SENATE BILL NO. 105 "An Act relating to the licensure of marital and family therapists; relating to professional liability insurance for marital and family therapists; relating to medical assistance for marital and family therapy services; and providing for an effective date." 9:04:53 AM Co-Chair MacKinnon discussed a brief history of the bill. The committee opened and closed public testimony on the bill on February 27, 2018. The committee had been working on compromise language to satisfy the concerns raised by members as well as the general public. Vice-Chair Bishop MOVED to ADOPT proposed committee substitute for SB 105, Work Draft 30-LS0442\N (Radford, 3/28/18). Co-Chair MacKinnon OBJECTED for discussion. SENATOR DAVID WILSON, SPONSOR, deferred to his staff, Mr. Zepp, to review the committee substitute changes. GARY ZEPP, STAFF, SENATOR DAVID WILSON, reviewed the Summary of Changes document (copy on file): Version J to Version N Section 1Amended Page 2, lines 16-24: The required total number of hours for the supervision of an Associate Marital and Family Therapist was corrected to 1,700 hours. The previous version incorrectly reflected 1,500 hours as the required total hours. Version R also clarifies that 100 hours of individual supervision and 100 hours of group supervision conducted one or more supervisors is included in the 1,700 hours. Section 1 - Deleted Page 2, lines 29-31: The requirement for $30,000 of professional liability insurance was deleted. Insurance to cover state investigative costs is not currently available as envisioned. A national company does offer professional liability insurance, but the coverage would reimburse the licensee for their investigative costs and not the state investigator costs. The idea of professional liability insurance was to pay for state investigative costs and keep downward pressure on the state investigative costs so that the costs wouldn't be allocated amongst current licensees and increase their existing license fees. Mr. Zepp continued to read the summary of changes: Section 2 Amended Page 3, lines 5 -13: Properly re-state the titles for the healthcare professions listed that are authorized to provide group supervision of an Associate Marital and Family Therapist while in training. The titles of certain healthcare professionals were verified by the State Medical Board. Section 4 and 5 - Deleted Page 4, lines 8 Page 5, line 1: Sections 4 and 5 were deleted because SB 169, which has passed the Senate and is in the other body, amends the same statutes (AS 47.07.030) previously contained in sections 4 and 5 of SB 105. SB 169 amends statute by replacing a psychiatrist with a physician, to expand the direct supervisory capacity in providing behavioral health clinic services. As well as removing the 30% on - site requirement and replacing that by requiring a physician in person or available via a communication device. SB 105, as amended, is fully supported by the Board of Marital and Family Therapists. Please see the two letters of support from the Board. 9:09:42 AM Co-Chair MacKinnon WITHDREW her OBJECTION. There being NO further OBJECTION, it was so ordered. She invited Senator Wilson to comment on the bill. Senator Wilson discussed the bill. He explained the main purpose of the bill was to add the marital and family licensed therapist to the list of providers that were able to bill Medicaid allowing more access to services. The bill would enhance behavioral health capacity for underserved Alaskans who were on long waitlists to access services. He stated that the bill would offer opportunities for clinics to provide services at a lower cost. He elaborated that the way in which recruitment happened currently for licensed social workers with a Master of Social Work (MSW) degree took a significant amount of time, about 1 year or 1.5 years, to recruit. For some clinics, the cost of recruitment was over $100,000. The bill would result in a more abundant source of providers that were equally qualified to provide behavioral health services at a lesser cost with easier access. Senator Micciche asked the sponsor to explain the benefit of the bill and identify how much money would be saved in the long run. Senator Wilson replied that without having access to psychiatric services and providers at a lower cost, patients were going to the emergency room (ER). The cost for treatment at an ER often cost the state 10 times more than providing the services through local community clinics. He noted previous testimony by representatives from some of the community health centers who confirmed their facilities could provide behavioral health services at a lower cost than an ER. The Mat-Su Health Foundation reported the number of people accessing their ER and their inability to meet the needs of patients because of a lack of capacity. He also noted hearing testimony from 85 licensed psychiatrists in the State of Alaska. The Mental Health Working Group confirmed that their studies stated that Alaska needed an additional 106 to 184 psychiatrists to meet the national average and to cover the need in the state. He was hoping that patients could address their issues through a lower acuity of care instead of them being escalated to a higher acuity of care, which was more devastating to the individual and costlier to the state. 9:13:47 AM Senator Olson asked if the sponsor had checked with health corporations regarding the changes to the bill. Senator Wilson asked if Senator Olson was referring to the native health corporations or some of the larger providers. Senator Olson wondered, if he called up Maniilaq Health Center, whether they would be able to confirm that the bill sponsor had reached out to them about the proposed changes in the bill. Senator Wilson stated that Maniilaq Health Center was a member of the Alaska Primary Care Association (APCA), who was in full support of the legislation. He hoped Maniilaq Health Center would support the bill being a member of APCA. He relayed that half of the members of APCA were tribal entities that operated the community health centers. The trade association was in full support and had been lobbying to help support the bill. Senator Olson referenced the name change in Section 4 and 5. He asked if the Senator had talked with any of the physician groups such as the Alaska State Medical Association about the changes moving from psychiatrists to physicians. Senator Wilson responded in the negative. His office had worked with the department on the legislation. They were in full support of the change from psychiatrist to physician to meet more of the federal definitions and guidelines with conforming language. Senator Olson asked who "they" were. Senator Wilson specified Director Burns of the Department of Health and Social Services (DHSS). Co-Chair MacKinnon stated that the committee had removed from the bill another bill that was carried by another sponsor, Senator Giessel, regarding supervision and the definition Senator Olson referred to. Currently in Alaska state statute, in any individual medical provider's office a psychiatrist was required 30 percent of the time. She conveyed her point that there were two pieces of legislation that would affect the same portion of statute. With that in mind, she had a concern that the legislature would be dependent on two pieces of legislation by two different legislators ending across the finish line at the same time to accomplish what the legislature wanted to accomplish. Senator Wilson's bill allowed the billing and was not speaking directly to supervision. She asked if she was correct. Senator Wilson clarified that the bill addressed both supervision and the expansion of MSW's being able to bill Medicaid. Co-Chair MacKinnon directed her question around supervision. She asked about supervision in terms of the bill the committee had heard previously and whether it had to do with 30 hours. Mr. Zepp answered in the affirmative. He noted that the previous version of the bill in Sections 4 and 5 fell into the Medicaid billion section of the bill. In thinking of SB 105 there were two silos. The first silo was the training issue for an associate which was what the senator as trying to streamline and expand. The second silo was under the Medicaid billing to provided marital and family therapists under the optional Medicaid services, so they could bill and seek reimbursement. The Senator removed Sections 4 and 5 because Senator Giessel's bill clarified direct supervision from a physician with certain guidelines. 9:18:52 AM Co-Chair MacKinnon stated that she was willing to support the billing portion of the legislation because of seeing the results of an opioid epidemic in Alaska and other mental health needs that were being under-represented in communities across the state. She added that she thought supervision was important, and that Senator Giessel's bill along with Senator Wilson's bill both needed to reach the finish line. Senator Micciche thought both bills being discussed were advantageous to the clients and to the state. Co-Chair MacKinnon echoed the comments of Senator Micciche. 9:20:53 AM RANDALL BURNS, DIRECTOR, DIVISION OF BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via teleconference), discussed fiscal note OMB component 2660. The fiscal note specifically addressed the portion of the bill related to the addition of marriage and family therapists to the optional Medicaid statutes. The division had estimated what was thought to be a fair amount of additional costs to the Medicaid budget as the result of adding Marriage and Family therapists to the list of professions that could bill Medicaid for their services. He found that the bill would only apply to about 633 Medicaid- eligible recipients in the first year. Mr. Burns continued that most of the marriage and family therapists worked in clinics and did not bill Medicaid directly. There was no way of knowing how many of those individuals would opt to leave a clinic to start up a practice independently or start billing independently. The division tried to be conservative in its calculations. The division estimated approximately $1 million. He continued that $660,000 of the amount would be in federal match to the state's commitment of about $340,000. There was a small charge for FY 19 to make the changes to the state's Medicaid Management Information System to allow marriage and family therapists to bill Medicaid directly. Co-Chair MacKinnon stated that the committee required an updated fiscal note. She pointed out that the numbers were correct but the narrative on the back needed to change to reflect the new committee substitute before the committee. Mr. Burns stated that he was working on that presently. Senator Micciche thought the fiscal note addressed additional costs but did not capture any consideration for cost avoidance. He asked Mr. Burns if he intended to include some evaluation of cost avoidance that would result from the passage of the bill. Mr. Burns stated that he did not put cost avoidance in the fiscal note of the bill. He saw it falling within the more wholistic approach of SB 74 and the changes being made to the system by the 1115 waiver and the process. He thought estimating the savings resulting from adding marriage and family therapists to the list would be difficult. The division had not contemplated making such a representation in the fiscal note being reviewed. Co-Chair MacKinnon acknowledged that the number would be difficult to quantify, as there was a mixture of private versus government utilization. She indicated that the bill would contribute to an overall higher cost to the Medicaid system for the state. It was a new service that would be provided and reimbursed by the state with a significant portion of the reimbursement coming from the federal government in an effort to deploy the resources to those needing help, to divert ER access, and to lower care access. Co-Chair MacKinnon reported that someone from the Alaska Board of Marital Family Therapy had come online. She asked for the will of the committee. 9:25:43 AM AT EASE 9:27:21 AM RECONVENED Co-Chair MacKinnon relayed that the public hearing had closed on the bill. She indicated the committee was in receipt of her comments. She asked Ms. Cunningham if she had a brief comment she wanted to make to the committee. KAREN CUNNINGHAM, ALASKA BOARD OF MARITAL AND FAMILY THERAPY, ANCHORAGE (via teleconference), testified in support of the bill. She was a licensed marriage and family therapist (LMFT)and sat on the Alaska Board of Marital and Family Therapy. She reported that the board met to discuss SB 105 and unanimously affirmed their support for the statutory changes presented in the bill. One of the responsibilities of the board was to establish minimum requirements for applicants seeking licensure. Senate Bill 105 called for clarification that the hours required for licensure were 1700. The breakdown of the hours included 1500 face-to-face clinical hours and 100 hours each of individual and group supervision. Another responsibility of the board was to serve and protect public interest. The proposed legislation worked towards that end by allowing applicants greater options for supervisors which ultimately would lead to a greater number of LMFTs in the state. Currently, there was a limited number of LMFT supervisors which made it very difficult for new graduates applying for associate licensures to find an individual and a group supervisor willing to commit to a minimum of 2 years. Co-Chair MacKinnon relayed that the committee had written comments from the board. Ms. Cunningham did not have anything to add to the letter that had been written. She appreciated the opportunity to speak. Co-Chair MacKinnon stated it was her intent to move the bill. She had an agreement from the sponsor and the boards that were contacted in support of the new language in the bill. Senator Micciche understood the fiscal note and the logic behind it. He was concerned that the department seemed unwilling to put on the record that there would likely be an offset to the costs of the bill. Not all of the additional services in the state's portfolio of Medicaid billing had panned out as a cost saving measure. He would have liked to have heard more from the department that it recognized there would be an offset rather than a $340,000 UGF match. He hoped the amount would have been lower due to the offset. With the expansion of Medicaid, additional services, and new waivers the legislature had not seen the savings in the waivers that he would have liked to have seen. He was concerned with UGF spending increases. He supported the additional services but was worried that the department was not formally recognizing an offset. 9:31:36 AM Senator von Imhof relayed that she sat on the Healthcare Blueprint Committee. The committee was in phase 2 of identifying areas of concern. The committee was flushing out the five areas of concern it identified to put together a recommendation to create a systemic transformation of Alaska's healthcare system. One of the five areas of concern was access to primary care providers. She thought the bill addressed the issue by qualifying a marital therapist as a provider. She thought the bill was consistent with the direction of the blueprint committee. Although the committee was still in progress, she supported the bill because she believed it provided greater access, particularly in rural Alaska, by allowing telehealth to be part of the solution and for rural citizens to have access to a variety of healthcare providers in numerous forms. The intent of the systemic change of Alaska's healthcare system was to lower the cost by having more access to a variety of healthcare providers and through preventive care versus costly crisis management. She thought the unquantifiable downstream savings was a guess but was consistent with the values of the blueprint committee she sat on. 9:33:54 AM Co-Chair MacKinnon agreed with Senator Micciche and Senator von Imhof. She would be supporting the bill because she believed the bill did what Senator von Imhof had discussed. She was concerned with providers abusing the system. She looked at some abuse in the dental field. For instance, some dentists performed unnecessary extractions on young children and billing Medicaid. Another example were adults having all of their teeth removed without a particularly good reason or back up materials. She continued that as long as providers behaved in the best interest of the people that were seeking care from them, the system should see a decrease. However, if providers decided to use it as a funding source for their individual practices and started billing excessively, the system would break. Co-Chair MacKinnon continued that Alaska's heath care costs were 30 percent higher than the national average and America's health care costs were higher than anywhere else on the planet. Alaskans were faced with a low demographic and high needs. They were at the mercy of hospitals, pharmaceuticals, insurance companies, and access to care in general. Senate Finance and the legislature were working to provide lower cost care to Alaskans. The bill was a step in the right direction. It required cooperation from the providers to be judicious in the way they accessed Medicaid funding which had a federal match. Senator Miccichie suggested by moving it from an emergency room to a doctor's or provider's office the cost would be lower, and the net of providers would be larger for those seeking services. Co-Chair MacKinnon continued to discuss the bill. She thought the department had provided a fiscal note with the possibility of an increased cost. The department had tried to quantify it, knowing that there were variables that could lower the overall cost. She appreciated that the fiscal note was not indeterminate. She preferred the legislature striking a balance between understanding the possible implications and how providers, insurance companies, hospitals, and pharmaceuticals working together could meet Alaskans healthcare needs. Like other small states, Alaska's legislators struggled to lower the costs for their constituents. 9:37:33 AM Vice-Chair Bishop made a comment about the general services line of the fiscal note for the development of business rules and the Medicaid Management Information System detailing the parameters for services and reimbursement. He suggested the department tract the legislation to see if there was a savings rather than a UGF spend. He thought the bill should result in a savings. Co-Chair MacKinnon suggested that Senator Wilson implement some tracking method for the particular billing code to look at how providers were using the service. She suggested a follow-up. She saw the bill as a benefit to hospitals and providers and she hoped it translated into quality care that was appropriate and effective for people trying to access care. Senator Wilson appreciated the comments from committee members. He had hoped the bill would increase access to care. His intention was not to increase the state's burden. He thanked the committee for hearing the bill. Co-Chair MacKinnon reflected that Mr. Zepp had been a pleasure to work with in answering questions from committee members and from her team. She was thankful that there was an enthusiastic effort to meet and answer questions that were difficult to answer. Vice-Chair Bishop MOVED to report CSSB 105(FIN) out of Committee with individual recommendations and the accompanying fiscal notes. There being NO OBJECTION, it was so ordered. CSSB 105(FIN) was REPORTED out of committee with a "do pass" recommendation and with one new forthcoming fiscal impact note from the Department of Health and Social Services and one new fiscal impact note from the Department of Commerce, Community and Economic Development. 9:42:33 AM AT EASE 9:46:35 AM RECONVENED