Legislature(2019 - 2020)BUTROVICH 205

03/13/2019 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:31:14 PM Start
01:31:32 PM Presentation: Overview of the Department of Health and Social Services
03:01:02 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation: TELECONFERENCED
Overview of the Department of Health & Social
Services by Commissioner Adam Crum
-- Testimony <Invitation Only> --
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                         March 13, 2019                                                                                         
                           1:31 p.m.                                                                                            
                                                                                                                                
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Senator David Wilson, Chair                                                                                                     
Senator John Coghill, Vice Chair                                                                                                
Senator Gary Stevens                                                                                                            
Senator Cathy Giessel                                                                                                           
Senator Tom Begich                                                                                                              
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
All members present                                                                                                             
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
PRESENTATION: OVERVIEW OF THE DEPARTMENT OF HEALTH AND SOCIAL                                                                   
SERVICES                                                                                                                        
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
No previous action to record                                                                                                    
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
ADAM CRUM, Commissioner Designee                                                                                                
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Gave an overview of the Department of Health                                                              
and Social Services.                                                                                                            
                                                                                                                                
SANA EFIRD, Assistant Commissioner                                                                                              
Finance and Management Services                                                                                                 
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: Reviewed the DHSS budget.                                                                                 
                                                                                                                                
CLINTON LASLEY, Director                                                                                                        
Alaska Pioneer Homes                                                                                                            
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT: Provided  an  update on  the Alaska  Pioneer                                                             
Homes.                                                                                                                          
                                                                                                                                
ALBERT WALL, Deputy Commissioner                                                                                                
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Provided an  update on the Alaska Psychiatric                                                             
Institute.                                                                                                                      
                                                                                                                                
NATLIE NORBERG, Director                                                                                                        
Office of Children's Services                                                                                                   
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:   Provided  an  update  on   the  Office  of                                                             
Children's Services.                                                                                                            
                                                                                                                                
SHAWNDA O'BRIEN, Director                                                                                                       
Division of Public Assistance                                                                                                   
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: Provided an update  on the Division of Public                                                             
Assistance.                                                                                                                     
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
1:31:14 PM                                                                                                                    
CHAIR DAVID WILSON  called the Senate Health  and Social Services                                                             
Standing Committee meeting  to order at 1:31 p.m.  Present at the                                                               
call to  order were Senators  Coghill, Giessel,  Stevens, Begich,                                                               
and Chair Wilson.                                                                                                               
                                                                                                                                
                                                                                                                                
^Presentation: Overview  of the  Department of Health  and Social                                                               
Services                                                                                                                        
 Presentation: Overview of the Department of Health and Social                                                              
                            Services                                                                                        
                                                                                                                                
1:31:32 PM                                                                                                                    
Chair Wilson  announced the presentation  of the Overview  of the                                                               
Department of Health  and Social Services by  the commissioner of                                                               
the  department.  He  noted  that  representatives  from  various                                                               
divisions of the Department of  Health and Social Services (DHSS)                                                               
were also in attendance.                                                                                                        
                                                                                                                                
1:32:31 PM                                                                                                                    
ADAM  CRUM,  Commissioner  Designee,  Department  of  Health  and                                                               
Social  Services  (DHSS), Anchorage,  Alaska,  said  he would  be                                                               
presenting  some of  the  department's  highlights and  successes                                                               
along with things they are trying to improve.                                                                                   
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM said  the mission  and vision  of the                                                               
department is  to promote and  protect the health  and well-being                                                               
of Alaskans. This authority is  outlined in Article 7, Sections 4                                                               
and 5 of the Constitution of  the State of Alaska. What DHSS does                                                               
is  important. They  touch  the  lives of  all  Alaskans at  some                                                               
point.  It is  incumbent  upon them  to  effectively spend  their                                                               
dollars  for  the  greatest  benefit  of  the  population.  Their                                                               
ongoing  priority is  to find  efficiencies in  how they  provide                                                               
these  services, whether  through  IT  upgrades, process  change,                                                               
updated  training protocols,  or increased  emphasis on  customer                                                               
service.  As they  address internal  methodologies,  they have  a                                                               
long-term  goal   of  identifying  and  working   with  community                                                               
partners that provide  services to maximize the  dollar spent and                                                               
to directly address community issues.                                                                                           
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM presented the organization  chart for                                                               
DHSS.                                                                                                                           
                                                                                                                                
1:34:19 PM                                                                                                                    
SENATOR BEGICH  said Commissioner  Crum just  said that  his goal                                                               
was to  find efficiencies,  and yet  at the  same time  he talked                                                               
about constitutional  authority. Those aren't  about efficiencies                                                               
but  about protecting  the health  and  well-beings of  Alaskans.                                                               
Senator Begich asked  how efficiencies fit in  when government is                                                               
not a  profit-making business. These  are the things that  no one                                                               
pays for. These are the people  who have needs. He read Section 4                                                               
and 5 of the Alaska  Constitution, "The legislature shall provide                                                               
for the  promotion and  protection of  public health  and provide                                                               
for  public   welfare."  He  asked  how   efficiencies  meet  the                                                               
protection  of public  health  for  those who  are  not the  most                                                               
efficient folks for them to care for.                                                                                           
                                                                                                                                
COMMISSIONER DESIGNEE CRUM said  their goal is the administration                                                               
of  those dollars  to  make sure  they are  as  efficient pass  a                                                               
through as possible,  so that the maximum benefit  of the dollars                                                               
is touching the people who need them.                                                                                           
                                                                                                                                
1:35:44 PM                                                                                                                    
SENATOR GIESSEL  asked if an  example of that would  be improving                                                               
the eligibility assessments of applicants for Medicaid.                                                                         
                                                                                                                                
COMMISSIONER  DESIGNEE CRUM  replied  that it  is  items such  as                                                               
that,   whether  it   be  eligibility   for  public   assistance,                                                               
enrollment verification or  to make sure that there  is as little                                                               
fraud as possible and that they  are truly helping those who need                                                               
it.                                                                                                                             
                                                                                                                                
1:36:18 PM                                                                                                                    
SENATOR GIESSEL said that when  she looks at nonprofit web sites,                                                               
they often list  DHSS as one of their funders.  She noted that he                                                               
talked  about partnering  with local  groups and  asked how  that                                                               
works.                                                                                                                          
                                                                                                                                
COMMISSIONER  DESIGNEE CRUM  replied  that they  work with  local                                                               
providers  through  the  grant  process.  Many  times  the  local                                                               
providers  are  service-based  with  volunteers  and  have  lower                                                               
overhead  and  work  directly  with   individuals  in  need.  The                                                               
department  is working  on  being  outcomes-based with  increased                                                               
reporting from partners to make sure they are truly helping.                                                                    
                                                                                                                                
1:37:18 PM                                                                                                                    
SANA  EFIRD,  Assistant   Commissioner,  Finance  and  Management                                                               
Services,  Department  of  Health  and  Social  Services  (DHSS),                                                               
Juneau, Alaska, presented slide  4 showing the budget information                                                               
for  the seven  core  services that  DHSS  identified about  five                                                               
years  ago through  a results-based  budgeting activity  that all                                                               
divisions participated in:                                                                                                      
                                                                                                                                
        • Protect and promote the health of Alaskans                                                                            
        • Provide qualify of life in a safe living environment                                                                  
          for Alaskans                                                                                                          
        • Manage health care coverage for Alaskans                                                                              
        • Facilitate access to affordable health care for                                                                       
          Alaskans                                                                                                              
        • Strengthen Alaska families                                                                                            
        • Protect vulnerable Alaskans                                                                                           
        • Promote personal   responsibility   and   accountable                                                                 
          decisions by Alaskans                                                                                                 
                                                                                                                                
MS. EFIRD said that  the process took about a year  and a half to                                                               
two years.  Divisions tried  to identify  the true  core services                                                               
addressed in  the constitution through public  health and welfare                                                               
that  are serving  with their  dollars. The  slide shows  how the                                                               
current  proposed  governor's budget  is  aligned  to these  core                                                               
services. With  a new commissioner  and leadership, they  will be                                                               
looking at  this process  again to determine  if those  are still                                                               
the core services.                                                                                                              
                                                                                                                                
CHAIR WILSON asked  her to provide a one line  description of the                                                               
services. He was lost about  "promote personal responsibility and                                                               
accountable decisions by Alaskans," which  is 64 percent of their                                                               
budget.                                                                                                                         
                                                                                                                                
MS. EFIRD responded that those  are preventive activities such as                                                               
education  about how  to help  Alaskans be  more accountable  for                                                               
their  own  health  and  promotion  of  ways  that  they  can  be                                                               
healthier, such  as not smoking  and obesity efforts,  to address                                                               
things that will cost more money down the road.                                                                                 
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM added  that the department  was asked                                                               
to prioritize the  services they provide and  it is exceptionally                                                               
difficult to  do. The services  they deliver are mandated  by the                                                               
constitution  and  state  and federal  statute.  While  a  direct                                                               
ranking of  the priorities  may not  be possible,  they are  in a                                                               
continuous state of improvement.                                                                                                
                                                                                                                                
SENATOR  GIESSEL said  she was  going to  ask if  the percent  of                                                               
general funds  expended for  each core service  shown on  slide 4                                                               
exemplified the priorities,  but he was saying that  was not true                                                               
or it couldn't be put in a box.                                                                                                 
                                                                                                                                
1:41:33 PM                                                                                                                    
COMMISSIONER DESIGNEE CRUM  replied that it is hard to  put it in                                                               
the box because they do womb  to tomb and deal with prenatal care                                                               
all the way  to burial relief services. The  items have different                                                               
priorities to  individuals and  groups and  that is  difficult to                                                               
quantify.                                                                                                                       
                                                                                                                                
CHAIR WILSON  said it  is not impossible  to do,  just difficult.                                                               
Other  states such  as Oregon  have listed  these in  priority by                                                               
bringing stakeholders  to the table.  He knows that no  one wants                                                               
to pit seniors against kids in  a priority list, but other states                                                               
have  done these  tasks.  He was  hoping to  see  that with  this                                                               
department,  to bring  stake  holders  to the  table  and have  a                                                               
systematic approach on  how to rank these decisions.  They are in                                                               
a time  that calls  for looking  at what  services the  people in                                                               
Alaska  want.   The  department   could  help   coordinate  these                                                               
exercises  to help  engage stakeholders.  That was  his goal  two                                                               
years  ago when  he asked  for a  ranking. He  wanted to  start a                                                               
process and conversation  about what core services  the people of                                                               
Alaskans are looking  for in order to prioritize  those needs. He                                                               
said he  hoped DHSS  could look  at what  other states  have done                                                               
with that ranking model to prioritize these services.                                                                           
                                                                                                                                
SENATOR  BEGICH  asked  if  the  percentages  on  the  far  right                                                               
represent general funds in that category.                                                                                       
                                                                                                                                
MS. EFIRD answered yes.                                                                                                         
                                                                                                                                
SENATOR  BEGICH  highlighted  that  64  percent  of  funding  for                                                               
"promote  personal responsibility  and  accountable decisions  by                                                               
Alaskans" comes from  general funds and about a  third comes from                                                               
federal money.                                                                                                                  
                                                                                                                                
MS. EFIRD agreed.                                                                                                               
                                                                                                                                
SENATOR BEGICH  said that if  they looked at it  differently, the                                                               
largest component  of general  funds is  for "provide  quality of                                                               
life  in a  safe living  environment for  Alaskans," followed  by                                                               
"protect  and  promote  health,"  and  then  "protect  vulnerable                                                               
Alaskans."                                                                                                                      
                                                                                                                                
MS. EFIRD answered yes.                                                                                                         
                                                                                                                                
1:44:20 PM                                                                                                                    
SENATOR  BEGICH said  he  wanted  to hear  how  they are  meeting                                                               
"protect vulnerable Alaskans"  with proposed regulatory increases                                                               
at the  Pioneer Homes. He  said he hoped  to hear how  efforts at                                                               
privatizing  the Alaska  Psychiatric Institute  (API) works  into                                                               
affordable  health care,  the quality  of life,  and safe  living                                                               
environment  for  Alaskans.  He  also  wanted  to  hear  how  the                                                               
department is  meeting these  particular goals  with some  of the                                                               
proposed  cuts. Chair  Wilson  indicated that  he  has asked  for                                                               
priorities. Senator  Begich asked if the  priorities delivered to                                                               
the  Office of  Management and  Budget came  from their  division                                                               
directors and why the committee couldn't get that list.                                                                         
                                                                                                                                
CHAIR  WILSON said  some  of the  upcoming  slides might  address                                                               
Senator Begich's  questions, but he  asked for a response  to the                                                               
questions about priorities.                                                                                                     
                                                                                                                                
MS.  EFIRD responded  that  they did  provide  the core  services                                                               
priorities list to  the Finance Committees and  they will provide                                                               
it to this committee.                                                                                                           
                                                                                                                                
CHAIR WILSON said  he would distribute the list  to the committee                                                               
members.                                                                                                                        
                                                                                                                                
1:45:59 PM                                                                                                                    
MS. EFIRD said that slide 5  compared the governor's DHSS FY 2020                                                               
budget to the  FY2019 management plan. The total  budget for FY19                                                               
management plan  was $3,249,951.5 as compared  to $2,468,798.4 in                                                               
the governor's  amended budget,  which is close  to a  25 percent                                                               
reduction.  The funding  sources  consist of  58 percent  federal                                                               
funds; five percent other funds,  which are interagency receipts;                                                               
and  36   percent  general  funds,   of  which  90   percent  are                                                               
unrestricted and  10 percent are  designated. The  largest source                                                               
of designated general  funds are fees paid to  the Pioneer Homes,                                                               
child   support  collections   for  children   in  foster   care,                                                               
background and  application fees,  and fees  for birth  and death                                                               
certificates.                                                                                                                   
                                                                                                                                
MS. EFIRD said  looking at the chart shows  that the unrestricted                                                               
general funds (UGF)  is reduced by $336,649.8, which  is about 30                                                               
percent.  The  other large  reduction  is  in federal  funds.  In                                                               
putting  together   the  budget,   they  were  directed   by  the                                                               
governor's core tenets:                                                                                                         
                                                                                                                                
        • Focus on core services                                                                                                
        • Expenditures cannot exceed existing revenue                                                                           
        • Maintain and protect our reserves                                                                                     
        • Does not take additional funds from Alaskans through                                                                  
          taxes or the PFD                                                                                                      
      • Must be sustainable, predictable, and affordable                                                                        
                                                                                                                                
SENATOR BEGICH  said that in earlier  testimony, the commissioner                                                               
said that one  of the reasons for privatizing API  was because in                                                               
the long run, if  they could not run API in  a safe and effective                                                               
manner, they would lose the ability  to staff it and these people                                                               
would be back  in hospital emergency rooms.  Senator Begich asked                                                               
if giving up half a billion  dollars in matching federal funds is                                                               
going  to do  the same  thing by  pushing the  Medicaid expansion                                                               
population and others  who will lose coverage  back on hospitals,                                                               
but at a significantly higher magnitude.                                                                                        
                                                                                                                                
COMMISSIONER DESIGNEE CRUM replied that  DHSS will manage this as                                                               
best  as they  can with  the resources  provided. API  would have                                                               
lost  federal funding  through  the  certification process.  They                                                               
will address that  later. It is a  big ask, but it  is the fiscal                                                               
reality of the state. They are  going to have to work around this                                                               
and work with partners on this.                                                                                                 
                                                                                                                                
SENATOR BEGICH  said the  federal Medicaid  match to  state funds                                                               
varies from 50/50, 90/10, and at  times 100 percent. That is half                                                               
a  billion dollars  in  a time  of fiscal  crisis.  He asked  how                                                               
saying goodbye to  $452 million meets that goal  and the criteria                                                               
the  commissioner is  describing. He  said that  various entities                                                               
from the health  care field have told him that  that burden could                                                               
close virtually every  hospital in the state except  the five big                                                               
ones.  He asked  how that  would promote  and protect  the public                                                               
health of Alaskans.                                                                                                             
                                                                                                                                
COMMISSIONER  DESIGNEE  CRUM  responded that  next  Tuesday  more                                                               
detail will  be available in  the House. They are  verifying with                                                               
the Centers  for Medicare  and Medicaid  Services (CMS)  what the                                                               
first phase of  the Medicaid budget plan is going  to be. They do                                                               
have a goal of protecting  those critical access hospitals around                                                               
the  state and  providing access  to primary  care as  well. This                                                               
week Deputy Commissioner  Steward is in D.C. working  with CMS to                                                               
get verification  on how  they can move  forward with  that. They                                                               
have been cognizant of those issues, to keep hospitals open.                                                                    
                                                                                                                                
SENATOR BEGICH said that he hoped  he would be cognizant of that.                                                               
It is nearly half a billion dollars.                                                                                            
                                                                                                                                
COMMISSIONER  DESIGNEE  CRUM  said  the  mission  of  the  Alaska                                                               
Pioneer Homes is to provide  elder Alaskans a home and community,                                                               
celebrating  life  through its  final  breath.  The Pioneer  Home                                                               
budget does  show a reduction, but  it needs to be  noted that no                                                               
current resident of the Pioneer  Homes will be moved. The ability                                                               
to pay  is not  a criterion  for entering  the homes.  The budget                                                               
proposes  increasing rates  to  match costs  and  those with  the                                                               
ability to  contribute will  be asked  to do  so. The  state will                                                               
contribute to the care of those who cannot.                                                                                     
                                                                                                                                
1:52:42 PM                                                                                                                    
CLINTON LASLEY,  Director, Alaska Pioneer Homes,  Juneau, Alaska,                                                               
said the Alaska  Pioneer Homes have a long history.  In 1913, the                                                               
first facility was  put into place in Sitka. Most  of the Pioneer                                                               
Homes  were built  in the  1960s  with the  mission of  providing                                                               
elders a home  and community, celebrating life  through its final                                                               
breath. Putting forward  the rate increase was  a tough decision,                                                               
but  for too  many  years the  Pioneer Homes  did  not have  rate                                                               
increases. That is  how they got into the situation  they are in.                                                               
There  were four  rate increases  over the  last 15  years for  a                                                               
total of 15 percent while the  inflation rate was 35 percent. The                                                               
question is how  to correct it. This rate increase  is to protect                                                               
the  Pioneer  Homes  and  to  ensure  they  are  truly  providing                                                               
assistance  to individuals  who need  it. Because  the rates  are                                                               
artificially low,  they are providing  assistance to  every elder                                                               
in a  home. He  asked whether,  when the  state is  in a  time of                                                               
financial  challenges, they  should  be  providing assistance  to                                                               
everyone  or  should the  rates  reflect  the cost  of  providing                                                               
services.                                                                                                                       
                                                                                                                                
MR. LASLEY  said the Anchorage Pioneer  Home is putting in  a new                                                               
nine-bed neighborhood.  Last year  they received  capital funding                                                               
to build  out that neighborhood. It  is for seniors 65  and older                                                               
with  dementia  and  complex  behaviors,  such  as  self-harm  or                                                               
excessive   wandering.  Those   individuals  were   being  placed                                                               
inappropriately in emergency rooms, sometimes  at API. There is a                                                               
need for these services. They have  been working with the city to                                                               
make sure  they have everything  in place for the  building. They                                                               
are excited about having the  nine-bed neighborhood open in early                                                               
FY  20.   For  the   past  year,  they   have  been   working  on                                                               
transitioning  14 beds  at the  Palmer  Pioneer Home  to what  is                                                               
considered   VA    [Veterans   Affairs]   Skilled    beds.   This                                                               
classification  provides the  same services  they provide  today,                                                               
but it increases  their VA per diem reimbursement  from $47.36 to                                                               
$107.16. They  are hoping that will  be in the place  in the next                                                               
30 days, and  they are hoping to expand the  number of those beds                                                               
in the future.                                                                                                                  
                                                                                                                                
1:56:23 PM                                                                                                                    
COMMISSIONER DESIGNEE  CRUM said the division  has an expectation                                                               
of reaching  90 percent  occupancy across the  system by  July 1.                                                               
The Anchorage  Pioneer Home will  provide a major benefit  to the                                                               
system by  putting these individuals  in the care  situation that                                                               
they  need. If  this is  viable,  they will  continue looking  at                                                               
that. It is an exciting time  for the Pioneer Homes because these                                                               
individuals with complex behaviors need  to be protected and they                                                               
will have a place for them.                                                                                                     
                                                                                                                                
SENATOR BEGICH said  51 percent of Pioneer Home  residents are on                                                               
private pay.  He asked, based  on the proposed  regulations, what                                                               
is the most that someone will pay monthly.                                                                                      
                                                                                                                                
MR.  LASLEY said  they have  proposed  five levels  of care.  The                                                               
highest level of  care, level five, would be $15,000  a month for                                                               
those  complex   behaviors,  but   those  are  not   the  typical                                                               
residents.  For  most,  the  high  end would  be  a  little  over                                                               
$13,000, which  is what the  services cost. Last year  the Mental                                                               
Health Trust  Authority paid for a  study on how to  best use the                                                               
six facilities with a look  at different staffing models to serve                                                               
those  needs.  That study  considered  that  the current  highest                                                               
level of care, level three, costs  $100,070 a year to provide 24-                                                               
hour nursing care services. The  Pioneer Home is a hybrid between                                                               
assisted living and low-level skilled  nursing. Their model is to                                                               
have elders  come into the homes  and live through until  the end                                                               
of  life. As  they live  through that  cycle they  age in  place,                                                               
which requires that higher level of care at $13,000 a month.                                                                    
                                                                                                                                
SENATOR BEGICH asked if the  state seeks repayment from someone's                                                               
estate after that person dies.                                                                                                  
                                                                                                                                
MR. LASLEY said about 30 percent  of individuals in the homes are                                                               
on  the payment  assistance program.  That is  in regulation  and                                                               
statute.  For  individuals  who require  some  level  of  payment                                                               
assistance, they do  file a claim against the estate  at the time                                                               
of death  for the  portion indebted  to the  state. That  is done                                                               
with a simple letter to the court.                                                                                              
                                                                                                                                
2:00:32 PM                                                                                                                    
SENATOR STEVENS  said that it  seems that the Pioneer  Homes have                                                               
changed. Fifty  years ago,  people who went  into the  homes were                                                               
just old.  Now they seem to  be dementia facilities. He  asked if                                                               
that were true and if so, why did that happen.                                                                                  
                                                                                                                                
MR.  LASLEY responded  that when  the Pioneer  Homes were  built,                                                               
they had  wet bars. It  was a  different setting. When  they were                                                               
built, everyone  walked in the  door. That  is not the  case now.                                                               
The  average age  of  individuals  coming into  the  homes is  81                                                               
because  people are  able  to  live in  their  homes longer.  The                                                               
average age in  the homes is 87. About 55  percent have dementia.                                                               
About 75 percent of the people on  the wait list are coming in at                                                               
the highest level of care.                                                                                                      
                                                                                                                                
CHAIR  WILSON said  last session  there was  a lively  discussion                                                               
about whether  the Pioneer Homes  are skilled  nursing facilities                                                               
but not labeled as such. It  looks like they are upping the level                                                               
of care  in Palmer  to a  skilled nursing  facility. He  asked if                                                               
there are enough skilled nursing facilities in Alaska.                                                                          
                                                                                                                                
MR. LASLEY answered that there is  a huge need for those services                                                               
in the  state. The  Department of Labor  statistics say  that the                                                               
number of  Alaskans age 65 and  older will double in  the next 15                                                               
years. The state is not keeping  up with the demand. The Veterans                                                               
Skilled  classification   for  the  beds   in  Palmer  is   a  VA                                                               
classification  and   not  skilled   in  the  usual   sense.  The                                                               
reimbursement rate is for what the  VA calls a skilled rate. They                                                               
are still  an assisted living  facility. They do  provide nursing                                                               
care 24 hours a day.                                                                                                            
                                                                                                                                
CHAIR WILSON said that a  few years ago skilled facilities wanted                                                               
to come to Alaska, but their  applications were denied due to the                                                               
Certificate  of Need  process. Now  Mr.  Lasley says  there is  a                                                               
shortage, but the state denied  these applicants. He asked if Mr.                                                               
Lasley could reconcile the difference.                                                                                          
                                                                                                                                
COMMISSIONER  DESIGNEE  CRUM replied  that  that  was before  his                                                               
time. In Wasilla two skilled  nursing facilities are being built.                                                               
They will continue  to evaluate the capacity for the  rest of the                                                               
state.                                                                                                                          
                                                                                                                                
SENATOR BEGICH  asked if he is  currently in any talks  about the                                                               
privatization of the Pioneer Homes.                                                                                             
                                                                                                                                
COMMISSIONER DESIGNEE CRUM answered not at this time.                                                                           
                                                                                                                                
2:04:39 PM                                                                                                                    
CHAIR  WILSON   said  he  thought  that   the  study  recommended                                                               
privatization of  the pharmaceutical entity within  the homes. He                                                               
asked if  they are  looking at  that as  an efficiency  to reduce                                                               
costs.                                                                                                                          
                                                                                                                                
MR.   LASLEY  said   that  the   study  recommendation   for  the                                                               
privatization  of pharmaceutical  services  was found  not to  be                                                               
cost  effective  for the  state.  The  one  area where  they  are                                                               
looking at privatization is for  hospitality services. That was a                                                               
recommendation in  2016 legislative  intent language  because the                                                               
Juneau Pioneer Home has contracted  out for hospitality services,                                                               
which includes  food, housekeeping,  and laundry service,  for 30                                                               
years.                                                                                                                          
                                                                                                                                
CHAIR WILSON said  they didn't cover the $15  million increase in                                                               
the Pioneer Home budget [for payment assistance].                                                                               
                                                                                                                                
COMMISSIONER DESIGNEE CRUM said that  when they proposed the rate                                                               
increases to  match costs, they  understood that a  large portion                                                               
of that population would need  payment assistance. They initially                                                               
threw out  the $15  million. They are  collecting data  and doing                                                               
projections based  on the information  about people who  can pay.                                                               
They  are  trying to  find  a  complete  number for  the  payment                                                               
assistance program as they get more data.                                                                                       
                                                                                                                                
CHAIR WILSON asked  if the administration would  use that funding                                                               
to offset  the additional cost to  help ensure that no  one would                                                               
be kicked out of the homes.                                                                                                     
                                                                                                                                
COMMISSIONER DESIGNEE CRUM answered yes.                                                                                        
                                                                                                                                
SENATOR BEGICH said he thought  assistance was being cut from $30                                                               
million to $15 million.                                                                                                         
                                                                                                                                
2:07:31 PM                                                                                                                    
MS. EFIRD  said the  Unrestricted General  Funds (UGF)  are being                                                               
cut  for the  Pioneer  Homes. They  are seeing  a  change in  the                                                               
budget structure. There was a  component added. All the UGF prior                                                               
to the  FY 20 were budgeted  in the Pioneer Homes  component. The                                                               
UGF  was cut,  and  $15  million was  added  back  in a  separate                                                               
component for the  assistance payment. The increase  was given to                                                               
the  Pioneer  Homes  in  designated   general  funds  to  collect                                                               
additional  fees. The  UGF  has been  cut and  there  has been  a                                                               
structure change  to show that  general fund  assistance payments                                                               
will come into the Pioneer Homes as a needs-based program.                                                                      
                                                                                                                                
SENATOR BEGICH clarified  that $30 million UGF  was provided from                                                               
the state.  Now it will  be $15  million with the  expectation to                                                               
make up  the $15 million, or  whatever the need is,  based on the                                                               
higher fees charged.                                                                                                            
                                                                                                                                
MS.  EFIRD answered  that  is correct.  To go  back  to what  the                                                               
commissioner  just said,  they  are looking  at  the $15  million                                                               
general  fund  number, doing  more  calculations,  and trying  to                                                               
project based on information they have  on who is private pay and                                                               
when they may no longer be able  to afford the rate to see if $15                                                               
million is the right number.                                                                                                    
                                                                                                                                
SENATOR  BEGICH said  he  wanted to  clarify that  it  is not  an                                                               
increase of $15  million to this budget. It is  a decrease of $15                                                               
million in  terms of  the state support.  He said  he appreciates                                                               
that they are going to look at the impacts.                                                                                     
                                                                                                                                
2:09:52 PM                                                                                                                    
CHAIR WILSON said that they are  at about $13,000 a month and the                                                               
previous speaker  spoke to a  38 percent increase in  health care                                                               
costs without rates  changing and that something has  to be done.                                                               
He clarified that they are considering what can be done.                                                                        
                                                                                                                                
COMMISSIONER DESIGNEE CRUM answered correct.                                                                                    
                                                                                                                                
CHAIR WILSON  noted that Deputy  Commissioner Albert Wall  was on                                                               
the phone.                                                                                                                      
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM noted that  they had been  before the                                                               
committee before  to discuss API. The  goal of API is  to provide                                                               
emergency and  court-ordered inpatient psychiatric services  in a                                                               
safe environment  using culturally-sensitive,  effective, person-                                                               
centered  treatment  followed by  a  referral  to an  appropriate                                                               
level of care  and support for recovery from  mental illness. API                                                               
reports directly to Deputy Commissioner  Wall. He as commissioner                                                               
assumed  his  authority under  Title  47  to actually  take  over                                                               
management  of  API and  implement  a  private contract  for  API                                                               
management. It  should be  noted that  because of  those actions,                                                               
CMS  has extended  their funding  capability until  mid-May, when                                                               
there will be  another review process. They were  in serious risk                                                               
of losing their federal authority  to spend and bill back against                                                               
Medicaid, so this is an important aspect and a very good win.                                                                   
                                                                                                                                
CHAIR WILSON  asked if  the department  had received  notice from                                                               
CMS yet on the status of some of those filings.                                                                                 
                                                                                                                                
2:11:40 PM                                                                                                                    
COMMISSIONER DESIGNEE  CRUM said their certification  and ability                                                               
to bill has  been extended. They have been given  an extension of                                                               
their provisional licensing  until June 30. Their  ability to act                                                               
as a  hospital continues. They  have various ongoing  issues with                                                               
litigation.  They  have  OSHA  [Occupational  Safety  and  Health                                                               
Administration]  still  pending.  They  want  to  be  transparent                                                               
throughout this  process. They have  created a website  that they                                                               
consistently add  information to.  Every time  they respond  to a                                                               
public  request, they  post their  answers. The  website has  API                                                               
governing  body  minutes,  documents  from  emergency  operations                                                               
center for  psychiatric care  capacity response,  and feasibility                                                               
studies.                                                                                                                        
                                                                                                                                
SENATOR  BEGICH  said  that at  that  meeting  that  Commissioner                                                               
Designee Crum referenced, Wellpath was  on the line and on record                                                               
that they  formed in October.  He went through the  emails online                                                               
and Wellpath  did not form  until November. He  expressed concern                                                               
that the  company wasn't  fully truthful.  His bigger  concern is                                                               
the Chilkat  unit. He  has worked with  the Division  of Juvenile                                                               
Justice in the  past and been part of the  juvenile justice field                                                               
since  86. He  understands that  the Chilkat  unit was  closed in                                                               
December. It  is a unit that  uses a lot of  restraints. Shutting                                                               
it down  can count  favorably toward how  they appear  because of                                                               
the many things done in that  unit. He asked when they are likely                                                               
to reopen that unit, if that  is the intent. He asked if Wellpath                                                               
has experience  working with juveniles in  a psychiatric setting.                                                               
Wellpath  is on  the record  as saying  not to  look back  at the                                                               
record of the  prior companies that existed. He  is talking about                                                               
their  ability  to  run juvenile  facilities.  He  is  especially                                                               
concerned  because   Deputy  Commissioner  Wall   implied  during                                                               
testimony  that  they were  looking  at  Wellpath as  a  juvenile                                                               
option for them.                                                                                                                
                                                                                                                                
SENATOR STEVENS asked what the Chilkat unit is.                                                                                 
                                                                                                                                
SENATOR  BEGICH  answered  that  it is  a  psychiatric  unit  for                                                               
minors. Acute  psychiatric cases  are sent  there, many  from the                                                               
Division  of  Juvenile Justice,  and  segregated  from the  adult                                                               
population.                                                                                                                     
                                                                                                                                
CHAIR STEVENS asked if they are in the same facility.                                                                           
                                                                                                                                
SENATOR BEGICH said that API has  a number of different units for                                                               
different characteristics of care.                                                                                              
                                                                                                                                
CHAIR  WILSON said  Deputy Commissioner  Wall  could explain  his                                                               
error about the timeline in the previous committee meeting.                                                                     
                                                                                                                                
SENATOR BEGICH said it was a Wellpath error.                                                                                    
                                                                                                                                
CHAIR  WILSON said  that  there is  a  timeline discrepancy  that                                                               
Deputy  Commissioner Wall  could  straighten out.  The state  has                                                               
four  or five  other psychiatric  level-four facilities  that can                                                               
help  out  with   youth,  so  there  is  no   shortage  for  that                                                               
population.                                                                                                                     
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM deferred to Deputy  Commissioner Wall                                                               
and noted  that Mr. Wall was  spending 95 percent of  his time on                                                               
this issue.                                                                                                                     
                                                                                                                                
2:16:15 PM                                                                                                                    
ALBERT  WALL,  Deputy  Commissioner,  Department  of  Health  and                                                               
Social Services (DHSS), Anchorage,  Alaska, said that the Chilkat                                                               
unit is not closed and currently  has patients. It has never been                                                               
closed since he  started working in December. There  was a period                                                               
where  the occupants  of the  Chilkat  ward had  been taken  into                                                               
court custody and  taken to the Juvenile  Justice facility across                                                               
the parking  lot. There was  some time with  no one on  the ward,                                                               
but  it  could not  be  characterized  as closed.  Currently  one                                                               
person is there.  North Star is the  largest psychiatric provider                                                               
for children  in the state. The  children who end up  at API tend                                                               
to  be  on  the  far  end of  severity  and  acuity  for  serious                                                               
emotional  disturbance  and  usually  have  complications  around                                                               
developmental disabilities as well.                                                                                             
                                                                                                                                
MR.  WALL  said   he  was  not  sure  about   what  the  timeline                                                               
discrepancy was. He noted he was calling from API.                                                                              
                                                                                                                                
SENATOR   BEGICH   said   there    have   been   other   timeline                                                               
discrepancies, but the only discrepancy  he was talking about was                                                               
when  he  asked  when  Wellpath   formed.  They  wanted  a  clear                                                               
differentiation from past entities  that had formed Wellpath. The                                                               
Wellpath representative  said that  they formed in  October 2018.                                                               
In the emails on the website  he saw the formation as November 7,                                                               
2018.                                                                                                                           
                                                                                                                                
CHAIR WILSON said that he would  pass that off because no one was                                                               
there from Wellpath to testify.                                                                                                 
                                                                                                                                
SENATOR BEGICH  said he also  asked if they have  experience with                                                               
adolescent treatment.                                                                                                           
                                                                                                                                
CHAIR  WILSON  asked Deputy  Commissioner  Wall  if he  knew  the                                                               
answer.                                                                                                                         
                                                                                                                                
2:19:44 PM                                                                                                                    
MR. WALL  said they have  not talked about their  experience with                                                               
children. They are  working on the adult backlog  of care problem                                                               
they have in  the state. He is  aware that there is  a backlog of                                                               
children who need  care. The issue is with  limited resources how                                                               
they  are  going to  prioritize  the  care  that they  can  give.                                                               
Preference is  being granted on  legal issues to adults  who have                                                               
forensic needs  or are on  the Title 12  side of the  house. That                                                               
has  been their  conversations thus  far. They  have a  very good                                                               
relationship  with  North  Star  Hospital, which  has  taken  the                                                               
majority  of children.  The Chilkat  unit has  ten beds  with one                                                               
occupant. The rest of the care is being diverted to North Star.                                                                 
                                                                                                                                
SENATOR BEGICH  asked who will  do the medical  billing, Wellpath                                                               
or the state.                                                                                                                   
                                                                                                                                
MR. WALL  said another question  had been  about the CMS  plan of                                                               
correction. He  is at API because  the survey team from  CMS just                                                               
left  the  building.  The  plan   of  correction  is  an  ongoing                                                               
negotiation  between the  state  and its  federal partners.  They                                                               
return  to  the building  periodically  at  unannounced times  to                                                               
survey whether they are on track  with the plan of correction and                                                               
to resurvey any incidents between  the time the plan is submitted                                                               
and the  time the team arrives.  A team showed up  the day before                                                               
yesterday. They  do have  a current plan  of correction  with the                                                               
Centers  for  Medicare  and  Medicaid   Services  that  has  been                                                               
accepted,  except  for  the  survey done  today,  which  will  be                                                               
specified  and put  out  in writing.  They do  have  the plan  of                                                               
correction, which is a public document and on the website.                                                                      
                                                                                                                                
MR. WALL  said the question  about billing  came up in  the House                                                               
Finance subcommittee meeting. The contract  with Wellpath is a by                                                               
bed contract. There  is a dollar amount per  bed. The third-party                                                               
billing, with Medicaid, with self-pay  for some patients, will be                                                               
a function  of Wellpath. However,  the money will be  retained by                                                               
the state  and the contract fees  will be paid out  of that money                                                               
and  the  federal  match,  which   primarily  comes  through  DSH                                                               
[Disproportionate Share  Hospital]. It is  a little bit  of both.                                                               
The contract  is online.  Billing will  be the  responsibility of                                                               
the vendor.                                                                                                                     
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM mentioned that the  chair had alluded                                                               
to another timeframe issue. They  have a letter of response about                                                               
emails and language  and intent. There was a  conflation of dates                                                               
among the  emails. They will  be posting a letter  explaining the                                                               
date timeframe.                                                                                                                 
                                                                                                                                
2:25:17 PM                                                                                                                    
SENATOR  STEVENS said  the commissioner  had  been talking  about                                                               
efficiencies and  now he  was talking about  a ten-bed  unit with                                                               
one person and they have a  partnership with North Star. He asked                                                               
what the overall goal is.                                                                                                       
                                                                                                                                
COMMISSIONER  DESIGNEE   CRUM  said  this  will   be  an  ongoing                                                               
evaluation. They have an increased  need for forensic beds in the                                                               
state,  which  has  to  do   with  the  criminal  side  to  judge                                                               
competency. As  they evaluate  their needs,  there may  be enough                                                               
units  and private-contract  partners  like North  Star that  can                                                               
satisfy the  need for  the children side  that they  can convert.                                                               
This will  be an ongoing assessment  that they will work  on with                                                               
their partners.                                                                                                                 
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM said that Gennifer  Moreau-Johnson is                                                               
the acting  director for  the Division  of Behavioral  Health. In                                                               
November  of  2018 they  received  an  1115 Medicaid  waiver  for                                                               
substance  use  disorder. The  goal  is  to intervene  early  and                                                               
increase  access to  regionally-based and  culturally appropriate                                                               
outpatient treatment  services for these disorders  and increased                                                               
access  to local  crisis and  community-based subacute  treatment                                                               
and  wraparound  services.  Currently,  they  have  either  detox                                                               
centers or API and nothing in  the middle. The goal is to provide                                                               
increased access  to these facilities.  It will  ultimately drive                                                               
down costs.  Using these community-based  systems will  mean less                                                               
inpatient,  residential,   and  emergency  care.  They   will  be                                                               
pursuing many different aspects.                                                                                                
                                                                                                                                
COMMISSIONER DESIGNEE CRUM said that  because of the 1115 waiver,                                                               
they were able to partner  with the Mental Health Trust Authority                                                               
to  do  an infrastructure  analysis  of  existing facilities  and                                                               
ability to  provide services  in Alaska.  The project  started in                                                               
January with  visits to regional  hubs and will conclude  in May.                                                               
Behavioral  health  service  providers   are  being  surveyed  to                                                               
determine infrastructure  needs to provide the  proposed services                                                               
for  each of  the 1115  waiver population  groups. The  Office of                                                               
Children's  Service   (OCS)  is  also  participating.   They  are                                                               
traveling  to hubs  as  a  team to  do  assessments of  available                                                               
resources.                                                                                                                      
                                                                                                                                
2:28:10 PM                                                                                                                    
COMMISSIONER DESIGNEE CRUM explained why OCS is included:                                                                       
                                                                                                                                
        • A 2017 Federal Audit of Alaska's child welfare system                                                                 
          identified  that   the  services  that   OCS  purchases                                                               
          through   grants  family   support,  preservation   and                                                               
          reunification  are not  adequate and  additionally, the                                                               
          availability   of   a  continuum   of   community-based                                                               
          substance abuse  and mental health services  needed for                                                               
          families in the child welfare system is not adequate.                                                                 
        • Drawing attention to the unique service needs of child                                                                
          in protective services (CPS) involved families.                                                                       
        • Identifying provider capacity and interest for                                                                        
          providing  prevention services  that will  be available                                                               
          through the new Family First Prevention Services Act.                                                                 
        • Combining these efforts strengthen intradepartmental                                                                  
          working  relationships;  and,  reduce  interruption  of                                                               
          services at  the community  level since  providers need                                                               
          only set aside time for one meeting instead of two.                                                                   
                                                                                                                                
COMMISSIONER DESIGNEE CRUM  said that the goal of OCS  is to work                                                               
in  partnership  with families  and  communities  to support  the                                                               
well-being  of  Alaska's  youth  and children.  It  is  a  large,                                                               
important  division.   The  legislature  passed  HB   151,  which                                                               
provided and funded new OCS positions.  They had an issue of very                                                               
high  caseloads  which created  high  turnover.  It was  hard  to                                                               
retain workers. Of the first  31 positions that were allocated in                                                               
2017, the  majority went  to the office  in Wasilla.  The average                                                               
caseload was  around 41; now  the average is 13  per caseworkers.                                                               
New positions were added for 2018. Those dollars have helped.                                                                   
                                                                                                                                
2:30:30 PM                                                                                                                    
CHAIR  WILSON asked  about the  status  of the  first cohort  for                                                               
tribal  compacting  and  whether  more entities  would  join  the                                                               
compact this year.                                                                                                              
                                                                                                                                
2:30:50 PM                                                                                                                    
NATLIE   NORBERG,  Director,   Office  of   Children's  Services,                                                               
Department of Health and Social  Services (DHSS), Juneau, Alaska,                                                               
said the first  full cohort consisted of 18  cosigners. The first                                                               
year has been  spent primarily on implementing the  scope of work                                                               
regarding relative searches. They had  held off on signing up new                                                               
cosigners for  the first  year. If they  are moving  forward with                                                               
the compact, it can be renegotiated in 2020.                                                                                    
                                                                                                                                
CHAIR  WILSON   asked  who  will   decide  whether   the  compact                                                               
continues.                                                                                                                      
                                                                                                                                
MS.  NORBERG  answered  that the  administration  must  make  the                                                               
decision about whether they are  moving forward with the compact.                                                               
All aspects  of the compact are  very much negotiated in  a group                                                               
way  among   the  cosigners.  She   thought  the   cosigners  are                                                               
interested in more cosigners signing  on if there is an interest.                                                               
A lot depends on the  funding and availability to share resources                                                               
among the cosigners.                                                                                                            
                                                                                                                                
2:32:36 PM                                                                                                                    
SENATOR  COGHILL said  they passed  HB  151 with  more money  for                                                               
staffing. He asked about the stabilization of the workforce.                                                                    
                                                                                                                                
MS. NORBERG  said they  were able  to give  the Wasilla  office a                                                               
large  infusion of  new staff  in 2017  and that  office turnover                                                               
rate is  beginning to  stabilize but  it is  by no  means stable.                                                               
Statewide  the turnover  rate is  51 percent.  It is  still high.                                                               
They are not  seeing the benefits of the  positions they received                                                               
last year going into full effect.  Many of the staff are still in                                                               
training mode and have not been able to take on full caseloads.                                                                 
                                                                                                                                
SENATOR COGHILL  said he wanted  a general picture. They  did not                                                               
solve the  problem. They  were working  on it,  but they  did not                                                               
solve the problem.                                                                                                              
                                                                                                                                
SENATOR  BEGICH asked  when they  do expect  to see  the training                                                               
process finish  and when  will these new  employees take  on full                                                               
caseloads.                                                                                                                      
                                                                                                                                
MS. NORBERG said  HB 151 requires additional  training for staff.                                                               
It will take six months for  the training to go into full effect.                                                               
New workers need  six months on the job to  take a full caseload.                                                               
They just finished a round  of strong recruitment efforts for the                                                               
21 new positions. They have  ongoing caseworker turnover. The new                                                               
caseload caps statutorily  don't go into effect  until July 2020.                                                               
They  are certainly  hopeful that  the many  different strategies                                                               
that they will be employing  will stabilize the workforce by then                                                               
so they can implement the caps.                                                                                                 
                                                                                                                                
CHAIR WILSON said that OCS will  be back next week when they give                                                               
their response to the Citizen Review Panel.                                                                                     
                                                                                                                                
SENATOR BEGICH said  he has the same concern  as Senator Coghill.                                                               
They fund the positions. They need  to know when things will look                                                               
different. If they are not  going to look different, then retool,                                                               
redo. He asked if they could  come back with some general targets                                                               
about  when  they   can  expect  changes  based   on  the  robust                                                               
recruitment she described.                                                                                                      
                                                                                                                                
CHAIR WILSON  said he will give  them his questions so  they will                                                               
be prepared to answer next week.                                                                                                
                                                                                                                                
2:36:36 PM                                                                                                                    
COMMISSIONER  DESIGNEE  CRUM said  that  Tracy  Dompeling is  the                                                               
director of the Division of  Juvenile Justice. The mission of the                                                               
division  is to  hold  juvenile offenders  accountable for  their                                                               
behavior,  promote  the safety  and  restoration  of victims  and                                                               
communities,  and   assist  offenders   and  their   families  in                                                               
developing skills  to prevent crime.  They have had  success with                                                               
the Trauma Informed Effective Reinforcement (TIERS) Program:                                                                    
                                                                                                                                
        • With technical assistance from national experts,                                                                      
          implemented (TIERS) program at the McLaughlin Youth                                                                   
          Center, Girls Detention and Treatment Units.                                                                          
        • The TIERS program is a gender and trauma responsive                                                                   
          approach to working with female youth.                                                                                
        • In the past 12 months these units have seen a 30%                                                                     
          reduction in the number of youth restraints per month                                                                 
          compared to the previous year.                                                                                        
                                                                                                                                
COMMISSIONER  DESIGNEE CRUM  said the  goal is  to have  no youth                                                               
restraints. He  described a  job training  success at  the Bethel                                                               
facility.  Through  a  grant  program  a  youth  was  exposed  to                                                               
industry and under the supervision  of the facility staff, worked                                                               
on maintenance of vehicles. He  now is in a comprehensive welding                                                               
and training program while holding down a job.                                                                                  
                                                                                                                                
CHAIR  WILSON  asked about  the  potential  closure of  the  Nome                                                               
facility. The  privatization study  looked at facilities  in Nome                                                               
and Kenai.  He asked about the  process for why Nome  was chosen,                                                               
vs. Kenai, which is on the road system.                                                                                         
                                                                                                                                
COMMISSIONER  DESIGNEE  CRUM said  the  Nome  facility had  about                                                               
eight individuals  a day,  which is an  occupancy rate  around 50                                                               
percent. That is a lower  occupancy rate. There are also facility                                                               
and  structural  issues. They  would  have  to do  a  substantial                                                               
capital investment project or look toward something else.                                                                       
                                                                                                                                
SENATOR BEGICH  said he  thought Nome  was an  eight-bed facility                                                               
with a couple of crisis bed.                                                                                                    
                                                                                                                                
COMMISSIONER DESIGNEE CRUM said perhaps it was 11 or 12.                                                                        
                                                                                                                                
SENATOR   BEGICH  said   they   still  own   the  facility.   The                                                               
privatization  study  recommended  against privatization,  so  he                                                               
asked  what they  will do  with the  facility. Commissioner  Crum                                                               
described the  success of  the Division  of Juvenile  Justice. He                                                               
commends the division for the job  they are doing. That is why he                                                               
was  taken aback  when he  heard  Mr. Wall  mentioned looking  at                                                               
Wellpath as  potentially playing a  role in the  privatization of                                                               
the Division of  Juvenile Justice. He asked  if Commissioner Crum                                                               
is looking at privatizing that division.                                                                                        
                                                                                                                                
2:40:18 PM                                                                                                                    
COMMISSIONER DESIGNEE CRUM answered no;  it was initially just an                                                               
idea they were  throwing around, but they have  not explored that                                                               
any further. Nome  is nine beds. They were trying  to explore the                                                               
importance  of the  Nome  facilty to  the  region. They  explored                                                               
different options.  The privatization study  called for it  to be                                                               
privatized by a  group to be run as a  juvenile justice facility.                                                               
With  the 1115  waiver, they  were looking  at whether  a funding                                                               
mechanism is in place so that  a regional group could run that as                                                               
substance abuse  treatment center. They are  in preliminary talks                                                               
with  one  partner.  They  have   also  had  initial  talks  with                                                               
Representative  Foster.  Representative Foster  understands  that                                                               
they are  trying to find  a viable option  for that to  provide a                                                               
service. This  is a  long-term goal. They  believe that  having a                                                               
substance abuse  treatment center  could be  good for  the region                                                               
and  satisfy their  CMS partners  by providing  access in  remote                                                               
areas and  it would be  easier to provide  culturally appropriate                                                               
and sensitive material in a therapeutic environment.                                                                            
                                                                                                                                
2:41:52 PM                                                                                                                    
COMMISSIONER  DESIGNEE CRUM  said  the goal  of  the Division  of                                                               
Public Assistance is to promote  self-sufficiency and provide for                                                               
basic living expenses  for Alaskans in need. This  is the gateway                                                               
to the system at DHSS.  The eligibility technicians do screening.                                                               
They have  been known for  the backlog.  In 2017, at  the highest                                                               
point they  had had a  backlog of 28,991  applications. Currently                                                               
it is  just under 10,000. They  have made a fantastic  effort. He                                                               
had  shared with  the committee  during his  confirmation hearing                                                               
that  his concern  about the  backlog  and the  lack of  services                                                               
provided  was  one  of  the  reasons he  was  interested  in  the                                                               
department, so he is very proud of this aspect.                                                                                 
                                                                                                                                
SHAWNDA  O'BRIEN,   Director,  Division  of   Public  Assistance,                                                               
Department of Health and Social  Services (DHSS), Juneau, Alaska,                                                               
said  they  have been  working  with  the Alaska  Native  Medical                                                               
Center  to  outstation  staff there,  primarily  to  address  the                                                               
backlog issue with their members  with Medicaid. Through external                                                               
and  internal  collaborative efforts,  they  are  days away  from                                                               
outstationing five staff members there.  They have had one person                                                               
there for years.  They are looking at  replicating that elsewhere                                                               
with other providers.  Once they have tested that  out, they will                                                               
offer that to other facilities.                                                                                                 
                                                                                                                                
CHAIR WILSON said hospitals can  have their own staff be Medicaid                                                               
verifiers.  He  asked how  outsourcing  staff  is different  from                                                               
using a staff person at another medical facility.                                                                               
                                                                                                                                
MS. O'BRIEN responded  that it is beneficial to  retain work with                                                               
their own  employees because  those staff can  work on  more than                                                               
Medicaid applications. They can continue  to work on the backlogs                                                               
from  other  offices. They  will  have  the  same access  to  the                                                               
system.  They will  focus on  the  members and  backlog for  that                                                               
facility,  but  they  will  continue   statewide  work  on  other                                                               
programs. Some programs are not  allowed to be outstationed, such                                                               
as  eligibility determinations  for SNAP  [Supplemental Nutrition                                                               
Assistance Program]. This will continue  with the same work model                                                               
they have  in place while  addressing the backlog on  a statewide                                                               
level and address concerns of tribal partners.                                                                                  
                                                                                                                                
CHAIR WILSON asked how they will maintain security of data.                                                                     
                                                                                                                                
2:45:29 PM                                                                                                                    
MS. O'BRIEN  answered that  since they  will be  their employees,                                                               
they will  have the same  security parameters as  existing staff.                                                               
They  will be  seated  in  office spaces  not  accessible to  the                                                               
public. The material  they have access to will  be housed through                                                               
the  state network  and mainframe.  All  HIPAA [Health  Insurance                                                               
Portability  and Accountability  Act] requirements  will be  met.                                                               
They are  working on procuring an  electronic document management                                                               
system to eliminate paper files.                                                                                                
                                                                                                                                
CHAIR WILSON asked  if that is in addition to  the current system                                                               
and what is  the status of the transition from  one system to the                                                               
other.                                                                                                                          
                                                                                                                                
MS. O'BRIEN  said the  eligibility system  is called  ARIES. They                                                               
have two systems. Medicaid is  done through the ARIES system. The                                                               
legacy   system   EIS   is  for   all   the   other   eligibility                                                               
determinations. They  are moving forward with  the development of                                                               
ARIES. The  electronic document management system  will accompany                                                               
both of those  systems. The intent is that  whatever is purchased                                                               
will  interface with  the other  systems as  well as  offer other                                                               
efficiencies they don't have, such  as an electronic notification                                                               
process.                                                                                                                        
                                                                                                                                
CHAIR  WILSON said  that is  the possibility  of three  different                                                               
systems. He asked  how efficient that is. This year  he has heard                                                               
about 27 different database upgrades  for the state of Alaska. It                                                               
would  be  wonderful if  the  divisions  could work  together  to                                                               
upgrade  systems. These  are all  databases. He  hoped they  were                                                               
working  with  the  Department of  Administration  to  centralize                                                               
this.  He  questioned  how  they can  continue  the  approach  of                                                               
independent contracts all doing one database at a time.                                                                         
                                                                                                                                
MS. O'BRIEN  said they are looking  at using the same  system the                                                               
Department of Revenue purchased  for the permanent fund dividend.                                                               
It will just  manage paper to make their process  a paperless one                                                               
without any paper  files spread out across the  state. The intent                                                               
is  for  efficiency and  they  are  working  with the  Office  of                                                               
Information  Technology at  the Department  of Administration  to                                                               
utilize the existing vendor they  have already authorized for the                                                               
state.                                                                                                                          
                                                                                                                                
2:49:07 PM                                                                                                                    
CHAIR WILSON said  he was glad to hear that  because not everyone                                                               
in the state is  doing that. In terms of staff,  last year a bill                                                               
increased staff.  He asked  about the status  of hiring  for that                                                               
staff.                                                                                                                          
                                                                                                                                
MS.  O'BRIEN  said  they  have  hired  all  but  eight  of  those                                                               
positions.  An  additional  20 were  authorized  in  last  year's                                                               
session. They  are in different  stages of training.  The backlog                                                               
has diminished.  They still anticipate needing  the staff because                                                               
they want  to stabilize  the workforce  while they  implement the                                                               
document management  processes. That will  take about at  least a                                                               
year  to implement  because of  the  number of  paper files  now.                                                               
Through  other  efforts,  whether  through  the  proposed  budget                                                               
reductions  or other  mandates,  they will  have  an increase  in                                                               
workload  this   summer.  As  they  make   their  processes  more                                                               
efficient,  such as  through  technology  enhancement, they  will                                                               
continue looking at the workforce  to see how they stabilize over                                                               
the next  year. The priority  of the division is  stabilizing and                                                               
evaluating   staffing   needs   after  addressing   the   backlog                                                               
completely.                                                                                                                     
                                                                                                                                
COMMISSIONER DESIGNEE CRUM said that  when he was taking tours of                                                               
facilities within the  department, he stopped at  the Division of                                                               
Public Assistance. In Wasilla alone  there is a 1,400 square feet                                                               
room  with filing  cabinets  and banking  boxes  to the  ceiling.                                                               
There is  so much  manual processing  within the  department that                                                               
these modernization efforts will take  a long time, but they will                                                               
make  the   search  system  much   faster  and   allow  increased                                                               
responsiveness.                                                                                                                 
                                                                                                                                
MS. O'BRIEN said their training  delivery method is under review.                                                               
They  are  looking  to  reduce  travel  costs  for  training  for                                                               
eligibility staff. It  can take up to one to  two years to become                                                               
fully competent  in all the  eligibility determinations. It  is a                                                               
complex  process.  They will  have  designated  trainers in  each                                                               
office so  they can start  training staff  from the day  they are                                                               
hired, rather  than having them  work on other things  until they                                                               
can attend training.                                                                                                            
                                                                                                                                
2:52:32 PM                                                                                                                    
SENATOR COGHILL said turning the corner  on the backlog will be a                                                               
big deal.  He asked what the  pay ranges are for  the eligibility                                                               
technicians.                                                                                                                    
                                                                                                                                
MS. O'BRIEN  said the  lowest level  eligibility technician  is a                                                               
range 14 and is expected  to know complex rules about eligibility                                                               
and keep up  with any changes. It is about  $86,000 annually with                                                               
benefits included.                                                                                                              
                                                                                                                                
SENATOR BEGICH asked what the take home pay is.                                                                                 
                                                                                                                                
MS. O'BRIEN replied that is about 30 percent less.                                                                              
                                                                                                                                
SENATOR COGHILL said he wanted  to give a shoutout to eligibility                                                               
technicians because they and the DMV are the face of Alaska.                                                                    
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM said the  mission of the  Division of                                                               
Public Health is  to protect and promote the  health of Alaskans.                                                               
This  division  manages a  lot  of  Medicaid systems  and  setup,                                                               
electronic  interfaces.  He  asked   if  the  committee  had  any                                                               
questions  about  this division  and  their  Medicaid budget  and                                                               
goals.                                                                                                                          
                                                                                                                                
2:54:32 PM                                                                                                                    
CHAIR WILSON  said they  are working  hand-in-hand with  CMS with                                                               
the  new  waivers. He  asked  if  they  are  looking at  any  new                                                               
waivers. That  would help with  any guesstimates  about approvals                                                               
from CMS.                                                                                                                       
                                                                                                                                
COMMISSIONER DESIGNEE CRUM  answered that it is  a combination of                                                               
differ waivers.  He was proud  to announce that they  are meeting                                                               
with CMS  Administrator Seema Verma  that week. They will  have a                                                               
better idea of the timeframe in  the coming weeks. Next week they                                                               
will try to  release phase one, cost  containment strategies that                                                               
they  know they  can  achieve  in FY20.  Phase  two  will be  the                                                               
larger,  grand scheme  change, the  overall plan.  Primary levers                                                               
for  phase  one will  be  rate  adjustments, service  utilization                                                               
adjustments,   program   and   administrative   adjustment,   and                                                               
maximizing levers in order to retain the individuals on that.                                                                   
                                                                                                                                
CHAIR  WILSON  said  currently,   the  budget  has  decreases  in                                                               
Medicaid  pending. Hopefully  they will  have these  waivers, but                                                               
they have  to set prices  in the budget  by July  1 to go  out to                                                               
providers. They may not get an answer from CMS by July 1.                                                                       
                                                                                                                                
COMMISSIONER DESIGNEE CRUM said a  lot of Medicaid dollars on the                                                               
federal side  have a  lot of  approvals tied  to them.  Phase one                                                               
will be about  things they have control over, such  as state plan                                                               
amendments that they  have already verified or  are verifying now                                                               
with CMS. They  are getting a lot of answers  this week that they                                                               
will give to the House next week.                                                                                               
                                                                                                                                
CHAIR WILSON said  he would rely on Senator Coghill  to follow up                                                               
in the HSS subcommittee process.                                                                                                
                                                                                                                                
SENATOR BEGICH said he wanted to  refer to the first slide, which                                                               
was  about protecting  and promoting  public health  and welfare.                                                               
Saving money for  the state in public health shifts  that cost by                                                               
reducing  medical coverage  for people  who can't  afford it  and                                                               
pushes   them   back   into  emergency   room   care.   That   is                                                               
counterintuitive to  him. Commissioner Crum  should keep  that in                                                               
mind. If it is only a  dollars-and-cents issue, he asked why they                                                               
are letting $452 million go.                                                                                                    
                                                                                                                                
SENATOR  COGHILL said  last year  as  they were  wrapping up  the                                                               
session, they  had a  $45 million surprise.  He would  rather not                                                               
see that, so  he asked Commissioner Crum to keep  them abreast if                                                               
he knew of anything big coming.  That was a shocker for them. The                                                               
first round was $90 million and then cut to $45 million.                                                                        
                                                                                                                                
SENATOR  GIESSEL said  she wanted  to  comment as  a health  care                                                               
provider about  promoting and protecting the  health of Alaskans.                                                               
The  second to  last bullet  on  slide 4  says "promote  personal                                                               
responsibility  and  accountable  decisions by  Alaskans."  As  a                                                               
health care provider, she cannot  make someone well. She can help                                                               
them become  well by providing  tools to make  personal decisions                                                               
and take on  responsibility for their health. No  amount of money                                                               
is going  to promote  and protect the  health of  Alaskans unless                                                               
they  are taking  personal responsibility  and being  accountable                                                               
for themselves. She just had to say that.                                                                                       
                                                                                                                                
CHAIR  WILSON   said  they   will  schedule   the  rest   of  the                                                               
presentation for a later time.                                                                                                  
                                                                                                                                
COMMISSIONER DESIGNEE  CRUM said this  part of the  process makes                                                               
them  better  as  they understand  the  importance  of  outcomes,                                                               
particularly  with  positions.  He  appreciates  the  distinction                                                               
Senator  Begich made  about what  are the  efficiencies they  are                                                               
trying to gain.  It is about making what they  do as efficient as                                                               
possible so they can help even more individuals.                                                                                
                                                                                                                                
3:01:02 PM                                                                                                                    
There being  no further  business to  come before  the committee,                                                               
Chair  Wilson adjourned  the Senate  Health  and Social  Services                                                               
Standing Committee at 3:01 p.m.                                                                                                 
                                                                                                                                

Document Name Date/Time Subjects
Senate HSS March 13 Dept Overview Presentation.pdf SHSS 3/13/2019 1:30:00 PM
DHSS Departmental Overview by Comm. Crum