Legislature(2003 - 2004)
03/22/2004 01:31 PM Senate HES
| Audio | Topic |
|---|
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
SENATE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
March 22, 2004
1:31 p.m.
TAPE (S) 04-13
MEMBERS PRESENT
Senator Fred Dyson, Chair
Senator Lyda Green, Vice Chair
Senator Gary Wilken
Senator Bettye Davis
Senator Gretchen Guess
MEMBERS ABSENT
None
COMMITTEE CALENDAR
SENATE BILL NO. 373
"An Act relating to residency and internship permits issued by
the State Medical Board; and providing for an effective date."
MOVED SB 373 OUT OF COMMITTEE
SENATE BILL NO. 364
"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: SB 373
SHORT TITLE: PHYSICIAN INTERNS AND RESIDENTS
SPONSOR(s): HEALTH, EDUCATION & SOCIAL SERVICES
03/19/04 (S) READ THE FIRST TIME - REFERRALS
03/19/04 (S) HES
03/22/04 (S) HES AT 1:30 PM BUTROVICH 205
BILL: SB 364
SHORT TITLE: LIMIT STATE AID FOR MENTAL HEALTH CARE
SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR
03/08/04 (S) READ THE FIRST TIME - REFERRALS
03/08/04 (S) HES, FIN
03/19/04 (S) HES AT 1:30 PM BUTROVICH 205
03/19/04 (S) -- Meeting Canceled --
03/22/04 (S) HES AT 1:30 PM BUTROVICH 205
WITNESS REGISTER
Dr. HAROLD JOHNSTON
Director, Family Practice Residency
Providence Alaska Medical Center
POSITION STATEMENT: Provided information on SB 373.
MR. BILL HOGAN
Director, Division of Behavioral Health
Department of Health &
Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Presented SB 364.
MR. ROBERT HAMMAKER
Treatment and Recovery Section
Division of Behavioral Health
Department of Health & Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Answered questions pertaining to SB 364.
MS. STACIE KRALY
Senior Assistant Attorney General
Human Services Section, Civil Division (Juneau)
Department of Law (DOL)
PO Box 110300
Juneau, AK 99811-0300
POSITION STATEMENT: Provided information on SB 364.
ACTION NARRATIVE
TAPE 04-13, SIDE A
CHAIR FRED DYSON called the Senate Health, Education and Social
Services Standing Committee meeting to order at 1:31 p.m.
Present at the call to order were Senators Wilken, Guess, and
Chair Dyson. Senators Davis and Green arrived while the meeting
was in progress.
SB 373-PHYSICIAN INTERNS AND RESIDENTS
The committee took up SB 373.
CHAIR DYSON presented the sponsor statement as follows:
Current Alaska statutes require that all residents
participating in the WAMI/Family Practice Residency
program receive a permit by the State Medical Board
for a period not to exceed 18 months after the date of
issue. Renewal permits to continue residency [or
internship] are also issued by the board, for a period
not to exceed 18 months after the date of renewal.
Given that the program is a three-year program, all
residents are required to get the renewal. The
renewal process has been fraught with problems.
Residents have needed to interrupt their training on
multiple occasions because the renewed permits were
not issued efficiently. This legislation would extend
the period from 18 to 36 months.
CHAIR DYSON indicated that Senators Davis and Green had joined
the meeting.
DR. HAROLD JOHNSTON, a family physician, and director of
Providence Alaska's family practice residency in Anchorage,
testified via teleconference that this bill extends the initial
permit length for resident physicians from 18 months to three
years so that it corresponds with the length of the training
program. Family physicians are required to have a total of
three years of residency training in order to be board
certified. Current law allows the permit for a maximum of 18
months. This requires that the residents renew their permits
half way through the training program; this poses problems for
the Division of Occupational Licensing. The processing of the
licensing renewal requests has created difficulties on several
occasions, which has almost caused residents to stop their
training.
DR. JOHNSTON explained that when the 18-month requirement was
originally established, physicians in Alaska only needed to have
one year of training before being eligible for a full license.
The 18-month term for resident permits allowed residents to
complete the first year of training and still have an additional
six months to get paperwork processed for the regular license.
Several years ago the state law changed, requiring physicians to
have two years of residency before obtaining an unrestricted
license, which means the 18-month permit is inadequate to get
the resident through his/her initial licensing period. The
ideal situation would be for permits to be issued for a three-
year period from the start of training because in this scenario,
there would be no requirement for a renewal.
CHAIR DYSON asked if there was anybody present from the
administration or the [Division of Occupational Licensing] to
speak to the bill. Hearing no response, he then asked, "Do you
have any idea, Dr. Johnston, how we got into this remarkable
fix?"
DR. JOHNSTON re-stated that it was because the law had changed.
Originally the 18-month permit was fine because only one year of
training was required before getting an unrestricted license.
About two or three years ago, the Legislature changed the
requirement, and now physicians need to have at least two years
- and sometimes three years - of training before getting an
unrestricted license. He said he has worked with the State
Medical Board on this issue, and at the January meeting after
some considerable debate, a resolution unanimously passed in
support of changing this to 36 months.
SENATOR GARY WILKEN moved to report SB 373 out of committee with
individual recommendations.
CHAIR DYSON asked if there was any objection. Seeing and
hearing none, it was so ordered.
1:40 p.m.
SB 364-LIMIT STATE AID FOR MENTAL HEALTH CARE
MR. BILL HOGAN, Director of the Division of Behavioral Health,
Department of Health and Social Services (DHSS) provided
background to members that diagnosis, evaluation and treatment
(DET) is an important component of Alaska's current mental
health care system. A number of hospitals in the state,
particularly in Fairbanks, Juneau, Ketchikan, Cordova, Homer,
Valdez, Sitka, Bethel, and Kodiak provide beds for individuals
who are experiencing a psychiatric emergency or who are in
psychiatric crises. The two primary providers are Fairbanks
Memorial Hospital (20 beds) and Bartlett Regional Hospital in
Juneau (12 beds). In many of the other communities listed,
there are usually only one or two beds used for this purpose.
The concept is that by stabilizing a person in his/her community
hospital, he/she would not have to enter Alaska Psychiatric
Institute (API) in Anchorage but could be served in his/her own
community.
MR. HOGAN continued that historically the division - formerly
known as Mental Health - has received bills from DET providers.
The division has scrutinized situations to determine if
admissions were appropriate and has monitored stays in various
hospitals; however, under current statute, the division doesn't
have the authority to actively manage those stays. SB 364
proposes that [the division] have the authority to proactively
manage such stays in these various facilities. The bill
stipulates that within 24 hours, hospitals will be required to
notify the division of the rationale for an admission and to
then work with the division (over time) to ensure that a
patient's length of stay is appropriate. The bill also
establishes the provision that DET services are not
entitlements, and that payment for services can only be for up
to the amount appropriated by the Legislature; the department is
under no obligation to pay once those dollars have been
exhausted. The department proposes to work collaboratively with
DET providers and is not suggesting that the number of beds in
communities be reduced.
MR. HOGAN referred to an outline in the committee packet and
highlighted that in FY 00, approximately $1,901,480 was spent on
this service. Through FY 03, an increasing number of dollars
was spent, with the amount in FY 03 at approximately $3,384,430;
the cost for services has grown substantially. There is less
money available in the FY 04 budget, and even fewer dollars are
proposed in the FY 05 budget. He said one stipulation is that a
portion of this service is funded through DSH (disproportionate
share hospital) payments, which are payments that hospitals
receive to offset the cost of providing services to indigent
individuals. He said that at Senator Davis's request, he has
included the number of individuals served in each facility from
FY 00 through FY 03; the summary also includes the average
length of stay and the cost of providing those services.
CHAIR DYSON asked if the savings to the state was $100,000.
MR. HOGAN confirmed that savings would be approximately $100,000
minimum, once the bill is initiated.
CHAIR DYSON asked why the costs went up and then down
approximately $1,000,000 in FY 04 and then another $435,000 in
FY 05.
MR. HOGAN explained that the amount went up because of the
division's inability to effectively manage the program. The
number of people served in FY 03 is lower than the previous
fiscal year's, "So I cannot say to you or say to committee
members that the cost has gone up because we're serving more
people, because that is not the case."
CHAIR DYSON questioned if it was possible that even though there
wasn't an increase in the number of people being served, that
more intense needs and more comprehensive treatment drove those
costs up.
MR. HOGAN confirmed that an increase in the length of stay could
be one rationale.
CHAIR DYSON referred to Mr. Hogan's previous comment - "the
department didn't manage" - and asked if the inference was that
individuals were receiving inappropriate treatment, or receiving
more treatment than was appropriate.
MR. HOGAN responded this may be inferred, however, "until we
have the capacity or the capability to effectively manage, I am
just not sure at this point."
SENATOR GRETCHEN GUESS asked who, under this proposal, would
manage the stays. She questioned who would be making the
decisions at the end of the day whether or not a person should
be discharged.
MR. HOGAN replied this needs to be developed and that specifics
on how to manage would be in regulation. It is the division's
intent to use Dr. Hopson, API's Medical Director, who is a
psychiatrist and who directed the Fairbanks unit before working
for the division at API. He said if there is contention
concerning a patient's admission or discharge, that discussion
needs to take place between two physicians; therefore regulation
would include a process to include Dr. Hobson in the discussion.
SENATOR GUESS asked, "Who trumps? The medical director at API
or the physician on the ground?"
MR. HOGAN replied that this was not included in the bill's
intent, and it is certainly something the division would
consider. He said that ultimately the state trumps since the
state is paying for the service.
SENATOR GUESS asked what happens to the institution and to the
patient if the state does not get notified within 24 hours; how
would such 24-hour notification be managed.
MR. HOGAN responded this would be more clearly defined in
regulation. He said this would involve a lot of work and he was
not suggesting that division staff manage this; First Health
Services Corporation currently does this for children in
residential psychiatric facilities and may possibly be used.
SENATOR GUESS said there was no mention in the fiscal note of
contract labor with First Health. She gave the hypothetical
example of admitting someone at the Fairbanks facility, and
inadvertently not reporting this within the 24-hour period. She
asked if the provider would then not get paid because connection
with the state was not made within 24 hours.
MR. HOGAN said the division would be flexible and would
understand extenuating circumstances, as the desire would be to
continue collaborating with providers and not to set up
adversarial relationships. "We clearly need a mechanism to be
able to more closely monitor these stays."
SENATOR GUESS said, "You said in here that you wanted to make
sure it's not an entitlement, and you moved a 'shall' to a
'may'." She asked what happens to a patient in a situation in
which there is no more money in the budget and the decision is
made to not pay anymore; can the hospital not take the person
because the state has run out of money or does the hospital
still have to take that patient. She asked how this works, and
if costs are then born by others who use that hospital.
MR. HOGAN said it was his understanding that if someone appears
in the emergency room, that hospital is obligated to ensure that
the individual gets to the right kind of service, which in this
case would be API. This would be unfortunate because, even
though API provides excellent service, it defeats the intention
of being close to home; API would be out of the individual's
community. The other option might be attempting to stabilize
the person outside of the hospital setting, and the hospital
would work with community providers to devise alternatives.
SENATOR GUESS said if this were an in-hospital stay, the idea
would be to get that person out of the hospital as soon as
possible and into one of the community service providers. She
asked if the cost per patient at these facilities was higher or
lower than at API.
MR. HOGAN said the cost was higher than at API.
CHAIR DYSON referred to the average number of days, and asked if
this was for people who were involuntarily committed.
MR. HOGAN replied that this was not absolutely necessary.
CHAIR DYSON ascertained that people are evaluated, voluntarily
or not, at one of these resources, and in looking at the number
of days, there seems to be a fair amount of disparity between
the different institutions. He suggested that someone testify
on how professionals proceed with the evaluation, and in
particular, address the length of time that is reasonable. He
suggested that people with multiple diagnoses would require a
longer period of time as would people with mental health
problems who had been traumatized and/or who have chemical
dependency issues needing to be stabilized.
SENATOR LYDA GREEN asked about DES/DET.
MR. HOGAN replied that DES (diagnoses, evaluation, and
stabilization) usually refers to shorter term - three to seven
days - while "treatment" is longer term.
SENATOR GREEN asked about a discussion in the Legislature
several years ago regarding the DET process, and recalled that
the purpose was to stop direct entry into API and keep people
situated throughout the state.
MR. HOGAN confirmed that this was the intention.
SENATOR GREEN asked if this was in statute or in policy. She
received a response [from an unidentified person in the
audience] that this was in statute.
2:00 p.m.
SENATOR GREEN asked if "Fairbanks" and "Bartlett" were treatment
facilities whereas the others were DES facilities; she received
confirmation from Mr. Hogan that this was the case. She said if
this detracts from the original purpose of handling things
closer to home, and "by pro-rating and saying we don't have
enough money to keep doing this at the going rate, therefore
we're cutting the rate or discontinuing it" then most people in
crisis will go to API "which has another whole set of problems
for us." She asked if there was a way to evaluate whether
people were being enrolled correctly and getting into the
correct services immediately, a way in which each facility would
need to be responsible for this. She questioned whether any
facility or population would be advantaged by this change or
grandfathered-in, and asked, "Are certain people going to be at
the top of the pecking order?"
MR. HOGAN responded that there is a movement towards
standardized screening and assessment so that the same
instrument would be used statewide to stipulate the level of
care required for the person being assessed, but it's not
currently in place. The division will actively work with
providers to ensure that people actually need a certain level of
service and the specified length of stay, but it ultimately
comes down to one person's opinion against another's. The
intent is to ensure that people are getting the required care,
while at the same time containing the costs of service. The
division intends to continue working with communities, such as
Palmer, to develop at least a couple of [DET] beds. However,
there would be serious reservations about the state paying for a
large (16 - 20 bed) facility, as there isn't money to pay for
the current level of DET services.
SENATOR GREEN asked where the dollars come from that are being
used for this.
MR. HOGAN replied that it was general fund dollars with some DSH
dollars.
SENATOR GREEN asked if DSH was a form of Medicaid.
MR. HOGAN said it was not Medicaid, but was federal dollars. He
explained that DSH assists hospitals in providing services to
indigent individuals - those without insurance or Medicaid - as
those costs are born by the hospitals.
SENATOR GREEN asked if anyone who wasn't indigent was included
in these figures.
MR. HOGAN replied that if someone has Medicaid or third-party
insurance, obviously the service is paid for in that way. This
is designed for individuals without Medicaid or any insurance,
that is, there is no third-party payor.
SENATOR GREEN added, "and under 185 percent poverty." She asked
if this was a new or current qualifier.
MR. HOGAN replied he didn't know, and deferred to Mr. Hammaker.
MR. ROBERT HAMMAKER, Manager of the Treatment and Recovery
Section, Division of Behavioral Health, DH&SS, stated that the
185 percent poverty level is current and will continue.
CHAIR DYSON asked about the state's or a DET center's liability
if there is a misdiagnosis.
MR. HOGAN said he wasn't sure and would be happy to research
that question.
CHAIR DYSON continued with the hypothetical example of someone
who is dangerous to self or others being misdiagnosed and then
doing harm. He asked if the state would be in danger of being
sued. In this situation the state, in efforts to responsibly
reduce the length of stay, ends up in court with a person
saying, 'because of the complexity of the problem, that was too
short a time, and the state in its efforts to control cost,
forced an inadequate evaluation period' and then this person
goes out and murders somebody. He emphasized that his interest
was in the patient receiving the best treatment appropriate for
him/her, and expressed reluctance to switch this responsibility
away from the primary caregiver, who ought to be a very
qualified professional. He asked what other states have done,
inquiring as to whether other states have entitlement language -
as Alaska does - or if the language was more permissive, such as
what is being proposed.
MR. HOGAN said he didn't know but could research this.
CHAIR DYSON referred to people living on the street who might be
homeless, who have mental health problems or substance issues
and who are dangerous to self or others, people going through an
involuntary commitment process. He said this process has saved
quite a few lives and in the long term, some costs. He asked
what percentage of this population is in the system, versus
people who are referred by DPS, family members, or mental health
workers.
MR. HOGAN restated the question for clarification, asking if
what was wanted was the number or percentage of individuals
served through DET who may have been homeless and who are
involuntarily committed.
CHAIR DYSON confirmed he was asking about people who "kind of
come from that population; I'm sure I'm not doing a good job of
defining it."
SENATOR GUESS then asked if a community could not handle a case,
does it currently go to API anyway; she received nonverbal
confirmation that this was correct. She continued by asking
about the cost per bed day for DES, DET, API, and non-API.
MR. HOGAN said he could access that information.
SENATOR GUESS suggested that if discussion on treatment was
going to be between the medical director of API and the
hospital, to include it in the bill so that "we don't get into a
situation where we have a bureaucrat at the state level telling
a doctor in Valdez that they have to let someone go."
MR. HAMMAKER responded that a patient would be discharged to API
or to an acceptable community program; he/she doesn't go from a
local hospital to having no services.
SENATOR GUESS said that whether it's discharged to the community
or remains in the facility, the conversation should be between
two people who are knowledgeable rather than between a doctor
and a deputy commissioner or a head of a division, that is,
someone without the medical background.
SENATOR DAVIS said, "You want to establish that this is not an
entitlement and you said there was a ruling or an opinion, and
you were going to get a copy to me which I did not get."
MR. HOGAN responded that he had determined about an hour ago,
that this was oral tradition within the division, meaning that
prior to his coming to the division, he was told (until very
recently) that there had been an attorney general's opinion
indicating that DET was an entitlement; however, there has never
been such a formal, written opinion, he said.
MS. STACIE KRALY, Senior Assistant Attorney General, Human
Services Section, Civil Division (Juneau), Department of Law
(DOL), testified that there is no attorney general's opinion
dealing with the entitlement issue with respect to the DET
program. Historically, about when DET statutes were amended to
create Title 47, Chapter 31, there was litigation in Juneau
pertaining to an individual who had been involuntarily
committed, received a bill from Bartlett, and wasn't happy about
having to pay it. Through the settlement of that issue, Title
47, Chapter 31 was drafted and amended to address some of these
payment issues. She referred to the language of Sec. 47.31.010
- Eligibility for assistance - subsection (a), "The department
shall provide financial assistance under this chapter..." and
surmised that there was at least an argument or a discussion
regarding taking the leap from the word "shall" and turning it
into an entitlement argument on the part of an attorney or a
recipient of services, to say, "you shall provide assistance for
me." She said the argument could be made - but it has never
been DOL's position or past administrations' - despite
information that Mr. Hogan may have received when he came
onboard.
SENATOR BETTYE DAVIS said, even though there was nothing stated
in writing that this was an entitlement, "you haven't done
anything to follow up on that since you found out that it was
orally ... just an opinion."
MR. HOGAN repeated that he had just confirmed this with Ms.
Kraly at today's hearing, and it is something that he will be
following-up on.
CHAIR DYSON said the reference to "the department doesn't need
to spend more money than the legislature appropriates" indicates
there is no control regarding people who come in the door of
this process. More has to do with people who need help and need
evaluation. "What we appropriate will be based upon [your]
recommendation, and some consideration for the state's financial
situation." He asked if, by that language, a commitment is
being made not to have a supplemental budget if the number of
intakes for the process accelerates for some reason.
MR. HOGAN responded that he understood that DHSS Commissioner
Gilbertson is not interested in a supplemental at this time.
SENATOR GREEN asked how facilities determine the rates, that is,
are the rates negotiated or the same across the state.
MR. HOGAN said rates are determined according to a cost-based
Medicare rate.
TAPE 04-13, SIDE B
MR. HOGAN continued that rates vary from hospital to hospital,
depending on the cost of providing services at that hospital.
SENATOR GREEN asked if this was the only way to determine the
rate.
MR. HOGAN responded that he wasn't sure, but this was the
current determination.
SENATOR GREEN asked if federal law requires the state to do
this.
MR. HOGAN said not to his knowledge.
SENATOR GREEN considered that there were no federal matching
funds to soften what the state does, other than DSH.
MR. HOGAN agreed that the use of DSH dollars was the way to
soften the cost to the state.
SENATOR GREEN referred to Sec. 7, "if the department determines
that the amount of appropriations ... is less than ... and the
department has given notice ... the department may reduce the
rates calculated..." and asked, "so you could go off the
Medicare rate at that point?"
MR. HOGAN responded this would be an option. He said the answer
to the question of what this might look like had not yet been
determined.
CHAIR DYSON asked what enabled the savings of $1,050,000 between
the FY 03 and FY 04 budgets.
MR. HOGAN said that part of the problem is that the department
would like providers to submit bills within 90 days of the end
of the fiscal year. Currently providers can submit bills for FY
03, through December of FY 03, so six months after the fact,
bills are still being received from the previous fiscal year.
Therefore, these dollar amounts are for what's been expended
during those fiscal years, because bills are received through
the end of the calendar year. He said he wished he had the
confidence that all of the FY 03 payments were for the FY 03
expenditures, adding that nothing has been done to limit the
cost or to limit expenditures.
CHAIR DYSON clarified that the columns on the spreadsheet should
be shifted somewhat to the right. He asked if the difference
between FY 03 and FY 04 was a billing/timing problem, rather
than there being less people requiring services or that the
services were more efficient.
MR. HOGAN agreed this was true.
CHAIR DYSON asked if the additional savings of $435,000 would
result from better management due to the department's oversight,
and from the facilities doing better.
MR. HOGAN confirmed this to be so.
SENATOR GREEN asked if the department typically experienced such
billing delays regarding medical receipts.
MR. HOGAN responded that other providers could bill Medicaid for
up to one year after the provision of service. From that
perspective, six months could be considered as reasonable. The
department maintains that the six-month delay is difficult to
manage; that's why a 90-day maximum submission time for bills is
being requested.
CHAIR DYSON stated for the record that he has a perceived
conflict of interest; his wife is a licensed public health
mental health provider and has the authority to have people
involuntarily committed. He then suggested that Commissioner
Gilbertson or someone speaking on the commissioner's behalf
speak to the issue of, once the more intense management and
efficient use of resources is achieved, what will be done if
there are still more people needing the services, and "you all
are hard and fast on not coming back with a supplement." He
said he appreciates the efforts at getting control of costs, as
that could make more money available to serve greater needs.
CHAIR DYSON held SB 364 in committee.
There being no further business to come before the committee,
CHAIR DYSON adjourned the Senate Health, Education and Social
Services Standing committee meeting at 2:30 p.m.
| Document Name | Date/Time | Subjects |
|---|