Hawaii-2018-SB182-Introduced

SECTION 1. The legislature finds that the federal Patient Protection and Affordable Care Act of 2010 encourages states to develop innovative approaches to the delivery of integrated health services. The legislature further finds that Hawaii has a bold history as an innovator in ensuring that its residents have access to health care. The Hawaii Prepaid Health Care Act and the State's medicaid program have provided access to comprehensive managed care for low income families. The State can create more effective alternative solutions for affordable health care, however, by better integrating public health systems in order to balance public health care needs with the associated costs to the State.

The overall fiscal costs and burden of substance use disorders with co-occurring mental health disorders on Hawaii's public health care system are unsustainable. Studies indicate that a small percentage of patients in the United States consume a disproportionate share of health care resources. According to a 2013 report from the Agency for Healthcare Research and Quality, this one per cent of the population, known as "super users", consumes twenty-one per cent of the nearly $1,300,000,000,000 spent each year on health care nationwide. In Hawaii, it has been reported that about five per cent of the medicaid population accounts for about forty-nine per cent of the State's annual health care costs. Considering the 2015 MedQuest budget, this means about 16,000 people on MedQuest cost over $1,000,000,000. Super users' most common conditions involve multiple illnesses, one of which is often substance abuse. Similarly, patients who frequent emergency departments tend to suffer chronic illnesses or have multiple psychosocial risk factors, such as substance abuse, mental illness, or homelessness. The commonality among most super users is that they lack the social network to help them coordinate their aftercare. For example, many super users do not have a regular physician, so whenever medical care is necessary they turn to the community hospital, which is often the most expensive and least efficient type of care for their needs.

The legislature further finds that while the costly cycle of substance abuse is currently a financial burden on the State's health care system, it is also a treatable disease worthy of more attention and resources. Recent discoveries in the science of addiction have led to significant advances in drug abuse treatment that help people successfully manage their addiction and resume productive lives. While the social welfare factors that contribute to addiction present a complex problem, research indicates that treatment for substance use disorders can be effective and reduce costs to the health care and criminal justice systems. Research shows that about seventy per cent of addiction and mental health costs can be averted by effectively providing relevant treatment before the onset of more serious chronic conditions. Treating all of super users' complex issues in an integrated way is a sound social investment because it effectively reduces duplication and overutilization. Recent studies have proven that every $1 spent on treatment saves $4 in health costs.

Therefore, the purpose of this Act is to:

(1) Require the department of health to establish a comprehensive and coordinated continuum of treatment services for substance abuse and co-occurring mental health disorders that includes certain goals and benefits, and submit progress reports to the legislature regarding the status of funding for improving these treatment services;

(2) Establish a task force within the department of health to address health care and payment reform steps through the implementation of an effective addiction treatment system that is a component of health care to improve outcomes and reduce overall health care costs; and

(3) Appropriate funds to the department of health for substance abuse and addiction treatment.

SECTION 2. (a) The department of health shall improve the treatment of substance abuse and co-occurring mental health disorders in the State by applying the basic principles of health care reform. The department shall establish a comprehensive and coordinated continuum of treatment services with the following goals and benefits:

(1) Access to care: expand access to care for Quest members and uninsured persons so that any qualified low income person that meets medical necessity can be admitted to the appropriate modalities of care, such as residential, day treatment, intensive outpatient, and outpatient for the length of stay that meets medical necessity; provided that funding would make care available or supplement shortages of authorized care until access to authorized Quest funding or any other funding is approved;

(2) Integrated behavioral health care with primary care physicians: provide a framework for Quest members and uninsured persons that addresses addiction in a more effective manner and involves primary care by:

(A) Creating a referral system through which Quest or uninsured persons who have completed specialized substance use disorder treatment may receive ongoing follow up care by primary care physicians; and

(B) Creating a feedback loop between primary care providers and specialized substance use disorder treatment providers to ensure collaboration and improved responses to patients who have lapses or relapses in recovery;

(3) Preventative care: enhance preventative acute care and support, which is a fraction of the cost of repetitive acute care episodes and severe substance abuse treatment, to ensure that super users do not progress to worse chronic conditions by providing sufficient integrated care to meet their complex needs and cover expenses for medical and licensed staff to provide co-occurring disorders treatment, qualified staff for criminality treatment, recovery oriented services, and services for other secondary and tertiary issues that are caused or exacerbated by substance use disorders; provided that recovery oriented services should include peer mentoring and case management for individuals with more chronic conditions, housing (first month or two), vocational rehabilitation, and access to appropriate physical medical care;

(4) Evidenced-based care: all funding and treatment interventions should follow evidenced-based care using a multidisciplinary and multi-systemic context where it is understood that one size does not fit all, and only existing, experienced, and appropriately-credentialed organizations with demonstrated infrastructure and expertise provide required services quickly and effectively; and

(5) Transitional care management: comprehensive transitional care for several days or weeks during the super user's transition to substance use disorder treatment in a community setting following discharge from an inpatient care facility or emergency room; provided that transitional care management services be provided by qualified specialty care professionals or other coordinators of care who facilitate medically necessary referrals and connect patients to substance use disorder services to ensure there is little to no gap in services between inpatient and substance abuse treatment; provided further that during the transition time, transitional care management staff communicate with treatment agencies, coordinate admittance to treatment, support self-management, ensure adherence to treatment regimen and medical management, and assist the patient and family with accessing needed care and services including primary care, substance use disorder or co-occurring disorder treatment, and other behavioral health care.

(b) The department of health shall submit a progress report to the legislature concerning the status of the funding for improving substance use disorder and co-occurring disorder treatment no later than twenty days prior to the convening of the regular sessions of 2018 and 2019.

SECTION 3. (a) The department of health shall convene a task force to address health care and payment reform steps through the implementation of an effective addiction treatment system that is a component of health care to improve outcomes and reduce overall health care costs.

(b) The task force shall:

(1) Provide multi-disciplinary teams to review and recommend policy changes in state and insurer systems for substance use disorders;

(2) Utilize the federal model of Recovery-Oriented System of Care as outlined by the Substance Abuse and Mental Health Administration;

(3) Continue to integrate primary health care with addiction treatment, providing education and training to primary care providers on screening, brief interventions for mild or moderate substance use disorder conditions, and referrals to specialized substance use disorder treatment for moderate to chronic conditions;

(4) Develop a treatment program for mild to moderate conditions for substance use disorders and co-occurring disorders;

(5) Support transitional care management for emergency rooms to deal with patients with chronic substance use disorder or co-occurring disorders;

(6) Ensure Quest members and uninsured patients have adequate access to all modalities of substance abuse treatment, including residential, day treatment, and outpatient treatment that meets minimum levels of utilization according to medical necessity;

(7) Develop offender re-entry programs that target offenders with chronic substance use disorders or co-occurring disorders so that needed services can be accessed immediately;

(8) Design payment reform models for reimbursement that adequately address the complex care needed for super users or other chronic conditions of substance use disorders or co-occurring disorders, promote collaboration, and consider risk adjustments; and

(9) Determine the additional amount of funding needed to improve outcomes and reduce overall health care spending by providing funding for all modalities (residential, day treatment, intensive outpatient, outpatient, and aftercare) for substance use disorders, co-occurring disorders, criminality, dual services, case management, peer mentoring, and recovery-oriented services.

(1) One member of the house of representatives;

(2) One member of the senate;

(3) Director of health or the director's designee;

(4) Director of human services or the director's designee;

(5) Director of public safety or the director's designee;

(6) Member representing the Hawaii Substance Abuse Coalition;

(7) Member representing the Hawaii Medical Association;

(8) Member representing the University of Hawaii John A. Burns school of medicine's psychiatric department;

(9) Member representing a Hawaii inpatient or emergency room hospital; and

(10) Any other member as assigned by the task force.

(d) The department of health shall submit a progress report to the legislature concerning the status of the task force for improving substance use disorder and co-occurring disorder treatment no later than twenty days prior to the convening of the regular session of 2018 and a final report of findings and recommendations no later than twenty days prior to the convening of the regular session of 2019.

SECTION 4. There is appropriated out of the general revenues of the State of Hawaii the sum of $336,000,000 or so much thereof as may be necessary for fiscal year 2017-2018 and the same sum or so much thereof as may be necessary for fiscal year 2018-2019 for substance abuse and addiction treatment.

The sums appropriated shall be expended by the department of health for the purposes of this Act.

SECTION 5. This Act shall take effect on July 1, 2017, and shall be repealed on June 30, 2019.

INTRODUCED BY:	_____________________________

THE SENATE	S.B. NO.	182
TWENTY-NINTH LEGISLATURE, 2017
STATE OF HAWAII