ASHNHA Behavioral Health Committee Wednesday August 1, 2012

9am-10am Call in: 1- 888-537-7715 Code: 25797511#

Chair: Dr Andy Mayo-North Star Behavioral Health

Staff: Karen Perdue, CEO - ASHNHA

Guest: Randall Burns, Emergency Services Program - Department of Health and Social Services

(confirmed)

Ron Adler, Administrator - Alaska Psychiatric Institute ( confirmed)

1. The API Data Report-- Randall 2. API’s FY12 Admissions – Highest Ever (Ron) 3. ASHNHA DSH Regulation Comments—Karen Perdue 4. Hospital ED’s and mental health / psychiatric emergencies – Statute Defines every hospital as an

“evaluation facility” capable of holding a mental health / psychiatric emergency patient up to 72 hours

5. Continuing DLC Lawsuit (trial moved from Nov to January) 6. Any Transport Issues / Concerns? 7. Telebehavioral health Interest

2011 -20 12 A S HN H A E XECU TIVE COMMIT TEE *

Chair Bruce Lamoureux, Providence Alaska Health System Mike Powers, Fairbanks Memorial Hospital

Chair Elect Annie Holt, Alaska Regional Hospital Laurie Dotas, PrestigeCare

Sec/Treasurer Don Rush, Providence Kodiak Medical Center Robert Letson, South Peninsula Hospital

Past Chair Pat Branco, PeaceHealth Ketchikan Medical Center Millie Duncan, Wildflower Court

Karen Perdue, ASHNHA President & CEO Noel Rea, Wrangell Medical Center

Roald Helgesen, ANTHC *also APSCI Board

May 24, 2012

ASHNHA Comments on Proposed Regulatory Changes to 7 AAC 150.180: Methodology and Criteria for

Additional Payments as a Disproportionate Share Hospital

Comment Summary

Thank you for the opportunity to comment on the proposed regulations related to this important program

which currently provides funding for vital emergency psychiatric services in selected Alaska hospitals.

ASHNHA is deeply concerned that these regulations would artificially limit future financial support for

core services to behavioral health patients in Alaska and does not adequately plan for leveraging this

funding for additional DET or DES or other hospital based behavioral health services. Community hospitals

are not adequately meeting the needs of patients today who come to our emergency rooms with mental

health and substance abuse issues.

ASHNHA members have expressed their concerns regarding inadequate behavioral health response on

numerous occasions in industry-Department forums. Addressing the needs of these patients is a top priority

for us. This dialogue should include the future of DSH.

We are concerned that some provisions that currently exist in regulations are being eliminated: one that

comes to mind is the SAPT provision. At least one hospital that has a relatively large FSL would like to

enhance its substance abuse services and has expressed this need to the Department. The Department

acknowledges the inequity in grant funding for this program but has lacked the tools to address it. State

match may now be available for this purpose through the alcohol tax appropriation or could be made

available in the future through other appropriations to leverage this hospital’s DSH allocation. It is not wise

to eliminate this tool to address the pressing Alaska problem of substance abuse.

The federal DSH program is undergoing major changes. ASHNHA is concerned that promulgation of these

regulatory changes are premature since there is not clarity about the future of the Medicare and Medicaid

DSH funding in Alaska and what impact federal statutory changes will have on the existing program. Not

only are there specific statutory provisions that decrease Medicaid and Medicare DSH, there is a major

expansion of Medicaid eligibles authorized under law. What impact will these changes have on the DSH

program beginning in 2014 and forward? ASHNHA will request this information from the Department to

better assess the future of the DSH program in Alaska.

While we fully support the Alaska Trauma Designation Fund, we do not want to see two vital hospital

services compete for a declining revenue source at least until we know more about the funding landscape.

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ASHNHA would request that these regulations not be adopted at this time and in this form and that the

Department engage in a stakeholder consultation process to develop a fuller understanding of the future of

the Alaska DSH program and its purposes. That stakeholder process should include the specific hospitals

that generate the DSH allocation.

Understanding of Current Situation

For more than a decade, Alaska DSH funds have been dedicated to funding IMD and DET services for four

Alaska hospitals. It is our understanding that the funding is distributed in the following manner*:

Total DSH Fed DSH Only

API (approx.; dependent on final calcs) 13,458,316.00 6,729,158.00

DET Bartlett Regional Hospital 1,441,524.00 720,762.00

Fairbanks Memorial Hospital 1,836,056.00 918,028.00

DET Subtotal 3,277,580.00 1,638,790.00

SPE Providence Alaska Medical Center 3,343,719.00 1,671,960.00

TOTAL

20,079,615.00 10,039,908.00

*Source: Letter from Commissioner William Streur to Ryan Smith CEO Central Peninsula Hospital, February 14,

2011-these amounts may not be reflective of numbers recorded by individual hospitals, but we do not have

another centralized set of numbers at this time so we rely on DHSS numbers in this document.

The FY 2011 Alaska DSH allotment was approximately $20.4 million, an amount that has been relatively

stable over time. After subtracting the IMD DSH allotment of $6.7 million for API, approx. $13.7 million

in DSH funds were available for distribution to the State’s eligible non IMD hospitals.(North Star

Behavioral Health is an IMD but does not meet the uncompensated care standard). In Alaska, a total of 14

hospitals including API are eligible for funding- eleven are not. Only four receive funding now.

It is our understanding (as reflected in the chart above) that Alaska is using only about half of or $10

million of the possible $20.4 million it could access. In other words, today Alaska could be expending over

$40 million in DSH related payments instead of $20 million.

Clearly today Alaska has adequate DSH allocation to fund its current commitments and add programmatic

activity. However, it is our understanding that over several years there has been informal dialogue about

committing the unused DSH allocation to additional purposes. These discussions have been tempered by

two factors: the lack of state match and the uncertain future of the DSH program.

Concomitantly, hospitals and mental health advocates have requested access to the DSH funding to

supplement state funding to enhance mental health and substance abuse services. None of these

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conversations have resulted in regulatory changes or financial investments.

Current Federal Status:

It is our understanding that there will be substantial diminishment of Federal DSH allocation in the years to

come. ACA provisions include:

· Reduce Medicare Disproportionate Share Hospital (DSH) payments initially by 75% and subsequently increase payments based on the percent of the population uninsured and the amount of uncompensated care provided (Effective fiscal year 2014)

· Reduce aggregate Medicaid DSH allotments by $.5 billion in 2014, $.6 billion in 2015, $.6 billion in 2016, $1.8 billion in 2017, $5 billion in 2018, $5.6 billion in 2019, and $4 billion in 2020. Require the Secretary to develop a methodology to distribute the DSH reductions in a manner that imposes the largest reduction in DSH allotments for states with the lowest percentage of uninsured or those that do not target DSH payments, imposes smaller reductions for low-DSH states, and accounts for DSH allotments used for 1115 waivers. (Effective October 1, 2014) Alaska is a low

DSH state so the reductions will be minimized compared to High DSH states.

· The Secretary is currently considering how DSH reductions will be spread across the States. Alaska is participating with the American Hospital Association on input to the Secretary.

· Middle Class Tax Relief and Job Creation Act of 20112 Sec. 3203 - Rebasing State DSH

Allotments for Fiscal Year 2021. This provision extends the DSH payment reductions from the

ACA for one additional year. This provision is estimated to generate $4.1 billion in savings over

the next eleven years.

We will request consultation with Alaska’s DHSS to determine what these statutory changes might mean to

Alaska’s DSH allocation. However, currently we are concerned that there is not clarity among our industry

about the future of Medicaid DSH funds in Alaska and there has not been a recent consultation process

prior to the promulgation of these regulations to appropriately plan for the decline of or future priority use

of these funds as they become more limited.

What is the impact of the ACA and subsequent provisions on Alaska’s Medicaid and Medicare DSH

allocation? Since these provisions take place in FFY 2014, information on DSH changes should be made

available to affected stakeholders prior to adoption of any regulations adding new services. Hopefully, the

impact will be minimal on the existing investments that Medicaid DSH currently funds.

In addition, the ACA contemplates a major expansion of Medicaid eligible individuals which may affect the

DSH allocation and computation in various categories of DSH such as MUI and LI. What is the potential

impact of the Medicaid expansion in 2014 on the DSH program?

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Proposed Regulations Remove the Prioritization of Service:

It is our understanding that the current regulations prioritize IMD and related non-IMD related services.

Emergency psychiatric and behavioral health services should be prioritized in the use of the DSH

allocation. To the extent the proposed regulations eliminate the prioritization process at a time when DSH

allocations may be declining, ASHNHA opposes such action.

FSL Limit and how it affects eligible hospitals with multiple DSH eligible services:

Not all hospitals are eligible for DSH funds. Tribal hospitals for instance are not generally eligible.

Therefore, it is not a simplistic match source for all hospitals seeking trauma designation. Will PAMC,

Bartlett or Fairbanks be able to accommodate both services within their allocation? It would be helpful to

know this information prior to implementing these regulations.

Oppose Cap on allocation to existing SPE and DET Services:

We strongly oppose the imposition of caps on the existing services. The proposed regulations set the caps at

$4 million DET, and $3 million SPE. We don’t understand the purpose of such caps unless it is to limit

future service of a statutory program not embedded in these regulations. Under this cap methodology if

future DET sites are added they will be funded primarily from the general fund. We believe that the funding

of emergency psychiatric and behavioral health services through DSH is the TOP priority of the DSH

program and capping these investments is moving the program in the wrong direction.

We oppose the artificial distinction of capping the SPE and DET services separately as they are part of a

continuum of services. The caps impose a financial limit for the future without adequate programmatic

planning. The caps would limit service enhancement, growth for cost of living and the addition of other

DET sites financed by DSH.

It is possible that the “cumulative annual total” currently allocated to the SPE exceeds or bumps up against

the proposed caps.

Growth and enhancement of DET and DES sites/services needed:

DET and DES services are both authorized in Title 47. These services are essential for providing patients

with appropriate care in their community hospitals and the need for these services is growing.

· The Designated Evaluation and Treatment (DET) component provides fee-for-service funding, on

a payer-of-last resort basis, to designated local community hospitals. These designated hospitals

provide involuntary evaluation and treatment services to people court-ordered under AS 47.30.655

– AS 47.30.915, and to people who meet commitment criteria but have agreed to voluntary

services in lieu of commitment under AS 47.31.010(b)(1)(B).

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· A Designated Evaluation and Treatment (DET) facility may provide up to 1) 72-hours of inpatient

psychiatric evaluation; 2) 7 days of crisis stabilization and treatment services; and 3) 40 days of in-

patient psychiatric hospital services as close to the consumer's home, family, and support system

as possible. Component funding also supports consumer and escort travel to designated hospitals

and back to their home community on discharge.

· A Designated Evaluation and Stabilization (DES) facility may provide up to 72-hours of inpatient

psychiatric evaluation services and up to 7 days of crisis stabilization and treatment services.

· DES / DET psychiatric emergency services is a significant component within the Division of

Behavioral Health continuum of behavioral health services and is essential to controlling

admissions to Alaska Psychiatric Institute (API), Alaska’s only public psychiatric hospital

Every day patients in need of psychiatric care present at their local hospital in need of evaluation and

treatment. It is far preferable for patients to get the services they need in their community—preventing the

stigma, trauma and expense of transport to State run IMD services at API. However, local community

hospitals struggle to provide adequate evaluation services given the complexity of providing these services

for a relatively low volume of patients.

In the last year, the Alaska courts have dealt with cases that have contested the ability of hospitals and

correctional facilities to provide adequate services to hold patients in local ER’s. There is a substantial

concern that patients are not getting adequate evaluation services and it is certainly true that patients being

held for evaluation are not receiving treatment. These patients are challenging to manage and often pose a

risk to themselves and others. It is reasonable to assume that these concerns from advocacy groups and

hospitals themselves will continue as patients with psychiatric and other behavioral health needs present to

their community hospital.

In April of 2011, ASHNHA and the Division of Behavioral Health convened CEOS and behavioral health

leaders from Southcentral hospitals to discuss the dire needs of behavioral health patients coming into our

hospitals. In August 2011, ASHNHA hosted a broad based panel discussion at its annual Ketchikan

meeting on this topic including patients coming into our hospitals and nursing homes. ASHNHA has

formed a behavioral health committee and continues to reach out to the Department on this topic through

this committee and our Long Term Care Committee. Our concerns are broadly expressed or this topic and

we would like to be involved in the continued planning for development of robust and appropriate response

to psychiatric and behavioral health needs including the DSH program.

The Department’s budget submission for FY 2012 discusses this challenge:

· Communities outside of Anchorage, Juneau and Fairbanks often do not have adequate facilities or

the professional staff necessary to safely stabilize persons experiencing local behavioral health

emergencies; often these communities only have a “seclusion room” in the local hospital or

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community health clinic, but if neither of these options are available, emergency responders have

to detain people in local jails pending transport to a psychiatric evaluation and/or treatment site.

Currently there are limited DES sites at local hospitals.

DES is a logical candidate for addition to the DSH allocation and should be considered as an added service

in these regulations. According to FY2012 Department budget documents, the Department currently

allocates up to $ 3 million in general funds to provide DES services.

With the proposed regulations, no additional DET sites could be accommodated.

Oppose elimination of Substance Abuse Treatment Provider (SAPT) DSH: The proposed regulations

eliminate many categories of DSH eligible providers. ASHNHA opposes the elimination of the SAPT

program. One Alaska hospital has been specifically requesting to provide substance abuse services through

their DSH allocation. Currently and additional general fund dollars such as those provided in the additional

pilot funds from the Alcohol tax could be used to leverage increased funds for their important programs.

Summary

ASHNHA requests that these regulations not be adopted at this time and in this form. We want to be clear;

we support the efforts of the State to enhance trauma services at Alaska’s hospitals. However, we are very

concerned about supporting and enhancing our emergency behavioral health response system in Alaska and

would like to be assured that DSH will be used to support existing services with adequate reflection of

rising costs, and that services will continue to be enhanced as possible using DSH. We have significant

unanswered questions which are raised here.

We would request a stakeholder process to discuss the future of Alaska’s DSH program and the prioritized

uses of DSH allocations taking into account the needs expressed by DSH earning hospitals in our State.

DSH hospitals are the ones that earn these allocations and should be involved in meaningful dialogue in

planning for the future of the program.

CC: Commissioner William Streur Dr. Ward Hurlburt, Deputy Commissioner Melissa Stone, Division of Behavioral Health ASHNHA Executive Committee Dr. Andy Mayo, Chair ASHNHA Behavioral Health Committee Jeff Jessee, CEO Alaska Mental Health Trust Authority

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