Notable budget language in Washington supplemental

Last week’s passage of the 2018 supplemental budget holds a few notable insertions of language that will be played out over the course of the fiscal year.

We thought we’d highlight a few here for you.  You can review the full 449- page budget legislation here, or take a look at the range of documents at

The governor has yet to sign or line-item veto parts of the bill, so this could still change.


Sec 204.2(o):  $250,000 to DSHS “to develop and implement a predictive modeling tool which identifies clients who are at high risk of future involvement with the criminal justice system and for developing a model to estimate demand for civil and forensic state hospital bed needs.”

Interesting that the state is trying to build a predictive modeling tool rather than subscribe to a service here.

Sec 204.2(p): $46,601,000 to DSHS “to pay fines plaintiff’s attorney fees, and increased court monitor costs for failing to meet court ordered timelines for competency restoration and evaluations under Trueblood v. Department of Social and Health Services.”

The lawsuit fees just keep coming at DSHS.  The Trueblood case was about DSHS not providing timely competency tests for individuals detained in county jails, thus leaving mentally ill people in jail rather than finding a more appropriate setting for them.  It was decided in 2016.

Sec 213.1(g): “No later than November 1, 2018, and each year thereafter, the authority shall report to the governor and appropriate committees of the legislature: (i) Savings attributed to behavioral and physical integration in areas that are scheduled to integrate in the following calendar year, and (ii) savings attributed to behavioral and physical health integration and the level of savings achieved in areas that have integrated behavioral and physical health.”

This was language that the HCA specifically wanted to stay away from since behavioral health integration was first codified in 2014.  The idea was that, while there would be savings, these savings would accrue to the MCOs.  The savings would then be reflected in future rate setting by actuaries, which would arguably be on a lower trend line than without integration.  So, the savings would be reflected in rates lower than they otherwise would be and not reflected in any line item that the legislature might use to fund other things.

The HCA initially included some savings in their 2015 supplemental budget, particularly drawn from King and Pierce County committing to move early on integration.  When those counties chose not to move until much later, those savings never materialized.  The HCA had to then justify a budget ask to cover the shortfall created in “booked” savings that never materialized.  And, they got beat up for it in the then-Republican controlled Senate.  They’ve fought this impulse ever since, but here it is in the Democratic budget.

Sec 213.1(ddd): $13,852,019 “for an increase in primary care provider rates for pediatric care services that are currently reimbursed solely at the existing medical assistance rates that are applicable for the child’s medical assistance eligibility group…  Both physician and nonphysician practitioners are eligible for these increases… Increases are based upon eligible codes.”

This provision backfills the increased pediatric payments that were elevated during years 2013 and 2014 under the Affordable Care Act.  This has been a tenet of Gov. Inslee’s and WSMA since the reduction of those rates in 2015.

 Sec 213.1(eee):  $150,000 for a study to “identify strategies for enhancing access to primary care for medical assistance clients.”

Medical assistance clients means Medicaid beneficiaries.

Sec 213.1(fff): $5.3m to increase rural hospital payments to 150% of fee for service for services provided to Pacific Islanders through June 30, 2019.

See SB 5683 for more information.  This is regarding COFA individuals, or the “compact of free association.”  This is a program few know about but which guarantees health care to those residents of Pacific Islands on which the United States tested atomic and nuclear weapons. A later section (hhh) allocates an additional $1,006,000 to this issue, though not specific to rural hospitals.

Sec 213.1(ggg):  $40,000 “to create a work group at the Robert Bree collaborative to identify best practices for mental health services regarding patient mental health treatment and patient management. The work group shall identify best practices on patient confidentiality, discharging patients, treating patients with homicide ideation and suicide ideation, recordkeeping to decrease variation in practice patterns in these areas, and other areas as defined by the work group. The work group shall be composed of clinical and administrative experts including psychologists, psychiatrists, advanced practice psychiatric nurses, social workers, marriage and family therapists, certified counselors, and mental health counselors.

Bree does great work.  Looks like they’ll spend more time on the complicated subject area of mental health.

Sec 213.1(ooo):  $500,000 “is provided solely for a community hospital located in Toppenish to convert fifteen existing acute care beds to long-term psychiatric beds.”

I always find it interesting when a specific town or institution is provided for in a budget note.  I can’t speak to whether this is an appropriate allocation, but it certainly is a nod to good advocacy work.

Sec 213.5(e):  $10,881,000 “provided solely for new crisis triage or stabilization centers.  The authority (HCA) must seek proposals from behavioral health organizations for the use of these funds based on regional priorities. Services in these facilities may include crisis stabilization and intervention, individual counseling, peer support, medication management, education, and referral assistance. The authority shall monitor each center’s effectiveness at lowering the rate of state psychiatric hospital admissions.”

This was probably an important oversight to not also include MCOs and/or BH-ASOs for those regions that are already integrated (Southwest WA, North Central WA), particularly with the rest of the state migrating away from BHOs by 2020.

Sec 213.5(h):   $1,125,000 “is provided solely for the Spokane county behavioral health organization to implement services to reduce utilization and the census at eastern state hospital.”

Sec 213.5(i)  $1,204,000 provided solely to reimburse Pierce and Spokane counties for the cost of conducting one hundred eighty-day commitment hearings at the state psychiatric hospitals.

Meanwhile, Spokane County is on the verge of trying to stave off some parts of integration in Medicaid.  In particular, it may object to the BH-ASO part of the integration model, seeking to keep that work at the County.  But, if the County is already requiring additional dollars from this budget above other BHOs in order to “reduce utilization and the census at eastern state hospital,” then maybe they aren’t doing as good of a job as they could be today.  Not sure why they’d want to keep that up in the new integration model (ie: keep the BH-ASO piece of the model in house).

Sec 213.5(n):  $5,971,000 “provided solely for the authority to increase rates for community hospitals that provide a minimum of two hundred medicaid psychiatric inpatient days. The authority must increase both medicaid and nonmedicaid psychiatric per-diem reimbursement rates for these providers within these amounts.

The hospital association always does a good job for its members.  What can I say…  There are a number of provisions in the bill where hospitals are provided payments, either through the MCO model or through the HCA directly.  I’m not passing judgement on the fiscal policy one way or the other.  Rather, I’m admiring the effective advocacy work of Chris Bandoli and his team.