SENATE BILL REPORT

SSB 5779

As Passed Senate, March 1, 2017

Title: An act relating to behavioral health integration in primary care.

Brief Description: Concerning behavioral health integration in primary care.

Sponsors: Senate Committee on Human Services, Mental Health & Housing (originally sponsored by Senators Brown and O'Ban).

Brief History:

Committee Activity: Human Services, Mental Health & Housing: 2/14/17, 2/15/17 [DPS-WM].

Ways & Means: 2/21/17, 2/23/17 [DPS(HSMH)].

Floor Activity:

Passed Senate: 3/01/17, 49-0.

Majority Report: That Substitute Senate Bill No. 5779 be substituted therefor, and the substitute bill do pass and be referred to Committee on Ways & Means.

Signed by Senators O'Ban, Chair; Miloscia, Vice Chair; Darneille, Ranking Minority Member; Carlyle, Hunt, Padden and Walsh.

Staff: Kevin Black (786-7747)

Majority Report: That Substitute Senate Bill No. 5779 as recommended by Committee on Human Services, Mental Health & Housing be substituted therefor, and the substitute bill do pass.

Signed by Senators Braun, Chair; Brown, Vice Chair; Rossi, Vice Chair; Honeyford, Vice Chair, Capital Budget ; Ranker, Ranking Minority Member; Rolfes, Assistant Ranking Minority Member, Operating Budget; Frockt, Assistant Ranking Minority Member, Capital Budget; Bailey, Becker, Billig, Carlyle, Conway, Darneille, Fain, Hasegawa, Keiser, Miloscia, Padden, Pedersen, Rivers, Schoesler, Warnick and Zeiger.

Staff: Sandy Stith (786-7710)

Background: Washington provides publically-funded health services to low-income residents who meet eligibility requirements through the state Medicaid program, branded Apple Health, through behavioral health organizations (BHOs), and other programs. The Apple Health program is delivered through private health plans called managed care organizations (MCOs) which contract with the state HCA. The MCOs provide physical health services to all clients and low-level mental health services to clients who do not meet Access to Care Standards. BHOs are provider networks managed by a county authority or group of county authorities that contract with the Department of Social and Health Services (DSHS). BHOs provide substance use disorder services and crisis services to all clients, and mental health services to clients who meet Access to Care Standards. Access to Care Standards are a functional test applied by BHO providers to determine a level of impairment caused by the presence of a mental health disorder.

Based on legislation adopted in 2014, the community behavioral health system in Washington, which is currently administered by BHOs, must be fully integrated in a managed care health system that provides behavioral health and medical care services to Medicaid clients by January 1, 2020. One region of Washington State is an early adopter of full integration and has been operating under fully integrated managed care contracts since January 1, 2016.

The Statewide Common Measure Set is a set of performance metrics established by the Performance Measures Coordinating Committee, pursuant to 2014 legislation. The Committee is charged with developing a manageable set of performance measures to track value and performance in the health care system.

The Dr. Robert Bree Collaborative is an organization funded by HCA which convenes public and private stakeholders to improve the quality, health outcomes, and cost effectiveness of health care in Washington State. Members of the Collaborative are appointed by the Governor. The Collaborative has published reports on topics such as accountable payment models, addiction and dependence treatment, cardiovascular health, obstetrics, potentially avoidable hospital readmissions, and pediatric psychotropic use.

A chemical dependency professional (CDP) is a person certified in chemical dependency counseling who meets education and training requirements established by DSHS. A CDP or CDP trainee may not practice in settings that are not licensed or certified as substance use disorder treatment facilities unless the CDP holds a second license as an advanced registered nurse practitioner, marriage and family therapist, mental health counselor, advanced social worker, independent clinical social health worker, psychologist, osteopathic physician, osteopathic physician assistant, physician, or physician assistant.

Summary of First Substitute Bill: HCA must complete a review of payment codes available to health plans and providers related to behavioral health by August 1, 2017, and make adjustments to payment rules if needed to facilitate integration of behavioral health with primary care. The review must include stakeholder involvement and include consideration of enumerated principles, including:

• allowing professionals to operate within their full scope of practice;

• allowing medically necessary behavioral health services for covered patients to be provided in any setting, including reimbursement of health and behavioral codes for services delivered by a specified list of behavioral health professionals;

• facilitating integration of physical and behavioral health through multifaceted models; and

• limiting restrictions relating to same day billing, prior authorization for low-level or routine behavioral health care, and requiring the patient to be present during service delivery to situations consistent with national coding conventions and consonant with accepted best practices in the field.

HCA must create a matrix listing all behavioral health related codes available for provider payment and clearly explain applicable payment rules to increase awareness among providers, standardize billing practices, and reduce common and avoidable billing errors. HCA must disseminate this information in a manner calculated to maximally reach all relevant plans and providers and update the Provider Billing Guide to maintain consistency of information. HCA must inform the Governor and Legislature by letter of the steps taken and results achieved once the work is complete.

Subject to appropriation, HCA must establish a methodology and rate which provides increased reimbursement to health care providers for behavioral health services provided to patients in primary care settings. The purpose is to increase the availability of behavioral health services for children and youth and to incentivize adoption of the Primary Care Behavioral Health Model.

HCA and DSHS must establish a performance measure to be integrated into the Statewide Common Measure Set which tracks effective integration of behavioral health services in primary care settings. A definition for Primary Care Behavioral Health is provided and an intent section describes the Primary Care Behavioral Health model for integration of physical and behavioral health care in primary care settings.

A restriction on CDPs and CDP trainees is repealed which prevents the CDP or CDP trainee from treating patients in settings that are not licensed or certified as substance use disorder treatment facilities unless the CDP holds a second license as an advanced registered nurse practitioner, marriage and family therapist, mental health counselor, advanced social worker, independent clinical social health worker, psychologist, osteopathic physician, osteopathic physician assistant, physician, or physician assistant.

This act is entitled the Youth Behavioral Health Protection Act.

Appropriation: None.

Fiscal Note: Available.

Creates Committee/Commission/Task Force that includes Legislative members: No.

Effective Date: Ninety days after adjournment of session in which bill is passed.

Staff Summary of Public Testimony on Proposed Substitute (Human Services, Mental Health & Housing): The committee recommended a different version of the bill than what was heard. PRO: This bill came from a community conversation in my district around suicide. A physician told us part of the problem is getting streamlined behavioral health care to kids. He can embed a behavioral health professional into his practice to perform a behavioral health assessment during the same primary care visit. Too many kids don't follow up with referrals, or can't manage the travel requirements. Nearly one in five kids is affected by behavioral health disorders. This bill will help kids get the care they need. Eighty percent of patients do not receive the behavioral health care they deserve. Integrated behavioral health consultants can provide necessary care by intervening at times of acute crisis. Behavioral health integration helps the patient and the physician alike. Many of our primary health clinics experience difficulties with billing codes and lack of reimbursement given the complexity of those codes from HCA. The review called for in the bill is absolutely necessary and will show the gaps where billings aren't being paid. Please amend section 4 to apply increased reimbursement rates to all patients, not just kids. Please update language to refer to osteopathic physicians. Washington ranks 48th out of 50 for access to appropriate behavioral health care. We started a primary care behavioral health program five years ago, and saw 13,000 unique patients last year. Ninety percent had a reduction in symptoms, and 60 percent had a complete remission. We decreased visits by the most intense patients by an average of two visits a year, making room for 4000 additional patients. As a father and husband, it's important to provide mental health coverage to the people who are most important.

OTHER: Clear, robust evidence indicates that behavioral health in primary care works. HCA will continue to work on developing a matrix of codes to explain billing options to providers, which allow all practitioners to practice to their fullest scope. HCA cannot authorize performance measures, but we are happy to work to develop options and refer them to the appropriate committee. Integrating primary care with behavioral health is absolutely essential. Please do not restrict these options to primary care settings. Behavioral health providers are also interested in integrating primary care in behavioral health settings. It is restrictive to only being able to access behavioral health in primary care.

Persons Testifying (Human Services, Mental Health & Housing): PRO: Senator Brown, Prime Sponsor; Dr. Thatcher Felt, Yakima Valley Farmworkers Clinic; Len McComb, WA State Hospital Assn.; David Knutson, WA Osteopathic Medical Assn.; Brian Sandoval, Yakima Valley Farm Workers Clinic, WA Assn. for Community and Migrant Health Centers. OTHER: Charissa Fotinos, HCA; Alicia Ferris, Community Youth Services.

Persons Signed In To Testify But Not Testifying (Human Services, Mental Health & Housing): No one.

Staff Summary of Public Testimony on First Substitute (Ways & Means): PRO: You need prevention, but to get prevention you need access to care. This bill is a result of community conversations around the disproportionate number of child suicides. We had 42 child suicides in my district last year. I worked with Dr. Feld from the American Academy of Pediatrics to streamline access. One way to streamline access is to have a mental health professional embedded in a primary care practice. There were also coding issues with regard to mental health CPT codes and this bill removes those issues as well.

Persons Testifying (Ways & Means): PRO: Senator Sharon Brown, Prime Sponsor.

Persons Signed In To Testify But Not Testifying (Ways & Means): No one.