SENATE BILL NO. 134 "An Act relating to medical assistance reimbursement for the services of licensed professional counselors; and providing for an effective date." 1:42:38 PM SENATOR DAVID WILSON, SPONSOR, indicated that SB 134 was an act relating to medical assistance reimbursement for the services of licensed professional counselors. The bill also benefited all Alaskans in need of behavioral health by expanding its capacity. The legislation would add licensed professional counselors (LPCs) to the Medicaid optional services. The concept of the bill was to expand behavioral health capacity and utilization for Alaskas most vulnerable population. Senator Wilson continued that Medicaid clients and all Alaskans had difficulty finding access to behavioral health care often waiting 3 to 6 months for appointments. In a state of crisis, they utilized the most expensive platinum level of care there was - Alaskas emergency rooms. He asserted that in current times, it was not where they need to be. He reported that it cost on average about $4360 for behavioral health assessment in Alaskas emergency rooms versus about $200 in a clinical setting. Adding more counselors to provide services in a clinical setting would provide Alaska with improved health care outcomes at a lower cost. The bill would provide the appropriate level of care with an appropriate level of health care providers. Costs were rising at an unsustainable rate and something needed to be done differently to stop the trend. Essentially, Alaska needed to retool its factories and systems to get more productive and better outcomes for Alaskan citizens. He asserted that SB 134 complimented HB 290, SB 120 and many other pieces of legislation in terms of the 1115 waiver to help provide a cost containment reduction increasing access for Alaskans with better outcomes of behavioral health services. He believed that other healthcare providers in Alaska agreed, as there were letters of support and people waiting to testify in favor of the legislation. His staff, Mr. Zepp, would be reviewing a PowerPoint Presentation for the committee. 1:45:16 PM GARY ZEPP, STAFF, SENATOR DAVID WILSON, began with slide 2 of the PowerPoint presentation titled "SB 134 "An Act relating to medical assistance reimbursement for the services of licensed professional counselors; and providing for an effective date" dated March 22, 2020 (copy on file). He relayed that SB 134 would add licensed professional counselors to the Medicaid optional services. The concept of the bill was to expand capacity and utilization of behavioral health care in a clinical preventative setting versus a state of crisis in Alaska's emergency rooms. Mr. Zepp continued that the expansion of behavioral health care was projected to reduce waiting for services and to improve the quality of care by providing the appropriate care by the appropriate healthcare provider. He reported that it would cost less than behavioral healthcare in emergency rooms across the state. In conversations with stakeholders, he heard about wait times for substance abuse disorders, suicide, depression, trauma from violence, and serious mental illness of anywhere from 3-6 months for Medicaid clients. It was due to a workforce shortage of behavioral healthcare professionals who were available to see Medicaid clients. Mr. Zepp thought everyone had seen examples of behavioral healthcare shortages that had been revealed in peoples daily lives and through stories in the media. Licensed professional counselors were a valuable cost-effective part of treatment for behavioral health care. The proposed legislation was a piece of the behavioral health capacity puzzle that already included marital and family therapists, licensed social workers, PhD psychologists, prescribing nurse practitioners, and medical doctors like psychiatrists and primary care physicians. There were approximately 717 active licensed professional counselors available in Alaska. Mr. Zepp turned to slide 3 regarding behavioral health. Many people were familiar with the term "mental health." Mental health covered many of the same issues as behavioral health, but the term only encompassed the biological component of the aspect of wellness. He read from the slide: Behavioral health is the scientific study of the emotions, behaviors, and biology relating to a person's mental well-being, their ability to function in everyday life, and their concept of self. "Behavioral health" is the preferred term to "mental health." A person struggling with his or her behavioral health may face stress, depression, anxiety, relationship problems, grief, addiction, attention-deficit/hyperactivity disorder or learning disabilities, mood disorders, or other psychological concerns. Counselors, therapists, life coaches, psychologists, nurse practitioners, or physicians can help manage behavioral health concerns with treatments such as therapy counseling or medication. Representative LeBon asked what the minimum qualifications were to become a licensed provider of mental health services to be eligible for Medicaid reimbursement. Mr. Zepp deferred to the various people online to address the question. Senator Wilson thought Deputy Commissioner Wall could answer Representative LeBons question. 1:49:11 PM ALBERT WALL, DEPUTY COMMISSIONER, DHSS, JUNEAU (via teleconference), responded that the requirements for licensure rested with occupational licensing. An academic and professional background check and a test were required. After making application and all that was entailed a person would become professionally licensed in the state. In the state plan for Medicaid, the states agreement with the federal government as to how it handled Medicaid, there were specific definition of health care provider types. He indicated that part of the lengthy process of getting a new provider type into the system could be addressed with the federal government after a bill was passed with the provider type. He was describing a multi-step process. First, a provider had to become an enrollable provider in statute. Second, the state had to add the professional licensure to Alaskas state plan with Centers for Medicare and Medicaid Services (CMS). Third, regulations had to come after the fact to put together the framework in which the new license type could bill Medicaid. There was a professional licensure board that had oversite of the license. The definition was included in the agreement with the federal government and the state would craft regulations in which to bill through. Mr. Zepp considered slide 4: "Why Medicaid clients and who are they?" He read from a prepared statement: "Why Medicaid clients and who are they? Medicaid provides health coverage and long-term care services for Alaska's most vulnerable: children, seniors, people with disabilities, pregnant women, and very low income or working poor. Medicaid clients have difficulties finding access to behavioral healthcare and often have to wait three to six months for appointments. So, you can imagine a person in crisis or someone who is ready to accept behavioral healthcare services and there isn't any access or are told it's available in three or four months. So, what are their options? Alaska's emergency rooms. SB 134 would directly impact the lives of our most vulnerable population of citizens, our poor, our young, and our seniors. Alaska's emergency rooms have been overwhelmed with volumes of Medicaid client's emergency situations in need of behavioral health. The leading cause of emergency room visit are related to alcohol disorders and the associated aliments of alcohol abuse. Often Medicaid clients have nowhere else to go due to the lack of access and the lack of capacity which causes patients to stay much longer in the emergency room than they should. Typically, if a Medicaid client is in a stage of crisis and there is not access to the appropriate care, they leave the facility and the cycle repeats itself. They will be back at the emergency room because they are open 24 hours a day, seven days a week." Mr. Zepp moved to slide 5: "Adult Untreated Behavior Health Statistics." He indicated that the following few slides reflected some of the statistics concerning the lack of behavioral health care, both nationally and within Alaska. He read from a prepared statement: Approximately, 70 percent of American's who need behavioral health services do not receive treatment. For substance use disorders it's about 92 percent that typically do not receive treatment; and adults with serious mental health issues, approximately 66 percent, do not receive behavioral health treatment. Without treatment in a timely manner, this often can lead to interactions with the police, the court systems, and the correctional facilities within our state. According to the "Bureau of Justice Statistics", approximately 51.4 percent of prisoner have a serious psychological distress and/or a history of a mental health problem 20 percent of those are considered "severely and persistently" mentally ill. Mr. Zepp discussed children untreated for behavioral Health on slide 6. He relayed that the chart showed levels of depression, anxiety, and behavioral health disorders by age for children. He read from a prepared statement: "As you can see, children are very much susceptible to behavioral health issues. Common behavioral health issues that our children experience include depression, anxiety, behavioral disorders, and the most common which is attention-deficit/hyperactivity disorder (ADHD). A child diagnosed with depression has approximately a 74 percent chance of having a co- disorder, like anxiety. If a child is diagnosed with depression and anxiety disorders, if not treated, they usually increase over time, and the child's behavioral health condition worsens. Boys are more likely than girls to have a mental, behavioral, or developmental disorder and children living below the poverty line have a 22 percent more likelihood of a mental, behavioral, or developmental disorder. SB 134 can expand the capacity of behavioral healthcare in our schools, our communities, and our healthcare facilities." 1:54:35 PM Mr. Zepp continued to slide 7 which discussed the Alaska assessment of behavioral health care needs. He read from a prepared statement: Mental disorders among children can cause serious changes in the way children typically learn, behave, or handle their emotions, which causing distress and problems throughout the day. This is absolutely tragic, and you have probably heard this previously, but according to the American Foundation for Suicide Prevention, the Alaska Bureau of Vital Statistics, and the State of Alaska, Office of Epidemiology: Alaska has the highest rate of suicide per capita in the country; In Alaska, suicide is the number one leading cause of death for ages 10-64; Alaska rate is 21.8 suicides per 100,000 people and in rural Alaska it is 35.1 per 100,000; There was a 13 percent increase in suicides between 2013-2017, as compared to 2007-2011; Toxicology results following suicides since 2015 show 70 percent involved one or more substances, most frequently alcohol; More than 90 percent of people who die by suicide have depression or diagnosable, treatable mental or substance abuse disorder." Mr. Zepp turned to slide 8: "Alaska assessment of behavioral health care needs." He continued to read from a prepared statement: "Later in our presentation, the expert testimony will be able to shed a light on the workforce shortage of behavioral healthcare professional available to treat Medicaid clients and Alaskans in general. The 2016 Alaska Behavioral Health Systems Assessment Report estimated that 145,790 adult Alaskans roughly 20% of the state's population - need behavioral health services. Despite the estimated need for mental health care in Alaska, the ratio of mental health providers to population is low compared to national levels. Also, most behavioral health professionals work in urban areas and in remote areas of the state, they have even lower provider/population ratios." Mr. Zepp moved to the chart on slide 9: "Alaska Emergency Room Department Super-Utilizer Facts Total Medicaid Billed Charges." He read from his prepared statement: "The chart above reflects the total cost that the State of Alaska has paid to emergency rooms for Medicaid clients throughout our state over the previous four years. As you can see, in 2016 the total costs were $233 million + and that amount has risen over the last four years by $47.1 million dollars or 21.1 percent. As an example, in 2019, the top 2.9 percent of "super- utilizers" consumed 16.3 percent of the charges at $46 million dollars (1,301 clients at an average cost of $35,357 annually). They had 10 visits or more per year, some as much as 50 visits per year. If we count the top 10.03 percent of "super-utilizers" (6,250 Medicaid clients) costs $114.0 million or 40.67 percent of the total charges annually (6,250 clients at an average cost of $18,240 annually). They had 5 visits or more per year. Costs are rising at an unsustainable rate and we have to do something different to stop this trend. We need to improve Medicaid programs and provide increased quality and become more cost efficient. We believe, and other healthcare providers in Alaska agree, by adding more LPC counseling services, we have a chance to improve these outcomes. 1:58:31 PM Representative Josephson asked what was typically the reason for an appointment. Mr. Zepp responded that the majority of Medicaid clients were seen in Alaska emergency rooms for substance abuse disorders. Representative Josephson assumed people were going through withdrawals. Co-Chair Johnston indicated there were some folks online that would likely be answering Representative Josephsons question. Representative Wool asked if the increase in Medicaid billed charges for emergency room services in 2018 and 2019 was due to Medicaid expansion. He had heard from hospitals prior to Medicaid expansion that they had several people going to the emergency room, as it was their only option. The hospitals were not billing because Medicaid was not available at the time. He suspected that the increase in charges was a result of an increase in Medicaid patients through the expansion. Mr. Zepp deferred to Deputy Commissioner Wall. Representative LeBon asked how emergency room repeat customers were intercepted and directed to providers. If people were to continue the pattern of showing up to the emergency room, the hospital would not refuse to treat the patients. Senator Wilson responded that the Mat-Su Health Foundation had the High Utilizer Mat-Su (HUMS) Project. He indicated members likely had an information sheet in their packets. It reflected an intensive case management program. He believed Providence had a similar program in place and had seen a significant drop in expenses. In talks with the Mat-Su Foundation and Providence, he found that they diverted patients for which they could not bill for services. He also noted another information sheet that talked about Medicaid super utilizers and why they entered emergency rooms, many of which were experiencing substance abuse or behavioral health issues. Mr. Zepp continued with his prepared statement regarding slide 9: "With the federal approval of state's 1115 waiver for behavioral healthcare services and by adding LPCs to the mix of behavioral healthcare professionals it offers an opportunity to expand capacity, increase the quality of care, lower the costs versus the crisis mode at the platinum level costs that the state has already paid. I'll repeat, the amounts shown above is what the state has already paid on behalf of Medicaid clients in Alaska for emergency room visits over the last four years." 2:02:29 PM Mr. Zepp continued to slide 10: "Alaska Emergency Room Department Super-Utilizer Facts Number of Medicaid Clients." He read from a prepared statement: "The chart above shows that the number of Medicaid clients in our emergency rooms have not increased but the costs have. The most common diagnoses for the top 2.7 percent super-utilizers are alcohol-related disorders and the associated ailments; The top 2.7 percent of "super-utilizers" are likely to be between 20-59 years old & 61 percent are females and 39 percent are males." Representative Tilton posed a question about how to change a persons behavior who was consistently going to the emergency room because it was what they knew to do. Mr. Zepp suggested that in a few minutes the committee would hear from the Mat-Su Health Foundation and from Jared Kosin, the CEO of the Alaska State Hospital and Nursing Home Association (ASHNA). Currently, they had two programs that had been in practice for about 2 years that were experiencing success in rerouting patients away from the emergency room to a clinical setting. Both programs had achieved health improvements and cost savings. Representative Tilton asked if the bill would increase availability of substance abuse providers. Mr. Zepp responded affirmatively. He noted that in 2018 the Senator had sponsored SB 105 which added licensed, marital family therapists to the Medicaid optional services. He thought there was a stereo type in place regarding licensed marital therapists and licensed professional counselors that their scope was limited in terms of what they could provide. However, the counselors could provide a wide variety of services up to, but excluding, the prescription of drugs. Licensed therapists could handle many modalities including: substance abuse, anxiety, schizophrenia, mood disorders, and depression. Mr. Zepp continued to slide 11: "Preventative behavioral health care can reduce costs." He continued reading his prepared statement: "There is good news however. Since the passage of SB 105, which added licensed martial and family therapists to the Medicaid Optional Services. Several programs aimed at diverting Medicaid clients from emergency rooms into more comprehensive coordinated care models are in practice right now. As you'll hear from Mr. Jared Kosin, the President and CEO of the Alaska State Hospital and Nursing Home Association and hopefully from the Mat-Su Health Foundation ladies, Ms. Elizabeth Ripley and Robin Minard. Programs are diverting "Super-Utilizers" from our emergency rooms in Alaska to a clinical or coordinated care setting and it does save money. These two are examples that are working in Alaska right now and achieving significant results. Most importantly, the Medicaid clients are receiving improved quality by the appropriate healthcare professions but at substantially reduced costs. This saves the Medicaid program money! By adding capacity with Licensed Professional Counselors to assist with behavioral healthcare issues, this enhances those programs as well as other private practice clinical settings too. We did want to touch on the fiscal note from our friends at the Department of Health and Social Services. It's understood they have to provide estimates of what programmatic changes may costs but we believe there is more to the story." Mr. Zepp thanked the stakeholders that supported the bill. He revealed a list of the stakeholders on the final slide. Co-Chair Johnston thanked the presenters and encouraged invited testimony to begin. 2:08:52 PM JARED KOSIN, PRESIDENT AND CHIEF EXECUTIVE OFFICER, ALASKA STATE HOSPITAL AND NURSING HOME ASSOCIATION, ANCHORAGE (via teleconference), indicated the association fully supported SB 134 and thought it was smart policy and a smart use of resources. He suggested the legislation would reduce visits to emergency rooms. Utilization would be reduced in 2 ways. First, it would create direct access to care in the community. In response to Representative Tiltons question regarding how to change behavior, he suggested that people would have an option other than going to a high level-of-care emergency department. He thought it was reasonable to think people would go to another provider for care. For those people that were hard-wired to go to an emergency room, they could be redirected via a successful discharge from an emergency department. He relayed that currently in the system of care, with the capacity issues at Alaska Psychiatric Institute (API), patients were going to the emergency room in crisis, being converted to Title 47 ex-parte patients, and were boarding at emergency departments for days at a time while they waited for an inpatient bed. Patients would then be discharged from their inpatient bed and would show back up at emergency rooms perpetuating a vicious cycle. The legislation would provide emergency departments with the option of making a warm handoff to a counselor in the community. The counselor could then take the patient working with them on a long- term basis. Such capacity was currently non-existent or, if it did exist, it was on a very low level. The bill would allow for more continuity of care. He sincerely believed SB 134 would decrease health care costs rather than increase them. Ultimately, the bill would save the state money. He urged members to support the bill. 2:13:00 PM Representative Tilton referenced Mr. Kosins statement about the bill allowing hospitals to make successful discharges because they would have the ability (currently not in existence) to handoff patients to providers. She asked if capacity of providers or the lack of the ability to bill Medicaid influenced why behavioral health providers were not presently used. Mr. Kosin responded that both applied. He used the Mat-Su Regional Medical Center as an example. It had a private family practice as part of its network of services called Solstice Family Care. Solstice Family Care had a licensed clinician who could provide services for Medicaid recipients. However, currently there was no way to bill Medicaid for its services. He asserted that without the ability to bill for services, the entity could not stay in business for very long. The bill would allow for a new avenue for discharging patients from the emergency department to the clinician at Solstice Family Care, work with the patient on a plan of care to help them through episodes that would otherwise land them back in the emergency room, and bill Medicaid. The cost for 15 visits to the clinician would equal approximately the same as a single visit to the emergency room. The economics were justifiable. Representative Carpenter asked about the likelihood the federal government would approve professional counseling services. He wondered if there were already other states that include it in their services. Mr. Zepp reported having reached out to the National Council of State Legislatures to do some research. They found that about 6 states including Montana, Washington, and Oregon, had already added licensed professional counselor services to their Medicaid optional services. 2:15:55 PM ROBIN MINARD, MAT-SU HEALTH FOUNDATION, WASILLA (via teleconference), relayed that the Foundation shared ownership in the Mat-Su Regional Medical Center and invested its profits back into the community in order to improve the health and wellness of Alaskans living in Mat-Su. She was testifying in strong support of SB 134. The bill was crucial because it would help address an important health issue facing Mat-Su residents every day - mental health and substance use problems. Licensed professional counselors were key behavioral health providers who could help with the mental health and substance use issues. Ms. Minard continued that the Foundation was aware the issues were difficult for Mat-Su residents because they had stated as much in the previous 3 community health needs assessments. She reported that in 2013 residents and professionals stated that the top 5 challenges they faced were alcohol and substance abuse, children experiencing trauma and violence, depression and suicide, domestic violence and sexual assault, and lack of access to behavioral health care. Residents with the list of issues could be helped with access to counseling. School nurses in the same survey were seeing waiting lists as long as 4-8 months for children and families that had Medicaid to get into see a counselor - much too long to have to wait. It was crucial that Alaska residents had access to behavioral health providers for care before their problems escalated to the state of crisis. Ms. Minard continued that Mat-Su Regional Medical Center and the community was inundated by residents who were in crisis related to behavioral health issues. In 2016, 3443 residents were seen in the emergency department with a primary behavioral health diagnosis, and those people had 8400 visits costing $43.8 million in facility charges. The cost did not include the costs associated with law enforcement or emergency transportation. The average cost per visit was over $5000 and, the average cost per patient was almost $13,000. Ms. Minard noted the senator mentioning the HUMS Program earlier in the meeting. She explained that HUMS was a program supported by the Mat-Su Health Foundation, the program was started as a way to provide care coordination and access to community support for high utilizers. High utilizers were defined as residents who have had 5 or more visits to the emergency department in a year and who were unable to independently access consistent, appropriate care in the community. The HUMS program had already resulted in dramatic cost savings. It had also alleviated significant trauma for patients as well as health care providers and families who often suffered trauma along with the patient. She urged members, as they delved into the data, to keep in mind that if people had access to care before their needs became a crisis, there would be far less need for a program such as HUMS. Ms. Minard relayed some of the results of the HUMS Program to-date. She reported a cost savings of $2.168 million over 2 years. In 2018, the top 3 utilizers saved $340,288 by not making emergency department visits. In the same year, 7 patients did not visit the emergency department at all after they enrolled in the HUMS Program. She relayed that enrollment was voluntary for the patient. The age of the patients ranged from 16-82, and 72 percent had Medicaid as their health insurance. She reiterated the importance of Medicaid clients having access to the whole continuum of care. The program had an external evaluator and the Foundation was still learning and tweaking the program to make it more effective and less expensive as time passed. Ms. Minard shared a couple of success stories from the program thus far. The first was a young adult client that had had 17 visits to the emergency department in the prior year. They had poorly managed diabetes and a substance abuse disorder. Most of their emergency department visits lead to inpatient admission into the intensive care unit (ICU). They had a long history of IV drug use and was non- compliant with primary care appointments. She continued that when the person was referred to the HUMS Program, the outlook was poor, and HUMS staff were told the client had little or no interest in improving their situation. With time and a listening ear, the HUMS staff built a rapport with the person and it quickly became obvious that the desire for a healthier life existed. She was happy to share that the client was currently sober; their diabetes was well managed; they had a driver's license; they were working a full-time job; and they had a great relationship with the primary providers office. Ms. Minard presented a second example. Another client had been extremely proactive with their care and improving their own quality of life. They had been able to maintain sobriety for over 6 months and enrolled in parenting classes to become a better parent in the hopes of regaining custody of their child. The program assisted with housing, getting them into substance use disorder treatment, and with purchasing needed hygiene and clothing items. The person had gained and maintained steady employment at a restaurant in walking distance of where they lived so they could get to work. The client was currently saving money to get their own apartment. She concluded that the HUMS Program showed great promise. However, even more promising was the idea that if there was more behavioral health care available earlier on, the HUMS program might not be needed in the future. The hope was for people to get care in a lower cost setting. She understood there was concern about adding costs to the Medicaid System. She asserted that SB 134 would do the opposite; it would allow behavioral health care to be provided in the least costly setting, thus, avoiding all of the more expensive care later. She thanked members for their time. 2:22:15 PM Co-Chair Johnston OPENED Public Testimony. JON ZASADA, POLICY INTEGRATION DIRECTOR, ALASKA PRIMARY CARE ASSOCIATION, ANCHORAGE (via teleconference), spoke in support of SB 134. He read from a prepared statement: "Alaskas 2 federally qualified health centers actively support SB 134 adding Medicaid reimbursement for LPCs has been a top priority in our efforts to expand access to behavioral health services for many years. Community health centers are already using LPCs in their practices to provide school-based services, individual counseling services, substance abuse disorder treatment, and in supporting care coordination activities. And this does include individual coaching on basic health and hygiene issues such as were addressing now with the COVID epidemic. However, these services provided by LPCs are not currently reimbursable. They are currently paid for through earned income, federal and private grant funds. This is not sustainable. Health centers have received considerable federal funding to expand behavioral health services in the primary care setting. They are required to provide behavioral healthcare that is integrated with medical, dental, pharmacy, and other services. Adding LPCs to the roster of billable providers enables health centers to make their services more sustainable. This is the national best practice. LPCs are a valuable, cost-effective component of team- based whole-person care. This is particularly important right now as we are doing everything that we can to keep patients out of emergency rooms and hospitals. Mild and moderate anxiety and depression are co-occurring conditions with chronic conditions including diabetes and hypertension. LPS are a vital provider type that can typically provide short-term counseling support that enhances the work of other medical, dental, and pharmacy team members in stabilizing and improving the health of emergent patients and assisting them in managing chronic conditions over time. Finally, in 2017, Alaska health centers reported a deficit of 12-18 behavioral health providers that could expand access to 6000 to 9000 additional patients. We support SB 134. It addresses a key need in Alaskas response to behavioral health, lends stability to efforts already underway, and offers another tool in our response to improving care and lowering the overall cost of care." Mr. Zasada thanked the committee for its time. 2:25:24 PM DON BLACK, EXECUTIVE DIRECTOR, BETHEL FAMILY CLINIC, BETHEL (via teleconference), introduced himself and read a prepared statement: "Our clinic employs one licensed clinical worker and one licensed professional counselor in our behavioral health department. When I last spoke, we were providing services to teens at the Bethel Youth Facility in efforts to reverse destructive habits while these students are still young. Our substance abuse programs were embedded in the community as well as at the Yukon-Kuskokwim Correctional Center where our staff provided group and individualized guidance. All that is gone while we hunker down. Although our delivery has changed, our services continue. We continue in more individualized services and, where possible, by electronic medium. More individualized services stretch our staff thin, but limited Medicaid billable staff stretches us even thinner. Were venturing into the unknown. We have no numbers to support where we are going. We just know, we just all know, we are going there. Look around the room, or if you are meeting electronically as I am, imagine youre looking around the room. See not just the faces of your colleagues. See not just the names of your colleagues. See the person. We are all gathering on a Sunday, not as an ordinary day but as a day to accomplish important business in the time remaining this session Meanwhile, there is a wave coming. We dont know how hard it will hit. We dont know when it will hit. We just know that it will hit, and there is nothing we can do to stop it. And we cant even swim, just float. This stressor just entered all of our lives. Some of those people around the room or virtual room will cope with this stressor better than others. It doesnt matter how we cope or appear to cope it was a stressor for everyone. Many of you have coping mechanisms to help you relax a morning cup of coffee and a newspaper at the local coffee shop. Closed. Church closed. A relaxing dinner with loved ones or friends after a long day closed. A trip to the gym or local pool to work off some anxiety, relax, and re- center all closed. We are helping our clients build mental and emotional tools to help them address the stressors in their own lives. Now we have a new stressor to add to the list. We anticipate more individualized time will be needed. We also anticipate a potential flood in demand of these services. For those in the Medicaid world, we may have to triage and choose between which services are billable and which services are not. I just closed my dental office on Friday and am re- purposing as many staff as possible to assist in the increased needs in other areas of our clinic. With the reduction in some services, the revenue to run the clinic becomes more of a concern. When I triage a behavioral health patient, part of that formula may have to include the sustainability of the overall clinic when it should be the greater need of the patient. Passing SB 134 allows me to focus more on the patients needs and less on the financial needs. Passing SB 134 allows me to have access to a broader range of billable behavioral health specialist labor pool. It amazes me how an entire globe is pivoting all in the same direction all at this very same point in time. SB 134 has become something different to me in the past few weeks. It has become our essential part of that pivot." 2:29:15 PM ERIC BOYER, PROGRAM OFFICER, ALASKA MENTAL HEALTH TRUST AUTHORITY, ANCHORAGE (via teleconference), indicated he also served as the chair for the Alaska Healthcare Workforce Coalition. The Coalitions primary focus was to increase the workforce in the healthcare industry across Alaska. The Trust and the Coalition supported SB 134 to be able to expand the number of behavioral health practitioners who could bill for Medicaid services which would increase the responsiveness of the healthcare community. People experiencing behavioral health disorders could be treated when they needed the help versus being put on a waitlist. Mr. Boyer continued that the Alaska Mental Health Trust Authority (AMHTA) was concerned about Trust beneficiaries' lives being improved. Beneficiaries included Alaskans with mental health issues, substance use disorders, developmental disabilities, Alzheimer's Disease and related dementia, and traumatic brain injury. In partnership with the Department of Health and Social Services, the Trust ensured Alaska had a comprehensive and integrated system of care to provide the necessary services and supports for beneficiaries in their community of choice and in the least restrictive setting possible. The legislation would create a more equitable distribution of health professionals in Alaska. It would expand options for behavioral health treatment and care, decrease the wait times experienced by many who were seeking behavioral health services, and prioritize helping out the most vulnerable beneficiaries across the state. He reiterated that the Trust fully supported SB 134. 2:31:22 PM SEVILLA LOVE, INTEGRATION COORDINATOR, ALASKA PRIMARY CARE ASSOCIATION, ANCHORAGE (via teleconference), had direct insight from her service in the healthcare field. She alluded to the failing attempt that Alaska health centers were currently facing because they could not meet the behavioral health needs of their communities due to the limitations barring them from hiring qualified behavioral health providers known as licensed professional counselors. She noted the bio, psycho, social, and economic impact of COVID-19 which would only exponentiate the dire need to prioritize the passage of SB 134. Ms. Love continued that the behavioral health issues on the system came at an exorbitant cost to state and federal funding. All of the conditions were preparing to swamp an already over-burdened emergency and acute response and social service system in the wake of COVID-19. Ms. Love reported there were LPCs available to go to work presently, but health centers were not able to hire them due to not being able to bill Medicaid. She indicated that when patients were sick, they went to their primary care provider. She referred to an article that reported up to 45 percent of people who died by suicide had visited their primary care provider within a month of their death. Additional research suggested that up to 67 percent of individuals who attempted suicide received medical care as a result of their attempt. She concluded that given the statistics she provided, primary care had an enormous potential to prevent suicide and connect people with the needed healthcare they required. Ms. Love continued that by capturing patients when they presented to primary care, providers could help them. She advocated removing all barriers between driving down costs while meeting the increasing behavioral health issues of individuals and families on their way into the system. She argued that prevention was needed immediately before state social youth and family services and psychiatric admissions were necessary. All of the issues were most appropriately prevented, met, and treated in primary healthcare centers. The licensed professional counselor workforce was needed to reduce future financial burdens and to save lives. 2:34:25 PM PRENTICE PEMBERTON, COUNSELING SOLUTIONS OF ALASKA, ANCHORAGE (via teleconference), spoke in support of SB 134. He provided a brief work history. He was currently in private practice and owned Counseling Solutions of Alaska. He had 23 therapists who worked for him in Anchorage and Eagle River. He was calling on behalf of all of them in support of the bill. Changing the rule that a psychiatrist had to supervise LPCs and licensed clinical social workers (LCSWs) was long overdue. He responded to an earlier question about qualifications. Licensed professional counselors need the same qualifications to provide therapy as those required for LCSWs and licensed marriage and family therapists (LMFTs). The qualifications included a graduate degree, 2 years of supervised work experience, passing a licensing exam, and taking continuing education credits. They were as qualified to provide therapy as any other LPSCs, LPSWs, or LMFTs. Mr. Pemberton conveyed that the preferred approach to treating kids and teens was psychotherapy first, then referral for evaluation by a psychiatrist. He thought things were currently done in reverse order. He argued that supporting families and kids in their community and allowing problem solving was the way to avoid further hospitalizations and the use of valuable emergency room resources. He suggested that Medicaid kids were some of the most vulnerable citizens Alaska had, yet they were denied reasonable access to much needed mental health services for them and their families. Mr. Pemberton continued that as a community mental health provider and medical social worker, one of his largest frustrations was not being able to find quality outpatient services. As a provider in private practice, he was contacted frequently by doctors, pediatricians, and family doctors looking for providers who would take their Medicaid clients, as they could not get them in anywhere. The emergency room was their last hope. Families were desperate to help their kids in crisis. He surmised that the state would pay for the care of todays children. The question was would the investment occur in the near term by paying for their health and wellness, or would it be in several years by paying for their institutionalization or incarceration. He thought much of the backlog could be alleviated. 2:38:29 PM Co-Chair Johnston CLOSED Public Testimony. Co-Chair Johnston asked someone to walk through the fiscal note. 2:39:09 PM GENNIFER MOREAU-JOHNSON, DIRECTOR, DIVISION OF BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via teleconference), spoke in support of the bill. The bill could expand access to care for eligible Alaskans statewide. She also noted the potential for expanded access for care in rural communities for individuals experiencing mild to moderate disturbances. There was also the potential decrease overtime of psychiatric emergency services and acute care services. Licensed professional counselors would also be able to provide screening, grief intervention, and referral to treatment which was a key element of the continuum of care. Co-Chair Johnston interrupted Ms. Moreau-Johnson. She asked if she could walk through the fiscal note. Ms. Moreau- Johnson deferred to Melissa Hill. MELISSA HILL, ADMINISTRATIVE OPERATIONS MANAGER, DIVISION OF HEALTH CARE SERVICES, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via teleconference), reviewed the fiscal note [OMB Component 3234]. The fiscal note showed a $55,900 services request to complete modifications to the Medicaid Management Information System (MMIS) that would add a new provider type and adjust associated business rules. Co-Chair Johnston set the bill aside. She confirmed that the amendments for another bill had been sent out via email. SB 134 was HEARD and HELD in committee for further consideration. 2:42:55 PM AT EASE 2:56:38 PM RECONVENED