Legislature(2017 - 2018)ADAMS ROOM 519
04/17/2018 09:00 AM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| SB185 | |
| SB105 | |
| SB92 | |
| HB119 | |
| HB409 | |
| SB105 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | HB 224 | TELECONFERENCED | |
| + | SB 185 | TELECONFERENCED | |
| + | HB 119 | TELECONFERENCED | |
| + | HB 409 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| += | SB 105 | TELECONFERENCED | |
| += | SB 92 | TELECONFERENCED | |
CS FOR SENATE BILL NO. 105(FIN)
"An Act relating to the licensure of marital and
family therapists; relating to medical assistance for
marital and family therapy services; and providing for
an effective date."
10:18:40 AM
SENATOR DAVID WILSON, SPONSOR, introduced himself.
GARY ZEPP, STAFF, SENATOR DAVID WILSON, provided a brief
bill summary. The bill provided expanded behavioral health
access to Alaskans. He shared there had been testimony from
therapists, emergency room (ER) doctors, school district
administrators, and federally qualified health centers in
Alaska. The bill would improve and streamline the training
for associates to become fully licensed marital and family
therapists to help provide expanded access to behavioral
health services. The bill was not being touted as a cost-
savings measure, but as a way to help Medicaid clients in
need of behavioral health services that were severely
lacking. However, there was great potential for cost-
savings if individuals could be diverted from emergency
rooms. He detailed that in 2016 the Mat-Su Memorial
Hospital had spent $43.8 million on ER services. He
detailed the costs had covered about 1,300 patients with an
average cost of $12,721 per person for one behavioral
health assessment. In a clinical setting the cost ranged
from $150 to $250.
Mr. Zepp referenced a 2017 document titled "Alaska Medicaid
Facts and Figures" published by the Department of Health
and Social Services (DHSS) (copy on file). He shared that
in 2016 Medicaid patients cost Alaska ER facilities $233
million and $245 million in 2017. He stressed the patients
were Medicaid clients the state was already paying for. He
explained if the individuals could be diverted from the ER
by expanding access and getting them into a clinical
setting there was a great potential for savings. He shared
there had been great support for the bill by various
healthcare providers and it had passed the other body
unanimously. He spoke to support by ER doctors, family
therapists, the state Board of Therapy, and the national
Board of Marital and Family Therapists. He noted DHSS had
provided a letter addressed to the committee providing more
detail on the bill [letter from the Division of Behavioral
Health Director Randall Burns dated April 13, 2018 (copy on
file)].
10:22:51 AM
Representative Wilson stated that the committee had
received a letter [from the Division of Health Care
Services Director Margaret Brodie dated April 19, 2018
(copy on file)] stating that the bill would expand
[Medicaid services] and that it would be necessary to ask
permission from the federal government to add the service.
She asked what the process entailed. Additionally, she
wondered about the process of going back to the federal
government to remove the service if the bill added a
substantial cost and no savings.
MARGARET BRODIE, DIRECTOR, DIVISION OF HEALTH CARE
SERVICES, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via
teleconference), answered that the bill would require a
state plan amendment; it would be an update to the current
state plan. If anticipated savings did not come to
fruition, a new state plan amendment would be made to
remove the providers' ability to provide the services.
Representative Wilson stated that savings had been shown
for HB 25. She wondered why it was so difficult to estimate
potential savings under HB 105.
Mr. Brodie replied that it was difficult to project savings
for SB 105 because it was not possible to anticipate who
would be utilizing the services. She explained that with
other bills the department was able to look at individuals'
diagnoses and what procedures were being done in order to
identify who would be able to utilize the services.
Representative Wilson was concerned about the $1 million
fiscal note. She was hoping to get a better understanding
of potential savings because now the committee understood
the service would be added [to the list of Medicaid
services]. She stated the process was long and the state
did not know how easy it would be to remove the service if
the savings did not come to fruition. Given that Medicaid
was currently one of the biggest [cost] drivers, she
believed the committee should be concerned about adding
more services.
Co-Chair Foster noted the committee would break for floor
session.
CSSB 105 (FIN) was HEARD and HELD in committee for further
consideration. [Note: the bill was heard again beginning at
2:20 p.m.]
10:26:37 AM
RECESSED
12:52:29 PM
RECONVENED
Co-Chair Foster relayed that the committee has posed some
questions earlier on SB 105, which were being worked on. He
relayed the bill would be heard last on the agenda.
CS FOR SENATE BILL NO. 105(FIN)
"An Act relating to the licensure of marital and
family therapists; relating to medical assistance for
marital and family therapy services; and providing for
an effective date."
2:20:33 PM
Co-Chair Foster noted the committee had heard the bill
earlier in the meeting.
Co-Chair Seaton mentioned his earlier question about
whether the bill would require a plan amendment.
Co-Chair Foster remarked that the bill sponsor had asked to
hear from Elizabeth Ripley with the Mat-Su Health
Foundation.
ELIZABETH RIPLEY, CEO, MAT-SU HEALTH FOUNDATION, WASILLA
(via teleconference), spoke in support of the bill. She
read from prepared remarks:
The foundation shares ownership in Mat-Su Regional
Medical Center and invests its profits back into the
community to improve the health and wellness of Mat-Su
residents. The Mat-Su Health Foundation fully supports
SB 105 because it will help our citizens access
behavioral health treatment services through marriage
and family therapists to get care early before their
problems escalate to a crisis stage. In the
foundation's 2013 Mat-Su community health needs
assessment, Mat-Su residents told us their top five
health issues were all related to mental health and
substance abuse. They asked us for a coordinated
system of care that makes treatment for behavioral
health more readily accessible. Instead, the way our
system currently works, Mat-Su Regional Medical Center
is the number one portal in Mat-Su for people
suffering from a behavioral health problem.
In 2016 alone, 1,196 patients with a behavioral health
diagnosis, 46 percent of which were on Medicaid, went
to the Mat-Su Regional emergency department (ED).
These patients had a total of 3,227 visits and their
charges totaled $14 million, not counting an
additional cost of $1.6 million estimated for law
enforcement, 911 dispatch, and transportation. If we
can intervene early with a system where all residents
can get timely access to a behavioral health provider
we can save pain, suffering, and money. By example, an
individual session for Medicaid is $75, while an
average charge for a behavioral health ED visit is
$4,370. Granted an individual needs more than one
visit early on to prevent a crisis, but even if you
paid for ten visits at $750 you would be saving
$3,600. The prevalence of mental health and substance
abuse problems and crises is increasing in the Mat-Su
and statewide. The average annual growth rate for
visits in our ED by patients with a behavioral health
diagnosis grew 20 percent from 2015 to 2017 due to the
opioid epidemic and lack of treatment access.
Additionally, from 2014 to 2017 the number of
behavioral health assessments required for patients in
crisis in our ED grew from 349 to more than 1,000 -
all in a hospital that does not currently provide
behavioral healthcare.
This legislation could bring the appropriate level of
care to people who need help when a problem first
starts instead of after it develops into a crisis. The
Mat-Su Health Foundation is actively doing its part to
build a complete behavioral health continuum of care
that's fully staffed with caring professionals. We
offer scholarships to train new behavioral health
providers and invest to help our nonprofits provide
badly needed services. We are financing care
coordination projects to keep people out of the ED and
institutional care and work to advocate for smart
policy like SB 105. We hope you will move this timely
and important legislation forward. Thank you.
2:24:54 PM
Co-Chair Foster invited the sponsor and staff to the
testimony table.
SENATOR DAVID WILSON, SPONSOR, introduced himself.
GARY ZEPP, STAFF, SENATOR DAVID WILSON, noted that Director
Margaret Brodie with the Division of Health Care Services
could provide an answer to Co-Chair Seaton's earlier
question about whether the legislation would require a
change in the state Medicaid plan.
Co-Chair Foster intended to take questions for Ms. Ripley
first.
Co-Chair Seaton presumed a large portion of individuals
coming into the Mat-Su hospital were there for drug abuse
reasons. He asked if marital and family therapists were
licensed to treat opioid and other drug abuse. He asked if
it would open a treatment avenue for the health foundation.
Ms. Ripley shared her understanding that the primary focus
of marital and family therapists was mental health.
Frequently, mental health and substance abuse cooccurred.
It was necessary to treat the underlying cause leading
someone to self-medicate. She believed marital and family
therapists would have the ability to address the mental
health component vital to addressing substance abuse.
Co-Chair Seaton asked if marital and family therapists were
licensed to treat mental health.
Ms. Ripley replied, "that's my understanding."
2:27:33 PM
Mr. Zepp noted that Ms. Brodie could answer Co-Chair
Seaton's question from earlier in the day regarding the
state Medicaid plan.
MARGARET BRODIE, DIRECTOR, DIVISION OF HEALTH CARE
SERVICES, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, replied
there was no cost to do a state plan amendment for the
addition or deletion of a service. The department had staff
to ensure the state complied with the state plan at all
times.
Co-Chair Seaton asked how difficult it would be to delete a
service if the bill did not accomplish what was intended.
Ms. Brodie answered that the process was easy; the
Department of Health and Social Services (DHSS) would write
a new state plan and submit it to the Centers for Medicare
and Medicaid Services (CMS).
Representative Wilson asked when the state had last deleted
a service from its Medicaid plan. Ms. Brodie responded that
she would have to follow up with an answer.
Representative Wilson stated the legislature had asked the
question frequently and had always been told proof of need
for the deletion of a service and what kind of a negative
impact it would have on individuals using the service would
have to be provided. She was amazed to hear that it would
be easy to remove something from the plan because it had
not been the understanding since she had been on the
committee. She asked if marital and family therapists were
currently able to do anything in the behavioral health
realm and to bill Medicaid if they were working under a
clinic.
Ms. Brodie answered in the affirmative. She elaborated that
the services could be billed to Medicaid if provided in a
clinic or the service could be provided anywhere if the
therapist was serving a duly eligible Medicare and Medicaid
recipient.
Representative Wilson asked for verification that if a
therapist was already able to bill Medicare and a client
also had Medicaid, the therapist could bill
Medicare/Medicaid even though they were not part of a
clinic.
Ms. Brodie agreed. She added that the state would pick up
the copayment.
Representative Wilson asked for verification that the bill
only pertained to therapists with an independent practice
and clients with Medicaid but not Medicare.
2:30:57 PM
Ms. Brodie responded in the affirmative pertaining to the
recipient. The provider would also have to be enrolled in
Medicare.
Representative Wilson referenced the fiscal note that
specified there were 100 licensed marital and family
therapists in Alaska. She wondered if there was a database
showing the number of independent therapists who may want
to take Medicaid patients.
Ms. Brodie deferred to the DHSS Division of Behavioral
Health.
Representative Guttenberg surmised that the reason for the
bill was not to expand the services provided by marital and
family therapists, but to expand the group of individuals
receiving the benefits the therapists had to offer. He
referenced the fiscal note that extrapolated the
anticipated number of individuals who would use the service
and what the cost would be. He wondered if there was a way
to estimate what the cost avoidance would be. He looked at
the 633 estimated recipients and considered what the cost
would be for the individuals to go to the emergency room.
He explained that in the future it would be helpful to look
back and know what the savings had been. He wondered if the
avoidance cost could be reflected in the fiscal note.
Ms. Brodie replied that she could do a calculation, but it
would not be 100 percent accurate. She could take all of
the emergency room visits and could extrapolate the number
of individuals who had received a diagnosis for a
behavioral health disorder. However, not all providers were
comfortable giving that type of diagnosis; therefore, the
figure would be off some.
Representative Guttenberg stated that in the future it
would be helpful to look back to see what the avoidance
cost had been in the five years since the passage of the
bill.
Co-Chair Seaton asked if Representative Guttenberg was
suggesting including a requirement for a report to the
legislature in the bill.
Representative Guttenberg thought it would be a good idea
in order to know in the future what avoidance costs had
come from the legislation. He hoped the department was
looking at avoidance costs to understand other places the
state needed to expand or contract services.
2:34:50 PM
Mr. Zepp believed the state was on the verge of what
Representative Guttenberg was asking for through a separate
bill (SB 74) and the federal 1115 Medicaid waiver the state
had recently submitted. The waiver was just upon the
shortage of behavioral healthcare and trying to manipulate
the system to demonstrate a project and redefine behavioral
healthcare and address the shortages throughout the state.
He believed the components were addressed in the 130-page
document submitted to the federal government by DHSS.
Co-Chair Seaton was trying to determine if the legislature
would be getting information back on the effectiveness of
expanding a service. He asked if the reporting requirement
needed to be more specific than a generalized report on
behavioral health. He wondered if the department could
provide the requested information in a report if the
legislation passed.
Ms. Brodie replied that the report would need to be
specialized because it could get lost in the other
activities the department was undertaking with waivers and
Medicaid reform. She relayed that the report was definitely
something DHSS could provide; if the department knew a
report was due it could compile the data beforehand.
Representative Wilson pointed to research in members'
packets from the Division of Behavioral Health that
mentioned an existing report. She believed the report could
help the legislature contemplate what should be included in
another report. She stated the legislature should be
concerned that in 2016 as a result of Medicaid expansion,
statewide payments to behavioral health providers was
$8,641,000, while in 2017 expansion brought in $25,173,825
to providers statewide. She stated the number was far
beyond $25 million. She thought it was necessary to be very
specific when determining what the report would include.
She wondered if Representative Guttenberg was talking about
only marital and family therapists or behavioral grants
throughout the state. She remarked there had been
significant discussion in the committee on where the money
was going and whether the state was seeing any return for
its money in terms of opioid and other issues related to
behavioral health. She added that the problem was
increasing as was the cost.
2:38:02 PM
Representative Wilson mentioned a document regarding a
Medicaid expansion legislative research grant (copy not on
file). She stated the document specified the DHSS was in
the process of developing a reporting tool that would
enable the legislature to get the type of information
[Representative Guttenberg was requesting]. She asked if
the tool had been finished.
RICK CALCOTE, MENTAL HEALTH CLINICIAN, DIVISION OF
BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL
SERVICES, ANCHORAGE (via teleconference), replied that he
did not have the information; the tool was being developed
elsewhere in the department.
Representative Wilson was uncertain who to talk to because
the report she was referencing anticipated the tool would
be operational by early 2018. She wanted to know whether
the tool had been developed and what information the state
had. She thought the tool could help determine how much
money would be diverted. She believed the bill needed more
work.
Vice-Chair Gara understood the need to expand the group of
people providing mental health services. He asked if adding
marital family services would add marital counseling as a
covered service.
Senator Wilson answered that marital and family therapists
were licensed to provide myriad services. He provided
examples including psychotherapy, group psychotherapy, and
substance abuse counseling dealing with family dynamic. He
clarified that it did not have to be limited to a family
unit, but included whatever the therapist was licensed to
do. He continued that marital and family therapists went
through similar schooling to social workers, and licensed
professional counselors. Marital and family therapists went
through the same licensure requirements through their board
and could provide the scope of services throughout. He
stated it was more than family counseling. He explained
that like a car mechanic that could treat more than one
limited issue on a car, marital and family therapists were
licensed professionals who were able to provide myriad
services. He believed Director Randall Burns with the
Division of Behavioral Health had addressed the issue in
his letter [to the committee co-chairs dated April 13, 2018
(copy on file)]. He reiterated that the services marital
and family therapists could provide were expansive.
2:41:54 PM
Co-Chair Seaton was concerned that getting a big report on
behavioral health services across the state would lose the
essence of whether expanding services for marital and
family therapists helped the system and decreased the
amount of behavioral health services provided in emergency
rooms. He was trying to determine whether requesting a
report in the four-year timeframe would provide the
information on give the information to determine whether
the system had improved and what the cost had been. He
thought looking at the overall system would lose the detail
about what was needed pertaining to the topic.
Ms. Brodie responded that after the bill's effective date
there should be one full fiscal year before the report was
required. She believed going out four or five years would
be too long. She explained there were a high number of
Medicaid reform initiatives underway; therefore, she
recommended tracking the information from the beginning in
order to receive actuals in the report. The savings would
show up in healthcare services Medicaid, not behavioral
health Medicaid. The savings would also show up in the
Department of Corrections, law enforcement, and the Office
of Children's Services. She did not know whether those
agencies would have the ability to track the information,
but Medicaid would.
Representative Wilson stated that the bill only included
marital and family therapists working independently. She
asked if there was a way to track only the individuals
under the bill.
Ms. Brodie answered there would be a way to track the
individuals through the bill because it would require
building specialized business rules into the Medicaid
Management Information System (MMIS). She detailed DHSS
could use the same rules to track who was paid under the
bill.
2:45:34 PM
Representative Wilson asked how many states had tried to
take extras out of their plan and had been denied.
Ms. Brodie did not know any states that had been denied.
There were states that had lengthy discussions with CMS and
had been required to prove access. However, other states
were far ahead of Alaska in behavioral health issues and
already had the infrastructure.
Representative Wilson requested information on the criteria
required to remove any extra services.
Vice-Chair Gara stated that he had first been told the
purpose of the bill had was to allow marital and family
therapists to provide behavioral health services. More
recently he had been asked if the bill would cover marital
counseling through Medicaid. He asked if the intent of the
bill was limited to allowing marital and family therapists
to provide direct behavioral health services or to expand
the services provided through Medicaid.
Senator Wilson confirmed the original intent of the bill
was to allow therapists not practicing in a community
behavioral health clinic the ability to bill Medicaid
through the optional service. The bill would allow a new
provider type to be added to the list of licensed providers
that could bill Medicaid, just like a licensed clinical
social worker could bill for marital and family counseling
through group therapy. Other non-marriage family therapists
could bill for the same services that those providers bill
for as well.
2:48:51 PM
Co-Chair Seaton asked whether January 2020 would be the
appropriate report deadline if the bill passed with its
current effective date.
Ms. Brodie thought it would be better to line the due date
up with the department's other Medicaid reports due at the
end of November.
Co-Chair Seaton asked for the year. Ms. Brodie replied
2020.
Co-Chair Seaton asked for verification that the following
was an adequate parameter for DHSS to design the data
collection: a report to the legislature on the
effectiveness and the cost-effectiveness of providing the
services allowed under the bill by the authorized providers
and the impact on diversion of services provided in more
costly settings.
Ms. Brodie replied in the affirmative.
Representative Wilson communicated she had a forthcoming
amendment.
2:51:06 PM
AT EASE
2:51:39 PM
RECONVENED
Co-Chair Foster stated there would be forthcoming
amendment. He set a deadline of 5:00 p.m. the following
day.
Senator Wilson relayed that the bill had been brought
forward to address behavioral health shortages in the
state. He emphasized there was an extensive line [for
behavioral health services] and he encouraged committee
members to reach out to their communities to learn how long
it took for someone to get scheduled for an integrative
behavioral health assessment. He stated the wait ranged
from several weeks to one month depending on what a person
needed to be seen for. He noted that residential substance
abuse treatment facilities had long waitlists. The bill
would help open a second door for individuals to access and
lessen the burden of Alaskans seeking mental health
services. He thanked the committee for hearing the bill.
Vice-Chair Gara thanked Senator Wilson for his patience.
CSSB 105(FIN) was HEARD and HELD in committee for further
consideration.
Co-Chair Foster reviewed the schedule for the following
day. He recessed the meeting to a call of the chair [note:
meeting never reconvened].