04/08/2009 01:30 PM Senate HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| SB66 | |
| SB168 | |
| SB169 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| *+ | SB 168 | TELECONFERENCED | |
| *+ | SB 169 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| = | SB 66 | ||
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
April 8, 2009
1:36 p.m.
MEMBERS PRESENT
Senator Bettye Davis, Chair
Senator Joe Paskvan, Vice Chair
Senator Johnny Ellis
Senator Joe Thomas
Senator Fred Dyson
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
SENATE BILL NO. 66
"An Act relating to a mental health patient grievance
procedure."
HEARD AND HELD
SENATE BILL NO. 168
"An Act relating to state certification and designation of
trauma centers; creating the uncompensated trauma care fund to
offset uncompensated trauma care provided at certified and
designated trauma centers; and providing for an effective date."
HEARD AND HELD
SENATE BILL NO. 169
"An Act appropriating $5,000,000 to the uncompensated trauma
care fund; and providing for an effective date."
HEARD AND HELD
PREVIOUS COMMITTEE ACTION
BILL: SB 66
SHORT TITLE: MENTAL HEALTH PATIENT GRIEVANCES
SPONSOR(s): SENATOR(s) DAVIS
01/21/09 (S) READ THE FIRST TIME - REFERRALS
01/21/09 (S) HSS, FIN
04/01/09 (S) HSS AT 1:30 PM BUTROVICH 205
04/01/09 (S) Bills Previously Heard/Scheduled
04/08/09 (S) HSS AT 1:30 PM BELTZ 211
04/08/09 (S) Heard & Held
04/08/09 (S) MINUTE(HSS)
BILL: SB 168
SHORT TITLE: TRAUMA CARE CENTERS/FUND
SPONSOR(s): HEALTH & SOCIAL SERVICES BY REQUEST
03/27/09 (S) READ THE FIRST TIME - REFERRALS
03/27/09 (S) HSS, FIN
04/08/09 (S) HSS AT 1:30 PM BELTZ 211
BILL: SB 169
SHORT TITLE: APPROP: TRAUMA CARE FUND
SPONSOR(s): HEALTH & SOCIAL SERVICES BY REQUEST
03/27/09 (S) READ THE FIRST TIME - REFERRALS
03/27/09 (S) HSS, FIN
04/08/09 (S) HSS AT 1:30 PM BELTZ 211
WITNESS REGISTER
TOM OBERMEYER
Staff to Senator Davis
Alaska State Legislature
Juneau, AK
POSITION STATEMENT: Commented on SB 66, SB 168 and SB 169.
BRENDA KNAPP, Program Administrator
Treatment and Recovery
Division of Behavioral Health
Department of Health and Social Services (DHSS)
POSITION STATEMENT: Supported the concept of SB 66, but had many
concerns.
JEAN MISCHEL, Attorney
Legislative Legal Services
Legislative Affairs Agency
State Capital
Juneau, AK.
POSITION STATEMENT: Answered questions on SB 66.
JAMES GOTTSTEIN, President/CEO
Law Project for Psychiatric Rights (Psych Rights)
POSITION STATEMENT: Strongly supported SB 66.
FAITH MEYERS, speaking for herself
POSITION STATEMENT: Supported SB 66.
DARENCE COLLINS, representing himself
POSITION STATEMENT: Supported SB 66.
RON ADLER, Director
Alaska Psychiatric Institute
Department of Health and Social Services (DHSS)
POSITION STATEMENT: Commented on SB 66.
DR. JAY BUTLER, Chief Medical Officer
Department of Health and Social Services (DHSS)
POSITION STATEMENT: Neutral stance on SB 168.
ROD BETIT, President/CEO
Alaska State Hospital and Nursing Home Association (ASHNHA)
POSITION STATEMENT: Supported the concept of SB 168.
MARK JOHNSON, former chief of Emergency Medical Services
POSITION STATEMENT: Supported SB 168.
ACTION NARRATIVE
1:36:32 PM
CHAIR BETTYE DAVIS called the Senate Health and Social Services
Standing Committee meeting to order at 1:36 p.m. Present at the
call to order were Senators Paskvan, Thomas, Dyson and Davis.
SB 66-MENTAL HEALTH PATIENT GRIEVANCES
1:37:01 PM
CHAIR DAVIS announced consideration of SB 66.
1:37:13 PM
TOM OBERMEYER, staff to Senator Davis, sponsor of SB 66, read
the sponsor statement. He explained that SB 66 replaces a one-
paragraph mental health grievance procedure under AS
47.30.184(7) with a much more comprehensive process. It
recognizes and protects to a much greater extent the
constitutional right of due process to an aggrieved patient who
is undergoing treatment at a public or private evaluation
facility or mental health unit.
Because of the exceptional circumstances under which such
patients are admitted and treated, due process requires special
safeguards. SB 66 provides a reasonable opportunity for informal
or formal resolution of concerns or grievances with timely
written complaints, responses and appeals, department review,
maintenance of records and reporting. It covers all state and
private mental health facilities or hospital mental health units
licensed in this state. New procedure requires detailed
complaint forms, written answers by an impartial body within
five days, three levels of appeal including response to urgent
grievances within 24 hours. The timelines are strict because
many patients are only in mental health facilities for a matter
of days and grievances or appeals cannot be heard before
discharge. A grievance may be filed at any time, but there is a
statutory limitation of year after being discharged from the
facility or unit.
1:38:39 PM
SB 66 provides notice of the grievance procedure upon admission
to the facility, easy access to grievance forms and a secure
complaint box in which to deposit the forms. The contents of the
complaint box are to be read each day, and the original copy of
the form must be kept in the patient record. The department is
charged with reviewing all grievances and responses. Facilities
and units must file quarterly reports of the number and type of
grievance and the resolution including litigation. SB 66
prevents mental health facilities or units from "front loading"
or asking patients to go through an informal complaint process
before filing a grievance. In this way grievances in the past
were reportedly were seldom heard and there is no written record
of a grievance on which to file an appeal.
The bill allows for personal representatives to act in the
interest of the patient in the grievance process as well as
providing an appointed patient advocate in the mental health
facility or unit.
He noted that the department sent over some suggestions that
include adding a definition of "grievance." He said typically
there is no record of what is going on and many of the people
who are involved in the process are denied due process because
they are mentally ill. He explained that due process involves
deprivation of life, liberty or property, and the main problem
here is a lack of liberty, particularly in those who are in
forced civil commitments. The department has said maybe this
bill should only apply to those, but they are trying to
recognize that this state doesn't have a procedure or standard
form that allows these patients to have routine issues dealt
with in a timely way.
Finally, three levels of appeal have been set up. The first two
levels go up to the commissioner; no response is needed. If they
want to appeal to the third level - the administrative hearing
officer, the department is asked to intervene. This means that
the hearing officer would make a determination, and then it
would be turned over to the commissioner to accept or make some
other determination. At that point, the administrative process
is over and the next step would be court. This does not
anticipate that the process of criminal law will not apply
should the police be called, but it ensures that there will be a
record of what goes on throughout the process.
1:42:51 PM
SENATOR PASKVAN moved to adopt the proposed committee substitute
(CS) to SB 66, labeled 26-LS0239\E, as the working document.
There being no objection, version E was before the committee.
SENATOR ELLIS joined the meeting.
1:44:07 PM
CHAIR DAVIS asked Mr. Obermeyer to explain the changes in the
CS.
MR. OBERMEYER said essentially the CS ties up some loose ends.
"Formal grievance" was replaced with "grievance" on page 2, line
2, and "written" was added before "notice" on page 3, line 2,
and "appeal" before "procedure" on line 9. On page 3, lines 12-
14 added "a written response to the grievance on the form
required by one of the subsection within five days after receipt
of the grievance and after each level of requested review."
The written response is supposed to include a list of options to
resolve the grievance including a level-3 appeal. It also
changed the time frame to appeal from 20 days to 30 in
subsection 5(c) on page 3, line 30. Page 4, lines 1-4 adds "the
hearing officer shall make findings and recommendations to the
commissioner who shall make a final written decision on or
th
before the 5 day after the commissioner receives the
recommendations." This is to give the department an opportunity
to resolve the matter at the lowest level, and if it is
determined it can't be resolved the patient can go to court.
MR. OBERMEYER said that the hearing process has many more
formalities and it is truly an independent body. One of the big
concerns in the process is that impartiality is almost
impossible unless you do get to an impartial administrative
hearing officer; however, the biggest problem is that most
grievances are not ever heard and there is no documentation that
they ever occurred.
1:47:56 PM
MR. OBERMEYER said language on page 5, lines 6-7, says the
facility or unit shall make a good faith effort to mail a
response to a grievant that has been discharged from the
facility. The facility is defined to mean "hospital or clinic in
which mental health patients receive evaluation or treatment and
for which public funds are provided" on page 5, line 26. Page 6,
lines 2-3 describes a unit as "a discrete portion of facility
dedicated to the treatment or evaluation of mental health
patients."
1:50:07 PM
BRENDA KNAPP, Program Administrator, Treatment and Recovery,
Division of Behavioral Health, Department of Health and Social
Services (DHSS), said they support the spirit of the bill and
share the legislature's desire to ensure that mental health
patients in the state are treated fairly, receive appropriate
treatment and that their concerns, when they have them, are
heard. But they do have some concerns with the bill as written
and those are in a memo.
She advised that first of all, there are already grievance
policies in place. Certainly the hospital facilities with
designated evaluation and treatment facilities and stabilization
facilities are all accredited by the joint commission are
required to have and follow grievance procedures. But within the
community system, which would also be impacted by this bill, any
grantee is required as part of their RFP procedure to provide a
copy of their grievance procedure for consumer complaints. That
has to be approved by the department in order for them to
receive funding. She said her experience is that having the
grievances resolved at the lowest level does work. If it can't
be resolved, the department is already required in AS 47.36.060
to investigate and respond to complaints made by a patient or an
interested party on behalf of a patient.
Although the current bill sets forth some new requirements - one
of them being the three levels of review - the third one
requiring department intervention, it does nevertheless require
that copies of all grievance activity and the resolutions of
those complaints be provided to the department. This would be a
huge volume of documentation, and the department would be
required to review all grievance documents that are provided for
compliance with the section.
1:53:41 PM
MS. KNAPP said although they might only be required to intervene
on the third level, all levels would require review for
compliance. Certainly if something was found to be mishandled
they would have an obligation to investigate and follow through.
So it raises a level of work for the department that has been
handled at the local level. They deal mostly in communities with
non-profits or with municipal or tribal entities that do have
their own governing boards where grievances of any sort are
resolved. "We have that that works."
The bill also requires a specific form to be used for
grievances. At this time the community programs have to design a
form and submit it to the department for approval. They are
given models they can use and have some latitude within their
own structure to tailor it to their own needs as long as some of
the core elements are there. Certainly the Joint Commission has
standards regarding what the grievance procedure and policy
would look like for the inpatient facilities. The state would
like to move toward accreditation of community facilities but
that represents a lot of money to providers.
Another concerning aspect of the bill is the broad definition of
grievance. Currently it is a concern or a complaint that is
unresolved. This bill broadens it to include "suggestions" which
widens the arena. It is too broad.
1:56:37 PM
MS. KNAPP pointed out that there are other venues for patients
and recipients of community based services to express their
concerns without having to fill out a form and wait for a formal
procedure - organizations such as the State Mental Health Board,
the Mental Health Trust Authority, the Disability Law Center,
Office of Public Advocacy and the Ombudsman. She concluded by
saying they are very willing to work with the committee on this
bill.
1:58:29 PM
CHAIR DAVIS asked how many grievances have come before the
department per year.
MS. KNAPP answered probably about five actual grievances in the
past five years.
CHAIR DAVIS asked if that doesn't seem odd to her.
1:59:10 PM
MS. KNAPP said that was not surprising, because she has worked
in the community system for many years and knows how grievances
are handled. It doesn't surprise her that they are resolved at
the level in which they occur. If a grievance involves a
criminal act, of course, it is referred to law enforcement.
SENATOR DYSON said he thought this bill changes what "grievance"
means and that more things might fall into it now.
MS. KNAPP agreed.
SENATOR DYSON asked her to help him understand the down side of
this from the department's perspective.
MS. KNAPP said if grievances can be successfully handled at the
level at which they occur, it seems appropriate to do that, and
to require that the department be copied on all documents
surrounding that seems like an unnecessary administrative
burden. They want staff to focus on real problems.
SENATOR DYSON asked if, in her profession, there is a
possibility of people using the grievance process
inappropriately out of spite.
MS. KNAPP replied that is true in any field, but all complaints
merit review.
2:03:16 PM
SENATOR DYSON asked since she said she appreciated the spirit of
the legislation if she was inferring that improvements could be
made to the system.
MS. KNAPP said that if there is the perception of a problem,
there is a problem. So it is important to look at the concerns
of those who perceive the problem and find what the reasons
might be.
SENATOR DYSON asked if this department had been audited in
regard to this issue in recent history.
MS. KNAPP said she did not know.
CHAIR DAVIS asked her to find out.
CHAIR DAVIS said Jean Mischel, drafting attorney for this
legislation, and they should ask her to address the change in
definition of "grievance" with her.
2:05:41 PM
MR. OBERMEYER commented that the definition of "grievance" was
intentionally put into the statute because many of the issues
that come before these facilities are often changed from what
might be a grievance to a suggestion or a complaint. So it gives
the facility the opportunity to talk the individual out of what
they are doing. This recognizes the problem of "front loading"
and making a grievance disappear.
2:07:39 PM
JEAN MISCHEL, Attorney, Legislative Legal Services, said the
definition used here is very broad. Alaska statue has no other
definition of grievance; so lacking that, the courts would apply
the dictionary definition. This change goes beyond that, and it
is a policy call for the legislature.
2:09:10 PM
JAMES GOTTSTEIN, President/CEO, Law Project for Psychiatric
Rights (Psych Rights), said he was on the Mental Health Board
and strongly supported SB 66. The board pushed through standards
for grievances and he wrote a letter to the Chair on 2/16/09 on
this issue. He said the administration didn't appreciate the way
mental health clients are marginalized just by being classified
as mental health clients. So whatever they do can easily be
dismissed and disregarded unless safeguards are in place. So it
is very important that this bill puts those safeguards in place.
Also, when he was still on the board they pushed for putting the
requirements they had negotiated with the department into
regulations so that they would be more permanent.
In line with what he said before about people being
marginalized, they are often really coerced into accepting
things, and that's another reason why there really should be
oversight of the process.
MR. GOTTSTEIN said it is interesting that the administration
would complain about the huge amount of paperwork if this were
enacted and at the same time say that there were only five
grievances in five years. It strains credulity to say only five
grievances were unresolved to the satisfaction of clients in
five years. He thought the current process was suppressing the
elimination of the problems that are going on.
2:13:24 PM
FAITH MEYERS, speaking for herself, supported SB 66. The current
psychiatric patient grievance procedure statute, AS 47.30.847,
does not adequately protect patients and their rights.{ As a
former psychiatric patient, she said she had been in acute care
psychiatric facilities, evaluation units and had received
treatment as an out-patient. As an advocate, she has talked to
former psychiatric patients and their newsletter includes
results of a recent survey that shows dissatisfaction with
current psychiatric patient procedures.
She stated that 10 different categories of clients receiving
services from the DHSS who are not satisfied can file an appeal
with the department or with an administrative law judge. Alaska
may be the only state that does not allowing psychiatric
patients to file an appeal to a higher level. Even individuals
in prisons or jails can file an appeal with the Department of
Corrections, but as of now all psychiatric patients do not have
a clear path to file an appeal either with DHSS or an
administrative law judge. Either would be acceptable.
MS. MEYERS said the loopholes in the current statute allow
psychiatric facilities to deny patients their right to file a
grievance at the time of their choosing. It is important that
patients receive a written copy of the grievance procedure and
associated rules, get a written response in a timely manner, be
able to file a grievance when they choose instead of having to
through the facility informal complaint resolution process
first, be able to appeal to a higher authority when dissatisfied
with the resolution, and to have grievance reporting that will
be looked at by more than one person within 24 hours for an
emergency grievance. These are all rights given by SB 66.
2:17:40 PM
DARENCE COLLINS, representing himself, supported SB 66. In
Maine, he said, people sued their DHSS equivalent to force
improvements in the state psychiatric patient grievance
procedure. In the state of Georgia, the legislature stepped in,
in 2008 and revised the grievance procedure statute after it was
shown that their equivalent of DHSS was not properly
investigating psychiatric patient complaints or keeping records
of them.
At ease at 2:18 p.m.
MR. COLLINS said the Alaska Psychiatric Institute (API) that is
managed by DHSS in a 2006 report showed 256 complaints filed by
patients in a 12-month period; not one was considered a
grievance, and not one person received a written response, which
is a federal requirement. The loophole and inadequacy in the
current grievance procedure statute allowed API to treat all
complaints informally. He enumerated complaints included safety,
sexual abuse, and medications. API has made some improvements,
but nothing stops them from going back to their old habits and
50 other facilities are still doing the same type of thing.
2:22:19 PM
MR. COLLINS said two reports from the Ombudsman's Office were
critical of DHSS because they did not want to keep statistics.
SB 66 will require DHSS to keep statistics. The same report
indicated that DHSS has not investigated a psychiatric complaint
in many years even though they are required to do so by AS
47.30.660. The department cannot by law delegate its
responsibility of investigating a patient's complaint to a non-
state entity, but that is exactly what DHSS is doing. He said
that revising and updating psychiatric patient procedure
statutes is a national trend as is making them uniform.
2:25:08 PM
SENATOR PASKVAN asked if an internal peer review process had
been performed at API, which is confidential.
RON ADLER, Director, Alaska Psychiatric Institute, Department of
Health and Social Services (DHSS), said, "We are always in a
continuous state of continuous quality improvement." All
complaints and grievances are review by both himself and the
medical director; they have a Patients' Rights and Ethics
Committee that reviews these and looks at trends and documents
them as they are relevant. The medical staff at API has a peer
review process that is confidential.
SENATOR PASKVAN asked how many of those processes have been
completed on average per year.
MR. ADLER responded that he could get that data for him.
SENATOR PASKVAN said he wanted to see if any of the 256
complaints were addressed in the 2006 review.
MR. ADLER stated that API deals with a number of people who have
disturbances of thoughts, and he takes exception to anyone who
says x number of people complain of sexual misconduct or
violence, whatever. That is just the kind of thing they hear
from people who are incapacitated at time of admission. Once
they stabilize, they will frequently either retract their
complaint or not acknowledge that it was going on out of
embarrassment.
2:29:34 PM
CHAIR DAVIS asked him to provide that information to her office.
SENATOR DYSON asked when someone has been involuntarily been
committed, has a guardian ad litem been appointed.
MR. ADLER answered that a "court visitor" and a public defender
come in and work with the patient and represent him in any legal
proceedings that are relevant to commitment status and
medication orders.
SENATOR DYSON said he worries about an organization that is far
less professional than API, that is just warehousing folks and
may not be properly caring for people. If that organization was
not being professional, how would an outside person ever find
out and "blow the whistle?"
2:31:40 PM
MR. ADLER replied that the federally funded authority in the
state is the Disability Law Center that is headquartered in
Anchorage, but has offices in Juneau and Fairbanks. They are
very active with API; their telephone number is at each
treatment unit, and if there is any allegation of violation of
human rights they are quick to investigate. The scope of the
Center's authority goes beyond that of the state hospital and
includes the private sector.
SENATOR DYSON asked who has oversight of conduct at the 50 other
facilities.
MR. ADLER responded that his impression is that Alaska is a very
small state; the Mental Health Board conducts quarterly meetings
in various parts of the state and spends a great deal of time
taking public testimony and/or holding town halls to get input
from the local constituents to see how the system can be
improved. It's always been amazing to him when a consumer of
services makes a statement that things aren't right without
going into detail. And then after testimony has closed, a number
of people who are involved in the system engage the person to
see what is wrong and a subcommittee is established to make
changes. That is the same process that started when Faith Meyers
brought complaints about her treatment at API.
MR. ADLER said he thinks Alaska has a very transparent and
collaborative process; it is very difficult for any type of
misconduct to occur. The things that need to be changed have
already been changed through a process of oversight and
collaboration through the variety of stakeholder meetings and
public testimonies that go on throughout the year.
2:35:32 PM
MS. KNAPP added that within the community system of 50 or so
grantee programs, these are voluntary programs; people are not
"committed" to them. If a person is deemed not competent to
manage her own affairs, a guardian would be appointed. If they
might be a danger to themselves they might be committed for a
period of time so they are not actually locked down. Family
members are often the guardians.
2:36:53 PM
SENATOR DYSON said the inference is that some of the people who
are complaining, if indeed it was bad, they could leave. He
assumed that people who are involuntarily committed are not free
to leave.
MS. KNAPP replied yes; that would be if they are in the
psychiatric unit under commitment at Bartlett Hospital, which is
the designated evaluation and treatment facility. But at the
community program like Juneau Alliance for Mental Health they
are free to leave.
SENATOR PASKVAN asked if the results of the medical review or
joint accreditation are confidential.
MR. ADLER answered that the joint commission review is public;
the peer and medical reviews are confidential.
2:38:52 PM
CHAIR DAVIS asked Ms. Knapp for a list of grantees and to
identify the levels of care provided by the grantees and
hospitals. She advised that the bill will probably not get
another hearing this session, but she was going to appoint a
subcommittee. Her feeling is that there is a reason for the
bill, and she appreciated the department's willingness to work
with her on it.
MS. KNAPP agreed.
SENATOR DYSON asked for any audits.
2:41:19 PM
CHAIR DAVIS said if one wasn't available, she may have to
request one. She closed public testimony and held SB 66 in
committee.
SB 168-TRAUMA CARE CENTERS/FUND
2:42:09 PM
CHAIR DAVIS announced consideration of SB 168.
TOM OBERMEYER, staff to Senator Davis, sponsor of SB 168, read
the sponsor statement. It is about state certification and
designation of trauma centers, creating the uncompensated trauma
care fund to offset uncompensated trauma care provided at
certified and designated trauma centers and providing for an
effective date.
SB 168 addresses the urgent need for a comprehensive statewide
trauma center system coordinating and integrating the efforts of
emergency medical services, public safety agencies, air medical
services and health care facilities to insure that patients
receive the most efficient and effective care from time of
injury through rehabilitation. Trauma care systems have been
shown to reduce death from injury by as much as 25 percent and
are recognized as an integral part of the state's EMS and
disaster response system. Only eight states have fully
functioning systems and 15 states have no system.
Trauma is any life threatening occurrence either accidental or
intentional that causes injuries. The leading causes of trauma
are motor vehicle accidents, falls and assaults; trauma is the
leading cause of death among Americans under 44 years of age.
A trauma center is a hospital, clinic or other certified entity
equipped to provide comprehensive emergency medical services to
patients suffering traumatic injuries. They were established by
the medical establishment in response to traumatic injuries that
often require complex and multi-disciplinary treatment including
surgery in order to give the victim the best possible chance for
survival and recovery.
2:43:57 PM
Section 1 in SB 168 adds subsection (c) to emergency medical
services to address the state certification and designation of
trauma centers. It creates the uncompensated trauma care fund
under section 2 to offset uncompensated trauma care provided at
certified and designated trauma centers and provides for an
immediate effective date.
The bill requires the commissioner to establish special
designations in regulation of levels of 1-4 of certified trauma
centers that shall be used to set compensation eligibility and
the amounts under the uncompensated trauma care fund. Although
current Alaska statutes revised in 1993 require certification of
hospitals, clinics or other entities representative of trauma
centers, they do not require or provide incentives for
participation. The uncompensated trauma care fund will provide
the needed incentives for hospitals for clinics and other
entities to seek certification as trauma centers.
Since the state's statutes and regulations in this area were
enacted over 15 years ago, only 3 of 24 eligible Alaska
hospitals reportedly have successfully completed the
verification and certification process as trauma centers. In
order to qualify as a trauma center, a hospital must meet
certain criteria established by the American College of
Surgeons. Trauma centers vary in their specific capacities and
are identified by levels 1-4; 1 being the highest. Higher levels
of trauma centers will have trauma surgeons available including
those trained in such specialties as neurosurgery, orthopedic
surgery, as well as highly sophisticated medical diagnostic
equipment and specialized treatment units. Lower levels of
trauma centers may only be able to provide initial care and
stabilization of a traumatic injury and arrange for transfer of
the victim to a higher level trauma care.
2:45:52 PM
MR. OBERMEYER said under the Alaska trauma center system, it is
anticipated that tertiary hospitals designated as higher level
trauma centers will insure the availability of critical care
specialists 24 hrs/day, 7 days/wk. The Alaska Native Medical
Center is a level 2 trauma center; Yukon Kuskokwim and Norton
Sound Regional Hospitals are level 4. It is believed that there
are adequate medical resources to establish more level 2 trauma
centers in Anchorage, and it is considered feasible to establish
level 3 and 4 centers throughout the state. Because of long
transport times trauma centers at all levels are necessary to
improve patient outcomes. Level 1 trauma centers have critical
care specialists in the hospital or on call at all times.
The closest level 1 trauma center is Harborview Medical Center
in Seattle. The operation of a trauma center is extremely
expensive. Some areas are underserved by trauma centers because
of this expense. For instance, Harborview is the only level 1
trauma center to serve the entire states of Washington, Idaho,
Montana, and Alaska.
He said that patient traffic at trauma centers can vary widely
as there is no way to schedule the need for emergency services.
A variety of different methods have been developed for dealing
with this. Halifax Health in Daytona Beach, Florida, reportedly
is employing a pod system to be provided by several different
small emergency departments at different hospitals rather than
one large trauma center.
It is anticipated that Alaska, likewise, will have to develop a
trauma center system which is best suited to its needs. It is
anticipated that persons critically injured in remote areas of
Alaska will be transported directly to a distant trauma center
by plane and helicopter for faster and better care than if they
had been transported to a closer hospital, which is not
designated a trauma center.
The designation, coordination and funding of a trauma center in
Alaska as provided under SB 168 will save time and lives. It
will also provide the financial incentives for more
participation by hospitals, clinics and other certified trauma
care entities which are not available under present law.
He drew the committee's attention to the attachments and
documents that indicate that in Alaska the leading cause of
death in persons ages 1 to 44 is trauma; the average number of
fatalities from trauma is 400 each year, and for every injury
death, 11 people are hospitalized for trauma-related injuries.
For every trauma death that occurs in the hospital, there are an
estimated 3 people discharged with permanent disability. On
average, more than 800 Alaskans are hospitalized annually with
central nervous system injury (spinal cord or brain injuries).
In 2004 motor vehicles were the leading cause of injury death
(117), followed by firearm injuries (116). In 2004, the economic
cost of hospital stays for trauma patients in Alaska was
estimated at over $73 million; 1 in 4 of those hospital
admissions were uncompensated.
CHAIR DAVIS set SB 168 aside.
SB 169-APPROP: TRAUMA CARE FUND
2:49:14 PM
CHAIR DAVIS asked Mr. Obermeyer to provide a brief overview of
SB 169.
MR. OBERMEYER explained that SB 169 is the appropriation bill
that asks the state to fund the uncompensated trauma fund at $5
million.
SB 168-TRAUMA CARE CENTERS/FUND
CHAIR DAVIS returned attention to SB 168 to continue taking
testimony.
2:50:46 PM
DR. JAY BUTLER, Chief Medical Officer, Department of Health and
Social Services (DHSS), said Alaska's trauma death rate has
declined over the last 30 years thanks to prevention efforts,
but it is still significant. The department took a neutral
stance on SB 168.
DR. BUTLER said, "A better job can be done with the medical
management of trauma victims." To begin a systematic approach to
improving trauma care in Alaska, the DHSS hosted the American
College of Surgeons' Committee on trauma system evaluation and
planning this past November. The committee noted that Alaska has
no trauma system and the report included over 70 recommendations
for improving trauma care and creating a statewide trauma
system. Among the priority recommendations was a recommendation
to require all acute care hospitals to seek trauma center
designation appropriate to their capacity within the next two
years to improve the quality of medical care for trauma victims
and improve outcomes.
DR. BUTLER said SB 168 provides an incentive for hospitals to
become certified trauma centers rather than creating a mandate.
It creates a fund for reimbursement of trauma care that would be
provided for care to uninsured or underinsured patients. There
are a number of potential sources of funds, and the department
has been working to develop the sources further. However, he
said because of the uncertainty involving funding, the
administration is taking a neutral stance on SB 168.
2:53:07 PM
SENATOR DYSON asked if the administration requested this bill.
CHAIR DAVIS replied no; it was requested by others than the
department.
2:54:10 PM
ROD BETIT, President/CEO, Alaska State Hospital and Nursing Home
Association (ASHNHA), said they support the concept of SB 168.
The detailed report from the College of Surgeons prescribes a
mandatory approach, which he didn't think would be well received
for a variety of reasons. This is a priority that his members
selected to work on in 2009, and he understands it is one of the
department's priorities, too. The trauma system needs to be
improved; the reasons why it hasn't happened need to be
understood why it hasn't happened before. Some of those include
the availability of physicians and their willingness to serve
because there are very significant and time sensitive
requirements around each classification level in the trauma
scheme, and the costs to do that. And since there is clear
evidence that if you have trauma centers, they attract more
uncompensated care that has to be dealt with as well as what
levels are care should be in each community.
He understood that Alaska has five designated facilities, four
of those are tribal. The one with the highest level designation
is Alaska Native Medical Center. Those are staff model hospitals
where the physicians work for those hospitals. One private
facility that is certified at the lowest level is co-located in
a community with one of those tribal facilities. The rest have
struggled with ways to meet the conditions of certification -
being private hospitals with physicians who do not work for them
and having a shortage of some of the types of physicians needed
and the ability to make sure the physicians will be there within
the time response required. This is one issue they don't know
how to solve at this point, but a group within the AHNSHA is
working on it. This is a great approach to try to pull more
facilities in and get them designated. Clearly, uncompensated
care is one way to do that, but unless they can figure out some
of the logistical problems around physician availability, they
won't get as far as the committee would like with this piece of
legislation.
2:57:49 PM
SENATOR PASKVAN asked, if it were funded at the $5 million
level, what range of hospitals would want to participate in the
plan.
MR. BETIT answered that since this deals with "a half a glass"
and deals with uncompensated care, but not with the physician
cost or availability, none said they would be willing to move
forward to get the designation. It's a step in the right
direction, but maybe the $5 million could be matched through
some disproportionate sharing funding that Medicaid makes
available that the state hasn't fully capitalized on. Maybe some
of that could also go into offsetting some of the increased
costs for the physician on call and recognizing that they have
to have the right physicians available to be on call. He hoped
to work with the department on these issues over the next few
months.
2:59:09 PM
MARK JOHNSON, former chief of Emergency Medical Services, said
during that time that he served, he worked very hard to develop
an EMS system in Alaska and made a lot of progress. One of the
issues they worked on was to improve the trauma system in Alaska
where they made some limited progress. In the 1990s with the use
of some federal grant funds, his office co-sponsored American
College of Surgeon reviews of eight different hospitals in
Alaska that created reports on their strengths and weaknesses.
Some hospitals have been reviewed multiple times. The report
that the college came out with addressed some issues mentioned
by Mr. Betit as well as going into a lot more detail on how to
solve some of the problems.
It's been said for many years, that trauma systems require
commitment, and unless the medical community and the hospitals
are willing to provide it, they aren't going to solve the
problem, Mr. Johnson said, and he's been dealing with it for
decades. The reality is that Alaska's hospitals are not meeting
national standards in trauma care, and the public is not well
served by that. Harris polls indicate that nationwide, people
actually think they live in a community with a trauma system,
but in fact in many places it doesn't exist.
MR. JOHNSON said reducing complications and lengths of stay can
produce better outcomes and more lives saved, and these can all
result in downstream long term savings. One of the biggest
problems in this state is on-call. Sometimes a surgeon is needed
immediately, but they must be called to find somebody available.
Those calls take time and that sometimes results in bad
outcomes. That should be pre-planned and pre-arranged; and
that's what this is about.
3:02:55 PM
SENATOR DYSON said "commitment" sounds like money.
MR. JOHNSON said to some extent that is true, but other things
can be done that don't cost much. You look at creative
solutions, and some are in this report.
CHAIR DAVIS said this bill will come back next session. [SB 168
was held in committee.]
3:04:11 PM
There being no further business to come before the committee,
she adjourned the meeting at 3:04 p.m.
| Document Name | Date/Time | Subjects |
|---|