Legislature(2019 - 2020)BUTROVICH 205

02/21/2020 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:33:53 PM Start
01:34:20 PM SB134
02:41:05 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ SB 134 MEDICAID COVERAGE OF LIC. COUNSELORS TELECONFERENCED
Heard & Held
-Invited Testimony Followed by Public Testimony-
+ Bills Previously Heard/Scheduled TELECONFERENCED
          SB 134-MEDICAID COVERAGE OF LIC. COUNSELORS                                                                       
                                                                                                                                
                                                                                                                                
1:34:20 PM                                                                                                                    
CHAIR WILSON announced the consideration  of SB 134, sponsored by                                                               
himself, and his intent to  hear a sectional analysis and invited                                                               
testimony and public  testimony. He called his aide  Gary Zepp to                                                               
the table.                                                                                                                      
                                                                                                                                
1:35:26 PM                                                                                                                    
GARY   ZEPP,   staff,   Senator  David   Wilson,   Alaska   State                                                               
Legislature,   explained  that   SB   134   would  add   licensed                                                               
professional  counselors (LPCs)  to  Medicaid optional  services.                                                               
The  concept  of  the  bill  is to  add  more  behavioral  health                                                               
counseling  services to  expand capacity  and utilization  within                                                               
Alaska. The expansion of behavioral  health care professionals is                                                               
projected to  reduce wait  time, improve the  quality of  care in                                                               
the  appropriate settings,  and  will cost  less than  behavioral                                                               
health  care  in emergency  rooms  across  the state.  Currently,                                                               
Medicaid clients have  a wait time of three to  six months to see                                                               
a  licensed behavioral  health  care  professional counselor,  if                                                               
they are  lucky enough to find  a provider who will  see Medicaid                                                               
patients,  mostly  because  of  the   lack  of  capacity  in  the                                                               
workforce  itself.  Everyone  has  seen  examples  of  behavioral                                                               
health  shortages  through media  or  what  people have  seen  or                                                               
experienced in their own communities.                                                                                           
                                                                                                                                
MR. ZEPP  said that LPCs are  a valuable, cost effective  part of                                                               
treatment for  behavioral health. This proposed  legislation is a                                                               
piece  of the  behavioral health  capacity that  already includes                                                               
licensed social  workers, Ph.D. psychologists,  prescribing nurse                                                               
practitioners,  and   medical  doctors  like   psychiatrists  and                                                               
primary  care physicians.  SB 134  would provide  the appropriate                                                               
care with the appropriate provider.                                                                                             
                                                                                                                                
MR. ZEPP pointed out that many  people are familiar with the term                                                               
mental  health,  which   covers  many  of  the   same  issues  as                                                               
behavioral health, but this term  only encompasses the biological                                                               
component of this aspect of  wellness. The term behavioral health                                                               
encompasses  all  contributions  to  mental  wellness,  including                                                               
substances and their abuse, behavioral  issues, habits, and other                                                               
external forces.                                                                                                                
                                                                                                                                
MR. ZEPP  asked why Medicaid  clients and who are  they. Medicaid                                                               
provides  health   coverage  and  long-term  care   services  for                                                               
Alaska's   most  vulnerable:   children,  seniors,   people  with                                                               
disabilities,  pregnant women,  and  very low  income or  working                                                               
poor.  Medicaid  clients  have  difficulties  finding  access  to                                                               
behavioral  health care  and  often  have to  wait  three to  six                                                               
months  for appointments.  Imagine someone  in crisis  who cannot                                                               
find access to behavioral health care  being told that it will be                                                               
available in  three to five  months. Then the option  is Alaska's                                                               
emergency rooms. Medicaid  clients show up in  emergency rooms in                                                               
a  crisis  state. SB  134  would  directly  impact the  lives  of                                                               
Alaska's most  vulnerable citizens.  Emergency rooms  have become                                                               
overwhelmed  by  the  volumes   of  behavioral  health  emergency                                                               
situations. ERs are  not usually equipped to handle  this type of                                                               
service. The  number one reason for  the use of ERs  for Medicaid                                                               
clients is  alcohol disorders and the  associated ailments. Often                                                               
Medicaid clients have  nowhere else to go because of  the lack of                                                               
access and capacity. This causes  patients to stay much longer in                                                               
ERs  and hospitals  than they  should. Typically,  if a  Medicaid                                                               
client is in  a crisis stage with no access  to appropriate care,                                                               
they leave and the cycle repeats  itself. The client will be back                                                               
in the emergency room  that is open 24 hours a  day, seven days a                                                               
week.                                                                                                                           
                                                                                                                                
MR.  ZEPP said  that approximately  70 percent  of Americans  who                                                               
need  behavioral health  services do  not receive  treatment. For                                                               
substance  abuse  disorders,  about  92 percent  do  not  receive                                                               
treatment. About 66 percent of  adults with serious mental health                                                               
issues  go  untreated.  Untreated behavioral  health  issues  can                                                               
increase the  risk of  cardiovascular disease,  diabetes, stroke,                                                               
Alzheimer's  disease,   osteoporosis,  pancreatic   disease,  and                                                               
hypertension. Besides  the unintended consequences for  folks who                                                               
need behavioral  health care and  don't receive it,  no treatment                                                               
in a  timely manner often  leads to interaction with  the police,                                                               
court  systems,  and  correctional facilities.  Approximately  42                                                               
percent of state  prisoners have a mental illness  and 20 percent                                                               
are considered severely and persistently mentally ill.                                                                          
                                                                                                                                
MR.  ZEPP said  that  the  most common  issues  for children  are                                                               
attention   deficit   hyperactivity    disorder,   anxiety,   and                                                               
depression. A  child diagnosed with depression  has approximately                                                               
a 74  percent chance of  having a  codisorder like anxiety.  If a                                                               
child diagnosed  with depression and  an anxiety disorder  is not                                                               
treated, the  condition worsens over  time. Boys are  more likely                                                               
to  have  a mental,  behavioral,  or  developmental disorder  and                                                               
children living below poverty line  are 22 percent more likely to                                                               
have a mental, behavioral, or developmental disorder.                                                                           
                                                                                                                                
1:41:46 PM                                                                                                                    
MR.  ZEPP said  that mental  disorders among  children can  cause                                                               
serious challenges  to the way children  typically learn, behave,                                                               
and  handle their  emotions, which  causes distress  and problems                                                               
throughout  the day.  According  to the  American Foundation  for                                                               
Suicide Prevention, suicide is the  number one cause of death for                                                               
ages 15-24 in Alaska. Nines times  as many people died by suicide                                                               
in  Alaska   in  2017  than  in   alcohol-related  motor  vehicle                                                               
accidents. Alaska's  suicide rate is  52 percent higher  than the                                                               
national average.                                                                                                               
                                                                                                                                
MR. ZEPP  said that  expert testimony  will shed  a light  on the                                                               
workforce  shortage  of   behavioral  health  care  professionals                                                               
available to treat Medicaid clients  and Alaskans in general. The                                                               
2016 Alaska  Behavioral Health  Systems Assessment  reported that                                                               
more  than 145,000  adult  Alaskans, 20  percent  of the  state's                                                               
population, are  in need behavioral health  services. Despite the                                                               
need  for mental  health  care  in Alaska,  the  ratio of  mental                                                               
health providers to  population is very low  compared to national                                                               
levels. Most work  in urban areas. The remote areas  in the state                                                               
have  even lower  provider-population  ratios. Understanding  the                                                               
magnitude,  composition, and  geographical  scope  of the  mental                                                               
health provider  shortage in  Alaska is seen  as the  great first                                                               
step  in developing  effective,  targeted  solutions to  increase                                                               
workforce capacity by adding licensed professional counselors.                                                                  
                                                                                                                                
MR. ZEPP  displayed a chart on  slide 9 of his  presentation that                                                               
reflects the  total the state  paid to emergency rooms  from 2016                                                               
through  2019  for  Alaska's Medicaid  clients.  The  costs  have                                                               
increased by $47.1  million, or 21.1 percent, over  the last four                                                               
years. This  is staggering.  The top  utilizers go  to the  ER at                                                               
least ten  times a  year and  sometimes as many  as 50  times per                                                               
year. The  cost of the 2.7%  (1,858 people) of the  top utilizers                                                               
is $42 million or $22,604 per  person per year. The cost of 11.6%                                                               
(7,996  people)  of  the  top utilizers  cost  $98  million.  The                                                               
committee can see where costs are going in the future.                                                                          
                                                                                                                                
MR. ZEPP said  that the state needs to  improve Medicaid programs                                                               
and  provide increased  quality and  become more  cost efficient.                                                               
Adding  more   licensed  professional  counseling   services  can                                                               
improve these outcomes.  Alaska has to do  something different to                                                               
stop this trend.  With the federal approval of  the 1115 Medicaid                                                               
waiver for behavioral health services,  adding LPCs to the mix of                                                               
behavioral health  professionals offers an opportunity  to expand                                                               
capacity, increase  the quality of  care, lower the cost  vs. the                                                               
crisis  mode,  platinum-level costs  that  the  state is  paying.                                                               
These  are the  costs the  state  has already  paid for  Medicaid                                                               
clients for behavioral health services.                                                                                         
                                                                                                                                
1:45:28 PM                                                                                                                    
MR. ZEPP  said that  from 2016  to 2019,  the number  of Medicaid                                                               
clients has actually  gone down by 6,614 or 9.6  percent, but the                                                               
costs  are rising.  The most  common  diagnosis for  the top  2.7                                                               
superutilizers  are  alcohol-related   disorders.  The  four-year                                                               
average for  the superutilizers  is 2.4 percent  and it  is 1,609                                                               
people at  $43.5 million. The top  2.7 percent were likely  to be                                                               
between  20 and  59 years  old, 61  percent are  female, and  the                                                               
four-year  annual  average cost  for  the  top 10.77  percent  of                                                               
superutilizers,  about  7,204  people, is  $103.4  million.  That                                                               
averages out to about $14,332 per person.                                                                                       
                                                                                                                                
MR. ZEPP said  that Mondays are the most common  days for a visit                                                               
to  the  emergency room.  The  estimated  cost for  a  behavioral                                                               
health assessment in Alaska's emergency  rooms is $4,300 vs. $150                                                               
to $250  per hour  for clinical work  by a  licensed professional                                                               
counselor. The state  needs to provide the  appropriate care with                                                               
the appropriate  healthcare provider. SB  134 has the  ability to                                                               
lower  costs for  Medicaid  clients'  behavioral health  services                                                               
that  the state  is  paying to  emergency rooms  for  those in  a                                                               
crisis state at a platinum-level cost.                                                                                          
                                                                                                                                
MR. ZEPP displayed the list of supporters for SB 134:                                                                           
                                                                                                                                
   • Alaska State Hospital and Nursing Home Association                                                                         
   • Providence Health and Services Alaska                                                                                      
   • Southeast Alaska Regional Health Consortium                                                                                
   • Alaska Regional Hospital                                                                                                   
   • Mat-Su Health Foundation                                                                                                   
   • Alaska Primary Care Association                                                                                            
   • Mat-Su Health Services                                                                                                     
   • Alaska Mental Health Trust Authority                                                                                       
   • Alaska Department of Health & Social Services                                                                              
   • Alaska Department of Commerce, Community & Economic                                                                        
     Development                                                                                                                
   • Discovery Cove Recovery & Wellness Center                                                                                  
                                                                                                                                
MR.  ZEPP  respectfully  asked  the committee  to  join  them  in                                                               
supporting SB 134.                                                                                                              
                                                                                                                                
CHAIR WILSON called Deputy Commissioner  Albert Wall and Gennifer                                                               
Moreau,  Director  of  the  Division  of  Behavioral  Health,  to                                                               
testify.                                                                                                                        
                                                                                                                                
1:48:33 PM                                                                                                                    
ALBERT WALL, Deputy Commissioner,  Medicaid & Health Care Policy,                                                               
Department  of  Health  and Social  Services  (DHSS),  Anchorage,                                                               
Alaska, gave Ms. Moreau the opportunity to speak first.                                                                         
                                                                                                                                
1:48:56 PM                                                                                                                    
GENNIFER  MOREAU,   Director,  Division  of   Behavioral  Health,                                                               
Department  of  Health  and Social  Services  (DHSS),  Anchorage,                                                               
Alaska,  thanked Senator  Wilson  for sponsoring  this bill.  The                                                               
Division of  Behavioral Health stands  ready to assist  with this                                                               
proposed  legislation  and is  eager  to  supply any  information                                                               
available to  the division for  full consideration of  this bill.                                                               
The potential benefits  are that the bill could  expand access to                                                               
care  to  eligible  Alaskans statewide,  especially  for  remote,                                                               
rural  communities  and for  individuals  with  mild to  moderate                                                               
disturbances.  There  is  the potential  decrease  over  time  of                                                               
psychiatric emergency services and  acute care hospital services.                                                               
Licensed professional  counselors will be able  to provide SBIRT,                                                               
screening, brief  intervention, and referral to  treatment, which                                                               
is  a key  element  to  the continuum  of  care.  By making  this                                                               
provider type  available to eligible  Alaskans, it  also provides                                                               
families  the  opportunity to  interact  in  a smaller  and  more                                                               
intimate setting,  where they may  be more  comfortable receiving                                                               
services.                                                                                                                       
                                                                                                                                
CHAIR WILSON  asked how  this would be  integrated with  the 1115                                                               
waiver.                                                                                                                         
                                                                                                                                
MS.  MOREAU  replied that  the  1115  waiver  is a  mechanism  to                                                               
develop a  full continuum  of care. The  whole driver  behind the                                                               
1115  is  to reduce  the  reliance  on  the  acute end  of  care.                                                               
Expanding    access,   especially    for   Medicaid    recipients                                                               
experiencing   mild    to   moderate    disturbances,   including                                                               
disruptions in  social determinants of health,  has the potential                                                               
to prevent the  future need for higher, more  expensive levels of                                                               
care.                                                                                                                           
                                                                                                                                
CHAIR WILSON called Jon Zasada to the table.                                                                                    
                                                                                                                                
1:52:16 PM                                                                                                                    
JON  ZASADA, Director,  Policy Integration,  Alaska Primary  Care                                                               
Association (APCA),  Anchorage, Alaska, said he  spent nine years                                                               
at the  Anchorage Neighborhood  Health Center.  One of  his roles                                                               
was supporting  the development of behavioral  health integration                                                               
programs. He noted that Sevilla  Love, a licensed clinical social                                                               
worker  and  the  Primary Care's  behavioral  health  integration                                                               
coordinator, would also be  testifying. She specifically supports                                                               
health centers across the state  in integrating behavioral health                                                               
into their  clinic operations,  addressing clinical  quality, and                                                               
developing behavioral health staff.  APCA supports the operations                                                               
and  development of  Alaska's 27  community  health centers.  Its                                                               
members voted  to support SB  134. Adding  Medicaid reimbursement                                                               
for LPCs has been a top  priority in its efforts to expand access                                                               
to  behavioral  health  for  many   years.  APCA  serves  113,000                                                               
patients  per year  through 560,000  visits at  160 clinic  sites                                                               
around the  state. APCA serves  10 percent of Alaskans.  About 85                                                               
percent of its patients have incomes  at under 200 percent of the                                                               
federal  poverty  level.  Around   20  percent  of  all  Alaskans                                                               
enrolled  in  Medicaid get  their  primary  care at  a  community                                                               
health  center.  About  10  percent  of  APCA  patients  come  in                                                               
primarily for  mild and  moderate behavioral  health care  and 15                                                               
percent of all  visits in a year are for  behavioral health. APCA                                                               
employs over 180 behavioral health providers of all types.                                                                      
                                                                                                                                
MR. ZASADA  said that he was  asked to provide remarks  about the                                                               
role  of LPCs  in behavioral  health services,  why reimbursement                                                               
for LPCs is vital in  addressing the demand for behavioral health                                                               
services, and  how they  provide care  and could  ultimately save                                                               
Medicaid money  by diverting patients  away from  emergency rooms                                                               
and more costly  care. He is still evaluating the  fiscal note to                                                               
determine  how it  would pertain  to the  primary care  system as                                                               
opposed to the behavioral health system.                                                                                        
                                                                                                                                
MR. ZASADA said LPCs are  a valuable, cost-effective component of                                                               
team-paced,  whole  person primary  care.  That  is primary  care                                                               
built around  medical, dental,  behavioral health,  pharmacy, and                                                               
support providers  working to  ensure patients  get all  the care                                                               
they  need  and supporting  them  with  the management  of  their                                                               
chronic  conditions. Making  LPCs  billable  under Medicaid  will                                                               
expand access  to care for  Alaskans in lower cost,  primary care                                                               
settings.  Passing the  bill is  the  first step.  Implementation                                                               
will   involve  changes   in   regulations.   APCA  has   started                                                               
conversations with DHSS about this.                                                                                             
                                                                                                                                
MR.  ZASADA  said the  bill  is  an  important component  of  the                                                               
Medicaid reforms that  were outlined in the 2016 SB  74 to expand                                                               
provider types to increase access  to behavioral health services,                                                               
not  just for  community  behavioral health  providers, who  were                                                               
reimbursed  for  providing  care for  ongoing  severe  behavioral                                                               
health and  substance abuse  issues, but  also providers  such as                                                               
federally qualified  health centers that specialize  in providing                                                               
mild  and moderate  community-based care.  LPCs are  an important                                                               
provider  type  within a  behavioral  health  team that  includes                                                               
licensed   clinical   social  workers   (LCSWs),   psychologists,                                                               
prescribing nurse  practitioners, and  medical doctors.  Each one                                                               
has  a unique  role. In  2017, APCA's  health centers  reported a                                                               
deficit of 12 to 18  behavioral health providers. Conservatively,                                                               
with those  numbers the  centers could provide  care to  6,000 to                                                               
9,000 additional  patients. From a clinical  standpoint, LPCs are                                                               
vital for one-on-one counseling in conjunction with LCSWs.                                                                      
                                                                                                                                
1:57:29 PM                                                                                                                    
MR. ZASADA said  that community health centers  are already using                                                               
LPCs  in   their  practice  to  provide   school-based  services,                                                               
counseling  services,   and  supporting  care   coordination  for                                                               
patients.  The addition  of LPCs  will increase  overall provider                                                               
retention and  satisfaction, another challenge to  health care in                                                               
Alaska. All  medical providers are  more likely to stay  in place                                                               
when there  is a full care  team of professionals working  at the                                                               
top of  their licensure.  The full medical  team model  will gain                                                               
increased efficiency  by being fully  staffed and  reimbursed for                                                               
the   first  time.   Community  health   centers  have   received                                                               
considerable  federal  investments  to expand  behavioral  health                                                               
services  and support  substance  use treatment  services in  the                                                               
primary care setting. Health centers  are required by federal law                                                               
to  provide behavioral  health that  is integrated  with medical,                                                               
dental, pharmacy, and  other services. Adding LPCs  to the roster                                                               
of  billable  providers  enables  health centers  to  make  their                                                               
services more  sustainable. Now  the LPCs  that APCA  employs are                                                               
funded  by nonsustainable  federal grants  and other  grants that                                                               
are not sustainable funding sources.                                                                                            
                                                                                                                                
MR. ZASADA  said that  mild and  moderate anxiety  and depression                                                               
are  co-occurring conditions  with  chronic conditions  including                                                               
diabetes   and   hypertension.   LPCs  can   provide   short-term                                                               
counseling  support  to  stabilize  and  improve  the  health  of                                                               
emergent patients  and assisting  them in managing  their chronic                                                               
conditions. LPCs  provide a range  of behavioral  health services                                                               
in schools  across the state. At  this time none of  that care is                                                               
reimbursed.                                                                                                                     
                                                                                                                                
MR.  ZASADA said  that  in an  integrated  clinical setting,  the                                                               
attending medical or  dental provider of a  patient with diabetes                                                               
might  discover the  patient is  showing signs  of depression  or                                                               
anxiety that  could affect  the patient's  ability to  follow the                                                               
treatment plan. This is the point  when an LPC would be called to                                                               
provide counseling  support for  the patient.  The LPC  will work                                                               
with  the  patient  around   personal  issues  affecting  overall                                                               
health, teach  behavioral skills, and address  social issues. The                                                               
goal of  the provider  team is  to get the  patient back  on path                                                               
with  a   treatment  plan,  improve  mental   health,  and  avoid                                                               
emergency care.                                                                                                                 
                                                                                                                                
2:01:03 PM                                                                                                                    
MR.  ZASADA said  that  in school-based  settings,  an LPC  might                                                               
provide individual  counseling, provide behavioral  health skills                                                               
education, and train teachers in how to support students.                                                                       
                                                                                                                                
MR. ZASADA said that APCA supports  SB 134. It addresses the need                                                               
for Alaska's response to  behavioral health, lends sustainability                                                               
to current efforts,  and offers another tool to  improve care and                                                               
lower its costs.                                                                                                                
                                                                                                                                
2:02:05 PM                                                                                                                    
KEVIN MUNSON,  Chief Executive Officer, Mat-Su  Behavioral Health                                                               
Services,  Wasilla,  Alaska, said  that  Mat-Su  Behavioral is  a                                                               
federally qualified  community health center and  also operates a                                                               
community  behavioral  health  program  funded by  the  state  of                                                               
Alaska. He  is the chair  of the Alaska Primary  Care Association                                                               
and sits  on the  executive committee  for the  Alaska Behavioral                                                               
Health   Association.  He   is  also   a  licensed   professional                                                               
counselor. His  training is  as a  marriage and  family therapist                                                               
but he is licensed  as an LPC. He has been in  the state 32 years                                                               
practicing both in behavioral health  and in primary care. It has                                                               
been  a  long-standing  desire  of  his  to  see  LPCs,  licensed                                                               
marriage and  family therapists and other  licensed mental health                                                               
professionals added to the list.                                                                                                
                                                                                                                                
MR. MUNSON said the committee has  heard a lot about access. When                                                               
he was in  college his university built a new  library. Some wise                                                               
soul who  had seen all  the lovely sidewalks for  other buildings                                                               
and all  the muddy paths decided  not to put sidewalks  in and to                                                               
wait  and watch  to see  how students  used paths  to get  to the                                                               
library  and then  the  sidewalks were  laid.  The mental  health                                                               
system was designed  a long time ago and put  in place in statute                                                               
and  in   regulation  and  in   practice.  SB  74   provided  the                                                               
opportunity  to take  a step  back and  do some  transformational                                                               
thinking about  how to  redesign. The way  in which  Alaskans are                                                               
using  services in  the  modern day  vs. where  things  are is  a                                                               
serious mismatch. Many  citizens use the emergency  rooms to meet                                                               
their behavioral health  needs. In large part that  is because of                                                               
lack  of access  to  behavioral health  services  in the  typical                                                               
locations where they would go to try to get it.                                                                                 
                                                                                                                                
MR. MUNSON  said that  now LPCs  are siloed  and only  allowed to                                                               
practice  in narrow  areas as  it relates  to Medicaid,  which is                                                               
limited to grant-funded  entities. Appropriate professionals need                                                               
to be  in the appropriate  places where citizens are  most likely                                                               
to  be  able  to  use   them.  The  suicide  rates  are  chilling                                                               
statistics. One  of the fundamental  problems is that  54 percent                                                               
of people who  complete suicide have had a primary  care visit in                                                               
the previous 30 days.                                                                                                           
                                                                                                                                
MR. MUNSON  said the primary  care provider may have  asked about                                                               
that  and may  have  made a  referral to  a  local mental  health                                                               
center or  counseling agency. Ninety  percent of  those referrals                                                               
go  nowhere. The  person just  drops out  of the  system. Federal                                                               
qualified  community health  centers have  integrated care  where                                                               
those  individuals  can have  a  warm  hand  off to  an  existing                                                               
counselor  within the  context of  primary care.  Several private                                                               
practices in  the state  of Alaska have  counselors who  do that.                                                               
They are paying  those counselors and not  getting reimbursed for                                                               
that,  especially  for  Medicaid  clients because  LPCs  are  not                                                               
eligible providers. It is not an expandable, replicable model.                                                                  
                                                                                                                                
MR.  MUNSON said  that he  employs six  licensed clinical  social                                                               
workers. Last year  he lost one, and it took  nine months to find                                                               
another one.  In that  month, he had  five opportunities  to hire                                                               
LPCs to  fill that slot. If  the state had a  reimbursable model,                                                               
he  could have  hired one.  He  has no  grant money  to fund  the                                                               
licensed  social workers.  They  are funded  by the  reimbursable                                                               
work they do. If he had a  funding stream for LPCs, since much of                                                               
his business  is Medicaid, he  could have replaced  that licensed                                                               
social worker in 30 to 60 days instead of 11 months.                                                                            
                                                                                                                                
MR.  MUNSON said  it is  about giving  citizens access  when they                                                               
want it and need it. Most folks  don't wake up in the morning and                                                               
think they  will go  see a  counselor that  day. It's  usually an                                                               
acute  crisis that  drives someone  to see  a counselor,  such as                                                               
trouble at  school, a divorce,  a lost job,  or a DUI.  Those are                                                               
the times  and circumstances  in which someone  is ready  but not                                                               
necessarily  able to  get help  because many  of the  helpers are                                                               
siloed in places  someone doesn't think of using or  can't get in                                                               
because the behavioral health system  is designed to take care of                                                               
the most impaired,  the most at risk, and the  most in need. That                                                               
leaves  individuals  who  are mild  to  moderate  without  viable                                                               
resources.                                                                                                                      
                                                                                                                                
2:10:32 PM                                                                                                                    
MR. MUNSON said those could be  made viable with a business model                                                               
for federally  qualified health  centers for  counseling programs                                                               
for  primary  care  and  group  practices to  take  care  of  the                                                               
Medicaid population. Removing the  statutory barrier for LPCs [to                                                               
bill for  Medicaid] creates a  pathway to  regulatory development                                                               
to provide access to citizens who  need care. If they have access                                                               
when they  need it, during  that initial crisis perhaps  they can                                                               
save  the marriage,  the children  no longer  become children  of                                                               
divorce with  disruptions to their education.  The children avoid                                                               
other  risks, they  don't develop  Adverse Childhood  Experiences                                                               
scores because  of intervention. Taking  care of people  at their                                                               
time  of need  can avoid  further, much  higher costs  because of                                                               
engagement  with  the  Office   of  Children  Services,  Juvenile                                                               
Justice,  and with  the courts  because appropriate  access to  a                                                               
service was provided when needed.                                                                                               
                                                                                                                                
MR. MUNSON  said that research  shows that  the best way  to take                                                               
care of  people is with a  primary care home team  of individuals                                                               
who  provide  wraparound services,  one  of  which is  behavioral                                                               
health. His center has seen  enormous success with individuals by                                                               
addressing  behavioral  health  problems,  such  as  anxiety  and                                                               
parenting issues, and with  intervention around lifestyle choices                                                               
and  change  management  for  people  who  have  chronic  medical                                                               
conditions.                                                                                                                     
                                                                                                                                
MR. MUNSON noted  that people with diabetes find it  hard to make                                                               
lifestyle changes.  The primary  care physician has  limited time                                                               
and,  quite   frankly,  limited  skill   in  how  to   do  change                                                               
management, but the behavioral health  specialist can step in and                                                               
talk  to  the  person  about   small,  incremental  changes  that                                                               
eventually  become  large,  lifestyle  changes  that  change  the                                                               
trajectory  of that  person's diabetic  care. Patients  get their                                                               
A1Cs  under  control,  lose  weight,   and  develop  an  exercise                                                               
program.  Since   2013,  his  center   has  been   operating  the                                                               
depression  management  care  IMPACT   model  that  involves  the                                                               
collaboration of  the primary care provider,  a licensed clinical                                                               
social  worker, and  a consulting  psychiatrist.  His center  has                                                               
seen enormous improvements in treatment  and has seen people ease                                                               
their depression,  go back  to work,  and put  relationships back                                                               
together because  the center  was able to  provide that  level of                                                               
intervention.                                                                                                                   
                                                                                                                                
MR. MUNSON said he employs  six licensed clinical social workers.                                                               
If  legislators could  wave  a  magic wand  and  LPCs could  bill                                                               
Medicaid, he  could add three  tomorrow and keep  them incredibly                                                               
busy. At  this point the  intake is within  one to two  weeks. It                                                               
could be a day or a couple of days and make a better impact.                                                                    
                                                                                                                                
MR.  MUNSON said  finally,  there  is the  notion  of equity.  If                                                               
someone  were to  look at  a licensed  clinical social  worker, a                                                               
licensed marriage and family therapist,  and a licensed practical                                                               
counselor providing counseling, assuming  they had about the same                                                               
amount  of  experience,  no  one   would  be  able  to  tell  the                                                               
difference.  They are  all well  trained, experienced,  competent                                                               
behavioral health  professionals. The  system recognizes  some of                                                               
the  credentials  only  because  they existed  at  the  time  the                                                               
regulations  were  drafted.  Subsequent professionals  have  been                                                               
excluded from  the process simply  because they were late  to the                                                               
party.                                                                                                                          
                                                                                                                                
2:17:08 PM                                                                                                                    
CHAIR WILSON opened public testimony.                                                                                           
                                                                                                                                
PATICK ANDERSON,  Chief Executive Officer, RurAL  CAP, Anchorage,                                                               
Alaska,  said he  was a  humble country  lawyer, but  in 2003  he                                                               
shifted to managing  rural health care systems. He  would love to                                                               
have  what Mr.  Zepp described  in rural  communities. RurAL  CAP                                                               
serves the hard  to serve, the 20 percent that  Mr. Zepp referred                                                               
to. Abraham  Maslow referred to  them as the  continental divide,                                                               
the  very hard  to  serve who  will  need professional  services.                                                               
RurAL  CAP serves  those individuals,  both in  Anchorage and  in                                                               
rural Alaska. It  is difficult to provide any  of those services.                                                               
RurAL CAP has  a grant to provide behavioral  health services for                                                               
Head Start.  RurAL CAP  operates 24 of  those. These  children go                                                               
without  basic  services  because  RurAL  CAP  doesn't  have  the                                                               
licensed  professionals   in  rural  Alaska.  When   he  was  the                                                               
executive  director at  Chugachmuit,  there  were two  behavioral                                                               
health aides in training. It took  four years of education and to                                                               
have the skill level and supervision is complex.                                                                                
                                                                                                                                
MR. ANDERSON  said that the  residents of Karluk Manor  and Sitka                                                               
Place are the hard to serve.  With the dearth of professionals in                                                               
the  state,  the  RurAL  CAP   clinical  team  is  being  poached                                                               
constantly. He has  had to raise salaries many times.  To open up                                                               
the  roles to  additional  counselors is  a  wonderful idea.  The                                                               
state can  utilize them  and will still  be short,  especially in                                                               
rural Alaska. He spent eight  years on the American Indian/Alaska                                                               
Native task force  on suicide prevention. It  is disheartening to                                                               
see the  needs go unserved every  day in rural Alaska.  RurAL CAP                                                               
is initiating  at board direction whole  community healing. RurAL                                                               
CAP  will need  advice  of professionals  and  the engagement  of                                                               
communities. Referring  to the  work of  Dr. Martin  Seligman and                                                               
the concept  of learned helplessness  and the dearth  of services                                                               
and hope in rural Alaska,  he is afraid that learned hopelessness                                                               
will  become the  norm. He  urged  the committee  to support  the                                                               
expansion of the ranks with licensed professional counselors.                                                                   
                                                                                                                                
2:20:59 PM                                                                                                                    
SEVILLA  LOVE,  Integration   Coordinator,  Alaska  Primary  Care                                                               
Association, Anchorage,  Alaska, said she is  a licensed clinical                                                               
social worker. She  has spent her 20-year clinical  career on the                                                               
front lines  of integration, in  both urban and rural  Alaska, in                                                               
primary   care  clinics   developing  cutting-edge   intervention                                                               
programs throughout Alaska. She  worked exclusively with suicidal                                                               
rural patients  at Alaska  Psychiatric Institute.  Eighty percent                                                               
of  the  people  she  worked   with  could  have  been  avoidable                                                               
admissions  if  they had  had  the  preventative care  that  they                                                               
needed in primary care. The  committee heard the numbers of those                                                               
going  unseen by  behavioral health.  She has  been the  provider                                                               
capturing those patients  who would not otherwise  have been seen                                                               
or been  willing to  be seen  and accept  an outside  referral to                                                               
behavioral  health because  the  care was  given  at their  first                                                               
place  of access,  which is  not specialty  standalone behavioral                                                               
health or treatment centers, but in primary care clinics.                                                                       
                                                                                                                                
MS. LOVE  said she now  works as the integration  coordinator for                                                               
the  Alaska Primary  Care Association.  She provides  training to                                                               
health centers  across Alaska  on how  to implement  a team-based                                                               
integrated  care model  by incorporating  behavioral health  into                                                               
their  daily provision  of  health care  services.  She sees  the                                                               
struggles of  health centers regarding  the quality of  care they                                                               
are able  to give. The  number one biggest  problem is a  lack of                                                               
access  to billable,  financially  sustainable behavioral  health                                                               
providers. Her clinics tell her  that they have looked across the                                                               
country for licensed  clinical social workers. They  are paying a                                                               
starting  salary of  over  $80,000 a  year,  plus loan  repayment                                                               
options, and  they still cannot  find a licensed  clinical social                                                               
worker or  psychologist to fill  the primary care role.  They are                                                               
desperate  and their  patients are  desperate for  the care.  She                                                               
also hears that  they have five LPCs who would  jump to take that                                                               
job that has  been open over a year, but  the centers cannot hire                                                               
them because they cannot pay  their salaries. She also hears that                                                               
the medical  staff is  drowning in  behavioral health  issues and                                                               
they cannot properly address them  without help and it is burning                                                               
them out  and the  turnover rates are  killing the  continuity of                                                               
care. It is not just  mental health issues. Chronic-care patients                                                               
also need behavioral health support  to make lifestyle changes to                                                               
improve  health. Her  centers ask  her why  they cannot  bill for                                                               
LPCs in primary care.                                                                                                           
                                                                                                                                
MS. LOVE  said that  health centers are  given this  massive task                                                               
requiring a  variety of tools,  but they  are told they  can only                                                               
use a  hammer to build  an integrated behavioral  health program.                                                               
This  is   inadequate.  Her  answers   to  their   questions  are                                                               
inadequate. Health centers  are left empty handed.  "When we walk                                                               
into a  clinic, we bring not  just our illness, but  we bring our                                                               
whole self  and our  lifestyle that will  impact the  outcomes of                                                               
our healing  and the community  wellness as a  whole . .  . Every                                                               
primary  care visit  is a  behavioral health  visit, and  we must                                                               
equip our  health centers with the  ability to meet this  need by                                                               
allowing LPCs  to become billable  providers in our  primary care                                                               
clinics," she said.                                                                                                             
                                                                                                                                
2:24:44 PM                                                                                                                    
ROBIN  MINARD,   Chief  Communications  Officer,   Mat-Su  Health                                                               
Foundation,  Wasilla,   Alaska,  said  that  the   Mat-Su  Health                                                               
Foundation  mission is  to  improve the  health  and wellness  of                                                               
Alaskans  living in  the Mat-Su.  SB  134 is  crucial because  it                                                               
helps  to  address  an  important   health  issue  facing  Mat-Su                                                               
residents every day, mental health  and substance abuse problems.                                                               
Licensed  professional  counselors   are  key  behavioral  health                                                               
providers  who  can help  with  these  problems. These  are  hard                                                               
issues  for Mat-Su  as shown  by  the last  two community  health                                                               
needs assessments.  In 2013 residents and  professionals said the                                                               
top five health challenges they  faced were alcohol and substance                                                               
abuse, children experiencing trauma  and violence, depression and                                                               
suicide,  domestic  violence  and  sexual assault,  and  lack  of                                                               
access  to behavioral  health care.  During that  same assessment                                                               
the foundation met with school  nurses throughout the borough who                                                               
said there  was a four to  eight month waiting list  for children                                                               
and  families with  Medicaid to  see a  counselor. Unfortunately,                                                               
not  much has  changed since  then. There  is still  a very  long                                                               
wait. When  these problems present  themselves, people  need help                                                               
then, not eight months later.  There are not enough mental health                                                               
providers in  Mat-Su or Alaska.  There is one provider  for every                                                               
860 residents. For  the top performer in the U.S.,  it is one for                                                               
every 330  residents. Residents need access  to behavioral health                                                               
providers so  they can  get care  early before  problems escalate                                                               
into the crisis stage.                                                                                                          
                                                                                                                                
MS. MINARD said that Mat-Su  Regional is inundated with people in                                                               
crisis related to  behavioral health. In 2016,  there were almost                                                               
1,200 residents seen  in the emergency department  with a primary                                                               
behavioral health  diagnosis. Those  1,200 people had  over 3,000                                                               
visits, and 46  percent were paid by Medicaid.  The top diagnoses                                                               
were suicidal ideation  and self-harm, alcohol-related disorders,                                                               
delirium, dementia,  and cognitive disorders. The  cost for those                                                               
visits was  $14 million  just in  facility charges.  If residents                                                               
could get immediate  access to care, pain and  suffering would be                                                               
saved, as well  as money. An individual  counseling session might                                                               
be around  $75 for Medicaid.  An average charge for  a behavioral                                                               
health emergency  visit is $4,370.  A person does need  more than                                                               
one behavioral  health visit, but  ten visits  at $75 would  be a                                                               
savings of $3,600  for just that one patient, not  to mention the                                                               
suffering  that people  go through.  The prevalence  of substance                                                               
abuse and mental health problems  in crisis is increasing in Mat-                                                               
Su and  statewide. This legislation  could bring  the appropriate                                                               
level  of care  to  people who  need care  when  a problem  first                                                               
presents.                                                                                                                       
                                                                                                                                
2:29:15 PM                                                                                                                    
DEBRA HAMILTON,  Executive Director, New Hope  Counseling Center,                                                               
Soldotna,  Alaska, said  she has  been  a professional  counselor                                                               
since  2013. Her  counseling center  is on  the campus  of Alaska                                                               
Christian College, which serves  predominantly young adult Alaska                                                               
Natives. It is also open to  the community. She has served on the                                                               
Board of  Professional Counselors since  2013 and is  the current                                                               
chair. Professional  counselors would  provide services  of great                                                               
quality.  Licensed  professional  counselors are  master's  level                                                               
counselors who  have extensive training and  required coursework.                                                               
Currently, there are 732  active licensed professional counselors                                                               
in the state with 447  approved supervisors actively training and                                                               
supervising the  next generation  of LPCs. There  is a  vacuum of                                                               
accessible services, so SB 134 should be supported.                                                                             
                                                                                                                                
2:31:39 PM                                                                                                                    
ERIC  BOYER,   Program  Officer,   Alaska  Mental   Health  Trust                                                               
Authority,  Anchorage, Alaska,  said he  serves as  the chair  of                                                               
Alaska Health  Care Workforce Coalition. Expanding  the number of                                                               
health  care practitioners  who can  bill Medicaid  will increase                                                               
that  responsiveness  to  treat  people  experiencing  behavioral                                                               
health  disorders  when  they  need  help  vs.  being  put  on  a                                                               
waitlist. The  Alaska Mental Health Trust  Authority is concerned                                                               
about  their  beneficiaries  and  how  to  improve  their  lives.                                                               
Beneficiaries  include Alaskans  with  mental illness,  substance                                                               
use   disorder,  developmental   disabilities,  Alzheimer's   and                                                               
related  dementia, and  traumatic  brain  injury. In  partnership                                                               
with  Department  of  Health  and  Social  Services  (DHSS),  the                                                               
authority  ensures that  Alaska has  a comprehensive,  integrated                                                               
system of care to provide  the necessary services and support for                                                               
beneficiaries as close to home as possible.                                                                                     
                                                                                                                                
2:33:37 PM                                                                                                                    
DON BLACK,  Board Member, Bethel  Family Clinic,  Bethel, Alaska,                                                               
said the clinic  employs one licensed clinical  social worker and                                                               
one licensed  professional counselor and has  an employee working                                                               
toward becoming an  LPC in the behavioral  health department. The                                                               
clinic provides  services to teens  at the Bethel  Youth Facility                                                               
in  efforts to  reverse destructive  habits while  these students                                                               
are still  young. The  substance abuse  programs are  embedded in                                                               
the  community as  well as  in  the Yukon-Kuskokwim  Correctional                                                               
Facility,  where staff  provides individual  and group  guidance.                                                               
Youth  services  are  also delivered  to  court-  and  medically-                                                               
referred patients.  The clinic receives  patients from  the local                                                               
community  and  surrounding  village.  As a  safety  net  medical                                                               
facility, some services are provided  without pay in the clinic's                                                               
efforts  to maintain  the health  of the  community. Such  is the                                                               
case  with services  provided by  the clinic's  LPC for  Medicaid                                                               
patients,  many of  whom are  youth from  villages where  suicide                                                               
rates are high,  even by Alaskan standards.  The clinic's greater                                                               
mission  is  to provide  for  the  health  of the  community,  so                                                               
sometimes the clinic does that  without pay, but the LPC provides                                                               
the same  level of care  as the licensed clinical  social worker.                                                               
The work  of the LPC is  recognized as equivalent to  the work of                                                               
the licensed  clinical social  worker and  is payable  by private                                                               
insurers, but  this same  work is not  recognized and  payable by                                                               
the  state's  Medicaid policies.  In  a  time of  addressing  the                                                               
opioid crisis, the clinic has one  hand tied behind its back. Its                                                               
delivery  of services  is restricted  simply because  of how  the                                                               
history  of   the  licensing   process  for   licensed  practical                                                               
counselor and  licensed clinical  social worker developed  in the                                                               
state. SB 134 unties that hand.                                                                                                 
                                                                                                                                
2:35:52 PM                                                                                                                    
JULIE  THOMPSON, Licensed  Professional Counselor,  Bethel Family                                                               
Clinic,  Bethel,  Alaska, said  she  is  a licensed  professional                                                               
counselor.  She  graduated  with  a  master's  in  mental  health                                                               
counseling in 2007.  She has 13 years  of experience specializing                                                               
in trauma-informed  interventions for people with  a diagnosis of                                                               
post-traumatic  stress   disorder  (PTSD)  and   substance  abuse                                                               
disorder.  She previously  worked  two years  as  a clinician  at                                                               
Yukon   Kuskokwim  Ayagnirvik   Healing  Center.   She  supported                                                               
individuals  in   their  efforts   toward  recovery   from  their                                                               
substance  use  disorder.  Over   90  percent  of  these  clients                                                               
suffered   from  coexisting   disorders,   usually  PTSD,   often                                                               
secondary to  trauma experienced as  children having grown  up in                                                               
severely   dysfunctional  homes   due  to   their  own   parents'                                                               
unresolved and  untreated traumatic histories. She  now works for                                                               
Bethel  Family  Clinic as  a  mental  health clinician.  However,                                                               
since she is no longer  under the Indian Health Service umbrella,                                                               
she is  not recognized by  Medicaid as a clinical  provider. This                                                               
is  tragic as  her agency  is a  primary partner  with the  Child                                                               
Advocacy  Center  whose  primary  mission is  to  provide  timely                                                               
interventions to children who have  been identified as victims of                                                               
sexual  abuse  and  trauma.  The  center  currently  employs  two                                                               
clinicians, herself, and  a colleague who is  a licensed clinical                                                               
social  worker. The  clinic has  been trying  to recruit  another                                                               
social worker for over a year.  It is not uncommon for the clinic                                                               
to have  seven referrals in a  week from the Advocacy  Center. At                                                               
this time the  clinic can respond to none of  them. Allowing LPCs                                                               
access to Medicaid  reimbursement will not only  save millions of                                                               
dollars,  money  that is  now  spent  on emergency  room  visits,                                                               
medevacked services, or legal  interventions, but will ultimately                                                               
save  lives.  "Please support  SB  134  and  help us  help  these                                                               
children, help us save their lives," she said.                                                                                  
                                                                                                                                
2:38:15 PM                                                                                                                    
JEIGH  STANTON  GREGOR,  representing self,  Petersburg,  Alaska,                                                               
said  he is  an LPC  in private  practice. He  and his  wife have                                                               
owned True North Counseling and  Consultation for seven years. SB                                                               
134  will allow  the most  vulnerable  the same  access to  high-                                                               
quality mental  health services as people  with private insurance                                                               
or the ability to pay out of  pocket. He is confident that in his                                                               
town  of 3,000  people, a  private practice  could thrive  seeing                                                               
only  Medicaid  clients. The  passage  of  SB  134 will  lead  to                                                               
reductions  in  costly emergency  room  visits  and acute  mental                                                               
health  crises.   Preventative  care   is  highly   effective  in                                                               
mitigating mental health  emergencies. If SB 134  passes, it will                                                               
be one of the  rare times that the state will  save lots of money                                                               
on mental  health care for  the most vulnerable  while increasing                                                               
mental health  care for the most  vulnerable. It is truly  a win-                                                               
win situation.  As an  LPC he  does his job  because he  wants to                                                               
help people  be well and improve  the quality of their  lives. It                                                               
is  disappointing not  to be  able to  serve the  most vulnerable                                                               
population, given  the way  the laws are  structured now.  He has                                                               
sent a letter to the committee.                                                                                                 
                                                                                                                                
2:40:21 PM                                                                                                                    
CHAIR  WILSON  closed  public  testimony and  held  the  bill  in                                                               
committee.                                                                                                                      

Document Name Date/Time Subjects
SB 134 - Sponsor Statement.pdf SFIN 3/16/2020 9:00:00 AM
SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Sectional Analysis.pdf SFIN 3/16/2020 9:00:00 AM
SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Fiscal Note DHSS Medicaid Svcs 2.15.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 SHSS Presentation 2.20.20.pptx SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Alaska ER Report_2016 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Alaska ER Report_2017 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
Sb 134 Alaska ER Report_2018 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Alaska ER Report_2019 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Arctic Mental Health Care Workforce Shortage _10-2-17 - DHSS 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Providence Health Alaska - LOS.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - LOS - Jeigh Stanton Gregor LPC.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Southeast Alaska Regional Health Consortium LOS.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Support Letter Discovery Cove 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Substance Abuse and Mental Health Services Administration - 2018 Key Indicators in the US 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 US DHSS - Supply and Demand for Behavioral Health Occupations 2016-2030 - DHSS 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 US General Account Office - Behavioral Health - Health Care Costs Untreated - February 2019 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Alaska State Hospital & Nursing Home Association - LOS.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Nat'l Survey of Children's Health 2011-2012 - DHSS -ACES 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 AMHTA - Strengthening System-CompPlan_2020-24 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Rural Health Research and Policy Center - Supply and Distribution of Behavioral Health Workforce - DHSS 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Alaska State Hospital & Nursing Home Association - LOS.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 AK Regional Hospital LOS 2.21.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134