Legislature(2017 - 2018)ADAMS ROOM 519
04/12/2018 09:00 AM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| SB126 | |
| SB105 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 386 | TELECONFERENCED | |
| + | SB 126 | TELECONFERENCED | |
| + | SB 105 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| += | SB 158 | TELECONFERENCED | |
HOUSE FINANCE COMMITTEE
April 12, 2018
9:07 a.m.
9:07:58 AM
CALL TO ORDER
Co-Chair Foster called the House Finance Committee meeting
to order at 9:07 a.m.
MEMBERS PRESENT
Representative Neal Foster, Co-Chair
Representative Paul Seaton, Co-Chair
Representative Les Gara, Vice-Chair
Representative Jason Grenn
Representative David Guttenberg
Representative Scott Kawasaki
Representative Dan Ortiz
Representative Steve Thompson
Representative Cathy Tilton
Representative Tammie Wilson
MEMBERS ABSENT
Representative Lance Pruitt
ALSO PRESENT
Juli Lucky, Staff, Senator Anna MacKinnon; Janey
McCullough, Director, Division of Corporations, Business
and Professional Licensing, Department of Commerce,
Community and Economic Development; Senator David Wilson,
Sponsor; Representative Ivy Spohnholz; Gary Zepp, Staff,
Senator David Wilson.
PRESENT VIA TELECONFERENCE
Dr. Jeff Moore, Orthopedic Surgeon, Anchorage; Debora
Stovern, Executive Administrator, State Medical Board,
Division of Corporations, Business and Professional
Licensing, Department of Commerce, Community and Economic
Development; Ken McCarty, past president, Board of Marital
and Family Therapists, Eagle River; Margaret Brodie,
Director, Division of Health Care Services, Department of
Health and Social Services; Rick Calcote, Chief, Risk and
Research Management, Division of Behavioral Health,
Department of Health and Social Services; Ken McCarty,
Marital and Family Therapist, Eagle River; Melissa
Kemberling, Director Of Programs, Mat-Su Health Foundation,
Matanuska-Susitna Borough; Amy Spargo, Assistant
Superintendent, Matanuska-Susitna Borough School District,
Palmer; Ben Shelton, President, Alaska American College of
Emergency Physicians, Anchorage; Laura Evans, State
Government Affairs Manager, American Association for
Marriage and Family Therapy, Virginia; Jon Zasada, Policy
Integration Director, Alaska Primary Care Association,
Anchorage.
SUMMARY
CSSB 105(FIN)
MARITAL/FAMILY THERAPY LIC & MED SERVICES
SB 105 was HEARD and HELD in committee for
further consideration.
SB 126 VISITING PHYSICIANS WITH SPORTS TEAMS
SB 126 was REPORTED out of committee with a "do
pass" recommendation and with one previously
published fiscal impact note: FN1 (CED).
SB 158 OIL/HAZARDOUS SUB.:CLEANUP/REIMBURSEMENT
SB 158 was SCHEDULED but not HEARD.
Co-Chair Foster reviewed the agenda.
SENATE BILL NO. 126
"An Act providing for an exception to the regulation
of the practice of medicine for a physician who
provides medical services to an athletic team from
another state."
9:08:52 AM
Co-Chair Foster reported that it was the first time the
bill was heard in committee.
JULI LUCKY, STAFF, SENATOR ANNA MACKINNON, shared that the
bill had been brought to the chair by a constituent who was
an orthopedic surgeon and member of the National Council of
Orthopedic Surgery and Spots Medicine. She explained that
the bill was part of a nationwide effort to provide
certainty for sports teams' physicians that were licensed
in another state and traveling with the team in other
states. The bill would add an exemption for state licensure
for the physicians traveling with sports teams. The
physician would have to be licensed to practice medicine in
another state, under a written contract to provide care to
an athletic team in that state and would be limited to
providing services to members of the team while they were
traveling or participating in a sporting event in Alaska.
The sponsor believed that the exemption was very specific.
She added that the first section of the bill dealt with the
exemption and the second section was a conforming amendment
that renumbered exemptions in existing statute.
Representative Wilson asked if the physicians would be
required to fill out any paperwork. Ms. Lucky answered that
the individuals would not have to fill out any additional
paperwork. She clarified that the bill did not allow any
hospital privileges. She relayed that the bill addressed
common concerns like an athlete who was without an asthma
inhaler and the student otherwise would have to go to a
clinic, which would be time consuming.
9:12:31 AM
Representative Thompson asked how other states handled the
issue. Ms. Lucky answered that the effort included getting
the measure passed in all 50 states. She reported that 48
states had either introduced or passed the legislation.
Representative Ortiz asked for the reason the constituent
had brought the issue forward. Ms. Lucky deferred to the
constituent to answer the question.
DR. JEFF MOORE, ORTHOPEDIC SURGEON, ANCHORAGE (via
teleconference), replied that he was the national delegate
for the American Orthopedic Society for Sports Medicine and
the bill was a national program for the society. He
concurred that the bill was currently passed in 35 states
and was pending in 14 states and only allowed authority to
treat "simple" health issues.
Representative Ortiz deduced that the legislation was a
national effort to standardize the rights for visiting
physicians. Mr. Moore answered in the affirmative.
9:15:23 AM
Representative Guttenberg thought the bill seemed simple
and positive but wondered about the "mechanics". He
provided a scenario of a team member that lost their asthma
inhaler and the team doctor wrote a prescription, but the
pharmacist recognized that the physician was from out of
state. He asked how the situation would work. Mr. Moore
replied that without the bill, typically the traveling team
doctor could not prescribe out of state and would need to
call a local physician to get a prescription filled. He
reiterated that the bill precluded surgery. Representative
Guttenberg asked how the Alaskan pharmacist would know the
traveling physician had the authority. Mr. Moore answered
that the pharmacist would need a national "DEA" number
[Drug Enforcement Administration Registration Number].
Representative Kawasaki asked if a physician would have the
ability to write an order for an X-Ray. Mr. Moore answered
that the physicians would not have any inpatient privileges
and would not be able to order an x-ray.
Co-Chair Foster OPENED public testimony.
Co-Chair Foster CLOSED public testimony.
Vice-Chair Gara reviewed the previously published fiscal
impact note from the Department of Commerce, Community and
Economic Development (DCCED) FN1 (CED). He noted the one-
time $2,500 for regulatory costs.
9:20:52 AM
Representative Guttenberg remarked that the committee saw a
variety of trivial fiscal notes. He asked what the $2,500
represented. Ms. Lucky deferred to DCCED.
DEBORA STOVERN, EXECUTIVE ADMINISTRATOR, STATE MEDICAL
BOARD, DIVISION OF CORPORATE, BUSINESS, AND PROFESSIONAL
LICENSING, DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC
DEVELOPMENT (via teleconference), replied that the fiscal
note represented the cost for the board to adopt
regulations to implement the statute change. Representative
Guttenberg voiced that the answer did not address his
question.
JANEY MCCULLOUGH, DIRECTOR, DIVISION OF CORPORATIONS,
BUSINESS AND PROFESSIONAL LICENSING, DEPARTMENT OF
COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT, answered that
the division estimated the costs to adopt regulations from
other similar previous regulation projects. The fiscal note
authorized the division to spend the money on behalf of the
licensees. Representative Guttenberg asked for further
clarification. Ms. McCullough replied that regulation
project costs did vary depending on the number of
interested parties that needed mail notification. She
stated that 731 people would be affected by the regulation
change. She pointed out that one newspaper ad was $772.
Ms. Lucky pointed out that the funds were receipt supported
services and General Fund (GF) was not used in updating
regulations.
Co-Chair Seaton MOVED to REPORT SB 126 out of committee
with individual recommendations and the accompanying fiscal
note. There being NO OBJECTION, it was so ordered.
SB 126 was REPORTED out of committee with a "do pass"
recommendation and with one previously published fiscal
impact note: FN1 (CED).
9:25:50 AM
AT EASE
9:26:15 AM
RECONVENED
CS FOR SENATE BILL NO. 105(FIN)
"An Act relating to the licensure of marital and
family therapists; relating to medical assistance for
marital and family therapy services; and providing for
an effective date."
9:26:22 AM
Co-Chair Foster indicated that Representative Ivy Spohnholz
carried the companion bill, HB 353 Marital & Family Therapy
Lic. & Services.
REPRESENTATIVE IVY SPOHNHOLZ, explained that the bill
updated and clarified the supervisory requirements for a
licensed Marital and Family Therapist (LMFT). The updated
requirements would allow the therapists to become eligible
for Medicaid reimbursement. The purpose of the bill was to
increase the access to behavioral health care, which
currently the state had a shortage of providers. She
indicated that the fiscal note was "modest" and would
reduce costs over the "mid-term" by allowing more people
struggling with behavioral health issues access to health
care before the condition was acute. She qualified that the
bill was not an expansion of Medicaid and was a "step in
the right direction" to increase access to behavioral
health care.
9:28:35 AM
SENATOR DAVID WILSON, SPONSOR, spoke to the legislation. He
explained that the bill involved the professional
application of assessments, treatments, and psychotherapy
services to individuals, families, and couples for the
purposes of treating and diagnosing emotional and mental
disorders. Currently, LMFTs were only allowed to provide
services in community health clinics or physician mental
health clinics, which limited the number of willing
providers. The legislation expanded medical assistance
reimbursement services to cover those services provided
directly and independently by LMFTs. He delineated that SB
105 specifically defined the supervision training hours and
requirements for an Associate Marital & Family Therapist,
expanded the list of approved healthcare professionals that
can provide group supervision of an Associate Marital &
Family Therapist and, added Marital & Family Therapy
services as eligible to render and bill for Medicaid-funded
services as independent practitioners under Alaska Statute
47.07.030 (b). He furthered that SB 105 "dovetailed" with
SB 169 (Medicaid: Behavioral Health Coverage) [Senator
Giessel - Adopted Both Bodies 05/04/2018] which removed 30
percent of onsite requirement for supervision and provided
for a telecommunication device option. He voiced that the
bill dealt with the shortage of behavioral health care
professionals that was addressed in SB 74 (Medicaid
Reform;Telemedicine;Drug Databas)[CHAPTER 25 SLA 16 -
06/21/2016] but was accidentally omitted during regulation
drafting by the Department of Health and Social Services
(DHSS). The department also discovered that the necessary
statute that would allow the regulations did not exist and
the bill also provided "clean-up" language for SB 74.
Finally, the bill also fit together with the departments
federal 1115 waiver [Allowed a state to use federal
Medicaid funds in ways that are not otherwise allowed.]
that authorized expansion of behavioral health services. He
related that DHSS's experienced challenges in extending
behavioral health services throughout the state due to the
geographic nature of the state and problems with
recruitment and retention of a behavioral health care work
force. He spoke to the cost of recruiting a licensed
clinical social worker of up to $100 thousand, which took
up to 6 months to fill versus recruiting a LMFT at a cost
of up to $40 thousand. The LMFTs were equally trained and
more plentiful.
9:31:57 AM
GARY ZEPP, STAFF, SENATOR DAVID WILSON, reviewed the
PowerPoint presentation titled "CCSB 105(FIN) -
Marital/Family Therapy" (copy on file). He reviewed items
on slide 1:
What is Behavioral Health?
The term "behavioral health" is the umbrella that
encompasses all contributions to mental wellness,
including substance abuse, behavior health disorders,
schizophrenia, bipolar disorder, and other mental
health concerns.
Behavioral health promotes well-being by preventing or
intervening in mental illness, such as depression or
anxiety, but also aims to prevent or intervene in
substance abuse or other addictions.
One in four Americans experience a mental illness or
substance use disorder each year, and the majority of
these people also have a co-occurring physical health
condition, according to the American Hospital
Association.
National Behavioral Health Needs:
20% of inmates in jails suffer from a serious
mental illness;
60% of inmates suffer from substance abuse
conditions;
80% of people who suffer from mental illness are
unemployed;
26% of all homeless shelter residents suffer from
severe mental illness;
34% of homeless people also have chronic
substance abuse issues.
Source: US National Library of Medicine/National
Institutes of Health; National Association of State
Mental Health Program Directors
Mr. Zepp believed that early intervention prevented an
emergency room (ER) crisis, incarceration, and
institutionalizing and individual with behavioral health
issues. He noted that ER visits costs were much higher than
therapy sessions. He moved to slide 2:
Alaska's Behavioral Health Needs:
Alaska's suicide rate is 21.8 per 100,000 people,
the national rate is 11.5 per 100,000 people;
Approximately 145,790 Alaskans need mental and
behavioral health services; Of those, only 19% receive
behavioral health services;
It's estimated that 65% of Alaska prisoners
suffer from some form of mental health issues and 80%
have drug or alcohol addictions;
In 2016, the Mat-Su Regional Emergency Department
spent $43.8 million for patients with behavioral
health diagnoses for 3,443 patients;
This does not include additional costs for law
enforcement, dispatch, and ambulance services.
Source: Arctic Mental Health Working Group; Alaska
Behavioral Health Systems Assessment Final
Report; Alaska Dispatch News; Treatment Advocacy Center
Alaska's Behavioral Health Care Shortages - Psychiatrists:
Alaska needs approximately 106 additional
psychiatrists to meet the national standard, per
100,000 adults;
Alaska is 20% - 54% below the estimated need for
psychiatrists in Alaska, as compared to national
standards;
2.9 years = average retention time for mental
health care providers in Alaska;
The ratio of vacant mental health provider
positions in rural Alaska is 1 in 5 as compared to 1
in 10 in urban Alaska.
Source: Arctic Mental Health Working Group
9:35:43 AM
Mr. Zepp adressed slide 3:
What is CSSB 105(FIN)?
If enacted, the proposed legislation would add
licensed Marital and Family Therapists to the list of
independent practitioners to address the shortage of
Medicaid-eligible behavioral health providers in the
state, afford more options for beneficiaries, and
increase access to behavioral health care.
Currently, licensed Marital and Family Therapists are
only allowed to provide services in community health
clinics or physician mental health clinics, which
limits the number of willing providers. CSSB 105(FIN)
expands medical assistance reimbursement services to
cover those services provided directly/independently
by licensed marital & family therapists.
Specifically, CSSB 105(FIN):
Defines the supervision training hours and
requirements for an Associate Marital & Family
Therapists. This will create a path for an associate
to become a fully licensed marital & family therapist.
This in turn creates more fully licensed marital &
family therapists and increases the capacity of
behavioral health services in our state!
Expands the list of approved health care professionals
that can provide group supervision of an Associate
Marital & Family Therapist; and Adds Marital & Family
Therapy services as eligible to render and bill for
Medicaid funded services as independent practitioners
under AS 47.07.030(b).
9:37:43 AM
Mr. Zepp specified that the bill mandated 1,700 hours of
clinical contact and of that amount 100 hours were
individual supervision and 100 hours of group supervision.
He delineated that Section 2, page 3, lines 5 through 13,
of the bill expanded the list of providers to 6 different
mental health care providers who could deliver group
supervision to the associates who were attempting to reach
the level of LMFT. He added that currently all supervisors
had to meet board approval. He moved to slide 4:
Benefits of CSSB 105(FIN) and how does it help Alaskans?
By expanding Medicaid optional services to
include licensed marital & family therapy, it provides
an opportunity to intervene early to help Alaskans, so
they don't end up in an expensive emergency room
setting or in a costly institutional setting;
Example: Private clinical hourly cost = $150 per
hour vs. $4,370 average one-time emergency room
behavioral health
cost
By increasing the number of health care
professionals available to provide services for those
who cannot currently receive services or are on a
waiting list for behavioral health services, both in
urban and rural areas of our state;
Improve behavioral health care services to
Alaskans improves their health outcomes and reduces
spending on physical health issues;
Add additional health care professionals to the
group supervision of an associate licensed marital &
family therapist should enable more associates to
become a fully licensed marital & family therapy;
Better access to behavioral health care leads to
positive outcomes and likely avoids expensive
emergency room care, correctional incarceration, or
psychiatric institutionalization.
9:39:35 AM
Mr. Zepp concluded on slide 5:
Acknowledgment and Thanks!
Thank you for your support of CSSB 105(FIN)
"An Act relating to the licensure of marital and
family therapists; relating to medical assistance for
marital and family therapy services; and providing for
an effective date."
CSSB 105(FIN) is supported by:
Alaska Board of Marital & Family Therapy;
American Association for Marriage and Family
Therapy;
Mat-Su Health Foundation;
American College of Emergency Physicians/Alaska
Chapter;
Alaska Emergency Room Physicians
Representative Guttenberg understood the need for the
legislation. He asked who set the standards for the hours.
He wondered where the requirements came from. Mr. Zepp
replied the hours had been established by the Board of
Marital and Family Therapists. Representative Guttenberg
asked if there had been any feedback from licensees. Mr.
Zepp deferred the answer to the past president of the
board.
KEN MCCARTY, PAST PRESIDENT, BOARD OF MARITAL AND FAMILY
THERAPISTS, EAGLE RIVER (via teleconference), voiced that
he was on the regulatory board for 6 years. He replied that
the language clarified the standard of 1,500 hours of
clinical time with 200 hours of supervised clinical time;
100 hours for individual and 100 hours for group. He
reported that the way the statue currently read caused
confusion. He furthered that the provision broadened the
supervisory role and was included due to the difficulty of
finding a licensed LMFT supervisor in areas of the state
like Utqiaqvik, Nome, Kotzebue, and even Seward. The board
noted that the supervisory shortage caused LMFT trainees to
pursue a different career. Other professionals lead
clinical groups in the areas noted therefore, the
opportunity was available for others to gain the
certification by allowing other behavioral health care
professionals to supervise LMFT trainees.
9:44:37 AM
Representative Guttenberg wanted to ensure potential
licensees did not consider that the hours were too high or
a barrier to entry. Mr. McCarty replied that he was a
licensed supervisor and had the ability to provide the 100
hours of individual supervision through an associate under
contract agreements in places like Utqiaqvik but could not
do a group in the same manner. The bill allowed the trainee
from a place like Utqiaqvik to capture the supervision.
Representative Spohnholz clarified that the bill did not
change the hours it took to become a LMFT. The bill
clarified the requirement statute and also allowed
supervisors from other professions to provide supervision.
She believed the provision would increase the number of
qualified LMFTs and had not heard any negative feedback
relating to the change.
Representative Tilton welcomed the students, parents, and
teachers from Academy Charter School in the Matanuska-
Susitna Borough in the audience.
Co-Chair Foster also welcomed the students.
9:48:11 AM
Representative Wilson remarked that the bill was adding
another optional service. She pointed to Section 3, page 3,
of the bill and read the following "? the department may
offer only the following optional services?" and listed the
LMFT category. Representative Spohnholz replied that they
were not adding an optional service. The bill only added
LMFTs to the range of options. Representative Wilson
believed it was an option.
Senator Wilson clarified that SB 105 merely added the LMFTs
to the list of professionals who had the ability to bill
individually for optional Medicaid services. Otherwise, the
LMFT would only be able to provide the services as part of
a community mental health clinic. Representative Wilson
stated that without the language they would not be
authorized to bill Medicaid and thought it was the whole
reason for the bill. She expressed concern over the $1
million fiscal note [FN4 (DHS)]. She noted that federal
receipts were in the amount of $660.5 million [thousand]
and the GF match was $340.3 thousand [FY 2020]. She
referred to the analysis on page 2 and read the following
"$1,581 annual per recipient cost times 633 recipients
equaled $1,000,773." She wondered where the number of 633
recipients had come from.
Mr. Zepp deferred to DHSS for the answer.
MARGARET BRODIE, DIRECTOR, DIVISION OF HEALTH CARE
SERVICES, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via
teleconference), answered that the Division of Behavioral
Heath prepared the fiscal note.
Co-Chair Seaton asked whether Ms. Brodie could answer the
question of whether the bill added an optional service and
the explain the difference between mandatory and optional
services. Ms. Brodie replied that the service was already
covered under the duly eligible recipients, which was
covered under Medicaid and Medicare. The bill added a
provider to a currently covered service.
9:52:42 AM
Representative Wilson did not understand the answer. She
wondered why it had to be added to AS 47.07.030 (b) if it
was not adding to the optional services list.
Senator Wilson deferred the answer to Mr. Calcote.
RICK CALCOTE, CHIEF, RISK AND RESEARCH MANAGEMENT, DIVISION
OF BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL
SERVICES (via teleconference), replied that SB 74 expanded
the list of licensed providers who could bill Medicaid
independently for Medicaid services. Under the statute,
LMFTs were not included on the list and the bill allowed
LMFTs to become independent providers for Medicaid
services.
9:55:17 AM
Representative Wilson stated it had been her exact point
that the bill added to the list of providers. She asked
whether the 633 individuals were currently receiving
services in a clinical setting and would switch to a
private setting and for the current number of providers
that would be able to bill Medicaid individually. She
stated that Medicaid "was one of the fastest growing areas"
and the bill was adding services, which was concerning to
her. Mr. Calcote responded that the fiscal note assumed
that a number of individuals were currently in the Medicaid
system and were receiving behavioral health treatment
through physicians' offices, mental health physician
clinics, and community behavioral health centers. He
delineated that by expanding the number of providers the
division assumed that individuals not currently being seen
within the Medicaid system would be served. The division
based the fiscal note on projected figures derived from
Medicaid prevalence data that indicated there were a number
of unserved recipients who were eligible but did not seek
services. In addition, the division used the national
average number of unserved recipients that was
approximately 10 percent. The division employed the
greatest number of participants that could possibly be
served (633) by expanding the new provider set. He
indicated that most likely the number would be fewer than
633. Representative Wilson asked how many providers were
currently unable to bill Medicaid. Mr. Calcote was unable
to answer the question accurately. He detailed that he
lacked the necessary data.
9:59:02 AM
Representative Wilson asked how many providers it would
take to service 633 participants.
Senator Wilson replied that currently there were roughly 85
LMFTs in the state. The numbers were currently unknown
because the choice to become a LMFT was personal. Some
businesses like the Federally Qualified Health Centers
would more likely pursue LMFTs to be able to bill Medicaid
for them. He emphasized that the bill was not "necessarily"
adding recipients to Medicaid, the recipients were
underserved, and the bill would "open the door" to provide
more access to mental health services. He suggested that
current LMFTs providing testimony could better answer the
question. Representative Wilson stated that she would wait
for public testimony to provide the answer.
Vice-Chair Gara remarked that leaving family problems
untreated was not "free". He noted that the state had the
highest rate of repeat child abuse and drug and alcohol
abuse, which affected children and families. He voiced that
fiscal notes do not report the amount of expenditures
avoided as a result of expanding services and thought the
information would be useful. He believed that not expanding
the services would cost the state more.
10:02:40 AM
Representative Kawasaki mentioned that currently clinical
social work services was part of the provider list. He
asked whether clinical social workers provided marital and
family advice for a patient. Senator Wilson was unsure of
the numbers and deferred the answer to providers. However,
he acknowledged that the number of clinical social workers
were much fewer and cost more to hire because their
services were in demand for other practices and services.
Representative Kawasaki returned to the question of whether
the bill was adding an optional service. He referred to the
fiscal note analysis on page 2 and read the following:
This fiscal note reflects the fact that licensed
marriage and family therapist services have been added
to the AS 47.07.030 list of Medicaid optional services
for which the State will reimburse.
Representative Kawasaki alluded to the conflicted testimony
regarding the optional service and felt that it was a
policy decision. He wanted a definitive statement regarding
whether the legislation was adding another optional service
that could potentially cost the state more in the future.
10:05:45 AM
Mr. Calcote responded that the addition of the LMFT
provider in statute would certainly allow them to bill
Medicaid services directly. The providers would no longer
have to bill through a community or behavioral health
clinic. He assumed that a small percentage of the Medicaid
population might seek the services of a LMFT independent
practitioner for extended treatment. He was unclear how
much the Medicaid bill would be affected. The fiscal note
was the division's best estimate and was in the "outside
range" of probability. The department would know more after
the bill took effect. Representative Kawasaki stated that
the current number of LMFTs were known and thought it was a
yes or no answer. He stressed that the bill offered a new
optional service to LMFTs who otherwise was unable to bill
Medicaid "prior to the bill passing". He asked whether he
was correct. Mr. Calcote replied in the affirmative. He
deferred to the sponsor for further answers.
Mr. Zepp replied that it was also his understanding that
LMFTs were currently eligible through community or
physicians' behavioral health clinics billing and the bill
authorized coverage for LMFTs to bill directly through an
independent practice.
Co-Chair Seaton wanted to gain clarity on the bill. He
asked if the bill was a "two-way street". The LMFT could
bill for a service listed under the Medicaid optional or
mandatory services and anyone who is qualified could bill
for marital and family therapy services. He asked whether
he was correct. Mr. Calcote clarified that family
psychotherapy was already an existing Medicaid billable
service and anyone qualified to provide the service may do
so. He restated that by changing the statute the bill
merely allowed LMFT to bill for Medicaid services. Co-Chair
Seaton asked if anyone else qualified could also bill for
marital and family therapy services.
10:12:42 AM
Mr. Calcote replied in the affirmative. Anyone licensed in
the state and was a qualified Medicaid provider of marital
and family therapy could provide the service.
Representative Thompson cited the presentation and surmised
that there was a severe shortage of family therapists in
the state. He deduced that the bill was attempting to
increase the number of providers covered under Medicaid.
He thought the untreated individuals could end up in the
emergency room (ER) or incarcerated. He viewed the bill "as
a cost avoidance in some fashion." He asked whether he was
correct. Senator Wilson answered in the affirmative.
Mr. Zepp interjected that the costs of ER services was
"astronomically higher" than treatment in a clinical
setting. He reported that according to DHSS 2016 data,
$621 million was spent in ER billing and 53.9 percent were
Medicaid clients. He determined that the state already bore
the costs because the first 23 hours in an ER was covered
by Medicaid and after that the hospital assumed the costs.
Representative Kawasaki supported the bill. He knew that
LMFTs would like the ability to bill Medicaid. He spoke
about arguments in other sectors of the medical field that
felt expanding services "cut into the market" of the
established licensees. He wondered if any behavioral health
care providers that currently billed Medicaid were opposed
to the bill. Senator Wilson replied in the negative.
Representative Guttenberg asked Ms. Brodie if there had
ever been reports done on avoidance costs. He thought it
would be interesting to see the difference between
individuals getting expanded coverage versus going to the
ER and if any previous data existed.
10:17:43 AM
Ms. Brodie responded in the negative. She elaborated that
the issue spread across other departments and divisions.
She exemplified the costs related to the Office of Children
Services (OCS) removing children from the home and the
state paying for therapy that was required to allow them to
return home coupled with the Department of Corrections
(DOC) involvement and the costs related to the use of ERs.
Representative Guttenberg recognized that costs were far
reaching to other agencies and institutions as well. He
would do some research on the national level.
Senator Wilson replied that an all claims database was
necessary to gather the data. Lacking the data base, it
would be difficult to extrapolate the data; the department
did not have the capability to perform the study.
Co-Chair Seaton referenced the fiscal note from DHSS. He
read the following from the last paragraph on page 2
some of those professionals are already billing for their
services under the umbrella of a mental health physician
clinic." He inquired whether mental health physician
clinics were currently providing marriage and family
therapist services and were able to bill for the services
without the service listed as an optional service or if the
clinics billed under another service such as psychological
services.
10:20:07 AM
Ms. Brodie answered that all behavioral health services
were optional services. Co-Chair Seaton was trying to
determine the current system. He asked whether some other
behavioral health providers were billing for marriage and
family therapist services under a different category. Ms.
Brodie deferred to Mr. Calcote.
Mr. Calcote replied that Co-Chair Seaton was correct.
Currently community behavioral health centers and mental
health physician clinics were able to bill any behavioral
health Medicaid clinic service that included individual,
group, or family psychotherapy. He expounded that any
qualified providers working in the provider agencies who
were able to deliver the services billed Medicaid with the
psychiatrist provider identification billing number. Co-
Chair Seaton asked if the bill would require a "plan
amendment" and whether it was in the fiscal note. Mr.
Calcote understood that the expansion did not require a
state plan amendment.
Representative Wilson pointed to the following on page 2 of
the fiscal note:
FY2019 General Fund Match in the Services Line: $50.0
for development of business rules in the Medicaid
Management Information System [(MMIS)] detailing the
parameters for services/reimbursement.
Representative Wilson thought the $50,000 cost seemed high
and inquired how the cost was derived. Ms. Brodie answered
that the expenditure was for the development of the
business rules. She elaborated that currently the system
was only able to accept claims from Medicare and had to
accept Medicaid only claims as well. The system development
for the MMIS was extremely expensive. Representative Wilson
was very uncomfortable with the fiscal note and how it was
developed. She agreed with the services the bill wanted to
provide and she thought most recipients were currently
receiving the services. She was not certain amending the
bill would help with the fiscal note. She thought the
fiscal note was "one-sided" and she wanted to see the "cost
shifting advantages."
10:24:18 AM
Co-Chair Foster noted there was a forthcoming amendment and
the bill would not report out of committee during the
current meeting. He asked the department to further examine
the fiscal note.
Vice-Chair Gara asked whether Mr. Calcote considered two
countervailing factors when writing the fiscal note. He
deduced that the number of recipients receiving the service
from more expensive providers who would switch to the LMFT
would reduce costs, but the state recession was increasing
Medicaid enrollment. Mr. Calcote answered that many
variables could not be completely quantified. The precise
number of LMFTs who would provide service to Medicaid
clients was unknown. The national 10 percent underserved
figure matched the states historic data. He elaborated that
even though the state may have 633 new people seek
services, the division did not know how many of the
individuals would seek services from an independent
provider versus a clinic and did not know how many
individuals would terminate services within a calendar
year.
10:27:01 AM
Vice-Chair Gara ascertained that Mr. Calote stated factors
that may lower the fiscal note yet other issues may
increase the fiscal note, like a prolonged recession. He
guessed that the department had developed a fiscal note
based on all factors "to the best of its ability". Mr.
Calcote replied in the affirmative.
Co-Chair Foster asked to hear from invited testimony.
Mr. McCarty testified in support of the bill. He stressed
that the state did not have enough providers. He had
conducted a survey in 2013 and had found that over 35
percent of the providers were working for agencies that
already billed for their services. He discovered that only
8 percent of LMFTs wanted to bill Medicaid directly, but at
least 8 percent more providers would be available. He
indicated that regarding addiction, morphine treatment was
only effective with psychotherapy. He had been concerned
over the fiscal note and in 2013 when SB 74 was being
deliberated he examined what happened in other states when
they included LMFTs as providers. He had found there was no
increase to the budget in other states and they experienced
reductions due to decreased visits to places like ERs,
mental institutions, or other intrusive interventions due
to early treatment.
Representative Kawasaki asked Mr. McCarty for the typical
hourly rate for LFMT services. Mr. McCarty replied that the
hourly rate and what the insurance would pay was different.
The hourly rate was $215 and typically insurance paid 80
percent of the rate.
10:32:54 AM
Representative Kawasaki asked whether Mr. McCarty was aware
of the audit and billing requirements for Medicaid and if
would he offer the service for Medicaid recipients. Mr.
McCarty answered that he had already done what was
necessary to become a Medicaid provider including spending
"tens of thousands of dollars." He expected that other
behavioral health "agencies" would demonstrate they were a
"trustworthy entity" and want to bill Medicaid.
10:33:50 AM
DR. MELISSA KEMBERLING, DIRECTOR OF PROGRAMS, MAT-SU HEALTH
FOUNDATION, MATANUSKA-SUSITNA BOROUGH (via teleconference),
spoke in support of the bill. She shared that the
foundation shared ownership in Mat-Su Regional Medical
Center. She elaborated that the foundation was "very in
touch" with Mat-Su residents. The foundation conducted a
community health needs assessment every three years. The
top challenges were related to behavioral health; alcohol
and substance abuse, childhood trauma, depression and
suicide, domestic violence and sexual assault, and lack of
access to behavioral health care. The bill would help
increase the number of providers available to clients. She
related that school nurses had conveyed to the foundation
that lack of access to behavioral health service was a
challenge due to a 4 to 8 months wait list for individuals
and families to see a counselor who accepted Medicaid. The
borough only had one behavioral health provider for every
860 residents versus one provider to every 330 residents in
other communities in the country. She informed the
committee that the Mat-Su Regional Medical Center had no
behavioral health treatment so an individual who went to
the ER with a behavioral health crisis would be stabilized
for a cost of $4,370. and most of those individuals went to
the ER 5 or more times per year. She indicated that in Mat-
Su roughly 300 individuals had behavioral health needs. She
offered that LMFT visits cost $150 per visit. She voiced
that the opioid crisis increased the need for behavioral
health and the foundation was attempting to build a
behavioral health continuum of care staffed with caring
professionals through investing in non-profits and
providing scholarships to train new behavioral health
providers. The effort was aimed at keeping individuals out
of institutional and ER care and was providing local jobs.
She believed that SB 105 would help the foundation
accomplish building its continuum of care.
Co-Chair Seaton was not finding that the bill authorized
marital and family therapists to do anything. He thought
that the bill provided for any qualified professional could
provide marital and family therapy services. He wondered if
there was another category of behavioral health or if the
idea of the bill was that marital and family therapy
services was not sufficiently covered. Ms. Kemberling
observed that in the Mat-Su a "handful of agencies" had
counselors including LMFTs that were able to bill Medicaid,
but individual providers were prohibited from billing
Medicaid. The clinics and agencies that billed Medicaid had
a significant shortage of staff. She concluded that if
private providers could bill Medicaid the result would
provide more access to families needing behavioral health
care.
10:41:03 AM
Co-Chair Seaton asked whether LMFTs would only be able to
bill Medicaid for marriage and family therapy services
under the bill. Ms. Kemberling answered that what the bill
allowed independent LMFTs to bill Medicaid. Co-Chair Seaton
asked for what services. He wondered if it was limited to
marital and family therapy.
Senator Wilson interjected that a marital and family
therapist was a designated licensure that was qualified
through educational experience and going through the
licensure process that made the licensee eligible to bill
for a myriad of therapies. He added that the therapy was
not limited to marriage and family issues per say but
included psychotherapy services and treating and diagnosing
mental disorders. Co-Chair Seaton asked Senator Wilson to
follow up with the definitions.
Representative Wilson ascertained that currently an
independent LMFT could not bill Medicaid but if the bill
passed a LMFT could bill for all services under the
parameters of the professional qualifications and
licensure. She asked if she was correct. Senator Wilson
replied in the affirmative.
10:44:36 AM
AMY SPARGO, ASSISTANT SUPERINTENDENT, MAT-SU BOROUGH SCHOOL
DISTRICT, PALMER (via teleconference), spoke in support of
the bill. She shared that her focus was on school safety
and advocated for increasing access to behavioral health
services for students in crisis and preventative health for
students who were experiencing trauma. The school district
engaged in a pilot program with the Mat-Su Health
Foundation. Five of the district's schools, through
behavioral health wellness grants, partnered with community
providers to work part-time in the schools and address the
behavioral health needs of the students and families. In
order to provide the services, the program needed Medicaid
eligible providers to give equal access to all families.
She discovered that there were not enough Medicaid eligible
providers in the borough. The bill allowed more private
providers to be eligible under the plan. She referenced the
conversation about how to quantify preventative work. She
related a 2015 study by the Center for Benefit Cost Studies
in Education from Columbia University that determined each
dollar spent on prevention returned the equivalent of $11
to students and society later. She noted the connection
between social and emotional learning and increased
academic performance.
10:47:48 AM
Co-Chair Foster OPENED public testimony.
BEN SHELTON, PRESIDENT, ALASKA AMERICAN COLLEGE OF
EMERGENCY PHYSICIANS, ANCHORAGE (via teleconference), spoke
in support of the bill. He related that as an ER physician
he cared for patients daily that were in crisis with mental
health conditions who were not able to access timely
outpatient care, which lead to the crisis. He believed that
timely outpatient care could have prevented their condition
from deteriorating into a crisis. He restated his support
for the bill.
LAURA EVANS, STATE GOVERNMENT AFFAIRS MANAGER, AMERICAN
ASSOCIATION FOR MARRIAGE AND FAMILY THERAPY, VIRGINIA (via
teleconference), spoke in support of the bill. The
organization represented approximately 62 thousand LMFTs.
She believed that the bill would expand access to mental
health services that were already covered and simply allow
more provider choice. She offered that a study showed a
decrease of about 21.5 percent ER utilization after 6
months of marrital and family therapy and that patients
were taking better care of their health generally.
Regarding the fiscal note, she believed the costs would be
minimal because the services were already covered, but
simply offered an additional provider to address the 10
percent increase in recipients. She indicated that the 10
percent increase would happen whether or not marital and
family therapy was part of the program because Medicaid was
an entitlement program. She noted that Alaskan LMFTs were
clinical providers and licensees could diagnose and provide
treatment for mental and behavioral disorders. The LMFT
therapy differed from other methods by employing a holistic
or systemic perspective and believed that the needs did not
occur in a vacuum and the individual's relationship dynamic
affected a person's mental or behavioral disorder. However,
the services provided were all clinical and able to be
billed via Medicaid. She stressed that the bill was not
providing for other services or non-clinical services to be
added to Medicaid reimbursement.
Vice-Chair Gara asked if the definition of family therapy
included treatment of a child or one parent individually.
Ms. Evans replied that LMFTs saw individuals and families
and thought the scenario merely related to the billing
code.
10:55:38 AM
JON ZASADA, POLICY INTEGRATION DIRECTOR, ALASKA PRIMARY
CARE ASSOCIATION, ANCHORAGE (via teleconference), testified
in support of the bill. He related that the association
represented Alaska's federally qualified health centers
that provided behavioral health care integrated with
medical services. The centers operated outside of the
community behavioral health centers and could not currently
bill for services provided by LMFTs. He voiced that
expanding the Medicaid billable labor force was the number
one priority for the association and it supported the bill.
He emphasized the chronic and serious shortage of billable
providers and some positions in the centers were open for
up to one year. Adding LMFTs to the list of providers would
enable the centers to serve a wide variety of patients. He
would submit additional written testimony.
Co-Chair Foster set an amendment deadline for the following
day at 9:00 a.m. He intended to hear the bill on Friday,
April 13, 2018.
SB 105 was HEARD and HELD in committee for further
consideration.
Co-Chair Foster reviewed the schedule for the following
meeting.
ADJOURNMENT
10:59:16 AM
The meeting was adjourned at 10:59 a.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB126 Sectional Analysis ver J 3.19.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 126 |
| SB126 Supporting Documents-Suport Letters 3.19.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 126 |
| SB126 Sponsor Statement 3.19.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 126 |
| CSSB 105(FIN) Arctic Mental Health Working Group - Alaska's Mental Health Needs 4.5.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 105 |
| CSSB 105(FIN) Consolidated LOS 4.5.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 105 |
| CSSB 105(FIN) Nat'l Assoc State Mental Health Program Directors_Fact Sheets on Behavioral Health 4.5.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 105 |
| CSSB 105(FIN) Sectional Analysis 4.5.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 105 |
| CSSB 105(FIN) Sponsor Statement 4.5.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 105 |
| CSSB 105(FIN) Summary of Changes 4.5.18.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 105 |
| CSSB 105(FIN) – LMFT PP.pdf |
HFIN 4/12/2018 9:00:00 AM |
SB 105 |