02/19/2002 03:12 PM House HES
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ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES
STANDING COMMITTEE
February 19, 2002
3:12 p.m.
MEMBERS PRESENT
Representative Fred Dyson, Chair
Representative Peggy Wilson, Vice Chair
Representative John Coghill
Representative Gary Stevens
Representative Sharon Cissna
Representative Reggie Joule
MEMBERS ABSENT
Representative Vic Kohring
COMMITTEE CALENDAR
CS FOR SENATE CONCURRENT RESOLUTION NO. 21(HES)
Supporting the development of adequate in-state treatment
capacity for severely disturbed children.
- MOVED CSSCR 21(HES) OUT OF COMMITTEE
HOUSE BILL NO. 309
"An Act relating to the Interstate Compact on Placement of
Children."
- BILL HEARING POSTPONED TO 2/21/02
PREVIOUS ACTION
BILL: SCR 21
SHORT TITLE:TREATMENT FOR DISTURBED CHILDREN
SPONSOR(S): HEALTH, EDUCATION & SOCIAL SERVICES
Jrn-Date Jrn-Page Action
01/18/02 1978 (S) READ THE FIRST TIME -
REFERRALS
01/18/02 1978 (S) HES
02/04/02 (S) HES AT 1:30 PM BUTROVICH 205
02/04/02 (S) Moved CS(HES) Out of
Committee
02/04/02 (S) MINUTE(HES)
02/06/02 2122 (S) HES RPT CS 5DP SAME TITLE
02/06/02 2122 (S) DP: GREEN, LEMAN, WILKEN,
WARD, DAVIS
02/06/02 2122 (S) FN1: ZERO(S.HES)
02/11/02 2155 (S) RULES TO CALENDAR 2/11/02
02/11/02 2158 (S) READ THE SECOND TIME
02/11/02 2158 (S) HES CS ADOPTED UNAN CONSENT
02/11/02 2158 (S) PASSED Y20 N-
02/11/02 2160 (S) TRANSMITTED TO (H)
02/11/02 2160 (S) VERSION: CSSCR 21(HES)
02/11/02 (S) RLS AT 10:30 AM FAHRENKAMP
203
02/11/02 (S) MINUTE(RLS)
02/13/02 2219 (H) READ THE FIRST TIME -
REFERRALS
02/13/02 2219 (H) HES
02/19/02 (H) HES AT 3:00 PM CAPITOL 106
WITNESS REGISTER
JERRY BURNETT, Staff
to Senator Lyda Green
Alaska State Legislature
Capitol Building, Room 125
Juneau, Alaska 99801
POSITION STATEMENT: Presented SCR 21 on behalf of the
resolution's sponsor, the Senate Health, Education and Social
Services Standing Committee.
RUSS WEBB, Deputy Commissioner
Department of Health and Social Services
P.O. Box 110601
Juneau, Alaska 99811-0601
POSITION STATEMENT: Supplied information regarding the types and
availability of mental health services in the state.
KATHY CRONIN, Chief Executive Officer
North Star Behavioral Health System
4500 Business Park Boulevard, Building C, Suite 10
Anchorage, Alaska 99503
POSITION STATEMENT: Testified in favor of SCR 21.
JIM MURPHY, Executive Director
Good Samaritan Counseling Centers
4105 Tudor Center Drive, Suite B-4
Anchorage, Alaska 99508
POSITION STATEMENT: Testified in favor of SCR 21.
ACTION NARRATIVE
TAPE 02-12, SIDE A
Number 0001
CHAIR FRED DYSON called the House Health, Education and Social
Services Standing Committee meeting to order at 3:12 p.m.
Representatives Dyson, Coghill, Stevens, and Cissna were present
at the call to order. Representatives Wilson and Joule arrived
as the meeting was in progress. [For minutes on the overview
presentations by Alaskans for Tobacco-Free Kids and the Alaska
Native Health Board, see the 4:00 p.m. minutes for this date.]
SCR 21-TREATMENT FOR DISTURBED CHILDREN
Number 0045
CHAIR DYSON announced that the committee would hear the CS FOR
SENATE CONCURRENT RESOLUTION NO. 21(HES), Supporting the
development of adequate in-state treatment capacity for severely
disturbed children.
Number 0101
JERRY BURNETT, Staff to Senator Lyda Green, Alaska State
Legislature, presented SCR 21 on behalf of Senator Green, chair
of the Senate Health, Education and Social Services Standing
Committee, the resolution's sponsor.
MR. BURNETT explained that over 300 severely emotionally
disturbed Alaskan children are currently receiving treatment in
residential facilities in other states. Families are being
separated, sometimes for years. The flexibility to provide an
appropriate mix of treatment between residential and community-
based care is lost when children must be sent to out of state
for treatment. Millions of state dollars and hundreds of jobs
are being exported each year.
MR. BURNETT continued to read from the sponsor statement which
states:
Alaska currently lacks the necessary facilities to
provide the full continuum of community-based and
residential care in Alaska for the treatment of
severely emotionally disturbed children. The largest
gap in this continuum is the lack of residential
treatment beds that can provide the necessary level of
care in Alaska. SCR 21 asks the Department of Health
and Social Services to work with the Alaska Mental
Health Board, the Alaska Mental Health Trust Authority
and other interested parties to strengthen this
continuum of services and to establish a priority for
the development of sufficient in-state residential
care to serve emotionally disturbed children who would
otherwise be placed in out-of-state facilities.
MR. BURNETT referenced materials in the bill packet outlining
costs of out-of-state treatment and the Report to the Alaska
Mental Health Board; Children and Youth Placed in Residential
Psychiatric Treatment Centers Out of State.
Number 0240
REPRESENTATIVE WILSON asked whether most states have their own
in-state residential services, and if Alaska is the only state
without these services.
MR. BURNETT replied that Alaska has 108 residential beds
available to emotionally disturbed [youth]; there are over 300
children out of state, however.
Number 0288
CHAIR DYSON sought confirmation that about $17 million is
supporting these children in out-of-state programs.
MR. BURNETT stated that the $17 million figure does not include
private insurance payments, travel expenses, or educational
services provided by the state. Consequently, there are "a few
more millions of dollars" being spent to treat Alaskan children
out of state, he added.
Number 0325
CHAIR DYSON drew attention to information from department
personnel that a child is usually accompanied by one person
while traveling out of state.
Number 0343
REPRESENTATIVE CISSNA asked about the amount the state pays for
out-of-state tuition for children in institutions. Do school
districts pay for educational costs in this case?
MR. BURNETT responded that he was unable to answer that
question.
Number 0445
REPRESENTATIVE STEVENS inquired whether the Alaska Native health
care system has beds for residential treatment.
RUSS WEBB, Deputy Commissioner, Department of Health and Social
Services, replied that he didn't believe this type of service is
generally covered by the insurance for Alaska Natives. There
are no specific facilities operated by Native organizations that
provide Residential Psychiatric Treatment Center (RPTC)
services, except for the one developed by the Southcentral
foundation. Some Native organizations operate facilities as
grantees of the department, he said, but these organizations do
not operate separate facilities funded through Native health
services.
Number 0558
REPRESENTATIVE CISSNA reiterated her question about educational
costs for children in residential programs out of state; she
requested specification about children in state custody versus
those not in state custody.
MR. WEBB answered that several years ago a special appropriation
was made to cover educational costs for children in state
custody in out-of-state placements; this prevented these costs
from being borne by school districts. School districts pay for
educational costs for students on an Individual Education Plan
(IEP). When this plan and the district agree that an out-of-
state placement is necessary for educational reasons, the
district will bear these costs. He noted that this is not
always the case; many of these children's placements are not for
educational purposes, and many don't have IEPs. He expressed
his belief that this applies to children both in and out of
state custody.
Number 0660
REPRESENTATIVE COGHILL asked about the types of services being
provided out of state.
MR. WEBB answered that the RPTC level of care is just below the
level of care provided by a hospital. Most children in out-of-
state placements are in this level of care. Alaska has many
more residential care beds than one hundred; he estimated Alaska
pays for close to 250 beds in four levels of care. Beyond these
four levels is RPTC care and then hospital care. He offered
that the reason so many children are leaving the state is the
lack of RPTC beds available in-state. Some children are in a
psychiatric hospital and upon discharge require a lower level of
care; this lower level of care is not available to them in-
state, so they must go to an out-of-state facility. He stated
that sometimes a bed is available to a child, but that the bed
is deemed an inappropriate placement for that child by the
treatment provider. Some specialty types of services are
unavailable in Alaska to treat some special populations of
children; he offered that these services would be unavailable
for the foreseeable future. He stressed that the key level of
care is the RPTC level; lack of beds at this level is the cause
of most children's leaving the state for treatment.
Number 0814
REPRESENTATIVE COGHILL asked if the RPTC level included drug and
alcohol rehabilitation.
MR. WEBB replied that RPTC treatment includes a variety of care,
but it is primarily mental health care. He noted that some
children have co-occurring disorders, and these disorders are
treated simultaneously. He stated the RPTC care is not
primarily a substance-abuse treatment program.
REPRESENTATIVE COGHILL asked if Denali KidCare covered a large
percentage of these costs.
MR. WEBB replied, "Denali KidCare picks up a good portion of it.
Medicaid picks up a good portion of the care for these kids at
the RPTC level."
Number 0861
REPRESENTATIVE COGHILL said, "Though we're talking about family
involvement, ... isn't it primarily for children who are out of
home? If you send somebody to a residential psychiatric
treatment center, is that a family continuum?"
MR. WEBB answered that RPTC care is an out-of-home type of care.
Many of these placements are the result of a family decision -
the child has a severe mental health problem that needs
treatment. He said that most of these children have been
treated in a psychiatric hospital and they are going to a RPTC
as part of a discharge plan from the psychiatric hospital. This
RPTC placement is part of the continuum of care; these children
will eventually go home to a community-based care program.
Number 0932
REPRESENTATIVE COGHILL referenced phone calls he has received
indicating that some families are having their children leave
home to enable them to be qualified for additional care funding
beyond the family's insurance. The rise in costs might be
attributed to this. He said, "How do we police that?"
MR. WEBB replied that he is not a Medicaid expert. He noted
that children who come into state custody become Medicaid-
eligible, because they are out of their family's custody. He
offered his opinion that a family's resources would be
considered for a child's Medicaid eligibility in a case where
that child remains in family custody. He said in order for a
child to be covered under [Medicaid], he/she must either be in
state custody or already qualify before receiving treatment;
children cannot become eligible by simply receiving treatment.
Number 1025
REPRESENTATIVE CISSNA noted that as a result of her experience
with the Alaska Youth Initiative (AYI), she thought the program
"was doing incredible stuff keeping kids in-state." She asked
if the program was being cut back.
MR. WEBB replied that the AYI program had neither been cut nor
expanded. He noted that the program had been adjusted to make
it more efficient for providers and others. The AYI program
encounters workforce issues due to the funding mechanism; grant
dollars are provided for treatment for individual children. A
budget is developed for each child. He said the AYI program
does not have separate money to maintain staffing; the program
"staffs up" to meet the individual needs of the child. This
presents a problem for the provider in [recruiting and
retaining] staff. He furnished that some children could be
served by AYI, but they cannot wait the six to eight weeks
necessary to ready the program. The child cannot stay in an
acute-care hospital for this time.
Number 1159
REPRESENTATIVE CISSNA pointed out that she has worked with
children in their family's custody where the child's psychiatric
condition required placement in an institution. She offered
that this situation almost necessitated the [family's
relinquishing custody to the state in order for Medicaid to
cover expenses], because the family's insurance would not have
covered the needed services. She likened this to people on
Medicare who "spend down their assets" to enable them to remain
in a home [that provides necessary care]. She said, "I don't
know if that's taking advantage of the system, or if it's just
staying alive."
MR. WEBB replied, "It's a continuum-of-care issue and
availability-of-services [issue]." He acknowledged that he has
heard families talk about their inability to provide necessary
services to their children. There have been families that have
said they must give up custody of their children to enable them
to get the services they need as a ward of the state.
Number 1256
REPRESENTATIVE STEVENS stated that of these 250 or 300 children
receiving treatment out of state, some have such serious
problems that it is unlikely they would be treated in Alaska.
He asked for the number of children out of state that would fall
into this category.
MR. WEBB explained that the 300 figure represents the number of
children receiving out-of-state treatment at any given point in
time. Of this 300 children, 250 are not in state custody and 50
are in state custody. He said that some very specialized types
of care are offered in facilities that serve children from all
over the country; it is unlikely that Alaska would develop this
type of facility to serve 2 to 4 children in the state. Most of
these [300] kids, he noted, could be served in the state if the
facilities were available.
Number 1340
REPRESENTATIVE STEVENS estimated that no more than 5 percent
would require this highly specialized care.
MR. WEBB responded that these figures were a "wild guess," but
the number is small.
Number 1360
REPRESENTATIVE COGHILL stated his understanding that Alaska does
not possess the "critical mass" to provide these specialized
services. He asked about the quality of services currently
being provided.
MR. WEBB responded that Alaska does have a good quality of care.
Some providers do not believe they are capable of caring for
certain children due to the reimbursement they receive, the
facility or staffing they possess, or other reasons. Those are
the children that go out of state, he said. He listed some
reasons that children go out of state for treatment: timely
care is unavailable; care is available, but providers don't
admit children they don't believe they are capable of treating;
and a type of care is unavailable.
Number 1427
REPRESENTATIVE WILSON asked for clarification, saying, "Of all
the children ... that are out of state, and they are all Alaska
residents that need care, 50 of those are in state custody. But
the rest of them are still needing care and they can't get it
inside the state, right?"
MR. WEBB agreed with a nod.
Number 1459
REPRESENTATIVE CISSNA stated that one of the reasons these
children are going out of state for treatment is because of a
public policy issue - the amount of funding made available for
this type of treatment.
MR. WEBB said, "That's a possibility. I'm not sure we
completely know the answers to all of those questions." He
noted that this is not a new issue to the department. It may
require money in the future, but now the department is assessing
the reasons children are going out of state: what their needs
are, what the impediments are to providing this service in-
state, and what actions are required to remove those
impediments. The department is working with providers, parents,
and advocates such as the mental health board and trust; they
have also discussed this with Representative Dyson. The
department is seeking answers to those questions, and it will
return to the legislature with answers, he concluded.
Number 1534
MR. BURNETT mentioned materials in the packet showing that costs
for the same level of care are less in Alaska than out of state,
because the treatment is for a shorter period.
CHAIR DYSON asked what the sponsor believes SCR 21 will
accomplish.
MR. BURNETT replied that SCR 21 gives the department an
assurance of the legislature's focus on this issue.
Number 1574
KATHY CRONIN, Chief Executive Officer, North Star Behavioral
Health Systems, said:
As you've already heard today, there are 300-plus
children in residential psychiatric treatment centers
in the Lower 48. This has ... a devastating, long-
term impact on these children, their families, and
ultimately on our state. Mental health treatment
should be provided closer to home. Coordination
between the residential provider and the outpatient
follow-up provider that will continue to see the
patient after discharge is essential. Most
importantly, treatment should involve the family.
MS. CRONIN continued:
Family treatment is a critical element of any child's
mental health care. Treatment in the local community
is good for the child, it's good for their family, and
it increases the chances of long-term success. The
legislature's support to bring Alaska children home
(indisc.-cough) encourage providers to expand
residential psychiatric services within our state. As
many as 450-600 jobs could be created by bringing
these children home. Valuable Medicaid dollars would
stay in the state instead of being sent to providers
in the Lower 48. The current state budget for
providers in the Lower 48 is in excess of $17 million.
The budget for Alaskan providers is less than 7
million. As you know, the Senate unanimously passed
this resolution on February 11. Many Senate members
provided moving testimony on our need as a state to
support our children. I would urge the House HES
Committee to support this resolution as well.
Number 1660
REPRESENTATIVE STEVENS asked about the size of communities able
to provide this kind of care.
MS. CRONIN replied that this treatment should be provided as
close to home as possible; it can be done in communities smaller
than Anchorage. She offered that the Palmer-Wasilla area, Kenai
Peninsula, and Southeast Alaska are obvious places to add
residential treatment services. An effective facility can have
as few as nine beds, she stated.
Number 1710
JIM MURPHY, Executive Director, Good Samaritan Counseling
Centers, testified via teleconference. He noted that his clinic
is the state's largest outpatient mental health clinic and
serves several hundred clients each week. He said:
We are consistently confronted with the clinical
situation where a child needs some kind of residential
treatment, but in order to provide that, oftentimes,
we are in a situation where our providers are sending
children out of state away from their families, ...
communities, ... schools, ... friends, ... [and]
providers here in Anchorage or in the Valley. And I
strongly encourage our state to work to bring our
children home. I think clinically, it's in the best
interests of our children; ethically, I think it's
absurd that we are sending these children away from
our state in order to receive treatment. As a
businessperson, of course, the economics that Ms.
Cronin has already mentioned to you is certainly a
consideration where we are exporting hundreds of jobs
outside of Alaska.
Number 1770
CHAIR DYSON asked Mr. Murphy if Alaska could, relatively
quickly, garner the expertise to staff in-state facilities.
MR. MURPHY replied that the Good Samaritan Counseling Center has
been working with the North Star Behavioral Health System to
develop facilities in the Palmer and Wasilla area. He offered
his belief that the necessary workforce could be acquired to
provide care.
Number 1806
REPRESENTATIVE COGHILL inquired which providers require children
to leave the state, Medicaid providers or insurance companies.
MR. MURPHY responded that by "providers" he meant doctors,
psychologists, or clinical providers working with a child. He
acknowledged that his clinic is often confronted with a child
needing more intensive treatment than can be provided on an
outpatient basis. Sometimes there is not a need for acute care,
but the child is placed there in spite of a residential
facility's appropriateness. When children who are placed out of
state begin transitioning back into Alaska, he noted, it was not
unusual for his agency to be contacted by an out-of-state
facility wanting to discharge a child to his agency for
outpatient services. He offered that sometimes this child has
been removed from his/her family for 12-18 months or more. This
situation is much different from the one in which a child is in
a residential treatment facility in Alaska. In this latter
situation, the coordination of treatment between agencies is
ongoing to manage care and work with the child's family. He
stated that from a care provider's perspective, it is in the
best interest of the child to work with local providers.
Number 1944
NANCY WELLER, Unit Manager, State, Federal & Tribal Relations,
Division of Medical Assistance, Department of Health & Social
Services, pointed out that for a person in an institutional
placement, whether it is in a hospital or a long-term care
facility, the financial eligibility rules change after 30 days
under federal Medicaid law. In that situation, the person is
financially responsible only for himself or herself. After 30
days, parents' income is not counted for Medicaid eligibility;
this does not affect the health insurance status of the child,
she stated. The family is responsible for the first 30 days'
costs, which can be considerable.
REPRESENTATIVE STEVENS cautioned that it is just as bad for a
child to be sent from Dutch Harbor to Anchorage for treatment,
for example, as to be sent to Seattle. If these treatment
facilities can be established to serve as few as nine children,
he encourages the department to put facilities in the
communities where these children live. He indicated his
interest in seeing demographics [pertaining to the incidence of
children requiring residential treatment in rural and urban
areas].
Number 2040
MR. WEBB emphasized that the primary focus is the RPTC level of
care. He pointed out that the $17 million out-of-state costs
versus the $7 million in-state costs are Medicaid costs for that
level of care and may include acute care. The department grants
funds for other levels of care for children in state custody, he
said. Those facilities at lower levels are spread throughout
the state and are in many smaller communities such as Nome,
Bethel, and Kodiak. The RPTC level of care in Alaska is
currently available only in Anchorage, he said. Other levels
are available in various parts of the state. He furnished that
the department's residential care budget is about $16 million.
Number 2111
REPRESENTATIVE JOULE expressed his hope that the legislature
will be as cooperative when the department is through with its
assessment as it is now.
Number 2138
REPRESENTATIVE CISSNA pointed out that it is the continuum of
programs that is missing. Different parts of the continuum are
being provided. She stated that Anchorage has three schools
that are producing graduate-level clinicians every year. Those
graduates are seeking jobs [outside of their field], but would
like to work in the field. She emphasized, "We don't have the
continuum of care." The Alaska Youth Initiative has psychiatric
programs. It takes those kids, who are sometimes doing poorly
under psychiatric care, into the community and uses "wraparound"
services. She said, "As a home-based therapist, I was having
mom and dad sometimes coming and helping me with the kids when
we were having problems with them. Being able to use that
family piece ... was wonderfully effective." She stated that
kids who had been experiencing intensive problems were doing
well as a result of this type of service. She offered that
putting those types of pieces in place and perfecting them would
save the state money.
MR. WEBB stated his fundamental belief that a balanced continuum
of care is necessary to ensure that children receive the correct
services and amounts of services. He furnished the department's
objective of creating a "master plan" to look at the continuum
of care. Advocates and families that have spoken with him are
opposed to the department's focus on one type of care, he
reported. The RPTC level of care is provided by private
entities, he indicated. The state purchases services from these
private providers. He noted that one of the reasons that
children are in out-of-state placements in because these private
providers have not developed the facilities in the state. He
said that most providers of lower levels of residential care are
nonprofit providers that have few resources and are largely
dependent on charitable contributions and department grants.
Number 2266
REPRESENTATIVE WILSON moved to report CSSCR 21(HES) out of
committee with individual recommendations and the accompanying
fiscal notes. There being no objection, CSSCR 21(HES) was
reported out of the House Health, Education and Social Services
Standing Committee.
CHAIR DYSON called an at-ease at 3:55 p.m. in order to prepare
for overview presentations by Alaskans for Tobacco-Free Kids and
the Alaska Native Health Board. [For minutes on the overview
presentations, see the 4:00 p.m. minutes for this date.]
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