The subcommittee on Health and Human Services was called to order at 3:40 p.m., on Tuesday, March 9, 1999. Chairman Sheila Leslie presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All Exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

COMMITTEE MEMBERS PRESENT:

Ms. Sheila Leslie, Chairman

Ms. Merle Berman

Ms. Dawn Gibbons

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Following roll call, Chairman Leslie opened the hearing on A.B. 178. She explained the bill was a result of community concerns for children who were Medicaid eligible and were not receiving mental health care. Northern Nevada was affected because Medicaid patients from that area were not in managed care as was the case for southern Nevada. The intent of A.B. 178 was to make sure such children received mental health care. Marriage and family therapists and licensed social workers in Nevada sometimes provided very specialized mental health care for children. When those therapists and social workers worked for the state, Medicaid reimbursed the state. When they worked in the private sector, the state plan prohibited reimbursement. Other states had elected to let licensed clinical social workers and licensed marriage and family therapists provide the service.

The Health and Human Services Committee had met the prior week and heard a lot of testimony in support of A.B. 178. No opposition was heard at that time. Ms. Leslie also wanted to study the fiscal impact of the bill.

First to testify in support of the bill was Mike Roser, President, Nursing Home Social Work Services. Mr. Roser told the subcommittee during prior testimony there were questions regarding whether the proposed program would tie into computer systems. It was his experience through consulting work he had done in California, Florida, New Mexico, and Nevada, with Medicare reimbursement for seniors over 65 years, and those under that age who were disabled, there was already a tie-in to Medicaid through a computer system. Nevada did not reimburse, New Mexico and California were reimbursed for 20 visits and Florida reimbursed with no limit on visits.

In 1991, continued Mr. Roser, he was administrator at Riverside Hospital in Reno, where patients were shipped to Utah because Medicaid did not pay. He attempted to convince Medicaid to keep those patients in the state so spouses still in the Reno area would not be separated. That was not possible. In 1993, when he went into private practice he tried to get Medicaid reimbursement. It was explained to him Medicaid had a choice as to who it wanted as providers, and licensed clinical social workers were not their choice.

Mr. Roser dealt mostly with Health Care Financing Administration (HCFA), who recognized licensed clinical social workers. Through HFCA, he was reimbursed 50 percent of Medicare billing. That amounted to about $35 per visit in his practice. There were approximately 43 nursing homes in Nevada, with about 4,000 patients. That figure was growing quite rapidly in the Las Vegas area. A few more nursing homes were coming into Reno, as well as one in Carson City. With that, a licensed clinical social worker would see approximately 10 to 15 percent of the nursing home population. There were approximately 600 visits per week not being reimbursed, according to Mr. Roser. It was very difficult to decipher the formulas for payment. Mr. Roser said there was a great need to fix those problems in the private sector.

Chairman Leslie asked if Mr. Roser saw A.B. 178 as a way to obtain reimbursement as a nursing provider. Mr. Roser expressed his opinion that licensed clinical social workers would not practice in Nevada realizing they would not get full fees. They would make approximately half what other states were paying.

Assemblywoman Berman wondered whether the bill addressed children only, as she believed, since it appeared the testimony referred to children, seniors, and nursing facilities. She commented the fiscal note might change if those segments were included.

Assemblywoman Leslie responded A.B. 178 was originally intended to address the children’s issue at Children’s Behavioral Services (CBS). However, further investigation revealed perhaps the Medicaid plan should be changed to include reimbursement to licensed clinical social workers and marriage and family therapists. The fiscal note would indeed change, but it was not a fixed figure at the moment.

Ms. Berman suggested the bill might need to be narrowed down immediately. Mr. Roser stated he understood that view but wanted to point out there were members of society such as quadriplegics who were 40 years old that needed in-home visits which were not reimbursed. Children’s Behavioral Services was in a very bad position in that while the children had desperate needs, the waiting list excluded immediate aid.

Ms. Leslie responded she understood Mr. Roser’s position and totally agreed. She appreciated his testimony regarding Children’s Behavioral Services. She also felt Ms. Berman had a good point.

Mr. Roser said he noticed a section in the bill stating the Aging Services Division, Health Division, and welfare administrator had been assigned as administrators, (Page 2, Line 10). He hoped that would not change.

Chairman Leslie answered that was existing law and would not be changed.

Stuart Gordon, M.S.W., Clinical Coordinator, Parents United, testified next in support of A.B. 178. Mr. Gordon told the committee his organization, a division of Family Counseling, provided clinical services and group treatment to survivors of sexual abuse, and to their families. Over 80 percent of those families were underinsured, with their primary source of payment being Medicaid.

One of the issues with which Mr. Gordon dealt was when families came to him, he needed to find a psychologist that would not only see children, which was difficult at best, but would accept Medicaid payment. Both circumstances combined made success in such endeavors rare indeed.

Another point Mr. Gordon brought up was because of the Medicaid stance on reimbursement, there frequently was a break in continuity of treatment. He had to tell the families they would be placed on a waiting list for CBS or a psychologist in the community that would accept Medicaid but in the meantime they would continue group therapy with him. One aspect of sexual abuse isolation was when people finally did break down and come forward for treatment there was a very small window, often only a few days, to begin treatment or the victim would revert to hiding from the pain again. Victims hid behind drug and alcohol abuse, and established many other kinds of negative coping devises.

Later on, those people were seen in prisons. Over 80 percent of women in prisons were survivors of sexual abuse. Eighty-five percent of women in drug and alcohol treatment facilities were survivors of sexual abuse. So the state paid later at a greater cost for not intervening early. Mr. Gordon said there were 14 children in his child survivor’s group, and all had been in the Children’s Cabinet. In his teen group, with just a few years difference in age, every girl in the group had been in Willow Springs or in West Hills, both of which were inpatient psychiatric hospitals. They were all on Medicaid, and the state was paying $1,000 a day per person to have the girls in those facilities, as opposed to $60 a week to see them in individual treatment.

Mr. Gordon stressed he was very saddened to learn that adult treatment was not to be addressed by A.B. 178, since he could not envision seeing children without seeing their parents as well if the goal was to reunify those families. He said he could not find psychologists with enough openings to take those families. One out of 4 girls and one out 7 boys before the age of 18 were survivors of sexual abuse, and those statistics were optimistic. There had been 187 complaints in Washoe County in 1998. There were one 192 children on the waiting list at CBS, with a 7-week wait for an intake at Nevada Mental Health Institute.

Assemblywoman Gibbons wondered if there was some way to determine costs of using marriage and family therapists and licensed clinical social workers. Mr. Gordon said if cost was based on the Medicare system of reimbursement, there could be a savings of one-seventh over what psychologists received, or approximately $10 per session. The other costs included Medicaid funds for children who had been through the in-patient facilities. That number was quite large.

Ms. Leslie commented while children were on the waiting list for CBS, even though they were already eligible for Medicaid, they were still not receiving treatment. Therefore, if there was no service, there were no savings.

Mr. Gordon explained at the moment a private foundation covered costs at Parents United for treatment of children who were on Medicaid and on the waiting list for CBS. However, he did not know where funds would come from in the following year. Parents United used licensed clinical social worker interns to see those children, and so were able to see them at a fraction of the cost.

Assemblywoman Berman queried whether Mr. Gordon had stated he set up a non-profit foundation to treat the children in question. Mr. Gordon explained Parents United was an international organization. Family Counseling, where he worked, was a division of Parents United. He wrote grants through Parents United but did not have a private foundation from which to draw.

Next to testify in support of A.B. 178 was Efriam Estrada, M.S.W., Licensed Clinical Social Worker. Mr. Estrada told the subcommittee he had practiced in Nevada for over 20 years. He stated he received requests from Family and Children’s Services, the Juvenile Probation Department, and the Carson City School District to provide counseling to children. In many cases, the families had no ability to pay for those services. He got 25 to 30 requests a year to provide services, and could not accept all of them. Mr. Estrada took 10 or12 of those requests, and at 10 to 12 sessions per child, that amounted to approximately 140 hours per year. While he did not go into social work to get rich, he would like to break even so he could provide counseling for as many children as possible.

Alfredo Amezaga, Jr., Ph.D., Nevada State Psychological Association (N.S.P.A.), had also practiced for 20 years in Nevada, primarily for the Latino community. He testified the position of the association was a neutral one. However, they recognized the needs of the population and welcomed the providing of services if the diagnoses were made first by either a psychiatrist or psychologist.

Ms. Gibbons asked if it were more difficult to provide services to the Latino community if they were not American-born. Mr. Amezaga agreed there were several barriers. He had a client at present who was not eligible for state or Medicaid services. She had a physical deformity, and a serious need for counseling. He saw her pro bono, even though he did see Medicaid clients, purely because she obviously did not have access to funds or other services.

Ms. Berman asked how a diagnosis could be made if there were not enough psychologists available to do so. She wondered if the N.S.P.A. was satisfied patients would get proper care if a social worker or MFT made that diagnosis, or did the followup.

Mr. Amezaga stated the official position of the N.S.P.A. was a preference for the diagnosis to be provided by those with the training, background, and experience to make those diagnoses. He was not sure how many people were willing or available to do so. He had no way of knowing whether clients got proper care, other than he made his referrals to persons in whom he had confidence. If a psychiatrist or psychologist made the initial diagnosis, his comfort level with a marriage and family therapist or social worker doing followup would depend on who that person was.

Ms. Berman said apparently there was not the ability to pick and choose because of the demand for services. Mr. Amezaga replied since he had a commitment to the underserved population, he was comfortable with that level of followup.

Alicia Smally, President, National Association of Social Workers (N.A.S.W.), said the members of N.A.S.W. wanted to work with other professionals whenever possible. The regulations of that organization stated they diagnosed and treated emotional and behavioral disorders, conditions and addictions, so they had the ability to diagnose. It was always good to get psychological input, and sometimes testing.

Ms. Leslie explained the subcommittee would not address diagnostic abilities in various professions, although she appreciated the input. She stated she personally referred to a particular person depending on the needs of the client.

Janice Wright, Deputy Administrator, Division of Health Care Financing and Policy, told the subcommittee the first fiscal note supplied to the members recognized there were currently a specific number of people receiving services from psychologists. There were also licensed clinical social workers and marriage and family therapists who provided services through the Health Maintenance Organizations in southern Nevada. There were approximately 159 psychologists who were part of the 6,900 providers served with Medicaid. The Division of Health Care Financing and Policy used the dollars expended in Fiscal Year 1998 for the current fiscal note. The division did not keep track of unmet need. If there were people not receiving services, as indicated by the waiting list, that was not information Medicaid could supply.

In previous testimony, the Division of Health Care Financing and Policy heard concerns about waiting lists. Medicaid was funded on what was actually expended, not on the actual eligible people who were not receiving services. If everyone who was Medicaid eligible received all the services they needed, there would be no fiscal impact. However, the budget was built based on spending, not need. If services were expanded to include people on waiting lists, the issue of unmet need must be addressed. The waiting list information provided to the Division of Health Care Financing and Policy concerned children. It now appeared A.B. 178 did not specifically address children. Information about unmet need would enable the Division of Health Care Financing and Policy to provide a better analysis.

A.B. 178 also did not address the rate of reimbursement. Testimony referred to certain formulas and policies. Rate information would be required for a better analysis. That would require workshops, input from providers, and inclusion into an amended state plan.

If one made the assumption that all of the people currently in Clark County were receiving services through psychologists or health maintenance organizations which reimbursed marriage and family therapists or licensed clinical social workers, that segment of the population could be excluded from the fiscal note. That percentage currently was almost 68 percent. Of all the people who received services of psychologists, 67 percent were in Clark County. They would not receive any different services and so would not affect the fiscal note. That left 33 percent in the rest of Nevada, other than those receiving reimbursement by HMOs.

Those figures would then translate to 2,362 people served as an unduplicated count, and the question would be what was the cost to serve the additional 32 percent which was presumed to be the unmet need in areas other than Clark County. The figure Ms. Wright reached was $480,183 for the first year, and $513,153 for the second year.

Ms. Berman commented Ms. Wright’s figures contradicted what she had just heard happened in Washoe County. She was concerned the figure of 67 percent was a presumption that might not reflect the possibly larger problem in Washoe County. Ms. Wright explained the earlier fiscal note reflected the total amount paid to psychologists, and if the unmet need was the same, then the earlier note was correct. It might be larger based on current testimony. She was trying to give the subcommittee options of where the bill should be focused, and what the actual cost might be.

Ms. Leslie said her concern was with people who did not receive any help, as opposed to those who did. Les Gruner, Acting Program Manager II, Northern Nevada Child and Adolescent Services, had said earlier in the session that 30 percent of the children he had interviewed were already eligible for Medicaid and were on a waiting list. That was the segment with which she was concerned. That need was addressed neither in the old fiscal note, nor the new one. Ms. Wright reiterated the budget did not pay for people waiting for services. She asked for figures to reflect the set amount of people the subcommittee wanted to serve, and she could then develop a fiscal note based on that number. Mr. Gruner’s concern was the children he had on the waiting list were not the only ones to be served by A.B. 178. That was why he felt the original fiscal note might be more correct.

Ms. Leslie asked if the figures were narrowed down to the 30 percent of children not in managed care but on Medicaid or on the waiting list, the fiscal note was then to provide services to those children. Ms. Wright agreed, and stated the issue the subcommittee then needed to address was how that segment of children would be specified. The difficulty for Medicaid was once the state plan was amended, then everyone would be seen. They would at that point be underfunded, and might have to cut services. That was how waiting lists were created to begin with.

Ms. Leslie indicated she understood, but the reason she brought the bill forward to begin with was those children had already been on waiting lists for years.

At that point, testimony from the original committee meeting was placed in the subcommittee records (Exhibit C.) That testimony was submitted by Christine Bitonti, Ph.D., Licensed Clinical Social Worker, Northern Nevada HIV Outpatient Program, Education and Services (H.O.P.E.S.). Ms. Bitoni stated in her written testimony she was a Mental Health Commissioner for the State of Nevada. She was a founding member of the coalition of agencies, consumers, and professionals in northern Nevada who had been working collectively on behalf of mental health needs for over 5 years. A number of years ago, she had discovered a serious gap in access to services for children and young people in Nevada; in particular in for outpatient psychotherapy for early intervention, hospitalization, and followup services.

H.O.P.E.S., explained Ms. Bitonti, was a nonprofit medical clinic serving northern Nevada from the Idaho state line to Hawthorne and east to Utah. They had 250 clients and specialized in treatment of HIV and AIDS. Many of the patients did very well on their medications, but those who did not do well were subject to demoralization and clinical depression. Her estimate was that 25 percent of HIV and AIDS patients had serious mental health problems at some point in the course of their disease. The percentage was much higher among Medicaid patients, because they were poor and since their disease had progressed to the point where they were eligible for Medicaid, they had many more health and social problems with which to deal. As a result, they suffered much more frequently from serious depression and anxiety.

The key to health for HIV patients, continued Ms. Bitonti, was consistency with medications. If a client missed more than an occasional dose, the virus began to replicate. Research showed depression was a major reason people stopped taking the medications. It was necessary to treat the mental health issues of the HIV and AIDS population if success was to be had in treatment of the physical disease.

Ms. Bitonti explained those with health insurance through their employer had reasonably good access to outpatient services. Those with no health insurance at all could access services through the Nevada Mental Health Institute, which was difficult at best without psychiatric emergency services available. It had been her experience patients had to decompensate to the point of needing hospitalization before they could receive adequate treatment. And then, upon release, there were few options for followup.

Ms. Bitonti concluded quite frequently she would choose to refer a client to a social worker or marriage and family therapist, depending on the issues presented. Many therapists specialized in treating certain populations or disorders. It was critical to find a good match for the client’s needs. She was surprised that social workers, who’s professional mission it was to serve the poor, were excluded from doing so in Nevada through Medicaid. Marriage and family therapists, who specialized in intervening in dysfunctional family processes could not be put to use in the early treatment of mental disorders in Medicaid families.

As a Mental Health Commissioner, Ms. Bitonti urged the passage of A.B. 178 because it was not only fair, it represented an opportunity to expand access to mental health services for impoverished Nevadans, particularly those in rural areas where it was likely a licensed clinical social worker or marriage and family therapist could be found.

Ms. Berman told the Chair she did not realize how many people were affected and because it was such an important bill she wanted to make a suggestion for the entire committee to pass the bill and get a fiscal note with some teeth to it.

Ms. Leslie agreed, and asked if Ms. Berman felt the bill should be narrowed to include only children. Ms. Berman responded she felt the only chance of getting anywhere with the bill was, it should be narrowed down to children under the age of 19.

Assemblywoman Gibbons concurred with that opinion. Though she hated to leave so many needy people out of the bill, in the long run A.B.178 needed to be passed as soon as possible.

Mrs. Wright asked if the subcommittee would like a revised fiscal note for the amended version of A.B. 178 to reflect 30 percent of the 300 or so children on the waiting list. Ms. Leslie returned she wanted to research the waiting list issue with rural mental health clinics. She understood Clark County had the only mandatory managed care in Nevada, and her concern was for children in the rest of the state on waiting lists not covered under managed care that were eligible for Medicaid.

Ms. Berman suggested if the bill was limited as discussed, it would help the bill through the Assembly Committee on Ways and Means, so it was probably best to limit the population affected to Washoe County.

Jon Sasser, Washoe Legal Services, agreed with most of the assumptions from Ms. Wright in that if there were people with unmet needs, that was money not spent on Medicaid and therefore would need to be in the budget. If everyone in Clark County was in a managed care plan, those figures needed to be removed. The question was how many children in the balance of the state were affected, and were there savings that should be backed out of the normal cost of serving those children.

Mr. Sasser said he thought from the previous testimony there were children in institutions that did not need to be there if they received the services as described in A.B. 178. If they were in institutions paid by Medicaid that would be a direct saving to Medicaid. If they were in institutions paid by another method, it was not a direct saving to Medicaid. In his experience, it was difficult to get those institutions to voluntarily lower their budgets.

Mr. Sasser commented he did not know if it could be stated children on waiting lists would never be served. But if the timeline for those services indicated a delay of 6 months, for example, the number of visits would lessen for that reason, which would indicate a saving to Medicaid as well. That should be taken into account, along with the savings from the difference in hourly rates of social workers or Marriage and family therapists who charged less than psychologists or psychiatrists. All those factors could be backed out of the budget, as well as the people in rural areas who were not even on the lists

Helen Foley, representing Marriage and Family Therapists, spoke in favor of

A.B. 178. She said historically Marriage and family therapists received about 30 percent less in reimbursement than psychologists, so Ms. Wright might also take that into account as a cost saving.

Ms. Gibbons wondered how many children were on the waiting list in Carson City.

Alicia Smally, President, National Association of Social Workers, Nevada Chapter, responded while she did not have that figure, she believed people on the waiting list in Children’s Behavioral Services were not just from Washoe County. They included children from Carson City, Storey, Douglas and Lyon counties as well.

Chairwoman Leslie stated she would send A.B. 178 to the full Assembly Committee on Health and Human Services Committee and recommend the bill be amended to include children not on managed care and only in northern Nevada.

There being no further business before the subcommittee, Chairman Leslie adjourned the hearing at 4:25 p.m.

RESPECTFULLY SUBMITTED:

Lois McDonald,

Committee Secretary

APPROVED BY:

Assemblywoman Sheila Leslie, Chairman

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