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