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Initiatives

Statement of The Hospital & Healthsystem Association of Pennsylvania

Before the Senate Public Health and Welfare Committee

Submitted by

Paula A. Bussard
Chief Strategy Officer
The Hospital & Healthsystem Association of Pennsylvania (HAP)

Harrisburg, Pennsylvania
September 30, 2015

Introduction

Chair Vance and members of the committee, I am Paula A. Bussard, chief strategy officer for The Hospital & Healthsystem Association of Pennsylvania (HAP). HAP represents and advocates for the nearly 240 acute and specialty care hospitals and health systems across the state and the patients they serve.

I am joined today by Paul Kettlewell, PhD, from the Geisinger Health System, and Shelly Rivello, from J.C. Blair Memorial Hospital. We appreciate the opportunity to present the views of hospitals and health systems regarding the process of 302 commitments, as well as considering this issue in the larger context of needed behavioral health care services across the commonwealth.

Background

Pennsylvania, like other states, has civil commitment laws that establish the criteria for determining when involuntary treatment is appropriate for individuals with severe mental illness who cannot or are unwilling to seek needed care voluntarily.

Pennsylvania’s Mental Health Procedures Act was enacted in 1976, and provides for involuntary commitment and treatment, known as 302 commitments. The Act enumerates the rights of individuals subject to treatment.

Treatment may include inpatient care, partial hospitalization, or outpatient treatment. Under the act, treatment includes “the diagnosis, evaluation, or rehabilitation needed to alleviate pain and distress, and to facilitate the recovery of a person from mental illness and shall also include care and other services that supplement and aid or promote such recovery.”

Much has changed in Pennsylvania regarding the treatment for mental health illness since 1976. This has included:

  • The closure of state hospitals caring for individuals with long-term mental health illnesses, and a greater reliance on free-standing psychiatric facilities and inpatient psychiatric units at general acute care hospitals.
  • The establishment of the HealthChoices program—Pennsylvania’s mandatory Medicaid managed care program—that has separate programs for physical and behavioral health. While Medicare and commercial insurers do not separately offer two programs, health plans may subcontract with a behavioral health care management company to oversee mental health care services.

Issues

At the same time, much has not changed in that individuals needing mental health care often do not receive needed care timely. They may lack access to the full breadth of mental health services and/or the resources to access such services.

Not only have state facilities closed, we have also seen closures of behavioral health units in hospitals because of inadequate reimbursement. Medicaid comprises the single largest payer for mental health services in most general acute care hospital units. Payments for mental health services under Medicaid simply have not kept pace with the cost to treating these individuals.

For those individuals needing immediate evaluation and treatment because they present a danger to themselves or others, they may enter the health care system through hospital emergency departments, crisis centers, health care practitioners’ offices, the criminal justice system, or the county mental health system.

Understanding such a complex system and how to approach the system can be daunting for families and for practitioners.

Because facilities often serve broad geographic regions, a key aspect stressed by HAP’s members that provide behavioral health care is the need for consistency in the 302 commitment process by the court system and by county mental health agencies.

While that seems to reflect common sense, we do appreciate that there are challenges in various parts of the state in funding, in the capacity of the health system and county agencies to care for individuals with mental illness, and in community needs for health care. Hearings, such as this one, allow policymakers to consider how to improve the process to the benefit of the individuals needing care.

Health care delivery and payment are undergoing a rapid transformation—from volume to value purchasing—and from a focus on episodic health care needs to population health. In this transformation, health care providers recognize the importance of engaging patients and their families to improve use of health care services, as well as to assure compliance and continuity of care.

Given the stigmas associated with behavioral health care and the need to protect seriously mentally ill individuals from being misdirected in health care, laws create individual rights and privacy in mental health.

Continued dialogue with policymakers, practitioners, mental health advocates, and patients are essential to make sure that concepts that we find working so well to support individuals with other types of chronic illnesses—such as diabetes, congestive heart failure, etc.—are incorporated into care for individuals with mental illness.

Broader Context of Behavioral Health Care

We know that members of this committee understand that there are gaps in the current behavioral health care system. This past year, HAP’s member hospitals and health systems identified a series of issues that we believe need to be addressed in improving access to quality behavioral health care services to assure that the right care is provided in the right setting and at the right time.

These issues include:

  • Encouraging dialogue with public and private payers to support payment strategies and policies that encourage and support integration.
  • Allowing advanced practice professionals to practice to their full extent of their scope of practice in behavioral health settings. Mental health facilities are regulated by the Department of Human Services, which has not updated standards as has occurred with facilities licensed by the Department of Health.
  • Identifying metrics that can be used to evaluate the effectiveness of physical health and behavioral health care integration.
  • Continuing to identify and share best practices and models of integrated care to enable hospitals and health systems to better serve community behavioral health needs.
  • Providing for the use of telemedicine/telepsychiatry to improve access to needed care, including appropriate reimbursement.
  • Supporting hospital engagement in public health efforts to curtail opioid abuse and overdoses, and to improve “warm handoffs” to ongoing care.
  • Supporting efforts to include behavioral health providers in incentive programs that enable use of electronic health records and participation in health information exchanges.
  • Evaluating the state’s current privacy laws affecting sharing of behavioral health information between health care providers to determine the need for change as a means of improving continuity and follow-up care.
  • Encouraging collaborative efforts with other community organizations and with the single county authorities in efforts to address behavioral health needs arising from community health needs assessments (pursuant to the Affordable Care Act as a requirement for 501 (c) 3 tax-exempt entities).

This is an ambitious list of priorities that HAP’s member hospitals and health systems will be focusing on in the coming years to improve care integration and access to needed behavioral health services.

Closing

I’d like to turn now to my fellow panelists:

  • Dr. Paul Kettlewell will talk specifically about pediatric patients and efforts to prevent the need for emergency hospitalizations. Voluntary treatment and family engagement for these patients is always preferred over involuntary commitments.
  • Shelley Rivello will speak to a community hospital’s experience with the commitment process and the particular concerns that emanate in a rural community. There are many challenges facing individuals in need of mental health care in these communities.

We thank you for the opportunity to present the hospital community’s views on 302 commitments and the importance of strengthening the behavioral health care system in the commonwealth. Once all three of us are done testifying, we will be pleased to answer any questions you may have.

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