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 SENATE BILL NO. 134,                                                               
"An  Act relating  to medical  assistance  reimbursement for  the                                                               
services of  licensed professional counselors; and  providing for                                                               
an effective date."                                                                                                             
                                                                                                                                
CHAIR WILSON,  speaking as sponsor  of SB 134, stated  his intent                                                               
to  hear  a  sectional  analysis  and  take  invited  and  public                                                               
testimony.                                                                                                                      
                                                                                                                                
1:35:26 PM                                                                                                                    
GARY   ZEPP,   Staff,   Senator  David   Wilson,   Alaska   State                                                               
Legislature,  began a  PowerPoint on  SB  134. He  read slide  2,                                                               
SB134:                                                                                                                          
                                                                                                                                
     SB 134  would add 717 Licensed  Professional Counselors                                                                    
     to the  Medicaid Optional Services. The  concept of the                                                                    
     bill  is  to  expand  behavioral  health  capacity  and                                                                    
     utilization  for Alaska's  most vulnerable  population,                                                                    
     our  Medicaid population.  If behavioral  health issues                                                                    
     can  be  treated  in a  preventative  manner  within  a                                                                    
     clinical  setting,  rather than  a  crisis  stage at  a                                                                    
     platinum  level, the  costs lesson  and the  quality of                                                                    
     the  healthcare  services   improves.    This  proposed                                                                    
     legislation  is a  piece of  the  puzzle for  providing                                                                    
     behavioral health services to Alaskans.                                                                                    
                                                                                                                                
MR. ZEPP reviewed slide 3, Behavior Health:                                                                                     
                                                                                                                                
     Behavioral  health  is  the  scientific  study  of  the                                                                    
     emotions,   behaviors,  and   biology  relating   to  a                                                                    
     person's mental  well-being, their ability  to function                                                                    
     in   everyday  life,   and  their   concept  of   self.                                                                    
     "Behavioral health"  is the  preferred term  to "mental                                                                    
     health."     A  person  struggling  with   his  or  her                                                                    
     behavioral   health   may  face   stress,   depression,                                                                    
     anxiety,   relationship  problems,   grief,  addiction,                                                                    
     attention-deficit/hyperactivity  disorder  or  learning                                                                    
     disabilities,  mood disorders,  or other  psychological                                                                    
     concerns.     Counselors,  therapists,   life  coaches,                                                                    
     psychologists, nurse  practitioners, or  physicians can                                                                    
     help manage behavioral  health concerns with treatments                                                                    
     such as therapy counseling or medication.                                                                                  
                                                                                                                                
MR.  ZEPP  said licensed  professional  counselors  (LPCs) are  a                                                               
valuable,  cost  effective  part   of  treatment  for  behavioral                                                               
health. This  bill provides  one piece  of the  behavioral health                                                               
capacity  that already  includes licensed  social workers,  Ph.D.                                                               
psychologists,  prescribing  nurse   practitioners,  and  medical                                                               
doctors, including psychiatrists and primary care physicians.                                                                   
                                                                                                                                
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 that term  only encompasses the biological                                                               
component of the  aspect of wellness. The  term behavioral health                                                               
encompasses  all  contributions  to  mental  wellness,  including                                                               
substance abuse,  behavioral issues,  habits, and  other external                                                               
forces.                                                                                                                         
                                                                                                                                
MR. ZEPP  turned to  slide 4,  Why Medicaid  clients and  who are                                                               
they? He read:                                                                                                                  
                                                                                                                                
     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.  So  you  can imagine  a                                                                    
     person in crisis who  cannot find behavioral healthcare                                                                    
     access  or are  told it's  available in  three or  four                                                                    
     months, what are [their] options?                                                                                          
                                                                                                                                
     Alaska's  emergency room  facilities  are  in a  crisis                                                                    
     mode treating behavioral health issues.                                                                                    
                                                                                                                                
     SB  134 would  directly impact  the lives  of our  most                                                                    
     vulnerable  population  of   citizens,  our  poor,  our                                                                    
     young, and our seniors.   Alaska's emergency rooms have                                                                    
     been   over-whelmed    with   volumes    of   emergency                                                                    
     situations. The leading cause is  alcohol disorders and                                                                    
     the associated aliments of alcohol abuse.                                                                                  
                                                                                                                                
     Often Medicaid clients have no  where else to go due to                                                                    
     access and  then the lack  of capacity  causes patients                                                                    
     to stay  much longer  in the  emergency room  than they                                                                    
     should.   Patients who  have serious  behavioral health                                                                    
     issues.                                                                                                                    
                                                                                                                                
MR.  ZEPP reviewed  the statistics  on slide  5, Adult  Untreated                                                               
Behavior  Health Statistics.  He reported  that approximately  70                                                               
percent of Americans  who need behavioral health  services do not                                                               
receive treatment, and  92 percent of those  with substance abuse                                                               
disorders and  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. When people  who need treatment do  not receive it,                                                               
it often leads to interaction  with the police, the court system,                                                               
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  reviewed  the  bar   charts  on  slide  6,  Children's                                                               
Untreated Behavioral  Health Statistics.  It indicates  that 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  reviewed  slide 7,  Alaska  assessment  of  behavioral                                                               
health care needs, which states:                                                                                                
                                                                                                                                
     Mental Health Care Needs                                                                                                   
                                                                                                                                
     Alaska's  suicide  rate is  among  the  highest in  the                                                                    
     nation,  with the  prevalence among  the Alaska  Native                                                                    
     population, particularly  in the  most remote  areas of                                                                    
     the  state,  surpassing  that  of  the  general  Alaska                                                                    
     population  (figure  1).  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.                                                                    
     One  component  necessary   to  address  mental  health                                                                    
     issues is  a well-trained  cadre of mental  health care                                                                    
     providers to provide preventive support and treatment.                                                                     
                                                                                                                                
     There  are  several  reasons  why  individuals  needing                                                                    
     mental  health services  do not  receive them.  In some                                                                    
     cases,  the   perceived  stigma  associated   with  the                                                                    
     problem  or  illness   prevents  the  individuals  from                                                                    
     seeking help.  In other cases, individuals  may be more                                                                    
     comfortable  seeking  help from  alternative  providers                                                                    
     such   as  faith-based,   traditional/culture-based  or                                                                    
     peer-support   resources    within   their   community.                                                                    
     Finally,  particularly  in remote  areas,  availability                                                                    
     and access  to mental  health care providers  are often                                                                    
     limited.                                                                                                                   
                                                                                                                                
     The  most  common  issues for  children  are  attention                                                                    
     deficit  hyperactivity  disorder (AHDH),  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  disorders, if  not treated,                                                                    
     they  usually  increase  over  time,  and  the  child's                                                                    
     condition worsens.                                                                                                         
                                                                                                                                
MR. ZEPP said  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. In 2017,  nine times as many people died by                                                               
suicide  in   Alaska  than   in  alcohol-related   motor  vehicle                                                               
accidents. Alaska's  suicide rate is  52 percent higher  than the                                                               
national average.                                                                                                               
                                                                                                                                
1:42:57 PM                                                                                                                    
     How Many Behavioral Health Care Providers Are Needed?                                                                    
     Despite   the  number   of  individuals   in  need   of                                                                    
     behavioral   health  care   services,   the  ratio   of                                                                    
     behavioral  health  care  providers  to  population  is                                                                    
     lower  in  Alaska  than nationally.  Furthermore,  most                                                                    
     providers work  in urban areas,  such that  the state's                                                                    
     remote  areas   have  even   lower  provider/population                                                                    
     ratios.                                                                                                                    
                                                                                                                                
     There are many types  of behavioral health providers in                                                                    
     Alaska     (e.g.,      psychiatrists,     neurologists,                                                                    
     psychologists,  counselors,   clinicians,  technicians,                                                                
     behavioral nurse  practitioners, and  behavioral health                                                                    
     aides),  though as  an example,  here we  consider only                                                                    
     the shortage  of psychiatrists.  Two  studies estimated                                                                    
     a need  for 25.96  and 15.37 psychiatrists  per 100,000                                                                    
     adults  nationally,  with  the authors  of  the  second                                                                    
     study noting  that the behavioral health  care needs of                                                                    
     rural   populations  may   not  have   been  adequately                                                                    
     captured.                                                                                                                  
                                                                                                                                
     National estimates  do not account for  Alaska's unique                                                                    
     population,  geography, and  need  but can  serve as  a                                                                    
     benchmark  for estimating  the number  of psychiatrists                                                                    
     needed in  Alaska.  Based  on 2010 Census  data, Alaska                                                                    
     needs 184 or 106 psychiatrists, respectively.                                                                              
                                                                                                                                
MR.  ZEPP  said  understanding the  magnitude,  composition,  and                                                               
geographical  scope of  the mental  health  provider shortage  in                                                               
Alaska  is  seen  as  the first  step  in  developing  effective,                                                               
targeted  solutions  to  increase workforce  capacity  by  adding                                                               
licensed professional counselors.                                                                                               
                                                                                                                                
1:43:39 PM                                                                                                                    
MR.  ZEPP  reviewed  the  chart   on  slide  9,  titled,  "Alaska                                                               
Emergency  Room  Department,   Super-Utilizer  Facts,  and  Total                                                               
Medicaid Billing charges." He said  this chart 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. 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  percent or                                                               
1,858  top utilizers  is $42  million or  $22,604 per  person per                                                               
year. The cost  of 11.6 percent or 7,996 of  the top utilizers is                                                               
$98 million.                                                                                                                    
                                                                                                                                
MR. ZEPP  said 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.  With  the federal  approval  of  the 1115  [Behavioral                                                               
Health Medicaid Waiver,  also known as 1115  waiver], adding LPCs                                                               
to  the   mix  of  behavioral  health   professionals  offers  an                                                               
opportunity  to expand  capacity, increase  the quality  of care,                                                               
lower the  cost versus the crisis  level costs that the  state is                                                               
paying.  The state  has  already paid  these  costs for  Medicaid                                                               
clients for their behavioral health services.                                                                                   
                                                                                                                                
1:45:28 PM                                                                                                                    
MR. ZEPP reviewed  the statistics on slide  10, "Alaska Emergency                                                               
Room  Department,   Super-Utilizer  Facts,  Number   of  Medicaid                                                               
Clients." He  said the chart  shows that  from 2016 to  2019, the                                                               
number of Medicaid clients has gone  down by 9.6 percent, but the                                                               
costs are rising. Alcohol-related  disorders were the most common                                                               
diagnoses for the  top 2.7 percent, or 1,609  super utilizers and                                                               
the cost  was $43.5  million. The four-year  average for  the top                                                               
10.77 percent  or 7,204 users  was $103.4 million or  $14,332 per                                                               
person. The top  2.7 percent were likely between 20  and 59 years                                                               
old. Of  these patients,  61 percent were  female and  39 percent                                                               
were male.                                                                                                                      
                                                                                                                                
MR. ZEPP reviewed slide 11,  Preventative Behavioral Health Care.                                                               
He said the estimated cost  for a behavioral health assessment in                                                               
Alaska's emergency rooms  is $4,300 versus $150 to  $250 per hour                                                               
for clinical  work by a  licensed professional counselor.  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.                                                                                                        
                                                                                                                                
MR. ZEPP displayed the list of supporters of 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 members to support SB 134.                                                                          
                                                                                                                                
1:48:56 PM                                                                                                                    
GENNIFER  MOREAU,   Director,  Division  of   Behavioral  Health,                                                               
Department  of  Health  and Social  Services  (DHSS),  Anchorage,                                                               
Alaska, said  the Division of  Behavioral Health stands  ready to                                                               
assist with this proposed  legislation. She highlighted potential                                                               
benefits  of  SB  134,  which  could expand  access  to  care  to                                                               
eligible  Alaskans   statewide,  especially  for   remote,  rural                                                               
communities   and  for   individuals   with   mild  to   moderate                                                               
disturbances.  The bill  could  potentially decrease  psychiatric                                                               
emergency services  and acute care  hospital services  over time.                                                               
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. Families  may  be  more comfortable  receiving                                                               
services in those settings.                                                                                                     
                                                                                                                                
CHAIR WILSON  asked how  this would be  integrated with  the 1115                                                               
waiver.                                                                                                                         
                                                                                                                                
MS. MOREAU  replied the 1115 waiver  is a mechanism to  develop a                                                               
full continuum  of care. The  driver behind  it is to  reduce the                                                               
reliance on the  acute end of care.  Expanding access, especially                                                               
for  Medicaid recipients  who are  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. 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                                                               
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 LPCs are  a valuable, cost-effective component of                                                               
team-paced,  whole person  primary  care. Primary  care is  built                                                               
around medical, dental, behavioral  health, pharmacy, and support                                                               
providers working to  ensure patients receive care  and help them                                                               
manage  their  chronic  conditions. Making  LPCs  billable  under                                                               
Medicaid will expand  access to care for Alaskans  in lower cost,                                                               
primary care settings.                                                                                                          
                                                                                                                                
MR.  ZASADA  said the  bill  is  an  important component  of  the                                                               
Medicaid reforms  that were outlined  in the 2016 Senate  Bill 74                                                               
to expand provider types to  increase access to behavioral health                                                               
services.  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.  In 2017,  APCA health  centers reported  a                                                               
deficit of 12 to 18  behavioral health providers. Conservatively,                                                               
they 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  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 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. Currently, 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. At  this point 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  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  Health Services,                                                               
Wasilla, Alaska, said Mat-Su  Behavioral is a federally-qualified                                                               
community  health  center.  It operates  a  community  behavioral                                                               
health program  funded by the  state. He  serves as the  chair of                                                               
the Alaska  Primary Care  Association and  sits on  the executive                                                               
committee for  the Alaska Behavioral Health  Association. He said                                                               
he is  trained as a marriage  and family therapist, but  he works                                                               
as a licensed professional counselor  (LPC). He has practiced for                                                               
32 years in Alaska in behavioral  health and 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 [SB  134] provides an  opportunity to  step back                                                               
and do some  transformational thinking about how  to redesign the                                                               
system.  Many citizens  use  the emergency  rooms  to meet  their                                                               
behavioral health needs  because of lack of  access to behavioral                                                               
health services in traditional settings.                                                                                        
                                                                                                                                
MR. MUNSON said that in terms  of Medicaid, LPCs are only allowed                                                               
to  practice in  narrow areas  limited to  grant-funded entities.                                                               
Appropriate  professionals need  to be  in places  where citizens                                                               
will most  likely use  them. The  suicide rates  provide chilling                                                               
statistics, such  that 54  percent of  people who  commit suicide                                                               
have had a primary care visit in the previous 30 days.                                                                          
                                                                                                                                
MR. MUNSON  said the primary  care provider may have  asked about                                                               
suicidal thought  and may  have referred the  patient to  a local                                                               
mental  health center  or counseling  agency.  Ninety percent  of                                                               
those referrals do  not result in a visit to  a counselor and the                                                               
patient  drops out  of the  system.  Federal qualified  community                                                               
health centers have integrated care  for individuals to receive a                                                               
hand off to  an existing counselor within the  context of primary                                                               
care. Several private practices in  the state have counselors who                                                               
do  so.   The  Mat-Su  Behavioral  Health   Services  pays  those                                                               
counselors  but is  not reimbursed  for Medicaid  clients because                                                               
LPCs  are  not  eligible  providers. It  is  not  an  expandable,                                                               
replicable model, he said.                                                                                                      
                                                                                                                                
MR. MUNSON said he employs  six licensed clinical social workers.                                                               
Last year  it took  nine months  to find  a replacement  when the                                                               
agency  lost   a  social  work.   In  one  month,  he   had  five                                                               
opportunities to hire LPCs to fill  the slot, which he could have                                                               
done if the state had a  reimbursable model. His program does not                                                               
have  grant money  to fund  the licensed  social workers  who are                                                               
funded by  the reimbursable work  performed. He offered  his view                                                               
that since much of his business  is Medicaid, if he had a funding                                                               
stream  for LPCs,  he could  have replaced  that licensed  social                                                               
worker in 30 to 60 days.                                                                                                        
                                                                                                                                
MR. MUNSON highlighted  the need to provide  citizens with access                                                               
to counselors.  Usually an acute  crisis drives someone to  see a                                                               
counselor, such as  trouble at school, a divorce, a  lost job, or                                                               
driving while  under the influence.  Those are  the circumstances                                                               
in which someone  is ready but not necessarily able  to get help.                                                               
Sometimes  that  is because  the  helpers  are siloed  in  places                                                               
someone does not  think of using or the person  cannot get access                                                               
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  fall in  mild to  moderate need  without                                                               
viable resources.                                                                                                               
                                                                                                                                
2:10:32 PM                                                                                                                    
MR. MUNSON said  a business model for  federally qualified health                                                               
centers  for  counseling  programs  for primary  care  and  group                                                               
practices could  take care of  the Medicaid  population. Removing                                                               
the  statutory  barrier for  LPCs  [to  bill for  Medicaid]  will                                                               
create a path to provide access  for citizens who need care. When                                                               
people have access to behavioral  health care during that initial                                                               
crisis,  it is  possible  to salvage  marriages  and children  no                                                               
longer  face  disruptions and  can  avoid  other risks,  such  as                                                               
Adverse  Childhood Experiences  scores  due  to intervention.  It                                                               
could  also  avoid  interventions   by  the  Office  of  Children                                                               
Services, Juvenile Justice, and the courts.                                                                                     
                                                                                                                                
MR. MUNSON  said the  research shows  that the  best way  to take                                                               
care of  people is with  a primary  care 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,                                                               
parenting issues, lifestyle choices  and providing management for                                                               
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 skills  to help  them, but  the behavioral  health specialist                                                               
can  talk to  the person  about small,  incremental changes  that                                                               
eventually become  large, lifestyle changes that  will 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 finally, there  is the notion of  equity. People                                                               
cannot differentiate between the  services of a licensed clinical                                                               
social worker, a marriage and  family therapist, and a counselor.                                                               
These professionals are all  well trained, experienced, competent                                                               
behavioral health  professionals. The  system recognizes  some of                                                               
the  credentials only  because these  professions existed  at the                                                               
time the regulations were  drafted. Subsequent professionals have                                                               
been excluded from the process.                                                                                                 
                                                                                                                                
2:17:08 PM                                                                                                                    
CHAIR WILSON opened public testimony on SB 134.                                                                                 
                                                                                                                                
PATICK ANDERSON,  Chief Executive Officer, RurAL  CAP, Anchorage,                                                               
Alaska, said  RurAL CAP serves  the hard to serve  individuals in                                                               
Anchorage  and rural  Alaska. RurAL  CAP has  a grant  to provide                                                               
behavioral health  services and operates 24  Head Start programs.                                                               
These children go without basic  services because RurAL CAP lacks                                                               
licensed professionals in rural Alaska.                                                                                         
                                                                                                                                
MR. ANDERSON said  the residents of Karluk Manor  and Sitka Place                                                               
are hard to serve communities.  He supported opening the roles to                                                               
add additional counselors.  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.  The  RurAL  CAP  board  has  initiated  whole  community                                                               
healing.  RurAL   CAP  will  need  professionals   and  community                                                               
engagement  to   do  so.  He   expressed  concern   that  learned                                                               
helplessness  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  in in                                                               
primary  care  clinics  in urban  and  rural  Alaska,  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 with preventative  primary care. She has been                                                               
the provider capturing the unseen  behavioral health patients who                                                               
would not otherwise have been seen or been willing to be seen.                                                                  
                                                                                                                                
MS. LOVE said she currently  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                                                               
the  daily  health  care  services. She  said  she  observes  the                                                               
struggles  health  centers  have  to provide  quality  care.  The                                                               
number one  problem is  lack of  access to  billable, financially                                                               
sustainable behavioral  health providers.  The clinics  she works                                                               
with tell her their clinics  have sought licensed clinical social                                                               
workers throughout  the Lower  48. These  clinics pay  a starting                                                               
salary of  over $80,000 a  year plus loan repayment  options, but                                                               
still  cannot   find  a  licensed   clinical  social   worker  or                                                               
psychologist to  fill the primary  care role. Their  patients are                                                               
desperate for care.  However, many LPCs would be  willing to fill                                                               
the  vacancies,  but  the  centers  cannot  hire  them.  Further,                                                               
medical  staff  face  burnout  so the  turnover  rates  kill  the                                                               
continuity of  care. Chronic-care  patients also  need behavioral                                                               
health  support  to  make  lifestyle  changes  to  improve  their                                                               
health.                                                                                                                         
                                                                                                                                
MS.  LOVE said  health  centers have  massive  tasks but  limited                                                               
options  to build  an integrated  behavioral health  program. She                                                               
said health  centers must  be allowed  to meet  behavioral health                                                               
needs using LPCs as billable providers in primary care clinics.                                                                 
                                                                                                                                
2:24:44 PM                                                                                                                    
ROBIN  MINARD,   Chief  Communications  Officer,   Mat-Su  Health                                                               
Foundation, Wasilla, Alaska, said  the Mat-Su Health Foundation's                                                               
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.                                                                                                                 
                                                                                                                                
She reported that  in 2013, residents and  professionals said the                                                               
top  five health  challenges 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 on  Medicaid to see a  counselor. Unfortunately, not                                                               
much  has changed  since  then. People  need  help when  problems                                                               
arise,  not eight  months later.  She said  there are  not enough                                                               
mental health  providers in Mat-Su  or Alaska, that there  is one                                                               
provider for every  860 residents, but in the U.S.,  the ratio is                                                               
one for every 330 residents.  Residents need access to behavioral                                                               
health  providers to  obtain care  before problems  escalate into                                                               
the crisis stage.                                                                                                               
                                                                                                                                
MS.  MINARD  said  Mat-Su Regional  Hospital  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.  These  patients                                                               
comprised  3,000  visits,  46  percent  of  which  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                                                               
in  facility  charges alone.  If  residents  could get  immediate                                                               
access to care,  pain, suffering, and costs  would be diminished.                                                               
An  individual counseling  session may  average $75  for Medicaid                                                               
patients,  but   an  average  charge  for   a  behavioral  health                                                               
emergency  room  visit is  $4,370.  The  prevalence of  substance                                                               
abuse and mental health problems  in crisis is increasing in Mat-                                                               
Su and  statewide. SB  134 could bring  the appropriate  level of                                                               
care to people 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 could  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. She offered her support for SB 134.                                                                        
                                                                                                                                
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  people experiencing  behavioral  health                                                               
disorders.   The    Alaska   Mental   Health    Trust   Authority                                                               
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.                                                               
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 degree 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  a substance                                                               
use  disorder. Over  90 percent  of these  clients suffered  from                                                               
coexisting  disorders, usually  PTSD, often  secondary to  trauma                                                               
experienced  as children  growing  up  in severely  dysfunctional                                                               
homes due  to their parents'  unresolved and  untreated traumatic                                                               
histories. She  now works  for Bethel Family  Clinic as  a mental                                                               
health  clinician. However,  since she  is not  under the  Indian                                                               
Health  Service umbrella,  she is  not recognized  as a  clinical                                                               
provider by  Medicaid. She  characterized this  as 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 patients the same  access to                                                               
high-quality  mental  health  services  as  people  with  private                                                               
insurance or  the ability to  pay out  of pocket. He  offered his                                                               
belief that a private practice  could thrive if its patients were                                                               
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. He  characterized SB  134 as  a win-win.  He                                                               
wants to  help people be  well and  improve the quality  of their                                                               
lives.                                                                                                                          
                                                                                                                                
2:40:21 PM                                                                                                                    
CHAIR WILSON closed public testimony on  SB 134 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