Legislature(2017 - 2018)BUTROVICH 205
03/05/2018 01:30 PM Senate HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| SB169 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | SB 169 | TELECONFERENCED | |
SB 169-MEDICAID: BEHAVIORAL HEALTH COVERAGE
1:30:41 PM
CHAIR WILSON announced the consideration of SB 169. He
entertained a motion to adopt the CS as the working document.
SENATOR MICCICHE moved to adopt the proposed CSSB 169, version
30-LS1283\J, as the working document.
1:31:24 PM
CHAIR WILSON objected for purposed of discussion.
1:32:25 PM
SENATOR GIESSEL, Alaska State Legislature, sponsor or SB 169
said the CS addresses access to mental health care services in
Alaska. She related that Alaska leads the nation in suicide and
domestic violence. Alaska's suicide rate is twice the national
average. Sixty-six percent of Alaskan adults have one or more
Adverse Childhood Experiences. Twenty percent of Alaska adults
have been diagnosed with a behavioral health disorder. Substance
abuse and misuse is not something new to the state. As a
lifelong Alaskan--like Senator Begich, she has been aware of
issues of alcohol and illegal substances in the state for her
entire lifetime. At the core of these issues are things like
Adverse Childhood Experiences, isolation, depression, just to
name a few. Alaska lacks sufficient behavioral health services
to meet the needs and has for decades.
She said in 2015 the Senate worked on SB 74, the Medicaid reform
bill. One intent of the bill was to expand behavioral health
care services through an expanded clinician base. In other
words, enabling more clinicians to offer services by removing
restrictions to providing services under Medicaid. This was a
big issue in Senate Finance. There were three meetings a week
for a month. Behavioral health services was a huge priority. At
that time, the Division of Behavioral Health assured the
committee that it could address through regulation the rule, AAC
135.030(e), that limits who can provide behavioral health
clinical services. "But then they came back two years later and
said, 'Oops, sorry. We'll need a statute,'" she said.
SENATOR GIESSEL said two years passed while they waited for this
to happen. Nonetheless, it was enacted, but there is no visible
improvement in mental health care services. Waitlists are 18
months to 2 years in length. The Division of Behavioral Services
says Medicaid expansion has increased the demand for behavioral
health and substance abuse treatment by nearly 5,000 adults.
Emergency rooms have become behavioral health clinics. Emergency
units have nowhere to place these people. One anecdotal report
is that some emergency rooms had to hold these folks for as long
as 13 days. A friend who was in an emergency room for several
hours was brought a food tray with a spoon as the only utensil.
Because it is so common to have behavioral health patients in
the emergency room, it simply provides "safe trays" for all the
patients in the emergency room. That underscores the magnitude
of the problem. Not only is the emergency room the most
expensive form of treatment, it is an inappropriate use of
emergency beds. The Alaskans who go to emergency rooms are still
not getting the services they need.
She referenced a letter from the Mat-Su Health Foundation that
underscores this issue. The Division of Behavioral Health has
applied for a Section 1115 Behavioral Health Demonstration
Waiver. It is undergoing public comment until April 15. When she
asked how long it will be before something is done, she was told
two more years. Alaskans cannot wait two more years for critical
services. SB 169 is intended to do what the 1115 demonstration
waiver is supposed to do: rebalance the current behavioral
health care system to reduce the overreliance on acute and
institutional care and shift to more community-based or regional
care, to intervene as early as possible before symptoms cascade
into functional impairments, and to improve the overall
behavioral health care system.
She explained that only a few clinics in Anchorage can accept
patients for behavioral health services and be able to bill
Medicaid. Under a rule put in place by bureaucrats, a
psychiatrist must be physically present 30 percent of the time
and supervising other providers in order to bill Medicaid. This
drastically limits access to vital behavioral health care. There
are only 114 psychiatrists licensed in the state of Alaska. Some
clinics with special waivers and federally-funded community
health centers will accept Medicaid patients but these are
limited. She brought up the example of Dr. Tracey Wiese, a
psychiatric mental health nurse practitioner, who cannot
supervise anyone.
1:39:35 PM
SENATOR GIESSEL said the recidivism reduction program, part of
SB 91 that passed in 2016, established help for the
rehabilitation of parolees but most need behavioral health or
substance abuse services, adding yet more to the population of
need. The Department of Corrections is experimenting with
Vivitrol, but they also need behavioral health services.
Medicaid providers are limiting their clientele to the most
severe cases or those who are leaving the corrections system.
The letter from the Governor's Council on Disabilities and
Special Education addresses that aspect.
She said SB 169 states that the behavioral health clinic
services may be provided by psychiatrists or psychiatric mental
health advanced nurse practitioners. Direct supervision is
required of other clinicians in order to be reimbursed by
Medicaid. That supervision can be provided by a psychiatrist or
psychiatric mental health advanced nurse practitioner. The bill
defines direct supervision as being provided either in person or
telehealth. Criteria are included for supervision. The bill will
go into effect 90 days after the governor signs it, which is
sooner than two years from now. She noted that the bill is
supported by the Mat-Su Health Foundation, the Governor's
Council on Disabilities and Special Education, and the Alaska
Behavioral Health Association. Behavioral health services is one
of the legislative priorities of the Alaska Council of School
Administrators.
1:43:05 PM
CHAIR WILSON asked for an explanation of the difference in the
CS for SB 169.
1:43:33 PM
JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State
Legislature, presented the differences between version D and
version J of SB 169. She said the difference is the addition of
another supervisory person on page 1, starting on line 7. This
is an "advanced practice registered nurse licensed under AS
08.68 who is certified to provide psychiatric or mental health
services." Beginning on page 1, line 13, going to the second
page, are some sidebars and descriptions of what the oversight
should entail.
1:44:27 PM
CHAIR WILSON removed his objection. Finding no further
objection, version J was adopted.
SENATOR BEGICH called the bill timely and necessary. "Let's move
forward," he said.
SENATOR MICCICHE asked how many advanced nurse practitioners are
licensed in Alaska.
SENATOR GIESSEL said the estimate is 150. The CS would double
the number of potential supervisors but would also open the door
to more telehealth. Some clinics with waivers are using out-of-
state psychiatry oversight. This bill would ensure that that
door is open even wider.
SENATOR MICCICHE asked if there is a specific certification
associated with psychiatric or mental health services.
SENATOR GIESSEL said the statutes do not parse out the multiple
specialty certifications of nurse practitioners. That is defined
in regulation.
1:46:45 PM
CHAIR WILSON opened public testimony on SB 169.
1:47:18 PM
JON ZASADA, Policy Integration Director, Alaska Primary Care
Association, supported SB 169. He said the Alaska Primary Care
Association supports the bill and appreciates that Senator
Giessel recognizes that the current supervision model serves as
a bottleneck for the provision of behavioral health services.
The Association does request that physicians be added as a
provider type to supervise LMFTs [licensed marriage and family
therapists]. Expanding the behavioral health labor force has
been the number one priority of Alaska community health centers
for the past two years. They also support SB 105 and HB 353.
Community health centers have made major investments in
behavioral health that have resulted, in the last two to three
years, in a 25 percent increase in encounters with patients, the
addition of many new providers in health centers, and over
11,000 Alaskans receiving behavioral health services through
local community health centers. There is a shortage of billable
providers. In a recent behavioral health work force survey, they
are down 12 to 18 health providers in health centers across the
state that could serve up to 9,000 additional patients. They
want to be able to supervise new providers as they come in. That
is why they support the bill and the addition of physicians as
supervisors.
SENATOR MICCICHE said why AS 08.64 would not allow a general
practitioner to fulfill the supervisory role.
SENATOR GIESSEL said that is the State Medical Board statute.
She said she initially wanted to say either a "physician
licensed under or advanced nurse practitioner with specialty."
However, Randall Burns, Director of the Division of Behavioral
Health advocated that it remain a psychiatrist so the specialty
care would be there. She said she nevertheless has no opposition
to opening the door as wide as possible.
1:50:42 PM
ART DELAUNE, Member, Governor's Council on Disabilities and
Special Education, supported SB 169. He said besides
representing the Governor's Council, he also was testifying as a
parent and guardian. His 24-year-old son has severe depression,
anxiety, and schizophrenia. He has ongoing suicidal thoughts and
has been admitted to hospital three times. Fairbanks, like other
communities, is lacking mental health services. It has been two
to four years since mental health has been accessible to those
who are low income, have only Medicaid, or no health insurance.
No private practice is accepting Medicaid. Access to mental
health services is almost nonexistent. He supports SB 169
because it would allow more access to professionals for those in
need. His son has been waiting 2.5 years for services at
Fairbanks Community Mental Health. When he is overwhelmed he has
to go to Fairbanks Memorial Hospital, which is a costly
alternative and is just for crises. His son is no longer
employed because of his mental health condition. He gets
medications but that is about all. A lot of people are waiting
for care. One small agency in town tried to operate a wellness
program. The biggest barrier was needing an on-site psychiatrist
30 percent of the time for Medicaid billing requirements, so
that program is gone. Federal Medicaid mandates the supervision
of therapists by psychiatrists. The use of television technology
and other modern technologies would greatly enhance mental
health services for people in communities, especially in rural
areas. He just retired last week from Access Alaska and saw a
great need for mental health services in rural areas. The
Governor's Council on Disabilities and Special Education
supports SB 169 and he does too.
1:55:23 PM
At ease.
1:57:24 PM
CHAIR WILSON reconvened the meeting and closed public testimony.
SENATOR GIESSEL said they all understand the urgency and
importance of the topic.
CHAIR WILSON held SB 169 in committee.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 169 30-LS1283 D.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |
| CS for SB169 SHSS v J 2-28-18.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |
| SB169 Sponsor Statement (CS, vsnJ) 3-2-18.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |
| SB169 Sectional Analysis CS vsn J 3-2-18.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |
| SB169 Letter of Support GCDSE 2-16-18.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |
| CS for SB169 SHSS v J 2-28-18.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |
| SB169 Letter of Support ABHA 2-23-18.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |
| Fiscal Note SB 169.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |
| SB169 Letter of Support MatSu Health Foundation 3-4-18.pdf |
SHSS 3/5/2018 1:30:00 PM |
SB 169 |