Legislature(2015 - 2016)Fairbanks LIO
05/14/2015 10:00 AM House LEGISLATIVE BUDGET & AUDIT
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| Audio | Topic |
|---|---|
| Start | |
| Public Testimony: Department of Health and Social Services Performance Review | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
LEGISLATIVE BUDGET AND AUDIT COMMITTEE
Fairbanks, Alaska
May 14, 2015
10:04 a.m.
MEMBERS PRESENT
Representative Mike Hawker, Chair
Representative Lance Pruitt
Representative Steve Thompson
Representative Sam Kito
Senator Cathy Giessel
MEMBERS ABSENT
Senator Anna MacKinnon, Vice Chair
Senator Lyman Hoffman
Senator Bert Stedman
Senator Click Bishop
Senator Pete Kelly (alternate)
Representative Kurt Olson
Representative Mark Neuman (alternate)
OTHER LEGISLATORS PRESENT
Representative Tammie Wilson
COMMITTEE CALENDAR
PUBLIC TESTIMONY: DEPARTMENT OF HEALTH AND SOCIAL SERVICES
PERFORMANCE REVIEW
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
JIM WALDINGER
Public Consulting Group
Boston, Massachusetts
POSITION STATEMENT: Shared background information explaining
their involvement with the Department of Health and Social
Services performance review.
SHARI HOLLAND
Public Works
Austin, Texas
POSITION STATEMENT: Shared background information explaining
their involvement with the Department of Health and Social
Services performance review.
JEANETTE GRASTO, President
NAMI (National Alliance on Mental Illness) of Fairbanks
Fairbanks, Alaska
POSITION STATEMENT: Testified during the performance review of
Department of Health and Social Services (DHSS).
REPRESENTATIVE TAMMIE WILSON
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Spoke during the performance review of
DHSS.
SANTA CLAUS
North Pole, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
RICK SIKMA, Pastor
Fairbanks, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
ALLISON LEE, Executive Director
ResCare Alaska
Fairbanks, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
ROGER HUGHES
Fairbanks, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
MARIA RENSEL
Fairbanks, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
GERALD BROWN, Pharmacist
Fairbanks, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
KAREN VAN REINAN
Fairbanks, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
REBECCA DAVIES
Savannah, Georgia
POSITION STATEMENT: Testified during the performance review of
DHSS.
JOLENE SUTTON
Anchorage, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
DEBORAH BROLLINI
Anchorage, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
CRIS TYREE
Wasilla, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
PAUL NELSON
Haines, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
KIMBERLY BOOKEY
Fairbanks, Alaska
POSITION STATEMENT: Testified during the performance review of
DHSS.
ACTION NARRATIVE
10:04:27 AM
CHAIR MIKE HAWKER called the Legislative Budget and Audit
Committee meeting to order at 10:04 a.m. Representatives
Hawker, Thompson, and Kito and Senator Giessel were present at
the call to order. Representative Pruitt arrived as the meeting
was in progress. Also in attendance was Representative Wilson.
^Public Testimony: Department of Health and Social Services
performance review
Public Testimony: Department of Health and Social Services
performance review
10:04:46 AM
CHAIR HAWKER announced that the only order of business would be
public testimony on the performance review of the Department of
Health and Social Services. He offered some background of the
performance review process, detailing that this performance
review was of the Behavioral Health Services, the Long Term Care
Services, and the overall organizational administrative
infrastructure of the department. He clarified that this
meeting did not require a quorum to conduct business, as this
was only a "listening post activity." He shared that the Alaska
State Legislature had passed House Bill 30 which required that
the Legislative Audit Division would conduct a review of the
performance of each of the State of Alaska's major operating
agencies on a ten year cycle. He emphasized that this was not
an audit, a budget hearing, or a budget review but was focused
on the performance of the agency in meeting its missions and
goals in its service to the public. He reported that the
current performance review was for the Department of Health and
Social Services, and that the final report would be available at
a later date. He explained that, as a part of the review
process, the Legislative Audit Division would engage the service
of professional outside contractors with specific experience and
skills relative to the agency being evaluated. He introduced
the two consulting contractors, the Public Consulting Group, who
were reviewing the Divisions of Behavioral Health and Long Term
Care, and Public Works, who were reviewing the organizational
and administrative structure of the department.
CHAIR HAWKER explained that this was an opportunity specifically
for the public to speak to the contractors to allow better
understanding for the public's perspective of the relationship
between the public and the department and its operational
performance. He shared that these comments would be taken into
serious consideration. He reiterated that the comments would be
directed toward review of the behavioral health and long term
care services, and with especial emphasis toward the overall
organizational structure of the department and its ability to
enable or inhibit an efficient and effective operation. He
noted that written testimony would also be forwarded to the
contractors.
10:10:12 AM
JIM WALDINGER, Public Consulting Group, introduced his company,
reporting that they had been founded in 1986 and worked almost
exclusively in the public sector with health and human service
agencies nationwide, focusing on policy, reimbursement, and
general system assessments. He acknowledged that Public
Consulting Group had been contracted by the Division of
Legislative Audit for a performance review on the behavioral
health and long term care systems, and, for the past two months,
they had two teams collecting data, meeting with Department of
Health and Social Services staff, and engaging with providers
around Alaska to better understand these systems. He shared
that all the state staff and providers had been extremely
accommodating and open in discussions with his staff. He
reported that his group was currently in the process of
synthesizing this information and data.
10:12:12 AM
SHARI HOLLAND, Public Works, explained that Public Works was a
consulting group which worked with state and local governments
and that they had done several performance reviews of this
magnitude over the last few years. She reported that Public
Works was reviewing the organizational and administrative
structure of the Department of Health and Social Services for
the performance review. She noted that they were finishing up
the field work, which had included extensive interviews and
focus groups with state employees statewide. She reported that
her group was also conducting research nationwide on best
practices. She lauded the interactions Public Works had had
with department staff.
10:13:40 AM
CHAIR HAWKER opened public testimony.
10:14:13 AM
JEANETTE GRASTO, President, NAMI (National Alliance on Mental
Illness) of Fairbanks, explained that the NAMI mission was to
support education and advocacy for people with serious mental
illness and their families. She declared that the mental health
system in Fairbanks had broken about one and a half years prior,
and, for about three weeks, there had not been any public mental
health service until the Anchorage Community Mental Health
Services, Inc. (ACMHS) came to their aid. ACMHS was helping to
re-build the program, although fiscal constraints were slowing
it. She stated that ACMHS did not have the capacity to meet the
current needs, even as the more serious mentally ill in
Fairbanks were being moved to Anchorage. She asked if the
review team had spoken with consumers, as they were an essential
component for information to the success of the [behavioral
health] division. She relayed that people with serious mental
illness needed a continuum of care for recovery, and this did
not exist in Fairbanks. She relayed that the people currently
being accepted into the Fairbanks community mental health
services were those coming out of institutional care, such as
hospitals or jail. She pointed out that private individuals
were "way down on the list for being admitted into services,
which isn't right." She described that continuum of care
included a doctor available all of the time, and she offered an
anecdote for a medication issue. She spoke about case
management, access to counseling and therapy, and vocational
support, noting that recovery for many individuals was marked by
a return to work. She pointed out that people needed day
treatment with a place to go and rebuild their skills, and
housing. She declared that there was not any supported housing
or assisted living for people with mental illness in Fairbanks,
reporting that it was really hard to manage a mental illness
without housing. She relayed that, although the State of Alaska
had requested that Fairbanks do an assessment of housing needs
before there was funding and building, there was an immediate
need for medical stability for many people. She stated that
family and peer support was essential, especially for
information of where to get help. Although NAMI could provide
this support, they had no funding other than through donations
and fund raisers. She acknowledged that [Division of]
Behavioral Health wanted to serve the seriously mentally ill,
but she questioned where support for the medium mentally ill
would be delivered. She stated that it had been proven that
these people were fine with treatment, but without treatment
they would "end up in the hospital." She declared that another
serious issue in Fairbanks was for limited availability to
Medicaid paid counseling or therapy, as current capacity was
filled, and expanded access would keep people out of the
hospital. She emphasized that without services at the local
community level of care, there would be services needed
institutionally, which was so much more expensive.
10:22:04 AM
REPRESENTATIVE TAMMIE WILSON, Alaska State Legislature, asked if
the review for behavioral health included the grantees, as well
as the clients.
10:23:03 AM
SANTA CLAUS referenced his background as a former special
assistant to the deputy police commissioner of New York City, as
well as a former emergency response chaplain and child and
victim advocate. He expressed his concern with the way the
Office of Children's Services (OCS) was working, and his
displeasure with the current director. He offered his belief
that none of the recommendations for change to OCS from the
Office of the Ombudsman had been adopted. He referenced an
example of an alleged incident as an example of the need for a
change. He offered his belief that OCS should be put on notice,
suggesting that the listed job description, experience, and
qualifications should be examined. He suggested that a
grievance process be implemented.
10:32:34 AM
RICK SIKMA, Pastor, shared his background in family and marriage
counseling, noting that he had been a pastor for 40 years. He
shared an anecdote regarding a prior meeting with OCS which
resulted in his questioning the "rules of the state." He
recognized that there were occasions for removal of children
from homes, but he suggested that there were organizations other
than OCS that could have dealt with these situations. He
reflected on earlier meetings he and other pastors had attended
with OCS, and he recollected his understanding for some of the
agreements.
MR. SIKMA, in response to Representative Wilson, offered his
belief that the aforementioned meetings had occurred about five
years prior.
10:37:56 AM
ALLISON LEE, Executive Director, ResCare Alaska, explained that
this was a statewide agency serving more than 800 Alaskans for
home and community based services. She said that she was
testifying as a citizen, as she was currently on medical leave
from her position. She reported that she began her career as a
nurse assessor in home and community based services in rural
Alaska more than 10 years prior. She shared that she had worked
in "some capacity with the Department of Health and Social
Services, particularly senior and disability services." She
noted that the current leadership at DHSS had genuinely sought
public comment, participation from stakeholders, and provider
input, especially as they were now faced with some complicated
issues from both state and federal mandates. She reported that
the provider community had concerns with the Division of Senior
and Disabilities Services staff interpretations of waiver
regulations which denied eligibility to older Alaskans. She
suggested that there had been issues with the fair hearing
process, and, although she stated that it had vastly improved,
she encouraged the [performance review] contractors to look into
this process to ensure the effective use of resources. She
offered three suggestions for consideration, which included an
opportunity for comprehensive person centered care management
and care coordination, though not limited to home and community
based services, but across the spectrum of care. She relayed
that an individual receiving waiver services could have multiple
case managers, and that this was an opportunity for a holistic
approach to case management and care coordination, especially
with the federal mandate for conflict free case management. She
suggested to look at the provider certification and quality
assurance unit within the division, as it had gone through a lot
of change and shifted a lot of resources to meet its needs. She
encouraged more mutual understanding between the providers and
the division on the requirements and realities in delivery of
services, although she questioned the best use of resources.
She reported that biannual on-site reviews were now required,
and, as she had eight locations across Alaska, this would be
better and more effectively served with a review in Anchorage as
all of her programs were the same throughout the state. She
listed the multiple audits she conducted and pointed out that
this did lead to "a certain degree of audit fatigue." She
offered her belief that an on-site review shortly after
certification would be excellent for establishing a partnership
and on-going relationship, offering an example of the
educational audits in Montana. She expressed her hope and
concern that the Division of Senior and Disabilities Services
had the internal and external resources and support necessary to
do the heavy lifting to realize the very real dream of achieving
substantial reform in home and community based services, with
conflict free case management, the 1915(i) and 1915(k) options.
She explained that these options provided real opportunities for
savings in the Medicaid home and community based services
programs, and offered the ability to increase access to services
to the underserved populations which were currently being served
in more costly care environments. In response to Chair Hawker,
she explained that the 1915(k) option was the community first
choice option, introduced a few years prior, and that a lot of
the current Medicaid services could be moved to this option, as
it had some enhanced case management and a 6 percent enhanced
FMAP (Federal Medical Assistance Percentages). She acknowledged
that this was a specialized area within the waiver services, and
that the 1915(i) option would allow individuals with severe
mental illness, Alzheimer's and related dementia, and other
currently underserved populations to be served outside more
costly environments. She encouraged that the review process
speak with the provider agencies.
CHAIR HAWKER lauded the success by providers for developing the
home and community based service alternatives to traditional
institutional services, noting that Alaska was the national
leader in development of this approach.
MS. LEE pointed out that most people would prefer to be at home
at the end of their lives.
10:48:37 AM
ROGER HUGHES offered further testimony to an earlier anecdote by
Mr. Sikma.
CHAIR HAWKER suggested that Mr. Hughes speak with the Office of
the Ombudsman, which could often provide a venue for pursuit of
concerns with state agencies.
10:54:52 AM
MARIA RENSEL reported that she had recently been asked to attend
a TDM (team decision meeting) by the mother of two children
involved in a case with OCS. She related her experience with
OCS, noting that it was "a bad experience." She offered her
belief that this was the "tip of the iceberg" and was indicative
of OCS's daily operation. She described her role at the TDM as
a "watchdog," a representative of the family to ensure that
things were conducted correctly, and shared that she had only
listened during the meeting. She offered her comments regarding
the meeting.
11:01:58 AM
CHAIR HAWKER noted that Patrice Lee would be submitting public
testimony.
11:02:40 AM
GERALD BROWN, Pharmacist, asked for support to Medicaid
Expansion.
CHAIR HAWKER clarified that this was not a Medicaid hearing, and
was a performance review of the Department of Health and Social
Services.
MR. BROWN spoke about the reimbursement schedules for
prescriptions, noting that they were sub-adequate, based on
rates and costs determined by CMS (Centers for Medicare and
Medicaid Services) that were below the cost of acquisition, as
these rates did not include shipping to Alaska. He stated that
the dispensing fees had also been reduced and that the maximum
allowable cost, arbitrarily set by CMS, was not adequate. He
reported that there had been increases in prices, but a decrease
in the reimbursement. He stated that often the margins were
dropping by more than 50 percent, sometimes to between 5 and 10
percent below the acquisition costs. He pointed out the
difficulty for local pharmacies to maintain their businesses.
He mentioned his concern for the University of Alaska system
mandate for mail order pharmacy, a requirement for prescription
service outside of the State of Alaska. He spoke about the
rebates to Medicaid and other insurance companies, suggesting
that a drug business was placed into the second or third tier if
they did not offer a rebate. He opined that the rebates were
paid by increasing the prices to the local pharmacies, and that
it was the insurance companies processing the claims which made
the money. He said that the Medicaid system was still making
money on rebates, and that the net cost was not fully
transparent. He remarked that this had to be dealt with on the
national level, as well.
CHAIR HAWKER asked if the pharmacy provider could choose not to
fill prescriptions in which they did not have any profit margin,
but still remain a registered provider on other products.
MR. BROWN replied that, as they were under contract for both
commercial and Medicaid, when they were presented a
prescription, they were obligated to fill that prescription, as
a provider. He pointed out that 95 percent of their revenue was
determined by someone else, noting that the prices were
determined by the third party insurance, even though they had no
idea of the cost. He said that the dispensing fees,
transmission fees, labels, and vials were not covered under
this. He said that the costs were now an unrealistic amount,
and that the pharmacies were asking to either have the
dispensing fees increased, or have a more realistic rate with a
bigger buffer percentage included for Alaska. He said that
ultimately, the pharmacies were subsidizing these programs. He
reported that Medicaid was considering mail order for its
recipients, and he strongly suggested not to do this, as this
was not good health care. He offered an anecdote defining some
of these problems.
CHAIR HAWKER referenced providers who had elected not to take on
Medicaid because of the inadequate reimbursement rates, and
asked if pharmacists would go this same route.
MR. BROWN replied that small pharmacies were very close to this,
especially with the inverse reimbursement rates and a recent
change to dispense policies for small pharmacies.
11:18:44 AM
KAREN VAN REINAN referenced an article about the increase in
children taken into custody by the state, and spoke about the
Indian Child Welfare Act (ICWA), abuses by OCS, and attacks
against families.
11:35:49 AM
REPRESENTATIVE WILSON expressed her hope that the funding
sources for OCS would be reviewed, as well as the processes for
ICWA and OCS.
11:39:09 AM
REBECCA DAVIES offered a story of a current interaction with OCS
at the apartment of her niece, Jolene Sutton.
JOLENE SUTTON interjected and explained the background for the
interaction.
CHAIR HAWKER acknowledged the concerns and stated that it was
inappropriate for the legislature to be interfering with the
actions of the case worker.
11:49:28 AM
DEBORAH BROLLINI shared her personal experiences about working
with the commissioner's office at DHSS, reflecting that the
office mandate had been to treat every Alaskan entering the
office as if they were the governor. She offered her thoughts
about OCS, and the trauma and long term impact for breaking up a
family. She shared that she had worked in research for the
Alaska Native Tribal Health Consortium (ANTHC). She opined
that, although prevention was the means to reduce health care
costs, the model could not be broadly applied as each community
was different. She asked that communities participate in the
policy making. She offered an anecdote about the release of
health data. She opined that complaints about OCS should
receive due process.
11:54:11 AM
CRIS TYREE offered her personal anecdote about interactions with
OCS.
12:04:09 PM
PAUL NELSON offered his personal opinions about interactions
with OCS.
12:06:21 PM
CHAIR HAWKER closed the online public testimony.
12:06:42 PM
KIMBERLY BOOKEY offered her opinion about interactions with OCS.
12:11:22 PM
REPRESENTATIVE WILSON offered her belief that the Department of
Labor & Workforce Development had reviewed OCS and suggested
that the job descriptions be clarified. She declared her desire
that social work activity be clearly defined. She questioned
the amount of money being spent in the court room process for
OCS hearings. She expressed her desire that the OCS procedures
be reviewed.
12:19:12 PM
CHAIR HAWKER closed public testimony on the performance review
of Department of Health and Social Services.
12:19:36 PM
ADJOURNMENT
There being no further business before the committee, the
Legislative Budget and Audit Committee meeting was adjourned at
12:19 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Agenda_LBA_14May15_FAI DHSS Testimony.pdf |
JBUD 5/14/2015 10:00:00 AM |