Legislature(2019 - 2020)BUTROVICH 205
02/26/2020 01:30 PM HEALTH & SOCIAL SERVICES
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SB 134-MEDICAID COVERAGE OF LIC. COUNSELORS 1:33:16 PM CHAIR WILSON announced the consideration of SB 134. He noted that he was a sponsor and that on February 21 the committee had heard an overview of the bill and took public testimony. He called on invited testimony. 1:35:16 PM DAVE WALLACE, Chief Executive Officer, Mat-Su Regional Medical Center, Palmer, Alaska, said that Mat-Su Regional is a 125-bed acute care hospital in the fastest growing service area in Alaska. He mentioned its size because a year ago it was a 74-bed hospital. It did a 35-bed med-surge expansion and then last month, added a 16-bed behavioral health unit. The Medicaid coverage for licensed professional counselors is important because it is part of the continuum of care for behavioral health. The lack of behavioral health services in Mat-Su and throughout the state is an issue of concern. Mat-Su Regional would like to have care provided at the most appropriate level. If more counselors are able to be paid to see Medicaid patients with behavioral health needs, it will keep the patients from going to a higher, more expensive level of care, which for Mat- Su Regional means overutilization of its emergency department. This will be better for everyone. The patients will receive treatment in an environment that is exclusively meant for their needs. It will relieve stress on the already overtaxed emergency department, and it will save the state money. MR. WALLACE said that Mat-Su Regional is working with the Mat-Su Health Foundation to reduce the overuse of the emergency department through approaches like the High Utilizer Mat-Su project, HUMS. HUMS targets patients that have used the emergency department at least five or more times in a year. Sixty-eight percent of these patients are Medicaid recipients. The majority, if not all, are suffering from a primary or secondary diagnosis related to behavioral health. His counterparts with the foundation have testified that they are saving money through this program. MR. WALLACE said the number of patients served is relatively small, but a small number of patients overutilizing the emergency department is too much. Mat-Su regional estimates that over a million dollars has been saved by reducing the number of ER visits related to this population. If there were more counselors to see behavioral health patients in the community, there would be savings to the state in Medicaid services. Mat-Su Reginal has had a counselor on staff for five years who works in a primary care clinic and has been waiting to see Medicaid patients. Sixty percent of the population that comes to the emergency department has a behavioral health diagnosis and would benefit from counseling. Without this important payment mechanism, she cannot see Medicaid patients. SB 134 adds an important piece to the continuum of care. 1:39:12 PM ELIZABETH RIPLEY, Chief Executive Officer, Mat-Su Health Foundation, Wasilla, Alaska, said SB 134 is crucial because it will help address an important health issue facing Mat-Su residents every day, mental health and substance use disorders. Licensed professional counselors are key behavioral health providers for these issues. Mat-Su residents said these are prominent issues in the last three community needs assessments conducted by the foundation. In the first one conducted in 2013, residents and professionals said that the top five health challenges are 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. These issues can all be helped by residents seeking counseling. SB 134 would expand the workforce that could provide that counseling to residents who have Medicaid. Mat-Su school nurses say they see waiting lists of four to eight months for children and families with Medicaid to see counselors. Mat-Su has skilled and trained licensed professional counselors in communities across Mat-Su that could see these children and others, but they aren't because they cannot be paid for their services. MS. RIPLEY said the prevalence of mental health and substance use disorders and crises is increasing in Mat-Su and statewide. The average annual growth rate for visits to the Mat-Su Regional emergency department by patients with behavioral health diagnoses grew 20 percent from 2015 to 2017 due to the opioid epidemic and lack of treatment access. As Dave Wallace just shared, the hospital now has an inpatient unit up and running. Previously, the hospital provided no behavioral health care treatment. Passage of SB 134 could bring the appropriate level of care to people who need help when a problem first starts instead of after it develops into a crisis. Mat-Su Regional is inundated by residents in crisis with behavioral health problems. In 2016, 3,443 residents were seen in the emergency department with a primary behavioral health diagnosis. Those 3,443 people had 8,400 visits, and 46 percent were on Medicaid. The top diagnoses were suicidal ideation and self-harm, alcohol- related disorders, delirium, dementia, and cognitive disorders. MS. RIPLEY said the costs for those visits was $43.8 million dollars in facility charges alone. This does not include the costs associated with law enforcement or emergency transportation. The average charge per visit was $5,216 and the average cost per patient was $12,725. Clearly, the emergency department is the least cost effective place to treat behavioral health problems. If intervention can be provided early with a system that provides more immediate access to a behavioral health provider for all residents, the state would save a ton in pain and suffering as well as money. An individual session for Medicaid is $75 while an average charge for a behavioral health visit to the emergency department is $4,370. Granted, an individual needs more than one visit to prevent a crisis, but even 10 visits would save $3,600. 1:44:22 PM MS. RIPLEY said that access, however, remains a problem. Very few primary care practices employ behavioral health providers. She knows of two primary care practices in Mat-Su, outside of federally qualified health centers, that employ a behavioral health clinician and there are many primary care practices. One reason there is so little integration of behavioral health into these practices is that those providers cannot bill Medicaid. Another reason was a shortage of psychiatrists to supervise behavioral health providers, but with the passage of SB 169 in 2018 that allows behavioral health care providers to be supervised by any physician, that barrier has been overcome. She thanked Senator Giessel for sponsoring SB 169. MS. RIPLEY said the next step is have more behavioral health providers who can bill Medicaid, thus making the inclusion of behavioral health services sustainable in physician offices. This bill, combined with SB 105, which allowed Medicaid billing for marriage and family counselors that passed last session, will do just that. A number of pieces are falling into place to provide more upstream intervention for behavioral health care. MS. RIPLEY noted that Mr. Wallace had referenced HUMS. The foundation started HUMS as a way to provide care coordination and access to community supports for high utilizers, defined as residents who had five or more visits in the emergency system in a year and who were, for whatever reason, unable to independently access consistent and appropriate care and support in the community. Mr. Wallace mentioned the dramatic cost savings of more than one million dollars a year. The foundation is entering the third year of the project. It also has alleviated significant trauma for not just the patients, but for the health care providers and family who often suffer trauma along with the patients. "The current director of the HUMS program, Dr. Quimby, told me that when he took over for Dr. Zink, who is now the chief medical officer for the state of Alaska, he took it over as a favor to her and he really didn't believe this was going to work. And he said, 'I'm a believer now. I'll talk about it to anybody.' In fact, he said, 'I like coming to work more now because the patients I'm serving actually get help,'" she said. MS. RIPLEY said that if people had access to care and support before their needs become a crisis and they came to the emergency department, there would be far less need for a program like HUMS. The project has had more than $2.168 million in cost savings. The project does have a third party evaluator who is tracking progress and the need for course correction. In 2018, $347,288 in emergency room charges was saved with the top three utilizers alone. That same year seven patients did not use the emergency department at all after enrollment in HUMS. The age of the superutilizers ranges from 16 to 82. Seventy-two percent had Medicaid coverage. Besides the data and cost savings, she wanted to share the human piece of the impact of HUMS. Dr. Quimby told this story at the annual meeting of the health foundation of a young adult who had had 17 visits to the emergency department in the previous year before enrolling in HUMS. He was not managing his diabetes and had a long history of substance use disorder. Most of his emergency visits led to inpatient admission in the intensive care unit. The client had a long history of IV drug use, was noncompliant with primary care appointments, and his outlook was poor. The hospital staff believed this young man was going to die. HUMS was told the client had little to no interest in improving his situation. The HUMS team built a rapport with the client and he did want to change. This client is now sober and his diabetes managed. He is working full time and has a great relationship with his primary care provider. He has years to live to make a positive difference. 1:50:47 PM JARED KOSIN, President and Chief Executive Officer, Alaska State Hospital and Nursing Home Association, Anchorage, Alaska, said this bill is good policy. People talk constantly about how to lower the cost of care. This is how to do it, invest in the continuum of care at the community level, where it is a lot cheaper, and reserve those higher level, more expensive settings for people who actually need it. He was talking to a CEO of a facility yesterday, and the CEO said this bill is a test and if this bill fails, he would know whether anyone cares about the behavioral health crisis. This is a very practical step forward. 1:51:46 PM CHAIR WILSON solicited a motion. 1:52:01 PM SENATOR VON IMHOF moved SB 134, version 31-LS1261\A, from committee with individual recommendations and attached fiscal notes. 1:52:17 PM There being no objection, the motion passed.