House Majority Caucus Room
State Capitol, Boise, Idaho
Wednesday, December 3, 2003
The meeting was called to order at 9:14 a.m. by Cochairman Representative Bill Deal. Other
Task Force members present were: Cochairman Senator Dean Cameron, Senators Joe Stegner
and John Goedde and Representatives Max Black, Kathie Garrett and Gary Collins. Senators
Sheila Sorensen and Fred Kennedy and Representative Margaret Henbest were absent and
excused. Staff members present were Caralee Lambert and Charmi Arregui.
Others present included: Senator Skip Brandt; Senator Dick Compton; Bob Seehusen, Idaho
Medical Association; Julie Taylor, Blue Cross; Lyn Darrington, Regence BlueShield of Idaho;
Ken McClure, Givens Pursley; Woody Richards, Moffatt Thomas; Steve Tobiason, Idaho
Association of Health Plans; Christine Pickford Ph.D. and Cindy Anderson, Employers Health
Coalition of Idaho; Kate Vanden Broek, Idaho State Planning Grant; Teresa Molitor, Idaho
Academy of Commerce & Industry (IACI); Shad Priest, Phyllis Stephenson, and Mary Hartung,
Department of Insurance; Ray Millar and Ken Deibert, Idaho Department of Health & Welfare;
Greg Hahn, Idaho Statesman; Candice Crow Ph.D., Molly Steckel and Deborah Katz, Idaho
Psychological Association; Tony Poinelli, Idaho Association of Counties; Ulla Saarek; J. R.
VanTassel, Nez Perce County Commissioner; Bill Foxcroft, Idaho Primary Care Association;
Leslyn Phelps, Executive Director, Glenns Ferry Health Center; and Mike Brassey, St. Lukes
Regional Medical Center.
A motion was made by Representative Max Black to approve the minutes dated October 8,
2003, seconded by Representative Gary Collins. The motion passed by voice vote.
Mr. Laren Walker, AmeriBen Solutions, was invited to report on the Idaho Individual High
Risk Reinsurance Pool. Mr. Walker handed out the most recent board-approved financial
statement, dated September 30, 2003. A copy is on file in the Legislative Services Office. The
balance sheet for the program reflected assets including $6,908,998 in cash due to the current
year tax revenue. More than half of that cash ($3.6 million) came in just prior to the preparation
of the balance sheet. Total assets for 2003 were $6,911,020 compared to $4,127,694 for 2002.
Total liabilities for 2003 were $3,875,247 compared to $1,798,348 for 2002. The fund balance
for 2003 was $3,035,773 on September 30, 2003.
Statement and expenditures for the nine months ending September 30, 2003, reflected
$4,958,656 in total revenues/income compared to $3,244,152 for 2002. The pool is receiving
about $141,025 per month in premiums for a total of $1,295,647 as of September 30, 2003
compared with $831,647 for 2002; the reason for the significant increase is the number of ceded
lives, or the level of activity in the program which has grown each year. Investment options are
being explored to increase the interest income. Total expenditures of $1,798,583 include claims
incurred as of September 30, 2003, compared to $1,351,817 for 2002. Looking at a pure loss
ratio (premiums compared to claims paid) premiums were $1,295,647 compared to claims of
$1,798,583, which is a point of interest. Other significant expenses for 2003 include $108,585 in
administration fees including legal and actuary fees. The fund balance ending September 30,
2003 was $3,035,773.
Mr. Walker reported that as of October 20, 2003, the pool included 1,393 total ceded risks
(lives) with 43 additions and 98 terminations (in October) totaling 1,338 lives. The non-smoker
Catastrophic B plan had 475 and 360 in the non-smoker standard plan, which were the most
highly used plans. The non-smoker numbers were significantly higher than the smokers. Ceded
risks by carrier reflected 420 insured by Carrier A, 886 by Carrier B, and 32 for all other carriers
in the state, totaling 1,338 lives in the program. Activity in the program since inception has
grown steadily from January, 2001, to January, 2003. There has been a slight decline since
January, 2003, fluctuating from 1,200 to 1,500 ceded lives.
Representative Black inquired about the trend of the plan maturing and leveling off between
1200-1500; if the tax premium income grows, could a surplus develop and what would happen if
that does occur? Mr. Walker answered that these are high-risk individuals with a million dollar
maximum per individual, so high claims are expected. An organ transplant could cost over
$500,000. The pool has not seen a claim over $200,000 as yet, but those dollars could be eaten
up rapidly, and higher claims are anticipated. Most claims have been in the $50,000 to $100,000
range and his report itemized claims over $50,000 for 2002 and 2003.
Mr. Walker pointed out that a 32% street rate increase for the program in 2004 was
recommended by the actuary representative based on studies and trends, which raised debate
among the board members. The board determined that a 15% rate increase was appropriate since
the board's intent is to make the plan affordable.
Representative Deal noted that the report on this pool was made because the Health Care Task
Force is the oversight committee for the high risk pool.
Dr. Candice Crow Ph.D., Idaho Psychological Association (IPA), next addressed the Task
Force. The IPA comprises about 120 psychologists throughout the state, both in the public and
private sectors, and this organization tries to evaluate and assess issues pertinent to psychologists
and also the status of mental health services. Dr. Crow conducted an informal survey to get a
clearer perspective. She stated that she has been licensed as a psychologist since 1975, working
in both public and private settings and was in charge of the mental health care program in
Region IV in Idaho before going into private practice. There is a 100% consensus of the IPA
that the most severe problem with regard to mental health is access to appropriate mental health
care, especially for those with serious mental illness and limited financial resources. Idaho's
mental health care program, in her opinion, has been broken for years. Financial resources limit
access to mental health for many people who are indigent, are uninsured, or are on Medicaid or
Medicare, and for insured individuals who may have mental health benefits but cannot meet out-of-pocket expenses that are established in insurance plans. There is a tremendous stigma
attached to mental illness, which makes it difficult for patients to seek treatment or for loved
ones to support those who have mental problems. It is extremely difficult to get a Medicaid
patient referred to appropriate mental health care, and referrals to a psychiatrist (to evaluate for
medication) may take 5 to 12 weeks. If a psychologist is in private practice, they are not able to
get direct reimbursement from Medicaid. That closes doors to many people who might want to
access various providers throughout the state. If there is a lengthy delay to access service, it is
not unusual for an individual to simply give up any hope of treatment. It is imperative that these
mentally ill patients continue to take their medications and get the treatment they need. There is
a lack of qualified mental health care professionals in Idaho, especially psychiatrists. It is a
tragedy that community law enforcement and physicians are being taken away from their
important jobs to cope with mentally ill patients who are not receiving the care they need.
Dr. Crow continued by stating that the fragmentation between mental health care services and
substance abuse services in Idaho indicates a lack of coordination; each is organized, funded and
operated very differently. This is a huge problem identified by the IPA because a patient with
both mental health care and substance abuse issues cannot get help for both in the same place.
They are not getting the treatment they need, especially when trying to get a patient hospitalized
through a commitment process. Dr. Crow stated that she does not know how much of the
problem is a reflection of the vague language in the law or the difficulty in coordination of
services. There is also confusion between law enforcement and the hospitals in response to
mental health problems. Often the problem is based on cost, and schools are even hesitant to
address mental health issues due to special education requirements for certain students. Cost
factors cause many children and adults to fall through cracks and deteriorate even further,
eventually costing the state much more than if they received appropriate treatment in the
beginning. Funding is limited, but the mental health care system in Idaho must be fixed because
many individuals are being denied appropriate mental health and substance abuse critical care.
Dr. Crow believes that ACT teams need to be expanded so that more support and better funding
is in place to provide services to more patients. Intensive case management and intervention
needs to be the focus, especially in rural areas where there are no mental health care
professionals to deal with an acute crisis. Dr. Crow highly recommends more funding for
mental health care in Idaho, but first an evaluation needs to be done in terms of where money is
currently being spent. In addition to looking at a funding mechanism, problems of the uninsured
and Medicaid need to be addressed by increasing the reimbursement rate for psychiatrists so that
they will be willing to treat patients. Independent reimbursement status for psychologists and
other mental health care professionals would also help in terms of access to care. Expansion of
ACT teams is necessary as well as more local, secure in-patient psychiatric bed capability. Too
many patients are being transported from rural areas to a more populated area for treatment, then
released with little or no follow-up care in their own communities and no coordination of
services. Coordination of mental health and substance abuse services need to be addressed in
insurance plans so there is not discrimination. We need to expand the plans and programs for
early intervention such as the Red Flags program, which involves going into rural communities
and talking to parents, teachers and children to educate as to the early warning signs of
depression, suicide and the potential for violence.
Mr. Ken Deibert, Administrator of Family and Community Services, Idaho Department of
Health & Welfare (IDHW), was the next speaker. Mr. Deibert is responsible for adult and
children's mental health services as well as substance abuse programs operated by the state of
Idaho. IDHW partners with Medicaid and the private sector in providing mental health care to
individuals with resources they have available within the limitations, guidelines and funding
resources of IDHW. Mr. Deibert stated that he has observed over 30 years an increase in
awareness about mental health issues in the 1960's followed by a significant decline in interest in
commitment to the provision of mental health services through the U.S. and within Idaho. Idaho
has consistently been among the top ten states in suicide rates. Idaho doesn't have a
comprehensive system of mental health services to adequately meet the needs of its citizens with
mental illness. However, Idaho does have some of the best professionals, hospitals and
dedicated individuals both in the private and public sectors. IDHW needs to evaluate and look
more comprehensively at mental health care needs and how to best address them.
Mr. Ray Millar, Adult Mental Health Program Manager in the Central Office for Adult Mental
Health Services for Family & Community Services, IDHW, handed out the "Idaho Department
of Health & Welfare Mental Health Services Information Packet," a copy of which is on file in
the Legislative Services Office. The Task Force asked IDHW to address specifically:
Mr. Millar stated that the organizational structure of IDHW includes seven mental health care
regions, two state hospitals and the Idaho State School and Hospital serving persons with
developmental disabilities. The state of Idaho serves any individual 18 years of age or older who
has a severe and persistent mental illness and who meets the following two criteria:
1. The individual must have a diagnosis under DSM-III R or DSM-IV of schizophrenia, schizoaffective disorder, major affective disorder, delusional disorder or a borderline personality disorder; and
2. This psychiatric disorder must be of sufficient severity to cause a disturbance in role
performance or coping skills in at least two of these areas on either a continuous or an
intermittent (at least once per year) basis: Vocational/academic, financial,
social/interpersonal, family, basic living skills, housing, community or health.
In addition to the above population, IDHW serves any individual 18 years of age or older who is
experiencing an acute psychiatric crisis, including suicidal and/or homicidal behavior and who
may end up in an inpatient psychiatric facility if mental health intervention is not provided
promptly. Only short-term treatment or intervention, not to exceed 120 days, is provided to this
Mr. Millar stated that Idaho has one of the most rationed mental health service delivery systems
in the nation for publicly funded services. IDHW provides services to the most severe and most
ill. There are other individuals who have a severe mental illness who do not receive services due
to prioritization. IDHW's Assertive Community Treatment Team (ACT) has admission criteria
which states that individuals are refractory, meaning their illness (even when receiving treatment
and on medication) does not mean they remain stable over time. Patients also have frequent
contact with the legal system, histories of incarcerations and hospitalizations. IDHW calls ACT
teams "hospitals without walls" and a psychiatrist is assigned directly to that team up to 16 hours
per week of immediate care for individuals assigned to that team, as well as several nurses and
master level clinicians. As a team they serve the highest risk group of individuals that would
otherwise be in hospitals. The team has about eight hours of weekly contact with their patients.
Representative Deal asked what happens to a person who has an acute crisis if IDHW's
treatment does not exceed 120 days. Mr. Millar answered that if a patient does not meet the
first criteria of having "a severe and persistent mental illness" IDHW provides treatment the first
120 days, the ACT or Crisis Intervention team stabilizes the situation, and then that individual is
transitioned to other community providers or other medication follow-up services, such as
psychiatrists. The funding is inadequate for this care after the 120 days, even though there are
services for the indigent. They may be referred to a private mental health clinic provider or a
psychosocial rehabilitation provider, depending on circumstances.
Senator Cameron asked how many of those individuals would then end up on the state's
indigent rolls. The catastrophic fund for indigents is paying a significant amount for mental
health and substance abuse treatment and Senator Cameron asked if that is occurring after they
exhaust the benefits available through IDHW. Mr. Millar responded that IDHW's services are
prioritized and many indigents receive care. IDHW does make referrals to county welfare
indigent programs to receive medications or to pursue funding for counseling services sometimes
for domestic violence or substance abuse. A large number of people IDHW serves are indigent;
27% of the people are not only the severe, persistent mentally ill clients who have Medicaid
funding or insurance, and IDHW's collections are very low in trying to collect from Medicare,
private insurance or Medicaid. Mr. Millar continued that while the federal government
prioritizes serious mental illness, IDHW prioritizes serious and persistent mental illness.
Individuals with a serious mental illness such as a gulf war veteran who has post-traumatic stress
disorder, or a person who has panic attacks would not be served by the Department unless the
individuals were experiencing psychiatric crisis. In Idaho, IDHW goes one step further and
prioritizes serious and persistent mental illness such as bipolar disorder, schizophrenia, or major
depression that is so severe that it causes them to be unable to work and results in them being
hospitalized. There are two levels and serious mental illness includes a larger number of
individuals. According to the 2000 U.S. Census out of 924,923 representing 71% of total
population, the number of adults in Idaho with mental illness, serious mental illness or severe,
persistent mental illness totaled 184,984, or 20% of the adult population. The federal
government requires IDHW to provide services at a minimum for those with serious mental
illness, which is for 49,946 or 5.4% of Idaho's adult population. IDHW prioritizes their services
to those with severe persistent mental illness and serves 24,048 or 2.6% of Idaho's adult
population. In fiscal year 2003, IDHW served 14,032 to date or 1.5% of adult population. There
is a tremendous amount of unmet need for individuals even with a serious mental illness and
about 25,000 who could be accessing IDHW's services as severe persistent mentally ill when
compared to any other state. The ongoing IDHW caseload numbers about 6,000. Mr. Millar
noted that children with serious emotional disturbance aged 0 to 17 equals 5% of 369,030,
totaling 18,452. Mr. Millar then passed out a handout entitled: "Idaho Council on Children's
Mental Health - Community Report Card, December, 2002" which is on file in the Legislative
Mr. Millar stated that IDHW provides the following "core" adult community mental health
services in all seven regions: Screening; targeted case management; crisis intervention;
psychiatric rehabilitation; assertive community treatment; psychiatric services; and short-term
mental health intervention. State Hospital South features 90 adult beds, 30 skilled nursing beds
and 16 beds for adolescents. The cost per patient day was $407 in 2002. State Hospital North
(SHN) features 50 beds and currently admits patients committed by the judicial system; in 2002
the cost per patient day was $358. There are waiting lists at both hospitals for IDHW's highest
intensity services for inpatient psychiatric services and the wait is around 10-24 days. Local
hospitals serve those patients in the meantime. There is no wait for individuals to be assessed or
screened at outpatient services.
Senator Cameron asked how much money IDHW spends on community mental health centers.
Mr. Millar's handout lists services provided in each region and Senator Cameron mentioned
that his observation is that patients sometimes are only being given free cigarettes; he challenged
that list of services being provided. What role do free cigarettes play in helping with mental
health problems? Mr. Millar responded that he also shares concerns and admitted that in the
IDHW regions they are not serving large numbers in day treatment any longer, and have focused
on ACT teams. IDHW does have a team or a portion of an ACT team in each region; however,
those teams are not fully staffed and do not necessarily meet national standards. IDHW does not
have certified, fully funded or fully functional ACT teams, but IDHW is preparing to meet
national standards and have improvement plans in place.
Senator Cameron inquired if the community health centers that are privately owned, but are
funded by Medicaid reimbursement, fall under assertive community treatment? Mr. Millar
confirmed that the centers are usually private services that would be reimbursed, typically by
Medicaid. IDHW's services are primarily centered near urban centers.
Mr. Millar continued by stating that IDHW's family and children's services offices are located
in the following seven regions: Coeur d'Alene; Lewiston; Caldwell; Boise; Twin Falls;
Pocatello; and Idaho Falls. IDHW is not seeking a way to build 2-3 more state hospitals. Mr.
Millar addressed IDHW's community services expenditure report dated September, 2003 broken
down for adults and children. Idaho ranked 46th nationally for actual mental health dollars spent
per capita in fiscal year 2001. Idaho is the 5th fastest growing state and had the 3rd highest
growth rate from 1990-1998.
As to differences of IDHW's regional programs, Mr. Millar stated that some have more field offices than others, some provide more rural services, with more urban access to psychiatric care. All regions have contracts with local health care providers that provide services beyond IDHW's "core" services. He noted the following mental health system challenges:
1. Service Gaps: voluntary inpatient services; longer term inpatient; longer term substance abuse treatment; rural mental health services & providers; secure inpatient services for violent offenders; and treatment of co-occurring disorders.
2. Early intervention/prevention services
In order to improve the system, Mr. Millar set forth IDHW's recommendations: Implement full insurance parity for mental illness; realign resources and technology; implement evidence based practices; develop statewide standards for service delivery; develop new alternatives to hospitalization; increase service system coordination; increase availability of voluntary mental health services for non-priority populations; implement early intervention/prevention services; develop a secure forensic facility for violent offenders; continue to support statewide suicide prevention plan; support care management strategies for service delivery; implement a comprehensive data system for mental health services; support provision of mental health care in jail and prison; and implement recommendations of President's New Freedom Commission. The goals and recommendations of the Freedom Commission are outlined in a handout distributed by Mr. Millar. A copy of the handout is on file with the Legislative Services Office.
Representative Black asked for clarification regarding IDHW's community services
expenditure report showing mental health receipts for fiscal year 2002 as $3,408,700. Mr.
Millar answered that the number represented primarily Medicaid receipts as well as sliding-fee
payments from clients. Mr. Deibert explained that in the state mental health hospital system,
when an individual is committed to the state of Idaho, their private insurance does not pay for the
cost of care in a state psychiatric facility; Medicaid does not pay for inpatient psychiatric care
even if the person is Medicaid eligible. State Hospital North receives practically no receipts
because they serve only adults. The receipts that IDHW receives for payment of services for
State Hospital South are primarily limited to treatment of adolescents. IDHW cannot get
Medicaid reimbursement or insurance reimbursement for services provided in the state operated
psychiatric hospitals. That limitation exists in code and rule. Representative Black cited an
instance of a patient who was billed $139,000 for services received from State Hospital South.
Mr. Deibert clarified that IDHW was obligated to submit a bill for services whether or not that
individual can pay. IDHW's ability to collect is diminished with the vast majority of individuals
entering the state hospitals. Representative Black requested that IDHW provide a dollar
amount for the services billed by IDHW and the amount received from such billings. Mr.
Deibert stated those figures would be forthcoming. Mr. Deibert added that the expenditure
report represents receipts for outpatient services only and not inpatient.
Representative Garrett requested a region by region synopsis of the caseload differences
between IDHW regions and asked if there was a difference between needs and services in
different regions. Mr. Millar answered that the caseload differences vary according to the
services they receive. The largest number of services are provided by ACT teams. IDHW's
Region IV (covering Boise, McCall and Mountain Home) has the largest number of ACT teams.
Almost 50% of state hospital beds are occupied by residents in Ada County. Court related
evaluations have risen from 60-80 per month in Region IV several years ago to 130-150 per
month currently. IDHW used to get defense attorneys and judges ordering evaluations related to
competency to participate in their defense in numbers from 5-6, and recently the number has
risen to 18 per month.
Senator Stegner referenced the Community Services Expenditure Report under adult
community mental health services for fiscal year 2003, which shows $16,438,100 total. He
stated that it appeared the Legislature cut the funding by nearly $2 million for that service, but in
fact the appropriation for that fiscal year was $18,131,700. IDHW shifted funds downward in
four different categories, reflecting a funds adjustment reduction of $832,000, a transfer between
programs of $120,000, and other adjustments for a total reduction of about $1.8 million or 10%.
He queried why, if there is so much need for increased service delivery for mental health
services to adults in Idaho, IDHW reduced its own appropriation by 10%. Mr. Deibert
responded that the last few years have been challenging for IDHW from a funding perspective
and the funds returned to the general fund are those potential carryover funds requested by the
Governor to be returned to the general fund to address the deficit at the end of the fiscal year.
Those funds were returned to the general fund at the Governor's request. The fund shifts could
not be explained specifically by Mr. Deibert without looking at detail. IDHW set as a priority,
working with the Governor's office, that the focus of any cuts made over the past two years had
the least amount of impact in children's services in both mental health and child protection
services. Within the Division of Family and Community Services, that left IDHW very few
options. Substance abuse, mental health and developmental disabilities were areas that ended
up with reductions to meet the budgets for those programs. Mr. Deibert volunteered to respond
to Senator Stegner's inquiry in detail after gathering more data. Senator Stegner stated that it
does appear to be a pattern not only in adult mental health but with the budget for State Hospital
North, which was appropriated $6.2 million with actual expenditures $5.7, a reduction of nearly
10%, and an appropriation to State Hospital South of $16.3 million with expenditures of $16.5,
which went up. Developmental disability services had an appropriation of $18 million and
expenditures of $16.6 million. Children's services program under family and community
services received an appropriation of $55.1 million and expenditures were $51.9, a reduction of
$3.2 million. There appears to be a pattern of reduction in almost all categories and Senator
Stegner broadened his request for an explanation to all of those programs for fiscal year 2003.
Mr. Deibert responded that there were hold-backs during 2003 and those are reflected in the
figures presented. IDHW had a 3.5 percent general holdback within family and community
services which amounted to about a 7% reduction of programs. Maintenance of effort
requirements must be addressed, and for substance abuse, IDHW was within $3000 of falling
below federal maintenance of effort funding formula for substance abuse. If they had fallen
below that figure, IDHW would have lost federal dollars. IDHW ran into that same situation
with the infant and toddler program and were very close in mental health services for both adults
Senator Goedde commented that IDHW was working on a comprehensive data system since
1991 and asked when that might be finished. He also inquired about the accuracy of the IDHW
information being provided to the Task Force. Mr. Millar responded that within two years
IDHW will have a prototype of the database ready. With regard to the accuracy presented to the
Task Force, Mr. Millar stated that IDHW is doing better than in the past, but acknowledged
there have been duplications in their system. Senator Goedde stated that he heard that there are
existing assets not being utilized as well as they could be and that coordination would help.
IDHW's list of ways to improve the system do not appear to require any legislative directive for
a starting point. Senator Goedde asked what steps IDHW has taken on their own to implement
some of these improvements and to better utilize the assets. Mr. Millar answered that IDHW
has been working with public providers to change the role of the regional directors to work
specifically with hospitals, jails, county commissioners and other individuals in communities to
develop these coalitions. Improvements have been made in children's mental health by
developing 37 Children's Coordinating Councils in the last two years, bringing together schools,
the Department of Education and the IDHW itself, gathering other service providers into local
councils to review cases for children and staff these cases. For adults, IDHW has been trying to
maintain services and seek information about how they can improve their standards of practice.
Everyone recognizes that IDHW often sees the same clients publicly and privately and are
receiving services across programs and they are trying to better coordinate these programs.
Mr. Deibert added that some of the challenges faced in Idaho as well as other states are not self-imposed limitations. There are significant restrictions on funding from the federal government
and many strings are attached that often prevent adequate collaboration. Substance abuse and
mental health are both within the division of family and community services, but it is extremely
difficult to make these programs work with each other. Given the funding priorities and the
requirements of federal dollars, if a person has a mental illness and is also a substance abuser,
they may not qualify for substance abuse treatment with the federal priorities that are set for the
funding. In some cases, people with a mental illness are excluded from receiving substance
abuse treatment based upon the federal criteria.
Mr. Deibert continued by stating that IDHW is working with the courts to develop a strategic
plan between family community services around mental health, substance abuse and child
protection issues so that there is a more coordinated effort. IDHW recently signed a
memorandum of understanding with the Department of Corrections to assist them in the
development of services to individuals who are being released from the prisons who are in need
of mental health services and substance abuse services. The President's Freedom initiative, if
implemented, would enhance the state's ability to have funding flexibility.
Representative Deal requested that IDHW gather data for the Task Force regarding the money
available for mental care. Money from the general fund has been identified, but Representative
Deal asked for figures and sources of additional funding, including from the catastrophic
program from the counties and other grants that are used and available and what strings may be
attached. Mr. Deibert will gather that information but stated they do not have figures or facts
from the counties. Mr. Tony Poinelli agreed to work with Mr. Deibert to obtain this
information for the Task Force.
Representative Garrett requested more information regarding where mental health dollars are
already being spent, and suggested that if more dollars were spent on prevention and
medications, it would save money in the long run by avoiding crises.
Senator Goedde requested from IDHW facts about what has been done in the past several years
with regard to reorganizing, utilization or improvements in their system from IDHW's side. The
Task Force can see what needs to be done, but it would be worthwhile to see historically what
IDHW has done in the past several years.
Senator Stegner distributed a draft proposal relating to mental health services. A copy of this
draft proposal is available in the Legislative Services Office. Senator Stegner stated that the
proposal would be a very small but important step toward an effort to improve mental health care
services in Idaho. The draft basically sets in place a change in philosophy of the state about who
makes mental health care decisions and how these decisions are made. This proposal is the
product of four years of work by a group of people including an attorney, Senator Stegner,
county commissioners, clerks and other officials and hospital personnel. Health and mental
health care professionals and advocacy groups have also been involved. The process began
when the problem of defining the area of responsibility for mental health in Idaho arose. Is it a
county indigence problem or a state responsibility? It was evident that it was a much bigger
Senator Stegner stated that decisions need to be made at a regional level by concerned people
who work "down in the trenches" of mental health, who are committed to improving the system
and who recognize the deficiencies of the current system and the individual assets of a region.
The counties, in some cases, are too small to handle this. The committee's vision is to someday
have a behavioral health regional office in every region in the state, very similar to the public
health offices in Idaho, or possibly in combination with the public health offices. They'll be able
to set priorities and design a system unique to each region, recognizing that they'll have to share
assets and that small communities may not have every service right in town, but they will know
they have service within a reasonable distance. That is the vision of the committee, and Senator
Stegner's personal vision includes a state hospital in central Idaho. When 47% of the people are
transported to state hospitals from Ada and Canyon counties, we need one closer, and we haven't
increased beds in that service in fifty years, even though the population and the need has grown
incredibly. Senator Stegner stated that the function of the state hospitals should be expanded to
meet the service needs of the counties and local communities with regard to holdings,
commitments, voluntary commitments and substance abuse.
Senator Stegner asked the Task Force to give some consideration to the concept of regional
authority in making mental health care decisions which starts from the base and builds a system
responsive to local needs, rather than a top-down authority from the state of Idaho which
mandates downward. In order to do that, an existing structure in the state could be modified,
giving them a little authority (if they want to take it, which is optional) and setting up the process
to allow that. Senator Stegner's committee has been sensitive to IDHW, and their involvement
would still be key and would require their approval for any plan improvement. If this plan were
in place in one or all regions and they would want to take the initiative, they could develop a
plan that will allow that region to get full funding for an ACT team, since they are very effective
in reducing people moving through the state health, court and emergency room systems. ACT
teams create that concept of "hospitals without walls" and Senator Stegner thinks they should
be expanded statewide. ACT teams are not currently fully funded.
Senator Stegner's committee has developed a process where regionally, people can establish
behavioral health boards; this does not mean that this would be funded, but rather applications
could be submitted, the plans presented to IDHW for approval and the Legislature can work on a
plan for funding. Funding would involve increasing beer and wine taxes and putting that money
to specific uses, one being ACT teams. Senator Stegner recognizes the uphill battle of
increasing beer and wine taxes, but he hopes there is broad support from cities and counties and
there would be a component that would benefit education and liquor control enforcement. There
is a coalition that recognizes not only the policy improvements by changing beer and wine from
a volume to a price-based tax, but also the benefits of the money generated by that process.
Mr. Tony Poinelli, Idaho Association of Counties, spoke next in support of the draft proposal
introduced by Senator Stegner. He explained that the current law addressing mental health
advisory boards would be changed to "regional behavioral health boards," the primary reason
being that there is constant dual-diagnosis of individuals, with mental illness as well as substance
abuse problems. The regional behavioral health boards would allow the counties to be involved
more closely than they are at present, as well as other parties in the community who have a major
influence and impact in determining what needs are. In Section 2 of the draft proposal, the
makeup of the boards is outlined. All of the studies over four years suggest that more
involvement at the local level is needed. The appointments would be submitted to IDHW, but
the final appointments would still be made by the local commissioners and regional people.
Section 3 deals with individuals serving on the current advisory boards and it has been suggested
that members of the current mental health advisory boards serving their current terms may
continue until end of current term. Appointments made after that effective date would be made
in a manner to achieve the representation provided in that section as soon as reasonably
practical. Most of the mental health advisory boards are made up of consumers, licensed
practitioners, etc. There are not many who have any county representation. There may be a
welfare director, but there are no policy makers. The county commissioners are policy makers.
Under Section 4, additional duties were added. In Section 5, the focus is the creation of ACT
teams. There are ACT teams within each region, but only two may meet the national standards.
There are gaps with members of individuals on those ACT teams. Establishing 8-member ACT
teams that meet the national standards would be a good first step in all regions. The proposal
may not appear to do much, but it brings the right people together, including policy makers who
are not there now and will "hold everyone's feet to the fire."
Representative Garrett emphasized her support for strong community mental health. She
stated that there are inconsistencies and fragmentation in regions identified by IDHW. With
regard to development of statewide standards, best practices and service system coordination,
Representative Garrett inquired how the proposal would dovetail with those concerns. Mr.
Poinelli answered that they wanted to look at basic services for each region with each region's
different needs to allow flexibility. There is focus on ACT teams, but in some regions they may
have a need for a crisis response team if their ACT team is fully intact, fully funded and working
well. Local people need to determine what they feel their county's primary needs are, but every
region should have the same basic services. Mr. Poinelli emphasized the need to expand the
ACT teams in regions where they are not fully staffed, clarifying that these ACT teams must
remain under IDHW at the present time. The cost for a fully functioning ACT team of eight
members is $650,000, so $4,550,000 would be the approximate cost for the entire state.
Senator Stegner stated that the fiscal impact for the proposal would be zero; the key to this bill
would be the very last paragraph "Cooperative Service Plan Component" which would provide
that community groups develop the service plan. It would be Senator Stegner's hope that the
legislature could put forth a bill that would provide that money. That potential bill would have a
fiscal impact in terms of costs associated with the increase in readjustments of tax fees and
where that money would be specifically spent through dedicated funds.
Senator Goedde reiterated the proposal did not appear to do much if there was no tie to funding.
Senator Stegner answered that the proposal could be key in granting the authority to local
entities. It is a broad idea to improve a service and the immediate question is how to pay for it;
there is a way to fund it, if the legislature approves. It would not be a companion or substitute
bill; it would have to start in a specific committee in the House of Representatives because it's a
tax bill, it's an issue not really germane to that tax issue and to divide them made the most sense.
The draft slightly changes structure, but the wording is key in developing the actual authority for
these local groups to make these decisions. If this whole system worked and ACT teams became
successful, and if these behavioral health boards became an integral part in determining mental
health delivery system in a region, additional programs could be authorized for them to control.
Mr. Poinelli emphasized that right now in many areas of the state, there is a constant battle
between the state and the counties. By bringing the groups together, it does give some authority,
and meshing the two together will help communication and will bring policymakers into the
County Commissioner J. R. VanTassel explained that IDHW is funded by the Legislature and
does not garner revenue themselves. They therefore have a finite number of dollars to spend.
They have a well-defined clientele who cease to be served when that money runs out. On the
other hand, counties are operated by county commissioners who have to go directly to the
taxpayers to get the money. There are two different pools of money that are not working
together. IDHW can plan for mental health services, but counties just react to the bills they get,
and pay millions of dollars in reactive payments.
Senator Goedde stated that he likes things done on a local level, but his concern is that if boards
are established with a mission but no tools to accomplish that mission, this could lead to
Representative Deal requested that the proposal be circulated until the Task Force's next
meeting and if the sponsors want to bring the draft before the Task Force for consideration prior
to going before the Legislature, the Task Force will consider the proposal.
Ms. Leslyn Phelps, Executive Director, Glenns Ferry Health Center, gave a presentation on Community Health Centers (CHCs). Ms. Phelps presented on behalf of the Idaho Community Health Centers and the Idaho Primary Care Association, stating the CHCs are unique because of who they serve, where they are located, their local ownership in government and because of the comprehensiveness of the care they deliver. Ms. Phelps explained that CHCs serve medically under-served communities in Idaho and are not-for-profit corporations that:
CHC services are available to everyone. A sliding fee schedule is in place for low income,
uninsured, under-insured and under-served individuals. Everyone pays at least a nominal fee
and insurance is billed for those who have insurance.
Ms. Phelps stated that CHCs use limited resources effectively, including: federal grants;
favorable drug pricing (340B); cost-based reimbursement under the "Prospective Payment
System" (PPS) for Medicaid patients, low income or uninsured; patient revenues; and other
grants and donations. The mission of the CHC is to provide access to primary health care to all
residents in communities. They provide services without regard to insurance status or income.
CHCs serve high-need rural areas and communities. Seven CHCs provide primary health care
services, operating in 26 locations, and saw nearly 65,000 patients with 236,683 visits in 2002
state-wide. In 2002, CHC in Idaho had 203,295 medical encounters, 18,091 dental encounters,
and 15,297 mental health/substance abuse encounters. Current full-time equivalent by provider
type equals: 33.1% mid-level; 10.6% dental; 22.3% mental health; 35% physician.
Ms. Phelps said that Idaho CHCs are unique because they serve a higher proportion of Idahoans
who are poor. Eight-five percent of CHC patients are at or below 200% of poverty. Sixty-one
percent are below 100% of poverty and 47% are uninsured. CHCs provide a broad scope of care
to many Idahoans; 56% are white, 37% are Latino, 4% are Native American and 3% other.
CHC's philosophy is "everyone is responsible to pay" and services are not free and every
individual is charged for service delivered. Charges are based on local prevailing rates; charges
are approved by the CHC board of directors; individuals below 100% of poverty pay a nominal
fee; and there is a sliding fee available based on family income (poverty level guidelines).
Federal grant funds in 2002 accounted for 25.7% of revenues. 33% of revenues were from third-party reimbursement, insurance, private insurance, Medicaid and Medicare and 33% were from
Ms. Phelps stated that CHCs are guided by Idaho values. A majority of the board of directors
must be users of the CHCs. Board members represent a variety of areas of business expertise
vital to the operation of the CHC, and health care industry board representation is allowed and
critical to success. CHCs also follow rigorous performance and accountability requirements
regarding the administrative, clinical and financial operations, and are required to meet and
report key performance, effectiveness, and quality measures annually. Operational business and
health care plans are updated and reviewed annually. Risk management standards, including
continuous quality improvement activities, are incorporated on a quarterly/annual basis.
According to Ms. Phelps, the CHCs are cost effective because they reduce emergency room and
Ms. Phelps stated that the CHCs would like to partner with the state to increase their capabilities
to provide mental health services to their patients. Because their resources are limited, they
cannot meet the needs of communities without additional support. CHCs are asking the state to
fund a Primary Care Grant Program that would expand primary medical, mental, and dental care
capacity at CHCs. With four million dollars, Idaho CHCs would serve 13,072 additional patients
(approximately 44,500 visits) and the potential cost-avoidance could equal $90 for a primary
care visit versus $650 for an emergency room visit. According to the Idaho Primary Care
Association, increasing usage of CHCs and reducing emergency room care could save
$23,045,680 annually. Idahoans made 411,533 emergency room visits last year; 10% were for
non-urgent conditions that could have been treated in a primary care setting.
According to Ms. Phelps, CHCs in Idaho save the state $3.4 million annually in state Medicaid
expenditures alone. The federal government saves $1.00 in Medicaid expenditures for every
$1.00 it invests in Idaho's CHCs through the federal primary care grant program. The Idaho
Medicaid program spends $1,011 per beneficiary for children under age 20, $2,669 per
beneficiary for adults ages 20-64, $12,360 per elderly beneficiary; 39% of Idaho CHC patients
are children, 53% are adults ages 21-64 and 8% are the elderly. The average total Medicaid
spent for each CHC Medicaid patient is $2,798. Several studies have found that CHCs save the
Medicaid program more than 30% in annual spending per beneficiary due to reduced specialty
care referrals and fewer hospital admissions. According to the federal Bureau of Primary Health
Care, Idaho CHCs served 14,135 Medicaid patients last year.
Ms. Phelps, speaking on behalf of the Idaho Primary Care Association, expressed their desire to create a state primary and preventive care grant program to provide state funds to expand primary care capacity to serve low-income and uninsured Idahoans at Idaho CHCs. When the grant program is established, pursuant to an appropriation, a Primary and Preventive Care Grant Program Board will be appointed to oversee administration of the program. Service grants may be used to expand hours of operation, offer new services or hire additional clinical staff at CHCs.
The Primary Care Grant would follow the lead of at least 29 other states and create opportunities
for Idaho to leverage federal funds to expand primary care services. Arizona, Colorado, Oregon,
Utah and Washington all have state funded grants.
Senator Goedde asked how many uninsured people in Idaho fall below 200% of the Federal
Poverty Level? Mr. Bill Foxcroft answered that studies indicate that 2/3 to 3/4 of the uninsured
cannot afford to buy insurance. Senator Goedde asked for clarification because some people
who may be uninsured have luxury items such at snowmobiles, so "cannot afford" can be
interpreted in many ways, and he again requested a specific number of people who fall below
200% of the Federal Poverty Level. Mr. Foxcroft agreed to get that figure for the Task Force
on a state-wide basis.
Senator Cameron inquired about the current financing that CHCs receive. Ms.
Phelps responded that at the Glenns Ferry CHC, federal dollars represent about 45% of their
funding. Glenns Ferry receives a higher percentage because in rural areas there are fewer
resources available. Other CHCs receive 30-40%, depending on the year, from third party
Medicare, Medicaid and other insurance. In Glenns Ferry, many people have some insurance,
some for catastrophic illness which does not cover primary care. Currently, 187 insurance
companies are billed by the Glenns Ferry CHC and the rest of their funding comes from self-paid
patient fees, either nominal or reduced sliding fees. Senator Cameron requested a more formal
report to see where the specific dollar funding comes from for CHC. Ms. Phelps stated that the
Glenns Ferry budget is up to $1.8 million. Other CHCs are running from $3-5 million budgets.
CHC faces problems with health insurance rate increases for coverage and changes will have to
be adjusted accordingly to meet those rate increases.
Senator Cameron recognized the importance of the CHCs and reiterated that Ms. Phelp's
request from the Task Force for additional CHC funding caused him to wonder if the Legislature
had $4 million to spend on the uninsured population, where would Idaho get the most for their
money? If $4 million were put in through the Medicaid system, either through expanding CHIP
or other systems, at least a federal match on a 70%-30% basis or perhaps 80%-20% basis,
depending, the $4 million could be leveraged into about $12 million. Ms. Phelps suggested
working through this together since the uninsured population is growing; CHC could expand
their services and if they could do it through Medicaid, they could get the matching dollars; Ms.
Phelps would need time to gather more information about this. Senator Cameron admitted his
question may be a hypothetical one, since Idaho, in all likelihood, will not have an additional $4
million to spend on additional health care services despite the need. The Task Force recognizes
the need for citizens to be insured.
Senator Stegner stated that the savings calculations presented assumed that CHCs would garner
all of the 10% of non-urgent care. If the assumption is made that the study was correct yet CHCs
received only 5%, then the savings would only be 5%, and not the 10% shown in the handout.
Mr. Foxcroft answered that the handout shows how much inappropriate use is costing the state
that could be diverted to a primary care setting, especially if CHCs are open later or on
weekends. Senator Stegner continued that Idaho currently has a law that says hospitals have to
take all patients, whether or not they are urgent care, and asked if the legislature should consider
eliminating that statute and allow hospitals to divert non-urgent care services to a community
health center. Ms. Phelps responded she would not want to see this changed; however, if the
uninsured had a medical home where they could go in for visits, CHC estimates that those
uninsured people would be kept out of the hospital emergency rooms more often. In many
instances, non-urgent visits are seen in hospitals due to the hours at night or on weekends when
situations occur and primary care centers may not be open for service. CHCs could provide
extended hours with more funding.
Representative Garrett had questions regarding utilizing physicians for mental health services
at CHCs which concern consumers as well as family members as follows: 1) What type of
mental health treatment do CHCs give?; 2) What kind of services and what are the qualifications
of CHC's licensed mental health providers?; 3) Do CHCs serve the severe, persistent mentally
ill?; 4) Do CHCs have a restrictive formulary?; 5) What kind of training and diagnosis of
treatment do CHCs give your primary care physicians?; and 6) How do CHCs use a psychiatrist?
Ms. Phelps responded that due to billing with regard to state law, there are requirements for
professionalism and qualifications that must be met in order to treat patients. Primary care
physicians are allowed to treat depressed, highly stressed or anxiety-ridden patients. Patients
with severe conditions are referred to CHC's licensed clinical social workers, but they are not
allowed to prescribe any medications, so they must work collaboratively with a psychiatrist.
CHC does not have enough psychiatrists on staff. CHCs do work from a formulary which would
include psychotropic drugs, and follow-up would be a part of this.
Representative Garrett questioned if CHCs diagnose, treat, and prescribe medications for
mental health treatment, rather than psycho-social rehab or any therapy and regarding formulary,
do CHCs provide the full range of psychotropic medications including the new atypical
medications? Ms. Phelps answered that CHCs do provide counseling and, depending on the
education of the staff, they provide a system of support. It could be counseling such as drug and
alcohol abuse counseling. CHC is required to provide counseling due to their funding
requirements. Only psychiatrists or physicians prescribe medications. More severe diseases
require the treatment of a psychiatrist and CHCs do not provide any inpatient care.
On other matters, Representative Black asked about the status of the insurance premium tax.
Senator Stegner said that a bill is being drafted and will be before the Legislature to consider this
session. Representative Deal agreed that the premium tax issue should go before the Business
Committee, Commerce or Tax Committee.
Representative Collins asked about the status of the pending lawsuit? Steve Tobiason
answered that it was postponed from July to December of 2004, and the primary reason was to
allow more time for the legislative session because the discovery cutoff date was set for April 1st,
which created problems because discovery had to take place and that costs money. Both sides
agreed to move the trial date back so that they wouldn't have any further discovery until the
session is completed. Obviously, if there is a favorable outcome in the session, there would not
be any further need for the lawsuit. Senator Stegner added that he had received a letter from
MetLife and NY Life representing that companies who filed taxes under protest would give up
such claims if the Legislature was able to craft a solution. He stated that he was also expecting a
letter from General Fire & Casualty saying that the lawsuit would be dropped if an agreeable
legislative solution is adopted.
Senator Stegner continued by stating that draft legislation relating to the premium tax structure
was being drafted and would include in part a mechanism that would frontload some of the
programs currently funded with premium tax dollars.
The next meeting of the Health Care Task Force was scheduled for January 15, 2004, at 2:00 p.m. in the Senate Majority Caucus Room. The meeting was adjourned at 2:45 p.m.