HUMAN SERVICES RESTRUCTURING TASK FORCE

Institutions and Facilities Subcommittee
MINUTES

September 25, 1997 - Second Meeting of Five

MEMBERS PRESENT

The following legislators were also in attendance: Representative Dan Huseman and Representative Joe Kremer

MEETING IN BRIEF

Minutes prepared by John Pollak, Committee Services Administrator
Organizational staffing by Nicole Haatvedt, Legal Editor

  1. Administrative Business.
  2. Cherokee MHI.
  3. Managed Care.
  4. Central Point of Coordination (CPC).
  5. Upcoming Meetings.
  6. Materials Distributed to the Subcommittee and Filed With the Legislative Service Bureau.

SUBCOMMITTEE BUSINESS

1. Administrative Business.
The meeting was convened at 10:55 a.m. with a welcome from Senator Freeman, Representative Huseman, and Cherokee MHI Superintendent Tom Deiker, and recessed to tour the programs and grounds of the Cherokee MHI at 11:00 a.m. The meeting reconvened at 1:00 p.m. and adjourned at 3:05 p.m. The summary of the subcommittee's previous meeting on September 10, 1997, was approved as submitted.
2. Cherokee MHI.
Overview. Superintendent Deiker provided an overview of the changes in the MHI over the past 10 years and, with assistance from other MHI staff, responded to questions from members. Several questions were also directed to Department of Human Services (DHS), Division of Mental Health and Developmental Disabilities, Director Mr. Harold Templeman and DHS legislative liaison Ms. Karla McHenry.
Downsizing. Superintendent Deiker described the process of downsizing over a five-year period in which the workforce size of the MHI was reduced by 38 percent without forced layoffs. He noted that typical annual staff turnover was 3 percent and that there were essentially no new hires over the five-year period. During that time, the average length of patient stay was also reduced by 38 percent. Currently the average census for inpatient care is approximately 70 while annual admissions are approximately 900-1,000.
Alternate Uses. The MHI has performed alternate facility planning and has developed alternate, cost-effective use of the facilities. Programs using the facilities, viewed during the tour, include residential substance abuse treatment, juvenile detention, and juvenile residential treatment. These programs also contract with the MHI for ancillary services such as food and laundry. This sale of outside services reduces the per diem costs for the inpatient services.
Corrections Planning. Strategic planning and discussions with the Department of Corrections have taken place for possible programming for corrections populations with special needs. Special populations considered include aged persons, persons with deviant sexual behavior, persons with a chronic mental illness, a developmental disability, or both, and persons with chronic health care needs. The MHI role in coordinating with the Department of Corrections could be similar to that of a landlord or program administrator or the MHI could contract to provide services such as medical, psychiatric, and social work. Labor for renovation of facilities has been supplied by prison inmates in the past and it is believed that some existing MHI wards could be made secure for special correctional populations.
Discussion of Corrections Usage. In response to a question from Representative Heaton, Superintendent Deiker expressed the belief that the Cherokee MHI would be best able to deal with inmates who are elderly with medical infirmities, both from a resources and a cost standpoint. Mr. Templeman noted that the Cherokee MHI has many resources and that the experience working with correctional programs at the Mt. Pleasant and Clarinda MHIs has been positive. Senator Szymoniak noted that a recent ruling by a federal judge has called into question the correctional system's treatment of inmates with mental illness. Superintendent Deiker cautioned there are a number of inmates who have both high therapeutic and security needs. Senator Freeman and Representative Heaton both noted the effect of substance abuse offenses in contributing to prison overcrowding.
Providing Relevant Services. Superintendent Deiker explained the full array of psychiatric services made available to the more than 45 counties in the MHI's catchment area. Many counties are now purchasing transportation services in lieu of this function being performed by the county sheriff. In addition, the MHI is participating in internship programs for mid-level psychiatric health practitioners such as physician assistants and nurse practitioners. In response to a question from Chairperson Houser, Superintendent Deiker conjectured that the per diem for a comparable private hospital stay may range from $750-$1,000 as compared with the MHI per diem of approximately $400.
Shorter Stay. In response to a query from Senator Szymoniak regarding the effect of shorter stays on consumers, Superintendent Deiker said his review of research on this question indicated the effects are either positive or neutral.
3. Managed Care.
DHS is in the process of developing a request for proposals (RFP) for a vendor to provide managed care of adult mental health and substance abuse services under the Medical Assistance (Medicaid) Program. The current draft RFP also includes child welfare services along with the other two services, partly to allay federal concern about controlling the cost of these services. The Iowa Supreme Court recently issued a decision finding the state's cap on group foster care to be unconstitutional, which may affect the decision to include the services in the contract.
MHI. In response to a question concerning the use of MHIs by the state's current mental health managed care contractor, it was noted that the current managed care contract has an exclusion for adult mental health services at an MHI. Mr. Templeman said there are two problems with including these services in the current or a future contract. The problems involve a federal Medicaid prohibition against reimbursing freestanding facilities serving more than 50 mental health clients and the belief that under federal Medicaid requirements, inclusion of an MHI would require rebasing the entire rate structure for mental health services.
Political Support. Chairperson Houser noted that if a special session of the General Assembly had been held, a meeting of the Human Services Appropriations Subcommittee members would have been called to review the draft RFP. He asked legislative members to respond regarding the level of support among their caucus members for the current draft. House Republican members do not appear to support the draft RFP, in particular the inclusion of child welfare services in the managed care contract. Representative Foege had spoken with eastern Iowa members of the Democratic caucus who expressed similar concerns. He believes the consensus is to move very cautiously on child welfare services.
Decategorization. Members also expressed concerns that the current child welfare system is subject to limited funding and that transfer of responsibility of child welfare services to a profit-making managed care entity may further reduce the moneys available to fund services. Both Representative Foege and Ms. Schmidt expressed concern that the inclusion of these services in managed care would negatively impact many years of effort by local DHS, court, and county officials to cooperatively plan for child welfare services in projects where the funding for these services has been decategorized.
Provider Concerns. Mr. Gutmann recently attended a meeting of the Coalition of Children and Family Services in Iowa (a provider organization) in which juvenile court officials appeared clearly opposed to the draft RFP. He said the Coalition is making a formal request to DHS to work collaboratively with providers to improve the proposal. He said that the high level of documentation required by the current system causes many providers to expend additional resources on administrative staff for compliance. There is also concern that there is a lack of coordination with managed care covering some services and decategorization covering others.
Outcomes. Ms. Schmidt noted that the decategorization project in her area had just completed work on developing outcomes for the providers of services. She noted the benefits of local people designing the system for their area. Mr. Gutmann pointed out that the Medicaid Program is a medical insurance model which is difficult to apply to interventions in human behavior.
4. Central Point of Coordination (CPC).
A three-person panel presented regarding the system of using persons designated as the CPC to manage county funding of mental health and developmental disability services. The panel included Ms. Beth Crowell, CPC administrator for Monona, Shelby, and Harrison counties, Ms. Mae Hingtgen, CPC administrator for Cherokee County, and Ms. Robyn Wilson, State-County Assistance Team (DHS) staff providing technical support to CPCs in the DHS region in which Cherokee is located. Ms. Wilson distributed general materials describing the duties of CPC administrators.
Cherokee Comments. Ms. Crowell expressed approval for the efforts made by the Cherokee MHI to coordinate services with the CPCs. She noted that the level of communication concerning persons placed there has benefited consumers. According to Ms. Crowell, the MHI fills an important regional need for treatment of persons with extreme or violent behavior who are difficult or impossible to place with private providers. She noted the difficulty in locating services in rural areas and the important role played by the Cherokee MHI in filling needs for coordination of services and training. Ms. Hingtgen explained the importance of the Cherokee MHI in providing mental health services to residents of Cherokee County. She noted the institution's involvement with the local community. The MHI is of great assistance to CPCs in identifying an individual's county of legal settlement. Ms. Hingtgen expressed approval for the efforts made by the MHI in regard to improving discharge planning. The trend is toward community-based services and the MHI has worked hard to support this trend.
Substance Abuse - Dual Diagnosis. Panel members related problems with the distance traveling to the Mt. Pleasant facility, which is the only MHI with a substance abuse program. There are a number of difficult-to-treat persons who have a mental illness combined with a substance abuse problem. Representative Heaton described the efforts to create a dual diagnosis program at Mt. Pleasant for the treatment of these needs. There was discussion of the possibility of locating these programs at Cherokee.
Provider Negotiation. In response to a query by Representative Heaton regarding cost information supplied by providers to purchasers, it was suggested that in rural areas there is not much competition among providers for long-term services. The CPCs have the experience of working together closely with providers to control costs and provide needed services.
Out-of-State Placements. During discussion it was suggested that with some diagnoses, it is easier to place the person out-of-state than to obtain a placement at an MHI or state hospital-school, even though the out-of-state placement may be more expensive. Part of the problem lies in the success of the system used to restrict placements in the state institutions. Ms. McHenry explained the process used by the child welfare system to develop services in-state in order to decrease the number of out-of-state placements. Chairperson Houser asked that this information be supplied to the subcommittee.
RFP. Chairperson Houser asked the CPC panel to comment on the draft RFP for managed care. Concern was expressed regarding the RFP's restriction on MHI placements for individuals age 21 to 64 and it was asked if assistance on this point could be provided by Iowa Congressional representatives. Clarification is needed as to the responsibility of the managed care entity to provided "wrap-around" services. Other concerns related to exemptions in the contract for the state hospital-schools and the inclusion of child welfare services. Ms. Schmidt expressed the need to work more closely with the court system in ordering appropriate placements.
5. Upcoming Meetings.
The upcoming meeting at Glenwood on October 10 will convene at 9:30 a.m. The meeting on October 23 will include a short visit to the Juvenile Home at Toledo following the visit to the Independence MHI.
6. Materials Distributed to the Subcommittee and Filed With the Legislative Service Bureau.
a. A table supplying revenue, employment, usage, and cost information for the Cherokee MHI from FY 1992-1998, distributed by MHI Superintendent Deiker.
b. A chart comparing the cost per episode vs. per diem cost from FY 1992-1998, distributed by MHI Superintendent Deiker.
c. A description of the duties of the Central Point of Coordination Administrator, distributed by Ms. Robyn Wilson, State-County Assistance Team.
d. A report on DHS Institutions prepared by the Auditor of State, and distributed by Brad Trow, House Republican Caucus Staff.
e. A description of the Northwest Iowa Youth Emergency Services Center, a multicounty juvenile detention center, distributed on the tour by the center.

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