Legislature(2019 - 2020)SENATE FINANCE 532
02/11/2019 09:00 AM Senate HEALTH & SOCIAL SERVICES
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ALASKA STATE LEGISLATURE
JOINT MEETING
SENATE FINANCE COMMITTEE
SENATE HEALTH and SOCIAL SERVICES STANDING COMMITTEE
February 11, 2019
9:02 a.m.
9:02:35 AM
CALL TO ORDER
Co-Chair Stedman called the joint Senate Finance Committee
and Senate Health and Social Services Committee meeting to
order at 9:04 a.m.
SENATE FINANCE COMMITTEE MEMBERS PRESENT
Senator Natasha von Imhof, Co-Chair
Senator Bert Stedman, Co-Chair
Senator Click Bishop
Senator Lyman Hoffman
Senator Peter Micciche
Senator Donny Olson
Senator David Wilson
Senator Bill Wielechowski
SENATE FINANCE COMMITTEE MEMBERS ABSENT
Senator Mike Shower
SENATE HEALTH and SOCIAL SERVICES COMMITTEE MEMBERS PRESENT
Senator David Wilson, Chair
Senator John Coghill, Vice Chair
Senator Gary Stevens
Senator Cathy Giessel
Senator Tom Begich
ALSO PRESENT
Sandra Heffern, Executive Director, Effective Health
Design; Scott Leitz, Senior Fellow, NORC at the University
of Chicago.
PRESENT VIA TELECONFERENCE
Lynne Snyder, Ph.D., Principal Research Scientist, NORC at
the University of Chicago.
SUMMARY
ALASKA HEALTHCARE TRANFORMATION PROJECT UPDATE
Co-Chair Stedman introduced the members of the Senate
Finance Committee.
Chair Wilson introduced the members of the Senate Health
and Social Services Committee.
9:04:50 AM
Co-Chair von Imhof commented that healthcare has been a
topic of discussion in Alaska for several years. She noted
that some committees have been researching why the per
capita costs are so high in Alaska. One of the most recent
studies is the Alaska Healthcare Transformation Project
that she sits on along with Sandra Heffern, Elizabeth
Ripley and others. The project has a triple aim: to improve
population health, improve the patient experience, and
lower the per capita cost of healthcare. The hope is to
coordinate patient care, improve primary care utilization
rather than using the ER, change the way healthcare is paid
for in Alaska to provide more transparency, and increase
data analytics. She said the project raised $1 million last
year through the state and private foundations and then
hired NORC (National Opinion Research Center) with the
University of Chicago to help with the project. She said
the impetus of the current meeting is to check in with the
healthcare transformation team and NORC.
9:06:26 AM
Co-Chair Stedman highlighted that Senator von Imhof is the
budget subcommittee chair for health and social services
and some of the most challenging pieces of Alaska's current
budget concern these issues. He noted that this meeting
will provide good background before the governor's budget
is published.
9:07:39 AM
SANDRA HEFFERN, EXECUTIVE DIRECTOR, EFFECTIVE HEALTH
DESIGN, ANCHORAGE, stated that she and her colleagues would
present a brief history of the Alaska Healthcare
Transformation Project, the current efforts, and the future
direction of the project. Salient points will be briefly
discussed, and a more in-depth discussion off-line is
available if there is interest.
9:08:41 AM
Ms. Heffern reviewed slide 2, "History of Health Care
Reform Efforts in Alaska":
? 2007 Health Strategies Planning Council
? 2009 Health Care Commission
? 2010 Medicaid Task Force
? 2010 Affordable Care Act
? 2014 Medicaid Reform Advisory Group
? 2016 SB 74 Medicaid Reform
She discussed the past efforts and how healthcare has
transformed in Alaska. She noted that in 2007 under the
Palin administration, the Health Strategies Planning
Council convened. The Council created a list of seven
goals.
1. Health cost for all Alaskans will consistently be
below the national average
2. Alaska will have a sustainable healthcare
workforce
3. All Alaskan communities will have clean and safe
water and wastewater systems
4. Quality healthcare will be accessible to all
Alaskans to meet their healthcare needs
5. Personal responsibility and prevention in
healthcare will be top priorities for government, the
private sector, tribal entities, communities, families
and individuals
6. Develop and foster the statewide leadership
necessary to develop and support a comprehensive
statewide health and healthcare policy
7. Increase the number of Alaskans covered by health
insurance
She described how the work of the Council led to the
legislature establishing the Health Care Commission in 2010
to advise the state on policies for improving health and
healthcare for all Alaskans. The Commission was charged
with serving as the state health planning and coordinating
body as well as tasked with implementing the goals
previously established by the Health Strategies Planning
Council. She said the Commission studied issues related to
healthcare in Alaska and reported activities and
recommendations to the legislature. The commission was
defunded in 2015 and is no longer active.
9:10:45 AM
She continued that in 2010, Governor Parnell convened the
Medicaid Task Force, which was comprised of legislators and
state administrators, to address the growth in Alaska's
Medicaid program and budget. The Affordable Care Act
(Obamacare) was also established in 2010. She discussed how
the following years were spent addressing the
implementation of the Affordable Care Act. That included
looking at: the health market and the health insurance
marketplace, whether to expand Medicaid, and individual and
employer mandates.
In 2014, Governor Parnell convened the Medicaid Reform
Advisory Group which was designed to develop a proposal for
reforming the state's Medicaid program. She noted how this
group addressed: the stability and predictability in
budgeting, increasing the ease and efficiency of navigating
the system by providers, and providing whole care for the
patient by uniting physical and behavioral health
treatment.
She said that in 2016 under Governor Walker's
administration, Senate Bill 74, the omnibus Medicaid reform
bill, became law. Many of the legislators present at this
table were instrumental in the passing of that bill. She
stated that many of the components of Senate Bill 74
including telemedicine, pharmaceutical control with the
prescription drug monitoring program, moving toward a
coordinated care model and behavioral health reform are
some of the initiatives that have been implemented or are
currently in progress. She noted there have been numerous
efforts for health reform and she only discussed the last
12 years.
9:12:44 AM
She pointed out that the Anchorage Economic and Development
Corporation performs a business confidence inventory every
year (since 2010) and found that the main hinderance to
economic growth for business development is the cost of
health insurance. The cost of health insurance correlates
directly with the cost of healthcare. She noted that during
the 2017 legislative session there were many discussions
regarding the issue of driving down healthcare costs while
increasing quality and increasing access to healthcare for
Alaskans.
9:13:57 AM
Ms. Heffern addressed slide 3, "What is the Alaska
Healthcare Transformation Project":
A cross sectional collaboration of payers, providers,
policymakers and patient advocates working together to
transform Alaska's healthcare system.
She stated how the legislature, administration, and
provider organizations were brought together to
collectively discuss the issue of healthcare in Alaska.
From those discussions, the Alaska Healthcare
Transformation Project was developed.
9:14:45 AM
Ms. Heffern discussed slide 4, "Project Management
Committee":
? Senator Natasha von Imhof
? Representative Ivy Spohnholz
? Elizabeth Ripley, Mat-Su Health Foundation
? Kalani Parnell, Alaska Native Tribal Health
Consortium
? Becky Hultberg, Alaska State Hospital and Nursing
Home Association
? Nancy Merriman, Alaska Primary Care Association
? Mike Barnhill, Office of Management and Budget
Policy Director, State of Alaska
She discussed why the project was different than previous
efforts which have focused primarily on Medicaid. Medicaid
is a big part of Alaska's healthcare system; 27-28 percent
of the state's population receives health insurance through
Medicaid. However, that leaves out about 70 percent of
Alaska's population. She noted that Alaska has a relatively
small population and when efforts are focused on a single
area, significant cost shifting can occur. She reiterated
that this was why employers found health insurance costs a
hinderance to economic growth. She opined that not all
stakeholders impacted by health reform were brought to help
with previous efforts. She relayed her longstanding
experience in health and human services and noted the
benefit of having new perspectives brought to the table.
The current effort was a public private partnership while
previous efforts were mainly driven by government (while
government is a part of the current partnership, it is not
driven by government). She offered her belief that these
are the differences from past efforts that will lead to the
success of this project.
9:17:24 AM
Ms. Heffern addressed slide 5, "Vision":
The vision for Alaska's healthcare system is to
improve Alaskan's health while also enhancing patient
and health professional's experience of care and
lowering the per capita healthcare growth rate.
She noted the project was divided into phases. The project
began by bringing stakeholders and policymakers together to
discuss what needed to change within the healthcare system,
she said. She stated that from those discussions came the
quadruple aim of the project: the overall patient
experience, the provider's experience of care, the cost of
care, and access to care.
9:18:16 AM
Ms. Heffern discussed slide 6, "Guiding Principles":
? Focus on improving individual and population health
outcomes (defined holistically including mental,
behavioral, oral, vision and social health)
? Health coverage with common basic benefits for all.
There is shared responsibility in reforming and paying
for coverage, with everyone individuals, business,
insurers and governments playing a role.
? Focus on whole person/integrated systems of care
? Use proven healthcare delivery practices supported
by appropriate payment mechanisms
? Seeking recognition and ways to incorporate social
determinants of health in patients' care plans
9:19:04 AM
Ms. Heffern addressed slide 7, "Goals":
Healthy Alaskans:
? The percentage of Alaskan residents with a usual
source of primary care will increase by 15% within
five years
Healthy Economy:
? Reduce overall per capita healthcare growth rate to
the greater of 2.25% or Consumer Price Index within
five years
Everybody's Business:
? Align all payers, public and private, towards value-
based alternative payment models with streamlined
administrative requirements within five years
She referenced the tag line "Healthy Alaskans, Healthy
Economy, Everybody's Business" and noted that goals were
made for those three specific areas. She spoke to the first
slogan, "Healthy Alaskans." She noted a national survey,
the Commonwealth Scorecard, showed 68 percent of Alaskans
have a usual source of primary care (with the best state
being at 89 percent, leaving Alaska room for improvement).
She discussed the second goal, "Healthy Economy." The
Institute for Social and Economic Research (ISER) released
a report in 2018 that stated, Alaska's overall healthcare
spending growth rate from 1991-2014 was 7.8 percent
compared to the United States overall rate of six percent.
She reminded the committee that Alaska's healthcare costs
are 38 percent higher than the rest of the United States.
She discussed the last bullet, "Everybody's Business." She
said that since the Affordable Care Act passed, payment of
value versus payment of volume of care has grown
significantly and can take multiple forms including
accountable care organizations, global payments, or bundled
payments for care improvement. Alaska is unique in
geography and region; therefore, the goals were created so
the state would not be limited to following a specific
healthcare model. She highlighted that providers and
practitioners asked for a focus on how to streamline
administrative requirements because it is recognized that
the added cost of administration does not equate to better
outcomes or better patient care.
9:21:46 AM
Ms. Heffern addressed slide 8, "Strategy Development
Teams":
? Primary Care utilization
? Payment Reform
? Data Analytics
? Coordinated Care
? Social Determinants of Health
She said that in the second phase the project members
created strategy development teams. A group of 100 people
met over the course of four months for three hours a month
to discuss areas of question before making recommendations.
From those five groups the teams synthesized the questions
into four themes.
She then discussed slide 9, "Themes":
1. Alaska landscape previous projects, pilots,
demonstrations
2. Meta-analysis/Synthesis of reports and studies
3. National landscape what's happening in other
states
4. Spend/Cost analysis of Alaska healthcare
She recognized that in the last 10 years, Alaska has
accomplished a lot in healthcare reform. She noted the
importance of observing healthcare on the national level to
learn how other states have accomplished reform in
healthcare. Lastly, it was important to note what Alaska
was spending on healthcare and what the cost drivers were.
9:23:28 AM
Ms. Heffern discussed slide 10, "Budget and Funding":
? Governor's Budget $250,000
? Capital Budget $250,000
? Foundations $120,000 Mat-Su Health Foundation
$250,000 Rasmuson
? Other $130,000 Alaska Mental Health Trust, TBD
She stated that while the strategy development teams were
completing their work, funds for the project were collected
to support the research. She thanked the committee and
members present last year who secured $250,000 for the
project in the governor's operating budget under the
Department of Administration. There was $250,000 in capital
budget appropriation, $120,000 from the Mat-Su Health
Foundation, $250,000 from the Rasmuson Foundation, $100,000
from the Alaska Mental Health Trust, and an additional
$30,000 was contributed by someone who preferred to not be
identified. She said $1 million was selected because other
states with comparable populations used that amount to
pursue similar efforts in reforming healthcare. She stated
that a budget was developed, scopes of work were put
together, and specific contractors from other states were
solicited. Five entities responded to the requests for the
scopes of work and after scoring the responses, NORC at the
University of Chicago was selected as the contractor for
all four scopes.
9:24:55 AM
Ms. Heffern introduced slide 11, "Four Scopes of Work":
NORC at the University of Chicago and University of
Alaska Anchorage
She said Mr. Leitz with NORC would provide a synopsis of
their work.
9:25:42 AM
SCOTT LEITZ, SENIOR FELLOW, NORC AT THE UNIVERSITY OF
CHICAGO, displayed slide 12, "About NORC at the University
of Chicago":
NORC at the University of Chicago is an independent,
non-profit research institution that delivers reliable
data and rigorous analysis to guide critical
programmatic, business, and public policy decisions.
He thanked the committee for the privilege to update them
on the Healthcare Transformation Project. He stated that he
served as the project director and noted he was accompanied
by his colleague Lynne Snyder via phone, who would speak
later in the presentation. He briefly discussed slide 12
and added that NORC was established 75 years ago and acted
as an independent entity affiliated with the University of
Chicago.
9:27:14 AM
Mr. Leitz briefly spoke to slide 13 that listed NORC's
office locations.
9:27:22 AM
Mr. Leitz highlighted slide 14, "Research Areas":
Economics, Markets, and the Workforce
Education, Training, and Learning
Global Development
Health and Well-Being
Society, Media, and Public Affairs
He noted the areas of research NORC participated in
including health and well-being, work related to Medicaid,
health exchanges, and private sector healthcare. He added
that they had a variety of clients including federal and
state governments as well as private sector businesses.
9:27:41 AM
Mr. Leitz addressed slide 15, "About University of Alaska
Anchorage: ISER":
The Institute of Social and Economic Research (ISER)
at the University of Alaska Anchorage has been at the
forefront of public policy research in Alaska for more
than half a century. ISER's multidisciplinary staff
studies virtually all the major public policy issues
Alaska faces. That work helps Alaskans better
understand the state's changing economy and
populationand the challenges and opportunities that
come with change.
He noted that NORC has been working closely with colleagues
at the University of Alaska Anchorage. He recognized that
by working with a team that brought Alaska specific
knowledge was very important to ensuring that NORC
collectively understood the context and history of the
delivery system. He said NORC worked closely with ISER at
UA and Ralph Townsend (ISER Director) was present today and
available to answer any questions.
9:28:31 AM
Mr. Leitz discussed slide 16, "About University of Alaska
Anchorage: ICHS":
Institute for Circumpolar Health Studies (ICHS) is an
applied health research institute within the College
of Health at UAA. The focus of the Institute is
applied health research and evaluation relevant to
Alaskans. Research areas of interest include health
disparities, environmental health, rural health,
healthcare systems, and social determinants of health.
He mentioned that ICHS at the University of Alaska
Anchorage was another partner that NORC has been working
with during the project.
9:28:54 AM
Mr. Leitz addressed slide 17, "Project Overview":
? Provide the Alaska Healthcare Transformation
Project, Project Management Committee (PMC) with
objective information to:
? Learn from what has been done already in Alaska
via past experiments or meta-analysis of
reports/studies
? Learn from models, structures, and initiatives
in other states, and how to apply in Alaska
? Understand the drivers of the spending and cost
of healthcare in Alaska
? Steered by the PMC's vision, guiding principles, and
goals, and topic areas of interest
He stated that NORC was selected to provide the Healthcare
Transformation Project with objective information related
to the four main themes or scopes of work. He briefly
discussed each point on slide 17.
9:30:12 AM
Mr. Leitz described slide 18, "Project Scope":
? Four studies, each in response to a statement of
work issued by the PMC and focused on a set of guiding
principles and topic areas.
? Meta-Analysis. Identify and assess a group of
Alaska-focused reports and studies issued over
the past decade (2008 to the present) that focus
on delivery system reform related to the triple
aim of improved health, improved quality of care
and experience with care delivery (for patients
as well as the healthcare workforce), and reduced
per capita costs.
? Alaska Historical Project Scan. Identify and
assess selected delivery system reform
experiments in Alaska over the past decade (2008
to the present), with priority to characterizing
regional innovation within the state.
He highlighted that there has been a lot of work done on
this issue, so the project was not starting from scratch.
He explained how a meta-analysis looked across the data
from previous studies and reports and used research
techniques to find common themes threaded throughout the
reports. He said the second area of study was the Alaska
historical project scan which assessed former experiments
performed in Alaska, regionally and statewide, to glean
knowledge and information to help build a more efficient
and effective healthcare system.
9:31:47 AM
Mr. Leitz described slide 19, "Project Scope (cont.)":
? Four proposed studies continued?
? National Scan. Develop case studies for
selected states where delivery system reform
relevant to Alaska's five key topics of interest
offers lessons for prospective innovation.
? Drivers of the Health Care Costs and Spend in
Alaska. Review health care spending in the state
and the prospects and limitations of available
data sources that would support a fine-grained
analysis of cost drivers relevant to these
reforms. Based on this review, prepare a set of
estimates of potential reform-related savings and
a draft roadmap with proposed short-term (within
one year) and long-term steps that comprise one
or more pathways to reform.
? Dissemination-related tasks. Collaborate with the
PMC to present or support debriefings on key findings
and the roadmap, with creation of high-impact summary
materials (issue brief/fact sheet).
He said NORC was in the process of conducting a national
scan. Each state has its own way of accomplishing health
reform, so NORC wanted to look across a variety of states
and see where lessons learned may be applied to help Alaska
move forward on this issue. He noted the final area of
study, the drivers of healthcare costs and spend in Alaska.
Under this scope of work, NORC will be reviewing healthcare
spending in the state and find data sources to support a
more finely grained analysis moving beyond cost drivers
relevant to some of the reforms. He said NORC would do its
best to prepare a set of estimates on potential reform-
related savings and develop a draft roadmap that will give
logical next steps for health reform in Alaska. NORC will
also prepare several materials that will disseminate some
of the findings more broadly across the state.
9:32:59 AM
Mr. Leitz discussed slide 20, "Topic Areas of Focus":
Increasing primary care utilization
Coordinating patient care
Changing the way healthcare is paid for in Alaska
Increasing data analytics capacity
Addressing social determinants of health
He noted that the Project Management Committee (PMC)
identified five areas of focus that were key components in
achieving a successful reform system.
9:34:01 AM
Mr. Leitz discussed slide 21, "Timeline":
He said the first meeting was held in November 2018 which
involved in-person visits and an opportunity to meet with
the PMC to learn more details about the project. He noted
that NORC's work began with the meta-analysis and
historical scan reports that were submitted and reviewed in
February 2019. He said that by March 2019, a draft of the
national scan report and cost report would be reviewed by
the PMC. A final national scan report, based on feedback
from the PMC, would be completed by the end of March. The
cost report would be reviewed in April and then finalized
in May. He said that the final roadmap and report would be
finished in June, 2019.
9:35:28 AM
Mr. Leitz discussed slide 22, "Overview of Project
Deliverables":
He noted that the historical project scan and the studies
meta-analysis were important first products submitted to
the Project Management Committee. Those reports support the
ongoing analysis of what drives healthcare costs and spend
as well as provide relevant elements of the national scan
regarding Alaska.
9:36:10 AM
Mr. Leitz addressed slide 24, "Meta-Analysis: Methods":
? Conduct a systematic review to identify relevant
peer-reviewed and grey literature;
? Extract and compile quantitative and qualitative
data in a database; and
? Develop a report that explores commonalities across
the identified reports and studies, analysis of gaps
in understanding related to limitations of these
documents, themes that characterize available public
comments, and a summary of policy, programmatic, and
system redesign changes based on our review.
He noted that he would briefly discuss the methodology that
NORC used to produce the study results within the four
scopes of work. After, he would ask his colleague Lynne
Synder to help him discuss the findings of the meta-
analysis and historical scan. He highlighted that as seen
from the previous timeline, the national scan and the
healthcare costs and spending reports were not complete,
but he would give a flavor of what they were looking at.
He reiterated that a meta-analysis was taking a deeper look
at the reports that have been produced in the state,
whether in peer review journals or grey literature. He
explained that an example of grey literature was a report
produced by a foundation, the legislature or state agency
that was related to the healthcare system in Alaska. He
said that NORC conducted a systematic review of those
reports and extracted and complied quantitative and
qualitative information across those reports. They
developed a report that explored the commonalities within
all the reports, analyzed the gaps in the current
healthcare system, and characterized themes that keep
reoccurring across the system and reports which gave
insight on where to start with the reform process.
9:37:53 AM
Mr. Leitz noted slide 25, "Meta-Analysis: Methods":
? Systematically searched peer-reviewed and grey
literature for Alaska-based reports and studies
related to five topic areas
? Submitted list of reports and studies on November 5,
2018
? Developed database of reports and studies
? Identified key themes from reports and studies
? Developed final report, submitted on February 7,
2019
9:38:30 AM
Mr. Leitz discussed slide 27, "Alaska Historical Project
Scan: Methods":
? Refine a definition of health reform experiment,
services, and outcomes to guide scan of reforms since
2008
? Gather and analyze qualitative data on selected
experiments
? Develop a report that identifies regional patterns
and gaps in experiments across the topics of interest,
compares experiment features and outcomes, and
presents conclusions regarding policy, programmatic,
and system design recommendations for Alaska.
9:39:02 AM
Mr. Leitz discussed slide 28, "Alaska Historical Project
Scan: Methods":
? Identified Alaska-based experiments, focused on the
five topic areas
? Submitted list of experiments on November 5, 2018
? Searched peer-reviewed and grey literature,
including newspapers
? Conducted interviews with stakeholders
? Organized information on the experiments
? Submitted final report on February 7, 2019
He said that the PMC provided feedback to NORC on the list
of experiments and reduced it to approximately 11 different
experiments to focus on. NORC preformed an exhaustive
review of any peer review and grey literature, including
newspapers, to gain more information on the effectiveness
of those experiments and how well they worked in Alaska.
Mr. Leitz discussed slide 30, "National Scan: Methods":
? Develop a list of states involved in relevant health
reform models to inform in-depth analysis;
? Gather and analyze data on relevant models in
selected states, especially those with all payers
claims databases; and
? Develop a report that systematically analyzes and
compares the state health reform models, identifies
what is known about model results related to costs and
other outcomes, and presents conclusions regarding
policy, programmatic, and system design
recommendations for Alaska.
Draft Report: March 1, 2019
Final Report: March 29, 2019
9:40:58 AM
Mr. Leitz discussed slide 31, "National Scan: Case Studies
Reports":
? State Characteristics
? History of and Impetus for Health Reform
? Overview and Implementation of the Health Reform
Approach
? Details and Mechanics of Initiative
? Incorporation of Social Determinants of Health
? HIT, Data Analytics, All-Payers Claim Database
? Results, Lessons Learned, Next Steps
? Considerations for Alaska
He mentioned that slide 31 showed a list of what the seven
case studies would include.
He briefly referred to slide 32 which depicted a map of the
United States and listed the seven states that were
studied.
square4 Arkansas
square4 Colorado
square4 Maryland
square4 New Mexico
square4 North Carolina
square4 Oregon
square4 Washington
9:42:11 AM
Mr. Leitz reviewed slide 33, "National Scan: State Health
Reform Approach":
? Arkansas Health Care Payment Improvement
Initiative
? Colorado The Colorado Framework
? Maryland All-Payer Rate-setting System for
Hospital Services
? New Mexico Centennial Care and Medicaid-related
reforms and initiatives
? North Carolina Medicaid Transformation and Social
Determinants of Health
? Oregon Oregon Action Plan for Health
? Washington Healthier Washington
He noted that slide 33 listed the specific reforms studied
for each state. He stated that NORC was asked to
investigate these reforms and then see how they were
relevant to Alaska.
9:42:50 AM
Mr. Leitz discussed slide 35, "Spend and Cost of
Healthcare: Methods":
1) Review of Spending and Data
? Prepare a review of health care spending in Alaska,
including:
Identifying gaps in data source availability
that constrain a comprehensive accounting;
Identify sources of additional data to address
gaps;
2) Summarize extant knowledge on potential sources of
cost savings;
? integrate findings from all project tasks to
understand constraints to implementation of
reforms in Alaska
? make considerations regarding policy, program,
and system redesign in the state;
? Develop a report that presents a draft roadmap for
possible pathways to reform in Alaska, including
recommendations for both short- and long-term steps.
? Revise roadmap and disseminate findings in
coordination with the PMC, incorporating feedback from
the Steering Committee.
? Final Report, May 2019
He said that the methodology for the scope of spend and
cost of healthcare had two work streams. The first was to
review available data pertaining to spending and cost
within Alaska. The second was to summarize what is already
known on the potential sources of cost savings.
(He skipped slide 36)
9:44:48 AM
Mr. Leitz reviewed slide 37, "Alaska Spend and Cost of
Health Care: Revision of Roadmap and Dissemination of
Findings":
? Meet with PMC to review draft report and roadmap
? Upon PMC approval, coordinate with the PMC to
solicit feedback from the strategic development team
and convening groups
? Iterative process with PMC to develop final report
? In-person and virtual working visits
? Create high-impact, visually-oriented summary
materials (fact
sheet/short issue brief) and materials to support
debriefings that
PMC would schedule
? Potential Follow-on steps:
? Survey payers to understand what data exist and
can be obtained for improved study on payment
reforms
? Obtain and analyze data to further understand
cost drivers
? Engage stakeholders in structured process to
refine analyses and generate recommendations;
He explained that even though producing reports was
informative, the goal of the roadmap was to take
information and figure out how to best implement it. The
roadmap would be based on the four scopes of work and
through an iterative process between NORC and PMC, a
roadmap will be developed that has concrete information for
moving forward.
He said that this was a broad overview of the project, but
he wanted to discuss the two reports that were submitted to
the PMC last week concerning the meta-analysis and the
historical project scan. He said Dr. Snyder would discuss
the remaining slides.
9:46:20 AM
LYNNE SNYDER, PH.D., PRINCIPAL RESEARCH SCIENTIST, NORC AT
THE UNIVERSITY OF CHICAGO (via teleconference), displayed
slide 39, "Meta-Analysis: Methods":
? Reviewed 75+ reports related to five topic areas
? Analyzed information by:
? Topic Area
? Geography
? Population
? Payer
? Service
She introduced herself and mentioned her areas of
expertise. She discussed how the meta-analysis began with a
long list of studies and reports that have been published
in the last decade dealing with health reform in Alaska.
Nearly 300 reports were identified for the social
determinants of health section alone. She stated that the
NORC team divided into three groups and began the meta-
analysis process.
• ICER analyzed the payment reform and data analytics
topics
• ICHS (Institute for Circumpolar Health Studies)
analyzed the social determinants of health
• NORC analyzed the primary care utilization and
coordinated care (primary and coordinated care were
merged into one discussion)
She stated that the three teams tailored their approach to
data collection and analysis to reflect the different ways
in which studies and reports were presented for each topic.
She said a narrative was developed to explain what the
teams learned about the five topics.
9:48:28 AM
She explained that NORC took two approaches to interpret
the findings. For the topics of primary and coordinated
care and the social determinants of health. A matrix
synthesized key finding by theme including region,
population, or a certain social determinant like addiction.
She added that there was a draft of considerations for data
analytics and payment reform that was statewide in scope
and related to public or commercial payers. She explained
that along with the report, NORC submitted a free-standing
appendix (available in Excel and Word) of the meta-analysis
findings that noted the objectives reach report, study
design, population served and payer, data sources,
conclusions, and, where available, information about
funding.
9:49:33 AM
Ms. Snyder highlighted slide 40, "Meta-Analysis: Summary":
? Primary Care/Coordinated Care
? Promising models (evaluation): patient-centered
medical home, improved screening, telehealth &
ECHO (specialty co-management), behavioral
health, CCI ED diversion program, Strong Start
for Mothers (national evaluation)
? Data Analytics:
? Available data sources: CMS, commercial,
private; prospects for APCD
? Approaches to regional analysis
? Payment Reform
? Cost-shifting (state to federal)
? Movement from fee-for-service toward value-
based purchasing: managed care, capitation
? Challenge of low-volume, aligning payers
? Promising models: bundled care, FQHC Advanced
Primary Care (national evaluation)
? Social Determinants of Health
? Landscape of needs
? Promising models (evaluation): Housing First
She noted that information found through program
evaluations and peer review publications on primary and
coordinated care was very limited. She said that there was
more information about what Alaska needed in health reform
than what actually worked. Most of the reform data since
2008 was unevaluated. She said 39 reports were studied
relating to primary and coordinated care and 16 of those
reports were peer review journal articles and the rest were
grey literature. She listed the promising models for
primary and coordinated care.
o The Nuka System of Care and similar patient-
centered medical home models
o Screening to improve prevention of chronic
disease
o Telehealth delivery of services that extend the
reach of primary and specialty care and support
providers in the field (for example, through the
ECHO model of specialty co-management)
o Integration of behavioral health that is
preceding with the recent section of the 1115
waiver
o The diversion of patients from emergency
department visits and into primary care through
Medicaid's Coordinated Care Initiatives
o Sharing of electronic health record information
across emergency departments
o Improved maternal and child health through the
Strong Start for Mothers initiative
She noted that the reports and studies reviewed for this
project included reform in both tribal and non-tribal
delivery systems. Reform within the Department of Defense
and Veterans Administration delivery systems were not
within the scope this study.
She emphasized that for data analytics, there was a focus
on healthcare cost rather than data concerning access to
care or quality of care. She noted that the report gave
considerations for working with cost data, for conducting
regional analysis of costs, and for exploring the
feasibility of an all payers claims database (APCD) which
would enable analysis of utilization and costs by drawing
on claims of multiple payers. The report describes key data
sources that were used to analyze current healthcare costs
which included:
o The center for Medicare and Medicaid services
o Medicare research files
o The center's national health expenditure accounts
that allow for comparisons across states
o Three national and commercial insurance claim
databases
o Alaska state datasets that enable analysis of
cost as well as provider behavior and decisions
9:52:18 AM
She noted that a review of major payment reform initiatives
in the last decade were included in the report. The
discussions focused on recent developments related to
pricing transparency, regulation of pharmacy benefit
managers and of insurance reimbursement. She said there was
a trend of reduced spending accomplished by cost shifting
from state to federal government. The key example was the
reinsurance of the health insurance marketplace under the
section 1332 waiver. There is some movement from a fee-for-
service format toward value-based purchasing with interest
in Anchorage's upcoming united health demonstration of
Medicaid managed care health plan. She noted the
considerable challenges to reform in Alaska:
o Fragmented delivery systems
o The small number of commercial payers
o The low volume outside of Anchorage and Southeast
Alaska
o The result in difficulty in aligning payers
She added that under Senate Bill 74, there were some
promising models supported by federal one-time grants
including multiple initiatives of bundled payments for
episodes of care as well as the federally qualified health
center advanced primary care model.
She stated that for the topic of social determinants of
health there was a focus on needs assessment and a
consideration of non-medical influences on health and well-
being. She noted that NORC's findings aligned to the goals
for health set out by the Healthy Alaskans 2020 initiative
due to its broad-based consensus-oriented process. NORC's
approach was to review the prior work done by ICHS to
better understand the health influences that were
meaningful to Alaska's residents. She highlighted that this
revisioning of social determinants emphasized what factors
were impacting Alaskan's health. The teams considered
factors on an individual level such as age and ethnic
identity as well as those related to individual behavior
such as addiction and diet/exercise/nutrition and then
considered factors related to social relationships
specifically concerning Alaska's high suicide rates and
trauma and how each of these impact the need for health
services. She noted that their scale identifies a number of
factors on the neighborhood, community, region and state
level that are uniquely impacting Alaskan's health
including access to clean water and access to communication
through broadband and fiber optics as well as challenges
that are shared with other states including access to
quality healthcare and addressing workforce shortages (as
seen in other states with large rural populations). She
added that national and federal economic development,
revenue for Alaska programs that come from the federal
government, and related policies and programs in healthcare
have important influences on Alaskan's health. She said the
NORC team identified the number of needs to be addressed by
health reform related to addiction, trauma and suicide,
food and water security, and homelessness. For example, the
Housing First reform demonstration offers improved
outcomes.
9:56:13 AM
Ms. Snyder highlighted slide 41, "Alaska Historical Project
Scan: Methods":
? Initial list of 30 health reform experiments ? PMC
identifies 11 for focus
? Literature review to generate supplemental list of
reforms by topic area
? 5 key informant interviews
? Analyzed information by:
? Topic Area
? Geography
? Population
? Payer
? Service
She explained that the historical project began by
submitting a list of 29 reforms that had taken place within
the last decade. She noted that all the Senate Bill 74
experiments and pilot programs were considered one reform.
She stated the PMC advised the NORC team to focus their
research on 11 of the 29 reforms. She said that the
research identified a larger supplemental group of reforms
(almost 100) in each topic area which was used to fill in
the gaps on understanding the meaning of reform for each
topic. She added that they conducted a small number of key
informant interviews and reviewed state specific data of
healthcare prior to 2008 to provide background on health
reform in Alaska.
She explained how the report considers the set of 11
reforms in multiple ways, including trends in Alaska's
health since the era of hospital/clinic buildings and the
population growth that began during World War II. Reforms
to address workforce shortages, to bridge Alaska's long
distances and to assert self-determination and autonomy are
all enduring themes in the state's health history. She
stated how these themes better explain why Alaska has a
complex payer environment and multiple delivery systems.
She said that with the limited evidence available for any
one reform, an analysis of a group allowed NORC to make
preliminary observations about trends. The report includes
a short profile for each of the 11 reforms and an appendix
highlighting what could be learned about experiment goals,
current status, results and lessons learned.
She highlighted how four reforms were statewide in scope
with three relating to the Medicaid program and one related
to capacity building for providers. Another four reforms
are located in and around Anchorage and Mat-Su Borough
including the Southcentral Foundation Nuka System of Care
and three demonstrations funded by the Centers for Medicare
and Medicaid Services (CMS). She added that two reforms
were located in Southeast Alaska, but none of the reforms
were in the northern or interior regions of the state. She
said that in terms of leadership, most reforms were led by
tribal health organizations or by providers under agreement
with state agencies. She stated that reform funding came
mostly from federal entities like the Centers for Medicaid
and Medicare services.
She discussed how population reform targeted Medicaid
enrollees, beneficiaries of the Medicare program and Native
Alaskan residents. She said that validation was lacking in
terms of outcomes of documented reforms. She noted the team
identified program evaluations or peer review publications
specific to Alaska for six of the 11 initiatives. She said
the Southcentral Foundation for the Nuka System of Care
offered the most evidence of effectiveness while evidence
of other reforms was limited yet promising. Positive
findings are seen for the complex behavior initiative and
the coordinated care initiative emergency room diversion
program. She said the Kodiak Area Native Association's use
of electronic clinical reminders have been shown to improve
screening rates for preventive care and the PeaceHealth
Ketchikan care coordination pilot was associated with
improved care processes for diabetes.
She said national evaluation findings include data for
Alaska sites for three reforms including the advanced
primary care practice demonstrations for health clinics,
bundled payments for care improvement and the Strong Start
Program for Mothers and Newborns. However, generalizations
from national findings to local sites were unclear. She
highlighted how the pace of reforms has increased due to
Senate Bill 74 but there were many gaps concerning topics
of reform because regions, populations, and outcomes were
not included in the list of 11 reforms (or even in the
broader list of 104). She added that NORC did not identify
reforms related to dental or vision care, access to durable
medical equipment, or anything related to long-term
services and reports. Reforms are limited in terms of
tested payment models and delivery system changes listed
outside of primary care, she said.
10:01:45 AM
Ms. Snyder discussed slide 42, "Alaska Historical Project
Scan: Findings by Topic":
? Primary Care Utilization and Coordinated Care
? Patient-Centered Medical Home Models
? Behavioral Health Integration with Primary Care
? Emergency Department Utilization
? Care Coordination Systems
? Clinic-Based Reforms
? Payment Reform
? State-wide payment reform tied to delivery
system reform
? VBP: bundled payment models
? Data Analytics
? Electronic health records
? Telemedicine
? Data analytics to support care delivery
She stated that both the meta-analysis and history reports
gave similar considerations for further work related to
policy and programmatic reforms and delivery system change.
In terms of short-term and long-term policy changes, there
are some recommendations for the next two reports.
o First is to build on the historical experience of
Alaska's public officials and stakeholders with
multi-sector planning coalitions to bring all
parties to the table.
o Second is to continue to tap the comprehensive
set of recommendations around primary care
developed by the Health Care Commission and use
it as a launching point. It is important to
acknowledge that the patient center medical home
model, as a delivery system approach, may be tied
to different payment reforms and may not
necessarily yield substantial cost savings but
there may be improved access to care and quality
of care.
o Third is the importance of continued investment
in communication and transportation strategies
that bridge Alaska's distances and invest in the
state's own ability to deliver healthcare for its
residents (for primary and specialty care).
She stated that regarding programmatic changes, it was
important to identify and adopt nationally validated
performance measures that would be meaningful to health
reform in Alaska while supporting the state's current data
systems. She added that it was important to consider what
measure of access and quality of care were most important
for reform to expand considerations beyond that of cost.
She explained that in terms of system redesign changes, it
was important to acknowledge the defining characteristics
of healthcare delivery in the state which included deep
orientation towards fee-for-service reimbursement. She said
a lot can be done within a fee-for-service reimbursement
framework. She highlighted the importance of respecting the
powerful dynamic between federal and state level
organizations and a pull toward local autonomy. She stated
it was important to continue to realign Medicaid purchasing
with federal reform opportunities through wavier programs
as well as support greater coordination across health
services delivery and social services to address
contributions of social determinants of health to adverse
health outcomes. She thanked the committee and her
colleagues for the opportunity to present some of the
findings from the study.
10:05:05 AM
Mr. Leitz thanked the committee. He said this concluded the
presentation from NORC.
10:05:14 AM
Ms. Heffern noted that the Project Management Committee was
still evaluating the two reports. They will be available on
their website which is listed on the last slide (slide 43).
She highlighted that NORC would complete two other reports
regarding the national scan and would bring forward
recommendations about the reform structure that has worked
in other states. The cost drivers and spending on
healthcare in Alaska will also be a topic of discussion.
She said that from June till the end of the year, the PMC
will work on an implementation plan that will include
policy recommendations that will be brought to the state
administration, the legislature and the federal delegation.
She opined that implementing some of the reforms that come
out of this project could use federal help. She thanked the
committee the invitation to present this information. She
noted that the process of a cross sector collaboration like
this project takes a long time. She assured the committee
that the Healthcare Transformation team was being proactive
in addressing the cost of healthcare in Alaska while
looking at quality and access of healthcare.
10:08:04 AM
Senator Hoffman noted that many of the communities spread
across Alaska have limited access to healthcare. He asked
why the adequacies and efficiencies of healthcare
facilities in rural Alaska were not addressed in this
report.
10:09:15 AM
Ms. Heffern answered that she agrees that access to
healthcare is issue of concern in Alaska. She noted that
looking at the capacity of what was available within
individual communities was beyond the scope of the project,
but it may be a topic discussed in the next phase. She said
the current focus was to look at the overall healthcare
system and note where the gaps and cost drivers are in
order to assess what policy decisions need to be made. She
opined that if access to healthcare within rural
communities was addressed, it would need to move forward as
a policy decision and include the cost.
10:10:12 AM
Senator Hoffman said it was critical for Alaskans in remote
areas to have access to adequate healthcare and without
access it would be impossible to improve healthcare in
Alaska. He said that a vast hole was created within this
review because the topic was not addressed.
10:10:45 AM
Co-Chair von Imhof highlighted that Alaska is unique due to
its vast geography, lack of connected road systems, and a
relatively small population. She commented that there was
limited healthcare access even in Anchorage in some areas
such as a burn unit treatment or of a deep brain tumor. She
opined that Alaska may never solve certain issues around
this topic because of the population and geographic size
but it should be a topic of discussion to decide what
Alaskans are willing to accept.
10:12:10 AM
Senator Micciche pointed out the seven states highlighted
on page 32 and assumed they were not the result of a random
draw. He asked why those seven states were selected and if
there was a specific state (from that list) that had a
higher level of success with health reform or if they were
all at different stages of improvement.
10:12:45 AM
Ms. Heffern said correct, those seven states were not
randomly selected. She noted that Washington, Oregon and
Colorado were selected because of previous work done to
study their reforms. She briefly stated reasons why each
state was selected:
o Oregon has a coordinated care organization
structure that is bundled payments to each of the
coordinated care organizations.
o Colorado has a regional collaborative care
organization structure (very similar to Oregon)
done on a regional basis and doesn't perform a
shared savings or shared risk while Oregon does.
o Washington has a very structured managed care
type system and are looking at accountable
communities of health.
o Arkansas has restructured the health insurance
exchange.
o New Mexico has a large indigenous population.
o Maryland has a payment structure it has performed
with their hospitals.
10:14:15 AM
Senator Giessel commented that there was effort to change
Alaska's healthcare system. She opined that every dollar in
the healthcare industry has a formidable opponent to change
due to how the current system makes huge amounts of money.
She referred to slide 30 and asked which of the seven
states were ones with an all payers claims database, what
it cost to develop the database, how long it took to set up
the database, and how useful those databases have been.
10:15:08 AM
Ms. Heffern replied that the spend and cost report, which
will be release in May, will contain that information. She
said the recommendation to look at the all payers claims
databases came from the healthcare commission many years
ago. She agreed that every dollar in healthcare has a
constituent behind it. Thus, the effort to bring all the
different perspectives impacted by health reform into the
discussion. These include Premera, Atena, Moda, Medicaid,
Medicare, the union health trusts, legislators, Department
of Health and Social Services, and Department of
Administration.
10:17:03 AM
Senator Bishop asked if 68 percent of Alaskans are insured
(slide 7).
10:17:23 AM
Ms. Heffern answered no; 68 percent of Alaskans identify
that they have a usual source of primary care.
10:17:32 AM
Senator Bishop asked if that means 30 percent of Alaskans
are not insured.
10:17:35 AM
Ms. Heffern replied that there was a difference in
identifying a usual source of primary care and having
health insurance coverage. She offered her belief that
close to 14 percent of Alaskans do not have health
insurance coverage.
10:18:02 AM
Senator Coghill commented that he appreciated the work put
into this project especially the meta data. He noted that
he previously met with the University of Fairbanks and was
pleased to find out they were performing significant
research on the social determinants and economic impacts
related to Alaskan's health.
10:19:16 AM
Chair Wilson commented that he was looking forward to the
final reports and the map being released. He said he was
hopeful that this work would stimulate or provide impetus
for action going forward. He asked what subcontracting work
ISER and ICHS were performing and if their role was with
just the meta-analysis or throughout the entire project.
10:19:55 AM
Mr. Leitz replied that they were involved in the meta-
analysis and historical scan but also helped with the cost
and spend portion of the report. He stated that NORC would
also work with ISER and ICHS to analyze the impacts certain
reforms have on overall costs.
Co-Chair Stedman discussed the next day's agenda.
ADJOURNMENT
10:21:06 AM
The meeting was adjourned at 10:21 a.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| AHTP_LEG Senate_Feb 2019_FINAL.pptx |
SHSS 2/11/2019 9:00:00 AM |
Alaska Health Care Transformation Project |