Legislature(2005 - 2006)Anch LIO Conf Rm
10/25/2006 10:00 AM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
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| Using Alaska's Healthcare Dollars Wisely: Missions and Measures Review | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
Anchorage, Alaska
October 25, 2006
10:08 a.m.
MEMBERS PRESENT
Representative Peggy Wilson, Chair
Representative Paul Seaton, Vice Chair
Representative Sharon Cissna
MEMBERS ABSENT
Representative Tom Anderson
Representative Carl Gatto
Representative Vic Kohring
Representative Berta Gardner
OTHER LEGISLATORS PRESENT
Senator Bettye Davis
COMMITTEE CALENDAR
USING ALASKA'S HEALTHCARE DOLLARS WISELY: MISSIONS AND MEASURES
REVIEW
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
KARLEEN JACKSON, Commissioner
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Offered comments regarding the missions and
measures review.
STEPHANIE BIRCH, Chief
Women & Children, Family Health
Division of Public Health
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Provided information during the
presentation and answered questions.
TAMMY GREEN, Chief
Chronic Disease
Division of Public Health
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Provided information during the
presentation and answered questions.
CRISTY WILLER, Director
Central Office
Division of Behavioral Health
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Provided information during the
presentation and answered questions.
JERRY FULLER, Project Director
Office of Program Review
Office of the Commissioner
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Provided information during the
presentation and answered questions.
STEPHANIE WHEELER, Executive Director
Office of Faith Based and Community Initiatives
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Provided information during the
presentation and answered questions.
ACTION NARRATIVE
CHAIR PEGGY WILSON called the House Health, Education and Social
Services Standing Committee meeting to order at 10:08:09 AM.
Representatives Wilson and Seaton were present at the call to
order. Representative Cissna arrived as the meeting was in
progress. Senator Davis was also in attendance.
CHAIR WILSON announced that the only order of business would be
a summary of using Alaska's health care dollars wisely and a
review of the missions and measures of each division.
^USING ALASKA'S HEALTHCARE DOLLARS WISELY: MISSIONS AND
MEASURES REVIEW
10:10:47 AM
KARLEEN JACKSON, Commissioner, Department of Health and Social
Services (DHSS), began by stating that one of the biggest
challenges in healthcare and social service work is balancing
the competing needs of access to care, quality of care, and cost
of care. Today, she said, the focus would be on the missions
and measures that the departments are required to use in order
to evaluate whether the services being funded are producing
results.
10:12:18 AM
COMMISSIONER JACKSON noted that all of this relates to the
budget process. At this point, departments have provided
suggested budgets in to the Office of Management & Budget (OMB).
The OMB, she said, is now compiling a statewide budget which
will then be submitted to a transition team after the 2006
gubernatorial election. It is the transition team, she said,
that produces the final document to be released by December 15,
2006. The final decision will be made by the legislature. The
DHSS, she said, prioritized the budget line-items within each
division. This year, there are a total of 98 budget line-items
for DHSS. These line-items were broken into the following
themes: sustaining services; compliance issues; quality
assurance; healthy futures. She explained that the "healthy
futures" category was broken into two areas: projects with
measurable results and projects that "show promise." There are,
she said, flaws and benefits when prioritizing budget items.
One benefit is the ability to see the important programs, when
funding is short. However, there may be a low priority item
with demonstrative results, and a high priority item that does
not have results. Therefore, it is not simply a matter of
funding the first 50 items.
10:16:17 AM
COMMISSIONER JACKSON, in regard to prevention, posed the
following question: How can we prevent future funding [by
funding the types of programs that ensure less substance abuse
and lower suicide rates]? Another "lens" used to prioritize
items was "making sure that [DHSS] was truly looking at
measurable results." She opined that Cristy Willer has been
doing "an amazing job" of creating a way to prioritize grantees
and contractors in a way that shows whether the work is
providing the desired results. The federal government, she
said, is also "pushing in that direction."
[Due to technical difficulties, a portion of the audio is
repeated.]
10:17:35 AM
COMMISSIONER JACKSON then explained how to find the OMB Missions
and Measures web site. Once on the web site, she said, it can
be browsed by agency, overview, or by resource center. She
directed the members' attention to the agency section pointing
out that from here, various departments can be reached, and
noted that the missions and measures of other departments
affects the DHSS. From the DHSS section, she said, you can
access the "results summary," which gives an indication of any
problems in a particular division. Each division also offers
more specific indicators, which give more information on the end
result and the strategy used. This is a "work in progress."
10:28:48 AM
STEPHANIE BIRCH, Chief, Women & Children, Family Health,
Division of Public Health, Department of Health and Social
Services (DHSS), explained that the post neonatal death rate
measures the death rate of infants from one month after birth
through the first year. In regard to the post neonatal death
rate in Alaska, she said that the rate for Alaskan Natives is
4.1 times higher than the rate for non-Alaskan Natives. She
pointed out the Healthy People target is 1.5 deaths per thousand
live births. She explained that many factors "feed into" the
post neonatal death rate, beginning prior to conception. The
overall health of women, including level of obesity and chronic
diseases plays a role. She stated that in the 1980s, it was
"very rare to see anyone coming in with any ... chronic
diseases]. Over the last 20 years, this amount has grown to
almost 50 percent of women coming into pregnancy; in Alaska,
this is "fairly acute." Having access to early and continuous
prenatal care has been a struggle. She explained that reducing
the rate of smoking and drinking during the first trimester of
pregnancy would greatly improve the outcome, in addition to
having continuous prenatal care visits with trained
professionals. Ms. Birch stated that some early warning signs
are not recognized and the mothers are not transferred in for
care as early as is needed. This is also true of "urban
mothers." In addition, the program has shown poor outcomes in
regard to the low birth rate for African-American women.
10:33:06 AM
CHAIR WILSON inquired as to how often the problem is that the
mother doesn't go to prenatal care visits.
MS. BIRCH replied that the data collected in 2003 indicates that
over 40 percent of women who wanted prenatal care were unable to
receive it. She explained that this is partly due to insurance
coverage, and opined that nationally, there is less emphasis on
the importance of early prenatal care. She went on to say that
often, the first visit isn't scheduled until the 12 or 14 week
of pregnancy. She stated that the lifelong costs associated
with preventable birth defects are "quite outstanding."
Continually, she said, between 450-500 infants are delivered and
admitted to the neonatal intensive care unit, level three, at
Providence Alaska Medical Center. She said "what's impressive
about that number - you would think ... over time we would have
improved. But the babies are getting smaller.... So, that tells
us that we're not doing as good a job, in terms of picking up on
some of these chronic diseases [and infections] of moms."
MS. BIRCH went on to say that nationally, there is a focus on
improving oral healthcare for pregnant women, as high amounts of
bacteria in the system can cause infection of the placenta and
result in early delivery. Ideally, she said, women would come
in prior to pregnancy. She then explained that folic acid
supplements have made a huge impact on children born with neuro-
tube defects, adding that progress is being made in regard to
women's knowledge of folic acid, through the DHSS partnership
with the March of Dimes. The Special Supplemental Program for
Women, Infants and Children (WIC), she said, has worked with
DHSS to educate Alaskan Native women on the importance of folic
acid, along with the traditional foods with high folic acid
content. However, she said, there is still "a long way to go."
10:38:45 AM
REPRESENTATIVE CISSNA, in regard to folic acid, stated that it
this is not easy to obtain in many rural settings, and inquired
as to whether this relates to lack of access to prenatal care in
rural areas.
MS. BIRCH replied that having a supplement is preferable, adding
that the only way to get the supplement is to receive prenatal
care. Late access to prenatal care is the largest challenge to
Alaskan Native women, she said.
CHAIR WILSON opined that most of the clinics have vitamins to
give the women.
MS. BIRCH pointed out that women have to know that they're
pregnant. Furthermore, between pregnancies is an important time
to continue taking folic acid and identify and address other
issues.
10:41:04 AM
MS. BIRCH emphasized the need to focus on prevention. In
conclusion, early identification, prevention, and intervention
are the focus of the "improving birth outcomes" measurement.
10:42:38 AM
REPRESENTATIVE SEATON, in regard to sonograms and a possible
link to autism, inquired as to whether the prenatal use of
sonograms is restricted to medical necessity.
MS. BIRCH replied that she has not seen any scientific data on
that; however, Medicaid covers one ultrasound unless it is a
medical necessity. She added that in the private sector, there
has been much advertisement for women receiving ultrasounds in
order to have a photograph of the baby in utero; however, this
is not common.
REPRESENTATIVE SEATON asked "has the state done anything to
raise the red flag to the medical community about that?"
MS. BIRCH replied that she would need to discuss this further
with Medicaid.
CHAIR WILSON opined that this issue came up as a result of a
wealthy person purchasing a sonogram machine during pregnancy.
10:45:23 AM
TAMMY GREEN, Chief, Chronic Disease, Division of Public Health,
Department of Health and Social Services (DHSS), stated that she
would be speaking about diabetes and obesity in Alaska. In
regard to Diabetes, she stated that there are "broad range
ramifications for the healthcare system." It impacts the
quality of life for patients experiencing the disease, as well
as affecting the healthcare system as a result of other issues
such as renal failure and dialysis, which are "very costly" to
treat. Diabetes is a "multi-faceted problem." There has been,
she said, a rise in Type II diabetes in youth, which is related
to obesity.
MS. GREEN moved on to discuss obesity in Alaska. She pointed
out the goal of decreasing the adult obesity rate to less than
18 percent. If "overweight" is combined with obesity, she said,
the total is about 63 percent of the population. Obesity has
been linked to cancer, heart disease, stroke, and high
cholesterol, in addition to poor body image and emotional
issues. Obese and overweight people are less likely to want to
exercise, she said. A recent study showed that overweight youth
experience the same level of emotional trauma as those
experiencing cancer and chemotherapy. She said:
That really gives you that magnitude of what it's like
for a child to be overweight. And what we know is
that - if a child is overweight, it used to be that
people would say "Oh, they'll grow out of it, it's
baby fat," but the research doesn't bare that out. It
shows that, if a child is overweight coming into
school, the likelihood that they're going to
"normalize" or come out on the other end being a
normal weight is ... very unlikely. So, the sooner a
child experiences overweight or obesity, the more
likely they're going to be overweight as an adult.
Thus leading to all of the chronic diseases that are
going to impact their quality of life.
MS. GREEN went on to say that there is an obesity prevention and
control program that works with schools and communities in an
effort to make exercise more accessible along with finding
easier ways to get fruits and vegetables to the more rural
areas. The idea behind this, she said, is to make it easier to
live a healthy lifestyle.
10:52:53 AM
REPRESENTATIVE CISSNA expressed concern with regard to the
obesity chart. In 1999, she pointed out, Alaska was ahead of
the nation in obesity by a slight margin, but in 2005 the state
has moved ahead significantly.
CHAIR WILSON surmised that doctors are "really aware" of the
problem, which makes a difference.
MS. GREEN indicated that another year of information is needed
to show "trend data." At the current rate, she said, in the
next ten years, 80 percent of the population will be overweight
or obese. The Chronic Disease Policy Academy, she said, has
been looking at various areas regarding chronic disease over the
last few years, and supporting the idea of working with
communities.
10:55:53 AM
REPRESENTATIVE SEATON opined that it would be helpful to view
the information on a graph showing the national trend-line and
the Alaska trend-line.
MS. GREEN agreed that seeing the trends helps "crystallize" the
information.
10:56:37 AM
MS. GREEN moved on to discuss the measures relating to the
Division of Public Health. Specifically, she said, they would
be looking at coronary heart disease. She read from a handout
as follows: Alaska's coronary heart disease death rate is less
than 120 per 100,000 population. She pointed out that Alaska is
showing a decrease in death rate, and met the target in 2001 and
2002. She posed the question "how is this happening, [when] we
have these other things happening in terms of obesity and
diabetes, things that are impacting coronary heart disease?"
She then explained that this is specifically talking about the
death rate, rather than the incidence of the disease. There
have been, she said, "tremendous strides" in the treatment of
coronary heart disease, noting that these treatments include
medications, in addition to technical treatments. She pointed
out an error in the handout regarding the national death rate,
noting that it should read "n/a," as the data was not available.
CHAIR WILSON commented that "it's pretty exciting" for Alaska.
Especially, she said, because Alaska has so many difficult to
reach areas that face additional obstacles in emergency
situations.
10:58:53 AM
REPRESENTATIVE SEATON asked if the incidence rate of coronary
heart disease is available.
MS. GREEN replied that only the death rate is available at this
time.
REPRESENTATIVE SEATON inquired as to whether people with
coronary heart disease that "left Alaska for treatment and died
outside [of Alaska]" would be reported as an Alaska death or an
"outside death."
MS. GREEN replied that it "could be either." She explained that
it would depend on where the patient died. Other states will
report to vital statistics if the individual is still a resident
of Alaska. She opined that the reporting process has improved.
In addition, she said, more people are choosing to stay in
Alaska for treatment as a result of the higher level of care
available to them.
11:00:25 AM
REPRESENTATIVE CISSNA expressed interest in knowing whether the
lower death rate has any correlation to the success of smoking
cessation in the state.
MS. GREEN replied that while it is difficult to make direct
cause associations, the department is attempting to gather this
information. The national data shows that the rates are going
down due to increased treatment options more than smoking
cessation or weight loss.
REPRESENTATIVE CISSNA, in regard to the coronary heart disease
and cancer death rates, requested that the national numbers for
2005 be sent to offices via email.
MS. GREEN agreed to do so.
11:02:43 AM
MS. GREEN continued with Alaska's cancer death rate, which has
also decreased. This is due to early detection, which effects
the length and quality of life. However, the incidence of
cancer has increased. Lung cancer, she said, is the biggest
cause of cancer related death in Alaska, and noted that this is
directly related to smoking. She said "we have good news on
this front, but we still have a lot of work to do, in terms of
really trying to educate people and help people understand what
... they can do." She stated that people may feel helpless
about how they get cancer. There are many lifestyle changes
that can help to prevent cancer from occurring.
11:04:22 AM
MS. GREEN, in response to Chair Wilson, identified the following
four diseases as the top diseases in Alaska: lung cancer,
breast cancer in women, prostrate cancer in men, and colon
cancer.
REPRESENTATIVE SEATON asked if data is available regarding what
has been done to lower the smoking rate in Alaska.
MS. GREEN related that tremendous strides have been made with
the smoking cessation program. Within a year, she said, more
information will be available regarding what is working and what
is not working, in addition to where efforts should be
increased. The Quit Line program has had a good success rate,
and now offers nicotine replacement patches to callers who wish
to quit smoking. In addition, she said, the annual report on
tobacco cessation will give an update on the success of the
program.
CHAIR WILSON agreed with Representative Seaton regarding the
importance of seeing the aforementioned data.
11:07:57 AM
MS. GREEN moved on to discuss reducing the rate of smoking among
Alaskan youth. The goal, she said, was to have less than 19
percent of high school aged youth in Alaska use tobacco
products. This goal was met in 2003. In 1999, when the youth
risk behavior survey was conducted, the smoking rate was around
37 percent. This decrease was correlated with the increase in
the statewide tobacco tax, in addition to higher funding for
prevention. In 2005 there was no data due to the effort
required to obtain parental consent forms and ensure that enough
surveys are collected for "weighted data." Hopefully, she said,
the department will obtain enough data to show what has happened
between 2003 and 2007. Nationally, she said, the rates have
started to "flatten, and ... go up again." There has been a
"great amount of success." However, the department must ensure
that it continues to move in the right direction.
11:10:01 AM
CHAIR WILSON recalled that the active questionnaire requires
parental consent, and inquired as to whether the schools were
having trouble with the rate of return.
MS. GREEN replied that the law changed from "passive" to
"active" parental consent, adding that oftentimes, parents will
forget to respond. If the response rate is not high enough, the
data is not representative of the entire population, which is
what happened in 2003. She also noted that the scope of the
survey reaches beyond tobacco to include all areas that affect
chronic disease.
CHAIR WILSON offered her understanding that without the correct
data to show whether or not a program is effective, the state is
not allowed access to funding grants that it might otherwise
receive.
MS. GREEN replied yes, and agreed that this would benefit from
further review by the legislature. In response to a question
from Representative Seaton, she explained that a bill to change
from "active" to "passive" consent failed to pass during the
previous legislative session.
11:13:16 AM
CRISTY WILLER, Director, Central Office, Division of Behavioral
Health, Department of Health and Social Services, began by
reminding the committee of Alaska's rates in relation to
behavioral health. She explained that there are many societal
costs in addition to the human costs. In the United States, she
said, 500 million workdays were lost due to alcoholism. $277
paid by each taxpayer goes towards dealing with the
consequential burdens of substance abuse, while only $10 is put
towards prevention. Approximately 13 percent of each states
budget is put toward these issues. She cited a 2005 report by
the McDowell Group which shows a $738 million loss to the state
each year in terms of productivity, criminal justice,
healthcare, traffic accidents, and public assistance, in
addition to roughly $50 million given out in the form of grants
for direct treatment and prevention.
11:17:26 AM
MS. WILLER pointed out that many of the missions and measures
are attached to the departments because they are multi-faceted.
She then turned attention to the Bring the Kids Home program,
which would bring Alaskan youth back from out of state
placement, in addition to preventing youth from being placed out
of state. She directed attention to the first of three charts,
which is a line chart. She explained that this is not as useful
in terms of annual trends; however, it shows that in 2006, less
youth were being sent out of state during the last few months.
The bar chart, she said, shows the "turn the curve idea."
REPRESENTATIVE WILSON related a story of a family where five
children were removed and sent to separate homes. The state
then had to pay for the children to fly and see a counselor in a
different town. She opined that if the counselor had come to
the children this would have saved the state money and been
"less traumatic" for the children. She inquired as to the rules
regarding this type of situation.
11:23:23 AM
MS. WILLER replied that she does not "know the regulations well
enough to understand how that could happen." She noted that
some children and adults in Alaska are "falling through the
cracks" as a result of funding regulations and priorities. The
department has had meetings to identify which type of family is
most likely to experience this, and how to solve this problem.
11:24:45 AM
REPRESENTATIVE SEATON opined that the graph shows less in-state
occupancy than in 2001. He said "We had a couple of years where
we improved a little, and now we've dropped right back to where
we were in 2002." He inquired as to whether this interpretation
of the graph is correct.
MS. WILLER replied that the graph shows the "relative nature of
in-state and out-of-state." She then referred to a table
showing the number of youth in residential psychiatric treatment
placement over the last four years. The out of state placements
on the aforementioned table, for 2003 and 2004, shows an
increase in the number of youth sent out of state. She said
"the next two change numbers under it are showing less kids
being sent out of state. So, it's another turn." When the out-
of-state placements are subtracted from the total, the remainder
is youth in-state. She opined that an additional column would
make this clearer.
REPRESENTATIVE SEATON offered his understanding that the number
of youth out-of-state lowered from 2003-2006, adding that for
2001, the number of in-state youth would have been even higher.
CHAIR WILSON commented that the chart is confusing.
11:28:34 AM
MS. WILLER offered to redo the charts in order to graphically
illustrate the changes. She then expressed the need to keep in
mind that the emphasis of this program was in 2004. She went on
to explain that more beds have been added in-state, in addition
to increasing services with community service providers.
11:30:24 AM
CHAIR WILSON recalled that Bring the Kids Home is really about
providing more treatment in Alaska rather than sending them
outside to do so.
MS. WILLER agreed and noted that other systems have been
offered, such as the "gatekeeper system," which analyzes out-of-
state referrals to ensure that an "appropriate situation" for
the child to be in closer to home.
CHAIR WILSON recalled that previously there had been discussion
that parent or guardian insurance would be utilized prior to
Medicare.
11:32:32 AM
JERRY FULLER, Project Director, Office of Program Review, Office
of the Commissioner, Department of Health and Social Services
(DHSS), stated that this was a requirement of HB 426. He
explained that in the current Medicaid program, if a child has
insurance that would cover the needed services, the insurance
company is billed for the service. Unfortunately, he said, most
insurance companies do not cover [residential] psychiatric
treatment of youth.
11:33:23 AM
REPRESENTATIVE CISSNA commented that she has tracked the history
of "high-risk" youth for several decades. In the 80s, she said,
there was implementation of "wraparound services," which was
replicated in other states, although Alaska no longer offers
these services. Alaska, she said, has "moved away" from local
community solutions, along with losing grants that would allow
services that Medicaid does not. She said "services were
delivered that simply cannot be delivered under our present
funding source." She opined that the current system, in regard
to a rural setting, takes youth away from families permanently,
as the culture has been taken away from the child. She said "I
think it would be great for us to look back at our history,
figure out what did work in the past, and figure out what's
still here that might be used. ... I think if we're going to
really fix the problem, we have to ... use some of the talent
that ... is in the state, not constantly import new people."
MR. FULLER related that during a meeting of the Medical Care
Advisory Committee in Barrow, a recommendation was made for a
study to look back at the environment when behavioral health was
a "general funded program" with little Medicaid funds. The
Mental Health Trust Authority is funding such a study, he said,
which currently is in the beginning stages.
11:38:22 AM
REPRESENTATIVE SEATON inquired as to whether tickets must be
purchased in advance for parental visits, so that the state is
not paying the highest prices.
MR. FULLER replied that the parents are encouraged to see their
children on a routine basis. He stated that he does not know
whether the parents are required to purchase tickets in advance,
adding that the state does have a preferred contract with Alaska
Airlines, and should be receiving a reduced rate. More details
regarding this issue can be provided, he said.
REPRESENTATIVE SEATON said "I'd just appreciate getting [this
information]."
11:40:24 AM
MS. WILLER, in regard to closer case management of youth out-of-
state, stated that parental visits are not vacations, but are
"therapeutic events" for the family. To work closer with the
therapist, she said, means that any travel and communication is
planned out. In regard to the additional beds, she stated that
they are usually added in the larger communities. The program,
she explained, is intended to provide accessible services
outside of the residential programs. Currently, she said, there
are around 110 youth participating in individualized services.
These include in home services, independent living skill
training, treatment and foster care facilities, after school
programs, and parenting programs. The idea, she said, is not to
rely completely on residential programs.
11:42:22 AM
REPRESENTATIVE CISSNA recalled that the state had previously
done a study in collaboration with University of Alaska
Anchorage (UAA), which looked into how the states child welfare
programs were working, and if they were not working, why not.
She offered her understanding that the program did not have a
"good track record" of following a model program. She opined
that it may be helpful to the committee to revisit this study.
MS. WILLER replied that these studies can be found on the web
site, and agreed to forward this information to the members'.
REPRESENTATIVE CISSNA asked if the programs being utilized are
fitted with evidence-based models.
MS. WILLER replied the aforementioned study was used to develop
the standards and evaluate the need for "step down" services.
11:45:14 AM
CHAIR WILSON related her belief that more children need mental
health services each year, and inquired as to whether a study
has been done to discover the reason for this.
MS. WILLER answered that there are national prevalence studies
that show this information, and offered to research this. She
related that the aforementioned beds were already filled, and
said:
So ... I'm seeing the moving target that you're
describing, that really, the impact we're making on
that is going to be interesting to judge, because it's
against the growing trend line of needs. And, in
order to discuss the one, we have to discuss the other
with more specificity, you're right. So, that's
something we need to work on. We're working on ...
ball-parking prevalence studies for specific
populations of young people and adults: FASD,
traumatic brain injury, [autism]. As a way to
identify special populations of those kids that we're
ill-serving because, as I mentioned before, they're
falling through the cracks. But, in terms of
causality, I think we'll have to look more to the
national [studies].
11:48:50 AM
REPRESENTATIVE CISSNA said that over the past few years, she has
noticed individuals in community mental health discussing the
increase in the chronic mental health, while the capacity to
handle them is decreasing. She inquired as to how much the
department tracks these types of concerns.
MS. WILLER replied that there are four large provider groups in
the state, each of which she meets with on a monthly basis. For
the last 10 years, she said, due to a reduction in grant funds,
more programs have had to serve a "more acute" population. In
regard to why the population is growing, she stated that this
because the department is not able to focus on intervention and
prevention. She stated that the it is important to look at the
affects these issues have on jobs, primary care, and other
areas. Employees and practitioners are voicing frustration that
they must focus on populations in crisis.
11:53:38 AM
CHAIR WILSON pointed out that while school funding has been
increased over the last six years, the schools are still unable
to fund in-school counselors. She opined that it is "pretty
crucial" to look at school funding in this way, and ensure each
school has a counselor.
11:55:15 AM
MS. WILLER moved on to a chart showing the suicide rate in
Alaska. She explained that Alaska has double the US suicide
rate, and the Alaskan Native rate is four times the US rate.
Suicide is the number one cause of death for people under the
age of 50, and claims around 125 lives each year. She has
looked at studies done, and approximately 50 percent of the
family of the deceased reported that the person had a drinking
problem. 36 percent were arrested for drinking behavior, 50
percent were intoxicated with alcohol or other drug at the time
of death. 45 to 50 percent of the individuals were on drugs of
some kind. She related that 39 percent of the individuals had
insurance coverage for mental health issues. 50 percent were
depressed, 46 percent experienced a traumatic event, 92 percent
owned firearms, 53 percent had previous thoughts of suicide, and
20 percent experienced some form of abuse prior to the age of
nine. 25 percent witnessed violence, and a high percentage of
the individuals had a family member die during childhood. This
last factor, she said, may be tied into neonatal care.
MS. WILLER moved on to discuss attempted suicide. The study
shows that more than $4 million per year is used for
hospitalization of those who attempt suicide. This number does
not include specialization or technology, and at least $1
million each year is absorbed by the hospital. This is, she
said, one of the nexus points of behavioral health issues, and
connects with employment, poverty, cultural dislocation, among
other things. She said "this is the low point of where these
things combine to disrupt a person's life. And obviously, a
whole family-and communities, when there are cluster suicides,
of course, we see entire communities at risk." She noted that
the division has a suicide prevention program, which she feels
is a unique program because the money goes directly to the
community. She opined that the communities "make wrong guesses
sometimes," and suggested a follow-back study to show which
programs are the most successful. The ability of the division
to make a direct connection with the leaders of small
communities is "a good strategy."
12:00:58 PM
CHAIR WILSON inquired as to whether the aforementioned program
is working. She said "if we're spending money there, and we
haven't seen the results that we would like, maybe we should be
putting the money in a different area." She stressed the
importance of knowing where the money is going and whether or
not these programs are effective.
12:04:13 PM
MS. WILLER agreed that it is important to know what is working.
The prevention department is putting together an epidemiological
work group, which will produce the information that is needed.
The group is called "EPI group," she said, and offered to
distribute the minutes from the first meeting to the members'.
She then moved on to discuss the Alaska Psychiatric Institute
(API) readmission rate. This shows that 12.7 percent of
patients at API have been patients previously. This is much
higher than the national average, and shows that the community
services around the state are not equipped to handle the
individuals returned to the general population well enough to
keep them from returning.
REPRESENTATIVE SEATON offered his understanding that the
patients had not only been admitted before, but were admitted
again within 30 days of being discharged. He suggested that
this may be related to the lack of space or ill-equipped
community services.
MS. WILLER agreed that this is the case. She added that the
length of stay may be too short to "do the job."
CHAIR WILSON noted that the funding has been increased for API
personnel, adding that this may result in additional registered
nursing staff. She stated that hopefully, this would make a
difference.
COMMISSIONER JACKSON noted that there has been a positive trend
line over the last few years.
MS. WILLER added that this is a "multiplex" issue. Increased
salaries will improve the in-house services; however, the state
must "look elsewhere" for solutions.
12:07:50 PM
REPRESENTATIVE SEATON asked if an analysis would be done to
identify what API believes is the cause of the returning
patients.
MR. WILLER replied that the division has done work in this area,
relative to budget requests in addition to looking at what was
intended to happen when the program was downsized. The division
has also been looking at new ideas that may be more efficient.
The solutions include: better detox and crisis respite,
discharge planning, and housing.
CHAIR WILSON noted that some items are not available due to lack
of funding by the legislature. She inquired as to whether there
is a way to show the cause and effect of not funding these
areas.
MS. WILLER replied that this may be possible.
CHAIR WILSON opined that if there is a reason that API does not
have the support services, it would not be APIs fault.
12:10:29 PM
REPRESENTATIVE SEATON recalled that the previous year, the local
hospital funding issue was fixed. He inquired as to whether
this has helped hospitals retain patients for the first 3-5 days
without needing to send the patient to API.
MS. WILLER replied yes, but expressed the need to provide
numbers and highlighted that it's a lower level of care. She
opined that "loosening the reigns" has helped in rural areas,
and will continue to do so. API, she said, is involved in
"tele-behavioral health solutions." She stated that although
this would not apply to a person in acute psychiatric crisis, it
may impact APIs ability to contain those in need. Another
problem is that API must take those individuals brought to them
by the police, which is difficult, as it's a situation in which
there is a legal issue.
CHAIR WILSON expressed frustration with the lack of therapy that
the hospitals can provide because of the staff isn't qualified
to provide such.
12:14:45 PM
MS. WILLER moved on to the division's missions and measures, and
said that the two charts used represent responses for adults and
youth. She pointed out that this year, the responses are 23
percent higher than in previous years. She explained that the
charts show the results of surveys asking individuals in the
treatment program questions related to productivity. She noted
that this question is broad in order to include all types of
productivity, and said "defined loosely, how productive do you
feel? Because this is a therapeutic issue, this isn't
necessarily ... it's feeling productive, if you have a place to
go and work and feel like you're an able member of society-
[this] is a critical factor in well-being." The survey also
includes questions regarding physical, mental, and emotional
health, thoughts of self-harm, family and social support,
safety, sense of well-being, spirituality, financial security,
and housing. She stated that the patients are asked when they
arrive, when they leave, and after they have been on their own
for 6 and 12 months. This information is then compared.
MS. WILLER went on to say that the first chart shows individuals
self-assessment of their maintenance and improvement in each
area, noting that the adults show more improvement than the
youth. These surveys can be broken into more specific areas to
determine where the funds would best be spent. In regard to the
self harm measure, she explained that the question was "are you
thinking less about self harm?" She pointed out that this is
why it appears that the thoughts about self-harm are rising,
however, due to the wording of the question, the opposite is
true.
12:20:09 PM
REPRESENTATIVE SEATON, in regard youth productivity, offered his
understanding that more than half felt more productive, while
roughly 40 percent felt less productive. He opined that it is
important to provide individuals outlets "so that they feel they
have a meaningful life." He stated that the importance of this
measure needs to be communicated, adding that the 40 percent of
people who are feeling less productive really needs to be
addressed.
MS. WILLER agreed with this. She reiterated that one way to
focus would be to sort the results into more specific areas.
She opined that the concentration of suicidality among young
native males is related to the loss of "a very productive,
creative life, which now no longer is, for a variety of economic
and social ... reasons." She commented that while the state is
unable to have direct impact in all areas, it is attempting to
identify these issues and help communities organize in order to
have an impact.
12:24:09 PM
MS. WILLER moved on to explain the measure intended to track the
number of native entities that are able to bill for Medicaid.
She then explained the "satisfaction" measure. This shows
results of a survey given to patients to track satisfaction with
care. For residential programs, the patient is given the survey
when they leave the program and then mails it back. This, she
said, provides the patient with anonymity. The intent of the
measure is to track whether the state is improving its ability
to provide satisfactory treatment. The adult chart, which shows
data over a three year time period, shows more satisfaction from
2004-2006. The family and youth responses are "less
satisfactory." She pointed out that the youth were less
satisfied in 2005-2006. The information was also broken down by
ethnicity, and the youth, she said, were "fairly equal" in terms
of satisfaction, with the exception of access to services and
cultural sensitivities. In the aforementioned areas, she said,
the Alaska Native youth were less satisfied. In addition, she
pointed out that although the Alaska Native youth were less
satisfied, the satisfaction level was still high. She said
"This has something to do with outcomes, it has something to do
with ... successive treatment - not everything. We don't expect
people to be in our treatment programs to really like being
there, always. We're a challenging place. But, we think it's
certainly important to watch these trends and see where it slips
and try to identify - in these components - what we can do
better with.
CHAIR WILSON inquired as to the number of children versus adults
in the program.
MS. WILLER replied that she does not have this information with
her; however, the surveys received a 94 percent higher response,
up from [2005]. She offered to forward this information.
CHAIR WILSON stated that this information would be "nice to
have," adding that if the adults outnumber the children in the
program, the program may need to focus more on the children in
order to change the future number of adults in the program.
12:30:06 PM
REPRESENTATIVE SEATON asked for clarification regarding the
numbers on the last chart.
MS. WILLER agreed to take a closer look at the charts to ensure
that the numbers are correct.
REPRESENTATIVE SEATON in regard to the suicide rate, asked if
those individuals with access to insurance had or had not
utilized this insurance, and whether the programs used were
affective. He commented that half of the individuals with
mental health care available to them had committed suicide and
posed the question "where's the problem?" He expressed hope
that this information would be available in the future.
MS. WILLER agreed and added that she would like to find out how
"insurance" is defined, also. She questioned whether this was
referring to private insurers or Indian health services. In
addition, she said, there were statistics showing how many of
those individuals who committed suicide were seeing a therapist,
and how many weeks it had been since the last visit. She
offered to gather this information.
12:32:47 PM
COMMISSIONER JACKSON, in regard to the productivity measure,
stated that the department had previously attempted to include a
category titled "open opportunities" in the budget, which would
have addressed the issue that individuals "need something that
they can do that makes them feel productive." However, this was
not included in the final budget. She said that, perhaps, the
members would be able to come up with a better way to "frame
this," as this is something that needs to be addressed.
12:33:24 PM
STEPHANIE WHEELER, Executive Director, Faith Based and Community
Initiatives (FBCI), Department of Health and Social Services
(DHSS), said that the national Faith Based and Community
Initiatives (FBCI) program was established as a result of an
executive order from the President in 2001, and is an expanded
version of the previous administrations "Charitable Choice"
program. The FBCI program, she said, seeks to strengthen and
expand the capacity of faith based and community organizations,
to provide federally and state funded social services. This
would enable the community groups to meet the needs of local
individuals facing life challenges. She noted that there has
been controversy regarding the FBCI program, one of which is the
"separation of church and state." She explained that the FBCI
program has guidelines and regulations in place in order to deal
with this. There are 11 federal agencies with FBCI offices, and
the DHSS works closely with the federal agencies, as well as
with regional partners. In addition, she said, 32 states
currently have state FBCI offices.
MS. WHEELER moved on to explain the [federal] FBCI program
priorities. These include: at-risk youth; domestic violence;
substance abuse; homelessness; poverty; healthy marriage
initiative; welfare-to-work; prison re-entry; HIV/AIDS. The
Alaska FBCI office was established in January 2005, and is
supported by an 22 member advisory council. The state
priorities, she said, are "pretty much in-line" with the
national priorities, and focus on healthcare related issues. In
addition to the aforementioned priorities, the state has added
suicide prevention and hunger.
12:37:07 PM
MS. WHEELER stated that the state FBCI program has been working
with the federal partners, and is considering three additional
priorities. These are: combat war veterans; at-risk seniors;
disaster relief planning. In regard to at-risk seniors, she
explained that seniors are one of the fastest growing
populations in the state. In addition, one third of the seniors
in Alaska are living in poverty. She pointed out that Florida
is considering providing preventative healthcare to its seniors,
and is working on model projects which include faith-based
organizations. The aforementioned projects would provide day-
care services for seniors, and would provide supportive services
on-site. The faith-based organizations would work with
government agencies to provide these services. The model
programs, she said, are showing a decrease in cost of healthcare
for the seniors involved in the programs. In regard to disaster
relief, stated that faith-based organizations were affective in
the aftermath of Hurricanes Katrina and Rita.
12:39:10 PM
MS. WHEELER then discussed the FBCI programs in Alaska. Project
Access, she said, provides insurance coverage to uninsured and
underinsured individuals. She referred to a previous PowerPoint
presentation titled "Partnerships Leverage Resources," and
stated that the aforementioned program is a "really good example
of how partnerships really do leverage resources."
12:39:52 PM
REPRESENTATIVE SEATON referred to a recent newspaper article
which stated that seniors would soon need to move from Alaska
due to an inability to receive Medicare. He inquired as to
whether the FBCI would influence the availability of Medicare
for seniors in the state.
MS. WHEELER replied that the FBCI program does not; however,
creating partnerships creates more ideas on how to provide these
services to seniors. This includes pulling in faith-based
organizations and volunteers to work on model projects.
12:40:54 PM
MR. FULLER explained that Medicare is federally operated, and
therefore the state does not have influence over this program.
He said:
The issue in the newspaper, over the last several
months, has to do with a reimbursement reduction to
physicians that occurred in January of [2006],
specific to Alaska. In January of [2007], at a
national level, there is anticipated to be another 5
percent reduction to physician services. Our
delegation, and I would say, all of the congressional
delegations are very much aware of that. And they're
all working very hard to have a legislative fix during
this "lame-duck" session. Our delegation already has
language written to repair the [2006 and 2007] damage,
to tack on to the national movement. So, it remains
to be seen, but ... it's strictly a federal issue that
the state has no influence over.
REPRESENTATIVE SEATON requested clarification regarding when
doctors cannot or will not take Medicare patients.
MR. FULLER replied that it is the physicians' choice. He
explained that some physicians that have previously chosen to
see Medicare patients are now informing the patient that he/she
no longer accepts Medicare, and therefore can no longer see the
patient. He said "Unless they want to pay cash. So, that's
their access route at this point." Additionally, he said, if
the patient is covered by any other type of insurance, including
state insurance, Medicare must pay before the secondary forms of
insurance will pay. He said "if the doctor drops his acceptance
of Medicare, it affectively shuts them off from all their
insurance benefits, whatever they might be." The remaining
access, he said, is very minimal. Alaskan Native patients do
still have benefits through tribal health corporations. There
are also community clinics which receive public health service
grants, which are often overloaded with patients.
REPRESENTATIVE SEATON asked if the only influence possible would
be an expansion of the community health care clinics. He also
inquired as to whether establishing these clinics is state or
federally regulated.
MR. FULLER replied that the state has some ability to designate
areas of the state "medically underserved," which is the "open
gateway to the federal side." Over the last few years, he said,
the state received a "huge expansion," and he is unsure of what
the remaining opportunity is, in terms of expanding the capacity
in the current areas or adding additional areas.
UNIDENTIFIED SPEAKER stated that there are community health
centers in over 22 organizations throughout the state. These
are distributed across 100 communities. These centers are
federally funded. Many of the sites, she said, were tribal
sites, with very few centers that are newly constructed. This
is mainly expansion and reinforcement of many existing sites.
Within the last week, she said, new access points have been
announced by the Health Resources and Service Administration
(HRSA). She explained that the communities must have a
medically underserved area designation, which is federal
designation. The majority of areas throughout the state which
meet the criteria are currently designated as such. She noted
that many communities interested in providing the services do
not meet the criteria, adding that the sites must compete
against other states and communities which have applied for the
same funds. In the past, she said, other state resources have
been applied to primary care organizations and services;
however, these were direct grants, and none are currently
available.
REPRESENTATIVE SEATON inquired as to whether the community
health centers accept Medicare.
UNIDENTIFIED SPEAKER replied yes, adding that the centers must
first be attentive to the patient load distribution. She
pointed out that Medicaid and Medicare must be included in the
centers financial projection.
REPRESENTATIVE SEATON asked if the legislature plays a role in
helping establish or continue access [to medical care] for the
senior population that is not able to see a private doctor.
UNIDENTIFIED SPEAKER replied that she is unable to answer this
question at this time. She explained that many of the sites
receive a combination of state and federal funding.
12:49:49 PM
CHAIR WILSON surmised that the legislature could require the
doctors to see a percentage of Medicare patients, or require the
secondary insurance companies to pay, even if Medicare does not.
COMMISSIONER JACKSON suggested holding an additional meeting to
discuss the difference between Medicare and Medicaid, in
addition to what the legislature can do.
CHAIR WILSON agreed, adding that while the funding may currently
be available, it is important to consider whether this can be
sustained in the future.
12:52:09 PM
MS. WHEELER continued her presentation by discussing the healthy
marriage initiative. Alaska, she said, had an opportunity to
"do some creative things around the healthy marriage
initiative." However, she said, this was very short-lived. In
fiscal year 2005 (FY05) $150,000 was dedicated to healthy
marriage initiatives, along with $500,000 the following year.
Over half of the healthy marriage grantees were faith-based
organizations. National research shows that children of
families involved in the healthy marriage programs do better in
school, have better access to healthcare, and show less at-risk
behavior. If the opportunity to recreate these programs were to
arise, she would encourage the legislature to take a look at the
national outcomes from this initiative.
CHAIR WILSON opined that one reason this program is no longer
funded is due to a lack of evidence showing its effectiveness.
MS. WHEELER returned to health care and community initiatives.
The FBCI program is developing healthcare ministries within
faith-based organizations. There are, she said, over 46 faith-
based organizations participating, adding that these are
primarily prevention and intervention measures. She pointed out
several different programs around the state which are involved
in these initiatives, including one in Anchorage and Sitka.
These programs are volunteer run. The Tribal Community
Development Coalition oversees the Minority Education Health
Committee, which is developing similar healthcare ministries.
The FBCI program works closely with the Alaska State Community
Service Commission (ASCSC), which tracks and recruits
volunteers.
12:56:47 PM
MS. WHEELER moved on to discuss combat war veterans. In regard
to Alaskan Native individuals who go to war, she stated that a
number of healthcare issues are showing up. It is unknown
whether these issues are preexisting or are aggravated by war
conditions. The concern, she said, is when the aforementioned
individuals return to the rural areas of the state - Nome,
Bethel, Dillingham, and Juneau - there are no veteran outreach
services. The veteran outreach programs are considering a
partnership with the Indian Health Services in these areas in
order to provide the appropriate services.
CHAIR WILSON asked if the veteran's family will have services
available, also.
MS. WHEELER replied that this will be considered, as well.
CHAIR WILSON asked if the military provides funding for these
services.
MS. WHEELER replied that because there are no veteran's services
available, this is something that the veteran's administration
will need to look at, and this is currently being done.
CHAIR WILSON opined that this information should be passed on to
the congressional delegation, as there are "quite a few people
from Alaska compared to other states." She surmised, then, that
the congressional delegation may be able to channel additional
funds to Alaska for this purpose.
MS. WHEELER said that a meeting is scheduled for December 6,
during which she will bring up this issue. In 2005, she said,
the DHSS implemented the Alaska Partnership for Healthy
Communities. This initiative, she said, is intended to improve
the collaboration among government agencies and communities.
Several related projects also exist. In regard to the MatSu
Family Centered Services pilot project, she said:
Over the summer, [the department] did an evaluation of
that MatSu pilot project. And what they found was
that they took these 15 families, who are the hardest
to serve, within the division of public assistance,
and tried to figure out why these families were not
moving towards self-sufficiency. And, putting all of
the pieces together, 50 percent of these families
actually had children who were involved with the
juvenile justice center - and this is the ... beauty
of community partnerships - 50 percent of the adults
in those families ... had some kind of involvement
with the adult criminal justice system, ... 70 percent
of those families had some type of involvement with
the Office of Children's Services, ... and ... many of
these families were challenged with substance abuse,
mental health issues, domestic violence, and other
physical health issues. And so, when - if one agency
who's working with these families, there wouldn't have
been the opportunity to collaborate on looking at
priorities for these families. Instead, what you
would have had, was families running from agency to
another agency, to another agency, and really feeling
overwhelmed by the pressure of trying to meet the
demands of all of these agencies that they're involved
with. And so, this is a wonderful community
collaborative partnership that really takes a look at
these priorities for the families. Families are -
this is family centered services, so these services
are actually wrapped around these families to deal
with each of their issues, one ... step at a time....
So, by working with community partners, organizations
and agencies, they are better able to prioritize
services, develop a common plan with all the agencies
involved, and are actually moving these families
toward self-sufficiency. That was an eye-opener that
we discovered over the summer, and ... a really good
thing.
There is a similar project happening ... with the
Fairbanks Family Centered Services pilot project. And
... you've heard already, some of the projects working
under the children's policy team, regarding bringing
the kids home. [In addition,] there's the early
childhood development project and care
coordination....
1:04:03 PM
CHAIR WILSON asked if missions and measures had been set up for
the Family Centered Services pilot projects, in order to see the
changes over time. She opined that this would be helpful during
future presentations to the legislature.
MS. WHEELER agreed, and added that there has been discussion
regarding ways to create similar projects in other communities.
She concluded by saying that the FBCI office recently received a
grant award through the Compassion Capital Funds (CCF) in the
amount of $500,000. She explained that CCF is the cornerstone
of the national FBCI program. This is, she said, the only "new
pot of money" dedicated to FBCI. She went on to say that CCF is
designed to help organizations partner with the federal
government, in order to strengthen the organizations ability to
serve those in need. It is also intended to increase
effectiveness, enhance the ability to provide social services,
and expand to create additional community collaboration. Last
year, Alaska received $550,000 through the CCF capacity building
grant. This year, she said, the amount "almost doubled," adding
that the Eskimo Community Center in Nome was awarded $300,000,
in addition to several smaller FBCI organizations around the
state that received $50,000 each. The state office, she said,
will work alongside the aforementioned organizations, and will
provide training and technical assistance. In addition, she
stated, it will be working with federal partners to do "more
stringent evaluations" in order to see whether the FBCI programs
are working.
1:08:45 PM
MR. FULLER began his presentation by stating that he would be
available for follow-up discussions regarding long-term care.
He explained that a recent report projected out an extreme
increase in cost for long-term care over the next 20-25 years,
and the Medicaid budget would be "quadruple." This growth, he
said, is mostly due to demographics: baby boomers, and
individuals moving to Alaska to retire. If those who retire in
Alaska have retirement benefits, this is good; however, when
these benefits run out, Medicaid is used. He went on to say
that the average daily rate for nursing homes in Alaska in 2005
was $371 per day, which is over $1,100 per month.
MR. FULLER stated that the "problem" with Medicaid is that "it's
too successful," and is the "safety net" when other sources
fail. He referred to a recent newspaper article which stated
that private employers are either dropping health insurance
coverage or charging more for it. He said:
You can understand that, that's business. It's a
global economy we're in ... competing with countries
with no benefits. But, bottom line, those folks
without benefits, will, when they need healthcare,
find it someplace. Whether it's at the emergency
room, or healthcare coverage for their children
through Denali Kid Care. Sooner or later, it's gonna
fall to Medicaid.
MR. FULLER went on to say that Alaska has done a "good job"
containing costs. This has been done by keeping many nursing
home bed rates "relatively flat, for quite a number of years,"
he said, adding that there are roughly 600 beds throughout the
state. In addition to the aforementioned bed rates, he said,
the state has provided waivers permitting people to live in
their own homes, or in assisted living homes within their
community. He noted that while these cost less than nursing
homes, it is still a significant cost. Referring to a report
done by The Lewin Group, he said that under the current system,
the Medicaid budget will quadruple by the year 2025. He
stressed the importance of finding a more sustainable approach.
1:13:05 PM
CHAIR WILSON asked if the state will be able to sustain the
projected increase in the Medicaid budget.
MR. FULLER replied that this will depend on many factors, which
are beyond his scope of knowledge. In response to an additional
question, he surmised that using current rates and information,
the state would not be able to sustain the aforementioned
increase. He opined that the state needs to make the program as
sustainable as possible, and the needs to work with the governor
and the legislature to make the necessary changes. In regard to
the missions and measures for long-term care, he said that these
are minimal and do not apply to the challenge faced by Medicaid.
Once the necessary changes are decided on, new measures should
be decided on, in order to show whether the changes are
successful. He said:
As you're well aware, you see all the inputs that go
into all of the systems throughout the state. It's
our job to come up with measurable outputs that show
that we're meeting with challenges, if you will. And
so, right now, it's totally inadequate, at least from
my point of view.
1:15:09 PM
REPRESENTATIVE SEATON offered his understanding that a large
percentage of costs utilized in the healthcare system are used
within the last two months of life. He inquired as to whether
the agency has begun looking for a programmatic way to address
this issues. He opined that choices need to be made regarding
maintaining quality of life and funding, adding in his opinion,
funds should not be taken away from children's health and well-
being and put into the last two months of life. However, he
said, he does not know of any ideas addressing this issue.
MR. FULLER replied that a proposal is likely to be made to the
governor during the next legislative session. On a national
level, he said, there is indication that disease management
programs can reduce the cost of care. He said:
We've been flirting ... with proposing a couple
different specific disease management scenarios where
providing the case management and also working with
the provider system about best practices to manage
those disease states. Again, at the national level,
the term is "return on investment." You spend a buck,
what do you save? And that's really soft - that's why
we've been reluctant to just go full boar with this.
But, I think our judgment is that there's enough
information out there that we should at least get
started in that direction. Now, that's not going to
create huge savings-it may not create any savings for
the end of life issues, but it's a small beginning.
MR. FULLER went on to say that the current system needs to be
examined for ways to use healthcare dollars wisely. One way
would be to adapt technology to meet the needs of long-term care
patients. This would include cameras and audio set up in-house,
as a way to check in on those individuals. He opined that while
this may not meet all the needs, all possibilities need to be
considered. Currently, he said, Alaska considers "assisted
living" to be anything from a single person in a private home to
pioneer homes, which he opined does not make sense going
forward. He surmised that the services provided would be
different in a small residence compared to a larger facility.
If this difference is significant, the reimbursement methodology
needs to be reconsidered. He stated that over the next 5 years,
the state needs to figure out what would best meet the future
needs. He said "I wish I could say that if we do A, B, and C,
it's gonna decrease the cost by ... 5 percent a year, but I'm
not smart enough to be able to do that."
CHAIR WILSON stated her belief that this is not possible. Even,
she said, if the cost per person is decreased, there will not be
a drop in the cost, as there would be more people. She
surmised, then, that if the growth could be contained, this
would be fortunate.
1:19:54 PM
REPRESENTATIVE SEATON expressed concern that the assisted living
models discussed would be "going by the wayside." He stated
that several of his constituents who run small homes are being
regulated out of business, which places the patients into the
larger institutions. He opined that if these smaller homes go
out of business, the state will have to "start from scratch" and
decide whether to have assisted living homes or change to the
larger institutions. He noted that the state does not
differentiate between the two.
MR. FULLER replied that this is a good example of why the state
needs to carefully consider what is termed "assisted living" and
what the requirements are for a pioneer home versus a privately
owned assisted living facility. He stated that the next
legislative session would provide a good opportunity to deal
with these issues and see whether the changes are statutory or
regulatory.
CHAIR WILSON pointed out that this same scenario is occurring
regarding daycare. She related the story of a constituent who
remodeled her kitchen in order to meet the regulatory
requirements; however, when she was finished, she was told that
there were additional requirements that needed to be met. She
surmised that if a package of information was made available to
business owners, this might be avoided. She opined that by
adding requirements, the businesses have additional costs, which
may result in an inability to remain in business. Additionally,
the state does not allow these daycare providers to count
children who do not show up, even if it is due to the
irresponsibility of the parents.
1:25:24 PM
COMMISSIONER JACKSON replied that these issues were also noted
during the certification and licensing centralization process.
She said "If we have instances where things are not working for
good providers that need to be operating, then we'd sure
appreciate having specifics, so we can look into those and see
what we can do to help them. ... It's about being sure we've got
appropriate providers being supported in doing what they're
doing."
1:26:03 PM
MR. FULLER returned to his presentation, stating that the
department commissioned a long-term care study by Public
Consulting Group (PCG). This study contains many
recommendations. In addition, Senate Finance commissioned a
separate RFP to look at the entire Medicaid program, and is due
to the legislature in February. He surmised that this would
contained significant recommendations in terms of changes to the
long-term care system. He stated that he does not feel more
studies are needed, but that the information on hand needs to be
discussed.
MR. FULLER went on to discuss the transition. He said that this
will take time. The providers will need time to make changes,
and reimbursement methods will need to change in order to
appropriately reimburse for the new system. Additionally,
clients will need time to readjust. He opined that some
individuals do not like change, therefore it needs to be done
thoughtfully. The role and training needs of caregivers may
change, he said, particularly if electronics are used. The
state will also need to make changes to adjust. The state, he
said, has a responsibility to have significant oversight to
ensure that nothing is going wrong. He expressed hope that
during the next legislative session, the philosophy of long term
care will be discussed. He said:
What's the states role, here? I mean, there's the
Medicaid program that can finance a fairly broad
array, but what's the state's philosophy for the
Medicaid program? And, I just want to throw out-that
you could view our long-term care system as full
employment for everyone. Just ignore, completely,
that it's taking care of people - of the frail and the
elderly - you could view it as a complete employment
system for the state. Because you could set it up to
employ lots of caregivers. I don't think we want to
do that, but we need to have that discussion, I think.
And then, the parameters around aging and place.
Additional, new supports that the state should provide
or wants to provide, to keep someone living with that
daughter or daughter-in-law an extra few months.
Because, bottom line, those are the primary caregivers
in our current system. Nothing to do with the state,
just the family stepping up and taking care of those
folks.
CHAIR WILSON said "If we had an income tax, we could give them a
break on their income tax."
MR. FULLER opined that the state has many ways to support
families in order to keep the elderly at home longer, which
could be cost-effective if properly put together. He went on to
say that this also relates to personal responsibility. In
regard to those individuals who move to Alaska later in life and
run out of personal insurance, he questioned whether it is the
state's responsibility to subsidize this. He pointed out that
services provided to Alaska Natives by tribal health
corporations are federally funded, adding that there has been
discussion with tribal health corporations regarding what might
be done in the future to meet the needs of members. This would
be funded by general fund savings, and is more "culturally
appropriate." He stated that he is looking forward to working
with the legislature and the governor to "move this forward,"
adding that "failing to do [something] is not acceptable."
1:32:33 PM
REPRESENTATIVE SEATON said that he looks forward to addressing
these issues, and agreed that a goal, method, and philosophy are
needed. He said "unless we have those, we're just seeing
problems and trying to throw a band aid at it, but it doesn't
get to the complexity."
1:33:33 PM
COMMISSIONER JACKSON said:
It's not an easy process, it's easier to talk about
other things, healthcare-dealing with access and
quality, and costs is not going to get easier as time
goes on. And a lot of things we haven't even touched
on today, that you know are looming.... But I do
think, that if we look at things, as Alaskans, in a
new way, we can come up with some solutions that will
work here, regardless of what happens with Medicare
and Medicaid.
COMMISSIONER JACKSON went on to say that it is important to
continue to stay involved, in order to continue the discussions.
She urged the members' to become more familiar with the missions
and measures, and hold the department accountable when these do
not make sense or need to be "tweaked." In addition, she
questioned what lens will be used for spending general fund
dollars, and said "how do we honor people for giving something
up to come together in partnerships, when in fact, it may not be
in their individual business' best interest?"
CHAIR WILSON stated that she plans on having joint meetings in
the future.
COMMISSIONER JACKSON, in regard to higher risk areas, encouraged
the members' to consider getting the communities involved in
finding an answer to the problem. She pointed out that one
answer may be a pilot program such as the Family Centered
Services pilot programs. She went on to say:
As we work through this process, this committee has
taken a leadership role in dealing with healthcare.
And the department is trying to do that in small ways,
as well, everything from trying to make sure our
buildings are smoke-free at the state level ... to
working with issues of obesity and diabetes down the
road. So, I thank you for that, and I encourage you
to continue it, all of you who may be here....
1:36:50 PM
REPRESENTATIVE SEATON asked what it would take for a pilot
project that gives out vitamins to a specific region, in order
to gather data that would show positive results.
COMMISSIONER JACKSON replied that this is a good idea, and
offered to look into this and come back with a response.
CHAIR WILSON commented that this might be a good preventative
measure.
REPRESENTATIVE SEATON opined that it is important to look at it
and see if it solves broader community problems, in addition to
the more specific issues discussed earlier. He noted that there
are additional details to consider.
CHAIR WILSON added that there would be different needs for
children and adults.
REPRESENTATIVE SEATON opined that purchasing a high quantity [of
vitamins] in order to have a pilot project may "have some
benefit."
1:41:16 PM
CHAIR WILSON stated that the next meeting will pull all the
issues of the past few months together. The meeting is
scheduled to occur on November 8, 2006.
1:47:40 PM
ADJOURNMENT
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned at 1:48 p.m.
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