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Testimony: House Bill 424, House Human Services Committee

Statement of The Hospital and Healthsystem Association of Pennsylvania

For the

House Human Services Committee, Pennsylvania House of Representatives

Submitted by Jennifer Jordan
Vice President for Regulatory Advocacy

Harrisburg, Pennsylvania
March 12, 2019

The Hospital and Healthsystem Association of Pennsylvania (HAP) advocates for approximately 240 member organizations across the commonwealth, as well as for the patients and communities they serve.

HAP appreciates the opportunity to provide comments to the committee about House Bill 424 and looks forward to working with Representative Heffley and the General Assembly on efforts to reduce substance use disorder (SUD) in Pennsylvania.

Every day, Pennsylvania’s hospitals and health systems see the effects of the commonwealth’s opioid epidemic. During 2017, 1 in 37 hospital admissions were opioid related, according to the most current research brief released by the Pennsylvania Health Care Cost Containment Council (PHC4). Pennsylvania hospitals are on the frontline of the opioid epidemic and play a key role in the commonwealth’s response strategy. Hospitals are working diligently to transition patients from the emergency department (ED) to treatment; screen for maternal drug use; increase access to medication assisted treatment (MAT); and serve as a local nexus for care coordination. Access to treatment continues to be the greatest challenge for many organizations.

HAP commends and supports the overall intent of House Bill 424. However, while the themes communicated throughout House Bill 424 match closely with the goals and vision of our members, HAP is concerned that the mechanics of the legislation may not reach the ultimate goal that providers and policy makers are trying to attain. This goal is a seamless and effective process to ensure that individuals suffering from substance use disorder receive evidence- based, patient centric treatment.

HAP is currently working to better understand existing barriers to treatment. In our research, we have found that there are many factors that can affect the implementation of a plan such as the one contained in House Bill 424. For example:

  • Barriers for patients and providers across the commonwealth are not the same. Access to services varies greatly due a number of elements:
    • Transportation needs
    • Insurance design
    • Geography
    • Time-of-day for referral
    • Patient complexity (Examples: co-occurring diagnosis, pregnancy)
    • Types of treatment providers (Example: abstinence vs. medically assisted)
  • Comprehensive data on treatment capacity is not widely available. There is no single place to find state-wide capacity data
  • There is a difference between the number of licensed providers and the number of available treatment slots. Providers may be licensed to provide this care, but they can also impose limits on the number of these patients they see
  • It is unclear who is responsible for funding/supplying assessment, recovery support, and care management services
  • Emerging best practices are continuing to evolve and just now are being tested. Hardwiring warm hand-off programs through legislation may hinder innovation and adoption of best practices

Additionally, HAP worked with the Department of Human Services (DHS) to develop the Hospital Quality Improvement Program focused on follow-up treatment after an ED visit for opioid use disorder (OUD). This is a new hospital quality incentive program as of 2019.

Health systems have the opportunity to earn “process” incentives by implementing defined clinical pathways. The department has allocated $35 million for set benchmark and incremental improvement payments. These pathways will help the health systems get more individuals with OUD into treatment and improve the 7 day follow-up performance during 2019. Hospitals may implement all or any of the following four clinical pathways:

  • ED initiation of buprenorphine with warm hand-off to the community
  • Direct warm hand off to the community for MAT or abstinence based treatment
  • Specialized protocol to address pregnant women with OUD
  • Direct inpatient admission pathway for methadone or observation for buprenorphine induction

The following chart illustrates how many hospitals have filed attestation to date:

Pathways for Hospital Quality Incentive Program

​Specific to House Bill 424, the hospital community would request that the following items are considered while continuing to develop a warm hand-off program:

  • Consider using language to expand the use of a warm hand-off program to those affected by substance use disorder and not limit it to survivors of an opioid overdose
  • Require the use of evidence-based treatment to make sure treatment provided to patients is medically sound and effective
  • Ensure a coordinated effort with existing providers and collaborate with various other stakeholders (state agencies and provider associations) to align resources, leverage existing technical expertise, and avoid duplicative efforts
  • Avoid duplicating incentives and programs
  • Avoid burdensome reporting requirements and allow providers to maintain focus on the patient
  • Identify a sufficient and sustainable funding source to support and expand warm hand- off efforts
  • Consider the liability concerns when emergency medical services personnel choose where to transport an overdose patient
  • Recognize the significant challenges that Pennsylvania’s strict privacy laws present in reporting and data collection. They require additional and explicit patient consent to disclose information regarding mental health and drug and alcohol treatment
  • Clarify the timeframe requirement of six months for participation by providers but twelve months for Department of Health guidelines
  • Remove the condition of participation for emergency department licensure
  • Remove compliance with the training and reporting requirements of this process as a condition of participation in the Medicaid program
  • Consider the complexities of setting Medicaid rates to reimburse for these services

The aforementioned challenges speak to why HAP recommends that developing the task force enumerated within House Bill 424 be the first step in creating a warm hand-off procedure that can truly meet the needs of individual communities.

Additionally, HAP supports a resolution to direct the Joint State Government Commission to study the impact of behavioral health holds on EDs and the impact on behavioral health patients and the other patients seeking care in the ED. This also will help to shine the light on capacity issues and potential oversights within the behavioral health system.

Finally, HAP also recommends the following considerations for future discussion on treatment capacity:

  • Clearly identify a hub for local delivery systems and map out/articulate a comprehensive vision of how siloed funding streams will be integrated to achieve program goals
  • Leverage new federal spending to build on the existing, county-level drug and alcohol delivery system with consistent and sustainable funding
  • Increase support for county-level assessment and recovery housing and recovery support services, in addition to expanding capacity for drug treatment and MAT services
  • Establish performance metrics and publish public-facing reports to inform future policymaking

HAP is committed to being part of the solution to the opioid crisis and SUD, to being a disseminator of promising best practices, sharing lessons learned, and increasing connectivity between hospitals, single county authorities, treatment providers, and recovery supports to improve the warm hand-off process. Again, HAP appreciates being able to share the experiences of our members and welcomes any opportunity to engage on this issue.

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Topics: State Advocacy, Substance Use Disorder

Revision Date: 3/12/2019

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