,
$678,000 from the UGF funded with Medicaid receipts. She
explained that this was for placements of individuals with civil
psychiatric needs in which API or a DET facility might not be
the best placement. She pointed out that these individuals
could have complex medical needs as well as behavioral health
needs.
3:38:50 PM
MS. CARPENTER said DHSS was requesting disproportionate share
(DISH) hospital funding, which would be $4.5 million
undesignated general fund (UGF) money matched with $4.5 million
federal funding. She pointed out that there had been a two-year
appropriation in 2018 of $14 million to expand services.
MS. CARPENTER said DHSS sees DISH as important for stability in
psychiatric crisis response. She said Alaska Regional Hospital
("Alaska Regional") was able to get $2 million over two years
for a category of DISH funding called "substance abuse treatment
provider." Alaska Regional was qualified because of its
contract with the MyHealth Clinic, to which Alaska Regional
referred patients for outpatient substance abuse treatment. The
DISH funding received was critical to keeping that clinic open,
she stated, and if the DISH funding ended at the end of FY 20,
then analyzation of services would need to take place and only
some allowed to continue. Ms. Carpenter offered by way of
example a social worker who had been dedicated to the ER, who,
without funding, would likely be shifted to assisting with
discharge planning for Medicaid patients with longer lengths of
stay. Telepsychiatry has been implemented in the past year to
complement the tele-behavioral health program, Ms. Carpenter
related, adding that a behavioral health response team had been
put in place with the funding as well. Even though DISH funding
is for uncompensated care, all payers have benefited from the
additional positions.
MS. CARPENTER offered as a last example Fairbanks Memorial,
which received $2.2 million to set up a single point of entry
psychiatric emergency room. Fairbanks Memorial had been one of
Alaska Regional's providers for 20 years, and funds it had
received for the single point of entry allowed it to improve
quality of care in the ER with patients who were seeking help
with behavioral and mental health services. In order to
accomplish this, Fairbanks Memorial had hired additional
personnel including social workers, security officers,
psychiatrists, and legal assistants. Ms. Carpenter acknowledged
the work Fairbanks Memorial had done for behavioral health, and
relayed details about the number of encounters during its single
point of entry, in which they tripled the requirement of its
contract.
3:42:50 PM
MS. CARPENTER related the last fiscal piece was increasing DET
secure transport by $500,000, which went back to Chair
Zulkosky's comment about making sure there were enough resources
to get individuals back to their home communities.
3:43:09 PM
CHAIR ZULKOSKY asked how many beds were available at Bartlett,
Mat-Su Regional, and Fairbanks Memorial, as well as at the DES
facilities.
MS. CARPENTER said she would follow up with DES information, but
noted that Fairbanks Memorial had 20 beds, Bartlett 12, and Mat-
Su 16, for a total of 48 beds outside API. In response to a
follow-up question, she offered her understanding that API had
50 beds, but she said she would get back to the committee with
that information.
3:44:17 PM
The committee took an at-ease from 3:44 p.m. to 3:49 p.m.
HB 86-MENTAL HEALTH HOSPITAL: CONTRACTS/BIDS
3:49:00 PM
CHAIR ZULKOSKY announced that the next order of business would
be HOUSE BILL NO. 86, "An Act relating to a state-owned
inpatient mental health treatment hospital; and providing for an
effective date." [Before the committee, adopted as a work draft
on 3/28/19, was the proposed committee substitute (CS) for HB
86, Version 31-LS0623\U, Marx, 3/26/19.]
3:49:08 PM
REPRESENTATIVE SPOHNHOLZ, in response to Chair Zulkosky,
[renewed] the motion to adopt the proposed committee substitute
(CS) for HB 86, Version 31-LS0623\U, Marx, 3/26/19, as the
working draft.
3:49:21 PM
CHAIR ZULKOSKY objected for the purpose of discussion.
3:49:43 PM
REPRESENTATIVE ZACK FIELDS, Alaska State Legislature, as prime
sponsor of HB 86, using a PowerPoint presentation, shared some
history and facts about API on slides 2-3. He said API had far
fewer beds than were needed to meet present needs, which created
a myriad of problems ranging from people with psychiatric
illnesses not receiving treatment, which put Alaskans at risk
and necessitated hospitals' holding of psychiatric patients in
the ER, guarded one-on-one, effectively driving up the cost of
health care. Representative Fields noted the controversy
surrounding attempted privatization of API since the
introduction of HB 86; some headlines from news stories could be
seen on slide 4 of the PowerPoint. The state was not
permanently privatizing API, he said; Wellpath (WP) continued to
have shorter-duration contracts to provide some management
services. What HB 86 would do was prevent overall privatization
of the entire facility, he related, while not prohibiting
privatization of certain functions within API.
3:51:45 PM
REPRESENTATIVE FIELDS related there were many troubling examples
of negligent care at WP facilities across the U.S., and Correct
Care Solutions, which was the former name of WP, had been sued
about 1,400 times since 2003, including substantiated claims of
wrongful death and inadequate care.
3:52:58 PM
REPRESENTATIVE FIELDS, referencing slides 5-6, shared with the
committee a timeline of API's relationship with WP and the
latter's corporate history. Referencing slides 7-8,
Representative Fields noted there had been a high turnover of
numerous positions under WP. Staff were concerned with WP
management, he related, and there has been criticism, including
in the media, of WP's failure to bring conditions at API where
they needed to be. Referencing slide 9, Representative Fields
noted that the legislature had looked at API management in a
recent comprehensive study in 2017, examining a wide range of
options for managing the facility ranging from wholesale
privatization to partial privatization to modified state
management. In the study, full privatization entailed decreased
quality of service and higher costs, and recommended state
management with outsourcing what they considered non-core
services. Consistent with the 2017 study, HB 86 would ensure
public management with opportunities to outsource certain
functions, but not management of the whole facility.
3:55:24 PM
REPRESENTATIVE FIELDS noted public support for continued public
management of API, as exemplified on slide 10. Pacific
Consulting Group (PCG) had looked at private management of
facilities such as API, and when those facilities were privately
managed for profit, it cost a significant amount of extra money
in terms of profit margin on top of basic operations of the
facility. In conclusion, Representative Fields stated that the
for-profit model was incompatible with the basic mission of API
because it created an ongoing incentive for the private owner to
provide inadequate staffing to meet patients' and employees'
needs.
3:56:19 PM
REPRESENTATIVE FIELDS said HB 86 had some adjusted terminology
and did allow for privatization of certain functions, a good
balance to ensure the entity that ran API had a public mission
but there was flexibility to run the facility and adjust to
current needs.
3:57:01 PM
REPRESENTATIVE PRUITT confirmed API had been managed by the
state prior to the last election. He then asked, when looking
at the Ombudsman's report and some things that occurred under
state management including the sexual assaults in 2018 and 2019,
why state management would be better than a private entity. He
also mentioned HB 86 seemed to group all private entities in
with WP, when the important consideration was that the most
vulnerable of the population were properly cared for, no matter
who managed the facility.
3:58:44 PM
REPRESENTATIVE FIELDS expressed that the issue was complex and
said he was aware of three bills all addressing different
aspects of problems with API. He admitted that passing HB 86
would not, in and of itself, solve the problems. Representative
Fields said he appreciated the committee's hearing another bill
he introduced addressing API staffing and capacity issues. He
said the sexual assault and other safety-related incidences were
related to inadequate staffing. He said he has a problem with
"a profit motive." He said he would not have the same problem
with a non-profit running the facility because the same problems
did not exist in terms of incentives. He said the legislature
must appropriate sufficient money "to run the facility" while
recognizing that not having sufficient funds "creates the public
safety and cost ripple effect." He said he thinks HB 86 would
be one part of a broader solution. In the last year, WP has
had a chance to fix problems with API and they have not done so,
he added.
4:00:48 PM
JAKE METCALFE, Executive Director, Alaska State Employees
Association, testified in support of HB 86 and said he agreed
with Representative Fields' statements. Mr. Metcalfe shared the
Alaska State Employees Association (ASEA) experience with its
staff at the facility. Understaffing and underfunding had been
problems for a long time, he related, including with WP. One of
the more concerning aspects, he shared, were the discussions of
outsourcing having created a high amount of instability in the
workplace: according to ASEA calculations, 75 people have left
in the last year for the reason of uncertainty regarding what
will happen at the facility. Employees do not want to work for
a private contractor; they want leadership, he shared. Some of
those who have left had been at API their entire careers, he
added.
MR. METCALFE blamed the privatization for the employees'
departure. They had been told a feasibility study would be
done, he related, at the end of February when it had been
announced that WP would come in as the contractor. It had not
been done, which resulted in litigation. There had been a
feasibility study scheduled for April [2019], and then June, and
then September, and then December, before the February date was
missed, and [at the time of Mr. Metcalfe's testimony] one more
had been scheduled for March 9. The inability to get a study
done, or to provide the results, has created moral issue in the
workplace. Mr. Metcalfe referenced the 2017 study
Representative Fields had brought up, which showed privatization
would only be successful by a major cut in staff. This created
safety problems for staff and patients alike, he reiterated.
MR. METCALFE noted there had been problems not only with staff
but with leadership, as there had been between five and seven
chief executive officers (CEOs) during the current
administration, in addition to another six prior to the
privatization effort. Leadership had changed every couple of
months, both under state management and with WP in the facility.
From ASEA's standpoint, Mr. Metcalfe stated, the situation was
"privatization by attrition," both within leadership and among
staff who took care of people in need. Among neither group was
the instability welcome, he said, and the way to fix the problem
was to have the state run it and to staff it properly.
4:07:28 PM
REPRESENTATIVE PRUITT said that sexual assaults were due not to
a lack of funding but to failure by staff, and since WP has been
at the helm there has been additional training of staff.
4:09:23 PM
MR. METCALFE replied he had been with ASEA since 2018 and knew
from experience dealing with API what the record was like prior
to that time. He said he also knew from his experience dealing
with WP and the privatization issue he would stand by API as a
state-run facility as opposed to one run by WP. He admitted
this stance did not account for perfection of all staff, and it
was possible additional training may in certain cases be
required. Mr. Metcalfe shared some background prior to the
transition to WP. He said that in his experience the problem
was with the transition to WP, but API had been underfunded and
understaffed for many years. He said stable leadership and
adequate staff were needed on all levels, and if that were able
to happen, issues such as sexual assault would be able to be
prevented. He reiterated understaffing would not work at a
hospital that is at full capacity. State-run programs implement
decisions by policy makers that the funding and staffing will be
adequate because of the constitutional obligation to provide the
service to people, he added.
4:13:30 PM
REPRESENTATIVE PRUITT said that funding and bed levels had been
increased in 2017, and one of the sexual assaults was in spring
of 2018. Even when additional funding was given, assaults
happened, he stated.
4:15:38 PM
MR. METCALFE said funding had been increased but it had not been
enough, as API had been underfunded for years prior to 2017, and
the 2017 funding had in fact been a "Band-Aid funding approach."
As far as WP was concerned, Mr. Metcalfe stated 70 staff had
left since the WP takeover, including six to seven new CEOs.
Mr. Metcalfe repeated that WP lacked leadership and admitted the
cause may be other bills which addressed wage issues and other
changes. He stated that privatization had not been successful
in psychiatric facilities; the state had made the decision to
care properly and responsibly for its vulnerable people and not
"ship them out."
4:18:52 PM
REPRESENTATIVE PRUITT clarified that the state still did manage
the facility with WP as a consultant.
4:19:33 PM
REPRESENTATIVE SPOHNHOLZ pointed out API was still a public
institution. There had been a contract last year for the
takeover of the hospital which had not been awarded. A look at
the records, she continued, showed Centers for Medicare &
Medicaid Services (CMS) citations at API had started to rise in
2015 and coincided with many years of tough fiscal situations.
Costs had to be cut in many areas and the budget had to be
managed, she imparted, and API had been under-resourced,
especially when taking into consideration the high level of
training needed to support patients. Representative Spohnholz
asked whether there was any language in HB 86 that would prevent
API from contracting with experts to help improve outcomes.
4:21:15 PM
REPRESENTATIVE FIELDS replied there was not.
4:21:19 PM
CHAIR ZULKOSKY asked about the status of the new feasibility
study being conducted by API on privatization and state
management.
4:21:50 PM
CLINTON LASLEY, Deputy Commissioner, Office of the Commissioner,
Department of Health and Social Services, replied the
feasibility study was due to DHSS March 9. He said it had four
focal points: maintaining a state-run facility with
enhancements to try to get back to the 80-bed capacity; looking
at privatization, whether through a for-profit or non-profit
organization; providing an option for public corporation while
remaining a state-owned facility; and contracting out some
services, as was currently done.
4:23:24 PM
CHAIR ZULKOSKY asked when DHSS began the feasibility study Mr.
Lasley referenced.
MR. LASLEY replied the contract had been awarded in October
[2019] and had been due to be finalized at the end of February,
but the contractor did ask for some additional information, and
an extension had been granted until March 9.
4:23:48 PM
REPRESENTATIVE SPOHNHOLZ asked what DHSS was seeking to
understand or learn after a privatization study which consisted
of 98 pages had just been done in 2017.
4:24:22 PM
MR. LASLEY replied there were now four options, which was a
different approach. Instead of "just a typical privatization
study," the feasibility study at hand looked at the best
mechanism to run the hospital, he stated.
REPRESENTATIVE SPOHNHOLZ asked how many state psychiatric
hospitals in the U.S. were privately run.
MR. LASLEY replied he did not know.
REPRESENTATIVE SPOHNHOLZ asked whether there was a model in
other places DHSS was trying to follow or if it was on a general
fact-finding mission.
4:25:52 PM
ALBERT WALL, Deputy Commissioner, Office of the Commissioner,
Department of Health and Social Services, regarding why another
privatization study would be done in such quick succession,
stated that the older study, began in 2016 and published in
2017, showed that beginning in 2013 there had been a series of
state-run hospitals having the same problems as API. There were
laws which required states to care for inpatient psychiatric
patients in a timely fashion, and many states had been failing
in that regard. Because of these failures, many states were
experiencing lawsuits. Mr. Wall related that in a presentation
to the Senate Health and Social Services Standing Committee in
February 2019, new findings, court orders, and rulings across
different states had been revealed. Other states, through U.S.
Department of Justice injunctions, had been appointed court
monitors for their state-run hospitals, and DHSS had wanted to
take this into account in a privatization study to bring it up
to date.
4:28:03 PM
REPRESENTATIVE FIELDS noted that in the 2017 feasibility study
PCG did look at eight privatization options, and PCG's letter to
the committee did address privatization in different states and
proclaimed it a "disaster."
4:28:56 PM
BESSE ODOM, Staff, Representative Zack Fields, Alaska State
Legislature, on behalf of Representative Fields, prime sponsor,
presented the Sectional Analysis for the proposed committee
substitute (CS) for HB 86, labeled 31-LS0623\U, Marx, 3/26/19,
[included in members' packets], which read as follows [original
punctuation provided]:
Section 1. This section amends AS 36.30.300, the
statute on Single Source Procurements, to add a new
subsection, (f) that prohibits creation of contracts
relating to the ownership or management of an
inpatient mental health treatment hospital established
under AS 47.30.660 (c) (see Section 4)
Section 2. This section amends AS 36.30.310, the
statute on Emergency Procurement, to add a new
subsection, (b) that prohibits the use of these
statutes to create contracts relating to the ownership
or management of an inpatient mental health treatment
hospital established under AS 47.30.660 (c) (See
Section 4)
Section 3. This section amends AS 47.30.660 (b) to
correspond with a new subsection in AS 47.30.660 (c),
that is established in Section 4.
Section 4. This section amends AS 47.30.660 to add a
new subsection, (c), that requires the Department of
Health and Social Services manage an "inpatient mental
health treatment hospital" in the State. It prohibits
the state from delegating or contracting for the
ownership or management of such a facility. It also
defines "inpatient mental health treatment hospital"
for the purposes of this section.
Section 5. This section amends the uncodified law of
the State of Alaska to define the applicability of new
subsections established in Section 1, Section 2,
Section 3 and Section 4, to contracts entered into,
amended, extended or renewed after the effective date
of this Act.
Section 6. This section amends the uncodified law of
the State of Alaska to state if this Act takes effect
after February 1st 2019, it is retroactive to February
1st 2019.
Section 7. This section provides for an effective
date; it would take effect immediately on passage
under AS 01.10.070 (c).
4:31:52 PM
CHAIR ZULKOSKY removed her objection to the [renewed] motion to
adopt the proposed committee substitute (CS) for HB 86, Version
31-LS0623\U, Marx, 3/26/19, as the working draft. There being
no further objection, Version U was [once again] before the
committee.
CHAIR ZULKOSKY announced that HB 86 would be held over.
HB 183-ALASKA PSYCHIATRIC INSTITUTE
4:32:19 PM
CHAIR ZULKOSKY announced that the final order of business would
be HOUSE BILL NO. 183, "An Act relating to the duties of the
Department of Health and Social Services; relating to the duties
of the Department of Labor and Workforce Development; and
relating to staffing and wage standards for the Alaska
Psychiatric Institute."
4:32:29 PM
REPRESENTATIVE SPOHNHOLZ moved to adopt the proposed committee
substitute (CS) for HB 183, Version 31-LS1211\S, Marx, 3/3/20,
as the working draft.
4:32:44 PM
CHAIR ZULKOSKY objected for the purpose of discussion.
4:32:55 PM
REPRESENTATIVE ZACK FIELDS, Alaska State Legislature, as prime
sponsor of HB 183, gave a PowerPoint presentation. Referencing
slide 2 of the PowerPoint, he explained that HB 183 would
address staffing and capacity issues in order to provide safe
conditions at the Alaska Psychiatric Institute (API). The
proposed legislation would also address the need in the
community for public safety and a cost-effective healthcare
system by addressing staff retention and correcting wage
disparities that currently exist. A low, but necessary, floor
had been set for maintaining bed counts, according to
Representative Fields. Bed count statistics were included in
slides 3 and 4 of the presentation. He said HB 183 would also
require an annual report by the Department of Health and Social
Services (DHSS) on related activities, including staffing
standards. In terms of bed counts, Representative Fields said
even 80 beds would be a lower amount than several decades ago.
At lower bed counts, API was full or almost full most of the
time, he related. Moving on to slide 4, he pointed out that the
bed count in the Adolescents Acute Care level was zero, which
was a big problem for public safety in the broader community as
well as for Alaskans who needed safe treatment.
4:35:26 PM
REPRESENTATIVE FIELDS said he had heard from health care
providers how dangerous it was when a lack of capacity at API
forced hospitals to hold psychiatric patients in the ER, often
for days, if not weeks. When that happened, he related, the
patients required one-on-one guards, which was not safe for
medical providers or Alaskans headed to the emergency room (ER)
for different issues. The costs were then passed on directly to
private health insurance payers including the state itself, he
added. He said providers were not only unable to get reimbursed
for these costs, but the administration was passing on more
costs to private payers, in this case the state. Situations
that created uncompensated care got passed directly back to the
state, he explained, which put pressure on premium cost growth
and made it more difficult to find sustainable fiscal solutions.
REPRESENTATIVE FIELDS, directing attention to slides 6 through
9, addressed the problem of ER holds for psychiatric patients, a
result of inadequate capacity at API, which was a problem in
Southcentral, Southeast, and the Interior. He highlighted the
importance of adequate staffing and related the story of assault
on an aide in 2019. He said the state department recognized the
lack of adequate staff when it issued a very large fine.
According to Representative Fields, the problems of violence
continued to grow.
4:38:20 PM
REPRESENTATIVE FIELDS said there was a disconnect between staff
inadequacies not being addressed and belief in the mission of
API among the same staff. In this way staff were making a
sacrifice to work at API as they put themselves in harm's way,
he related. According to slide 10, staff left API because of
bad management and mishandling of safety concerns, and staff
were also concerned about constant changing of management
including CEOs and doctors. He said the least employees
deserved was fair compensation as they would be safer working
elsewhere where they would be paid fairly. Referencing slide
11, he said HB 183, in its attempt to deal with staffing and
capacity issues, was consistent with the 2019 Ombudsman's report
and the 2017 feasibility study. He noted that staffing issues
had been addressed in the past, but, echoing what Mr. Metcalfe
had said, they were not addressed in such a way that sufficed to
meet the real needs at API.
4:39:57 PM
REPRESENTATIVE TARR asked about the prevailing rate of wages for
similar work and, since there was only one state-run facility,
whether North Star Behavioral Health System ("North Star") was
the comparison. She asked whether there was potential to limit
the ability of the union to negotiate for something better or
whether it was "not less than" language.
REPRESENTATIVE FIELDS replied it would be a new policy to
establish a prevailing wage; however, prevailing wages were
nothing new. He confirmed "not less than" language ensured a
prevailing wage floor was consistent with collective bargaining
agreements, and if the state and unions wanted to set wages
higher for comparable positions due to API's challenging work
environment, then that would be the state's and union's
prerogative. In terms of comparable positions, the prevailing
wage language was based on comparable positions in other
sectors. He added that other prevailing wages in the broader
market should be looked at, not just North Star and API.
4:42:11 PM
REPRESENTATIVE SPOHNHOLZ pointed out the disparity for wages,
referencing psychiatric nurses at Providence Health & Services
being paid $12 per hour more than those at API. She asked how
the number of 55 beds was reached, as 50 beds were currently
operational, but the facility had capacity for 80 beds.
REPRESENTATIVE FIELDS answered that the lowest and most
conservative number was decided upon based on a look back at the
need for occupied beds. He questioned whether a higher number
would be safer for the community and said the lower number was
chosen in order to determine the number of patients who would be
able to be treated at API instead of at less appropriate
facilities.
REPRESENTATIVE SPOHNHOLZ opined that the staffing ratios should
be appropriate, and she indicated that forcing slots to be open
when there was no capacity to fill them was what led to the
current staffing issue. She added that API needed to work
toward functioning at its full capacity, as there used to be 160
inpatient beds; considering population growth, anything less
than full capacity could not be justified.
REPRESENTATIVE FIELDS said that he would be supportive and defer
to the will of the committee regarding the correct number of
beds. Addressing Representative Tarr's question, he said DHSS
had contended prevailing wages would conflict with collective
bargaining agreements, and that unions that represent employees
have stated that was not their view.
4:45:22 PM
REPRESENTATIVE TARR commented things become more expensive when
they were not done right the first time. She indicated that
this is a time for not being "penny wise, ... pound-foolish"
when there is a choice to have a high-functioning facility with
adequate staffing.
4:45:58 PM
BESSE ODOM, Staff, Representative Zack Fields, Alaska State
Legislature, on behalf of Representative Fields, prime sponsor,
presented the Sectional Analysis for HB 183, beginning with AS
18.05.020, the statute regarding submission of an annual report
by DHSS to the legislature. Under HB 183, the report must
include: the number of employees who vacated positions during
the reporting period; the number of funded positions that are
vacant; a description of efforts made to recruit and retain
employees; the number and cost of additional positions if
additional positions are deemed necessary; and the amount and
purpose of additional funding if additional funding is deemed
necessary.
MS. ODOM related that Section 2 amended AS 23.10.055(b), the
statute regarding employee compensation rate, with conforming
language that reflected Section 3 of HB 183. Version S would
amend the language to "hospital employee" rather than "health
care provider", she explained. Section 3 amends AS 47.30.660 to
increase and maintain bed counts, implement staffing standards,
and establish wages as determined by the Department of Labor and
Workforce Development (DLWD). Section 4 would define
applicability of HB 183 to contracts entered, amended, extended,
or renewed on or after the effective date.
4:47:36 PM
CHAIR ZULKOSKY removed her objection to the motion to adopt the
proposed committee substitute (CS) for HB 183, Version 31-
LS1211\S, Marx, 3/3/20, as the working draft. There being no
further objection, Version S was before the committee.
4:47:50 PM
MARK REGAN, Legal Director, Disability Law Center of Alaska
(DLC), said DLC was the plaintiff in one of the lawsuits that
led to the requirement there be a plan for fixing problems in
the civil commitment evaluation system. He informed the
committee he was there to testify as to API's role regarding the
decision whether folks needed longer-term commitments. For
DLC, the problem got bad in Fall 2018 when there was the report
of working conditions at API followed by a collapse in the
capacity of the facility, which had been up around 80 and
included 70 civil beds and 10 forensic beds and had gone down to
about half of that very quickly amid a myriad of problems. Mr.
Regan related one of the problems was that word had gone out
from API and from DHSS what would need to happen was when
someone potentially dangerous to self or to others was picked
up, that person, if in Southcentral Alaska, would typically be
taken to API for evaluation - but that API had been at capacity
and not taking people. Then word went out from API that some
people that fit the above description would have their liberties
taken away from them and would have to stay either in a
correctional facility such as the Anchorage Correctional Complex
or even in jail with people who had been accused of crimes until
a place opened at API and they could be evaluated there.
MR. REGAN stated there was no problem in transferring the
patients; there was a real problem with API being unable to
evaluate them and they were forced to sit in a hospital ER. The
lawsuit was regarding what the law said should be done with
people experiencing these types of problems. He said DLC
thought it was the responsibility of the state government, and
principally DHSS, to care for and minimize the length of time
people would be required to stay in jails and ERs.
4:52:40 PM
MR. REGAN stated what would happen with HB 183 was there would
be a requirement that staffing would be at 55 civil beds, for a
total of 65 with the 10 forensic beds, which would be better
than what it was now, as only 40 were available for civil
patients at the time of his testimony. The question from DLC's
perspective, according to Mr. Regan, was whether it would be
enough to solve the problem such as the one that arose in the
fall of 2018. He answered it would probably not be and offered
some alternatives for the committee to consider: DLC had
proposed to the court that DHSS send evaluators to locations
people were to determine whether they would need civil
commitment. He also mentioned, as an alternative, an off-site
Crisis Now facility, which would enable a place that was not API
to conduct evaluations in a non-institutional setting. Together
with a rebuilding of capacity at API, DLC believed that the
problem of people being stuck in jail or in hospital emergency
rooms could be reduced. Mr. Regan added that according to the
way the law was written, evaluation was supposed to take place
immediately. He added that the problem did not start in Fall
2018 but had been happening sporadically for many years.
4:56:08 PM
CHAIR ZULKOSKY said the committee would return to invited
testimony on HB 183 at its next meeting.
CHAIR ZULKOSKY announced that HB 183 was held over.
4:57:08 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 4:57 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Fiscal Summary for Settlement of 3AN-18-09814CI.pdf |
HHSS 3/5/2020 3:00:00 PM |
Addressing Gaps in the Crisis Psychiatric Response System |
| Addressing Gaps in the Crisis Psychiatric Response System--2 page overview.pdf |
HHSS 3/5/2020 3:00:00 PM |
Addressing Gaps in the Crisis Psychiatric Response System |
| HB183 ver M Supporting Document Combined Letters of Support 3.3.2020.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 183 |
| HB 183 v.S.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 183 |
| CSHB 86 ver U Letters of Support 3.28.19.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 86 |
| Addressing Gaps in the Crisis Psychiatric Response System.PDF |
HHSS 3/5/2020 3:00:00 PM |
Addressing Gaps in the Psychiatric Response System |
| HB 86 Version U Amendment 1.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 86 |
| HB 183 Version S Amendment 1.pdf |
HHSS 3/5/2020 3:00:00 PM |
HB 183 |