Legislature(2017 - 2018)CAPITOL 106

04/03/2018 03:00 PM HEALTH & SOCIAL SERVICES

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Audio Topic
03:05:44 PM Start
03:07:24 PM SB169
03:56:59 PM Confirmation Hearing(s)
04:00:32 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Confirmation Hearings: State Medical Board TELECONFERENCED
+ SB 169 MEDICAID: BEHAVIORAL HEALTH COVERAGE TELECONFERENCED
Moved CSSB 169(RLS) Out of Committee
-- Testimony <Invited/Public> --
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         April 3, 2018                                                                                          
                           3:05 p.m.                                                                                            
                                                                                                                                
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Ivy Spohnholz, Chair                                                                                             
Representative Tiffany Zulkosky, Vice Chair                                                                                     
Representative Sam Kito                                                                                                         
Representative Geran Tarr                                                                                                       
Representative David Eastman                                                                                                    
Representative Jennifer Johnston                                                                                                
Representative Colleen Sullivan-Leonard                                                                                         
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Matt Claman (alternate)                                                                                          
Representative Dan Saddler (alternate)                                                                                          
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
CS FOR SENATE BILL NO. 169(RLS)                                                                                                 
"An Act relating to the definition of 'direct supervision' for                                                                  
purposes of medical assistance coverage of behavioral health                                                                    
clinic services."                                                                                                               
                                                                                                                                
     - MOVED CSSB 169(RLS) OUT OF COMMITTEE                                                                                     
                                                                                                                                
CONFIRMATION HEARING(S)                                                                                                         
                                                                                                                                
State Medical Board                                                                                                           
                                                                                                                                
     Dr. Catherine Hyndman - Dillingham                                                                                         
                                                                                                                                
     - CONFIRMATION(S) ADVANCED                                                                                                 
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: SB 169                                                                                                                  
SHORT TITLE: MEDICAID: BEHAVIORAL HEALTH COVERAGE                                                                               
SPONSOR(s): SENATOR(s) GIESSEL                                                                                                  
                                                                                                                                
01/31/18       (S)       READ THE FIRST TIME - REFERRALS                                                                        
01/31/18       (S)       HSS                                                                                                    
03/05/18       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
03/05/18       (S)       Heard & Held                                                                                           
03/05/18       (S)       MINUTE(HSS)                                                                                            
03/07/18       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
03/07/18       (S)       Moved CSSB 169(HSS) Out of Committee                                                                   
03/07/18       (S)       MINUTE(HSS)                                                                                            
03/12/18       (S)       HSS RPT CS  5DP   NEW TITLE                                                                            
03/12/18       (S)       DP:    WILSON,   BEGICH,    VON   IMHOF,                                                               
                       MICCICHE, GIESSEL                                                                                        
03/21/18       (S)       RULES WAIVED PUBLIC HEARING NOTICE,RULE                                                                
                         23                                                                                                     
03/22/18       (S)       RLS AT 8:15 AM FAHRENKAMP 203                                                                          
03/22/18       (S)       Moved CSSB 169(RLS) Out of Committee                                                                   
03/22/18       (S)       MINUTE(RLS)                                                                                            
03/26/18       (S)       RLS RPT CS 5DP   NEW TITLE                                                                             
03/26/18       (S)       DP:     MEYER,    MICCICHE,     GARDNER,                                                               
                        MACKINNON, KELLY                                                                                        
03/26/18       (S)       TRANSMITTED TO (H)                                                                                     
03/26/18       (S)       VERSION: CSSB 169(RLS)                                                                                 
03/29/18       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/29/18       (H)       HSS                                                                                                    
04/03/18       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
SENATOR CATHY GIESSEL                                                                                                           
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Presented SB 169 as the sponsor of the                                                                   
bill.                                                                                                                           
                                                                                                                                
TOM CHARD, Executive Director                                                                                                   
Alaska Behavioral Health Association                                                                                            
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of SB 169.                                                                          
                                                                                                                                
KEN HELANDER, Advocacy Director                                                                                                 
AARP Alaska                                                                                                                     
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of SB 169.                                                                          
                                                                                                                                
ROBIN MINARD, Director                                                                                                          
Public Affairs                                                                                                                  
Matanuska-Susitna Health Foundation                                                                                             
Wasilla, Alaska                                                                                                                 
POSITION STATEMENT:  Testified in support of SB 169.                                                                          
                                                                                                                                
PAUL TOPOL, MD                                                                                                                  
Legislative Representative                                                                                                      
Alaska Psychiatric Association                                                                                                  
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified during discussion of SB 169.                                                                   
                                                                                                                                
RICK CALCOTE, Chief of Risk and Research Management                                                                             
Policy and Planning Section                                                                                                     
Division of Behavioral Health                                                                                                   
Department of Health and Social Services                                                                                        
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Answered questions during discussion of SB                                                               
169.                                                                                                                            
                                                                                                                                
RANDALL BURNS, Director                                                                                                         
Central Office                                                                                                                  
Division of Behavioral Health                                                                                                   
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified during discussion of SB 169.                                                                   
                                                                                                                                
DENISE DANIELLO, Executive Director                                                                                             
Alaska Commission on Aging                                                                                                      
Division of Senior and Disabilities Services                                                                                    
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:  Testified in support of SB 169.                                                                          
                                                                                                                                
KEELEY OLSON, Executive Director                                                                                                
Standing Together Against Rape (STAR)                                                                                           
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Testified in support of SB 169.                                                                          
                                                                                                                                
CATHERINE HYNDMAN, MD                                                                                                           
Appointee                                                                                                                       
State Medical Board                                                                                                             
Dillingham, Alaska                                                                                                              
POSITION STATEMENT:  Answered questions during the confirmation                                                               
hearing for the State Medical Board.                                                                                            
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
3:05:44 PM                                                                                                                    
                                                                                                                                
CHAIR IVY SPOHNHOLZ  called the House Health  and Social Services                                                             
Standing   Committee    meeting   to    order   at    3:05   p.m.                                                               
Representatives  Spohnholz,  Johnston,  Eastman,  and  Kito  were                                                               
present at  the call to  order.  Representatives  Zulkosky, Tarr,                                                               
and Sullivan-Leonard arrived as the meeting was in progress.                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ announced that the  confirmation hearing would be                                                               
heard later in the meeting.                                                                                                     
                                                                                                                                
          SB 169-MEDICAID: BEHAVIORAL HEALTH COVERAGE                                                                       
                                                                                                                              
                                                                                                                                
3:07:24 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ announced that the  first order of business would                                                               
be  CS FOR  SENATE BILL  NO. 169(RLS),  "An Act  relating to  the                                                               
definition  of  'direct  supervision'  for  purposes  of  medical                                                               
assistance coverage of behavioral health clinic services."                                                                      
                                                                                                                                
3:08:08 PM                                                                                                                    
                                                                                                                                
SENATOR CATHY GIESSEL, Alaska State  Legislature, stated that the                                                               
proposed  bill  improved  access   to  behavioral  health.    She                                                               
presented  a  PowerPoint,  "Access  to  Behavioral  Health,"  and                                                               
shared  slide 2,  "Defining  Behavioral Health."    She read  the                                                               
federal definition for behavioral  health:  "Mental and emotional                                                               
well-being, and  actions that affect  wellness."  She  added that                                                               
this  encompassed   mental  health  promotion,   prevention,  and                                                               
recovery.  She declared that there  was an urgent need in Alaska,                                                               
and pointed to slide 3, "The  URGENT Problem."  She reported that                                                               
this  data  had  been  gathered   by  the  U.S.  Arctic  Research                                                               
Commission.    She  emphasized   that  Alaska  lacked  sufficient                                                               
behavioral health care providers,  slide 4, "The URGENT Problem,"                                                               
and referenced the  Medicaid Reform bill, passed  in 2015, Senate                                                               
Bill  74.   She relayed  that  there had  been a  request of  the                                                               
Division  of  Behavioral Health  to  address  AAC 135.030,  which                                                               
limited the  providers of behavioral health  services to Medicaid                                                               
beneficiaries.   In  2017, after  review,  the Division  reported                                                               
that  a  statute change  was  necessary,  as the  Medicaid  rules                                                               
stated that behavioral health services  could only be provided in                                                               
a  mental health  physician  clinic  and must  be  provided by  a                                                               
psychiatrist,  or under  their direct  supervision.   This  meant                                                               
that  the psychiatrist  had to  be on  the premises  at least  30                                                               
percent  of the  time the  clinic was  open.   She declared  that                                                               
"this  is  an  exceedingly  narrow door...  for  services  to  be                                                               
provided."  She pointed out  that, consequently, very few clinics                                                               
were able  to accept Medicaid billed  behavioral health services,                                                               
and the  waiting lists for services  were up to 2.5  years, slide                                                               
6, "Resulting  BH Access Crisis."   She pointed out that  it then                                                               
became  necessary  to use  the  hospital  emergency rooms,  often                                                               
holding patients for days, which  was the most expensive service.                                                               
She  declared  that this  was  an  inappropriate and  ineffective                                                               
approach  to the  necessary care.    She shared  that, since  the                                                               
passage of  Senate Bill  74, there had  not been  any improvement                                                               
for  access, slides  7 -  8, "Efforts  by Division  of BH."   She                                                               
acknowledged that  the Division of Behavioral  Health had applied                                                               
for  an  1115 behavioral  health  waiver,  although it  could  be                                                               
another two years prior to its  completion even as the numbers of                                                               
people  needing  these services  was  increasing.   She  reported                                                               
that, in  FY17, Medicaid Expansion  had added 5,000  more adults,                                                               
pointing  out that  Senate Bill  91 [Passed  in the  Twenty-Ninth                                                               
Alaska State  Legislature] had a provision  to provide behavioral                                                               
health services  to help  rehabilitate parolees,  slides 9  - 10,                                                               
"Alaska NEEDS."   She spoke  about the four  detention facilities                                                               
for  the most  serious  and chronic  offenders,  "kids that  need                                                               
behavioral health  services," slide 11, "Juvenile  Justice."  She                                                               
reported that, as  more and more children were  being reported as                                                               
abused, with  Adverse Childhood Experiences  (ACEs) adding  up to                                                               
impact them  for their lifetime, behavioral  health services were                                                               
needed but limited, slide 12, "Office of Children's Services."                                                                  
                                                                                                                                
3:13:25 PM                                                                                                                    
                                                                                                                                
SENATOR GIESSEL declared that currently  the clinics had to limit                                                               
their clientele to  the most serious cases, or  those leaving the                                                               
correctional system, slide 13, "What's  happening?"  She reported                                                               
that  there were  only 85  licensed psychiatrists  in the  state,                                                               
although it  was unclear  how many  were still  practicing, slide                                                               
14,  "Alaska psychiatrists."   She  listed  the other  behavioral                                                               
health  practitioners, comprising  almost 2,000  clinicians, that                                                               
could  provide services  if they  had  the required  supervision,                                                               
slide 15,  "Alaska has variety  of Clinicians."  She  stated that                                                               
SB 169  would change this  rule for necessary supervision  to any                                                               
physician  either  in person  or  by  communication device,  with                                                               
direct supervision still required  for MFT, LCSW, counselors, and                                                               
psychologists,  slide  16, "SB  169  (version  U) does..."    She                                                               
explained that the definition for  direct supervision was updated                                                               
to include  either in  person or  by communication  device, slide                                                               
17, "SB  169 does..."   She directed attention  to page 1  of the                                                               
proposed  bill, which  listed the  criteria for  supervision, and                                                               
added that  the effective date  would be 90 days  after signature                                                               
by the governor.                                                                                                                
                                                                                                                                
3:15:11 PM                                                                                                                    
                                                                                                                                
SENATOR GIESSEL declared that the  behavioral health access issue                                                               
could  be addressed  now,  and telehealth  could  be expanded  to                                                               
effectively serve  rural areas, slide  18, "SB 169  Opens Doors."                                                               
She  shared the  list  of organizations  supporting the  proposed                                                               
bill, slide 19, "Support."                                                                                                      
                                                                                                                                
3:15:36 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE    SULLIVAN-LEONARD    shared   a    concern    by                                                               
psychiatrists  for   the  oversight  of  patients   and  directed                                                               
attention to slide 15.   She asked if other medical professionals                                                               
would be  considered as  "re-upping prescriptions  for behavioral                                                               
medications as  opposed to long  term oversight and care  for the                                                               
behavioral health itself."                                                                                                      
                                                                                                                                
SENATOR  GIESSEL,  in  response,  said that  she  understood  the                                                               
concern.  She reported that  although physicians were educated in                                                               
behavioral  health treatment,  this  was not  as  expansive as  a                                                               
psychiatrist.   She  said that  those other  providers would  not                                                               
necessarily  advocate for  prescriptions, as  they could  provide                                                               
counseling,  particularly for  children.   She reported  that, as                                                               
children  were  probably being  over  medicated  these days,  the                                                               
behavioral health  practitioners listed  on slide 15  would focus                                                               
on the  counseling aspect.   She acknowledged  that psychiatrists                                                               
would  still  have  a  role  and would  still  be  involved  with                                                               
services.                                                                                                                       
                                                                                                                                
3:17:41 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE ZULKOSKY  pointed out that  there had also  been a                                                               
letter of  support from  the Alaska  Native Health  board, adding                                                               
that  tribal  health  was  often   the  most  comprehensive  care                                                               
accessed in the rural communities.                                                                                              
                                                                                                                                
3:18:49 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE EASTMAN asked how  this proposed bill would impact                                                               
the relationship between psychiatrists and psychologists.                                                                       
                                                                                                                                
SENATOR GIESSEL  said that  she would not  make a  prediction for                                                               
the collaboration between clinicians,  although she expressed her                                                               
hope  that appropriate  collaboration would  continue to  provide                                                               
the best health care for Alaskans.                                                                                              
                                                                                                                                
3:19:42 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ opened invited testimony on SB 169.                                                                             
                                                                                                                                
3:19:54 PM                                                                                                                    
                                                                                                                                
TOM   CHARD,  Executive   Director,   Alaska  Behavioral   Health                                                               
Association,   explained  that   the  Alaska   Behavioral  Health                                                               
Association was  a trade group of  about 65-member organizations,                                                               
representing  mental  health  and   drug  and  alcohol  treatment                                                               
providers  in  Alaska.    He  referenced  the  written  testimony                                                               
submitted earlier, which detailed many  of these same points.  He                                                               
shared   the  way   the  association   evaluated  proposals   and                                                               
legislation,  noting  that  they   reviewed  cost,  quality,  and                                                               
access.   He  said  that  the proposed  bill  would increase  and                                                               
improve   access  to   behavioral   health  treatment   services,                                                               
emphasizing that more behavioral  health treatment was necessary.                                                               
He declared support for the proposed  bill, adding that it was "a                                                               
step  in  the  right  direction."   He  pointed  to  the  written                                                               
comments which  detailed some cost  avoidance opportunities.   He                                                               
offered belief  that the actual  quality of care for  both direct                                                               
service  and supervision  would depend  on the  license, so  that                                                               
strict  enforcement of  licensing requirements  from the  medical                                                               
board  would  provide  adequate   supervision  and  assurance  of                                                               
quality care.                                                                                                                   
                                                                                                                                
3:22:35 PM                                                                                                                    
                                                                                                                                
KEN HELANDER,  Advocacy Director,  AARP Alaska, stated  that AARP                                                               
supported this  forward thinking  approach to provide  relief for                                                               
the  serious  shortage  of  behavioral  health  services.    They                                                               
supported  the broadening  of  supervision  of behavioral  health                                                               
providers  to include  physicians  generally,  which would  allow                                                               
more clinicians to offer their  services, to be reimbursed and to                                                               
intervene earlier in order to  prevent more costly emergency room                                                               
treatment.   They  also  supported the  ability  to provide  this                                                               
supervision via  electronic or communication  devices, as  it was                                                               
critical  to the  unique geography  and  resource limitations  of                                                               
Alaska.                                                                                                                         
                                                                                                                                
3:24:19 PM                                                                                                                    
                                                                                                                                
ROBIN MINARD, Director,  Public Affairs, Matanuska-Susitna Health                                                               
Foundation,  paraphrased  from  a  letter  dated  March  4,  2018                                                               
[Included in members' packets] which read:                                                                                      
                                                                                                                                
     The Mat-Su  Health Foundation strongly  supports Senate                                                                    
     Bill 169,  "Medicaid, Behavioral Health  Coverage," and                                                                    
     we  appreciate that  it is  being heard  in the  Senate                                                                    
     Health and Social Services Committee.                                                                                      
                                                                                                                                
     The  prevalence of  mental health  and substance  abuse                                                                    
     issues  is  increasing  in the  Mat-Su  and  statewide.                                                                    
     There  are severe  gaps in  the continuum  of care  for                                                                    
     behavioral health, and these  gaps cause minor problems                                                                    
     to  go untreated,  often resulting  in escalation  that                                                                    
     erupts  in devastating  and  costly full-blown  crisis.                                                                    
     Sadly, Alaska's  main paths  to behavioral  health care                                                                    
     are emergency  rooms and jail.  We all know  this isn't                                                                    
     where we  should be investing our  state's dollars, but                                                                    
     that is exactly what we are doing today.                                                                                   
                                                                                                                                
     In 2016  alone, 3,443  patients with  behavioral health                                                                    
     diagnoses went  to the  Mat-Su Regional  Medical Center                                                                    
     Emergency  Department.  Their   charges  totaled  $43.8                                                                    
     million, and  that's not counting additional  costs for                                                                    
     law  enforcement,  911  dispatch,  and  transportation,                                                                    
     which were estimated  at $1.6 million for  2013 and are                                                                    
     significantly higher  today. The average  annual growth                                                                    
     rate for  visits for patients with  a behavioral health                                                                    
     diagnosis to  the Mat-Su Regional  Emergency Department                                                                    
     grew 20  percent from 2015 to  2017. Additionally, from                                                                    
     2014  to   2017,  the   number  of   behavioral  health                                                                    
     assessments  required for  patients  in  crisis in  the                                                                    
     emergency department  grew from 349 to  more than 1,000                                                                    
       all  in a  hospital that  does not  currently provide                                                                    
     behavioral health care.                                                                                                    
                                                                                                                                
     In   the  Mat-Su   Health   Foundation's  2013   Mat-Su                                                                    
     Community Health  Needs Assessment, the people  of Mat-                                                                    
     Su told  us that the  top five health issues  they were                                                                    
     concerned about  were all related to  mental health and                                                                    
     substance abuse.  Mat-Su citizens want an  improved and                                                                    
     coordinated  system of  care that  makes treatment  for                                                                    
     behavioral  health more  readily accessible.  Thousands                                                                    
     of  Alaskans  of all  ages     children, families,  and                                                                    
     older  Alaskans -  are  struggling  with mental  health                                                                    
     concerns. They  came from all  walks of life,  and they                                                                    
     live all  across our great  state. One thing  they have                                                                    
     in common is  that they have problems  that they simply                                                                    
     cannot tackle on their own.  Another thing they have in                                                                    
     common  is   that  there  is   not  enough   access  to                                                                    
     behavioral health care.  This legislation helps address                                                                    
     these issues. It will improve  access, reduce cost, and                                                                    
       most importantly    help people to get  the care they                                                                    
     need.                                                                                                                      
                                                                                                                                
3:26:58 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ opened public testimony on SB 169.                                                                              
                                                                                                                                
3:27:09 PM                                                                                                                    
                                                                                                                                
PAUL  TOPOL, MD,  Legislative Representative,  Alaska Psychiatric                                                               
Association,  expressed understanding  for  the serious  problems                                                               
with access to mental health  care in Alaska, although there were                                                               
concerns  for the  impact on  quality, as  a physician  providing                                                               
supervision  without specified  qualifications  did  not seem  to                                                               
have adequate protections for assuring competency.                                                                              
                                                                                                                                
3:28:23 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  EASTMAN  asked  if  there was  concern  that  the                                                               
proposed  bill would  increase the  pressure on  psychiatrists to                                                               
accept "sub-standard people into those new roles."                                                                              
                                                                                                                                
DR. TOPOL  explained that, without very  clear expectations about                                                               
the  necessary qualifications,  there would  be people  providing                                                               
supervision  without  anything  other  than  a  medical  license.                                                               
Although there was great faith  for the professional integrity of                                                               
physicians to only  be involved with things they know  how to do,                                                               
there was  a large gap in  training between a psychiatrist  and a                                                               
family  practitioner without  specific  experience in  oversight.                                                               
He expressed  concern for  the people  designated to  provide the                                                               
"stopgap supervision."                                                                                                          
                                                                                                                                
REPRESENTATIVE EASTMAN  asked if  there was  any liability  for a                                                               
licensed provider should a patient be abused by a psychiatrist.                                                                 
                                                                                                                                
DR.  TOPOL   declared  that  the   liability  would  be   on  the                                                               
psychiatrist or the person in the role of supervisor.                                                                           
                                                                                                                                
3:30:42 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ  asked for a  remedy or proposal to  the shortage                                                               
of behavioral health care providers for the Medicaid population.                                                                
                                                                                                                                
DR. TOPOL said that this was  "an extremely complex issue, so the                                                               
short answer  is no."   He  stated that  the association  was not                                                               
entirely sure  that the  proposed bill would  do as  it proposed,                                                               
and  that it  would not  open the  flood gates  for providers  as                                                               
there  were  other   complexities,  including  the  reimbursement                                                               
rates, problems,  and regulations  of Medicaid.   He  opined that                                                               
although  the proposed  bill was  an attempt  to expand  scope of                                                               
practice for  other providers, he  was not sure it  would improve                                                               
access.                                                                                                                         
                                                                                                                                
3:32:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  ZULKOSKY asked  if  proposed SB  169 allowed  for                                                               
supervision  by a  physician even  though the  physician was  not                                                               
providing  the behavioral  health services;  instead it  could be                                                               
clinical  psychologists,   social  workers,  or   other  licensed                                                               
counselors.                                                                                                                     
                                                                                                                                
DR. TOPOL, in response to  Representative Zulkosky, expressed his                                                               
agreement, although it  begs the question for the  purpose of the                                                               
supervision by  people with  no specific  training for  what they                                                               
were supervising.  He asked why this was proposed.                                                                              
                                                                                                                                
3:34:51 PM                                                                                                                    
                                                                                                                                
RICK CALCOTE, Chief  of Risk and Research  Management, Policy and                                                               
Planning Section,  Division of  Behavioral Health,  Department of                                                               
Health and Social  Services, explained that only  a mental health                                                               
physician clinic  required supervision by a  psychiatrist, as all                                                               
the  employees were  licensed providers.   He  stated that  these                                                               
clinics had been around "for a  very long time in regulation, and                                                               
mental health  physician clinics  have not  been well  defined at                                                               
all in  statute."  He  reported that  the earliest he  could find                                                               
mention in  regulation was in the  1970s.  He offered  his belief                                                               
that the intent was to have  a specialist who understood the need                                                               
for mental  health treatment, especially  for children  or adults                                                               
who required  medication with the additional  therapy needs being                                                               
addressed by  the other  licensed providers.   He stated  that it                                                               
was desired to  have supervision by someone who  was a specialist                                                               
in mental health and not a general physician.                                                                                   
                                                                                                                                
3:37:24 PM                                                                                                                    
                                                                                                                                
RANDALL BURNS,  Director, Central Office, Division  of Behavioral                                                               
Health, Department of Health and  Social Services, added that the                                                               
Medicaid rule,  under federal law,  was that a physician  must be                                                               
supervising  clinic services.   He  referenced the  definition of                                                               
supervision  in the  proposed bill  and offered  his belief  that                                                               
this narrowed  the number of non-psychiatrist  physicians willing                                                               
to  provide this  level  of supervision  in  a behavioral  health                                                               
services clinic because of the requirements.                                                                                    
                                                                                                                                
3:39:15 PM                                                                                                                    
                                                                                                                                
SENATOR   GIESSEL  reported   that   health   care  had   changed                                                               
significantly since  this rule  was implemented  in approximately                                                               
1970.    She pointed  out  how  broad  the  federal law  was  for                                                               
Medicaid   services   reimbursement   and   she   proposed   that                                                               
supervision  could be  provided  by a  psychiatric mental  health                                                               
specialist nurse practitioner, as  they were specially trained in                                                               
behavioral health.   She pointed  out that this was  not possible                                                               
under federal  law.  She  noted that  she had written  to federal                                                               
officials regarding  the challenges  and significant  shortage of                                                               
providers  that Alaska  faced  with  behavioral health  services.                                                               
She emphasized that this was a  federal rule and not a law passed                                                               
by Congress.   She stated that, as many  clinics were integrating                                                               
behavioral health  with other services, there  were professionals                                                               
to help  with the  necessary supervision.   She pointed  out that                                                               
the clinicians listed in the  proposed bill were not incompetent.                                                               
She emphasized that this federal  rule was very outdated and that                                                               
"there  are  enough  patients  for  everyone  to  make  a  living                                                               
serving."                                                                                                                       
                                                                                                                                
CHAIR SPOHNHOLZ  expressed her agreement that  the rule requiring                                                               
this  supervision  was  well  outdated  and  a  lot  had  changed                                                               
including  the required  level of  education  for the  behavioral                                                               
health  therapists outlined  in the  proposed bill.   She  stated                                                               
that  it was  necessary  to  create an  efficient  way to  ensure                                                               
meeting federal rules while not  creating unnecessary burdens for                                                               
health care practitioners.                                                                                                      
                                                                                                                                
3:43:31 PM                                                                                                                    
                                                                                                                                
SENATOR GIESSEL  pointed out that  this proposed bill  opened the                                                               
door for telehealth.                                                                                                            
                                                                                                                                
3:43:57 PM                                                                                                                    
                                                                                                                                
DENISE DANIELLO, Executive Director,  Alaska Commission on Aging,                                                               
Division  of  Senior  and Disabilities  Services,  Department  of                                                               
Health  and Social  Services (DHSS),  paraphrased  from a  letter                                                               
dated March 27, 2018, which read [Included in members' packets]:                                                                
                                                                                                                                
     The  Alaska Commission  on Aging  (ACoA) is  pleased to                                                                    
     offer support  for SB  169 (RLS)  "Medicaid, Behavioral                                                                    
     Health Coverage,  "Version U" that is  authored by you.                                                                    
     The  prevalence  of  behavioral  health  conditions  is                                                                    
     increasing  in  Alaska  due to  critical  gaps  in  the                                                                    
     continuum of care.  Many rural and remote  areas of the                                                                    
     state  experience  an  acute   lack  of  mental  health                                                                    
     services  which  further  exacerbates  the  problem  of                                                                    
     access to  care. In those areas  with limited capacity,                                                                    
     providers are  unable to serve those  without insurance                                                                    
     coverage or  ability to private pay  which include many                                                                    
     vulnerable, low-income people.  While Alaska has mental                                                                    
     health  care   professionals,  including   marital  and                                                                    
     family  therapists, licensed  clinical social  workers,                                                                    
     and  clinic psychologists,  there are  constraints that                                                                    
     limit how these providers can offer services.                                                                              
                                                                                                                                
     The Commission agrees that SB  169 addresses this issue                                                                    
     by (1)  expanding options to meet  the required mandate                                                                    
     for clinical supervision to  be conducted either onsite                                                                    
     or   remotely,    utilizing   telehealth    and   other                                                                    
     communication  devices to  provide consultation,  which                                                                    
     will  help to  increase access  for Alaskans  living in                                                                    
     rural and remote areas of  the state at a reduced cost;                                                                    
     and  (2)  allowing   physicians,  which  includes  both                                                                    
     psychiatrists and  physicians licensed under  AS 08.54,                                                                    
     to  perform   the  required  clinical   supervision  of                                                                    
     behavioral health therapists.                                                                                              
                                                                                                                                
     Mental  health  and  substance   misuse  issues  are  a                                                                    
     growing concern  for many Alaska seniors  that have not                                                                    
     received appropriate attention.  Moreover, the aging of                                                                    
     baby  boomers is  expected to  increase the  number and                                                                    
     percentage  of  older  adults having  substance  misuse                                                                    
     disorders. According to the  Substance Abuse and Mental                                                                    
     Health   Services  Administration   (SAMHSA)  and   the                                                                    
     Centers for Disease Control  and Prevention, nearly one                                                                    
     in  five adults  age  65+ has  one  or more  behavioral                                                                    
     health  conditions  defined  as   a  mental  health  or                                                                    
     substance   use   disorder.   Based  on   2017   Alaska                                                                    
     population estimates for persons  age 65 and older, 20%                                                                    
     would amount  to 16,600 older  Alaskans. Many  of these                                                                    
     seniors  have  complex   medical  conditions  including                                                                    
     chronic pain,  diabetes, cancer,  and heart  disease as                                                                    
     well  as   mental  health  conditions,   substance  use                                                                    
     disorders, and cognitive impairment such as dementia.                                                                      
                                                                                                                                
     In  comparison to  their national  counterparts, Alaska                                                                    
     seniors  have  consistently   higher  rates  for  binge                                                                    
     drinking, heavy  drinking, smoking, obesity as  well as                                                                    
     a   greater   percentage  reporting   frequent   mental                                                                    
     distress,  according  to  the  Alaska  Behavioral  Risk                                                                    
     Factor   Surveillance  Survey,   2016  findings.   Age-                                                                    
     adjusted   mortality   rates   for  persons   age   65+                                                                    
     attributed to behavioral health  causes are both higher                                                                    
     among Alaska  seniors than  national averages  for this                                                                    
     age cohort and on the  rise in Alaska for older adults.                                                                    
     Alcohol  use   disorders,  in  particular,   have  been                                                                    
     identified as a major risk  factor for the onset of all                                                                    
     types of  dementia, based on  a recent  study published                                                                    
     by the  Lancet Public Health Journal  (2018), including                                                                    
     Wernicke-Korsakoff  Syndrome,  vascular  dementia,  and                                                                    
     young  onset  Alzheimer's.  Further,  substance  misuse                                                                    
     often   increases   a    senior's   risk   for   falls,                                                                    
     particularly   for   those    who   take   prescription                                                                    
     medications.                                                                                                               
                                                                                                                                
     SB  169  addresses  the  need   to  improve  access  to                                                                    
     behavioral  health care  services by  expanding options                                                                    
     to  meet  the  supervision  oversight  requirement  for                                                                    
     mental  health  therapists. Further,  this  legislation                                                                    
     will  help to  offset  emergency  room charges  through                                                                    
     improved access to care as  well as being of benefit to                                                                    
     patients   released   from   the   Alaska   Psychiatric                                                                    
     Institute  so  that  they are  able  to  acquire  their                                                                    
     prescribed  medications in  a  timely  manner as  these                                                                    
     patients are only provided  with a two-day prescription                                                                    
     upon  their release.  ACoA supports  SB 169  to advance                                                                    
     access  to care  for more  Alaskans, reduce  costs, and                                                                    
     improve utilization  of our existing  behavioral health                                                                    
     workforce  to  provide   more  timely  and  appropriate                                                                    
     behavioral health treatment for Alaskans of all ages.                                                                      
                                                                                                                                
3:48:33 PM                                                                                                                    
                                                                                                                                
KEELEY OLSON, Executive Director,  Standing Together Against Rape                                                               
(STAR), stated support for the  proposed bill.  She reported that                                                               
many  of their  clients  only  had Medicaid  as  a resource,  and                                                               
although STAR offered free trauma  therapy, she acknowledged that                                                               
the current rules  were "a bureaucratic barrier  to providing all                                                               
of the  resources that we  could for  a very epidemic  problem of                                                               
behavioral health  needs."   She pointed to  the rates  of sexual                                                               
trauma in Alaska and, with  the difficulty for accessing care, it                                                               
was  often necessary  to resort  to  emergency psychiatric  care.                                                               
She noted  that many people would  defer care until it  came to a                                                               
critical  stage  instead  of  dealing with  it  initially.    She                                                               
reported that  people could not access  crime victim compensation                                                               
if they had not filed a police report.                                                                                          
                                                                                                                                
3:53:13 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ closed public testimony on SB 169.                                                                              
                                                                                                                                
3:53:25 PM                                                                                                                    
                                                                                                                                
The committee took a brief at-ease.                                                                                             
                                                                                                                                
3:54:17 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE ZULKOSKY  moved to  report CSSB  169(RLS), Version                                                               
30-LS1283\U,  out of  committee  with individual  recommendations                                                               
and the  accompanying fiscal  notes.   There being  no objection,                                                               
CSSB  169(RLS)  was  moved  from  the  House  Health  and  Social                                                               
Services Standing Committee.                                                                                                    
                                                                                                                                
3:54:41 PM                                                                                                                    
                                                                                                                                
The committee took a brief at-ease.                                                                                             
                                                                                                                                
^CONFIRMATION HEARING(S)                                                                                                        
                    CONFIRMATION HEARING(S)                                                                                 
                      State Medical Board                                                                                   
                                                                                                                                
3:56:59 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ announced that the  final order of business would                                                               
be a confirmation hearing for the Alaska State Medical Board.                                                                   
                                                                                                                                
3:57:08 PM                                                                                                                    
                                                                                                                                
CATHERINE  HYNDMAN, MD,  Appointee, State  Medical Board,  stated                                                               
that she  was a family physician  who had been practicing  in the                                                               
Bristol Bay Region since 2000.   She said that she was interested                                                               
in an  appointment to the board  because she would like  to offer                                                               
service to more  of the state and [indisc].   She shared that she                                                               
really enjoyed  her experience working  in remote Alaska  and she                                                               
offered her  belief that she  could bring  a vision to  the board                                                               
for the more remote areas of the state.                                                                                         
                                                                                                                                
3:58:44 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ asked what brought her to Dillingham.                                                                           
                                                                                                                                
DR. HYNDMAN explained that she  had originally come for vacation,                                                               
loved  the  area, and  decided  to  leave  her practice  in  West                                                               
Virginia.  She  shared that the move had enabled  her to practice                                                               
more of the medicine for which  she had been trained.  She stated                                                               
that she loved working with the local population.                                                                               
                                                                                                                                
3:59:54 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE ZULKOSKY moved to  advance the confirmation of Dr.                                                               
Catherine Hyndman,  appointee to the Alaska  State Medical Board,                                                               
to a  joint session  of the House  and Senate  for consideration.                                                               
She  reminded the  committee that  signing  the report  regarding                                                               
appointment in  no way reflects  individual members'  approval or                                                               
disapproval  of the  appointee,  and the  nominations are  merely                                                               
forwarded to the full legislature  for confirmation or rejection.                                                               
There being no objection, the confirmation was advanced.                                                                        
                                                                                                                                
4:00:32 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being no  further business before the  committee, the House                                                               
Health  and  Social  Services   Standing  Committee  meeting  was                                                               
adjourned at 4:00 p.m.                                                                                                          

Document Name Date/Time Subjects
SB169 Letter of Support GCDSE revised 3-28-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support ABHA 2-23-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support AARP 3-12-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support AK Child and Family 3-26-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support AK Cmmsn on Aging 3-28-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support AKMHT 3-28-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support MatSu Health Foundation 3-4-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support Wiese 2-19-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Sectional Analysis vsn U 3-26-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Sponsor Statement vsn U CSSB(RLS) 3-26-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Summary of Changes 3-27-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Supporting Document PPt slides 3-26-18.2.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Supporting Document vsn U Info Points 3-26-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 vsn D 2-2-18.PDF HHSS 4/3/2018 3:00:00 PM
SB 169
SB169(HSS) vsn O 3-8-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support STAR 3-27-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169
SB169(RLS) Fiscal Note DHSS BH 3-26-18.PDF HHSS 4/3/2018 3:00:00 PM
SB 169
SB169(RLS) vsn U 3-26-18.PDF HHSS 4/3/2018 3:00:00 PM
SB 169
SB169 Letter of Support Native Health Bd 4-3-18.pdf HHSS 4/3/2018 3:00:00 PM
SB 169