Legislature(2019 - 2020)Anch LIO Lg Conf Rm
01/09/2020 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| Presentation(s): Medicaid Reform Update | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
January 9, 2020
3:03 p.m.
MEMBERS PRESENT
Representative Ivy Spohnholz, Co-Chair
Representative Matt Claman (via teleconference)
Representative Harriet Drummond
Representative Geran Tarr
Representative Sharon Jackson
Representative Lance Pruitt
MEMBERS ABSENT
Representative Tiffany Zulkosky, Co-Chair
COMMITTEE CALENDAR
PRESENTATION: MEDICAID REFORM UPDATE
- HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
ADAM CRUM, Commissioner
Office of the Commissioner
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Presented a PowerPoint overview titled
"Medicaid Reform Update."
RENEE GAYHART, Director
Director's Office
Division of Health Care Services
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Presented during the PowerPoint overview
titled "Medicaid Reform Update."
GENNIFER MOREAU-JOHNSON, Director
Division of Behavioral Health
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Testified during the PowerPoint
presentation on Medicaid Reform Update.
HEATHER CARPENTER, Health Care Policy Advisor
Office of the Commissioner
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Testified during the update on Medicaid
Reform.
NANCY MERRIMAN, Executive Director
Alaska Primary Care Association (APCA)
Anchorage, Alaska
POSITION STATEMENT: Gave a presentation entitled, "Community
Health Centers the Value Opportunity."
APRIL KYLE, President
Alaska Behavioral Health Association
Anchorage, Alaska
POSITION STATEMENT: Presented, "Update on SB 74 Behavioral
Health Reforms."
JARED KOSIN, President
Alaska State Hospital and Nursing Home Association (ASHNHA)
Anchorage, Alaska
POSITION STATEMENT: Presented a PowerPoint overview titled,
"MEDICAID: A Critical Component in Alaska's System of Care."
ACTION NARRATIVE
3:03:28 PM
CO-CHAIR IVY SPOHNHOLZ called the House Health and Social
Services Standing Committee meeting to order at 3:03 p.m.
Representatives Spohnholz, Drummond, Jackson, Pruitt, Tarr, and
Claman (via teleconference) were present at the call to order.
^PRESENTATION(S): MEDICAID REFORM UPDATE
PRESENTATION(S): MEDICAID REFORM UPDATE
3:03:57 PM
CO-CHAIR SPOHNHOLZ announced that the only order of business
would be a presentation updating Medicaid reform in Alaska,
noting that this consisted of about $2.4 billion in the budget.
3:05:03 PM
ADAM CRUM, Commissioner, Office of the Commissioner, Department
of Health and Social Services (DHSS), directed attention to the
PowerPoint titled "Medicaid Reform Update," noting that Medicaid
Reform was ongoing. He discussed slide 2, "Topics," directing
attention to Senate Bill 74, which was passed in 2016, and the
status of the 2019 cost containment measures. Moving on to
slide 3, "Senate Bill 74 (2016)" he explained that this was a
bi-partisan, comprehensive, holistic approach to the entire
health care system in Alaska, allowing programs to be developed
to change health care, make Medicaid better, and put together
many plans to give DHSS the authority to move forward. He noted
that he would discuss Coordinated Care Projects, Behavioral
Health System Reform, Electronic Explanation of Benefits, Tribal
Reclaiming, Pharmacy Initiatives, Fraud, Waste & Abuse, and
Telehealth. He stated that slide 4, "Coordinated Care
Projects," meant working in partnerships with patients and
providers to facilitate the appropriate delivery of health care
and resulting in improved health and lower costs.
3:07:33 PM
RENEE GAYHART, Director, Director's Office, Division of Health
Care Services, Department of Health and Social Services,
directed attention to the coordinated care projects mentioned in
Senate Bill 74. She added that DHSS had also been asked to
enhance existing efforts, which included case management. She
pointed to Medicaid recipients who used services across the
Medicaid spectrum and explained that DHSS was now working to
assign these recipients to a single primary care and pharmacy
provider to allow for efficiencies in the management of care.
3:09:26 PM
MS. GAYHART moved on to the Alaska coordinated care
demonstration projects, slides 4 and 5, and reported that Senate
Bill 74 created a mechanism for DHSS to partner and contract
with third party outside entities, which included managed care
organizations (MCOs) and accountable care organizations. She
shared slide 6, "Alaska Coordinated Care Demonstration
Projects," and reported that DHSS had negotiated with four
respondents to RFPs (Request for Proposal) and gave a notice of
intent to award with United Health Care and with Providence
Family and Medical Center for a medical home model.
3:12:03 PM
COMMISSIONER CRUM directed attention to "United Health Care:
Managed Care Organization," slide 5, said that, although DHSS
had been working on this prior to the current administration, it
had been evaluated within the current context of planning and
was now determined to be a concern for its impact on
beneficiaries. He stated that, as other options were being
reviewed for the ability to "mesh together into a global managed
care system," it was decided not to proceed with the United
Health Care contract.
CO-CHAIR SPOHNHOLZ asked if it was possible to move forward with
a managed care project excluding the tribal health population.
COMMISSIONER CRUM replied that United Health did not want to put
the decision on hold until the state made its decision for how
to move forward with the process in a way to best take care of
the tribal health partners.
CO-CHAIR SPOHNHOLZ asked if there could be an integration of a
managed care demonstration project as a sister company of United
Health Care was now managing the behavioral health.
COMMISSIONER CRUM said that this would be evaluated as the
process moved forward.
CO-CHAIR SPOHNHOLZ asked about the timeline for the next steps
on managed care.
COMMISSIONER CRUM replied that DHSS was most intrigued with the
local and regional aspect for serving the specific population
and was reviewing a possible pilot project in conjunction with
the Medicaid reform strategist and the stakeholder groups over
the upcoming months.
3:14:51 PM
MS. GAYHART moved on to slide 7, "Alaska Medicaid Coordinated
Care Initiative," AMCCI, and also known as the "superutilizer"
initiative. She shared some of its history, noting that in 2016
Alaska was one of seven states to receive a national grant for
review of this in conjunction with consulting services. She
reported that there was a focus on the reduction of emergency
room visits by helping people manage chronic conditions and
offering case management. She added that telephonic case
management was also being reviewed, even though the contract
with MedExpert [International] had not been renewed. She noted
that Senate Bill 74 also suggested that the Alaska State
Hospital and Nursing Home Association (ASHNHA) work with
superutilizers.
3:17:47 PM
CO-CHAIR SPOHNHOLZ asked whether concern with delivery was the
rationale for not renewing the MedExpert contract.
MS. GAYHART replied that, as DHSS was reviewing enhancement of
the care management program for additional cost containment, the
state had decided to pick up services from existing contracts.
3:18:52 PM
COMMISSIONER CRUM explained that a large aspect of Senate Bill
74 was to "to address the shortage of psychiatric inpatient beds
and residential substance use disorder treatment programs, and
the fragmented system of community-based behavioral health
providers and insufficient treatment services, particularly in
rural areas," slide 8, "Behavioral Health System Reform." He
added that Senate Bill 105, passed in 2018, allowed for licensed
marital family therapists to independently bill Medicaid and
that Senate Bill 169 allowed any physician to operate a mental
health physician clinic and supervise the provision of care in
the clinic via distance delivery. He added that Senate Bill 74
also removed the requirements that Medicaid behavioral providers
be grantees of DHSS, allowing DHSS to move toward the 1115
waiver.
3:20:07 PM
GENNIFER MOREAU-JOHNSON, Director, Division of Behavioral
Health, Department of Health and Social Services, discussed
slide 9, "1115 Behavioral Health Waiver." She explained the
three components, which read, in part:
Substance Misuse Disorder Treatment Component
? Approved in November 2018
? Became effective January 1, 2019
MS. MOREAU-JOHNSON added that currently there were 38 providers
in 108 locations certified to provide 1115 Substance Abuse
Services. She reported that the revenue generated from these
1115 waivers was helping the agencies even more than the earlier
grants as the predominance were Medicaid expansion recipients
with a 90 - 10 match. She continued with slide 9, which read in
part:
Behavioral Health Component
? Approved September 2019
? Will be implemented by June 30, 2020
MS. MOREAU-JOHNSON explained that this was moving more quickly
as it was not necessary to do the implementation plan with the
federal government. She finished slide 9, which read in part:
Administrative Services Organization
? Contracted with Optum Health in November 2019
? Goes live on February 1, 2020
CO-CHAIR SPOHNHOLZ asked whether claims would be paid by the
administrative services.
MS. MOREAU-JOHNSON said that was correct, that claims would be
paid out of two systems until July 1 when Optum would begin to
pay all the claims, do the utilization review, and offer
technical support for providers.
3:24:06 PM
REPRESENTATIVE TARR asked whether, as the administrative and
billing services were currently being handled by state
employees, there would be any attrition when these services were
transferred.
MS. MOREAU-JOHNSON replied that there were already multiple
contracts with Optum performing some of these existing contracts
and that state employees would not be replaced.
3:25:27 PM
MS. GAYHART discussed slide 10, "Electronic Explanation of
Medical Benefits (EOMBs)," which read:
Were made available October 2018 August 2019
? Low participation rates and contract expenses that
exceeded overpayments identified and other benefits.
? Division of Health Care Services plans to
reintroduce in early FY2021
MS. GAYHART explained that, although DHSS recognized the EOMB
portion of Senate Bill 74, it had been temporarily put on hold.
She said that the current contract with MedExpert was expiring
at the same time an extension was being negotiated with the
fiscal agent contract. As these EOMBs were being developed into
the contract with Conduent, a one-time design and build of this
EOMB process would cost about $514,000, which was matched by
federal dollars at 90 - 10; whereas, the EOMBs were currently
costing between $1.3 - $1.5 million annually. She stated that
this would be implemented by FY 21. She pointed out that, even
with these EOMBs, there were additional extensive fraud controls
in place, emphasizing that DHSS took fraud very seriously.
CO-CHAIR SPOHNHOLZ asked if this meant bringing the EOMB process
in-house.
MS. GAYHART replied that this would be handled by the fiscal
agent, Conduent.
3:29:39 PM
COMMISSIONER CRUM reminded the committee that this would be
built into the system at the 90 - 10 percent match.
CO-CHAIR SPOHNHOLZ expressed concern about Medicaid fraud by
providers, noting that it was constructive to educate the
utilizers.
3:30:53 PM
COMMISSIONER CRUM paraphrased slide 11, "Tribal Health
Reclaiming Efforts," which read:
Tribal Medicaid beneficiary claims have been
reimbursed at 100% federal match for services provided
by or through a tribal health facility.
? Dependent on collaboration with Tribes and
providers:
? Care Coordination Agreements ? Referrals ? Exchange
of Records
3:31:26 PM
MS. GAYHART turned attention to slide 12, "Tribal Health
Reclaiming Savings," and said they were meeting the targets set
forth in Senate Bill 74 by the Centers for Medicare and Medicaid
Services, through an official state health letter, to qualify
for a 100 percent match. She reported that there were now more
than 1700 care coordination agreements and that, even though the
percentage of referral verifications was going up, there were
still some issues with health information exchanges as not all
the providers had the same electronic health record systems.
She pointed out that, as it was not required to designate your
race in the Medicaid system, if some Alaska Natives did not
designate, the reimbursement was not 100 percent. She declared
that the division was currently meeting its targets.
3:35:10 PM
CO-CHAIR SPOHNHOLZ commended Ms. Gayhart for saving $200 million
to date.
3:36:00 PM
COMMISSIONER CRUM paraphrased slide 13, "Fraud, Waste & Abuse,"
which read:
Eligibility Verification system
? Both SB 74 and the Center for Medicare and Medicaid
Services have requirements for verification systems
for Medicaid recipients.
? The U.S. Food and Nutrition Service also has
verification system requirements for its programs
(SNAP)
? DHSS is putting out a Request for Proposals for a
system that would meet both sets of requirements.
CO-CHAIR SPOHNHOLZ commented that the 2019Medicaid Reform Report
had noted a $10.2 million savings, the result of curtailing
fraud abuse by providers.
3:38:22 PM
REPRESENTATIVE TARR commented on the issues with implementation
of coordination between the two state verification systems and
asked if this new system would replace both the existing systems
and allow for system wide efficiency.
COMMISSIONER CRUM offered his belief that, over time, this new
system would integrate both the existing systems, although it
would be a delayed process. He added that, in addition to the
Eligibility Verification System (EVS), an electronic document
management (EDM) system would be implemented to allow documents
to be scanned with a program to collect and organize the data
and more easily track recipients. He declared that this unified
process would save staff time and better serve the customers to
the Division of Public Assistance.
3:39:55 PM
HEATHER CARPENTER, Health Care Policy Advisor, Office of the
Commissioner, Department of Health and Social Services, in
response to Representative Tarr, stated that the current
eligibility system was different from the Eligibility
Verification System. This new EVS system would work with the
current eligibility system and final eligibility determinations
had "to be made by actual state employees per CMS rules." She
explained that this eligibility system would look at all of an
individual's assets, including those in other states, and notice
whether there were multiple identifications. She reiterated
that this would be linked with contractors.
REPRESENTATIVE TARR expressed her concern for the purported
administrative inefficiencies of the current system.
COMMISSIONER CRUM expressed his agreement.
3:42:41 PM
REPRESENTATIVE TARR noted that there had been a hesitation from
the associations regarding the electronic time sheets for
personal care attendants and asked if there had been an
administrative change to ensure this would happen.
COMMISSIONER CRUM replied that the EVS system had to be
implemented to be in compliance with the 21st Century Cares Act,
although DHSS had needed to request a good faith extension. He
said that DHSS would work closely with the groups to fix any
areas limited by technology.
3:44:33 PM
CO-CHAIR SPOHNHOLZ suggested that there could be an update with
the public assistance process from the Division Director.
3:45:03 PM
COMMISSIONER CRUM introduced slide 14, "Telehealth," a breakdown
of the use and expenditures for the telehealth system.
MS. GAYHART continued with slide 14, explaining that Senate Bill
74 dictated an expansion of telehealth to primary care,
behavioral health, and urgent care, which, in Alaska, was used
as a mode of service delivery. She declared that the program
had been successful since FY 16, and pointing to slide 15,
"Telehealth," she listed the top disease categories as tracked
by the diagnosis on each claim. She reported that most claims
were for mental and behavioral health. She noted that many of
the claims indicated youth diseases, which allowed for a
transportation savings. She pointed out that Anchorage, Bethel,
Nome, and Fairbanks all had high utilization in telehealth. She
described both the interactive telehealth method of a patient
and a provider on the screen, and the store and forward method
which allowed x-rays and other lab work to be put into the
system for review. She said it was difficult to do a "one for
one" comparison including transportation costs, as sometimes
telehealth spurred a need for transportation. She reported that
the tribal health organization, as they often had the necessary
equipment, was the biggest provider and utilizer of the service.
3:49:44 PM
CO-CHAIR SPOHNHOLZ asked if there could be an approximation of
costs that would include travel costs in all the cases.
MS. GAYHART replied that some of those analyses required a
support system and not just a "data pull by a single analyst."
She declared that this was "definitely on the radar to work on
this year, we're just not there yet." In response to Co-Chair
Spohnholz, she explained that a decision support system would
allow a comparison of claims by the system instead of manually
by an individual.
CO-CHAIR SPOHNHOLZ asked about the elimination of the
origination fee for Medicaid to out of state billings.
3:52:24 PM
MS. MOREAU-JOHNSON, in response to Co-Chair Spohnholz, said that
she would research that.
3:52:35 PM
REPRESENTATIVE CLAMAN asked what could be done to encourage
providers, other than tribal health, to increase their use of
telehealth especially in the remote areas in Alaska.
MS. GAYHART declared that the cost of the equipment, as well as
connectivity, often excluded certain providers.
REPRESENTATIVE CLAMAN declared that it was frustrating as there
seemed to be such easy access and lower costs to technology.
MS. GAYHART added that DHSS struggled with security concerns
with texting and cellphones. She referenced a telehealth
workgroup during Senate Bill 74, noting that the regulations
demanded a strong security component.
3:55:02 PM
COMMISSIONER CRUM reported that DHSS was having internal
discussions for ways to proceed.
CO-CHAIR SPOHNHOLZ added that telehealth was one of the ways to
increase access to health care and to control costs. She shared
the difficulty of recruiting mental health providers in Alaska,
especially in small communities, and expressed her support for
the increase of telehealth as an appropriate level of care.
COMMISSIONER CRUM stated, "we put forward a lot of stuff this
last session in order to meet our budgetary goals" and
paraphrased slide 16, "FY 2020 Cost Containment Measures," which
read:
DHSS proposed several Medicaid-related cost
containment measures during the FY2020 budget
preparation process.
Expected savings from several of these were
incorporated by the Legislature into the final budget
submitted to the Governor.
I will quickly review the status of each.
COMMISSIONER CRUM moved on to paraphrase slide 17, "FY 2020 Cost
Containment Measures," which read:
5% Provider Rate Reduction for Medicaid services
Withholding Medicaid Rate Inflation Adjustments
Hospital Diagnostic Related Groups (DRGs)
Long Term Care Rate Reduction
Cost-Based End Stage Renal Disease
Pharmacy Adjustments
COMMISSIONER CRUM added that, as DRG was a very complicated
process, DHSS had hired a contractor to do an analysis working
directly with the stakeholder groups to identify where this
process could come in. He pointed out that Alaska was a fee for
service state, whereas DRGs allowed for bundled payments with a
movement toward a value-based payment system. Referring to the
long-term care rate reduction, he stated that there was an issue
with the upper payment limit, so it was necessary to implement a
three percent reduction.
3:58:36 PM
MS. GAYHART stated that the cost-based end stage renal disease
was on track for the expected savings as DHSS had set a lower
rate. She declared that there were several efforts with
pharmacy adjustments, including Senate Bill 44 which allowed the
state to update the Medicaid preferred drug list and do prior
authorizations for the medications list. She shared that there
was an expected savings for $6 million.
3:59:39 PM
COMMISSIONER CRUM mentioned that some of the cost containments
would not allow a sufficient level of access to care for the
home and community-based services, so these waivers "have been
held harmless" from both cost containments and would continue to
receive the normal rates.
CO-CHAIR SPOHNHOLZ asked about the process and timeline for the
five percent provider rate reduction.
COMMISSIONER CRUM explained that the agreements with Alaska
State Hospital and Nursing Home Association (ASHNHA) would delay
implementation of the five percent reduction and that the
difference for what had been removed since July 1 had now been
paid back.
CO-CHAIR SPOHNHOLZ asked if this included hospitals and nursing
homes.
COMMISSIONER CRUM explained that the nursing homes were under
the long-term care and would include all providers except for
the critical access and primary care.
4:01:31 PM
COMMISSIONER CRUM moved on to paraphrase slide 18, "FY 2020 Cost
Containment Measures," which read:
Limit Physical Therapy/Occupational Therapy/Speech
Therapy to 12 visits per year
Cost of Care Collection Improvements
Medicare Part B Premiums Recovery
Expand Care Management Program
Implement Nurse Hotline
COMMISSIONER CRUM noted that children's physical, speech, and
occupational therapies were exempt from these service limits,
and added that should a physician determine that an individual
required more service, the physician could submit an appeal to
DHSS.
4:02:09 PM
CO-CHAIR SPOHNHOLZ asked for clarification that the limit for
the therapies was separate for each therapy.
4:02:21 PM
MS. GAYHART replied that this would soon be released for
regulatory comments. She said that the limit for the amount
allowed for an option should the provider determine that
additional services were necessary. In response to Co-Chair
Spohnholz, she clarified that the limits were per category.
4:03:30 PM
MS. GAYHART said that individuals in long-term care situations
could qualify for Medicaid, although they may have to contribute
to their cost of care. She said that DHSS was taking steps to
collect these obligations from both the recipient and the
representatives. She pointed out that this was a federal
regulation, pointing out that there was the potential for a $1
million savings.
4:04:41 PM
REPRESENTATIVE JACKSON asked, regarding the five percent
provider rate reduction, whether this differed for a Medicaid or
private provider, and if so, would it discourage private
providers working with Medicaid patients.
COMMISSIONER CRUM explained that rate reductions were mandated
by the Centers for Medicare and Medicaid Services to ensure that
there was not a loss of providers. He reported that, in Alaska,
Medicaid paid higher than Medicare. He stated that DHSS
recognized the expense and difficulty of providing services in
Alaska.
4:06:28 PM
MS. GAYHART returned attention to slide 18 and stated that DHSS
paid the Medicare Part B premium for those eligible individuals
who could not afford the premium. She discussed expansion of
the care management program to include 500 additional people
this year, with another 1,000 individuals during the next year.
She explained that this would be conducted through the quality
assurance unit. She said the implementation of a nurse hotline
had been delayed along with the delay of United Health Care.
4:09:04 PM
REPRESENTATIVE DRUMMOND asked how many superutilizers there were
in Alaska and what kind of progress had been made toward a
reduction to that number.
MS. GAYHART explained that the term superutilizer was also used
for high utilizers, and in her division, the care management
program was looking to expand its management to include 1,000
people in that program. She noted that many of these people may
not be on the program long term, dependent on the types of
services needed.
REPRESENTATIVE DRUMMOND asked what percentage of those 1,000
individuals represented superutilizers.
MS. GAYHART offered her understanding that, in the Medicaid
population of about 210,000 individuals, about 1,000 were
considered superutilizers with an additional 100 people
considered to be high utilizers.
4:12:50 PM
COMMISSIONER CRUM directed attention to slide 19, "FY 2020 Cost
Containment Measures," which read:
? Electronic Visit Verification
? Timely filing allowance reduction
? Transportation Efficiencies
? Adult Preventive Dental
COMMISSIONER CRUM explained that the timely filing allowance
would shorten the time limit for a provider to file a Medicaid
claim from 12 months past service to 6 months. He noted that
this would require a change to statute, although DHSS now felt
that this would not result in any savings. In response to
Representative Claman, he clarified that this option would not
be pursued.
4:14:01 PM
COMMISSIONER CRUM explained that, although the initial
transportation efficiencies were projected to save $8.2 million,
the tribal entities had taken on a large part of the savings
through management. He stated that the adult preventive dental
had originally been considered an optional service, but with the
Patient Protection and Affordable Care Act, it was now an
essential health benefit. There had been a decision to fully
re-instate this program. In response to Co-Chair Spohnholz, he
offered his belief that those providers who had been denied
compensation since October, could now submit their claims.
CO-CHAIR SPOHNHOLZ stated that for providers, especially with
the small profit margin from Medicaid patients, not getting a
payment was "a bit of a challenge so every effort that could be
made to expedite that, I think, will make a lot of difference."
4:16:42 PM
REPRESENTATIVE JACKSON asked whether the nurse hotline had been
discontinued. She declared that the hotline saved a lot of
money in times of concerns or problems. She expressed her
desire that there was not abuse from dentists.
COMMISSIONER CRUM replied that DHSS was still exploring the
nursing hotline in a cost appropriate manner. He shared that
many providers were sharing ways to prevent abuses and continue
to offer appropriate care.
COMMISSIONER CRUM reported that the DHSS Medicaid consultant was
working to "put forward something that everybody understands is
do-able and good for Alaska moving forward." He added that DHSS
was actively engaging in partner relationships, noting that DHSS
did not deliver health care, but helped to enable the delivery
of health care.
4:21:25 PM
NANCY MERRIMAN, Executive Director, Alaska Primary Care
Association (APCA), explained that APCA was "the statewide
training and technical assistance provider for community health
centers across the state and also their membership
associations." She paraphrased slide 2, "We Believe:" which
read:
We Believe:
? Primary care is key to healthcare savings and value
? Primary care seeks more opportunities to integrate
with other care providers
? Primary care needs more flexible payment structures
? Primary care should be comprehensive and integrated
We also Believe:
? SB 74 was a step in the right direction
MS. MERRIMAN recapped slide 3, "Community Health
Centers/Federally Qualified Health Centers," which read:
27 CHC Organizations operating ~170 Clinics in Alaska
? 113,000 Alaskans in more than 500,000 visits
? Less than $100 Million Medicaid spend
? CHCs provide more high-value and less low-value care
? Nationally, CHCs save Medicaid ~24% over care in
non-CHC settings
MS. MERRIMAN discussed slide 4, "SB 74 and Primary Care Missed
Opportunities?", which read:
SB 74 had 16 Major Medicaid Redesign Initiatives
Few had direct opportunities for primary care:
? Coordinated Care Demonstration Projects
? Section 2703/1945 Health Homes
Challenges of the Time:
? $3-4 Billion budget deficit
? No State Dollars were put toward significant system
reform
? A need for short-term savings
These concerns continue to burden us today.
4:26:27 PM
MS. MERRIMAN said they were encouraged but there was still a
long way to go and it would take meaningful investments. She
turned attention to slide 6, "Our Investments and priorities
align with SB 74 goals," which read:
CHC Data analytics and population health platform
($1.5 Million)
o Health information
o Disease Prevention & Wellness (risk stratification,
referral tracking, visit planning)
o Quality Measures
? Proposal: The Alaska Health Home Pilot
o Coordinated Care Demonstration proposal
o 1945 Waiver = Health Home
o Redesigning the Payment Process
? Patient-Centered Medical Home (PCMH)
o 18 of 27 CHCs recognized
o Team-Based integrated care
MS. MERRIMAN stated that care coordination services that were
required to be provided, and were high value and low cost, were
not reimbursed by any payer. She pointed out that these low
cost and high value services really made a difference,
especially for the highly complex, expensive patients with many
health conditions. She noted that although SB 74 provided an
opportunity to be innovative with new tactics to improve health
outcomes and save on costs, implementation on some of the
initiatives had been elusive. She directed attention to the
1945 waiver, which would allow Alaska to establish a health home
program and had been included in legislation and the Milliman
Report of October 2018. She added that the Centers for Medicare
and Medicaid Services still offered financial support to states
with development of these health home programs, noting that the
90 percent FMAP (Federal Medical Assistance Percentage) offered
for those care coordination services was still available for
eight quarters. She noted that the initiative had not moved
forward, even though it was an opportunity for meaningful
coordinated care demonstration with health center expertise and
high value care delivery. She declared that this was a
recognized, proven program to pay for high value, low cost
services for highly complex patients, lamenting that this
opportunity had been missed, but she expressed the hope that the
program possibility would be examined again. She opined that
primary care needed to be recognized and supported.
MS. MERRIMAN discussed slide 7, "CHCs continue to be the best
deal in healthcare," which read:
Future:
? We're Investing in the exploration of:
o A Clinically Integrated Network and
o Value-Based Pay
? We're seeking:
o Reimbursement for Coordinated Care
o An expanded list of reimbursable Provider Types that
would enhance integrated services
? We value:
o Transparency in Administrative and Legislative
Changes
o Inclusion of stakeholder voices and perspectives
MS. MERRIMAN shared an anecdote about a practice that, due to a
lack of funds, had to decline participation in a valuable
project that would have delivered robust information about their
patients and their consumption habits. She declared that APCA
valued transparency, both in administrative and legislative
changes to the Medicaid program moving forward, adding that
stakeholder and provider perspectives would inform the process
and help with successful reforms. She stated that primary care
and preventive health saved Alaska money, was good for patients,
and was good for Alaska.
4:33:32 PM
REPRESENTATIVE TARR asked if the suggestions for the expanded
list and reimbursement for coordinated care were allowable
within the state plan, hence could be changed at the state
level, or would they need to be changed at the state plan
amendment level.
MS. MERRIMAN offered her belief that expanding the list of
reimbursable providers could be done at the state regulation
level. She added that coordinated care services were tougher,
and she opined that those had a "really good chance of being
covered within the demonstration project" and were included in
the Providence Primary Care Practice demonstration project as a
per member per month amount above the cost of the usual visit.
She noted that this flexible payment allowed the practice to
deliver the services that were not reimbursable and would have
been difficult to get reimbursed on a per item basis.
4:35:17 PM
APRIL KYLE, President, Alaska Behavioral Health Association,
contextualized what the behavioral health system in Alaska looks
like today. She informed the committee that there are
committed, effective, and competent behavioral health providers
who are delivering good services and making meaningful
improvements in their communities. The problem, she said, is
that the supply of behavioral health providers and services
doesn't reach the demand, which leaves a lot of Alaskans without
the behavioral health care that they need. When Alaskans can't
access that behavioral health care because there aren't enough
services there becomes an increased demand for law enforcement,
criminal justice, and the Office of Children's Services (OCS).
The state is in a position where there's not enough behavioral
health services and a small group of providers who want to meet
that need, which leaves a gap in the system. Next, she
addressed reform and the 1115 waiver, calling it
"transformational" for behavioral health in Alaska. The idea
behind the 1115 waiver was to recognize the gap between the
supply and demand and create an environment where new services
could be built in the continuum. She further noted that by
building out those new services, an argument was made that the
state would save money in other parts of its healthcare
delivery. The 1115 waiver specifically says that the state will
bring online 30 new outpatient treatment programs and 200 new
residential treatment beds. She said, "think about all the
Alaskans today who need those services right now but aren't able
to access them because they don't exist in our continuum." The
1115 waiver ideology is that building up those services will
save money by providing less expensive, earlier interventions in
real time, "because treatment works, and recovery is possible."
4:44:01 P M
REPRESENTATIVE TARR sought clarification on the percentage of
providers that have joined the 1115 waiver environment thus far.
MS. KYLE explained that the first step in becoming an eligible
provider under the 1115 waiver is to apply and seek approval.
According to the Division of Behavioral Health (DBH), she said,
there are five or six providers that are being reimbursed in the
1115 [waiver] environment and prepared to meet the regulatory
requirements.
4:45:46 PM
REPRESENTATIVE CLAMAN expressed concern about the discussion
coming from the executive branch regarding a withdraw from
Medicaid expansion. He asked how that would impact the 1115
waiver.
MS. KYLE stated that the 1115 [waiver] services are largely paid
through federal (indisc.) services. The ability to launch new
behavioral health services depends on the environment of the
(indisc.) continuing. She reported that if Medicaid expansion
was in threat, the ability to move forward for behavioral health
would be in jeopardy.
REPRESENTATIVE CLAMAN asked Ms. Kyle if she knows the current
position of this administration on whether it will continue
efforts to potentially roll back [Medicaid].
MS. KYLE said she doesn't want to speak for the administration.
4:47:45 PM
COMMISSIONER CRUM, in response to Representative Claman, said
that at this point in time, [the administration] has not had any
discussion about the removal of Medicaid expansion.
REPRESENTATIVE CLAMAN opined that any move to try to roll back
the expansion would be devastating to Alaska. He said he is
somewhat encouraged that the administration doesn't seem to be
pursuing that at this point.
CO-CHAIR SPOHNHOLZ concurred.
4:48:46 PM
MS. KYLE resumed her presentation, directing attention back to
Medicaid reform and the impact on behavioral health (slide 2).
She said the Administrative Services Organization (ASO) is in
contract and scheduled to launch the first part of its service
February 1, 2020. She noted that only a handful of providers
will be submitting claims on that day. She continued by saying
that SB 74 aims to increase access by allowing any willing
provider to participate in the Medicaid behavioral health
continuum. Part of that, she said, includes creating an even
playing field regarding the administrative responsibilities and
the obligations of behavioral health providers who had
previously been delivering Medicaid services. The ASO is cast
with decreasing the administrative burden on providers; however,
that work hasn't started yet. Finally, she related that SB 74
called for the improved integration of behavioral health and
primary care, which the 1115 waiver and behavioral health reform
has yet to address.
MS. KYLE turned her attention to the next steps (slide 3). She
said the good news is that the Alaska Behavioral Health
Association (ABHA) has a solid business case that says they save
money by developing more behavioral health services. She
reiterated that the 1115 waiver creates the environment for
those services to be developed. However, to be successful,
reform efforts depend on three things. First, predictable,
sustainable operational funding so providers can launch new
services. Second, start-up capital to fund the system changes,
which means updates to billing systems and medical records for
better care, as well as required quality data reporting to
transforming outreach and clinical delivery, she said. Third,
transparent open conversations and involvement in planning
stages for providers.
4:54:14 PM
REPRESENTATIVE JACKSON expressed her desire for all Alaskans to
have the opportunity to be above the poverty level. She said,
"I don't want us to, like, neglect that idea in order to receive
government funds to provide them to keep them there."
4:55:48 PM
MS. KYLE responded by addressing addiction services. She
indicated that lives are changed by the journey through
treatment and into recovery. She indicated that the goals of
those in addiction and mental health treatment are about
education, employment, housing, and reconnecting with family.
She said behavioral health is a stabilizing factor, adding that
many success stories are not clinical outcome measures as much
as they are functional outcome measures.
4:57:13 PM
REPRESENTATIVE TARR sought clarification on the start-up
capital. She questioned whether the state would be providing
grants to individual providers.
4:58:45 PM
MS. KYLE replied in the past, the legislature has appropriated
dollars, which were offered through competitive grant processes
for new programs to launch. That, she said, has proven
successful. She noted that the behavioral health network of
providers is operating on thin margins. She added that she
doesn't want to speak for the trust; however, there is a big gap
between supply and demand, and everyone will need to think about
where the dollars will come from to launch the needed services.
5:00:08 PM
REPRESENTATIVE TARR, in response to Ms. Kyle, surmised that the
state could offer a competitive grant for technology and
infrastructure upgrades necessary to participate in the 1115
waiver program.
MS. KYLE cautioned the idea that the dollars would be for
technical assistance. She suggested that, "if we can trust that
the payment will be in the future what we calculate now, and if
we can have the launch dollars then we can really bring those
services online."
5:01:22 PM
CO-CHAIR SPOHNHOLZ emphasized that behavioral health providers
as well as other health providers are businesses like any other
organization. They need to know what their potential revenue
streams can be to provide a service in order to build a business
model that is sustainable. If there isn't predictability, she
said, it creates an operating environment where risk is not
enabled. She reiterated the importance of a stable operating
environment.
5:02:14 PM
JARED KOSIN, President, Alaska State Hospital and Nursing Home
Association (ASHNHA), provided a PowerPoint presentation titled,
"MEDICAID: A Critical Component in Alaska's System of Care." He
explained that to understand SB 74 and the future of reforms
it's important to know where Medicaid stands today. He said
that Medicaid and health care in general are highly connected in
Alaska, which means that Alaska's system of care has major
vulnerabilities: capacity and effect of reimbursement (slide 2).
He described health care as a system in the concept of a
continuum (slide 3). He stated that Alaska's continuum is not
efficient for "good reasons." One of those being capacity
challenges, or not enough beds for the population. He argued
that this, in turn, drives up health care costs. He explained
how system inefficiencies are driving and trapping patient care
at the highest cost point because the lack of long-term care
facilities or assisted living homes to discharge hospital or
emergency department inpatients (slides 4-5). Mr. Kosin
continued by describing a chart on slide 6 labeled,
"Hypothetical Payor Mix (admissions)." He said that people
enrolled in government programs like Medicaid and Medicare often
pay less than the actual cost of patient care and consequently,
private payers are paying more (slide 7). He then turned to
reform. He reiterated that Alaska's system is fragile, adding
that it needs to be stabilized before making decisions that will
affect it. He discussed making rational changes through data-
driven decisions and payment reform, as well as innovative ideas
on how to keep patients at a lower cost of care (slide 8).
5:18:41 PM
CO-CHAIR SPOHNHOLZ commented on an issue related to workforce
supply. She reported that two separate University of Alaska
programs that provide behavioral health care and physical health
care training are on the chopping block as a result of budget
cuts. She said this will hinder the ability to have a
sufficient workforce to provide the health care that this state
needs. She said that it is important to remember that health
care operates in a larger system and thanked Mr. Kosin for
calling attention to that.
5:20:56 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 5:20 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| ABHA One Page Presentation Summary 01.09.2020.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |
| Alaska Trust Beneficiary Scorecard for ABHA Presentation 01.09.2020.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |
| ASHNHA Presentation 01.09.2020.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |
| ABHA Presentation 01.09.2020.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |
| APCA Presentation 01.09.2020.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |
| DHSS Medicaid Reform Update Presentation 01.09.2020.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |
| DHSS MH-Continuum-of-Care-0-to-21.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |
| DHSS MH-Continuum-of-Care-18-and-older.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |
| DHSS SUD-Continuum-of-Care-12-and-older.pdf |
HHSS 1/9/2020 3:00:00 PM |
Medicaid Reform |