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." 10:18:40 AM SENATOR DAVID WILSON, SPONSOR, introduced himself. GARY ZEPP, STAFF, SENATOR DAVID WILSON, provided a brief bill summary. The bill provided expanded behavioral health access to Alaskans. He shared there had been testimony from therapists, emergency room (ER) doctors, school district administrators, and federally qualified health centers in Alaska. The bill would improve and streamline the training for associates to become fully licensed marital and family therapists to help provide expanded access to behavioral health services. The bill was not being touted as a cost- savings measure, but as a way to help Medicaid clients in need of behavioral health services that were severely lacking. However, there was great potential for cost- savings if individuals could be diverted from emergency rooms. He detailed that in 2016 the Mat-Su Memorial Hospital had spent $43.8 million on ER services. He detailed the costs had covered about 1,300 patients with an average cost of $12,721 per person for one behavioral health assessment. In a clinical setting the cost ranged from $150 to $250. Mr. Zepp referenced a 2017 document titled "Alaska Medicaid Facts and Figures" published by the Department of Health and Social Services (DHSS) (copy on file). He shared that in 2016 Medicaid patients cost Alaska ER facilities $233 million and $245 million in 2017. He stressed the patients were Medicaid clients the state was already paying for. He explained if the individuals could be diverted from the ER by expanding access and getting them into a clinical setting there was a great potential for savings. He shared there had been great support for the bill by various healthcare providers and it had passed the other body unanimously. He spoke to support by ER doctors, family therapists, the state Board of Therapy, and the national Board of Marital and Family Therapists. He noted DHSS had provided a letter addressed to the committee providing more detail on the bill [letter from the Division of Behavioral Health Director Randall Burns dated April 13, 2018 (copy on file)]. 10:22:51 AM Representative Wilson stated that the committee had received a letter [from the Division of Health Care Services Director Margaret Brodie dated April 19, 2018 (copy on file)] stating that the bill would expand [Medicaid services] and that it would be necessary to ask permission from the federal government to add the service. She asked what the process entailed. Additionally, she wondered about the process of going back to the federal government to remove the service if the bill added a substantial cost and no savings. MARGARET BRODIE, DIRECTOR, DIVISION OF HEALTH CARE SERVICES, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via teleconference), answered that the bill would require a state plan amendment; it would be an update to the current state plan. If anticipated savings did not come to fruition, a new state plan amendment would be made to remove the providers' ability to provide the services. Representative Wilson stated that savings had been shown for HB 25. She wondered why it was so difficult to estimate potential savings under HB 105. Mr. Brodie replied that it was difficult to project savings for SB 105 because it was not possible to anticipate who would be utilizing the services. She explained that with other bills the department was able to look at individuals' diagnoses and what procedures were being done in order to identify who would be able to utilize the services. Representative Wilson was concerned about the $1 million fiscal note. She was hoping to get a better understanding of potential savings because now the committee understood the service would be added [to the list of Medicaid services]. She stated the process was long and the state did not know how easy it would be to remove the service if the savings did not come to fruition. Given that Medicaid was currently one of the biggest [cost] drivers, she believed the committee should be concerned about adding more services. Co-Chair Foster noted the committee would break for floor session. CSSB 105 (FIN) was HEARD and HELD in committee for further consideration. [Note: the bill was heard again beginning at 2:20 p.m.] 10:26:37 AM RECESSED 12:52:29 PM RECONVENED Co-Chair Foster relayed that the committee has posed some questions earlier on SB 105, which were being worked on. He relayed the bill would be heard last on the agenda. 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." 2:20:33 PM Co-Chair Foster noted the committee had heard the bill earlier in the meeting. Co-Chair Seaton mentioned his earlier question about whether the bill would require a plan amendment. Co-Chair Foster remarked that the bill sponsor had asked to hear from Elizabeth Ripley with the Mat-Su Health Foundation. ELIZABETH RIPLEY, CEO, MAT-SU HEALTH FOUNDATION, WASILLA (via teleconference), spoke in support of the bill. She read from prepared remarks: The foundation shares ownership in Mat-Su Regional Medical Center and invests its profits back into the community to improve the health and wellness of Mat-Su residents. The Mat-Su Health Foundation fully supports SB 105 because it will help our citizens access behavioral health treatment services through marriage and family therapists to get care early before their problems escalate to a crisis stage. In the foundation's 2013 Mat-Su community health needs assessment, Mat-Su residents told us their top five health issues were all related to mental health and substance abuse. They asked us for a coordinated system of care that makes treatment for behavioral health more readily accessible. Instead, the way our system currently works, Mat-Su Regional Medical Center is the number one portal in Mat-Su for people suffering from a behavioral health problem. In 2016 alone, 1,196 patients with a behavioral health diagnosis, 46 percent of which were on Medicaid, went to the Mat-Su Regional emergency department (ED). These patients had a total of 3,227 visits and their charges totaled $14 million, not counting an additional cost of $1.6 million estimated for law enforcement, 911 dispatch, and transportation. If we can intervene early with a system where all residents can get timely access to a behavioral health provider we can save pain, suffering, and money. By example, an individual session for Medicaid is $75, while an average charge for a behavioral health ED visit is $4,370. Granted an individual needs more than one visit early on to prevent a crisis, but even if you paid for ten visits at $750 you would be saving $3,600. The prevalence of mental health and substance abuse problems and crises is increasing in the Mat-Su and statewide. The average annual growth rate for visits in our ED by patients with a behavioral health diagnosis grew 20 percent from 2015 to 2017 due to the opioid epidemic and lack of treatment access. Additionally, from 2014 to 2017 the number of behavioral health assessments required for patients in crisis in our ED grew from 349 to more than 1,000 - all in a hospital that does not currently provide behavioral healthcare. This legislation could bring the appropriate level of care to people who need help when a problem first starts instead of after it develops into a crisis. The Mat-Su Health Foundation is actively doing its part to build a complete behavioral health continuum of care that's fully staffed with caring professionals. We offer scholarships to train new behavioral health providers and invest to help our nonprofits provide badly needed services. We are financing care coordination projects to keep people out of the ED and institutional care and work to advocate for smart policy like SB 105. We hope you will move this timely and important legislation forward. Thank you. 2:24:54 PM Co-Chair Foster invited the sponsor and staff to the testimony table. SENATOR DAVID WILSON, SPONSOR, introduced himself. GARY ZEPP, STAFF, SENATOR DAVID WILSON, noted that Director Margaret Brodie with the Division of Health Care Services could provide an answer to Co-Chair Seaton's earlier question about whether the legislation would require a change in the state Medicaid plan. Co-Chair Foster intended to take questions for Ms. Ripley first. Co-Chair Seaton presumed a large portion of individuals coming into the Mat-Su hospital were there for drug abuse reasons. He asked if marital and family therapists were licensed to treat opioid and other drug abuse. He asked if it would open a treatment avenue for the health foundation. Ms. Ripley shared her understanding that the primary focus of marital and family therapists was mental health. Frequently, mental health and substance abuse cooccurred. It was necessary to treat the underlying cause leading someone to self-medicate. She believed marital and family therapists would have the ability to address the mental health component vital to addressing substance abuse. Co-Chair Seaton asked if marital and family therapists were licensed to treat mental health. Ms. Ripley replied, "that's my understanding." 2:27:33 PM Mr. Zepp noted that Ms. Brodie could answer Co-Chair Seaton's question from earlier in the day regarding the state Medicaid plan. MARGARET BRODIE, DIRECTOR, DIVISION OF HEALTH CARE SERVICES, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, replied there was no cost to do a state plan amendment for the addition or deletion of a service. The department had staff to ensure the state complied with the state plan at all times. Co-Chair Seaton asked how difficult it would be to delete a service if the bill did not accomplish what was intended. Ms. Brodie answered that the process was easy; the Department of Health and Social Services (DHSS) would write a new state plan and submit it to the Centers for Medicare and Medicaid Services (CMS). Representative Wilson asked when the state had last deleted a service from its Medicaid plan. Ms. Brodie responded that she would have to follow up with an answer. Representative Wilson stated the legislature had asked the question frequently and had always been told proof of need for the deletion of a service and what kind of a negative impact it would have on individuals using the service would have to be provided. She was amazed to hear that it would be easy to remove something from the plan because it had not been the understanding since she had been on the committee. She asked if marital and family therapists were currently able to do anything in the behavioral health realm and to bill Medicaid if they were working under a clinic. Ms. Brodie answered in the affirmative. She elaborated that the services could be billed to Medicaid if provided in a clinic or the service could be provided anywhere if the therapist was serving a duly eligible Medicare and Medicaid recipient. Representative Wilson asked for verification that if a therapist was already able to bill Medicare and a client also had Medicaid, the therapist could bill Medicare/Medicaid even though they were not part of a clinic. Ms. Brodie agreed. She added that the state would pick up the copayment. Representative Wilson asked for verification that the bill only pertained to therapists with an independent practice and clients with Medicaid but not Medicare. 2:30:57 PM Ms. Brodie responded in the affirmative pertaining to the recipient. The provider would also have to be enrolled in Medicare. Representative Wilson referenced the fiscal note that specified there were 100 licensed marital and family therapists in Alaska. She wondered if there was a database showing the number of independent therapists who may want to take Medicaid patients. Ms. Brodie deferred to the DHSS Division of Behavioral Health. Representative Guttenberg surmised that the reason for the bill was not to expand the services provided by marital and family therapists, but to expand the group of individuals receiving the benefits the therapists had to offer. He referenced the fiscal note that extrapolated the anticipated number of individuals who would use the service and what the cost would be. He wondered if there was a way to estimate what the cost avoidance would be. He looked at the 633 estimated recipients and considered what the cost would be for the individuals to go to the emergency room. He explained that in the future it would be helpful to look back and know what the savings had been. He wondered if the avoidance cost could be reflected in the fiscal note. Ms. Brodie replied that she could do a calculation, but it would not be 100 percent accurate. She could take all of the emergency room visits and could extrapolate the number of individuals who had received a diagnosis for a behavioral health disorder. However, not all providers were comfortable giving that type of diagnosis; therefore, the figure would be off some. Representative Guttenberg stated that in the future it would be helpful to look back to see what the avoidance cost had been in the five years since the passage of the bill. Co-Chair Seaton asked if Representative Guttenberg was suggesting including a requirement for a report to the legislature in the bill. Representative Guttenberg thought it would be a good idea in order to know in the future what avoidance costs had come from the legislation. He hoped the department was looking at avoidance costs to understand other places the state needed to expand or contract services. 2:34:50 PM Mr. Zepp believed the state was on the verge of what Representative Guttenberg was asking for through a separate bill (SB 74) and the federal 1115 Medicaid waiver the state had recently submitted. The waiver was just upon the shortage of behavioral healthcare and trying to manipulate the system to demonstrate a project and redefine behavioral healthcare and address the shortages throughout the state. He believed the components were addressed in the 130-page document submitted to the federal government by DHSS. Co-Chair Seaton was trying to determine if the legislature would be getting information back on the effectiveness of expanding a service. He asked if the reporting requirement needed to be more specific than a generalized report on behavioral health. He wondered if the department could provide the requested information in a report if the legislation passed. Ms. Brodie replied that the report would need to be specialized because it could get lost in the other activities the department was undertaking with waivers and Medicaid reform. She relayed that the report was definitely something DHSS could provide; if the department knew a report was due it could compile the data beforehand. Representative Wilson pointed to research in members' packets from the Division of Behavioral Health that mentioned an existing report. She believed the report could help the legislature contemplate what should be included in another report. She stated the legislature should be concerned that in 2016 as a result of Medicaid expansion, statewide payments to behavioral health providers was $8,641,000, while in 2017 expansion brought in $25,173,825 to providers statewide. She stated the number was far beyond $25 million. She thought it was necessary to be very specific when determining what the report would include. She wondered if Representative Guttenberg was talking about only marital and family therapists or behavioral grants throughout the state. She remarked there had been significant discussion in the committee on where the money was going and whether the state was seeing any return for its money in terms of opioid and other issues related to behavioral health. She added that the problem was increasing as was the cost. 2:38:02 PM Representative Wilson mentioned a document regarding a Medicaid expansion legislative research grant (copy not on file). She stated the document specified the DHSS was in the process of developing a reporting tool that would enable the legislature to get the type of information [Representative Guttenberg was requesting]. She asked if the tool had been finished. RICK CALCOTE, MENTAL HEALTH CLINICIAN, DIVISION OF BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, ANCHORAGE (via teleconference), replied that he did not have the information; the tool was being developed elsewhere in the department. Representative Wilson was uncertain who to talk to because the report she was referencing anticipated the tool would be operational by early 2018. She wanted to know whether the tool had been developed and what information the state had. She thought the tool could help determine how much money would be diverted. She believed the bill needed more work. Vice-Chair Gara understood the need to expand the group of people providing mental health services. He asked if adding marital family services would add marital counseling as a covered service. Senator Wilson answered that marital and family therapists were licensed to provide myriad services. He provided examples including psychotherapy, group psychotherapy, and substance abuse counseling dealing with family dynamic. He clarified that it did not have to be limited to a family unit, but included whatever the therapist was licensed to do. He continued that marital and family therapists went through similar schooling to social workers, and licensed professional counselors. Marital and family therapists went through the same licensure requirements through their board and could provide the scope of services throughout. He stated it was more than family counseling. He explained that like a car mechanic that could treat more than one limited issue on a car, marital and family therapists were licensed professionals who were able to provide myriad services. He believed Director Randall Burns with the Division of Behavioral Health had addressed the issue in his letter [to the committee co-chairs dated April 13, 2018 (copy on file)]. He reiterated that the services marital and family therapists could provide were expansive. 2:41:54 PM Co-Chair Seaton was concerned that getting a big report on behavioral health services across the state would lose the essence of whether expanding services for marital and family therapists helped the system and decreased the amount of behavioral health services provided in emergency rooms. He was trying to determine whether requesting a report in the four-year timeframe would provide the information on give the information to determine whether the system had improved and what the cost had been. He thought looking at the overall system would lose the detail about what was needed pertaining to the topic. Ms. Brodie responded that after the bill's effective date there should be one full fiscal year before the report was required. She believed going out four or five years would be too long. She explained there were a high number of Medicaid reform initiatives underway; therefore, she recommended tracking the information from the beginning in order to receive actuals in the report. The savings would show up in healthcare services Medicaid, not behavioral health Medicaid. The savings would also show up in the Department of Corrections, law enforcement, and the Office of Children's Services. She did not know whether those agencies would have the ability to track the information, but Medicaid would. Representative Wilson stated that the bill only included marital and family therapists working independently. She asked if there was a way to track only the individuals under the bill. Ms. Brodie answered there would be a way to track the individuals through the bill because it would require building specialized business rules into the Medicaid Management Information System (MMIS). She detailed DHSS could use the same rules to track who was paid under the bill. 2:45:34 PM Representative Wilson asked how many states had tried to take extras out of their plan and had been denied. Ms. Brodie did not know any states that had been denied. There were states that had lengthy discussions with CMS and had been required to prove access. However, other states were far ahead of Alaska in behavioral health issues and already had the infrastructure. Representative Wilson requested information on the criteria required to remove any extra services. Vice-Chair Gara stated that he had first been told the purpose of the bill had was to allow marital and family therapists to provide behavioral health services. More recently he had been asked if the bill would cover marital counseling through Medicaid. He asked if the intent of the bill was limited to allowing marital and family therapists to provide direct behavioral health services or to expand the services provided through Medicaid. Senator Wilson confirmed the original intent of the bill was to allow therapists not practicing in a community behavioral health clinic the ability to bill Medicaid through the optional service. The bill would allow a new provider type to be added to the list of licensed providers that could bill Medicaid, just like a licensed clinical social worker could bill for marital and family counseling through group therapy. Other non-marriage family therapists could bill for the same services that those providers bill for as well. 2:48:51 PM Co-Chair Seaton asked whether January 2020 would be the appropriate report deadline if the bill passed with its current effective date. Ms. Brodie thought it would be better to line the due date up with the department's other Medicaid reports due at the end of November. Co-Chair Seaton asked for the year. Ms. Brodie replied 2020. Co-Chair Seaton asked for verification that the following was an adequate parameter for DHSS to design the data collection: a report to the legislature on the effectiveness and the cost-effectiveness of providing the services allowed under the bill by the authorized providers and the impact on diversion of services provided in more costly settings. Ms. Brodie replied in the affirmative. Representative Wilson communicated she had a forthcoming amendment. 2:51:06 PM AT EASE 2:51:39 PM RECONVENED Co-Chair Foster stated there would be forthcoming amendment. He set a deadline of 5:00 p.m. the following day. Senator Wilson relayed that the bill had been brought forward to address behavioral health shortages in the state. He emphasized there was an extensive line [for behavioral health services] and he encouraged committee members to reach out to their communities to learn how long it took for someone to get scheduled for an integrative behavioral health assessment. He stated the wait ranged from several weeks to one month depending on what a person needed to be seen for. He noted that residential substance abuse treatment facilities had long waitlists. The bill would help open a second door for individuals to access and lessen the burden of Alaskans seeking mental health services. He thanked the committee for hearing the bill. Vice-Chair Gara thanked Senator Wilson for his patience. CSSB 105(FIN) was HEARD and HELD in committee for further consideration. Co-Chair Foster reviewed the schedule for the following day. He recessed the meeting to a call of the chair [note: meeting never reconvened].