HB 167-MINORS IN FACILITIES OUTSIDE AK  3:04:03 PM CHAIR PRAX announced that the only order of business would be HOUSE BILL NO. 167, "An Act relating to the care of children in state custody placed in nonprofit institutions outside the state." 3:04:56 PM REPRESENTATIVE FIELDS, as prime sponsor, began the PowerPoint presentation, titled "HB 167" [hardcopy included in committee packet] on slide 2, which read as follows [original punctuation provided]: HB 167 seeks to improve in state care and reduce reliance on for profit out of state psychiatric residential treatment facilities (PRTF). Excessive reliance on out of state PRTFs is expensive, abusive, and perpetuates systematic violence against predominantly Alaska Native children. The result is that the State of Alaska pays high costs, often provides substandard care, sometimes even harming the mental and behavioral health of kids. 3:06:25 PM REPRESENTATIVE FIELDS showed slide 3, which read as follows [original punctuation provided]: 2022 DOJ Report: 1. In Alaska, children with behavioral health challenges are institutionalized out of state at high rates and for long periods 2. Many of these children are eligible for community based services and supports that Alaska offers through Medicaid, however the state has failed to provide necessary services to the extent that it violates Title II of the Americans with Disabilities Act (ADA). 3. With the adoption of the Medicaid 1115 Waiver, the State of Alaska must endeavor to provide the necessary community services for children in integrated and appropriate settings that do not rely excessively on institutionalization. 4. For profit institutions have been shown in many cases to be abusive, ineffective and expensive REPRESENTATIVE FIELDS moved to slide 4 and pointed to several headlines from news articles. He moved to slide 5 and noted that the issue of care not being provided in Alaska goes back a century. 3:08:16 PM REPRESENTATIVE FIELDS moved to slide 6 and stated that there is increasing public equity involvement nationally. He said that the Department of Justice (DOJ) report found that, when a private residential treatment facility is out of state, it is hard for families to travel and have a connection. He expressed the opinion that it is problematic when a profit motive plays into the care the state provides. He said that the quote on the slide was made by United Health Services Chief Financial Officer Steve Filton and discusses that, since there is a lack of community options, the facilities are able to extract higher profit margins. REPRESENTATIVE FIELDS paraphrased slide 7, which read as follows [original punctuation provided]: Provo Canyon is one of many PRTFs owned by Universal Health Services. Provo Canyon has a history of abuse allegations that span decades. Despite repeated complaints, Alaska continues to send children to Provo Canyon. According to the Alaska DOH, approximately 345 Alaskan children were sent to Provo Canyon between 2012 2022. Alaska spent more than $31 million in Medicaid funding over six years sending 511 kids to PRTFs like Provo Canyon in Utah. REPRESENTATIVE FIELDS moved to slide 8, which showed a diagram illustrating "profits over patients" as it relates to the troubled-teens industry. He suggested the companies see all the new assistance programs as profit opportunities. REPRESENTATIVE FIELDS showed slide 9, which read as follows [original punctuation provided]: Bring The Kids Home: A Model That Works The Bring The Kids Home (BTKH) Initiative was established in 2004 by the Alaska DHHS and the Alaska Mental Health Trust to address the high numbers of out of state placement of children and to provide resources for in state treatment. Primary Goals: 1. Significantly reduce the numbers of Alaskan youth placed in Outside PRTFs. 2. Build capacity and core competencies of in state providers to serve children with all levels of behavioral health needs. 3. Develop an integrated, culturally competent system to serve children as close to home as possible. 3:11:14 PM REPRESENTATIVE FIELDS turned to slide 10, which read as follows [original punctuation provided]: Bring the Kids Home (Con't) Accomplishments 28 new BTKH operating grants helped develop services in 12 communities. During FY 06/07 56 new in state beds were developed. Funded expanded culturally competent, close to home, tribal mental health services that accessed 100% federal reimbursement rate. Addressed workforce issues with new grants through training and mentoring. In FY 2007, enrolled 58 students in new "Residential Services Certificate Program REPRESENTATIVE FIELDS showed slide 11, which read as follows [original punctuation provided]: Bartlett Regional Hospital saw a need in the region to alleviate the high number of youth placed in out of state psychiatric facilities. Addresses urgent mental health needs by providing the first crisis center for youths in Southeast Alaska. Reduces the number of children experiencing a behavioral health crisis who must leave their communities and families. 8 bed capacity, 24/7 crisis care. Provides 23 hour crisis observation and stabilization and crisis residential services up to 7 days. REPRESENTATIVE FIELDS brought attention to slide 12, which read as follows [original punctuation provided]: The State is negotiating with USDOJ, and a negotiated agreement may provide guidance on how Legislature can support better in state care. Workforce shortages and API being over capacity are opportunities to look at systems improvement now. If the Legislature wants to support improvement of care in communities, this bill is an opportunity to convene Department of Health / Department of Family & Community Services Alaska Mental Health Trust Authority Tribal Entities Stakeholders to provide guidance on how legislature can support Bringing the Kids Home 3:14:15 PM COURTNEY OWEN, Staff, Representative Zach Fields, Alaska State Legislature, on behalf of Representative Fields, prime sponsor, offered the sectional analysis of HB 167 [copy included in committee packet], which read as follows [original punctuation provided]: Section 1: This section amends AS 47.14.100(a) to delete language that permits the department to place a child in its custody in for-profit institutions providing care outside of the state. This section adds language that clarifies that the department may place a child in its custody in a non-profit institution providing care outside of the state. Section 2: This section amends AS 47.14.112(d) to require the department to report annually to the legislature on the number of children placed in non- profit institutions providing care out of the state. 3:15:07 PM REPRESENTATIVE SADDLER questioned what the problem would be with for-profit institutions. REPRESENTATIVE FIELDS responded that the report from DOJ identified some of the for-profit institutions as having a history of abuse. He deferred further explanation to the invited testifiers. 3:16:52 PM JEFF JESSEE, representing self, shared that he retired in 2021. He came to Alaska in 1980 as a volunteer for the Disability Law Center. He shared that he served as the CEO of the Alaska Mental Health Trust Authority for 22 years and was the Dean of the College of Health at the University of Alaska Anchorage for four years. He said that this is the third time Alaska has faced this issue, as in the 1980s there was the Alaska Youth Initiative, which was designed to ameliorate the issue Representative Fields is seeking to address. He explained that the system was set up to develop individualized programs for children with severe need, and if there is no community-based option found, then the children would become institutionalized out of state. He recounted that, during Governor Frank Murkowski's administration with Gill Gilbertson as commissioner, there were 700 children cycling into out-of-state placements. He further recounted that the trust invested $15 million in developing the infrastructure. He stated that with venture capital for training and start-up funding for in-state programs, the number of children was lowered to 70. MR. JESSEE related that it is very difficult to get the kids back after being sent out of state, and regardless of whether the placement is for profit or not, a clinical record has been created that concludes being in the facility is the best option. He explained that creating an adequate system of community placements would not be complex, just difficult, as it would require a rate structure that provides an incentive for community providers in Alaska, whether nonprofit, for-profit, or Tribal. He explained that the formula used in the Bring the Kids Home initiative had the department work with the trust, providers, families, and other stakeholders to craft a plan. He explained that the first step would be to understand who is being sent out of state, how the child is sent, and what could have been done to keep the child in the state. He stressed that the amount of money spent on out-of-state placements is huge, especially when compared to the possible in-state cost. He suggested that investing in community services would reduce the cost of out-of-state placements. He pointed out that during the Alaska Youth Initiative, investments were made towards community programs and the number of out-of-state placements went down, as did the cost. He expressed encouragement that the issue is getting renewed attention. 3:26:42 PM KATIE BALDWIN-JOHNSON, COO, Alaska Mental Health Trust Authority (AMHTA), said it is important to recognize that the child exists within the family, and to better address child mental health, it must also be addressed in the context of the family. She acknowledged that the Bring Kids Home initiative has an impactful framework, as the system has progressed on the recommendations made. She pointed out that some of the strategies under the initiative are still working today to keep children in communities. She explained that one of the strategies focusing on early childhood has helped increase the attention to the age group of prenatal through age eight; furthermore, through the initiative therapeutic foster care was identified as an alternative to in-patient care. She added that this has been a cost-effective alternative to residential treatment. 3:30:10 PM MS. BLADWIN-JOHNSON said that AMHTA has been working with partners to improve its system and ensure that all beneficiaries have access to behavioral health care as close to home as possible. She commented that strengthening and growing the network of community-based services needs to be a priority, as well as providing start-up funding for expanding organizations. She concurred that examining the rate setting methodology is important and the trust needs to work on the Medicaid reimbursement structure. She stressed that with less workforce, services and programs are closing, and this is an exacerbated issue in rural communities where many may have limited access to resources. She said that one of the contributing factors in challenging access to behavioral healthcare is the number of providers that accept Medicaid. She continued that aside from behavioral health community providers, independent practitioners generally do not accept Medicaid patients. She suggested that if there were more providers that see Medicaid patients, access would expand, as too would the levels of care. 3:34:49 PM MS. BLADWIN-JOHNSON said AMHTA is working on the establishment and expansion of crisis stabilization services across the state. She pointed out that child intervention and prevention efforts are important, as the earlier children's needs are addressed, the less acute their symptoms become. She stressed that using out-of-state facilities should be a last option, when all others are exhausted. She concluded that the trust is looking forward to being included, along with state, community, and Tribal partners, to address the issues, such as crisis care, complex needs, and getting resources to families and children sooner. 3:37:28 PM ANGEL GONZALES, Board President, Facing Foster Care, shared that she was in foster care at 5 years old, until she was adopted at 16 years old. While she was not sent to a treatment facility, she had a younger brother who was, and she witnessed the negative effects on him and her foster siblings. She stated that she never saw someone who left the state for treatment come back better, and while she was working at Covenant House, she saw that the youth were worse off than when they went in. She said she had been terrified of treatment because of the outcomes she had seen. She shared that she would try her best to show she was a good child and did not need treatment. She shared a situation where she almost had to go into treatment since there was no foster placement; however, a placement was found at the last minute. She stressed that foster children need more support around them, and they should not be sent out of state to face abuse. She said that former foster children who are grown up now have long-lasting effects because of the medicine used while they were in treatment. During her time at Covenant House, she recounted that she saw children who were abandoned at out-of-state centers, and they would often end up in homeless shelters, as they did not know how to live outside of an institution. She noted that the chance is high that these children get picked up by traffickers, die, or go to jail. 3:43:22 PM REPRESENTATIVE MINA questioned the resources available before youth are referred for out-of-state treatment. 3:44:28 PM HEATHER CARPENTER, Health Care Policy Advisor, Office of the Commissioner, Department of Health (DOH), answered that the department first exhausts any in-state placement before an out- of-state one is considered. She said that the processes of both DOH and the Department of Family and Community Services (DFCS) are explained in the DOJ report. 3:45:30 PM TAMMIE WILSON, Family Coordinator, Office of the Commissioner, Department of Family and Community Services, explained that, when DFCS has a child who is at a facility, a packet of information is provided to all in-state providers. She said when there is no response, then specialized, out-of-state options are considered, namely ones that address the child's aggression. She said that the packets would be sent to Medicaid and non-Medicaid facilities, with the Medicaid facilities looked at first. She stressed that DFCS does not look as to whether the facility is for-profit or not, rather, what services the child would receive. 3:47:03 PM REPRESENTATIVE MINA asked what the wait times would be for a child waiting to be referred to an out-of-state facility. She questioned if there is a difference in wait times between nonprofit and for-profit facilities. MS. WILSON answered that many facilities have not opened the same number of beds as before the COVID-19 pandemic, and the more specialized facilities are the ones with wait lists. In response to a follow-up question regarding the average wait time, she said that it could be a week to two weeks. REPRESENTATIVE MINA asked what the conditions are of the child while they are waiting. MS. WILSON answered that if there is a bed, the child will be provided one while he/she "wait the wait list." 3:49:21 PM REPRESENTATIVE RUFFRIDGE noted that the price Medicaid pays for residential services varies from state to state, with some states lobbying for other state's Medicaid rates. He questioned the treatment rate that Alaska's Medicaid pays, and whether there is a different cost for in-state versus out of state. MS. CARPENTER answered that the rates are individualized for each provider. 3:50:37 PM FARING BROWN, Acting Director, Division of Behavioral Health, Department of Health, explained that each state undergoes a rate-setting process in collaboration with the federal Division of Behavioral Health, and this is done by examining the specialty areas in facilities. She explained that the rate can be the in-state Medicaid rate or higher, and Alaska has a higher rate for in-state facilities than out-of-state facilities. REPRESENTATIVE RUFFRIDGE asked if regulation directs the Alaska Medicaid program to never pay above what the in-state treatment would be for another state. He further asked if this rate is internally set, or if the legislature could provide guidance. 3:53:05 PM MS. CARPENTER explained that during the rate-setting process, DOH must work with the Centers for Medicare and Medicaid Services (CMS) and be deliberate in how rates are set. She said DOH's goal is to have as many services as possible in state in order to keep children in their home region at the lower level of care, and only escalate up to out-of-state care when necessary. She explained that CMS has other guidelines, as DOH must allow any willing provider to enroll in Medicaid, regardless of whether the provider is for-profit or not. She added that when thinking about out-of-state placement, DOH cannot make the final placement decisions, as it works with the parent or guardian. If the child is in state custody, DOH would work with the Office of Children Services (OCS) or the Division of Juvenile Justice (DJJ). 3:55:52 PM REPRESENTATIVE FIELDS relayed that the Kaiser Family Foundation published an article, titled Profit Strategies: Psychiatric Prioritize Out-of-State Kids, April 2022. He asked that this be distributed to committee members as it adds further context to the question. 3:56:15 PM CHAIR PRAX offered his understanding that the rates are controlled, and as far as Alaska is concerned, DOH is looking for a provider who can provide the service. He asked if providers with a higher price would come into play. MS. CARPENTER responded that DOH is looking for providers to enroll, as it cannot pay Medicaid until a provider enrolls in Alaska Medicaid. She shared that in looking at Medicaid rates for hospitals in the state, they are all individual and at cost- based rates. She offered to provide additional material around how Medicaid rates are set. 3:57:54 PM MS. WILSON clarified that the facilities are not soliciting DFCS, rather, DFCS is actually soliciting them. She said that some cases are so specialized there is no in-state placement option. She explained that part of her job is to figure out what the child's discharge will look like when he/she comes back to Alaska, ensuring that the child has all the coordination needed to be successful and reunited with the family. 3:59:42 PM REPRESENTATIVE SADDLER questioned whether the provider shortage is for a particular skill or just overall. MS. WILSON answered that DFCS has opened the Complex Care Unit so it can be determined why children have been sent out of state. It would also determine whether the child would still have the same issues if in the beginning there was a different kind of care. She said that the current issue for providers is needing staff for therapy, substance abuse, and specialized foster care. REPRESENTATIVE SADDLER asked if there is anything intrinsically improper with for-profit out-of-state facilities. MS. WILSON shared that she works with both for-profit and nonprofit facilities, and she ensures that they have the same requirements for meeting the needs of the child. 4:03:19 PM REPRESENTATIVE SUMNER requested the bill sponsor to address the fiscal notes. REPRESENTATIVE FIELDS explained that the proposed legislation points to a problem that has already been identified by DOJ. He expressed the hope that the bill would prompt discussion with those in Alaska who have experience around the problems of for- profit out-of-state facilities. He expressed the opinion that the state should consider the best way to ensure these facilities are only used as a last resort. He pointed out that in-state care needs to be "fleshed out." He shared that DOH has created a working group recently that will be examining rates over the summer. He expressed the hope that by January 2024, the committee will have thought about what should be in the bill and how it can line up with the working group's solutions. 4:05:50 PM MR. JESSEE, in response to Representative Saddler, said that he has not compared incidents in the state to incidents in other states; however, he suggested that every state struggles with foster care. He explained that the children who are put into intensive community services have high incidences of childhood trauma; therefore, any early on support to the family and the child would minimize the amount of trauma; thus, reduce the need for services later. 4:08:35 PM REPRESENTATIVE SADDLER offered his understanding that there is an inadequate supply of community-based services in rural Alaska. He asked whether it is realistic to provide rural areas the range of services needed. MR. JESSEE answered that the entire continuum of care cannot be in a small village; however, the Tribal health system has developed resources. For example, there are behavioral health aides in many villages. He concurred that providing services early is important and may lead to the child not having to leave the village. 4:10:38 PM CHAIR PRAX asked about the shift from 700 children to 70 children placed in out-of-state care facilities. REPRESENTATIVE FIELDS confirmed that the number of children in out-of-state care facilities is about 70 today, with about 20 in state custody. 4:11:20 PM MS. CARPENTER explained that there were 965 children in out-of- state placement in 2004, and the children were covered by Medicaid or in state custody. As of yesterday, she stated that there are 70 children in out-of-state care paid for by the state's Medicaid dollars. She added that, since DOJ began its investigation in 2020, out-of-state placements have been reduced by 25 percent. 4:12:34 PM CHRISSY VOGELEY, Special Assistant, Office of the Commissioner, Department of Family and Community Services, stated that the number of children in state custody that are in out-of-state facilities is 25. According to historical records going back to 2008, she stated that at any given time there has been about 30 children in the state's custody who were placed out of state. MS. WILSON reminded members that before a child goes out of state, the placement goes through a court hearing to examine why the child's needs cannot be met in Alaska. She said that these placements are reviewed every six months. 4:13:39 PM REPRESENTATIVE SADDLER asked for the difference between the 25 and 70 figures that have been referenced. MS. CARPENTER answered that 70 children have Medicaid as a payment source to the facilities, and 25 children are in state custody. In response to a follow-up question, she stated that the 25 children are also on Medicaid. She continued that for a child with a specialized need, DOH must find a provider who meets this need. She said this may also include a provider that is not yet enrolled in the Medicaid program. She pointed out that Ms. Wilson has been working to get specialized need providers enrolled in the program. 4:16:07 PM MS. WILSON added that there are currently five children who are in private-pay agreements with facilities, with the requirement that these facilities work towards enrolling in Medicaid. She elaborated that the agreement provides a bridge between getting the care for the child and ensuring facilities are enrolling in Medicaid. 4:17:50 PM REPRESENTATIVE MINA asked if there is legislation in other states that prohibits out-of-state, for-profit referrals for kids. REPRESENTATIVE FIELDS expressed uncertainty. 4:18:11 PM CHAIR PRAX inquired about legal challenges in trying to enforce specific organizations, whether for-profit or nonprofit. He asked for Legislative Legal Services to answer. REPRESENTATIVE FIELDS offered his understanding that the concern was not flagged by Legislative Legal Services. He suggested that the question would be how the state could best prioritize care in a legal way, while supporting the best care. 4:19:40 PM CHAIR PRAX asked whether the population of children needing service has complicated or intense needs. MS. WILSON answered "both," as the children are aggressive, even toward staff. She said that it is DFCS's responsibility to ensure that a child placed at a facility is monitored. She said the problem has been for the child to continue to be successful when back in Alaska. As initiatives like Bring the Kids Home have come, services have grown, and so has the complexity of children. 4:21:56 PM REPRESENTATIVE SADDLER questioned the success rate of DFCS's treatment systems and programs. MS. WILSON answered, "We've come a long way." She recounted a successful case and said there are more successes than not. She said that in any state, there are struggles in the balance in the kinds of services needed. 4:23:30 PM MS. CARPENTER shared that she had a direct family member receive care in an out-of-state facility. She stated that it is DOH's priority to get the best placements. She pointed out that the 1115 waiver was part of Senate Bill 74 [passed during the Twenty-Ninth Alaska State Legislature], and this has been hopeful. She explained that using this waiver, along with the Bring the Kids Home initiative, community level services were created. She said that this allows children and parents to be cared for at a lower level, intervening on a higher level of care. She stated that the goal is for kids to be kept home, closer to family, and the 1115 waiver supports this on the behavioral health side. She said DOH has expanded Medicaid- covered services to individuals who are at risk of developing a mental health or substance-use disorder. She explained that this is an important policy decision because previously an adult had to be diagnosed with mental illness or a child as severely emotionally disturbed, as "at risk" was not allowable criteria outside of a waiver. She said that this shift was done to get service to children sooner. She stated that consideration must be made toward getting more providers in the state and ensuring there are enough community-based providers for adults. She emphasized the importance of the continuum of care from childhood through adulthood. 4:26:39 PM CHAIR PRAX asked the testifiers to identify things that the departments have done to bring down the number of children in out-of-state care. MS. CARPENTER answered that there has been a collection of things over the years, including continued technical assistance to providers and efforts like the Complex Behavioral Collaborative. She explained that the biggest game changer has been the 1115 waiver, as well as bringing on new service lines that can be reimbursed, as this reduces reliance on grant-based efforts. She said that this past spring, DOH has approved a 4.5 percent increase to the 1115 waiver rate. 4:29:38 PM MS. WILSON addressed the fiscal note. She stated that if DFCS could not utilize half of the private, for-profit residential treatment centers, then over half of the children who are currently in care would have nowhere to go. She said that when DFCS finds the right placement for the child, and it happens to be out of state, there is a strict process to determine there were no other alternatives. She added that OCS has augmented rates, which would be higher pay for staff overseeing children who require more time. MS. CARPENTER added that in DOH's response to DOJ, it stated that a steering committee would be created to start the process of hearing from providers. She thanked the legislators for their interest in the topic. 4:32:16 PM REPRESENTATIVE FIELDS commented that it is indeed not a simple issue of the placements being in-state or out of state, as sometimes children are placed in Anchorage outside of their home region. 4:33:10 PM CHAIR PRAX asked if DOH would be reporting to the legislature before next session. MS. CARPENTER answered no; however, DOH would plan to keep stakeholders and legislators well-informed. 4:33:59 PM CHAIR PRAX thanked the bill sponsor and the invited testifiers. [HB 167 was held over.]