Legislature(2019 - 2020)BUTROVICH 205

02/21/2020 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:33:53 PM Start
01:34:20 PM SB134
02:41:05 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ SB 134 MEDICAID COVERAGE OF LIC. COUNSELORS TELECONFERENCED
Heard & Held
-Invited Testimony Followed by Public Testimony-
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                       February 21, 2020                                                                                        
                           1:33 p.m.                                                                                            
                                                                                                                                
                             DRAFT                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Senator David Wilson, Chair                                                                                                     
Senator Cathy Giessel                                                                                                           
Senator Mike Shower                                                                                                             
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Senator Natasha von Imhof, Vice Chair                                                                                           
Senator Tom Begich                                                                                                              
                                                                                                                                
OTHER LEGISLATORS PRESENT                                                                                                     
                                                                                                                                
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
SENATE BILL NO. 134                                                                                                             
"An Act relating to medical assistance reimbursement for the                                                                    
services of licensed professional counselors; and providing for                                                                 
an effective date."                                                                                                             
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: SB 134                                                                                                                  
SHORT TITLE: MEDICAID COVERAGE OF LIC. COUNSELORS                                                                               
SPONSOR(s): SENATOR(s) WILSON                                                                                                   
                                                                                                                                
01/21/20       (S)       PREFILE RELEASED 1/10/20                                                                               

01/21/20 (S) READ THE FIRST TIME - REFERRALS

01/21/20 (S) HSS, FIN 02/21/20 (S) HSS AT 1:30 PM BUTROVICH 205 WITNESS REGISTER GARY ZEPP, staff Senator David Wilson Alaska State Legislature POSITION STATEMENT: Presented SB 134 on behalf of the sponsor. ALBERT WALL, Deputy Commissioner Medicaid & Health Care Policy Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: Was available to answer questions about SB 134. GENNIFER MOREAU, Director Division of Behavioral Health Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: Provided information on SB 134. JON ZASADA, Director Policy Integration Alaska Primary Care Association (APCA) Anchorage, Alaska POSITION STATEMENT: Supported SB 134. KEVIN MUNSON, Chief Executive Officer Mat-Su Behavioral Health Services Wasilla, Alaska POSITION STATEMENT: Supported SB 134. PATICK ANDERSON, Chief Executive Officer RurAL CAP Anchorage, Alaska POSITION STATEMENT: Supported SB 134. SEVILLA LOVE, Integration Coordinator Alaska Primary Care Association Anchorage, Alaska POSITION STATEMENT: Supported SB 134. ROBIN MINARD, Chief Communications Officer Mat-Su Health Foundation Wasilla, Alaska POSITION STATEMENT: Supported SB 134. DEBRA HAMILTON, Executive Director New Hope Counseling Center Soldotna, Alaska POSITION STATEMENT: Supported SB 134. ERIC BOYER, Program Officer Alaska Mental Health Trust Authority Anchorage, Alaska POSITION STATEMENT: Supported SB 134. DON BLACK, Board Member Bethel Family Clinic Bethel, Alaska POSITION STATEMENT: Supported SB 134. JULIE THOMPSON, Licensed Professional Counselor Bethel Family Clinic Bethel, Alaska POSITION STATEMENT: Supported SB 134. JEIGH STANTON GREGOR, representing self Petersburg, Alaska POSITION STATEMENT: Supported SB 134. ACTION NARRATIVE 1:33:53 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 1:33 p.m. Present at the call to order were Senators Giessel, Shower, and Chair Wilson. SB 134-MEDICAID COVERAGE OF LIC. COUNSELORS 1:34:20 PM CHAIR WILSON announced the consideration of SB 134, sponsored by himself, and his intent to hear a sectional analysis and invited testimony and public testimony. He called his aide Gary Zepp to the table. 1:35:26 PM GARY ZEPP, staff, Senator David Wilson, Alaska State Legislature, explained that SB 134 would add licensed professional counselors (LPCs) to Medicaid optional services. The concept of the bill is to add more behavioral health counseling services to expand capacity and utilization within Alaska. The expansion of behavioral health care professionals is projected to reduce wait time, improve the quality of care in the appropriate settings, and will cost less than behavioral health care in emergency rooms across the state. Currently, Medicaid clients have a wait time of three to six months to see a licensed behavioral health care professional counselor, if they are lucky enough to find a provider who will see Medicaid patients, mostly because of the lack of capacity in the workforce itself. Everyone has seen examples of behavioral health shortages through media or what people have seen or experienced in their own communities. MR. ZEPP said that LPCs are a valuable, cost effective part of treatment for behavioral health. This proposed legislation is a piece of the behavioral health capacity that already includes licensed social workers, Ph.D. psychologists, prescribing nurse practitioners, and medical doctors like psychiatrists and primary care physicians. SB 134 would provide the appropriate care with the appropriate provider. MR. ZEPP pointed out that many people are familiar with the term mental health, which covers many of the same issues as behavioral health, but this term only encompasses the biological component of this aspect of wellness. The term behavioral health encompasses all contributions to mental wellness, including substances and their abuse, behavioral issues, habits, and other external forces. MR. ZEPP asked why Medicaid clients and who are they. Medicaid provides health coverage and long-term care services for Alaska's most vulnerable: children, seniors, people with disabilities, pregnant women, and very low income or working poor. Medicaid clients have difficulties finding access to behavioral health care and often have to wait three to six months for appointments. Imagine someone in crisis who cannot find access to behavioral health care being told that it will be available in three to five months. Then the option is Alaska's emergency rooms. Medicaid clients show up in emergency rooms in a crisis state. SB 134 would directly impact the lives of Alaska's most vulnerable citizens. Emergency rooms have become overwhelmed by the volumes of behavioral health emergency situations. ERs are not usually equipped to handle this type of service. The number one reason for the use of ERs for Medicaid clients is alcohol disorders and the associated ailments. Often Medicaid clients have nowhere else to go because of the lack of access and capacity. This causes patients to stay much longer in ERs and hospitals than they should. Typically, if a Medicaid client is in a crisis stage with no access to appropriate care, they leave and the cycle repeats itself. The client will be back in the emergency room that is open 24 hours a day, seven days a week. MR. ZEPP said that approximately 70 percent of Americans who need behavioral health services do not receive treatment. For substance abuse disorders, about 92 percent do not receive treatment. About 66 percent of adults with serious mental health issues go untreated. Untreated behavioral health issues can increase the risk of cardiovascular disease, diabetes, stroke, Alzheimer's disease, osteoporosis, pancreatic disease, and hypertension. Besides the unintended consequences for folks who need behavioral health care and don't receive it, no treatment in a timely manner often leads to interaction with the police, court systems, and correctional facilities. Approximately 42 percent of state prisoners have a mental illness and 20 percent are considered severely and persistently mentally ill. MR. ZEPP said that the most common issues for children are attention deficit hyperactivity disorder, anxiety, and depression. A child diagnosed with depression has approximately a 74 percent chance of having a codisorder like anxiety. If a child diagnosed with depression and an anxiety disorder is not treated, the condition worsens over time. Boys are more likely to have a mental, behavioral, or developmental disorder and children living below poverty line are 22 percent more likely to have a mental, behavioral, or developmental disorder. 1:41:46 PM MR. ZEPP said that mental disorders among children can cause serious challenges to the way children typically learn, behave, and handle their emotions, which causes distress and problems throughout the day. According to the American Foundation for Suicide Prevention, suicide is the number one cause of death for ages 15-24 in Alaska. Nines times as many people died by suicide in Alaska in 2017 than in alcohol-related motor vehicle accidents. Alaska's suicide rate is 52 percent higher than the national average. MR. ZEPP said that expert testimony will shed a light on the workforce shortage of behavioral health care professionals available to treat Medicaid clients and Alaskans in general. The 2016 Alaska Behavioral Health Systems Assessment reported that more than 145,000 adult Alaskans, 20 percent of the state's population, are in need behavioral health services. Despite the need for mental health care in Alaska, the ratio of mental health providers to population is very low compared to national levels. Most work in urban areas. The remote areas in the state have even lower provider-population ratios. Understanding the magnitude, composition, and geographical scope of the mental health provider shortage in Alaska is seen as the great first step in developing effective, targeted solutions to increase workforce capacity by adding licensed professional counselors. MR. ZEPP displayed a chart on slide 9 of his presentation that reflects the total the state paid to emergency rooms from 2016 through 2019 for Alaska's Medicaid clients. The costs have increased by $47.1 million, or 21.1 percent, over the last four years. This is staggering. The top utilizers go to the ER at least ten times a year and sometimes as many as 50 times per year. The cost of the 2.7% (1,858 people) of the top utilizers is $42 million or $22,604 per person per year. The cost of 11.6% (7,996 people) of the top utilizers cost $98 million. The committee can see where costs are going in the future. MR. ZEPP said that the state needs to improve Medicaid programs and provide increased quality and become more cost efficient. Adding more licensed professional counseling services can improve these outcomes. Alaska has to do something different to stop this trend. With the federal approval of the 1115 Medicaid waiver for behavioral health services, adding LPCs to the mix of behavioral health professionals offers an opportunity to expand capacity, increase the quality of care, lower the cost vs. the crisis mode, platinum-level costs that the state is paying. These are the costs the state has already paid for Medicaid clients for behavioral health services. 1:45:28 PM MR. ZEPP said that from 2016 to 2019, the number of Medicaid clients has actually gone down by 6,614 or 9.6 percent, but the costs are rising. The most common diagnosis for the top 2.7 superutilizers are alcohol-related disorders. The four-year average for the superutilizers is 2.4 percent and it is 1,609 people at $43.5 million. The top 2.7 percent were likely to be between 20 and 59 years old, 61 percent are female, and the four-year annual average cost for the top 10.77 percent of superutilizers, about 7,204 people, is $103.4 million. That averages out to about $14,332 per person. MR. ZEPP said that Mondays are the most common days for a visit to the emergency room. The estimated cost for a behavioral health assessment in Alaska's emergency rooms is $4,300 vs. $150 to $250 per hour for clinical work by a licensed professional counselor. The state needs to provide the appropriate care with the appropriate healthcare provider. SB 134 has the ability to lower costs for Medicaid clients' behavioral health services that the state is paying to emergency rooms for those in a crisis state at a platinum-level cost. MR. ZEPP displayed the list of supporters for SB 134: • Alaska State Hospital and Nursing Home Association • Providence Health and Services Alaska • Southeast Alaska Regional Health Consortium • Alaska Regional Hospital • Mat-Su Health Foundation • Alaska Primary Care Association • Mat-Su Health Services • Alaska Mental Health Trust Authority • Alaska Department of Health & Social Services • Alaska Department of Commerce, Community & Economic Development • Discovery Cove Recovery & Wellness Center MR. ZEPP respectfully asked the committee to join them in supporting SB 134. CHAIR WILSON called Deputy Commissioner Albert Wall and Gennifer Moreau, Director of the Division of Behavioral Health, to testify. 1:48:33 PM ALBERT WALL, Deputy Commissioner, Medicaid & Health Care Policy, Department of Health and Social Services (DHSS), Anchorage, Alaska, gave Ms. Moreau the opportunity to speak first. 1:48:56 PM GENNIFER MOREAU, Director, Division of Behavioral Health, Department of Health and Social Services (DHSS), Anchorage, Alaska, thanked Senator Wilson for sponsoring this bill. The Division of Behavioral Health stands ready to assist with this proposed legislation and is eager to supply any information available to the division for full consideration of this bill. The potential benefits are that the bill could expand access to care to eligible Alaskans statewide, especially for remote, rural communities and for individuals with mild to moderate disturbances. There is the potential decrease over time of psychiatric emergency services and acute care hospital services. Licensed professional counselors will be able to provide SBIRT, screening, brief intervention, and referral to treatment, which is a key element to the continuum of care. By making this provider type available to eligible Alaskans, it also provides families the opportunity to interact in a smaller and more intimate setting, where they may be more comfortable receiving services. CHAIR WILSON asked how this would be integrated with the 1115 waiver. MS. MOREAU replied that the 1115 waiver is a mechanism to develop a full continuum of care. The whole driver behind the 1115 is to reduce the reliance on the acute end of care. Expanding access, especially for Medicaid recipients experiencing mild to moderate disturbances, including disruptions in social determinants of health, has the potential to prevent the future need for higher, more expensive levels of care. CHAIR WILSON called Jon Zasada to the table. 1:52:16 PM JON ZASADA, Director, Policy Integration, Alaska Primary Care Association (APCA), Anchorage, Alaska, said he spent nine years at the Anchorage Neighborhood Health Center. One of his roles was supporting the development of behavioral health integration programs. He noted that Sevilla Love, a licensed clinical social worker and the Primary Care's behavioral health integration coordinator, would also be testifying. She specifically supports health centers across the state in integrating behavioral health into their clinic operations, addressing clinical quality, and developing behavioral health staff. APCA supports the operations and development of Alaska's 27 community health centers. Its members voted to support SB 134. Adding Medicaid reimbursement for LPCs has been a top priority in its efforts to expand access to behavioral health for many years. APCA serves 113,000 patients per year through 560,000 visits at 160 clinic sites around the state. APCA serves 10 percent of Alaskans. About 85 percent of its patients have incomes at under 200 percent of the federal poverty level. Around 20 percent of all Alaskans enrolled in Medicaid get their primary care at a community health center. About 10 percent of APCA patients come in primarily for mild and moderate behavioral health care and 15 percent of all visits in a year are for behavioral health. APCA employs over 180 behavioral health providers of all types. MR. ZASADA said that he was asked to provide remarks about the role of LPCs in behavioral health services, why reimbursement for LPCs is vital in addressing the demand for behavioral health services, and how they provide care and could ultimately save Medicaid money by diverting patients away from emergency rooms and more costly care. He is still evaluating the fiscal note to determine how it would pertain to the primary care system as opposed to the behavioral health system. MR. ZASADA said LPCs are a valuable, cost-effective component of team-paced, whole person primary care. That is primary care built around medical, dental, behavioral health, pharmacy, and support providers working to ensure patients get all the care they need and supporting them with the management of their chronic conditions. Making LPCs billable under Medicaid will expand access to care for Alaskans in lower cost, primary care settings. Passing the bill is the first step. Implementation will involve changes in regulations. APCA has started conversations with DHSS about this. MR. ZASADA said the bill is an important component of the Medicaid reforms that were outlined in the 2016 SB 74 to expand provider types to increase access to behavioral health services, not just for community behavioral health providers, who were reimbursed for providing care for ongoing severe behavioral health and substance abuse issues, but also providers such as federally qualified health centers that specialize in providing mild and moderate community-based care. LPCs are an important provider type within a behavioral health team that includes licensed clinical social workers (LCSWs), psychologists, prescribing nurse practitioners, and medical doctors. Each one has a unique role. In 2017, APCA's health centers reported a deficit of 12 to 18 behavioral health providers. Conservatively, with those numbers the centers could provide care to 6,000 to 9,000 additional patients. From a clinical standpoint, LPCs are vital for one-on-one counseling in conjunction with LCSWs. 1:57:29 PM MR. ZASADA said that community health centers are already using LPCs in their practice to provide school-based services, counseling services, and supporting care coordination for patients. The addition of LPCs will increase overall provider retention and satisfaction, another challenge to health care in Alaska. All medical providers are more likely to stay in place when there is a full care team of professionals working at the top of their licensure. The full medical team model will gain increased efficiency by being fully staffed and reimbursed for the first time. Community health centers have received considerable federal investments to expand behavioral health services and support substance use treatment services in the primary care setting. Health centers are required by federal law to provide behavioral health that is integrated with medical, dental, pharmacy, and other services. Adding LPCs to the roster of billable providers enables health centers to make their services more sustainable. Now the LPCs that APCA employs are funded by nonsustainable federal grants and other grants that are not sustainable funding sources. MR. ZASADA said that mild and moderate anxiety and depression are co-occurring conditions with chronic conditions including diabetes and hypertension. LPCs can provide short-term counseling support to stabilize and improve the health of emergent patients and assisting them in managing their chronic conditions. LPCs provide a range of behavioral health services in schools across the state. At this time none of that care is reimbursed. MR. ZASADA said that in an integrated clinical setting, the attending medical or dental provider of a patient with diabetes might discover the patient is showing signs of depression or anxiety that could affect the patient's ability to follow the treatment plan. This is the point when an LPC would be called to provide counseling support for the patient. The LPC will work with the patient around personal issues affecting overall health, teach behavioral skills, and address social issues. The goal of the provider team is to get the patient back on path with a treatment plan, improve mental health, and avoid emergency care. 2:01:03 PM MR. ZASADA said that in school-based settings, an LPC might provide individual counseling, provide behavioral health skills education, and train teachers in how to support students. MR. ZASADA said that APCA supports SB 134. It addresses the need for Alaska's response to behavioral health, lends sustainability to current efforts, and offers another tool to improve care and lower its costs. 2:02:05 PM KEVIN MUNSON, Chief Executive Officer, Mat-Su Behavioral Health Services, Wasilla, Alaska, said that Mat-Su Behavioral is a federally qualified community health center and also operates a community behavioral health program funded by the state of Alaska. He is the chair of the Alaska Primary Care Association and sits on the executive committee for the Alaska Behavioral Health Association. He is also a licensed professional counselor. His training is as a marriage and family therapist but he is licensed as an LPC. He has been in the state 32 years practicing both in behavioral health and in primary care. It has been a long-standing desire of his to see LPCs, licensed marriage and family therapists and other licensed mental health professionals added to the list. MR. MUNSON said the committee has heard a lot about access. When he was in college his university built a new library. Some wise soul who had seen all the lovely sidewalks for other buildings and all the muddy paths decided not to put sidewalks in and to wait and watch to see how students used paths to get to the library and then the sidewalks were laid. The mental health system was designed a long time ago and put in place in statute and in regulation and in practice. SB 74 provided the opportunity to take a step back and do some transformational thinking about how to redesign. The way in which Alaskans are using services in the modern day vs. where things are is a serious mismatch. Many citizens use the emergency rooms to meet their behavioral health needs. In large part that is because of lack of access to behavioral health services in the typical locations where they would go to try to get it. MR. MUNSON said that now LPCs are siloed and only allowed to practice in narrow areas as it relates to Medicaid, which is limited to grant-funded entities. Appropriate professionals need to be in the appropriate places where citizens are most likely to be able to use them. The suicide rates are chilling statistics. One of the fundamental problems is that 54 percent of people who complete suicide have had a primary care visit in the previous 30 days. MR. MUNSON said the primary care provider may have asked about that and may have made a referral to a local mental health center or counseling agency. Ninety percent of those referrals go nowhere. The person just drops out of the system. Federal qualified community health centers have integrated care where those individuals can have a warm hand off to an existing counselor within the context of primary care. Several private practices in the state of Alaska have counselors who do that. They are paying those counselors and not getting reimbursed for that, especially for Medicaid clients because LPCs are not eligible providers. It is not an expandable, replicable model. MR. MUNSON said that he employs six licensed clinical social workers. Last year he lost one, and it took nine months to find another one. In that month, he had five opportunities to hire LPCs to fill that slot. If the state had a reimbursable model, he could have hired one. He has no grant money to fund the licensed social workers. They are funded by the reimbursable work they do. If he had a funding stream for LPCs, since much of his business is Medicaid, he could have replaced that licensed social worker in 30 to 60 days instead of 11 months. MR. MUNSON said it is about giving citizens access when they want it and need it. Most folks don't wake up in the morning and think they will go see a counselor that day. It's usually an acute crisis that drives someone to see a counselor, such as trouble at school, a divorce, a lost job, or a DUI. Those are the times and circumstances in which someone is ready but not necessarily able to get help because many of the helpers are siloed in places someone doesn't think of using or can't get in because the behavioral health system is designed to take care of the most impaired, the most at risk, and the most in need. That leaves individuals who are mild to moderate without viable resources. 2:10:32 PM MR. MUNSON said those could be made viable with a business model for federally qualified health centers for counseling programs for primary care and group practices to take care of the Medicaid population. Removing the statutory barrier for LPCs [to bill for Medicaid] creates a pathway to regulatory development to provide access to citizens who need care. If they have access when they need it, during that initial crisis perhaps they can save the marriage, the children no longer become children of divorce with disruptions to their education. The children avoid other risks, they don't develop Adverse Childhood Experiences scores because of intervention. Taking care of people at their time of need can avoid further, much higher costs because of engagement with the Office of Children Services, Juvenile Justice, and with the courts because appropriate access to a service was provided when needed. MR. MUNSON said that research shows that the best way to take care of people is with a primary care home team of individuals who provide wraparound services, one of which is behavioral health. His center has seen enormous success with individuals by addressing behavioral health problems, such as anxiety and parenting issues, and with intervention around lifestyle choices and change management for people who have chronic medical conditions. MR. MUNSON noted that people with diabetes find it hard to make lifestyle changes. The primary care physician has limited time and, quite frankly, limited skill in how to do change management, but the behavioral health specialist can step in and talk to the person about small, incremental changes that eventually become large, lifestyle changes that change the trajectory of that person's diabetic care. Patients get their A1Cs under control, lose weight, and develop an exercise program. Since 2013, his center has been operating the depression management care IMPACT model that involves the collaboration of the primary care provider, a licensed clinical social worker, and a consulting psychiatrist. His center has seen enormous improvements in treatment and has seen people ease their depression, go back to work, and put relationships back together because the center was able to provide that level of intervention. MR. MUNSON said he employs six licensed clinical social workers. If legislators could wave a magic wand and LPCs could bill Medicaid, he could add three tomorrow and keep them incredibly busy. At this point the intake is within one to two weeks. It could be a day or a couple of days and make a better impact. MR. MUNSON said finally, there is the notion of equity. If someone were to look at a licensed clinical social worker, a licensed marriage and family therapist, and a licensed practical counselor providing counseling, assuming they had about the same amount of experience, no one would be able to tell the difference. They are all well trained, experienced, competent behavioral health professionals. The system recognizes some of the credentials only because they existed at the time the regulations were drafted. Subsequent professionals have been excluded from the process simply because they were late to the party. 2:17:08 PM CHAIR WILSON opened public testimony. PATICK ANDERSON, Chief Executive Officer, RurAL CAP, Anchorage, Alaska, said he was a humble country lawyer, but in 2003 he shifted to managing rural health care systems. He would love to have what Mr. Zepp described in rural communities. RurAL CAP serves the hard to serve, the 20 percent that Mr. Zepp referred to. Abraham Maslow referred to them as the continental divide, the very hard to serve who will need professional services. RurAL CAP serves those individuals, both in Anchorage and in rural Alaska. It is difficult to provide any of those services. RurAL CAP has a grant to provide behavioral health services for Head Start. RurAL CAP operates 24 of those. These children go without basic services because RurAL CAP doesn't have the licensed professionals in rural Alaska. When he was the executive director at Chugachmuit, there were two behavioral health aides in training. It took four years of education and to have the skill level and supervision is complex. MR. ANDERSON said that the residents of Karluk Manor and Sitka Place are the hard to serve. With the dearth of professionals in the state, the RurAL CAP clinical team is being poached constantly. He has had to raise salaries many times. To open up the roles to additional counselors is a wonderful idea. The state can utilize them and will still be short, especially in rural Alaska. He spent eight years on the American Indian/Alaska Native task force on suicide prevention. It is disheartening to see the needs go unserved every day in rural Alaska. RurAL CAP is initiating at board direction whole community healing. RurAL CAP will need advice of professionals and the engagement of communities. Referring to the work of Dr. Martin Seligman and the concept of learned helplessness and the dearth of services and hope in rural Alaska, he is afraid that learned hopelessness will become the norm. He urged the committee to support the expansion of the ranks with licensed professional counselors. 2:20:59 PM SEVILLA LOVE, Integration Coordinator, Alaska Primary Care Association, Anchorage, Alaska, said she is a licensed clinical social worker. She has spent her 20-year clinical career on the front lines of integration, in both urban and rural Alaska, in primary care clinics developing cutting-edge intervention programs throughout Alaska. She worked exclusively with suicidal rural patients at Alaska Psychiatric Institute. Eighty percent of the people she worked with could have been avoidable admissions if they had had the preventative care that they needed in primary care. The committee heard the numbers of those going unseen by behavioral health. She has been the provider capturing those patients who would not otherwise have been seen or been willing to be seen and accept an outside referral to behavioral health because the care was given at their first place of access, which is not specialty standalone behavioral health or treatment centers, but in primary care clinics. MS. LOVE said she now works as the integration coordinator for the Alaska Primary Care Association. She provides training to health centers across Alaska on how to implement a team-based integrated care model by incorporating behavioral health into their daily provision of health care services. She sees the struggles of health centers regarding the quality of care they are able to give. The number one biggest problem is a lack of access to billable, financially sustainable behavioral health providers. Her clinics tell her that they have looked across the country for licensed clinical social workers. They are paying a starting salary of over $80,000 a year, plus loan repayment options, and they still cannot find a licensed clinical social worker or psychologist to fill the primary care role. They are desperate and their patients are desperate for the care. She also hears that they have five LPCs who would jump to take that job that has been open over a year, but the centers cannot hire them because they cannot pay their salaries. She also hears that the medical staff is drowning in behavioral health issues and they cannot properly address them without help and it is burning them out and the turnover rates are killing the continuity of care. It is not just mental health issues. Chronic-care patients also need behavioral health support to make lifestyle changes to improve health. Her centers ask her why they cannot bill for LPCs in primary care. MS. LOVE said that health centers are given this massive task requiring a variety of tools, but they are told they can only use a hammer to build an integrated behavioral health program. This is inadequate. Her answers to their questions are inadequate. Health centers are left empty handed. "When we walk into a clinic, we bring not just our illness, but we bring our whole self and our lifestyle that will impact the outcomes of our healing and the community wellness as a whole . . . Every primary care visit is a behavioral health visit, and we must equip our health centers with the ability to meet this need by allowing LPCs to become billable providers in our primary care clinics," she said. 2:24:44 PM ROBIN MINARD, Chief Communications Officer, Mat-Su Health Foundation, Wasilla, Alaska, said that the Mat-Su Health Foundation mission is to improve the health and wellness of Alaskans living in the Mat-Su. SB 134 is crucial because it helps to address an important health issue facing Mat-Su residents every day, mental health and substance abuse problems. Licensed professional counselors are key behavioral health providers who can help with these problems. These are hard issues for Mat-Su as shown by the last two community health needs assessments. In 2013 residents and professionals said the top five health challenges they faced were alcohol and substance abuse, children experiencing trauma and violence, depression and suicide, domestic violence and sexual assault, and lack of access to behavioral health care. During that same assessment the foundation met with school nurses throughout the borough who said there was a four to eight month waiting list for children and families with Medicaid to see a counselor. Unfortunately, not much has changed since then. There is still a very long wait. When these problems present themselves, people need help then, not eight months later. There are not enough mental health providers in Mat-Su or Alaska. There is one provider for every 860 residents. For the top performer in the U.S., it is one for every 330 residents. Residents need access to behavioral health providers so they can get care early before problems escalate into the crisis stage. MS. MINARD said that Mat-Su Regional is inundated with people in crisis related to behavioral health. In 2016, there were almost 1,200 residents seen in the emergency department with a primary behavioral health diagnosis. Those 1,200 people had over 3,000 visits, and 46 percent were paid by Medicaid. The top diagnoses were suicidal ideation and self-harm, alcohol-related disorders, delirium, dementia, and cognitive disorders. The cost for those visits was $14 million just in facility charges. If residents could get immediate access to care, pain and suffering would be saved, as well as money. An individual counseling session might be around $75 for Medicaid. An average charge for a behavioral health emergency visit is $4,370. A person does need more than one behavioral health visit, but ten visits at $75 would be a savings of $3,600 for just that one patient, not to mention the suffering that people go through. The prevalence of substance abuse and mental health problems in crisis is increasing in Mat- Su and statewide. This legislation could bring the appropriate level of care to people who need care when a problem first presents. 2:29:15 PM DEBRA HAMILTON, Executive Director, New Hope Counseling Center, Soldotna, Alaska, said she has been a professional counselor since 2013. Her counseling center is on the campus of Alaska Christian College, which serves predominantly young adult Alaska Natives. It is also open to the community. She has served on the Board of Professional Counselors since 2013 and is the current chair. Professional counselors would provide services of great quality. Licensed professional counselors are master's level counselors who have extensive training and required coursework. Currently, there are 732 active licensed professional counselors in the state with 447 approved supervisors actively training and supervising the next generation of LPCs. There is a vacuum of accessible services, so SB 134 should be supported. 2:31:39 PM ERIC BOYER, Program Officer, Alaska Mental Health Trust Authority, Anchorage, Alaska, said he serves as the chair of Alaska Health Care Workforce Coalition. Expanding the number of health care practitioners who can bill Medicaid will increase that responsiveness to treat people experiencing behavioral health disorders when they need help vs. being put on a waitlist. The Alaska Mental Health Trust Authority is concerned about their beneficiaries and how to improve their lives. Beneficiaries include Alaskans with mental illness, substance use disorder, developmental disabilities, Alzheimer's and related dementia, and traumatic brain injury. In partnership with Department of Health and Social Services (DHSS), the authority ensures that Alaska has a comprehensive, integrated system of care to provide the necessary services and support for beneficiaries as close to home as possible. 2:33:37 PM DON BLACK, Board Member, Bethel Family Clinic, Bethel, Alaska, said the clinic employs one licensed clinical social worker and one licensed professional counselor and has an employee working toward becoming an LPC in the behavioral health department. The clinic provides services to teens at the Bethel Youth Facility in efforts to reverse destructive habits while these students are still young. The substance abuse programs are embedded in the community as well as in the Yukon-Kuskokwim Correctional Facility, where staff provides individual and group guidance. Youth services are also delivered to court- and medically- referred patients. The clinic receives patients from the local community and surrounding village. As a safety net medical facility, some services are provided without pay in the clinic's efforts to maintain the health of the community. Such is the case with services provided by the clinic's LPC for Medicaid patients, many of whom are youth from villages where suicide rates are high, even by Alaskan standards. The clinic's greater mission is to provide for the health of the community, so sometimes the clinic does that without pay, but the LPC provides the same level of care as the licensed clinical social worker. The work of the LPC is recognized as equivalent to the work of the licensed clinical social worker and is payable by private insurers, but this same work is not recognized and payable by the state's Medicaid policies. In a time of addressing the opioid crisis, the clinic has one hand tied behind its back. Its delivery of services is restricted simply because of how the history of the licensing process for licensed practical counselor and licensed clinical social worker developed in the state. SB 134 unties that hand. 2:35:52 PM JULIE THOMPSON, Licensed Professional Counselor, Bethel Family Clinic, Bethel, Alaska, said she is a licensed professional counselor. She graduated with a master's in mental health counseling in 2007. She has 13 years of experience specializing in trauma-informed interventions for people with a diagnosis of post-traumatic stress disorder (PTSD) and substance abuse disorder. She previously worked two years as a clinician at Yukon Kuskokwim Ayagnirvik Healing Center. She supported individuals in their efforts toward recovery from their substance use disorder. Over 90 percent of these clients suffered from coexisting disorders, usually PTSD, often secondary to trauma experienced as children having grown up in severely dysfunctional homes due to their own parents' unresolved and untreated traumatic histories. She now works for Bethel Family Clinic as a mental health clinician. However, since she is no longer under the Indian Health Service umbrella, she is not recognized by Medicaid as a clinical provider. This is tragic as her agency is a primary partner with the Child Advocacy Center whose primary mission is to provide timely interventions to children who have been identified as victims of sexual abuse and trauma. The center currently employs two clinicians, herself, and a colleague who is a licensed clinical social worker. The clinic has been trying to recruit another social worker for over a year. It is not uncommon for the clinic to have seven referrals in a week from the Advocacy Center. At this time the clinic can respond to none of them. Allowing LPCs access to Medicaid reimbursement will not only save millions of dollars, money that is now spent on emergency room visits, medevacked services, or legal interventions, but will ultimately save lives. "Please support SB 134 and help us help these children, help us save their lives," she said. 2:38:15 PM JEIGH STANTON GREGOR, representing self, Petersburg, Alaska, said he is an LPC in private practice. He and his wife have owned True North Counseling and Consultation for seven years. SB 134 will allow the most vulnerable the same access to high- quality mental health services as people with private insurance or the ability to pay out of pocket. He is confident that in his town of 3,000 people, a private practice could thrive seeing only Medicaid clients. The passage of SB 134 will lead to reductions in costly emergency room visits and acute mental health crises. Preventative care is highly effective in mitigating mental health emergencies. If SB 134 passes, it will be one of the rare times that the state will save lots of money on mental health care for the most vulnerable while increasing mental health care for the most vulnerable. It is truly a win- win situation. As an LPC he does his job because he wants to help people be well and improve the quality of their lives. It is disappointing not to be able to serve the most vulnerable population, given the way the laws are structured now. He has sent a letter to the committee. 2:40:21 PM CHAIR WILSON closed public testimony and held the bill in committee. 2:41:05 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Standing Committee at 2:41 p.m.

Document Name Date/Time Subjects
SB 134 - Sponsor Statement.pdf SFIN 3/16/2020 9:00:00 AM
SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Sectional Analysis.pdf SFIN 3/16/2020 9:00:00 AM
SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Fiscal Note DHSS Medicaid Svcs 2.15.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 SHSS Presentation 2.20.20.pptx SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Alaska ER Report_2016 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Alaska ER Report_2017 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
Sb 134 Alaska ER Report_2018 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Alaska ER Report_2019 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Arctic Mental Health Care Workforce Shortage _10-2-17 - DHSS 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Providence Health Alaska - LOS.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - LOS - Jeigh Stanton Gregor LPC.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Southeast Alaska Regional Health Consortium LOS.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Support Letter Discovery Cove 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Substance Abuse and Mental Health Services Administration - 2018 Key Indicators in the US 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 US DHSS - Supply and Demand for Behavioral Health Occupations 2016-2030 - DHSS 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 US General Account Office - Behavioral Health - Health Care Costs Untreated - February 2019 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Alaska State Hospital & Nursing Home Association - LOS.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Nat'l Survey of Children's Health 2011-2012 - DHSS -ACES 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 AMHTA - Strengthening System-CompPlan_2020-24 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 Rural Health Research and Policy Center - Supply and Distribution of Behavioral Health Workforce - DHSS 2.20.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Alaska State Hospital & Nursing Home Association - LOS.pdf SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 AK Regional Hospital LOS 2.21.20.pdf SHSS 2/21/2020 1:30:00 PM
SB 134