Legislature(2009 - 2010)Anch LIO Conf Rm
11/03/2009 01:00 PM Senate HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| Review: Centers for Medicare & Medicaid Services Moratorium | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
ANCHORAGE
November 3, 2009
1:06 p.m.
MEMBERS PRESENT
Senator Bettye Davis, Chair
Senator Joe Paskvan, Vice Chair
Senator Johnny Ellis
Senator Fred Dyson
Senator Joe Thomas
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
Review: Centers for Medicare and Medicaid Services Moratorium
HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record.
WITNESS REGISTER
REBECCA HILGENDORF, Director
Division of Senior and Disabilities Services
Department of Health and Social Services (DHSS)
POSITION STATEMENT: Delivered presentation on Medicare and
Medicaid services in Alaska.
JON SHERWOOD
Medicaid Special Projects
Division of Health Care Services
Department of Health and Social Services (DHSS)
Juneau, AK
POSITION STATEMENT: Provided information related to Medicare
and Medicaid services.
JIM BECK, Executive Director
Access Alaska
POSITION STATEMENT: Testified as to how the moratorium affected
PCA services.
KAY BRANCH, Coordinator
Elder Health
Alaska Native Tribal Health Consortium
POSITION STATEMENT: Testified as to how the moratorium affected
tribal health organizations.
SANDRA KOTTLE, representing her daughter
POSITION STATEMENT: Provided personal perspective of the
difficulties receiving Medicare and Medicaid services.
DENISE DANIELLO, Executive Director
Commission on Aging
POSITION STATEMENT: Commented about the value of home and
community based Medicaid services.
SHARON HOWERTON CLARK, Chair
Alaska Commission on Aging (ACOA)
POSITION STATEMENT: Stated support for DHSS in its efforts to
resolve the problems that led to the Medicaid waiver moratorium.
GWEN LEE, Executive Director
The Arc of Anchorage
Anchorage, AK
POSITION STATEMENT: Gave a provider's prospective of the broken
system.
RUTH NIMS, representing herself
POSITION STATEMENT: Testified that she had been denied chore
services and has had a hard time understanding why.
JOANNE WEISE, care coordinator
POSITION STATEMENT: Described the SDS denial of service that
placed Ms. Nims in great hardship.
DUANE WISE, Environmental Modification Contractor
KaJo Services, LLC.
POSITION STATEMENT: Testified from the perspective of a
Medicaid service provider.
JOANNE WISE, Care Coordinator
POSITION STATEMENT: Testified about the status of life after
the moratorium.
SHARON METTLER
Assisted Living Industry
POSITION STATEMENT: Testified as to how the moratorium affected
assisted living.
BRIAN RICHARDSON, CEO
Immediate Care
POSITION STATEMENT: Testified as to how the moratorium affected
PCA and respite services.
ACTION NARRATIVE
1:06:05 PM
CHAIR BETTYE DAVIS called the Senate Health and Social Services
Standing Committee meeting to order at 1:06 p.m. Present at the
call to order were Senators Ellis, Thomas, and Davis. Senators
Paskvan and Dyson arrived soon thereafter.
^Review: Centers for Medicare & Medicaid Services Moratorium
CHAIR DAVIS announced the business before the committee is a
review of the Medicare and Medicaid services moratorium.
1:07:09 PM
REBECCA HILGENDORF, Director, Division of Senior and
Disabilities Services, Department of Health and Social Services
(DHSS), said the Medicare and Medicaid Services moratorium was
imposed on June 26. It was lifted for personal care services on
August 6 and for waivers on August 28. She introduced the
department members who were available to assist with questions.
1:09:26 PM
Senator Dyson joined the committee.
MS. HILGENDORF said her presentation will provide an overview of
senior and disabilities services including a timeline of events,
a summary of contributing factors, the current situation,
corrective action plans, short-term strategies, and the context
for the Alaska plan moving forward.
SENATOR ELLIS said the committee is trying to understand "why in
the heck everything takes so long." In an effort to answer that
question, he asked her to address as she goes along whether she
has enough staff; whether the federal rules slow things down;
whether the AG's office responds too slowly, or if it's that the
governor gives poor direction.
MS. HILGENDORF replied she hopes it will be evident in the
presentation, but there isn't a problem with the AG's office.
That office always provides immediate response and is very
helpful.
1:11:56 PM
MS. HILGENDORF outlined the major 2003 DHSS reorganization that
created the Division of Senior and Disabilities Services.
Medicaid functions and budget and policy issues related to
seniors and disabled persons were consolidated into that new
division. The mission is to "Promote the independence of Alaskan
seniors and persons with physical and developmental
disabilities." The core services include, "Institutional and
community based services for older Alaskans and persons with
disabilities; [and] protection of vulnerable adults."
Today she will only focus on Medicaid services the division is
responsible for including: home and community based waiver
Medicaid services programs, care coordination, personal care
assistance, nursing home authorization, and quality assurance.
MS. HILGENDORF said Medicaid has evolved to allow the state to
provide long-term care services that enable people to live in
their homes and communities. This allows choice and is less
expensive than services in an institutional setting. Both home
and community based services waivers and personal care
assistance give people the choice of where they live and the
services that they receive.
Alaska has four Medicaid waivers that began in 1994: 1) adults
with physical disabilities; 2) older Alaskans; 3) children and
adults with developmental disabilities; and 4) children with
complex medical conditions. Reimbursable waiver services include
care coordination, chore services, adult daycare, day
habilitation, environmental modifications, intensive active
treatments, meals, respite care, residential support,
specialized equipment, specialized private duty nursing,
supported employment, and transportation.
Care coordinators help the applicant initiate the eligibility
determination process, develop the plan of care designed to meet
specific needs, and ensure the person's health welfare and
safety.
Personal care assistance is typically provided in the home by
healthcare paraprofessionals. An individual's limitations are
assessed to determine which services they are eligible to
receive and then the services are prior authorized. The division
certifies qualified agencies as PCA providers and people can
receive PCA services either through an agency or through the
consumer direct model.
The division is also responsible for the initial admitting
authorizations of Medicaid eligible applicants to 1 of the 15
skilled nursing facilities in the state. The over 700 nursing
home beds have an average annualized per person cost of more
than $197,000.
The quality assurance unit oversees the senior and disability
services certification and licensing staff and investigates
complaints against licensed service providers statewide. The
unit works closely with Adult Protective Services, the Office of
the Long-term care Ombudsman, Medicaid Fraud and Control Unit,
and Assisted Living Licensing.
1:17:42 PM
MS. HILGENDORF displayed a pie chart showing the number of
clients accessing the various services and programs under the
Division of Senior and Disabilities Services. Senior grants
represent 54.7 percent and serve 15,590 people; personal care
assistance services represent 11.6 percent and serve 3,307
people; developmental disabilities grants represent 6.6 percent
and serve 1,819 people; nursing homes represent 6.4 percent and
serve 1,819 people; adult protective services represent 5.6
percent and serve 1,603 people; older Alaskans waiver represents
4.7 percent and serves 1,338 people; mental retardation
developmental disabilities waiver represents 4.3 percent and
serves 1,213 people; adults with physical disabilities waiver
represents 3.2 percent and serves 1,213 people; adult protective
services general relief represents 2.0 percent and serves 577
people; and children with complex medical conditions waiver
represents .8 percent and serves 228 people.
1:19:01 PM
FY09 expenditures for Senior and Disabilities Medicaid Services
totals $298,841,000. The breakdown is as follows: nursing homes
$80,515,600 or 26 percent; personal care assistance $76,847,200
or 24 percent; and waivers $141,478,700 or 49 percent.
In September 2009 there were 3,676 home and community based
waiver recipients. "Earlier I mentioned that 3,307 people were
receiving personal care assistance for a total of about 7,000
people receiving either waiver or personal care assistance
services in Alaska," she said.
MS. HILGENDORF provided the following timeline of events:
· June 2005 HB 67 passed with intent language specific to
personal care assistance services.
· April 2006 the Division of Senior and Disabilities Services
implemented new personal care assistance regulations.
Other major activities on the timeline were associated with the
backlog of assessments either as a contributing factor or as a
response to dealing with the backlog. She highlighted that a
repository of information on the history of the reassessment
backlog does not exist. To gather information for this
presentation, she drew from a wide variety of sources.
MS. HILGENDORF displayed a graph to illustrate the growth in
access and popularity of PCA services. These services were
established in Alaska in 1986 and expanded in 2001 to offer
recipients the choice of hiring and managing their own PCA,
known as consumer directed personal care assistance.
· In 2000 PCA served 1,300 clients at a cost of $7.6 million.
· In 2005 PCA served over 3,800 clients at a cost of about
$80 million.
1:23:17 PM
In 2005 the 24th Legislature directed DHSS, in the FY06
operating budget, to make regulation changes to control the
costs of PCA services. HB 67 had 14 points in the intent
language, directed at the Division of Senior and Disabilities
Services, to slow and manage the growth of PCA services so there
would be no significant reduction in services in the future. The
changes in the regulations implemented in April 2006 were
designed to make PCA services more effective, accountable, and
ensure that those needing the services received them.
The regulatory response to the legislative intent language
included:
· Defining and clarifying the scope and purpose of the PCA
services.
· SDS piloted, modified, and adopted a new personal care
assessment tool (PCAT).
· A physician certification of medical condition was
required.
· SDS started conducting the assessments.
· Standby assistance was narrowly defined.
· All PCA services required prior authorization.
· Client eligibility requires substantial assistance in two
activities of daily living.
· Availability of formal and informal resources was
reestablished.
· PCA provider training, education, experience, and Medicaid
certification was defined and required.
· The shared living rule was defined.
· The responsibilities of the consumer directed personal care
agencies were clarified.
· Direct solicitation of clients from other PCA agencies was
prohibited.
When SDS was first formed in 2003 it tracked information using
40 different databases and spreadsheets that were neither
standardized nor linked. By 2006 the data systems were reduced
to 21. A business analysis was conducted to identify the various
information technology challenges faced by the division.
Recommendations that came from that analysis were to be used as
a basis for future system development.
MS. HILGENDORF highlighted for Senator Ellis that the division's
technology challenges - data or lack of data - have been both
part of the problem and solution and are a big reason that
things take so long.
The 2006 business analysis identified secondary Access and Excel
data systems for which there was little to no support. The
confusing maze of data systems, the changes identified in the
new PCA regulations, and 3,000 PCA participants coming into the
SDS system all at once from numerous providers made it clear
that the waiver and PCA assessment processes were in significant
trouble.
Most of the databases have been assimilated into DS3, the
acronym for the Division of Senior and Disabilities Services
data system, she said. In July 2006 another business analysis
was completed that related specifically to the assessment
processes. In August 2006 the operational data was centralized
onto the DS3 server. This framework allowed for the maintenance
of client demographic information and was web enabled. Legacy
data was migrated to create a master client index and
application interfaces were developed so staff could continue to
conduct timely and accurate daily business activities. Duplicate
client records were eliminated for those clients who received
both waiver and PCA services. Because both databases had flat
file architecture, new data overwrote existing data and there
was only one year of data in each system.
1:27:11 PM
DS3 was deployed primarily to support the assessment processes
and data holes continued to plague the system. In July 2007 a
professional programming services contract began in support of
the continued development and maintenance of the DS3. For the
next two years efforts focused on:
· Converting the existing data structure to one that adhered
to DHSS coding standards and migrated to a Microsoft
programming standard.
· Creating a system to manage provider entities.
· Building a system to assist with managing PCA services.
· Building a system to manage the assessment process,
including scheduling.
· Creating business processes and information technology
supports for adult protective services investigations.
· Developing the electronic consumer assessment tool.
· Improving the functionality of the PCA prior authorization
system.
· Long-term care capabilities that would allow nursing homes
to use DS3 for transmission of nursing home applicant
information were built into the system.
DS3 allows electronic processing of information directly related
to program management. It currently serves about 150 users,
contains client records for about 16,000 individuals, and logs
about 15,000 database actions per day. This centralization of
data management activities has helped bring SDS operational
capabilities into alignment with DHSS regulatory and policy
objectives.
1:30:36 PM
MS. HILGENDORFF made the following points regarding the 2006
assessment backlog:
· April 2006 the new PCA regulations went into effect.
Previously, the state reviewed about 300 plans per year and
the new regulations required prior authorization on every
plan. Over 3,000 recipients came in from agency assessors
with no documented processes to manage the influx of people
and information.
· By June 2006 the contractor was failing to keep up. By
August SDS suspended the use of the PCA tool for
reassessment and directed the contractor to focus on new
assessments. The state extended services.
· By August 2006 the backlog of PCA assessments was 700 and
waiver assessments were behind by 200.
· SDS considered phasing out the contract in order to perform
assessments in-house. A long-term care study indicated that
the state should manage all waiver services through direct
control of screening and assessments on a cost neutral
basis. The new system in which services were approved or
disallowed necessitated a more detailed comprehensive
review of plans that placed the legal obligation of
defending actions into the hands of the state and not a
contractor. The proposal for a phased-in approach was never
implemented.
· In September 2006 the division allowed RNs employed by the
providers to perform assessments. About 8 providers chose
to participate and completed a total of approximately 50
assessments per month. A reclassification of state-employed
nurses did not include nurse assessors of senior and
disability services so they did not benefit from the pay
increase. This further exacerbated the division's inability
to recruit and retain RN assessors.
· In October 2006 authorizations for PCA and waivers were
extended while SDS focused on completing initial
assessments. The extension was deemed the only mechanism
available to avoid undue hardship for participants and
providers.
· SDS estimated that the assessment backlog would be caught
up by the end of June 2007.
1:34:18 PM
MS. HILGENDORF displayed a bar graph showing the number of PCA
fair hearings in 2005 through 8/31/09. Fair hearings are a
formal process by which Medicaid applicants or participants may
get due process and dispute the state's findings related to
denial of care or reduction in services. The individual may
appear with legal representation before a professionally trained
hearing officer who will weigh the evidence and make the final
decision. Typically these hearings are preceded by a less formal
pre-hearing to allow exchange of information that frequently
leads to a resolution thereby negating the need for a fair
hearing. In 2005 there were only 25 PCA fair hearings, but when
the PCA regulations changed in early 2006 the number of hearings
jumped to 429. 2007 was the all time high with 875 hearings and
reflected the dissatisfaction with the 2006 change in
regulations and the impact they had on service access. She
reminded the committee that prior to the change in regulations
there was no eligibility status review and most recipients
received 35 hours [of service] per week. About 3,000 people
entered the system when the regulations changed and they were
assessed by an RN with a new assessment tool. Some didn't meet
eligibility criteria and others experienced a reduction or
denial of services.
In 2007 SDS had just two nurse assessors working fulltime on pre
and fair hearings, which contributed to the assessment backlog.
The other SDS nurses did waiver assessments, reviewed
reassessments and new assessments coming from contract nurses,
and reviewed and approved nursing home authorizations. The
dramatic drop in hearings after 2007 is believed to be the
result of better explanation of services by the assessors to the
clients. Current SDS training is producing more consistency and
reliability than when the assessments were contracted out.
1:37:26 PM
In May 2007 SDS stopped assigning assessments to agency nurses
because the contractor had hired additional staff and had
adjusted workloads. In October 2007 the assessment contract came
up for renewal and after some analysis SDS proposed to hire 12
state assessors and contract with 10 other assessors to manage
the almost 6,000 assessments being performed annually. The
budget analysis indicated that the state could save about $.25
million by doing the assessments itself and so SDS assumed that
responsibility in November 2007. A senior manager and four staff
were reassigned to the assessment unit and additional assessors
were hired with the expectation that all assessments would be on
target and on time by January 2008.
1:39:26 PM
MS. HILGENDORF displayed a slide summarizing the contributing
factors for the system being overwhelmed since 2003 when SDS was
formed.
· There was no well-developed plan or documented processes to
manage the 2006 PCA regulation changes.
· The PCA assessment tool and PCA eligibility criteria was
changed.
· There was a change in the assessment administration.
· All PCA services must be preauthorized.
· There was no database.
· There were ongoing difficulties recruiting/retaining RNs.
The vacancy rate was nearly 40 percent and sometimes
approached 50 percent.
· Demands for fair hearings skyrocketed with the regulation
changes.
· There was and continues to be a duplication of effort. For
example, a person may request both waiver services and
personal care assistance services. Both require a different
assessment and different service plan.
· Last winter SDS nurse assessors responded to a crisis at
the Mary Conrad Center. They did comprehensive assessments
on all the residents to ensure that they received the right
treatment and care.
· During the hiring freeze last year SDS was only allowed to
hire and fill vacancies in the adult protective services
unit.
· Since 2003 when SDS was formed it has had 3 directors and 5
PCA managers and is currently recruiting for the 6th PCA
manager.
· Lack of continuity, focus, and direction has contributed to
delays in integrating systems and developing standard
operating policies.
MS. HILGENDORF explained that the backlog of assessments was
discussed in a March 2009 teleconference with the centers for
Medicare and Medicaid services Region 10. In May an onsite
review was conducted and on June 26 a preliminary findings
report was issued. A moratorium was imposed so no new
participants could be admitted to the four waiver programs or to
PCA services. The Division of Senior and Disabilities Services
was found to be out of compliance with all required assurances
and was ordered to develop a corrective action plan, to
participate in mandatory training, and to access technical
assistance.
1:42:47 PM
SENATOR ELLIS asked why the turnover in the position of PCA
manager is so high.
MS. HILGENDORF replied some of the reasons for leaving include
returning to their home state, the job being overwhelming and
chaotic, a lack of resources, and better pay in a different job.
High turnover and the lack of a well developed plan certainly is
a contributing factor to things taking longer, she added.
CHAIR DAVIS asked why problems weren't addressed until things
got to the point that the federal government had to step in and
impose a moratorium.
1:45:41 PM
MS. HILGENDORF replied her presentation hasn't yet mentioned
that many people were and are working hard to resolve these
issues. When SDS was established senior services and
developmental disabilities were combined and that resulted in a
culture clash. Since that time they've been working to integrate
processes without having a framework to follow. Also, each of
the managers, herself included, have had different work
identified and have worked under different administrations that
have had different priorities. People who have worked at SDS and
in the department haven't been ignorant of the problems. They
have been trying to resolve issues and can always use additional
resources.
CHAIR DAVIS asked if she has asked the Legislature for
additional resources.
MS. HILGENDORF answered yes, part of the SDS director's job is
to identify resources and bring them forward. But there's a lot
of competition for resources and the directors haven't always
gotten what they asked for.
CHAIR DAVIS asked if the requests were put in the governor's
budget or if the Legislature had been approached directly.
MS. HILGENDORF replied she has been working as director since
December and this will be her second year submitting an outline
of the human and technology resources that SDS needs.
1:50:15 PM
SENATOR DYSON mentioned the E-CAT (electronic consumer
assessment tool) and asked if that would allow SDS to screen for
fraud.
MS. HILGENDORF answered yes. SDS works closely with the Medicaid
Fraud and Control unit, Assisted Living Licensing, and the Long-
term care Ombudsman Office and it's not uncommon for all those
agencies to work together to investigate fraud. SDS receives
regular training from the [Department of Law] Medicaid Fraud and
Control Unit and reports suspected fraud to that unit.
SENATOR DYSON expressed hope that those cases are vigorously and
publicly prosecuted.
1:54:01 PM
SENATOR THOMAS asked her to summarize, as she goes through the
corrective action plan, whether the action will correct the
system, if it will save money, or if it will create a more
efficient system. He commented that he hopes that the state is
using national consultants and that he would be more comfortable
if the contractors were paid on a bid versus a per capita basis.
MS. HILGENDORF said in the most recent study HDV Strategies Inc.
put together a manual of recommendations for Alaska's long-term
care. SDS decided to modify the recommendations and do the
things it can without any additional resources. She explained
that SDS staff members have done research on what other states
have done and they aren't shy about borrowing good ideas. With
respect to the CMS involvement starting in May, she said SDS has
worked closely with the National Quality Enterprise, a CMS
contractor that provides technical assistance. They are very
aware of best practices and provide advice on how to develop the
system to maximize resources and be more efficient.
1:58:24 PM
MS. HILGENDORF acknowledged that paying the contractor per
assessment was criticized at the time. Changes to the assessment
process include using state assessors that are paid a wage,
adding an educational component, and increased training and
oversight. Assessments can take up to four hours and efforts are
made to include the care coordinator, family members, and
advocates to help ensure that the assessment is comprehensive.
The analysis indicated that the state could do the assessments
on a cost neutral basis. However, that analysis factored in just
$80,000 to $100,000 for assessors' travel and the FY2009 SDS
travel budget was over $300,000. It's not uncommon for it to
cost several thousand dollars to assess a person living in a
small community.
SENATOR DYSON asked if those visits are always preannounced.
MS. HILGENDORF answered yes; that is critical for a
comprehensive assessment. She added that while responding to the
assessment backlog crisis, SDS started assessing seven days a
week.
SENATOR THOMAS said he hopes that the individuals on the ground
have the opportunity to provide input into making the system
more efficient.
2:04:53 PM
MS. HILGENDORF replied that is always a challenge, but they
strive to get feedback from the people who use the services, the
service providers, and the care coordinators. Earlier SDS
conducted community forums and currently is soliciting input
regarding regulatory changes related to home and community based
waivers and PCA. There is need to beef up the quality
improvement work group and to include more stakeholders. CMS has
also suggested expanding membership on the quality improvement
steering committee to include stakeholders. SDS is forming a
provider/stakeholder group to work specifically on the long-term
care plan, but the current focus is on the corrective action
plan.
CHAIR DAVIS recognized that Senator Paskvan had joined the
committee via teleconference.
2:06:30 PM
MS. HILGENDORF continued the presentation highlighting the
current situation.
· SDS and CMS meet weekly to review the program status. SDS
has clarified a number of areas including the
quantification of reassessment backlogs and the management
of the PCA services.
· On August 7, 2009 CMS lifted the moratorium on PCA
applications.
· On August 28, 2009, after receiving assurances from DHSS,
CMS lifted the moratorium on all four waivers.
· On September 3, 2009 SDS submitted a corrective action plan
(CAP) on time and as assured. This was completed after an
extensive effort between SDS staff and the National Quality
Enterprise Technical Assistance Group. A mortality review
report and a fair hearing analysis were also submitted.
· On October 15, 2009 SDS met the deadline for completing the
waiver reassessment backlog and is well on the way to
meeting the December 15, 2009 due date for the PCA
assessment backlog. As of November 14 there were only 298
PCA assessments in the backlog; 627 had been completed.
· The CAP is currently being revised to include more detail.
The target date for approval by CMS is November 20, 2009.
MS. HILGENDORF made the following points with respect to
implementation of the CAP:
· It will include quality assurance measures like developing
performance measures, monitoring for compliance, and
providing for remediation for noncompliance.
· Provider input and education will continue to occur for
performance measures, policies and procedures, and other
changes that impact service provisions.
· Short, mid, and long term business model decisions are
being made and staffing is being adjusted to meet the needs
of the changed system, particularly with the assessment
unit, the quality assurance unit, the waiver unit, and the
information technology unit.
· A waiver plan amendment for the mental retardation,
developmental disabilities reassessment process is under
evaluation.
· Rate setting inconsistencies and methodologies are being
addressed.
· Some changes will take place through regulation.
· Changing the model for mental retardation
developmental disabilities reassessments.
· Utilizing a streamline tool for PCA
reassessments.
· Defining processes that impact providers like
complete application and due date.
· Changing the adults with physical disabilities
waiver to allow habilitation services that are
currently only allowed for people on that waiver
with a developmental disability.
2:10:02 PM
MS. HIGENDORF highlighted the following short term strategies:
· All SDS vacancies will be filled. As of July 2009 non-nurse
assessors will complete the assessments for PCA services.
This will address the backlog and manage the anticipated
growth of the service. RN assessors will continue to assess
and determine the level of care for waiver applicants. To
address the backlog assessors were recruited from other
divisions within DHSS, SDS staff was reassigned, and SDS
received approval to hire 30 non-permanent assessors. Those
positions will remain open until the backlog is resolved.
Eight non-permanent office assistants were also hired to
provide administrative support.
· Streamlined processes include:
· Creation of the electronic waiver assessment tool
as well as implementation of an offline tool.
· The refined PCA assessment tool is currently
being piloted.
· Some assessment processes have been automated
· A refined mortality review process has been
implemented.
· Fair hearings are being resolved based on
clarified eligibility criteria that now conform
to the PCA state plan.
2:12:09 PM
MS. HILGENDORF said the context for the Alaska Plan moving
forward includes planning for a continued increase in
population, particularly older Alaskans. She displayed a slide
illustrating that in 2010 about 80,000 Alaskans will be over the
age of 60 and by 2030 that number will have grown to 150,000.
Alaskans over age 85 are expected to grow from about 5,000 in
2010 to over 12,000 in 2030. SDS believes that the number of
people with physical and developmental disabilities will also
grow and they will require additional support to stay in their
homes and communities.
2:13:19 PM
MS. HILGENDORF said that improving quality management is a
primary focus as SDS develops and implements the corrective
action plan. In the next 18 months SDS will need to build a
management system that is consistent with the CMS framework.
This will include identifying and selecting performance
indicators, collecting data on those indicators, creating
management reports, circulating information to individuals who
can influence quality, and developing systematic processes for
using the information. SDS is preparing to submit waiver
renewals prior to July 1, 2011 using quality standards that are
different than those used in the 2006 submission. The work of
the corrective action plan will help move SDS where it needs to
be in order to meet the new standards.
2:14:13 PM
MS. HILGENDORF highlighted the other initiatives that have been
incorporated into the corrective action plan as follows:
· Updating provider manuals.
· Making online training available.
· Establishing greater infrastructure to verify that services
are provided as prescribed.
· Establishing and implementing processes for evaluating
access to and quality of services.
· Utilizing alternative approaches to verify the background
of direct-care staff.
· Revising licensing and certification processes for assisted
living homes.
· Expanding information technology, building off DS3.
· Expanding the aging and disabilities resource centers as a
one-stop-shop resource for information, referral, and
access to necessary services.
· Utilizing a stakeholder advisory committee.
2:15:04 PM
SENATOR DYSON mentioned that the foster system is a good
business for some, and asked if the Legislature needs to do
something to help SDS avoid wrong incentives.
MS. HILGENDORF replied PCA is very important to people and the
growth of the program can be attributed to the fact that people
really want and need it. Because SDS didn't have a plan or
process things got out of whack, but it is working to map out
processes, establish policies, procedures and program memos, and
posting them. More training is being given and SDS is gearing up
the quality assurance unit to do more site visits to meet with
providers and offer technical assistance. She maintained that
most people are trying to provide a necessary service and they
should get a decent wage for doing so. There will always be
people who try to take advantage of the system but they will
likely be identified sooner as opposed to later.
SENATOR DYSON asked if the 38 new hires are in the upcoming
governor's budget.
MS. HILGENDORF replied those are short-term non-permanent
positions that coincide with the December deadline. She has
identified a number of positions that are needed in all units of
senior and disabilities services. With respect to the Medicaid
portion, a lot of needed resources have been identified in order
to move forward and manage the anticipated growth in the senior
population and general Alaska population.
SENATOR DYSON asked if these needs will be in the governor's
budget.
MS. HILGENDORF answered she hopes so.
CHAIR DAVIS asked if a request has been made.
JON SHERWOOD, Medicaid Special Projects, Division of Health Care
Services, Department of Health and Social Services (DHSS),
explained that the governor's budget is in the confidential
deliberative process and isn't yet public.
CHAIR DAVIS clarified that the Senator asked if the request was
made, not if it made it into the budget.
MR. SHERWOOD deferred on specifics and added that Ms. Hilgendorf
said she considered the resources she needs and has put that
forward for consideration.
2:23:54 PM
CHAIR DAVIS said she appreciates his answer, but the committee
wants to explore this further.
MR. SHERWOOD agreed to take the question back to see what
information he can provide.
SENATOR DYSON said he hopes that in this administration
departments will fight vociferously for perceived needs.
SENATOR PASKVAN referenced slides 20 and 7 and asked if SDS
believes that FY07 and FY08 were statistical anomalies and that
the increased expenditures are more in line with slide 20, which
shows increasing populations of Alaskans age 60 and age 85.
Therefore, it's appropriate to send a number that's greater than
$76.8 million, which is the FY09 number.
2:26:39 PM
MS. HILGENDORF said slide 7 shows that PCA services spiked in
FY06 and then went down in FY07 and FY08. What it doesn't show
is that the numbers are going up again, which reflects the
increase in Alaska's population.
SENATOR PASKVAN asked if it's fair to say that future growth may
be higher than the FY06 number as compared to the statistical
anomalies, which were lower numbers.
MS. HILGENDORF said, based on population growth, she believes
they'll see the PCA expenditures reach the FY06 level again in
the next few years, and they'll continue to go up after that.
2:28:34 PM
SENATOR PASKVAN asked if DHSS has an estimate of the number of
people who will need PCA services in FY11, which is the budget
that legislators will look at very soon.
MS. HILGENDORF said she believes that in FY11 about 3,500 people
will need PCA services.
SENATOR PASKVAN asked if that is approximately the same as FY08.
MS. HILGENDORF answered yes.
2:29:49 PM
MS. HILGENDORF thanked the DHSS leadership team for their
support and recognized the technical guidance from CMS and the
National Quality Enterprise Group. She also thanked the various
providers who make it work for people. Acknowledging that the
last few months have been rough, she expressed appreciation and
gave special recognition to the committed SDS staff. "It's
because of their effort, in large part, that the moratorium came
to a close," she said. She also recognized the Alaskans who
utilize these services and committed SDS to build a system that
will provide high quality, professional, and responsive
services.
MS. HILGENDORF maintained that the road map and the detail
provided in the corrective action plan will serve as a solid
foundation going forward.
CHAIR DAVIS said the committee isn't questioning what is or has
been done but believes that the public has a right to know what
happened and what it can do to assist.
At ease from 2:35:16 PM to 2:43:20 PM.
2:43:29 PM
CHAIR DAVIS opened public testimony.
JIM BECK, Executive Director, Access Alaska, said he would focus
on the PCA program and part of that is looking at how the
federal government came to shut down new applications to the
"precious Alaskan home and community based services programs."
In 2005 SDS didn't listen to outside experts or providers. Prior
to the 2006 regulation changes individuals, experts, and
providers repeatedly told SDS it could not do the assessments as
planned because it didn't have the capacity. He further pointed
out that it didn't take a medical professional to do a
functional assessment.
Some of the regulation changes, like prior authorization, were
good but it was obvious that they would slow the system to a
crawl. Access Alaska hoped that SDS would implement that in a
way that would work. He's pleased that the division is looking
at a different assessment tool because currently it is inhumane
and intrusive.
2:46:23 PM
Referencing the spike in the number of PCA fair hearings in
2007, he said the number of successful lawsuits clearly
demonstrates that the division was cutting hours when there
hadn't been a change in the recipients' condition. Service hours
were being reduced, sometimes for no plausible reason.
MR. BECK said there is an ongoing issue related to the time
required for processing and completing assessments, particularly
in rural Alaska. Many elders at the village level have given up
on the PCA program because it's slow, bureaucratic and doesn't
meet their needs. It's a shame that it's forcing some people to
end their lives in a nursing home rather than at home next to
the river. "We can do better than that, I'm sure of it," he
said.
He pointed out that there continues to be a bottleneck in
processing the assessments. It's fantastic that SDS has
completed some 600 assessments but they aren't being processed,
he said. "We have several in our organization that haven't been
touched since late June." Someone who has a fast moving disease
or disability will need to be reassessed before they receive
services, which places an additional burden on the assessment
need.
2:48:45 PM
MR. BECK said he hopes that the Legislature sees the need for a
solid PCA program. Multiple studies recommend strong home and
community based services and PCA services. The National Council
on State Legislatures looks at these programs as cost
containment tools for long-term care spending, which is fabulous
because this is where people want to receive services. He noted
that a fairly instructive 2004 legislative research report
looked at what it would cost if the PCA program was shut down.
It shows what would happen if the state failed to address the
growing need for long-term care. In 2004 nursing home care in
Alaska cost about $420 per person per day while PCA was $58 per
person per day. If all the people in PCA service at that time
had been served in nursing homes the cost would have been
$383,250,000. Obviously we need a strong, fair PCA and home and
community based services program, he said.
2:50:44 PM
MR. BECK said in-home care is a right granted under the
Americans with Disabilities Act and is supported by the Olmstead
Supreme Court decision. He maintained that the CMS moratorium
pushed the state toward a dangerous position in terms of not
being able to provide in-home care to people who have a right to
it. It was the state's actions that caused the federal
government to step in and impose the moratorium, which kept
people in nursing homes and hospitals unnecessarily.
He said he remains optimistic and believes SDS has the capacity
to listen to its customers. He appreciates the questions about
resources because he doesn't believe that SDS has asked for the
resources it needs. We need to suck it up, pay for good care,
and make sure that people have what they need, he said.
SENATOR ELLIS asked for a brief description of what the blue
button he's wearing stands for.
MR. BECK replied it's in support of establishing in statute a
schedule of regular and periodic rate reviews for home and
community based services as set forth in SB 32.
2:53:02 PM
KAY BRANCH, Elder Health Program Coordinator, Alaska Native
Tribal Health Consortium (ANTHC), said she will submit her
written comments. ANTHC co-manages the Alaska Native Medical
Center and provides statewide health services previously
provided under the Indian Health Service. The overarching goal
is to ensure that Alaska Natives have access to the full range
of long term care services within their home region.
ANTHC appreciates the SDS efforts to conduct timely assessments
and service delivery. However, the assessment is only one step
in the process of providing services. The total time between
submitting a screening and receiving care continues to be
problematic. She provided examples of a client who has been
awaiting services for five months since the initial screening
was submitted and a client who lives in a very remote area and
awaited services for 17 months. She noted that in the second
example a major factor in the delay was the inability to conduct
the assessment while the client was in the Alaska Native Medical
Center in Anchorage. Nor could client information on file at the
tribal health organization be used. Clearly, the ability to
conduct an assessment while somebody is in Anchorage would speed
things along.
2:59:15 PM
MS. BRANCH said although the PCA moratorium was lifted earlier
than the waiver moratorium, a backlog in completing the
assessments and reassessments in the PCA program currently
exists. After the 2006 regulation changes, tribal health
providers could no longer conduct assessments and now clients
and family wait for months before services start. Sometimes this
necessitates making intermediary arrangements such as placing a
loved one in a far away nursing or assisted living home.
As part of the Medicaid Reform Initiative several years ago,
tribal organizations developed a timeline to address the steps
between screening and service delivery. This was included in the
tribal long term care report presented to the state in December
2008 and ensured that services would be provided to a client
within one month of requesting services, given eligibility.
MS. BRANCH noted that in FY08 and FY09 the Alaska tribal health
organizations designed a tribal long term care service
development plan to increase access to both home and community
based and facility services for Alaska Native elders and persons
with disabilities. The report, which was distributed to DHSS in
December 2008, outlines the barriers to delivering services to
Alaska Natives, proposes solutions to increase access to these
programs, and details the benefits of service availability
through tribal health providers. This includes the 100 percent
savings to the state general fund Medicaid budget that is
realized when Alaska Natives are provided services from a tribal
facility. Copies of the report can be found on the ANTHC
website.
MS. BRANCH said that ANTHC looks forward to continued dialog on
how Alaska tribal organizations can participate more fully in
the delivery of long term care services.
3:02:30 PM
SENATOR THOMAS observed that it would seem to be fairly simple
to coordinate an assessment when a remote client is in Anchorage
receiving medical care. He asked if it is her understanding that
such coordination will not be allowed.
MS. BRANCH replied there has been dialog with DHSS but there are
still things to work through.
SENATOR THOMAS asked if it's just technical things that are at
issue.
MS. BRANCH replied other factors, like the moratorium, have
contributed to delays.
SANDRA KOTTLE said she is speaking on behalf of her daughter who
was assessed for personal care and PCA services two months ago.
Two weeks ago her daughter called to check on her status and was
told she needed to call back the following week. Several days
later her doctor told her she has Pancoast cancer; she could
live two days or two years. "As she's continually being turned
down, which process is going to win - the cancer or the process
of being given some help for the time that she has left?"
MS. HILGENDORF provided her phone number and offered to do what
she could to get her daughter into services.
3:07:27 PM
DENISE DANIELLO, Executive Director, Alaska Commission on Aging,
Department of Health and Social Services (DHSS), said she is
testifying in support of the due diligence of DHSS and SDS in
resolving the issues that resulted in the CMS waiver moratorium.
She will also talk about the value of home and community based
services for older Alaskans. Alaska seniors comprise about 12
percent of the state's population and each year that population
is growing between five and six percent.
MS. DANIELLO said about 1,300 older Alaskans are served by the
Older Alaskans Medicaid Waiver Program, which was affected by
the moratorium. This program provides seniors with home
delivered meals, chore help, respite care, transportation
services, care coordination, and other services based on their
health and income. They would otherwise be served by hospitals
and in nursing home settings. She reminded the committee that
Alaska was one of the very first states to emphasize the balance
between home and community based services and institutionalized
care for seniors. Different than other states, Alaska invested
in a continuum of services from community support services to
in-home support, to assisted living and nursing homes. It's an
approach that has been less costly and is more desirable because
it provides services closer to home.
MS. DANIELLO said that in Alaska the cost for a private room in
a nursing home is more than $219,000. The cost for a semi-
private room is $187,000 and the cost for a bed at an assisted
living facility is $60,000. The cost to be served by the Older
Alaskan Medicaid Waiver Program is $22,247, which means a
$40,000-$100,000 savings to the state "That in itself is a way
to control costs for long-term care spending," she said. The
average age of admission to pioneer homes has increased over the
last ten years indicating that home and community based services
work.
3:11:47 PM
MS. DANIELLO said DHSS and SDS responded quickly in the last two
months, but many vulnerable Alaskans did suffer needless
hardship awaiting services prior to and during the moratorium.
Hopefully the system will be improved and the department will be
able to ensure the health and welfare of people on the waiver
system. The Alaska Commission on Aging believes that there
shouldn't be a forced choice between cost controls and
responsive services. DHSS and SDS are encouraged to give high
priority to prompt assessments and service authorizations for
all waiver applicants. "Timely provision of services is the best
key to curtailing costs for the Medicaid program," she said.
3:13:45 PM
SENATOR THOMAS asked if she believes that the population
increases depicted on slide 20 are relatively accurate.
MS. DANIELLO answered yes; those 2007 estimates came from the
Department of Labor. Age 85 and older is the population that is
driving the increase, she added.
SENATOR THOMAS asked the source of the annual cost of care
figures she quoted.
MS. DANIELLO replied the numbers came from the Genworth 2009
Cost of Care Survey.
3:15:23 PM
SHARON HOWERTON-CLARK, Chair, Alaska Commission on Aging (ACoA),
Department of Health and Social Services (DHSS) said ACoA
advocated strongly against the Medicaid waiver moratorium. The
initial six month waiting period to resolve the problem was
totally unacceptable; during the moratorium many seniors
suffered needlessly while providers faced financial hardship. It
is thanks to DHSS Commissioner William Hogan and his loyal staff
that the moratorium, which should not have happened, was lifted
in two months.
3:18:48 PM
GWEN LEE, Executive Director, Arc of Anchorage, said she is
speaking from the provider point of view on living through the
years with a broken system. She reiterated Senator Ellis's
question, "Why does it take so long?" She knows the pain of
families who are waiting. The moratorium was lifted, but there
is still a quiet crisis brewing. Rates have been frozen for five
years and things are ready to boil over.
MS. LEE agreed with Ms. Hilgendorf that lack of continuity and
focus has plagued SDS. She said that same lack of planning and
processes has trickled down to the provider community. The Arc
of Anchorage has experienced difficulty continuing to deliver
quality services, it has problems planning with the board of
directors, it has problems answering the board of directors, it
has problems being competitive with the workforce, and it has
problems instituting and keeping up with technology needs. We
are unable to be patient much longer, she said.
MS. LEE said The Arc of Anchorage has operated with integrity
through the years; it has not brought lawsuits even though the
state pays different service providers differently for
delivering the same service. This is a serious question that has
for years gone unanswered. Until a fair and consistent rate
system is established, problems associated with delivering
services to vulnerable Alaskans will continue. It's time to put
aside the political flack and develop a fair system, Ms. Lee
stated.
3:23:23 PM
SENATOR THOMAS asked for some examples of the inequities of
provider reimbursement.
MS. LEE explained that in the home and community based waiver
system rates were constructed on a person-by-person basis based
on the provider's ability to construct a cost that was accepted
by the state. Providers were in different positions to put the
rates together so there are high rates and low rates. Five years
ago rates were frozen. She believes that the state recognized
that was problematic and that the approach probably had been in
error. We knew those rates weren't accurate, but we were told
that they would be fixed in six months. Four and a half years
later they haven't been fixed.
CHAIR DAVIS reported that SB 32 is in House Finance.
RUTH NIMS, representing herself, said she had been denied chore
and respite services and she has a hard time understanding why.
She is on a waiver and has had chore services.
3:28:18 PM
MS. HILGENDORF explained that the denial is probably related to
duplication of services. She could have access to choir services
through a waiver or through PCA, but not both. Responding to a
further question, she said she would call her tomorrow.
3:30:40 PM
JOANNE WISE, care coordinator for Ms. Nims, described the denial
of service by SDS that placed her in great hardship.
3:33:03 PM
DUANE WISE, Environmental Modification (EM) Contractor, KaJo
Services LLC., said he will provide written testimony. He liked
Senator Dyson's question about Medicaid fraud because there is
no such investigation in Alaska. He said that the regulations on
environmental modifications are clear; they are for the safety,
health and welfare of the recipient. However, the Division of
Senior and Disabilities Services has no policy and procedure
manual for EM services. He provided an example of a dangerous
wheelchair ramp and platform that was signed off. For years he
has asked SDS to put on a training program for EM contractors
but none has been forthcoming. New contractors coming in will be
given no training either, he said.
Two years ago he and other EM contractors were asked to submit
suggestions for the online cost estimate sheets. He did as he
was asked, but the form wasn't changed and it's still not a
requirement for EM contractors to use one standardized form.
Some don't even know that the form is available. He maintained
that the EM program needs to be under the auspices of a person
that knows construction codes and ADA requirements.
Access Alaska has Frank Box; he writes a scope of work for every
project so everyone is bidding on the same thing. No contractor
receives a check until he inspects the work and is sure that the
scope of work has been done. That isn't how the waiver program
works.
CHAIR DAVIS said the committee might want to hear more about
this and she is sure the division is noting his testimony.
MR. WISE said some things are turned down because they are a
deemed a "luxury", but the health safety and welfare of the
recipient might depend on that modification. He cited bathroom
tile and walk-in bathtubs.
3:45:21 PM
JOANNE WISE, Care Coordinator, Wise Care LLC., said she has
clients who after 225 days are still waiting for an approved
plan of care for the waiver. She cited an example of client who
was told she was part of the moratorium, but her level of care
had actually been approved prior to the moratorium. This client
has health and safety issues yet she still doesn't have
services. She cited a second example of a client who is still
waiting for services 77 days after her plan of care was sent for
renewal.
She claimed that the SDS website does not have current staff
information. It isn't clear to whom care coordinators should
address their concerns. The division has stated that it has
completed the required assessments, but her clients still don't
have approved plans of care and are still at risk. What the
division has provided is a new form to report critical
incidents. It appears that statistics are what is wanted, she
said.
On August 26 SDS sent a certified letter to a client stating
that the care coordinator had failed to submit a cost sheet and
therefore the client could either change care coordinators or be
dis-enrolled from the waiver. This shows that the division has
limited respect for care coordinators, she said.
She reported that over half of her clients don't have a current
level of care letter in their files. SDS reported to CMS that it
had corrected these standards, but her clients don't
substantiate this claim. This is a hardship for clients and
providers.
Responding to a question from Senator Davis, she agreed to
provide her written comments to the committee.
3:53:32 PM
SENATOR ELLIS asked if a cost sheet is documentation of actual
costs incurred.
MS. WISE said yes; when the care coordinator and client develop
a plan of care the annual cost for each service is attached in a
cost sheet. She pointed out the fallacy in attaching a cost of
service on the date that the level of care is approved when
there are no services delivered until the plan of care is
approved and prior authorizations are issued.
SENATOR ELLIS asked if the division had asked her for something
that she couldn't provide.
MS. WISE explained that the letter was sent because the care
coordinator hadn't done a close out. "It's a very difficult
working relationship with the Division of Senior and
Disabilities Services. … I'll probably have retaliation on
behalf of my testimony, but … I represent my clients and the
waiver services," she said.
3:56:29 PM
SHARON METTLER, representing the assisted living industry, said
the moratorium affected assisted living a little differently
than it affected PCA programs. She explained that people often
come into assisted living from the hospital as a general relief
(GR) $70/day client that is waiting to be assessed for the
waiver program. Whether or not those people have been assessed,
the assisted living home is still delivering the services as
though it were being paid for waiver services. Also, there are a
lot of people who are nursing home level of care on those
waivers, she said.
3:59:26 PM
MS. METTLER encouraged legislators to visit as many of the 600
some assisted living homes in the state as possible, and to
report the ones that aren't up to standard. Put them out of
business and place the people in good homes. "There certainly
are good homes out there that are providing services that they
are supposed to be providing," she said.
Referring to the DHSS presentation showing the FY09 expenditures
for Senior and Disabilities Medicaid Services, she suggested
that it would be more helpful if it showed a comparison between
the personal care assistant program, the assisted living
program, and the nursing homes. We provide an extremely valuable
service to the state and it's not reflected, she said.
4:03:53 PM
MS. METTLER mentioned the many meetings that have been held
trying to establish a fair rate methodology and said it's a
difficult task. She provided an example of the taxes on a home
in Mountain View versus mid-town and maintained that if the
department had done its job in 2002 on the cost based
reimbursement and had audited homes at the end of that year, the
people who did not perform would be out of business and the
people who did perform would be moving forward and providing a
good service.
4:06:00 PM
BRIAN RICHARDSON, CEO, Immediate Care, said he has been
pleasantly surprised that as a provider the SDS bureaucracy has
been easy to access and helpful on a day-to-day basis. However,
certain dynamics, such as accountability, are not in play. There
is no accountability to providers, PCAs or clients. CMS
addressed this in a June 26 letter to SDS stating, "The Medicaid
agency must satisfactorily provide CMS with the assurance that
necessary safeguards have been taken to protect the health and
welfare of the recipients of the services." CMS investigators
interviewed him and he had to say that SDS had done none of the
following: conducted an inspection at his offices, contacted him
to ask to do an inspection, contacted clients directly to
confirm services have been delivered, interacted with PCAs to
confirm they were actually doing services. SDS does a good job
with us but isn't closing the loop with PCAs and clients, he
said. Also, the use of information technology and databases is
far behind in the SDS program.
He suggested that to facilitate accountability SDS needs 1)
funding for a project team to assist and support organizational
change, 2) to report the average number of days between
receiving a packet from a provider and issuing a prior
authorization number, and 3) funding for a team to verify both
client health and safety and that the PCA is actually providing
the service.
4:15:34 PM
SENATOR THOMAS asked for copies of his notes. He expressed
amazement that there are few requirements for PCAs.
MR. RICHARDSON said there are base requirements, but there is no
verification at the state level that they exist.
4:18:12 PM
MS. HILGENDORF thanked Senator Davis. She has been listening
carefully and believes that working collaboratively changes will
be made.
SENATOR ELLIS asked if she thinks there is a problem with the
attention that the Medicaid Fraud Unit focuses on providers as
opposed to contractors.
MS. HILGENDORF said she believes that unit works hard and does
good work.
4:20:31 PM
MR. SHERWOOD, responding to a question, explained that the
federally required Medicaid Fraud Control Unit resides within
the Department of Law. DHSS makes provider fraud referrals to
that unit. He agreed to provide information on how the agencies
work together.
SENATOR ELLIS said it wouldn't surprise anyone to learn that
they concentrate on the big fish, but he's also concerned about
contractors who may be building substandard non-ADA compliant
facilities. It's a concern for that woman who may drive her
scooter off her porch, he said.
MR. SHERWOOD clarified that the Medicaid Fraud Control Unit is
responsible for criminally prosecuting for fraud and abuse of
Medicaid clients, but many things don't rise to that level and
fall back on DHSS to address.
4:23:44 PM
There being nothing further to come before the committee, Chair
Davis adjourned the Senate Health and Social Services Standing
Committee at 4:23 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| DHSS Report to Senate HSS Committee.pptm |
SHSS 11/3/2009 1:00:00 PM |
DHSS CMS Moratorium Presentation |