Legislature(2017 - 2018)BUTROVICH 205

03/05/2018 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:30:06 PM Start
01:30:41 PM SB169
01:59:37 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ SB 169 MEDICAID: BEHAVIORAL HEALTH COVERAGE TELECONFERENCED
Heard & Held
-- Testimony <Invited and Public> --
          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