Legislature(2017 - 2018)BUTROVICH 205

03/05/2018 01:30 PM Senate HEALTH & SOCIAL SERVICES

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Audio Topic
01:30:06 PM Start
01:30:41 PM SB169
01:59:37 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
-- Testimony <Invited and Public> --
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                         March 5, 2018                                                                                          
                           1:30 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Senator David Wilson, Chair                                                                                                     
Senator Cathy Giessel                                                                                                           
Senator Peter Micciche                                                                                                          
Senator Tom Begich                                                                                                              
MEMBERS ABSENT                                                                                                                
Senator Natasha von Imhof, Vice Chair                                                                                           
COMMITTEE CALENDAR                                                                                                            
SENATE BILL NO. 169                                                                                                             
"An Act relating to the definition of 'supervision or direct                                                                    
supervision' for purposes of medical assistance coverage of                                                                     
behavioral health clinic services."                                                                                             
     - HEARD & HELD                                                                                                             
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 WITNESS REGISTER JANE CONWAY, Staff Senator Cathy Giessel Alaska State Legislature Juneau, Alaska POSITION STATEMENT: presented the differences between version D and version J of SB 169. JON ZASADA, Policy Integration Director Alaska Primary Care Association Anchorage, Alaska POSITION STATEMENT: Supported SB 169. ART DELAUNE, Member Governor's Council on Disabilities and Special Education, Fairbanks, Alaska POSITION STATEMENT: Supported SB 169. ACTION NARRATIVE 1:30:06 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 1:30 p.m. Present at the call to order were Senators Giessel, Micciche, Begich and Chair Wilson. SB 169-MEDICAID: BEHAVIORAL HEALTH COVERAGE 1:30:41 PM CHAIR WILSON announced the consideration of SB 169. He entertained a motion to adopt the CS as the working document. SENATOR MICCICHE moved to adopt the proposed CSSB 169, version 30-LS1283\J, as the working document. 1:31:24 PM CHAIR WILSON objected for purposed of discussion. 1:32:25 PM SENATOR GIESSEL, Alaska State Legislature, sponsor or SB 169 said the CS addresses access to mental health care services in Alaska. She related that Alaska leads the nation in suicide and domestic violence. Alaska's suicide rate is twice the national average. Sixty-six percent of Alaskan adults have one or more Adverse Childhood Experiences. Twenty percent of Alaska adults have been diagnosed with a behavioral health disorder. Substance abuse and misuse is not something new to the state. As a lifelong Alaskan--like Senator Begich, she has been aware of issues of alcohol and illegal substances in the state for her entire lifetime. At the core of these issues are things like Adverse Childhood Experiences, isolation, depression, just to name a few. Alaska lacks sufficient behavioral health services to meet the needs and has for decades. She said in 2015 the Senate worked on SB 74, the Medicaid reform bill. One intent of the bill was to expand behavioral health care services through an expanded clinician base. In other words, enabling more clinicians to offer services by removing restrictions to providing services under Medicaid. This was a big issue in Senate Finance. There were three meetings a week for a month. Behavioral health services was a huge priority. At that time, the Division of Behavioral Health assured the committee that it could address through regulation the rule, AAC 135.030(e), that limits who can provide behavioral health clinical services. "But then they came back two years later and said, 'Oops, sorry. We'll need a statute,'" she said. SENATOR GIESSEL said two years passed while they waited for this to happen. Nonetheless, it was enacted, but there is no visible improvement in mental health care services. Waitlists are 18 months to 2 years in length. The Division of Behavioral Services says Medicaid expansion has increased the demand for behavioral health and substance abuse treatment by nearly 5,000 adults. Emergency rooms have become behavioral health clinics. Emergency units have nowhere to place these people. One anecdotal report is that some emergency rooms had to hold these folks for as long as 13 days. A friend who was in an emergency room for several hours was brought a food tray with a spoon as the only utensil. Because it is so common to have behavioral health patients in the emergency room, it simply provides "safe trays" for all the patients in the emergency room. That underscores the magnitude of the problem. Not only is the emergency room the most expensive form of treatment, it is an inappropriate use of emergency beds. The Alaskans who go to emergency rooms are still not getting the services they need. She referenced a letter from the Mat-Su Health Foundation that underscores this issue. The Division of Behavioral Health has applied for a Section 1115 Behavioral Health Demonstration Waiver. It is undergoing public comment until April 15. When she asked how long it will be before something is done, she was told two more years. Alaskans cannot wait two more years for critical services. SB 169 is intended to do what the 1115 demonstration waiver is supposed to do: rebalance the current behavioral health care system to reduce the overreliance on acute and institutional care and shift to more community-based or regional care, to intervene as early as possible before symptoms cascade into functional impairments, and to improve the overall behavioral health care system. She explained that only a few clinics in Anchorage can accept patients for behavioral health services and be able to bill Medicaid. Under a rule put in place by bureaucrats, a psychiatrist must be physically present 30 percent of the time and supervising other providers in order to bill Medicaid. This drastically limits access to vital behavioral health care. There are only 114 psychiatrists licensed in the state of Alaska. Some clinics with special waivers and federally-funded community health centers will accept Medicaid patients but these are limited. She brought up the example of Dr. Tracey Wiese, a psychiatric mental health nurse practitioner, who cannot supervise anyone. 1:39:35 PM SENATOR GIESSEL said the recidivism reduction program, part of SB 91 that passed in 2016, established help for the rehabilitation of parolees but most need behavioral health or substance abuse services, adding yet more to the population of need. The Department of Corrections is experimenting with Vivitrol, but they also need behavioral health services. Medicaid providers are limiting their clientele to the most severe cases or those who are leaving the corrections system. The letter from the Governor's Council on Disabilities and Special Education addresses that aspect. She said SB 169 states that the behavioral health clinic services may be provided by psychiatrists or psychiatric mental health advanced nurse practitioners. Direct supervision is required of other clinicians in order to be reimbursed by Medicaid. That supervision can be provided by a psychiatrist or psychiatric mental health advanced nurse practitioner. The bill defines direct supervision as being provided either in person or telehealth. Criteria are included for supervision. The bill will go into effect 90 days after the governor signs it, which is sooner than two years from now. She noted that the bill is supported by the Mat-Su Health Foundation, the Governor's Council on Disabilities and Special Education, and the Alaska Behavioral Health Association. Behavioral health services is one of the legislative priorities of the Alaska Council of School Administrators. 1:43:05 PM CHAIR WILSON asked for an explanation of the difference in the CS for SB 169. 1:43:33 PM JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State Legislature, presented the differences between version D and version J of SB 169. She said the difference is the addition of another supervisory person on page 1, starting on line 7. This is an "advanced practice registered nurse licensed under AS 08.68 who is certified to provide psychiatric or mental health services." Beginning on page 1, line 13, going to the second page, are some sidebars and descriptions of what the oversight should entail. 1:44:27 PM CHAIR WILSON removed his objection. Finding no further objection, version J was adopted. SENATOR BEGICH called the bill timely and necessary. "Let's move forward," he said. SENATOR MICCICHE asked how many advanced nurse practitioners are licensed in Alaska. SENATOR GIESSEL said the estimate is 150. The CS would double the number of potential supervisors but would also open the door to more telehealth. Some clinics with waivers are using out-of- state psychiatry oversight. This bill would ensure that that door is open even wider. SENATOR MICCICHE asked if there is a specific certification associated with psychiatric or mental health services. SENATOR GIESSEL said the statutes do not parse out the multiple specialty certifications of nurse practitioners. That is defined in regulation. 1:46:45 PM CHAIR WILSON opened public testimony on SB 169. 1:47:18 PM JON ZASADA, Policy Integration Director, Alaska Primary Care Association, supported SB 169. He said the Alaska Primary Care Association supports the bill and appreciates that Senator Giessel recognizes that the current supervision model serves as a bottleneck for the provision of behavioral health services. The Association does request that physicians be added as a provider type to supervise LMFTs [licensed marriage and family therapists]. Expanding the behavioral health labor force has been the number one priority of Alaska community health centers for the past two years. They also support SB 105 and HB 353. Community health centers have made major investments in behavioral health that have resulted, in the last two to three years, in a 25 percent increase in encounters with patients, the addition of many new providers in health centers, and over 11,000 Alaskans receiving behavioral health services through local community health centers. There is a shortage of billable providers. In a recent behavioral health work force survey, they are down 12 to 18 health providers in health centers across the state that could serve up to 9,000 additional patients. They want to be able to supervise new providers as they come in. That is why they support the bill and the addition of physicians as supervisors. SENATOR MICCICHE said why AS 08.64 would not allow a general practitioner to fulfill the supervisory role. SENATOR GIESSEL said that is the State Medical Board statute. She said she initially wanted to say either a "physician licensed under or advanced nurse practitioner with specialty." However, Randall Burns, Director of the Division of Behavioral Health advocated that it remain a psychiatrist so the specialty care would be there. She said she nevertheless has no opposition to opening the door as wide as possible. 1:50:42 PM ART DELAUNE, Member, Governor's Council on Disabilities and Special Education, supported SB 169. He said besides representing the Governor's Council, he also was testifying as a parent and guardian. His 24-year-old son has severe depression, anxiety, and schizophrenia. He has ongoing suicidal thoughts and has been admitted to hospital three times. Fairbanks, like other communities, is lacking mental health services. It has been two to four years since mental health has been accessible to those who are low income, have only Medicaid, or no health insurance. No private practice is accepting Medicaid. Access to mental health services is almost nonexistent. He supports SB 169 because it would allow more access to professionals for those in need. His son has been waiting 2.5 years for services at Fairbanks Community Mental Health. When he is overwhelmed he has to go to Fairbanks Memorial Hospital, which is a costly alternative and is just for crises. His son is no longer employed because of his mental health condition. He gets medications but that is about all. A lot of people are waiting for care. One small agency in town tried to operate a wellness program. The biggest barrier was needing an on-site psychiatrist 30 percent of the time for Medicaid billing requirements, so that program is gone. Federal Medicaid mandates the supervision of therapists by psychiatrists. The use of television technology and other modern technologies would greatly enhance mental health services for people in communities, especially in rural areas. He just retired last week from Access Alaska and saw a great need for mental health services in rural areas. The Governor's Council on Disabilities and Special Education supports SB 169 and he does too. 1:55:23 PM At ease. 1:57:24 PM CHAIR WILSON reconvened the meeting and closed public testimony. SENATOR GIESSEL said they all understand the urgency and importance of the topic. CHAIR WILSON held SB 169 in committee. 1:59:37 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Standing Committee at 1:59.

Document Name Date/Time Subjects
SB 169 30-LS1283 D.pdf SHSS 3/5/2018 1:30:00 PM
SB 169
CS for SB169 SHSS v J 2-28-18.pdf SHSS 3/5/2018 1:30:00 PM
SB 169
SB169 Sponsor Statement (CS, vsnJ) 3-2-18.pdf SHSS 3/5/2018 1:30:00 PM
SB 169
SB169 Sectional Analysis CS vsn J 3-2-18.pdf SHSS 3/5/2018 1:30:00 PM
SB 169
SB169 Letter of Support GCDSE 2-16-18.pdf SHSS 3/5/2018 1:30:00 PM
SB 169
CS for SB169 SHSS v J 2-28-18.pdf SHSS 3/5/2018 1:30:00 PM
SB 169
SB169 Letter of Support ABHA 2-23-18.pdf SHSS 3/5/2018 1:30:00 PM
SB 169
Fiscal Note SB 169.pdf SHSS 3/5/2018 1:30:00 PM
SB 169
SB169 Letter of Support MatSu Health Foundation 3-4-18.pdf SHSS 3/5/2018 1:30:00 PM
SB 169