HOUSE BILL NO. 361 "An Act relating to licensing of behavior analysts." 8:43:32 AM REPRESENTATIVE DAN SADDLER, SPONSOR, read from the HB 361 sponsor statement: Autism is a significant and growing problem in Alaska. Statistics show that one in 110 Alaska children - about 1 percent - are born with this developmental disability, characterized by a diminished ability to communicate, social isolation, and other symptoms. While not curable, autism is treatable. Scientific, peer-reviewed studies have shown that early intensive treatment in the form of Applied Behavioral Analysis offers the best opportunity to help people with autism improve their ability to function productively in society. Applied Behavior Analysis is recognized as the basis for the most effective form of treatment for autism by the U.S. Surgeon General, The National Institute of Child Health, and the American Academy of Pediatrics. You can best understand ABA as behavior modification therapy: It seeks to encourage appropriate behavior by assessing and managing the relationship between the environment and the desired behavior. Forty years of research shows that nearly half of people with autism who receive intensive early intervention and treatment do not require lifelong services and support -- and half can achieve normal functioning after two to three years. This can mean lifetime savings of $200,000 to $1.1 million for a person through the age of 55. One of the most important elements in successful autism treatment is having it provided by well-trained behavioral therapists - those who hold the nationally recognized credential of Board-Certified Behavioral Analyst, or BCBA. To qualify as a BCBA, applicants must have a minimum of a master's degree, plus extensive training and experience requirements of up to 1,500 hours of supervised practice in the field, 225 hours of graduate-level classroom work, or a year's experience teaching ABA at the university level. They must also pass the challenging BCBA certification examination. The Board-Certified Assistant Behavioral Analyst, or BCaBA credential, requires slightly lower standards. The state already supports the training of BCBAs through a grant to the Center for Human Development, at the University of Alaska Anchorage. There are about 20 to 30 BCBAs and BCaBAs in Alaska today, although not all of them are currently working in the field. Under current state law, Alaskans with BCBAs cannot bill health insurance companies or Medicaid for their services at a rate that reflects their high degree of training and professional skill because they are not formally licensed. HB 361 addresses this situation by providing for those holding the BCBA or BCaBA credentials in Alaska to be licensed by the Division of Professional Licensing, in the Alaska Department of Commerce, Community and Economic Development. Fourteen other states currently provide licensing and regulate behavior analysts. This approach has the strong support of Alaska BCBAs and of national autism advocacy groups. 8:46:32 AM Representative Saddler continued reading the sponsor statement: By ensuring licensing and higher standards of practice for BCBAs and BCaBAs, HB 361 will: · encourage more people to provide autism services in Alaska · offer higher reimbursement rates for professional providers · provide better outcomes for Alaska children with autism · save the state money by avoiding the need for costly institutional care, and · improve the quality of life for hundreds of Alaskans and their families 8:47:03 AM Vice-Chair Neuman thought the bill looked like good legislation and was interested in hearing more about it. Representative Guttenberg thanked the sponsor for bringing the bill forward. He wondered whether behavioral analysts would automatically slide into an existing board or commission. Representative Saddler replied in the negative; there was not currently a board of professional behavioral analysts. Representative Thompson asked for verification that there were currently 39 Board-Certified Behavioral Analysts (BCBA) in Alaska. Representative Saddler replied that there were approximately 24 BCBAs in the state. Additionally, there were a number of individuals currently going through the program supported by a grant through the Center for Economic Development. He did not know the number of Board- Certified Assistant Behavioral Analysts (BCaBA) in Alaska. Representative Thompson noted that it was expensive to run a board. He asked about licensing fees. Representative Saddler replied that a licensing board would not be required. Licensing came through the department similar to mortuary scientists and other small professional groups; there were not currently fees associated with a professional licensing board. There were some fees that members would pay for licensing, but he did not have the assessment of the cost. Representative Thompson remarked that Representative Saddler's response had satisfied his concern related to the cost per licensee. Representative Saddler added that BCBAs had been seeking the licensure and were willing to accept the national costs and records. He noted the existence of an Autism Insurance Task Force; one of entity's likely recommendations would be to seek licensure through the department at low cost and impact. 8:49:46 AM Representative Wilson wondered whether any investigations would take place. She understood that the majority of board costs were associated with investigations. She asked whether the board would have an investigator. Representative Saddler did not believe the licensees would have an assigned investigator. He detailed that any investigation work would be conducted by the Division of Corporations, Business and Professional Licensing under DCCED. He did not believe many professional boards had their own investigator. Co-Chair Stoltze relayed that some [professional boards] did have their own investigators. Representative Wilson asked to hear from DCCED related to investigative work and the difference between professional boards. She wanted to ensure that licensees were not saddled with costly investigation fees. Co-Chair Stoltze commented that the bill would receive the same scrutiny as any new board due to uncertainty on costs and revenues. He acknowledged the virtue of the idea contained in the legislation. 8:52:11 AM RICHARD KIEFER-O'DONNELL, ASSOCIATE DIRECTOR, UNIVERSITY OF ALASKA ANCHORAGE CENTER FOR HUMAN DEVELOPMENT, ANCHORAGE (via teleconference), spoke in support of the legislation. He detailed that the Center for Human Development was a federally funded University Center of Excellence on Developmental Disabilities; its role was to serve the entire state. The entity supported services and the development of workforce capacity. He focused primarily on the backstory associated with the development of the bill. He referred to work done by the Governor's Council on Disabilities and Special Education that began in 2006; the council developed several reports documenting the needs of children with autism and their families. The council had recommended that the state invest energy into the development of autism specialists. He detailed that a stakeholder meeting had been held in November of 2008 that included state agencies, the private sector, and families. The goal had been to develop recommendations about what the autism specialists should look like. The group had recommended that the Center of Human Development work to establish a BCBA training program. He spoke to funding from a trust and general funds. He discussed the decision to partner with an existing program due to the high need for BCBAs. Mr. Kiefer-O'Donnell relayed that the program was in its fifth cohort of students (a cohort worked for 2.5 to 3 years) working with children and adults with autism. He spoke to the success of the program. He discussed program requirements for certification. Existing BCBAs had been involved with the private sector, school districts, and the state. Additionally, they had been centrally involved with the implementation of the Complex Behavior Collaborative. He relayed that the program had been well-received and was cost-effective. He noted the existing demand for the advanced degree. Program participants were required to have a minimum of a master's degree. He spoke to the well- defined structure within the national credentialing board related to the monitoring of licensees and any associated grievances. 8:58:13 AM ANNETTE BLANAS, CENTER FOR HUMAN DEVELOPMENT, ANCHORAGE (via teleconference), testified in favor of the legislation. She mentioned the importance of licensure related to billing and the ability to retain professionals in Alaska. She discussed the importance of licensure in terms of quality control of professionals for families. Currently families with autistic children were desperate for services. She relayed that with so few options available, families would take any services they could get. She detailed that families had nowhere to direct concerns if services were of poor quality. She believed licensure would offer a level of quality control for professionals. Rural communities with limited access to professionals were at risk of receiving services by unqualified workers. She detailed that rural communities tended to be isolated from other professionals that would recognize the issues early on. The licensure process would provide a venue for addressing the issues. Lastly, families living in rural communities were often even more desperate for any type of services, which could lead families to accept low quality services. The low quality services could create more challenges than what may have existed before services were provided. She stated that licensure provided a foundation of minimum quality across the profession and in all communities; it would also implement a way for families to address ethical concerns. 9:01:18 AM RACHEL WHITE, DOCTOR AND OWNER, GOOD BEHAVIOR BEGINNINGS, ANCHORAGE (via teleconference), spoke in support of the bill. She spoke to her BCBA credentials at the doctorate level. Her company provided in-home services to children with autism. She believed licensing providers would help provide families with access to insurance-covered services. She relayed that currently some insurance companies would not cover behavioral analyst services because no state licensing existed. She communicated that there was a national board that oversaw behavioral analysts where ethical concerns could be directed. 9:03:08 AM LORRI UNUMB, VICE PRESIDENT, STATE GOVERNMENT AFFAIRS, AUTISM SPEAKS, SOUTH CAROLINA (via teleconference), testified in support of the legislation. She spoke to her professional background in the autism field. She worked as a professor at George Washington University Law School; she had a son with autism. She pointed to the national trend of BCBA licensure, which was driven in part by insurance legislation that had passed in 35 states including Alaska. At present 15 states had created a licensure or state certification for behavior analysts; Alabama had recently passed legislation. She believed Maryland had also passed legislation the previous day. She added that states were moving in the direction of licensure to ensure consumer protection. She had studied the bills nationwide and believed the current legislation was sound and well drafted. She detailed that some states had created new boards and other states had put licensure under existing boards. She opined that it could work fine either way. She was in full support of the bill's reliance on the existing national certification. She noted that the credential had been examined and approved by insurance companies. She agreed that the national Behavioral Analysts Certification Board disciplinary mechanism was a real enforcement piece; she had seen individuals lose their certification or receive other reprimands. The bill also created appropriate exemptions for those who should not require a license and created temporary licenses for individuals transferring from other states. 9:06:46 AM SUZANNE LETSO, CEO, ALASKA CENTER FOR AUTISM AND CONNECTICUT CENTER FOR CHILD DEVELOPMENT, CONNECTICUT (via teleconference), spoke in support of the bill. She spoke to her professional background. She pointed to four documents she had provided to the committee (copy on file). One document showed a budget that had been done for Kentucky; the net cost was roughly $7,000 and included the cost of running a disciplinary board. She believed one option was to run disciplinary processes through Alaska by temporarily deferring to the Behavioral Analyst Certification Board disciplinary process until an appropriation was made or sufficient revenue from fees were accumulated. She relayed that the cost of running a licensing program would be low because of the BCBA's ability to absorb costs. She communicated that the state stood to save substantial money by bringing children back in-state who were currently only able to be served out-of-state. She referred to a cost- benefit analysis pertaining to Texas, which determined that by providing intensive Applied Behavioral Analysis (ABA) approximately $208,000 had been saved per student throughout their 18-year education. She referred to a second cost-benefit analysis from a lifespan approach that found savings of $200,000 to $600,000 per child (conducted by Jacobson, Mulick, and Green). Lastly, she pointed to a document she had created on finances in Connecticut. The document looked at the cost of providing ABA placement services in and out of districts; providing the minimum adult day-service programs for people with disabilities for 60 years saved the state $200,000 per person. She relayed that if a disabled person could remain at home for 25 years prior to residential services it would save between $3 million and $4 million per person. She concluded that there were many ways the legislation could have a very positive impact. 9:11:30 AM Vice-Chair Neuman CLOSED public testimony. Representative Wilson requested to hear from the department. She spoke about concerns related to a small board's ability to absorb costs. She wondered if the professionals could be included under an existing board instead of creating a new one. SARA CHAMBERS, DIRECTOR, DIVISION OF CORPORATIONS, BUSINESS, AND PROFESSIONAL LICENSING, DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT, relayed that there were many variables that went into licensing. Centralized licensing statutes and regulations required investigations to take place in response to public complaints or other red flags (for all professions with or without a board). She had determined that potential cost to behavior analysts if licensed, would be fairly minimal. She estimated a $2,000 per year cost for investigative related costs. She noted that investigations could be triggered by license applications when there were requirements for potential licensees to disclose certain information. The initial biennium program estimates included one-time startup costs for a 25 to 42 person program of $700 to $1,200 for licensure. The number would dramatically decrease after the one-time startup had been paid with the first biennium fee (AS 08.01.065 required that all licensing costs were borne by licensees). She detailed that licensing fees for the program could be anywhere from $400 to $600 in the out years. She advised that her estimates erred on the more expensive end. 9:16:23 AM Representative Wilson believed one of the drivers behind the proposed implementation of the board was due to lack of insurance coverage for services. She asked for verification that insurance would pay if there was a board certification in place. Representative Saddler clarified that the program was not a professional licensing board model. He expounded that the program would fall under departmental licensure. He relayed that licensed providers would be subject to reimbursement from private insurance at a higher rate, which would benefit the public, providers, and families. Representative Wilson spoke to a bill from recent years related to payment by private insurance. She wondered if the lack of insurance coverage was a primary driver behind the legislation. She surmised that the proposal [for departmental licensure] had been used because it was less expensive for licensees than a board would be. Representative Saddler replied in the affirmative. He elaborated that BCBAs had experienced challenges billing for services in Alaska. Drawing on national experience, one of the recommendations was that licensing BCBAs would place them in a more easily identifiable category for private health insurance purposes. 9:18:23 AM Representative Thompson appreciated the clarification that the bill would not establish a board. He spoke to the expenses of board travel for meetings. He pointed to a letter in committee members' packets from Premera Blue Cross (copy on file) that suggested specifying that a provider was practicing within the scope of licensure or specialty standards. He asked if the bill sponsor had reviewed the recommendation. Representative Saddler answered that he had not thoroughly addressed the suggestion. He was amenable to the change. Representative Thompson wondered if Premera Blue Cross may require the inclusion of the language before it would honor an insurance claim. Representative Saddler believed the company had provided its support of the bill in writing. Representative Thompson agreed that the company supported the bill, but pointed to its language suggestion. Co-Chair Stoltze asked the bill sponsor to follow up on the suggestion. Representative Saddler agreed. Representative Guttenberg spoke to the fact that the bill would not create a board. He asked for verification that investigative fees would be included in license costs. Ms. Chambers replied in the affirmative. She elaborated that AS 08.01.065 required all costs attributable to a particular licensing program to be paid by licensees (whether there was a board or not). There were 20 boards and commissions and 19 licensed programs without boards or commissions. She detailed that a board or commission had the governance power to dig into practice policies that protect the public; whereas, administrative activities (e.g. issuance of licenses, performance of investigations, and other) were departmental requirements. However, a board had a significant role in driving the level of investigation within the scope of its sentencing guidelines. She summarized that investigative activity was a licensing cost that was legally required to be paid by licensees. She noted that the topic would be discussed over the interim with the legislature. 9:22:39 AM Representative Guttenberg asked for verification that investigation fees did not include criminal prosecutions. Ms. Chambers replied in the affirmative. She detailed that the department had civil authority, but not criminal authority. She referred to an example she had given in a separate bill hearing related to a potential prostitution investigation; the investigation would fall under the purview of the Department of Public Safety or municipal law enforcement. However, a conviction may have a domino effect on an individual's license. She referred to testimony from the national board that there was a strong opportunity for the national board to have a hand in effecting the level of investigation on licensure particularly because the bill leaned heavily on the certification. She elaborated that if an individual's certification was revoked by the national board there would be no cost to licensees, but the state would then have the opportunity to discipline or revoke a license as required by law. Representative Thompson believed the issue was very important. He believed the cost of going after a licensee for misbehavior was a responsibility of the state. He did not support saddling other licensees with the associated costs. He believed the issue should be addressed in the future. Co-Chair Stoltze discussed the cost of the legislation. He believed the fiscal notes had green lights. He pointed to a question related to the overall cost, which was an uncertainty associated with doing anything new in government. He stated that it was good to hear "autism speak." He believed it had been a silent and misunderstood subject, which effected many people. He appreciated the sponsor's efforts. Vice-Chair Neuman remarked that the committee was in support of the collaborative behavioral health program that worked to help autism patients. Co-Chair Stoltze hoped to hear the bill again soon. HB 361 was HEARD and HELD in committee for further consideration. 9:26:20 AM AT EASE 9:27:25 AM RECONVENED