Legislature(2023 - 2024)DAVIS 106
05/02/2023 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| HB167 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 167 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
HB 167-MINORS IN FACILITIES OUTSIDE AK
3:04:03 PM
CHAIR PRAX announced that the only order of business would be
HOUSE BILL NO. 167, "An Act relating to the care of children in
state custody placed in nonprofit institutions outside the
state."
3:04:56 PM
REPRESENTATIVE FIELDS, as prime sponsor, began the PowerPoint
presentation, titled "HB 167" [hardcopy included in committee
packet] on slide 2, which read as follows [original punctuation
provided]:
HB 167 seeks to improve in state care and reduce
reliance on for profit out of state psychiatric
residential treatment facilities (PRTF).
Excessive reliance on out of state PRTFs is expensive,
abusive, and perpetuates systematic violence against
predominantly Alaska Native children.
The result is that the State of Alaska pays high
costs, often provides substandard care, sometimes even
harming the mental and behavioral health of kids.
3:06:25 PM
REPRESENTATIVE FIELDS showed slide 3, which read as follows
[original punctuation provided]:
2022 DOJ Report:
1. In Alaska, children with behavioral health
challenges are institutionalized out of state at high
rates and for long periods
2. Many of these children are eligible for community
based services and supports that Alaska offers through
Medicaid, however the state has failed to provide
necessary services to the extent that it violates
Title II of the Americans with Disabilities Act (ADA).
3. With the adoption of the Medicaid 1115 Waiver, the
State of Alaska must endeavor to provide the necessary
community services for children in integrated and
appropriate settings that do not rely excessively on
institutionalization.
4. For profit institutions have been shown in many
cases to be abusive, ineffective and expensive
REPRESENTATIVE FIELDS moved to slide 4 and pointed to several
headlines from news articles. He moved to slide 5 and noted
that the issue of care not being provided in Alaska goes back a
century.
3:08:16 PM
REPRESENTATIVE FIELDS moved to slide 6 and stated that there is
increasing public equity involvement nationally. He said that
the Department of Justice (DOJ) report found that, when a
private residential treatment facility is out of state, it is
hard for families to travel and have a connection. He expressed
the opinion that it is problematic when a profit motive plays
into the care the state provides. He said that the quote on the
slide was made by United Health Services Chief Financial Officer
Steve Filton and discusses that, since there is a lack of
community options, the facilities are able to extract higher
profit margins.
REPRESENTATIVE FIELDS paraphrased slide 7, which read as follows
[original punctuation provided]:
Provo Canyon is one of many PRTFs owned by Universal
Health Services.
Provo Canyon has a history of abuse allegations that
span decades. Despite repeated complaints, Alaska
continues to send children to Provo Canyon.
According to the Alaska DOH, approximately 345 Alaskan
children were sent to Provo Canyon between 2012 2022.
Alaska spent more than $31 million in Medicaid funding
over six years sending 511 kids to PRTFs like Provo
Canyon in Utah.
REPRESENTATIVE FIELDS moved to slide 8, which showed a diagram
illustrating "profits over patients" as it relates to the
troubled-teens industry. He suggested the companies see all the
new assistance programs as profit opportunities.
REPRESENTATIVE FIELDS showed slide 9, which read as follows
[original punctuation provided]:
Bring The Kids Home: A Model That Works
The Bring The Kids Home (BTKH) Initiative was
established in 2004 by the Alaska DHHS and the Alaska
Mental Health Trust to address the high numbers of out
of state placement of children and to provide
resources for in state treatment.
Primary Goals:
1. Significantly reduce the numbers of Alaskan youth
placed in Outside PRTFs.
2. Build capacity and core competencies of in state
providers to serve children with all levels of
behavioral health needs.
3. Develop an integrated, culturally competent system
to serve children as close to home as possible.
3:11:14 PM
REPRESENTATIVE FIELDS turned to slide 10, which read as follows
[original punctuation provided]:
Bring the Kids Home (Con't)
Accomplishments
28 new BTKH operating grants helped develop services
in 12 communities.
During FY 06/07 56 new in state beds were developed.
Funded expanded culturally competent, close to home,
tribal mental health services that accessed 100%
federal reimbursement rate.
Addressed workforce issues with new grants through
training and mentoring.
In FY 2007, enrolled 58 students in new "Residential
Services Certificate Program
REPRESENTATIVE FIELDS showed slide 11, which read as follows
[original punctuation provided]:
Bartlett Regional Hospital saw a need in the region to
alleviate the high number of youth placed in out of
state psychiatric facilities.
Addresses urgent mental health needs by providing
the first crisis center for youths in Southeast
Alaska.
Reduces the number of children experiencing a
behavioral health crisis who must leave their
communities and families.
8 bed capacity, 24/7 crisis care.
Provides 23 hour crisis observation and
stabilization and crisis residential services up to 7
days.
REPRESENTATIVE FIELDS brought attention to slide 12, which read
as follows [original punctuation provided]:
The State is negotiating with USDOJ, and a negotiated
agreement may provide guidance on how Legislature can
support better in
state care.
Workforce shortages and API being over capacity are
opportunities to look at systems improvement now.
If the Legislature wants to support improvement of
care in communities, this bill is an opportunity to
convene
Department of Health / Department of Family &
Community Services
Alaska Mental Health Trust Authority
Tribal Entities
Stakeholders
to provide guidance on how legislature can support
Bringing the Kids Home
3:14:15 PM
COURTNEY OWEN, Staff, Representative Zach Fields, Alaska State
Legislature, on behalf of Representative Fields, prime sponsor,
offered the sectional analysis of HB 167 [copy included in
committee packet], which read as follows [original punctuation
provided]:
Section 1: This section amends AS 47.14.100(a) to
delete language that permits the department to place a
child in its custody in for-profit institutions
providing care outside of the state. This section adds
language that clarifies that the department may place
a child in its custody in a non-profit institution
providing care outside of the state.
Section 2: This section amends AS 47.14.112(d) to
require the department to report annually to the
legislature on the number of children placed in non-
profit institutions providing care out of the state.
3:15:07 PM
REPRESENTATIVE SADDLER questioned what the problem would be with
for-profit institutions.
REPRESENTATIVE FIELDS responded that the report from DOJ
identified some of the for-profit institutions as having a
history of abuse. He deferred further explanation to the
invited testifiers.
3:16:52 PM
JEFF JESSEE, representing self, shared that he retired in 2021.
He came to Alaska in 1980 as a volunteer for the Disability Law
Center. He shared that he served as the CEO of the Alaska
Mental Health Trust Authority for 22 years and was the Dean of
the College of Health at the University of Alaska Anchorage for
four years. He said that this is the third time Alaska has
faced this issue, as in the 1980s there was the Alaska Youth
Initiative, which was designed to ameliorate the issue
Representative Fields is seeking to address. He explained that
the system was set up to develop individualized programs for
children with severe need, and if there is no community-based
option found, then the children would become institutionalized
out of state. He recounted that, during Governor Frank
Murkowski's administration with Gill Gilbertson as commissioner,
there were 700 children cycling into out-of-state placements.
He further recounted that the trust invested $15 million in
developing the infrastructure. He stated that with venture
capital for training and start-up funding for in-state programs,
the number of children was lowered to 70.
MR. JESSEE related that it is very difficult to get the kids
back after being sent out of state, and regardless of whether
the placement is for profit or not, a clinical record has been
created that concludes being in the facility is the best option.
He explained that creating an adequate system of community
placements would not be complex, just difficult, as it would
require a rate structure that provides an incentive for
community providers in Alaska, whether nonprofit, for-profit, or
Tribal. He explained that the formula used in the Bring the
Kids Home initiative had the department work with the trust,
providers, families, and other stakeholders to craft a plan. He
explained that the first step would be to understand who is
being sent out of state, how the child is sent, and what could
have been done to keep the child in the state. He stressed that
the amount of money spent on out-of-state placements is huge,
especially when compared to the possible in-state cost. He
suggested that investing in community services would reduce the
cost of out-of-state placements. He pointed out that during the
Alaska Youth Initiative, investments were made towards community
programs and the number of out-of-state placements went down, as
did the cost. He expressed encouragement that the issue is
getting renewed attention.
3:26:42 PM
KATIE BALDWIN-JOHNSON, COO, Alaska Mental Health Trust Authority
(AMHTA), said it is important to recognize that the child exists
within the family, and to better address child mental health, it
must also be addressed in the context of the family. She
acknowledged that the Bring Kids Home initiative has an
impactful framework, as the system has progressed on the
recommendations made. She pointed out that some of the
strategies under the initiative are still working today to keep
children in communities. She explained that one of the
strategies focusing on early childhood has helped increase the
attention to the age group of prenatal through age eight;
furthermore, through the initiative therapeutic foster care was
identified as an alternative to in-patient care. She added that
this has been a cost-effective alternative to residential
treatment.
3:30:10 PM
MS. BLADWIN-JOHNSON said that AMHTA has been working with
partners to improve its system and ensure that all beneficiaries
have access to behavioral health care as close to home as
possible. She commented that strengthening and growing the
network of community-based services needs to be a priority, as
well as providing start-up funding for expanding organizations.
She concurred that examining the rate setting methodology is
important and the trust needs to work on the Medicaid
reimbursement structure. She stressed that with less workforce,
services and programs are closing, and this is an exacerbated
issue in rural communities where many may have limited access to
resources. She said that one of the contributing factors in
challenging access to behavioral healthcare is the number of
providers that accept Medicaid. She continued that aside from
behavioral health community providers, independent practitioners
generally do not accept Medicaid patients. She suggested that
if there were more providers that see Medicaid patients, access
would expand, as too would the levels of care.
3:34:49 PM
MS. BLADWIN-JOHNSON said AMHTA is working on the establishment
and expansion of crisis stabilization services across the state.
She pointed out that child intervention and prevention efforts
are important, as the earlier children's needs are addressed,
the less acute their symptoms become. She stressed that using
out-of-state facilities should be a last option, when all others
are exhausted. She concluded that the trust is looking forward
to being included, along with state, community, and Tribal
partners, to address the issues, such as crisis care, complex
needs, and getting resources to families and children sooner.
3:37:28 PM
ANGEL GONZALES, Board President, Facing Foster Care, shared that
she was in foster care at 5 years old, until she was adopted at
16 years old. While she was not sent to a treatment facility,
she had a younger brother who was, and she witnessed the
negative effects on him and her foster siblings. She stated
that she never saw someone who left the state for treatment come
back better, and while she was working at Covenant House, she
saw that the youth were worse off than when they went in. She
said she had been terrified of treatment because of the outcomes
she had seen. She shared that she would try her best to show
she was a good child and did not need treatment. She shared a
situation where she almost had to go into treatment since there
was no foster placement; however, a placement was found at the
last minute. She stressed that foster children need more
support around them, and they should not be sent out of state to
face abuse. She said that former foster children who are grown
up now have long-lasting effects because of the medicine used
while they were in treatment. During her time at Covenant
House, she recounted that she saw children who were abandoned at
out-of-state centers, and they would often end up in homeless
shelters, as they did not know how to live outside of an
institution. She noted that the chance is high that these
children get picked up by traffickers, die, or go to jail.
3:43:22 PM
REPRESENTATIVE MINA questioned the resources available before
youth are referred for out-of-state treatment.
3:44:28 PM
HEATHER CARPENTER, Health Care Policy Advisor, Office of the
Commissioner, Department of Health (DOH), answered that the
department first exhausts any in-state placement before an out-
of-state one is considered. She said that the processes of both
DOH and the Department of Family and Community Services (DFCS)
are explained in the DOJ report.
3:45:30 PM
TAMMIE WILSON, Family Coordinator, Office of the Commissioner,
Department of Family and Community Services, explained that,
when DFCS has a child who is at a facility, a packet of
information is provided to all in-state providers. She said
when there is no response, then specialized, out-of-state
options are considered, namely ones that address the child's
aggression. She said that the packets would be sent to Medicaid
and non-Medicaid facilities, with the Medicaid facilities looked
at first. She stressed that DFCS does not look as to whether
the facility is for-profit or not, rather, what services the
child would receive.
3:47:03 PM
REPRESENTATIVE MINA asked what the wait times would be for a
child waiting to be referred to an out-of-state facility. She
questioned if there is a difference in wait times between
nonprofit and for-profit facilities.
MS. WILSON answered that many facilities have not opened the
same number of beds as before the COVID-19 pandemic, and the
more specialized facilities are the ones with wait lists. In
response to a follow-up question regarding the average wait
time, she said that it could be a week to two weeks.
REPRESENTATIVE MINA asked what the conditions are of the child
while they are waiting.
MS. WILSON answered that if there is a bed, the child will be
provided one while he/she "wait the wait list."
3:49:21 PM
REPRESENTATIVE RUFFRIDGE noted that the price Medicaid pays for
residential services varies from state to state, with some
states lobbying for other state's Medicaid rates. He questioned
the treatment rate that Alaska's Medicaid pays, and whether
there is a different cost for in-state versus out of state.
MS. CARPENTER answered that the rates are individualized for
each provider.
3:50:37 PM
FARING BROWN, Acting Director, Division of Behavioral Health,
Department of Health, explained that each state undergoes a
rate-setting process in collaboration with the federal Division
of Behavioral Health, and this is done by examining the
specialty areas in facilities. She explained that the rate can
be the in-state Medicaid rate or higher, and Alaska has a higher
rate for in-state facilities than out-of-state facilities.
REPRESENTATIVE RUFFRIDGE asked if regulation directs the Alaska
Medicaid program to never pay above what the in-state treatment
would be for another state. He further asked if this rate is
internally set, or if the legislature could provide guidance.
3:53:05 PM
MS. CARPENTER explained that during the rate-setting process,
DOH must work with the Centers for Medicare and Medicaid
Services (CMS) and be deliberate in how rates are set. She said
DOH's goal is to have as many services as possible in state in
order to keep children in their home region at the lower level
of care, and only escalate up to out-of-state care when
necessary. She explained that CMS has other guidelines, as DOH
must allow any willing provider to enroll in Medicaid,
regardless of whether the provider is for-profit or not. She
added that when thinking about out-of-state placement, DOH
cannot make the final placement decisions, as it works with the
parent or guardian. If the child is in state custody, DOH would
work with the Office of Children Services (OCS) or the Division
of Juvenile Justice (DJJ).
3:55:52 PM
REPRESENTATIVE FIELDS relayed that the Kaiser Family Foundation
published an article, titled Profit Strategies: Psychiatric
Prioritize Out-of-State Kids, April 2022. He asked that this be
distributed to committee members as it adds further context to
the question.
3:56:15 PM
CHAIR PRAX offered his understanding that the rates are
controlled, and as far as Alaska is concerned, DOH is looking
for a provider who can provide the service. He asked if
providers with a higher price would come into play.
MS. CARPENTER responded that DOH is looking for providers to
enroll, as it cannot pay Medicaid until a provider enrolls in
Alaska Medicaid. She shared that in looking at Medicaid rates
for hospitals in the state, they are all individual and at cost-
based rates. She offered to provide additional material around
how Medicaid rates are set.
3:57:54 PM
MS. WILSON clarified that the facilities are not soliciting
DFCS, rather, DFCS is actually soliciting them. She said that
some cases are so specialized there is no in-state placement
option. She explained that part of her job is to figure out
what the child's discharge will look like when he/she comes back
to Alaska, ensuring that the child has all the coordination
needed to be successful and reunited with the family.
3:59:42 PM
REPRESENTATIVE SADDLER questioned whether the provider shortage
is for a particular skill or just overall.
MS. WILSON answered that DFCS has opened the Complex Care Unit
so it can be determined why children have been sent out of
state. It would also determine whether the child would still
have the same issues if in the beginning there was a different
kind of care. She said that the current issue for providers is
needing staff for therapy, substance abuse, and specialized
foster care.
REPRESENTATIVE SADDLER asked if there is anything intrinsically
improper with for-profit out-of-state facilities.
MS. WILSON shared that she works with both for-profit and
nonprofit facilities, and she ensures that they have the same
requirements for meeting the needs of the child.
4:03:19 PM
REPRESENTATIVE SUMNER requested the bill sponsor to address the
fiscal notes.
REPRESENTATIVE FIELDS explained that the proposed legislation
points to a problem that has already been identified by DOJ. He
expressed the hope that the bill would prompt discussion with
those in Alaska who have experience around the problems of for-
profit out-of-state facilities. He expressed the opinion that
the state should consider the best way to ensure these
facilities are only used as a last resort. He pointed out that
in-state care needs to be "fleshed out." He shared that DOH has
created a working group recently that will be examining rates
over the summer. He expressed the hope that by January 2024,
the committee will have thought about what should be in the bill
and how it can line up with the working group's solutions.
4:05:50 PM
MR. JESSEE, in response to Representative Saddler, said that he
has not compared incidents in the state to incidents in other
states; however, he suggested that every state struggles with
foster care. He explained that the children who are put into
intensive community services have high incidences of childhood
trauma; therefore, any early on support to the family and the
child would minimize the amount of trauma; thus, reduce the need
for services later.
4:08:35 PM
REPRESENTATIVE SADDLER offered his understanding that there is
an inadequate supply of community-based services in rural
Alaska. He asked whether it is realistic to provide rural areas
the range of services needed.
MR. JESSEE answered that the entire continuum of care cannot be
in a small village; however, the Tribal health system has
developed resources. For example, there are behavioral health
aides in many villages. He concurred that providing services
early is important and may lead to the child not having to leave
the village.
4:10:38 PM
CHAIR PRAX asked about the shift from 700 children to 70
children placed in out-of-state care facilities.
REPRESENTATIVE FIELDS confirmed that the number of children in
out-of-state care facilities is about 70 today, with about 20 in
state custody.
4:11:20 PM
MS. CARPENTER explained that there were 965 children in out-of-
state placement in 2004, and the children were covered by
Medicaid or in state custody. As of yesterday, she stated that
there are 70 children in out-of-state care paid for by the
state's Medicaid dollars. She added that, since DOJ began its
investigation in 2020, out-of-state placements have been reduced
by 25 percent.
4:12:34 PM
CHRISSY VOGELEY, Special Assistant, Office of the Commissioner,
Department of Family and Community Services, stated that the
number of children in state custody that are in out-of-state
facilities is 25. According to historical records going back to
2008, she stated that at any given time there has been about 30
children in the state's custody who were placed out of state.
MS. WILSON reminded members that before a child goes out of
state, the placement goes through a court hearing to examine why
the child's needs cannot be met in Alaska. She said that these
placements are reviewed every six months.
4:13:39 PM
REPRESENTATIVE SADDLER asked for the difference between the 25
and 70 figures that have been referenced.
MS. CARPENTER answered that 70 children have Medicaid as a
payment source to the facilities, and 25 children are in state
custody. In response to a follow-up question, she stated that
the 25 children are also on Medicaid. She continued that for a
child with a specialized need, DOH must find a provider who
meets this need. She said this may also include a provider that
is not yet enrolled in the Medicaid program. She pointed out
that Ms. Wilson has been working to get specialized need
providers enrolled in the program.
4:16:07 PM
MS. WILSON added that there are currently five children who are
in private-pay agreements with facilities, with the requirement
that these facilities work towards enrolling in Medicaid. She
elaborated that the agreement provides a bridge between getting
the care for the child and ensuring facilities are enrolling in
Medicaid.
4:17:50 PM
REPRESENTATIVE MINA asked if there is legislation in other
states that prohibits out-of-state, for-profit referrals for
kids.
REPRESENTATIVE FIELDS expressed uncertainty.
4:18:11 PM
CHAIR PRAX inquired about legal challenges in trying to enforce
specific organizations, whether for-profit or nonprofit. He
asked for Legislative Legal Services to answer.
REPRESENTATIVE FIELDS offered his understanding that the concern
was not flagged by Legislative Legal Services. He suggested
that the question would be how the state could best prioritize
care in a legal way, while supporting the best care.
4:19:40 PM
CHAIR PRAX asked whether the population of children needing
service has complicated or intense needs.
MS. WILSON answered "both," as the children are aggressive, even
toward staff. She said that it is DFCS's responsibility to
ensure that a child placed at a facility is monitored. She said
the problem has been for the child to continue to be successful
when back in Alaska. As initiatives like Bring the Kids Home
have come, services have grown, and so has the complexity of
children.
4:21:56 PM
REPRESENTATIVE SADDLER questioned the success rate of DFCS's
treatment systems and programs.
MS. WILSON answered, "We've come a long way." She recounted a
successful case and said there are more successes than not. She
said that in any state, there are struggles in the balance in
the kinds of services needed.
4:23:30 PM
MS. CARPENTER shared that she had a direct family member receive
care in an out-of-state facility. She stated that it is DOH's
priority to get the best placements. She pointed out that the
1115 waiver was part of Senate Bill 74 [passed during the
Twenty-Ninth Alaska State Legislature], and this has been
hopeful. She explained that using this waiver, along with the
Bring the Kids Home initiative, community level services were
created. She said that this allows children and parents to be
cared for at a lower level, intervening on a higher level of
care. She stated that the goal is for kids to be kept home,
closer to family, and the 1115 waiver supports this on the
behavioral health side. She said DOH has expanded Medicaid-
covered services to individuals who are at risk of developing a
mental health or substance-use disorder. She explained that
this is an important policy decision because previously an adult
had to be diagnosed with mental illness or a child as severely
emotionally disturbed, as "at risk" was not allowable criteria
outside of a waiver. She said that this shift was done to get
service to children sooner. She stated that consideration must
be made toward getting more providers in the state and ensuring
there are enough community-based providers for adults. She
emphasized the importance of the continuum of care from
childhood through adulthood.
4:26:39 PM
CHAIR PRAX asked the testifiers to identify things that the
departments have done to bring down the number of children in
out-of-state care.
MS. CARPENTER answered that there has been a collection of
things over the years, including continued technical assistance
to providers and efforts like the Complex Behavioral
Collaborative. She explained that the biggest game changer has
been the 1115 waiver, as well as bringing on new service lines
that can be reimbursed, as this reduces reliance on grant-based
efforts. She said that this past spring, DOH has approved a 4.5
percent increase to the 1115 waiver rate.
4:29:38 PM
MS. WILSON addressed the fiscal note. She stated that if DFCS
could not utilize half of the private, for-profit residential
treatment centers, then over half of the children who are
currently in care would have nowhere to go. She said that when
DFCS finds the right placement for the child, and it happens to
be out of state, there is a strict process to determine there
were no other alternatives. She added that OCS has augmented
rates, which would be higher pay for staff overseeing children
who require more time.
MS. CARPENTER added that in DOH's response to DOJ, it stated
that a steering committee would be created to start the process
of hearing from providers. She thanked the legislators for
their interest in the topic.
4:32:16 PM
REPRESENTATIVE FIELDS commented that it is indeed not a simple
issue of the placements being in-state or out of state, as
sometimes children are placed in Anchorage outside of their home
region.
4:33:10 PM
CHAIR PRAX asked if DOH would be reporting to the legislature
before next session.
MS. CARPENTER answered no; however, DOH would plan to keep
stakeholders and legislators well-informed.
4:33:59 PM
CHAIR PRAX thanked the bill sponsor and the invited testifiers.
[HB 167 was held over.]
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 167 Fiscal Note FCS-OCS.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 Psych Facilities Prioritize Out-of-State Kids - KFF 2022.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 ver A AK DOH 3 year review.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 ver A AK Justice Forum 2012.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 ver A Sectional Analysis 4.21.2023.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 ver A Sponsor Statement 4.21.2023.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 ver A.PDF |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 ver ADN Article 2019.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 ver DOJ Report 2022.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |
| HB 167 PowerPoint.pdf |
HHSS 5/2/2023 3:00:00 PM |
HB 167 |