Existing law establishes the Licensed Mental Health Service Provider Education Program within the Health Professions Education Foundation. Existing law authorizes a licensed mental health service provider, as defined, including, among others, a psychologist and a marriage and family therapist, who provides direct patient care in a publicly funded facility or a mental health professional shortage area to apply for grants under the program to reimburse his or her educational loans related to a career as a licensed mental health service provider, as specified. Existing law establishes the Mental Health Practitioner Education Fund in the State Treasury and provides that moneys in that fund are available, upon appropriation, for expenditure by the Office of Statewide Health Planning and Development for purposes of the program.

This bill would expand the program to apply to persons eligible under existing law who attain further education in order to practice as psychiatric-mental health nurse practitioners or physician assistants in psychiatric mental health settings, thereby allowing those practitioners to apply for grants under the program for reimbursement of those later-incurred educational loans.

Existing law establishes the Licensed Mental Health Service Provider Education Program within the Health Professions Education Foundation. Existing law authorizes a licensed mental health service provider, as defined, including, among others, a psychologist and a marriage and family therapist, who provides direct patient care in a publicly funded facility or a mental health professional shortage area to apply for grants under the program to reimburse his or her educational loans related to a career as a licensed mental health service provider, as specified. Existing law establishes the Mental Health Practitioner Education Fund in the State Treasury and provides that moneys in that fund are available, upon appropriation, for expenditure by the Office of Statewide Health Planning and Development for purposes of the program.

This bill would expand the program to apply to persons eligible under existing law who attain further education in order to practice as psychiatric-mental health nurse practitioners or physician assistants in psychiatric mental health settings, thereby allowing those practitioners to apply for grants under the program for reimbursement of those later-incurred educational loans.

Existing law establishes the Licensed Mental Health Service Provider Education Program within the Health Professions Education Foundation. Existing law authorizes a licensed mental health service provider, as defined, including, among others, a psychologist and a marriage and family therapist, who provides direct patient care in a publicly funded facility or a mental health professional shortage area to apply for grants under the program to reimburse his or her educational loans related to a career as a licensed mental health service provider, as specified. Existing law establishes the Mental Health Practitioner Education Fund in the State Treasury and provides that moneys in that fund are available, upon appropriation, for expenditure by the Office of Statewide Health Planning and Development for purposes of the program.

This bill would expand the program to apply to persons eligible under existing law who attain further education in order to practice as psychiatric-mental health nurse practitioners and or physician assistants who work in psychiatric mental health settings, thereby allowing those practitioners to apply for grants under the program for reimbursement of those later-incurred educational loans.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law establishes the Licensed Mental Health Service Provider Education Program within the Health Professions Education Foundation. Existing law authorizes a licensed mental health service provider, as defined, including, among others, a psychologist and a marriage and family therapist, who provides direct patient care in a publicly funded facility or a mental health professional shortage area to apply for grants under the program to reimburse his or her educational loans related to a career as a licensed mental health service provider, as specified. Existing law establishes the Mental Health Practitioner Education Fund in the State Treasury and provides that moneys in that fund are available, upon appropriation, for expenditure by the Office of Statewide Health Planning and Development for purposes of the program.

This bill would, on and after July 1, 2019, add nurse practitioners listed as psychiatric-mental health nurses, physician assistants who specialize in mental health services, and licensed educational psychologists, as specified, to those licensed mental health service providers eligible for grants to reimburse educational loans, and would make other conforming changes. Commencing July 1, 2019, the bill would also add the Physician Assistant Board and the Board of Registered Nursing to the list of entities from which the Health Professions Education Foundation must solicit advice in developing the program. would expand the program to apply to psychiatric-mental health nurse practitioners and physician assistants who work in psychiatric mental health settings, thereby allowing those practitioners to apply for grants under the program for reimbursement of educational loans.

This bill would declare that it is to take effect immediately as an urgency statute.

Existing law establishes the Licensed Mental Health Service Provider Education Program within the Health Professions Education Foundation. Existing law authorizes a licensed mental health service provider, as defined, including, among others, a psychologist and a marriage and family therapist, who provides direct patient care in a publicly funded facility or a mental health professional shortage area to apply for grants under the program to reimburse his or her educational loans related to a career as a licensed mental health service provider, as specified. Existing law establishes the Mental Health Practitioner Education Fund in the State Treasury and provides that moneys in that fund are available, upon appropriation, for expenditure by the Office of Statewide Health Planning and Development for purposes of the program.

This bill would add physician assistants who specialize in mental health services and psychiatric-mental health nurse practitioners to those licensed mental health service providers eligible for grants under the program.

GOVERNOR'S VETO

GV Bill Id:AB 2143

Author:(Caballero)

As Enrolled Ver:August 28, 2018

2/3 vote

Original Committee Reference: B. & P.

SUMMARY: Authorizes the licensed mental health service providers who may currently apply for educational loan repayment grants under the Licensed Mental Health Service Provider Education Program to apply for additional grants under the program if they subsequently attain licensure and currently practice as 1) a nurse practitioner registered as "psychiatric mental health nurses" with the Board of Registered Nursing or 2) a physician assistant who works in a psychiatric mental health setting.

The Senate amendments clarified that the applicants must be currently licensed as one of the existing types of mental health service providers under the program and deleted the urgency clause.

FISCAL EFFECT: According to the Senate Appropriations Committee, the Office of Statewide Health Planning and Development (OSHPD) notes a cost of $149,500 (Mental Health Practitioner Education Fund) in fiscal year 2019-2020, for a full-time limited limited-term (18 months) Staff Services Analyst in OSHPD's Health Professions Education Foundation (HPEF) to update program forms, applications, and regulations necessary to implement the bill.

COMMENTS:

Purpose. This bill is sponsored by the California Psychiatric Association. According to the author, "[w]ith some estimates that during any one year 20-25% of the population will benefit from mental health services, and 50% of our population over their lifetime will require those services, it is critical that we address the current and future needs of our citizens, particularly in underserved areas, most of which happen to be rural. Psychiatric expertise combines both mental health and medical training so that patients have access not only to psychotropic and other medications, but in adding a dimension of medical training, provides more integrated treatment of the physical and mental health needs of the patient. Encouraging licensed mental health professionals to also acquire medical training will bolster the psychiatric workforce, increase access to psychiatric services and allow more timely interventions when people need it the most."

Background. The Licensed Mental Health Service Provider Education Program (LMHSPEP) is one of several scholarship and loan repayment programs administered by the HPEF under OSHPD. Like the other HPEF programs, the LMHSPEP was statutorily created to encourage individuals from underrepresented communities to become health professionals and increase access to health providers in medically underserved areas.

According to the HPEF, an awardee under the LMHSPEP may receive up to $15,000 to repay educational loans for not less than a 12-month commitment practicing and providing direct patient care in an eligible site. Eligible sites include publicly funded or public mental health facilities, non-profit mental health facilities that contract with a county entity to provide mental health services, and designated mental health professions shortage areas.

By adding the specified practitioners to the list of licensees under the LMHSPEP, this bill seeks to increase the number of advanced practice medical professionals who specialize in mental health professionals practicing in designated shortage areas and incentivize mental health licensees to pursue additional licensure as a Physician assistant (PA) or a nurse practitioner (NP).

Physician Assistants. PAs provide health care services under the supervision of a physician and surgeon using delegation of services agreements (DSAs). PA functions include performing diagnostic, therapeutic, preventive, and health maintenance services. The Physician Assistant Board is the licensing entity under the Department of Consumer Affairs that licenses and regulates PAs. According to the DCA's 2017 Annual Report, the PAB has over 10,000 licensed PAs. Currently, there is no specialty license or certification for PAs.

Psychiatric Mental Health NPs. Nurse practitioners are advanced practice registered nurses (APRNs). Registered nurses (RNs) that meet the additional training and education requirements may apply with the BRN to become APRNs. The BRN also tracks psychiatric mental health nurses for purposes of disability insurance policies. RNs and APRNs that meet the additional education and training may apply to become a BRN-listed psychiatric mental health nurse, but there is no additional scope of practice. According to the DCA's 2017 Annual Report, the BRN has over 23,600 certified NPs and 324 psychiatric mental health nurses. It is unclear how many of the 324 psychiatric mental health nurses are also NPs.

GOVERNOR'S VETO MESSAGE:

This bill would expand eligibility for educational loan reimbursement grants, through the Licensed Mental Health Provider Education Program, to mental health providers who further their education to become physician assistants or nurse practitioners in mental health facilities.

Physician assistants and nurse practitioners are already eligible for educational loan repayment grants under the state's Advanced Healthcare Loan Repayment Program. Unfortunately, the loan repayment fund referenced in this bill lacks the necessary funding to pay for the hundreds of applications it currently receives. Adding more applicants as this bill requires just compounds the problem.

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301 FN: 0005241

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 2143

Author:(Caballero)

As Amended Ver:June 11, 2018

Majority vote

Original Committee Reference: B. & P.

SUMMARY: Authorizes the licensed mental health service providers who may currently apply for educational loan repayment grants under the Licensed Mental Health Service Provider Education Program to apply for additional grants under the program if they subsequently attain licensure and currently practice as 1) a nurse practitioner registered as "psychiatric mental health nurses" with the Board of Registered Nursing or 2) a physician assistant who works in a psychiatric mental health setting.

The Senate amendments clarified that the applicants must be currently licensed as one of the existing types of mental health service providers under the program and deleted the urgency clause.

FISCAL EFFECT: According to the Senate Appropriations Committee, the Office of Statewide Health Planning and Development (OSHPD) notes a cost of $149,500 (Mental Health Practitioner Education Fund) in fiscal year 2019-2020, for a full-time limited limited-term (18 months) Staff Services Analyst in OSHPD's Health Professions Education Foundation (HPEF) to update program forms, applications, and regulations necessary to implement the bill.

COMMENTS:

Purpose. This bill is sponsored by the California Psychiatric Association. According to the author, "[w]ith some estimates that during any one year 20-25% of the population will benefit from mental health services, and 50% of our population over their lifetime will require those services, it is critical that we address the current and future needs of our citizens, particularly in underserved areas, most of which happen to be rural. Psychiatric expertise combines both mental health and medical training so that patients have access not only to psychotropic and other medications, but in adding a dimension of medical training, provides more integrated treatment of the physical and mental health needs of the patient. Encouraging licensed mental health professionals to also acquire medical training will bolster the psychiatric workforce, increase access to psychiatric services and allow more timely interventions when people need it the most."

Background. The Licensed Mental Health Service Provider Education Program (LMHSPEP) is one of several scholarship and loan repayment programs administered by the HPEF under OSHPD. Like the other HPEF programs, the LMHSPEP was statutorily created to encourage individuals from underrepresented communities to become health professionals and increase access to health providers in medically underserved areas.

According to the HPEF, an awardee under the LMHSPEP may receive up to $15,000 to repay educational loans for not less than a 12-month commitment practicing and providing direct patient care in an eligible site. Eligible sites include publicly funded or public mental health facilities, non-profit mental health facilities that contract with a county entity to provide mental health services, and designated mental health professions shortage areas.

By adding the specified practitioners to the list of licensees under the LMHSPEP, this bill seeks to increase the number of advanced practice medical professionals who specialize in mental health professionals practicing in designated shortage areas and incentivize mental health licensees to pursue additional licensure as a PA or an NP.

Physician Assistants. Physician assistants (PAs) provide health care services under the supervision of a physician and surgeon using delegation of services agreements (DSAs). PA functions include performing diagnostic, therapeutic, preventive, and health maintenance services. The Physician Assistant Board is the licensing entity under the Department of Consumer Affairs that licenses and regulates PAs. According to the DCA's 2017 Annual Report, the PAB has over 10,000 licensed PAs. Currently, there is no specialty license or certification for PAs.

Psychiatric Mental Health NPs. Nurse practitioners are advanced practice registered nurses (APRNs). Registered nurses (RNs) that meet the additional training and education requirements may apply with the BRN to become APRNs. The BRN also tracks psychiatric mental health nurses for purposes of disability insurance policies. RNs and APRNs that meet the additional education and training may apply to become a BRN-listed psychiatric mental health nurse, but there is no additional scope of practice. According to the DCA's 2017 Annual Report, the BRN has over 23,600 certified NPs and 324 psychiatric mental health nurses. It is unclear how many of the 324 psychiatric mental health nurses are also NPs.

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301 FN: 0003959

 THIRD READING  

Bill No: AB 2143

Author:

:

Vote:

SENATE BUS., PROF. & ECON. DEV. COMMITTEE: 9-0, 6/18/18

AYES: Hill, Fuller, Allen, Dodd, Galgiani, Glazer, Hernandez, Pan, Wilk

SENATE HEALTH COMMITTEE: 9-0, 6/27/18

AYES: Pan, Nguyen, Beall, Hernandez, Leyva, Mitchell, Monning, Nielsen, Roth

SENATE APPROPRIATIONS COMMITTEE: 7-0, 8/6/18

AYES: Portantino, Bates, Beall, Bradford, Hill, Nielsen, Wiener

ASSEMBLY FLOOR: 70-0, 5/25/18 (Consent) - See last page for vote

SUBJECT:

SOURCE: California Psychiatric Association

DIGEST:

This bill highlights that specified licensed mental health professionals who are also licensed as a certified nurse practitioner or physician assistant are eligible for scholarship and loan programs through the Licensed Mental Health Service Provider Education Program (Program).

ANALYSIS:

Existing law:

1. Requires the Office of Statewide Health Planning and Development (OSHPD) to establish the Health Professions Education Foundation (HPEF) to administer the Health Professions Education Fund and related scholarship and loan programs for students from underrepresented groups. (Health and Safety Code (HSC) §§ 128330 – 128371)
2. Establishes the Program within the HPEF which is required to keep the fees from the different licensed providers separate to ensure that all grants are funded by those fees collected from the corresponding licensed provider groups, and states that the number of persons who may be considered for the Program shall be limited by the funds made available. (HSC § 128454)
3. Defines a “licensed mental health service provider” as a psychologist licensed by the Board of Psychology (BOP), registered psychologist, postdoctoral psychological assistant, postdoctoral psychology trainee employed in an exempt setting or employed pursuant to a State Department of Health Care Services waiver, marriage and family therapist (MFT),associate marriage and family therapist, licensed clinical social worker (LCSW), associate clinical social worker, licensed professional clinical counselor (LPCC), and associate professional clinical counselor. (HSC § 128454)
4. Requires the fees collected from the licensed mental health service providers in the Program to remain separate to ensure that all grants are funded by those fees collected from the corresponding licensed provider groups, among other limitations and parameters for the loan repayment program. (HSC § 128454 (d))
5. Establishes the BOP within the Department of Consumer Affairs (DCA) to license and regulate psychologists. (Business and Professions Code (BPC) § 2920)
6. Requires the BOP to collect until July 1, 2018, a $10 fee at the time of a licensee’s renewal and to transfer the fee to the State Controller for deposit in the Mental Health Practitioner Education Fund. After July 1, 2018, the fee increases to $20. (BPC § 2987.5)
7. Establishes the Board of Behavioral Sciences (BBS) within DCA to administer the Marriage and Family Therapist Act, the Educational Psychologist Practice Act, the Clinical Social Worker Practice Act, and the Licensed Professional Clinical Counselor Act. (BPC § 4990.12)
8. Requires the BBS to collect until July 1, 2018, a $10 fee at the time of a licensee’s renewal and to transfer the fee to the State Controller for deposit in the Mental Health Practitioner Education Fund. After July 1, 2018, the fee increases to $20. (BPC §§ 4984.75, 4996.65)
9. Establishes the Physician Assistant Board within the DCA to license and regulate physician assistants (PAs). (BPC §§ 3504-3512)
10. Establishes the Board of Registered Nursing (BRN) within the DCA to license and regulate registered nurses, including nurse practitioners (NPs) and BRN-listed psychiatric mental health nurses. (BPC §§ 2701, 2732.05(a))
11. Requires the BRN to maintain a list of psychiatric mental health nurses for purposes of disability insurance. (Insurance Code § 10176(c))

This bill:

1. Clarifies that a “licensed mental health service provider” also includes a psychologist licensed by the Board of Psychology, MFT, LCSW, and LPCC who is also either:
   1. An NP who is a listed as a psychiatric mental health nurse.
   2. A PA who works in a psychiatric mental health setting.
2. Clarifies that a dually-licensed grant recipient pursuant to 1), above, shall have his or her grant funded by the fees collected from his or her corresponding licensed provider group that contributes funds to the Program. 

Background

Mental health professional shortages. According to a March 2018 California HealthCare Foundation Almanac, Mental Health in California: For Too Many, Care Not There, nearly one in six California adults has a mental health need, and approximately one in 24 suffers from a serious mental illness that makes it difficult to carry out major life activities. About two-thirds of California adults with mental health needs, and two-thirds of adolescents with major depressive episodes did not get treatment in the last year.

HPEF and the Program. HPEF was established in 1987 to encourage persons from underrepresented communities to become health professionals and increase access to health providers in medically underserved areas. Supported by grants, donations, licensing fees, and special funds, HPEF provides scholarship, loan repayment and programs to students and graduates who agree to practice in California's medically underserved communities. The Program is administered by HPEF and became operational in 2005. An awardee may receive up to $15,000 to repay educational loans for not less than a 12-month commitment practicing and providing direct client care in an eligible site. Eligible sites include publicly funded or public mental health facilities, non-profit mental health facilities that contract with a county entity to provide mental health services, and/or designated mental health professions shortage areas. The United States Department of Health and Human Services develops shortage designation criteria to determine whether a geographic area, population group or facility is a Health Professional Shortage Area (HPSA) or a Medically Underserved Area/Population (MUA/P). HPSAs may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups, or medical or other public facilities. MUAs may be a whole county or a group of contiguous counties, a group of counties or civil divisions, or a group of urban census tracts in which residents have a shortage of health services. MUPs may include groups of persons who face economic, cultural or linguistic barriers to health care.

According to HPEF, award selection is based solely on the information and documents contained in the Program application. Selection for awards is based on work experience, cultural and linguistic competence, career goals, community background, and fluency in a language other than English. HPEF indicates that priority is given to individuals whose community background and commitment indicates the likelihood of long-term employment in a qualified facility even after the service obligation has ended. A Program recipient may receive up to three awards from HPEF.

Policy considerations. This bill does not alter the structure or incentives of the existing Program because the dual-licensed individuals addressed by this legislation are already eligible for funding by virtue of their existing mental health license. Current law does not prohibit individuals with subsequent licenses in any disciplines from applying to the Program.

The sponsor of this bill believes that individuals who have trained as mental health professionals and as specialty primary care providers are well situated to alleviate the dearth of psychiatrists in underserved areas.  However, it is unclear how many licensees meet these criteria; the DCA database indicates that 314 individuals have licenses at BBS or BOP and PA or NP, but they cannot presently tell whether either or both licenses are active or expired.

These criteria do not fully create psychiatrist extenders, either.  The sponsor notes that the benefit of engaging PAs and NPs in underserved areas is that both are able to prescribe medications, albeit under supervision.  One of the factors defining a federal health professional shortage area is the lack of physicians, however.  Thus, placing an individual in an area without physicians who needs a physician to fully do his or her job is not a solution.  NPs have been petitioning the Legislature for at least a decade to remove supervision requirements so they could provide a fuller spectrum of care in underserved areas.    

FISCAL EFFECT: Appropriation: Fiscal Com.: Local:

According to the Senate Appropriations Committee, this bill will cost $149,500 (Mental Health Practitioner Education Fund) in fiscal year 2019-2020, for a full-time limited limited-term (18 months) Staff Services Analyst in OSHPD’s HPEF to update program forms, applications, and regulations necessary to implement the bill.

SUPPORT: (Verified 8/7/18)

California Psychiatric Association (source)

Association of California Health Care Districts

California Academy of Child and Adolescent Psychiatry

California Access Coalition

California Chapter of the American College of Emergency Physicians

California Council of Community Behavioral Health Agencies

County Behavioral Health Directors Association

Depression and Bipolar Support Alliance

OPPOSITION: (Verified 8/7/18)

Board of Behavioral Sciences

Board of Psychology

ARGUMENTS IN SUPPORT: The California Psychiatric Association writes, “There are too few psychiatrists available to provide psychiatric services to meet demand in California, particularly in community mental health systems or underserved areas. Further, current expansion in psychiatric training programs is not sufficient to keep pace with increases in population, particularly as the psychiatric profession ‘grays’ and a substantial number approach retirement age.

“AB 2143 offers a solution by encouraging licensed mental health professionals to acquire further, medical training as a PA or PMHNP and to work in one those settings. Programs of education for PAs and NPs have for several decades provided well established pathways to gain competent medical training. PAs and NPs practice under the supervision of a physician and are able to provide medical care as well as medications. In a dually licensed individual who is both a mental health professional and medically trained the two skill sets would be merged and available to individuals in a publicly funded facility or mental health professional shortage area. A win win.”

ARGUMENTS IN OPPOSITION: The Board of Psychology writes, “[This bill] would still allow these dual licensed individuals to access limited funds that are intended to defray the educational costs associated with acquiring a license as a Psychologist (a doctorate in psychology, in educational psychology, or in education with the field of specialization in counseling psychology or educational psychology), and use these limited funds to instead pay for later-incurred educational loans associated with the educational requirements for their Nurse Practitioner or Physician Assistant license. Nothing in the bill clarifies that the grants would only be for those loans associated with their Psychologist license.”

ASSEMBLY FLOOR: 70-0, 5/25/18

AYES: Acosta, Aguiar-Curry, Baker, Berman, Bigelow, Bloom, Burke, Caballero, Calderon, Carrillo, Cervantes, Chau, Chávez, Chen, Chiu, Choi, Chu, Cooley, Cooper, Cunningham, Dahle, Daly, Eggman, Flora, Fong, Frazier, Friedman, Gallagher, Cristina Garcia, Eduardo Garcia, Gipson, Gloria, Gonzalez Fletcher, Gray, Grayson, Harper, Holden, Irwin, Jones-Sawyer, Kalra, Kamlager-Dove, Kiley, Lackey, Limón, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Muratsuchi, Nazarian, Obernolte, O'Donnell, Patterson, Quirk, Quirk-Silva, Reyes, Rodriguez, Rubio, Salas, Santiago, Mark Stone, Thurmond, Ting, Voepel, Weber, Wood, Rendon

NO VOTE RECORDED: Travis Allen, Arambula, Bonta, Brough, Levine, Mullin, Steinorth, Waldron

Prepared by:

8/8/18 13:01:54

**** END ****

SENATE COMMITTEE ON APPROPRIATIONS

Senator Anthony Portantino, Chair

2017 - 2018 Regular Session

AB 2143 (Caballero) - Mental health: Licensed Mental Health Service Provider Education Program

This bill does not meet the criteria for referral to the Suspense File.

Bill Summary:

Expands the definition of a licensed mental health (LMH) service provider, for purposes of educational loan repayment, to include a LMH service provider who is currently fully licensed by his or her respective board and who has subsequently attained further education and now practices as either a psychiatric mental health nurse or a physician assistant, as specified.

Fiscal Impact:

According to the Office of Statewide Health Planning and Development:

• $149,500 (Mental Health Practitioner Education Fund) in fiscal year 2019-2020, for a full-time limited limited-term (18 months) Staff Services Analyst in OSHPD’s Health Professions Education Foundation (HPEF) to update program forms, applications, and regulations necessary to implement the bill.

Background:

1. The Health Professions Education Foundation is the state’s only non-profit, established in 1987, to encourage persons from underrepresented communities to become health professionals and increase access to health providers in medically underserved areas. It is supported by grants, donations, licensing fees, and special funds, and provides scholarship, loan repayment, and programs to students and graduates who agree to practice in California's medically underserved communities. An awardee may receive up to $15,000 to repay educational loans for not less than a 12-month commitment practicing and providing direct client care in an eligible site. Eligible sites include publicly funded or public mental health facilities, non-profit mental health facilities that contract with a county entity to provide mental health services, and/or designated mental health professions shortage areas, as defined by the United States Department of Health and Human Services. Grant awards are prioritized for individuals whose community background and commitment indicates the likelihood of long-term employment in a qualified facility even after the service obligation has ended.

AB 1188 (Nazarian, Chapter 557, Statutes of 2017) increased from $10 to $20 the additional license renewal fee collected by the Board of Pharmacy from licensed psychologists and by the Board of Behavioral Sciences (BBS) from licensed marriage and family therapists and licensed clinical social workers (LCSW) for the LMH Program. AB 1188 also adds licensed professional clinical counselors (LPCC) to the definition of “LMH service provider” for participation in the LMH Program and requires the BBS to collect the additional $20 licensure renewal fee from LPCCs.

Proposed Law:

Assembly Bill 2143 includes the following provisions:

• Defines “licensed mental health service provider” to also include a person who is currently licensed by their respective board and has attained further education and practices as either a nurse practitioner or physician assistant, as defined.
• Requires a grant recipient to have their grant funded by fees collected from the corresponding licensed provider group of which they are a licensee.

Related Legislation:

The Legislature has considered similar proposals related to loan repayment program for specified health professionals, including:

• AB 2608 (Stone) adds an additional $5 fee on biennial license renewal for LMFTs, LCSWs, and LPCCs for the LMH Program and dedicates this revenue to repay educational loans for former foster youth. AB 2608 is pending consideration in this committee.
• AB 1188 increased from $10 to $20 the additional license renewal fee for purposes of the LMH Program and expands the types of professionals on whom the fee is assessed.

Staff Comments:

HPEF has awarded more than 14,721 scholarships and loan repayments totaling more than $169.7 million to California health professionals serving in all 58 counties in areas of unmet need.

-- END --

SENATE COMMITTEE ON HEALTH

Senator Dr. Richard Pan, Chair

BILL NO: AB 2143

SUBJECT: Mental health: Licensed Mental Health Service Provider Education Program.

SUMMARY:

Expands the definition of a licensed mental health (LMH) service provider, for purposes of educational loan repayment, to include a LMH service provider who is currently fully licensed by his or her respective board and who has subsequently attained further education and now practices as either a psychiatric mental health nurse or a physician assistant, as specified.

Existing law:

1. Establishes the LMH Service Provider Education Program (LMH Program) within the Health Professions Education Foundation (HPEF), which is administered by the Office of Statewide Health Planning and Development (OSHPD) to provide grants to reimburse educational loans related to a career as a LMH service provider. [HSC §128355 and 128454] 
2. Defines “licensed mental health service provider” as a psychologist licensed by the Board of Psychology (BOP), registered psychologist, postdoctoral psychological assistant, postdoctoral psychology trainee employed in an exempt setting as specified, marriage and family therapist (LMFT), associate marriage and family therapist, licensed clinical social worker (LCSW), associate clinical social worker, licensed professional clinical counselor (LPCC), and associate professional clinical counselor. [HSC §128454]
3. Requires fees collected for the LMH Program from the different licensed providers to be kept separate to ensure that all grants are funded by those fees collected from the corresponding licensed provider groups. [HSC §128454]
4. Establishes the BOP within the Department of Consumer Affairs (DCA) to license and regulate psychologists. Requires the BOP to collect a $10 fee at the time of a licensee’s renewal for deposit in the Mental Health Practitioner Education Fund (MHPEF) for purposes of the LMH Program. [BPC §2920 and 2987.5] 
5. Establishes the Board of Behavioral Sciences (BBS) within DCA to administer the LMFT Act, the Educational Psychologist Practice Act, the LCSW Act, and the LPCC Act. Requires the BBS to collect a $10 fee at the time of a licensee’s renewal for deposit in the MHPEF for purposes of the LMH Program. [BPC §4990.12, 4984.75 and 4996.65] 
6. Establishes the Board of Registered Nursing (BRN) within the DCA to license and regulate registered nurses, including nurse practitioners (NPs) and BRN-listed psychiatric mental health nurses. [BPC §2701 and 2732.05]
7. Establishes the Physician Assistant Board (PAB) within the DCA to license and regulate physician assistants (PAs). [BPC §3504, et seq.]

This bill:

1. Expands the definition of a “LMH service provider” to include a LMH service provider who is currently fully licensed by his or her respective board and who has subsequently attained further education and now practices in either of the following capacities:
2. An NP who is listed by the BRN as a psychiatric mental health nurse; and,
3. A PA who works in a psychiatric mental health setting.
4. Requires an NP or PA grant recipient to have his or her grant funded by the LMH Program fees collected from the corresponding licensed provider group of which he or she is a licensee.

FISCAL EFFECT:

According to the Assembly Appropriations Committee, this bill results in minor one-time costs to the HPEF within OSHPD to modify application materials (MHPEF).

PRIOR VOTES:

COMMENTS:

1. Author’s statement. According to the author, with some estimates that during any one year 20-25% of the population will benefit from mental health services, and 50% of our population over their lifetime will require those services, it is critical that we address the current and future needs of our citizens, particularly in underserved areas, most of which happen to be rural. Psychiatric expertise combines both mental health and medical training so that patients have access not only to psychotropic and other medications but, in adding a dimension of medical training, provides more integrated treatment of the physical and mental health needs of the patient. Encouraging LMH professionals to also acquire medical training will bolster the psychiatric workforce, increase access to psychiatric services, and allow more timely interventions when people need it the most.
2. LMH Program. AB 938 (Yee, Chapter 437, Statutes of 2003) established the LMH Program, which became operational in 2005. The LMH Program is administered by HPEF and is supported by grants, donations, licensing fees, and special funds. HPEF provides scholarship and loan repayment programs to students and graduates who agree to practice in California's medically underserved communities. For a 24-month service obligation in a medically underserved area, providing a minimum of 32 hours of direct patient care, an individual may receive up to $15,000 for loan repayment for practicing and providing direct care in a publicly funded or public mental health facility, a non-profit mental health facility, or a MHPSA. Applicants can receive three awards for a total possible award of up to $45,000 for loan repayment. Selection for awards is based on the following criteria: work experience; cultural and linguistic competence; career goals; community service; community background; and, fluency in a language other than English. Priority is given to individuals whose community background and commitment indicates the likelihood of long-term employment in a qualified facility even after the service obligation has ended.
3. LMH Program additional fee increase. AB 1188 (Nazarian, Chapter 557, Statutes of 2017) increases, beginning July 1, 2018, from $10 to $20 the additional license renewal fee collected by the BOP from licensed psychologists and by the BBS from LMFTs and LCSWs for the LMH Program. AB 1188 also adds LPCCs to the definition of “LMH service provider” for participation in the LMH Program and requires the BBS to collect the additional $20 licensure renewal fee from LPCCs.
4. NPs and PAs. According to the BRN, a psychiatric mental health nurse is an NP who possesses a master’s degree in psychiatric/mental health nursing, has two years of supervised experience providing services as a psychiatric/mental health nurse, and has applied to the BRN to be listed as a psychiatric mental health NP. According to the BRN Web site, as of May 31, 2018, there are 288 active and 16 inactive psychiatric mental health NPs in California. According to the PAB, some PAs work in specialty medicine such as oncology, cardiac surgery, and orthopedics, but the majority of practicing PAs work in general medicine. The PAB estimates that around 150 (1%) practicing PAs currently work in mental health services.
5. Behavioral health workforce in California. According to the March 2018 California Health Care Foundation (CHCF) Almanac, Mental Health in California: For Too Many, Care Not There, in 2016 California had about 75,000 licensed mental health professionals, with marriage and family therapists (31,349) comprising the greatest share, almost double the number of licensed psychologists (16,683). This workforce does not reflect the racial and ethnic diversity of the state, and many professionals, particularly psychiatrists (5,806) and psychologists will reach retirement age within the next decade (45% of psychiatrists and 37% of psychologists are over age 60.) Per-population rates of behavioral health professionals varied by California region: the Greater Bay Area’s rates were 38% to 67% greater than the state average while the Inland Empire and San Joaquin Valley regions had rates that were 39% to 88% lower than average. The Northern and Sierra regions had rates of psychiatrists and psychologists that were at least 40% lower than average. Under the Health Professional Shortage Area (HPSA) designation, areas are identified as having a shortage of primary care, dental care, or mental health providers. For mental health providers, the shortage is based on the availability of psychiatrists and other mental health professionals. Approximately 16% of Californians live in a mental health HPSA. According to OSHPD’s Web site, to qualify for designation as a mental health HPSA, an area must be a rational service area; the population-to-core mental health professional and/or the population-to-psychiatrist ratio meet established shortage criteria; and there is a lack of access to mental health care in surrounding areas because of excessive distance, overutilization, or access barriers. 
6. Double referral. This bill was heard in the Senate Business, Professions, and Economic Development Committee on June 18, 2018, and passed with a 9-0 vote.
7. Related legislation. AB 2608 (Stone) adds an additional $5 fee on biennial license renewal for LMFTs, LCSWs, and LPCCs for the LMH Program and dedicates this revenue to repay educational loans for former foster youth. AB 2608 is set for hearing in this Committee on June 27, 2018.
8. Prior legislation. AB 1188 increased from $10 to $20 the additional license renewal fee for purposes of the LMH Program and expands the types of professionals on whom the fee is assessed.

AB 938 established the LMH Program.

1. Support. The California Psychiatric Association, the sponsor of this bill, and other supporters state that California faces a significant shortage of behavioral health professionals, most notably in the public mental health system and in rural, underserved areas of the state. Supporters argue that mental health professional are in demand statewide, and that there is a mismatch between supply and demand for many types of professionals. Supporter also cite recent studies that show 45% of psychiatrists and 37% of psychologists are over the age of 60 and are expected to retire or reduce their work hours within the next decade. Supporters argue that this bill offers a solution by encouraging LMH service providers to acquire further training, and dually licensed individuals who are both a LMH service provider and medically trained would be able to merge two skill sets and be available to individuals in a publicly funded facility or mental health professional shortage area. Supporters cite that one in four psychiatrist positions in the public mental health system are unfilled at any one time, which limits patient access to psychiatric medical care, including the provision of psychotropic medications.
2. Opposition. The BOP argues that funds from the LMH Program are intended to provide incentives to individuals who will provide direct mental health services to underserved populations who incurred expense in gaining a license from the BOP or BBS, not for licenses granted by other boards. The BOP further argues that allowing psychiatric mental health NPs or PAs in psychiatric mental health settings to receive grants from fees intended to be paid to those practicing psychology in underserved communities defeats the purpose of having a self-funded educational fund intended to increase the availability of psychological services in underserved communities as the new recipients would not necessarily be providing services as a psychologist in the targeted areas.
3. Oppose unless amended. The BBS states that an LMFT, LCSW, or LPCC who is dually licensed in another field is already eligible for the LMH Program, if they are working in a qualified setting. The BBS also requests that licensed educational psychologists, who were previously amended out of this bill, be added back into this bill and eligible for the LMH Program.

SUPPORT AND OPPOSITION:

Support: California Psychiatric Association (sponsor)

American Academy of Pediatrics, California

Association of California Healthcare Districts

California Academy of Child and Adolescent Psychiatry

California Chapter of the American College of Emergency Physicians

California Council of Community Behavioral Health Agencies

County Behavioral Health Directors Association of California

Depression and Bipolar Support Alliance

Rural County Representatives of California

Oppose: Board of Behavioral Sciences (unless amended)

Board of Psychology

-- END --

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Jerry Hill, Chair

2017 - 2018 Regular

Bill No: Hearing Date: June 18, 2018

Subject:

SUMMARY:

Highlights that specified licensed mental health professionals who are also licensed as a certified nurse practitioner or physician assistant are eligible for scholarship and loan programs through the Licensed Mental Health Service Provider Education Program (Program).

Existing law:

1. Requires the Office of Statewide Health Planning and Development (OSHPD) to establish the Health Professions Education Foundation (HPEF) to administer the Health Professions Education Fund and related scholarship and loan programs for students from underrepresented groups. (Health and Safety Code (HSC) §§ 128330 – 128371)
2. Establishes the Program within the HPEF which is required to keep the fees from the different licensed providers separate to ensure that all grants are funded by those fees collected from the corresponding licensed provider groups, and states that the number of persons who may be considered for the Program shall be limited by the funds made available. (HSC § 128454)
3. Defines a “licensed mental health service provider” as a psychologist licensed by the Board of Psychology (BOP), registered psychologist, postdoctoral psychological assistant, postdoctoral psychology trainee employed in an exempt setting or employed pursuant to a State Department of Health Care Services waiver, marriage and family therapist (MFT),associate marriage and family therapist, licensed clinical social worker (LCSW), associate clinical social worker, licensed professional clinical counselor (LPCC), and associate professional clinical counselor. (Business and Professions Code (BPC) § 128454)
4. Requires the fees collected from the licensed mental health service providers in the Program to remain separate to ensure that all grants are funded by those fees collected from the corresponding licensed provider groups, among other limitations and parameters for the loan repayment program. (BPC § 128454(d))
5. Establishes the BOP within the Department of Consumer Affairs (DCA) to license and regulate psychologists. (BPC § 2920)
6. Requires the BOP to collect until July 1, 2018, a $10 fee at the time of a licensee’s renewal and to transfer the fee to the Controller for deposit in the Mental Health Practitioner Education Fund. After July 1, 2018, the fee increases to $20.
   (BPC § 2987.5)
7. Establishes the Board of Behavioral Sciences (BBS) within DCA to administer the Marriage and Family Therapist Act, the Educational Psychologist Practice Act, the Clinical Social Worker Practice Act, and the Licensed Professional Clinical Counselor (LPCC) Act. (BPC § 4990.12)
8. Requires the BBS to collect until July 1, 2018, a $10 fee at the time of a licensee’s renewal and to transfer the fee to the Controller for deposit in the Mental Health Practitioner Education Fund. After July 1, 2018, the fee increases to $20.
   (BPC §§ 4984.75, 4996.65)
9. Establishes the Physician Assistant Board within the DCA to license and regulate physician assistants (PAs). (BPC §§ 3504-3512)
10. Establishes the Board of Registered Nursing (BRN) within the DCA to license and regulate registered nurses, including nurse practitioners (NPs) and BRN-listed psychiatric mental health nurses. (BPC §§ 2701, 2732.05(a))
11. Requires the BRN to maintain a list of psychiatric mental health nurses for purposes of disability insurance. (Insurance Code § 10176(c))

This bill:

1. Clarifies that a “licensed mental health service provider” also includes a psychologist licensed by the Board of Psychology, MFT, LCSW, and LPCC who is also either:
   1. A NP who is a listed as a psychiatric mental health nurse.
   2. A PA who works in a psychiatric mental health setting.
2. Clarifies that a dually-licensed grant recipient pursuant to Item #1) above, shall have his or her grant funded by the fees collected from his or her corresponding licensed provider group that contributes funds to the Program. 

FISCAL EFFECT:

This bill is keyed fiscal by the Legislative Counsel. According to the Assembly Appropriations Committee analysis dated May 16, 2018, this bill has minor one-time costs to the Health Professions Educational Foundation within the Office of Statewide Health Planning and Development (OSHPD) to modify application materials (Mental Health Practitioner Education Fund).

COMMENTS:

1. Purpose. This bill is sponsored by the California Psychiatric Association. According to the Author’s office, “This bill will help to increase access to psychiatric services by providing an incentive for currently licensed mental health professionals to gain medical training using existing training programs. Using an existing loan repayment program for currently licensed clinical psychologists, clinical social workers, marriage and family therapists, and professional clinical counselors, this bill expands the criteria for loan repayment qualification to those who elect to further their education by attending currently established physician assistant or psychiatric mental health nurse practitioner program. They must, as is the requirement with the current loan repayment program, commit to work in designated underserved mental health areas or the community mental health system to qualify for the loan repayment program.”
2. Mental Health Professional Shortages. According to a March 2018 California HealthCare Foundation Almanac, Mental Health in California: For Too Many, Care Not There, nearly one in six California adults has a mental health need, and approximately one in 24 suffers from a serious mental illness that makes it difficult to carry out major life activities. About two-thirds of California adults with mental health needs, and two-thirds of adolescents with major depressive episodes did not get treatment in the last year.
3. HPEF and the Program. HPEF was established in 1987 to encourage persons from underrepresented communities to become health professionals and increase access to health providers in medically underserved areas. Supported by grants, donations, licensing fees, and special funds, HPEF provides scholarship, loan repayment and programs to students and graduates who agree to practice in California's medically underserved communities. The Program is administered by HPEF and became operational in 2005. An awardee may receive up to $15,000 to repay educational loans for not less than a 12-month commitment practicing and providing direct client care in an eligible site. Eligible sites include publicly funded or public mental health facilities, non-profit mental health facilities that contract with a county entity to provide mental health services, and/or designated mental health professions shortage areas. The United States Department of Health and Human Services develops shortage designation criteria to determine whether a geographic area, population group or facility is a Health Professional Shortage Area (HPSA) or a Medically Underserved Area/Population (MUA/P). HPSAs may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups, or medical or other public facilities. MUAs may be a whole county or a group of contiguous counties, a group of counties or civil divisions, or a group of urban census tracts in which residents have a shortage of health services. MUPs may include groups of persons who face economic, cultural or linguistic barriers to health care.

According to HPEF, award selection is based solely on the information and documents contained in the Program application. Selection for awards is based on work experience, cultural and linguistic competence, career goals, community background, and fluency in a language other than English. HPES indicates that priority is given to individuals whose community background and commitment indicates the likelihood of long-term employment in a qualified facility even after the service obligation has ended. A Program recipient may receive up to three awards from HPEF.

1. Related Legislation This Session. AB 2608 (Stone) of 2018 adds an additional $10 fee on biennial license renewal for licensed MFTs and LCSWs for the Program and dedicates this revenue to repay educational loans for former foster youth. (Status: This bill currently pending in the Senate Business, Professions, and Economic Development Committee.)
2. Prior Related Legislation. AB 1188 (Nazarian, Chapter 557, Statutes of 2017), increased from $10 to $20 the additional license renewal fee for purposes of the Program and expanded the types of professionals on whom the fee is assessed.

AB 938 (Yee, Chapter 437, Statutes of 2003), established the Program, which became operational in 2005.

1. Arguments in Support. The California Psychiatric Association writes, “There are too few psychiatrists available to provide psychiatric services to meet demand in California, particularly in community mental health systems or underserved areas. Further, current expansion in psychiatric training programs is not sufficient to keep pace with increases in population, particularly as the psychiatric profession “grays” and a substantial number approach retirement age.

“AB 2143 offers a solution by encouraging licensed mental health professionals to acquire further, medical training as a PA or PMHNP and to work in one those settings. Programs of education for PAs and NPs have for several decades provided well established pathways to gain competent medical training. PAs and NPs practice under the supervision of a physician and are able to provide medical care as well as medications. In a dually licensed individual who is both a mental health professional and medically trained the two skill sets would be merged and available to individuals in a publicly funded facility or mental health professional shortage area. A win win.”

1. Arguments in Opposition. The Board of Psychology writes, “[This bill] would still allow these dual licensed individuals to access limited funds that are intended to defray the educational costs associated with acquiring a license as a Psychologist (a doctorate in psychology, in educational psychology, or in education with the field of specialization in counseling psychology or educational psychology), and use these limited funds to instead pay for later-incurred educational loans associated with the educational requirements for their Nurse Practitioner or Physician Assistant license. Nothing in the bill clarifies that the grants would only be for those loans associated with their Psychologist license.”
2. Policy Considerations. This bill does not alter the structure or incentives of the existing Program because the dual-licensed individuals addressed by this legislation are already eligible for funding by virtue of their existing mental health license. Current law does not prohibit individuals with subsequent licenses in any disciplines from applying to the Program.

The sponsors of this bill believe that individuals who have trained as mental health professionals and as specialty primary care providers are well situated to alleviate the dearth of psychiatrists in underserved areas.  However, it is unclear how many licensees meet these criteria; the Department of Consumer Affairs’ database indicates that 314 individuals have licenses at BBS or BOP and PA or NP, but they cannot presently tell whether either or both licenses are active or expired.

These criteria do not fully create psychiatrist extenders, either.  The sponsors note that the benefit of engaging PAs and NPs in underserved areas is that both are able to prescribe medications, albeit under supervision.  One of the factors defining a federal health professional shortage area is the lack of physicians, however.  Thus, placing an individual in an area without physicians who needs a physician to fully do his or her job is not a solution.  NPs have been petitioning the Legislature for at least a decade to remove supervision requirements so they could provide a fuller spectrum of care in underserved areas.    

NOTE:

Double-referral to Senate Health Committee, second.

SUPPORT AND OPPOSITION:

Support:

California Psychiatric Association (Sponsor)

Association of California Health Care Districts

California Academy of Child and Adolescent Psychiatry

California Access Coalition

California Chapter of the American College of Emergency Physicians

California Council of Community Behavioral Health Agencies

County Behavioral Health Directors Association

Depression and Bipolar Support Alliance

Opposition:

Board of Behavioral Sciences

Board of Psychology

-- END --

Date of Hearing: May 16, 2018

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Lorena Gonzalez Fletcher, Chair

ABPCA Bill Id:AB 2143

Author:(Caballero) – As Amended Ver:May 7, 2018

Urgency: Yes State Mandated Local Program: No Reimbursable: No

SUMMARY:

This bill expands eligibility for an existing mental health loan repayment program. Specifically, this bill:

1. Adds physician assistants who work in a psychiatric mental health setting and psychiatric mental health nurse practitioners who are or were formerly behavioral health licensees to the list of licensed mental health service providers eligible for grants under the Licensed Mental Health Service Provider Education Program.
2. Specifies the grant is funded by the fees collected from the corresponding licensed mental health provider group of which the person is, or was formerly, a licensee.

FISCAL EFFECT:

Minor one-time costs to the Health Professions Educational Foundation within the Office of Statewide Health Planning and Development (OSHPD) to modify application materials (Mental Health Practitioner Education Fund).

COMMENTS:

1. Purpose. This bill is sponsored by the California Psychiatric Association to bolster the psychiatric workforce.
2. Background. The Licensed Mental Health Service Provider Education Program (mental health loan repayment program) is currently funded through license fees on mental health professionals and administered by the Health Professions Education Foundation within OSHPD. The program awards up to $15,000 in loan repayment, on a competitive basis, to qualified applicants who work in specified publicly funded mental health facilities or in a provider shortage area for two years. The program was created by AB 938 (Yee), Chapter 437, Statutes of 2003, and has been modified and expanded several times since then. This bill would expand eligibility for the program.
3. Related Legislation. AB 2608 (Stone), pending on the Suspense File in this committee, adds an additional $10 fee on biennial license renewal for Licensed Marriage and Family Therapists (LMFTs) and Licensed Clinical Social Workers (LCSWs) for the Licensed Mental Health Service Provider Education Program. The bill also dedicates the revenue to repay educational loans for former foster youth in these professions who commit to working in a publicly funded facility or a mental health professional shortage area for at least 24 months.
4. Prior Legislation. AB 1188 (Nazarian), Chapter 557, Statutes of 2017, increased from $10 to $20 the additional license renewal fee for purposes of the mental health loan repayment program and expanded the types of professionals on whom the fee is assessed.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: April 24, 2018

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 2143

Author:(Caballero) – As Amended Ver:April 2, 2018

SUBJECT: Mental health: Licensed Mental Health Service Provider Education Program.

SUMMARY: Adds physician assistants (PAs) who specialize in mental health (MH) services, licensed educational psychologists (LEPs), and psychiatric-mental health nurse practitioners (NPs) to the list of MH service providers eligible for grants under the Licensed Mental Health Service Provider Education Program (LMH Program). Requires the licensing Boards of these providers to collect an additional $20 fee at the time of license renewal. Contains an urgency clause to ensure that the provisions of this bill go into immediate effect upon enactment. Specifically, this bill:

1. Requires the Board of Registered Nursing (BRN) in addition to existing fees charged for the biennial renewal of a license, to collect an additional $20 fee from a psychiatric MH nurse at the time of renewal, to be deposited into the Mental Health Practitioner Education Fund (MHPEF).
2. Requires the Health Professions Education Foundation (HPEF), after entering into a contract with a PA specializing in MH services serving in a publicly funded facility or MH professional shortage area (MHPSA), to receive a grant, to notify the Physician Assistant Board (PAB) for purposes of collecting the fee described in 3) below.
3. Requires the PAB, after receiving a notice from HPEF that a PA specializing in MH services, in addition to existing fees charge for the biennial renewal of a licensee, to collect an additional $20 from the licensee identified in the notice at the time of renewal, to be deposited into the MHPEF.
4. Requires the Board of Behavioral Sciences (BBS), in addition to existing fees charged for the biennial renewal of a license, collect an additional $20 fee from a LEP at the time of renewal, to be deposited into the MHPEF.
5. Expands the LMH Program to allow MH service providers to apply for grants under the program to reimburse educational loans used to pay for education used to obtain a license as a PA who specializes in MH services or psychiatric MH NP.
6. Delays implementation of grants added pursuant to 5) above until July 1, 2019.

EXISTING LAW:

1. Establishes HPEF within the Office of Statewide Health Planning and Development to develop criteria for evaluating applicants for various scholarships and loan programs.
   
2. Establishes the LMH Program within HPEF and authorizes any licensed MH service provider, including a MH service provider who is employed at a publicly funded MH facility or a public nonprofit private MH facility that contracts with a county MH entity or facility to provide MH services, who provides direct patient care in a publicly funded facility or a MHPSA, to apply for grants under the LMH Program to reimburse his or her educational loans related to a career as a licensed MH service provider.
   
3. Defines licensed MH service provider to mean a psychologist licensed by the Board of Psychology (BoP), a registered psychologist, post-doctoral psychological assistant, post-doctoral psychology trainee employed in an exempt setting, as specified, or employed pursuant to a California Department of Health Care Services waiver, a licensed marriage and family therapists (LMFT), a marriage and family therapist (MFT) intern, a licensed clinical social worker (LCSW), and an Associate Clinical Social Worker (ACSW).
   
4. Establishes the licensing and renewal fees for LMFTs, MFT interns, LCSWs, ACSWs, and psychologists, and requires licensees to pay the Board an additional $10 fee at the time of license renewal, which is deposited in the MHPEF.
5. Defines a MHPSA as an area designated by the Health Resources and Services Administration of the United States Department of Health and Human Services to have shortages of MH providers and may be geographic (a county or service area), population (e.g., low income or Medicaid eligible), or facilities (e.g., federally qualified health centers, or state or federal prisons).
   

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, with some estimates that during any one year 20 to 25% of the population will benefit from MH services, and 50% of the population over their lifetime will require those services, it is critical that we address the current and future needs of our citizens, particularly in underserved areas, most of which happen to be rural. The author states that psychiatric expertise combines both MH and medical training so that patients have access not only to psychotropic and other medications, but in adding a dimension of medical training, provides more integrated treatment of the physical and MH needs of the patient. The author concludes that encouraging licensed MH professionals to also acquire medical training will bolster the psychiatric workforce, increase access to psychiatric services and allow more timely interventions when people need it the most.
2. BACKGROUND. According to a March 2018 California HealthCare Foundation Almanac, Mental Health in California: For Too Many, Care Not There, nearly one in six California adults has a MH need, and approximately one in 24 suffers from a serious mental illness that makes it difficult to carry out major life activities. About two-thirds of California adults with MH needs, and two-thirds of adolescents with major depressive episodes did not get treatment in the last year.
   1. MH workforce. Under the federal health professional shortage area designation, areas are identified as having a shortage of MH providers on the basis of availability of psychiatrists and other MH professionals. Approximately 16% of Californians live in a MHPSA. To qualify for designation as a MHPSA, an area must be a rational service area; the population-to-core MH professional and/or the population-to-psychiatrist ratio meet established shortage criteria; and there is a lack of access to MH care in surrounding areas because of excessive distance, overutilization, or access barriers. Core MH providers include psychiatrists, clinical psychologists, LCSWs, psychiatric nurse specialists, and LMFTs. MH providers in designated MHPSAs are eligible for the National Health Services Corp/State Loan Repayment Program, improved Medicare reimbursement, and enhanced federal grant eligibility. The distribution of licensed MH providers varies considerably among California regions. The Bay Area has the greatest concentration of licensed MH professionals, far exceeding the state average. The Inland Empire and San Joaquin Valley fall well below the state average for all MH professions. The Northern and Sierra region is below average in the numbers of psychiatrists and psychologists, but above average for MFTs.
   2. Providers subject to the provisions of this bill. According to the BRN, a psychiatric-MH nurse is a NP who specializes in Psych-Mental Health services. A Master’s Degree, Post-Master’s degree/certificate, or Doctor of Nursing Practice specifically in a NP program with an emphasis in Psych-Mental Health is required to obtain this certification. There are currently 637 active Psych-Mental Health NPs in California.

The Board of Behavioral Sciences (BBS) currently has 2,044 Licensed Educational Psychologists. Applicants must complete three years of full time experience (or the equivalent to three years of experience) working as a school psychologist to become licensed.

According to the PAB, some PAs work in specialty medicine such as oncology, cardiac surgery, orthopedics but the majority of practicing PAs work in general medicine. It is also not uncommon for them to work in multiple locations at any given time as well as switching practices. The PAB estimated that one percent, or around 150 practicing PAs currently work in MH services.

• 1. LMH Program. AB 938 (Yee), Chapter 437, Statutes of 2003, established the LMH Program, which became operational in 2005. The LMH Program is administered by HPEF and is supported by grants, donations, licensing fees, and special funds. HPEF provides scholarship and loan repayment programs to students and graduates who agree to practice in California's medically underserved communities. An awardee may receive up to $15,000 to repay educational loans over a 24-month period in exchange for a 24-month commitment to practicing and providing direct care in a publicly funded or public MH facility, a non-profit MH facility, or a MHPSA. Selection for awards is based on the following criteria: work experience; cultural and linguistic competence; career goals; community service; community background; and, fluency in a language other than English.
     
  2. Existing licensing fees. AB 1188 (Nazarian) Chapter 557, Statutes of 2017, increased from $10 to $20 the additional license renewal fee collected by the BoP from licensed psychologists and by the BBS from LMFTs and LCSWs for the LMH Program; adds licensed professional clinical counselors (LPCCs) to the definition of "licensed MH service provider" for participation in the LMH Program; and requires the BBS to collect the additional $20 licensure renewal fee from LPCCs. The provisions of AB 1188 will go into effect on July 1, 2018.
     

1. SUPPORT. The California Psychiatric Association (CPA) is the sponsor of this bill and notes that there are too few psychiatrists available to provide psychiatric services to meet demand in California, particularly in community MH systems or underserved areas. CPA states that this bill offers a solution by encouraging licensed MH professionals to acquire further medical training as a PA or psychiatric MH NPs and to work in these settings. CPA points out that PAs and NPs practice under the supervision of a physician and are able to provide medical care as well as medications.
2. RELATED LEGISLATION. AB 2539 (Mathis) creates a two-year pilot program, from January 1, 2019 to January 1, 2021, by changing the definition of "practice setting" for purposes of applying to participate in the Steven M. Thompson Physician Corps Loan Repayment Program to include practice settings in rural areas with at least 30% of patients who are uninsured, Medi-Cal beneficiaries, or beneficiaries of another publicly funded program. AB 2539 is currently pending in the Assembly Appropriations Committee.
3. DOUBLE REFERRAL. This bill has been double referred. It passed the Assembly Committee on Business and Professions with a vote of 13 to 0 on March, 20, 2018.
4. SUGESTED AMENDMENTS. As currently drafted this bill makes three additional types of MH providers subject to increased licensing fees, and requires their respective licensing boards to collect increased licensing fees for deposit into the MHPEF. However, as noted in the Background, there are only 637 psychiatric NPs in California, and only one percent of PAs are estimated to work in MH settings. The increased licensing fees for these individuals will not generate enough revenue to provide for a meaningful increase in grant funds, and educational psychologists generally practice in school settings. The Committee may wish to amend this bill to add psychiatric-MH NPs and PA’s who work in a psychiatric MH setting to the list of providers' eligible for grants under the LMH Program.

REGISTERED SUPPORT / OPPOSITION:

Support
California Psychiatric Association (sponsor)

Association of California Healthcare Districts

California Academy of Child & Adolescent Psychiatry

California Access Coalition

California Council of Community Behavioral Health Agencies

Community Clinic Association of Los Angeles

Depression and Bipolar Support Alliance

Rural County Representatives of California

Steinberg Institute

Opposition
None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097

Date of Hearing:

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Evan Low, Chair

ABPCA Bill Id:AB 2143

Author:(Caballero) – As Introduced Ver:February 12, 2018

NOTE: This bill is double referred and if passed by this Committee will be referred to the Assembly Committee on Health.

SUBJECT: Licensed Mental Health Service Provider Education Program: providers.

SUMMARY: Adds physician assistants (PAs) who specialize in mental health services and psychiatric-mental health nurse practitioners (NPs) to the list of licensed mental health service providers eligible for educational loan repayment grants under the Licensed Mental Health Service Provider Education Program (LMHSPEP).

EXISTING LAW:

1. Requires the Office of Statewide Health Planning and Development (OSHPD) to establish the Health Professions Education Foundation (HPEF), a nonprofit public benefit corporation, to administer the Health Professions Education Fund and related scholarship and loan programs for students from underrepresented groups. (Health and Safety Code (HSC) §§ 128330 – 128371)
2. Establishes the LMHSPEP, an educational loan repayment program for defined licensed mental health service providers, within the HPEF. (HSC § 128454)
3. Defines “licensed mental health service provider” as:
   1. A psychologist licensed by the Board of Psychology (BOP), a registered psychologist, postdoctoral psychological assistant, postdoctoral psychology trainee employed in in specified settings;
   2. A licensed marriage and family therapist (LMFT) or associate marriage and family therapist (AMFT);
   3. A licensed clinical social worker (LCSW) or associate clinical social worker (ACSW); and
   4. After July 1, 2018, a licensed professional clinical counselor (LPCC) or associate professional clinical counselor (APCCs). (HSC § 128454(b)(1))
4. Authorizes a licensed mental health service provider who provides direct patient care in (1) a publicly funded facility or (2) a mental health professional shortage area to apply for grants under the loan repayment program to reimburse related educational loans. (HSC § 128454(c))
5. Requires that the fees collected from the licensed providers included under the program remain separate to ensure that all grants are funded by those fees collected from the corresponding licensed provider groups, among other limitations and parameters for the loan repayment program. (BPC § 128454(d))
6. Establishes the BOP within the Department of Consumer Affairs (DCA) to license and regulate psychologists. (BPC § 2920)
7. Requires the BOP to collect until July 1, 2018, a $10 fee at the time of a licensee’s renewal and to transfer the fee to the Controller for deposit in the Mental Health Practitioner Education Fund. After July 1, 2018, the fee increases to $20. (BPC § 2987.5)
8. Establishes the Board of Behavioral Sciences (BBS) within the DCA to license and regulate LMFTs, AMFTs, LCSWs, ACSWs, LPCCs, and APCCs. (BPC §§ 4984.7, 4996.3, and 4999.120).
9. Requires the BBS to collect until July 1, 2018, a $10 fee at the time of a licensee’s renewal and to transfer the fee to the Controller for deposit in the Mental Health Practitioner Education Fund. After July 1, 2018, the fee increases to $20. (BPC §§ 4984.75, 4996.65)
10. Establishes the Physician Assistant Board (PAB) within the DCA to license and regulate PAs. (BPC §§ 3504-3512)
11. Establishes the Board of Registered Nursing (BRN) within the DCA to license and regulate registered nurses, including nurse practitioners and BRN-listed psychiatric mental health nurses. (BPC §§ 2701, 2732.05(a))
12. Requires the BRN to maintain a list of psychiatric mental health nurses for purposes of disability insurance. (Insurance Code § 10176(c))

FISCAL EFFECT: Unknown. This bill is keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by the California Psychiatric Association. According to the author, “[w]ith some estimates that during any one year 20-25% of the population will benefit from mental health services, and 50% of our population over their lifetime will require those services, it is critical that we address the current and future needs of our citizens, particularly in underserved areas, most of which happen to be rural. Psychiatric expertise combines both mental health and medical training so that patients have access not only to psychotropic and other medications, but in adding a dimension of medical training, provides more integrated treatment of the physical and mental health needs of the patient. Encouraging licensed mental health professionals to also acquire medical training will bolster the psychiatric workforce, increase access to psychiatric services and allow more timely interventions when people need it the most.”

Background. The LMHSPEP is one of several scholarship and loan repayment programs administered by the HPEF under OSHPD. Like the other HPEF programs, the LMHSPEP was statutorily created to encourage individuals from underrepresented communities to become health professionals and increase access to health providers in medically underserved areas.

According to the HPEF, an awardee under the LMHSPEP may receive up to $10,000 to repay educational loans for up to a 24-month commitment practicing and providing direct patient care in a qualified facility. Qualified facilities include publicly funded or public mental health facilities, non-profit mental health facilities that contract with a county entity to provide mental health services, and designated mental health professions shortage areas.

By adding the specified practitioners to the list of licensees under the LMHSPEP, this bill seeks to increase the number of advanced practice medical professionals who specialize in mental health professionals practicing in designated shortage areas and incentivize mental health licensees to pursue additional licensure as a PA or an NP.

PAs. PAs provide health care services under the supervision of a physician and surgeon using delegation of services agreements (DSAs). PA functions include performing diagnostic, therapeutic, preventive, and health maintenance services. The PAB is the licensing entities under the DCA that licenses and regulates PAs. According to the DCA’s 2017 Annual Report, the PAB has over 10,000 licensed PAs. Currently, there is no specialty license or certification for PAs.

Psychiatric Mental Health NPs. Nurse practitioners are advanced practice registered nurses (RNs). RNs that meet the additional training and education requirements may apply with the BRN. The BRN also tracks psychiatric mental health nurses for purposes of disability insurance policies. RNs that meet the additional education and training may apply to become a BRN-listed psychiatric mental health nurse, but there is no additional scope of practice. According to the DCA’s 2017 Annual Report, the BRN has over 23,600 certified NPs and 324 psychiatric mental health nurses. It is unclear how many of the 324 psychiatric mental health nurses are also NPs.

Prior Related Legislation. AB 1188 (Nazarian), Chapter 557, Statutes of 2017 increased from $10 to $20 the additional license renewal fee collected by the BOP from psychologists and by the BBS from LMFTs and LCSWs for the Licensed Mental Health Service Provider Education Program; added LPCCs to the definition of “licensed mental health service provider” for participation in the Licensed Mental Health Service Provider Education Program (Loan Program); and required the BBS to collect the additional $20 licensure renewal fee from Licensed Professional Clinical Counselors (LPCCs).

SB 1204 (Hernández) of 2016, would have increased from $10 to $20 the additional licensure renewal fee for Psychologists, LMFTs, and LCSWs, and required the BBS to collect the additional $20 renewal fee from LPCCs for deposit and participation in the Loan Program and would have increased the license application and renewal charge from $25 to $50 for physicians and osteopathic physicians to fund the Steven M. Thompson Physician Corps Loan Repayment Program. NOTE: This bill was held in the Senate Committee on Business, Professions and Economic Development.

AB 2543 (Berg) of 2008 would have established the Geriatric and Gerontology Workforce Expansion Act which allows any geriatric service provider, as defined, to apply for grants, on or after January 1, 2010, under the existing Licensed Mental Health Service Provider Education Program to reimburse for educational loans related to a career as a LMFT or intern or LCSW who provides geriatric services, as specified. NOTE: This bill was vetoed by Governor Schwarzenegger because it would have double-assessed fees for similar programs on the same professions.

AB 1852 (Yee), Chapter 557, Statutes of 2006, revised the definition of “licensed mental health care practitioner” related to the Loan Program to include a marriage and family therapist intern, associate clinical social worker, a psychologist licensed by the BOP, and a registered psychologist, postdoctoral psychological assistant, or postdoctoral psychology trainee employed in an exempt setting, as specified.

AB 938 (Yee), Chapter 437, Statutes of 2003, established the Licensed Mental Health Provider Education Program, to be developed by the Health Professions Education Foundation after soliciting advice from specified boards and agencies, to provide grants to specified practicing mental health providers in return for service in medically underserved areas. The Loan Program became operational January 1, 2005 and funded by a $10 surcharge on specified mental health professionals’ licensing fees, which would be deposited in the Mental Health Practitioner Education Fund.

ARGUMENTS IN SUPPORT:

The California Psychiatric Association (sponsor) writes in support, “[t]here are too few psychiatrists available to provide psychiatric services to meet demand in California, particularly in community mental health systems or underserved areas. Further, current expansion in psychiatric training programs is not sufficient to keep pace with increases in population, particularly as the psychiatric profession ‘grays’ and a substantial number approach retirement age.

[This bill] offers a solution by encouraging licensed mental health professionals to acquire further, medical training as a PA or PMHNP and to work in one those settings. Programs of education for PAs and NPs have for several decades provided well established pathways to gain competent medical training. PAs and NPs practice under the supervision of a physician and are able to provide medical care as well as medications. In a dually licensed individual who is both a mental health professional and medically trained the two skill sets would be merged and available to individuals in a publicly funded facility or mental health professional shortage area. A win win.”

ARGUMENTS IN OPPOSITION:

None on file.

POLICY ISSUE FOR CONSIDERATION:

Adding Additional License Types. Licensed Educational Psychologists (LEPs) are the only license type that is issued by the BBS that is not included under the program. Because it takes time for the HPEF to implement additional license types and to accumulate enough funds specific to the new license type to issue a grant, it may be better to add them sooner rather than later.

According to the DCA’s 2017 Annual Report, there were a total of 2,073 LEPs, 850 of which renewed that year (they renew on a biennial cycle). Assuming a similar number of LEPs continue to cover a grant or two in underserved areas.

Adding LEPs to this program may also incentivize more credentialed school psychologists to take the exam to become LEPs. According to the Department of Education’s DataQuest, there are close to 5,900 credentialed school psychologists in California.

IMPLEMENTATION ISSUES:

PA and NP Fees. The LMHSPEP is supported by fees from the included license types. However, this bill does not add a fee for the new licensees.

AMENDMENTS:

1. Require the HPEF to notify the PAB when a PA accepts an award under the program, and require the PAB to charge a $20 fee at the time of the awardee's renewal:

Section 3521.4 is added to the Business and Professions Code is to read:

3521.4. (a) Notwithstanding subdivision (c) of Section 3521.1, upon notification from the Health Professions Education Foundation that a licensee has accepted an award to repay educational loans as part of the Licensed Mental Health Service Provider Education Program established under Health and Safety Code Section 128454, the board shall do both of the following:

(1) In addition to the fees charged pursuant to Section 3521.1 for the biennial renewal of a license, the board shall collect an additional fee from the awardee of twenty dollars ($20) at the time the of renewal.

(2) The board shall transfer this amount to the Controller who shall deposit the funds in the Mental Health Practitioner Education Fund.

(b) This section shall become operative on July 1, 2019.

Section 128454 of the Health and Safety Code is amended to read:

(c)(1) Any licensed mental health service provider, including a mental health service provider who is employed at a publicly funded mental health facility or a public or nonprofit private mental health facility that contracts with a county mental health entity or facility to provide mental health services, who provides direct patient care in a publicly funded facility or a mental health professional shortage area may apply for grants under the program to reimburse his or her educational loans related to a career as a licensed mental health service provider, including educational loans used to pay for education used for licensure as a physician assistant or psychiatric mental health nurse practitioner as defined under subparagraphs (F) and (G) of paragraph (1) of subdivision (b).

(2) Upon acceptance of the contractual agreement specified under paragraph (1) of subdivision (d) by a physician assistant as defined under subparagraph (F) of paragraph (1) of subdivision (b), the Health Professions Education Foundation shall notify the Physician Assistant Board for purposes of collecting the fee.

1. Require the BRN to charge a $20 fee at the time of renewal for NPs who are also listed as a psychiatric mental health nurse with the BRN:

Section 2815.2 is added to the Business and Professions Code is to read:

2815.2. (a) Notwithstanding subdivision (d) of Section 2815.5, the board shall do both of the following:

(1) In addition to the fees charged pursuant to Section 2815.5(d) for the biennial renewal of a license, the board shall collect from a nurse practitioner who is listed as a "psychiatric mental health nurse" under Section 2732.05 an additional fee of twenty dollars ($20) at the time the of renewal.

(2) The board shall transfer this amount to the Controller who shall deposit the funds in the Mental Health Practitioner Education Fund.

(b) This section shall become operative on July 1, 2019.

1. Add LEPs and have BBS charge the corresponding fee:

Section 4989.69 is added to the Business and Professions Code is to read:

4989.69. (a) Notwithstanding paragraph (3) of subdivision (a) of Section 4989.68 and in addition to the fees charged pursuant to Section 4989.68 for the biennial renewal of a license, the board shall collect an additional fee of twenty dollars ($20) at the time of renewal. The board shall transfer this amount to the Controller who shall deposit the funds in the Mental Health Practitioner Education Fund.

(b) This section shall become operative on July 1, 2019.

Section 128454 of the Health and Safety Code is amended to read:

(b) For purposes of this article, the following definitions shall apply:

(1) “Licensed mental health service provider” means the following licensees:

(A) A psychologist licensed by the Board of Psychology, registered psychologist, postdoctoral psychological assistant, or postdoctoral psychology trainee employed in an exempt setting pursuant to Section 2910 of the Business and Professions Code or employed pursuant to a State Department of Health Care Services waiver pursuant to Section 5751.2 of the Welfare and Institutions Code.

(B) A licensed marriage and family therapist or associate marriage and family therapist.

(C) A licensed clinical social worker or associate clinical social worker.

(D) A licensed professional clinical counselor or associate professional clinical counselor.

(E) A licensed educational psychologist.

(F) A physician assistant who specializes in mental health services.

(G) A nurse practitioner licensed to practice pursuant to Article 8 (commencing with Section 2834) of Chapter 6 of Division 2 of the Business and Professions Code and listed as a psychiatric-mental health nurse.

1. Delay the implementation date for the new provisions under this bill to July 1, 2019.
2. Make conforming changes.

REGISTERED SUPPORT:

California Psychiatric Association (sponsor)

REGISTERED OPPOSITION:

None on file.

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301