Legislature(2023 - 2024)DAVIS 106
02/29/2024 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| Alaska Board of Nursing | |
| HB371 | |
| HB343 | |
| HB344 | |
| HB226 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| *+ | HB 344 | TELECONFERENCED | |
| *+ | HB 371 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| *+ | HB 343 | TELECONFERENCED | |
| += | HB 226 | TELECONFERENCED | |
HB 344-MEDICAL ASSIST. DEMONSTRATION PROJECTS
4:00:21 PM
CHAIR PRAX announced that the next order of business would be
HOUSE BILL NO. 344, "An Act relating to medical assistance
demonstration projects established by the Department of Health."
4:01:11 PM
HEIDI HEDBERG, Commissioner, Department of Health (DOH), offered
a brief introduction to HB 344 on behalf of the bill sponsor,
House Rules by request of the governor. She handed the
presentation of the bill over to Emily Ricci and Dr. Anne Zink.
4:01:53 PM
EMILY RICCI, Deputy Commissioner, Department of Health, co-
offered a PowerPoint presentation of HB 344 [hardcopy included
in the committee packet] on behalf of the bill sponsor, House
Rules by request of the governor. She opened on slide 2, "Total
Health Care Expenditures per Capita 2024," which includes a map
and states: "Medicaid is a critical tool to improving Alaska's
health care delivery system and patient outcomes." She
explained that Medicaid covers nearly 38 percent of Alaskans.
Health care costs in Alaska are high. She recommended Medicaid
as "a vehicle that the state can leverage" to "influence the
system" to improve health outcomes.
MS. RICCI moved to slide 3, "Alaska Medicaid Utilization," which
has a graph showing that 5 percent of beneficiaries in Medicaid
account for about half of Medicaid spending; within those, about
10 percent of beneficiaries account for approximately two-thirds
of Medicaid spending. Those with acute needs account for a
significant portion of "overall health care spend." She stated
the importance of evaluating where money is spent for the best
outcome and health of Alaskans.
MS. RICCI turned to slide 4, "Alaska Emergency Department
Utilization," noting that "a small number of individuals can
have a large impact on the system, particularly when they have
acute needs that are not being consistently met." She then
turned to Dr. Zink to continue with slide 4.
4:04:59 PM
ANNE ZINK, MD, Chief Medical Officer, Department of Health,
picked up on the PowerPoint presentation of HB 344, on behalf of
the bill sponsor, House Rules by request of the governor. She
gave an example of a patient who visited the emergency room 300
times in a year and said the system was failing him. She said
the purpose of the [section 1115 waiver under 42 U.S.C.
1315(a)], which would be established under HB 344, is to
facilitate figuring out what the "highest needs utilizers" need
is and how the state can spend money in a way reduces emergency
room visits and to figure out what key services outside the
hospital are available.
DR. ZINK turned to slide 5, "Chronic Conditions and Medical
Utilization," and she said it is intuitive that an increase in
chronic conditions equates to "more spend within the health care
system."
4:06:37 PM
MS. RICCI, in response to a question from Representative Sumner
as to what the top conditions resulting in the highest Medicaid
spend are, named mobility impairment as the highest. She also
named, in descending order, blood conditions, cardiovascular
disease, congenital disorders, diabetes, and drug and alcohol
abuse.
DR. ZINK added that not all conditions are modifiable, and DOH
is focusing on those conditions it can respond to with
intervention. She also noted that the waiver would not be done
"in isolation." She said there is a short program for
addressing chronic diseases in addition to looking at the
waiver.
MS. RICCI referred back to slide 3 and emphasized consideration
of a better way to meet the needs of and support individuals and
take advantage of opportunities for cost savings.
4:09:24 PM
DR. ZINK moved on to slide 6, "Learning from Alaskans," and she
highlighted the produce prescription program in the
Yukon/Kuskokwim Region that is specifically for people with
diabetes to help them improve their eating and has a side
benefit of helping those who grow produce in the region.
4:10:23 PM
DR. ZINK, in response to a question from Representative Sumner,
said this prescription program cannot supplant the Supplemental
Nutrition Assistance Program (SNAP). The waiver would be
specific to the patient and condition. She then noted the case
coordination project, shown on slide 6, which takes place at
Bartlett Regional Hospital. The program addresses those "MVP"
patients with high medical and social needs, with a focus on
bringing the community together to address transportation,
housing, and care needs in an attempt to keep those patients out
of the hospital where the cost of care is greater.
DR. ZINK turned to the next slide, "What Are Health-Related
Needs?," to a list of points on the left half of the slide,
which read as follows [original punctuation provided]:
Under the 1115 waiver, health-related needs services
must be:
theta Medically necessary
theta The choice of the beneficiary
theta Individually tailored
theta Distinct from population-based health interventions
(must supplement not supplant existing services)
DR. ZINK said this is concerning the top of the treatment
pyramid [shown on the right half of the slide]. She reiterated
that this looks at a limited number of people, who have a high
cost to the system and where medically tailored interventions
can make a big difference for them.
4:12:56 PM
DR. ZINK, in response to a question from Representative Mina
regarding how relevant a program from last year is to expanding
case coordination for high utilizers through the proposed
waiver, confirmed that the high utilization Mat-Su (HUMS)
program is similar to the MVP program in Juneau.
4:14:04 PM
DR. ZINK, in response to a question from Representative Saddler
regarding the expansive scope of "health related needs," shared
that one challenge the department has had is that the waiver can
be interpreted "as much more than it is." It is an opportunity
that the Centers for Medicare and Medicaid have made available.
She said 16 states have already implemented waivers along this
line, and DOH needs to show that "it is cost neutral" and
services are being used in the most cost-efficient way that is
the most beneficial for the patient. Using transportation in
example, she said this is about providing a ride to someone
leaving the hospital who may need it but not about providing
cars to everyone. In response to a follow-up question, she gave
examples of how the parameters of medical necessity are
established. She said the waivers could be based on health
conditions. She noted that DOH needs to do actuarial work after
coming to the legislature to begin the process.
4:17:26 PM
MS. RICCI, in response to a question from Representative Saddler
regarding chronic conditions, answered that the waiver will be
aimed at the 10 percent of the population driving 30 percent of
the costs. For each potential condition, the question will be
asked, "What is influencing this condition?" She talked about
not recycling back into the system to restabilize individuals.
She indicated that HB 344 is addressing the questions of why
some outcomes do not reflect the amount of money that is being
invested into the system and whether simple things effecting the
outcomes can be addressed. In response to a follow-up question,
she recapped the percentages shown on a previous slide.
4:20:53 PM
DR. ZINK returned to the PowerPoint to give examples of care
needs. She highlighted nutritional support services and gave
examples to illustrate the points on slide 8, "Example:
Nutrition Supports," which read as follows [original punctuation
provided]:
• Poor nutrition contributes to worsening medical
conditions and escalates to hospitalization
• During discharge planning, food insecurity is
identified as a need
• Nutrition services are tailored to address specific
medical needs
• Stabilizes after post-acute event
• Encourages timely discharge
• Maintains independent living
DR. ZINK brought attention to another example on slide 9,
"Example: Cycling Through API" [the Alaska Psychiatric
Institute], and gave examples that illustrated the slide, which
read as follows [original punctuation provided]:
• Co-occurring mental health and chronic health
diagnoses
• Unstable living conditions lead to poor medication
management
• Multiple admissions and delays in discharge
• Higher level of care than is medically necessary
4:23:41 PM
MS. RICCI discussed slide 10, "Tailoring Medicaid to Meet
Alaska's Needs," which read as follows [original punctuation
provided]:
• Medicaid is a state-federal partnership
• New federal support for Medicaid innovation
• 1115 waivers allow states to implement specific
strategies reflecting their population's unique needs
and priorities
MS. RICCI said the 16 states using the waivers are customizing
them to meet the needs of their state. She said DOH envisions
Alaska would take the same approach. She moved on to slide 11,
which asks the following questions:
Who are we serving?
What are we paying for?
How are we paying for it?
MS. RICCI said this is within the context of community-based
health settings or hospitals and facilities. It is a holistic
view to support Alaskans.
4:25:44 PM
DR. ZINK advanced to slide 12, "Goals," and highlighted that
they are to improve health outcomes and decrease downstream
costs. She said DOH has listened to a lot of other states that
have rolled out a waiver-use plan and the key takeaway is that
the process is a slow one, which provides the opportunity to
reflect and adjust.
MS. RICCI drew attention slide [13], "Why a bill?," which read
as follows [original punctuation provided]:
• Gives the Department the necessary authority to
pursue a new 1115 waiver opportunity for health-
related needs
• A health-related needs 1115 waiver would be distinct
from Alaska's existing 1115 waiver
• Allows the Department to conduct actuarial analysis
and develop the waiver application
4:27:21 PM
MS. RICCI, in response to a question from Representative Fields
as to whether actuarial analysis could encompass private sector
savings that impact the state, said DOH is working with
contractors, and that is something the department would like
them to look at. She added that in the context of cost-savings
for Medicaid 1115 waivers, the parameters of cost-savings are
specific to the Medicaid program.
4:28:44 PM
DR. ZINK, in response to a question from Representative Mina as
to whether the 1115 waiver could address individuals who are in
need of home- and community-based services, said there are other
waivers via Medicaid that could potentially be utilized, and she
emphasized the specificity of waivers.
MS. RICCI turned to slide 14, "Leveraging an 1115 Waiver to
Address Health-Related Needs," which read as follows [original
punctuation provided, with some formatting changes]:
Time-limited and medically necessary interventions
spanning:
Nutrition and Food Security
Workforce Development
Transportation
Temporary Housing
Case Management
MS. RICCI highlighted a distinction of case management that is
necessary to support individuals as they move from using these
services on a temporary basis to using them sustainably outside
the Medicaid program on a permanent basis. She said there are
new opportunities in the area of workforce development that DOH
will consider.
MS. RICCI next covered slide 15, "Financial Considerations,"
which read as follows [original punctuation provided]:
• Budget Neutrality: Centers for Medicare and Medicaid
Services requires budget neutrality for all 1115
waivers.
• Alaska Medicaid Spending: The legislature authorizes
Medicaid spending annually.
• Efficiencies in Care: There is strong evidence that
addressing health-related needs improves health
outcomes and reduces costs.
MS. RICCI noted that states have "the ability to leverage
federal savings at the beginning of the waiver to help stand up
the infrastructure necessary to support the changes that the
waiver is demonstrating."
4:32:57 PM
DR. ZINK brought attention to slide 16, "Sectional Analysis,"
which read as follows [original punctuation provided]:
Section 1.
Adds a new section (h) to AS 47.07.036. Sectional
Analysis 16
• Authorizes the department to apply for an 1115
waiver to establish one or more demonstration projects
focused on addressing health-related social needs for
Alaska Medicaid recipients in one or more specific
geographic areas.
• Defines "health-related needs" as social or economic
conditions that contribute to an individual's poor
health outcomes.
MS. RICCI added that this was modeled after the Medicaid reform
work of Senate Bill 74 [passed during the Twenty-Ninth Alaska
State Legislature].
DR. ZINK brought attention to slide 17, which outlines the
process and read as follows [original punctuation provided]:
Preparation
• Partner Engagement
• Tribal Engagement
• Technical Assistance
• Legislative Input & Authority
Development
• Actuarial Analysis
• Partner Engagement
• Tribal Consultation
• Waiver Proposal Drafting
Consultation
• Tribal Consultation
• CMS Negotiation
• Public Comment
Approval
• CMS Approval
• Annual Budget Process
Implementation
• Infrastructure and Capacity Building
• Services Available to Eligible Alaskans
Review
• Required Annual Reporting to CMS
• Annual Budget Process
• Renewal Opportunities
4:37:22 PM
MS. RICCI, in response to a question from Representative Saddler
regarding the capacity of DOH to apply for waivers, indicated
there is an Office of Health Savings within the Office of the
Commissioner. She said DOH needs three positions and mentioned
supportive positions in the Department of Law (DOL). She talked
about short-term and long-term perspectives and longevity. She
also mentioned the Division of Insurance can help with the
necessary contractual work.
DR. ZINK added that federal partners "see a real benefit in
moving this direction." She mentioned there are other
supportive partners, as well.
4:39:47 PM
REPRESENTATIVE RUFFRIDGE expressed appreciation of the partners
available and the hope that health care costs can be driven
down.
4:40:51 PM
CHAIR PRAX opened public testimony on HB 344.
4:41:22 PM
JEANNIE MONK, Senior Vice President, Alaska Healthcare &
Hospital Association (AHHA), testified in support of HB 344.
She said AHHA appreciates the demonstration projects DOH has
developed allowing collaboration between the department and
health care providers to create change. She noted that Alaska
has a "closed" health care system and, thus, it is a suitable
environment for testing and innovation. She stated that
hospitals feel the impact of health-related social needs daily
and address those needs. She relayed that AHHA members would
welcome the opportunity to partner with DOH to develop
demonstration projects and address problems. She reminded
committee members that in 2016, AHHA, [at that time named the
Alaska State Hospital and Nursing Home Association (ASHNHA)],
played a significant role in the development of Senate Bill 74.
She said AHHA sees HB 344 as building on that previous work and
thinks the proposed changes are complementary. She emphasized
the current need in Alaska for "systems change," and AHHA
strongly supports maximizing opportunities related to the 1115
waivers. She highlighted that rather than go to the emergency
room, people could have their needs met outside of the hospital.
She concluded with thanks to the committee for its consideration
of HB 344.
4:44:40 PM
OWEN HUTCHINSON, Healthcare & Homelessness Integration Manager,
Alaska Coalition on Housing and Homelessness, testified in
support of HB 344. He offered background information related to
the coalition, including that it is a United States Department
of Housing and Urban Development designated lead agency for
continuum of care for everyone in Alaska outside of Anchorage.
He said the coalition, on its own, is unable to care for all
homeless people in Alaska. In 2023, 18,000 people accessed
homeless services; 43 percent of them self-reported a disabling
condition, and 37 percent reported being Alaska Mental Health
Trust beneficiaries. He noted that 1115 waivers of varying
types are already being used in 47 states; in Arkansas and
Arizona, waivers allow service to people with serious mental
illness and substance abuse disorders. He said the coalition
sees improved health outcomes by addressing "the social
determinants of health in coordination with their medical care."
He mentioned an actuarial report from 2020 that revealed
"supportive housing" costs at approximately $50 per day per
person compared to API, which costs over $1,000 per day per
person. He said a waiver would help "reduce the number of
people accessing homeless services and increase the outflow into
housing." He thanked the committee for its consideration of HB
344 and urged members to pass it out of committee.
4:48:01 PM
BRIAN LEFFERTS, Director, Division of Public Heath, Yukon-
Kuskokwim Health Corporation (YKHC), testified in support of HB
344. He said this is an incredible opportunity for the state
and the Yukon-Kuskokwim Region and would result in improved
health outcomes. He offered information regarding YKHC and said
the region has many challenges that make health care access
difficult and expensive. He reported that there is strong
evidence suggesting that focusing on health-related social needs
can prevent the need to access costly and difficult to access
health care services, and this improves the quality of life
while also improving the overall strain on YKHC's overburdened
health care system, allowing the corporation to focus its
resources on other health care needs. He related that YKHC is
eager to work with DOH to pilot the 1115 Medicaid waivers
through demonstration projects to help meet basic needs. He
concluded by asking the committee to support HB 344.
4:49:58 PM
BRYNN BUTLER, Housing Coordinator, City of Fairbanks, testified
in support of HB 344 and gave "a passionate plea" to the
legislature to support it. She described the proposed
legislation as "a beacon of hope" for Alaskans in desperate need
of supported services. She said evidence clearly shows that
house-related needs "are the cornerstone of health outcomes,
accounting for up to 50 percent of the equation." Without
housing and transportation needs met, an individual's health
suffers. She opined that it is time for the state to "pave the
way for tailored services that will prevent negative health
outcomes" and shift focus to "cost-effective and preventative
intervention." She talked about breaking free from "the cycle
of costly intervention" and "embracing a new era of supportive
services." She asked to see "champions of change."
4:52:03 PM
CHAIR PRAX, after ascertaining there was no one else who wished
to testify, closed public testimony on HB 344.
4:52:17 PM
REPRESENTATIVE SADDLER stated that he had been involved with
Senate Bill 74 and appreciates the cost-saving aspect of the
work being done on HB 344.
4:53:08 PM
CHAIR PRAX thanked the presenters and announced that HB 344 was
held over.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 344 Fiscal Note DOH-MS.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 344 Presenter List Version A.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 344 Sectional Analysis Version A.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 344 Sponsor Statement.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 344 Summary Version A.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 344 Version A.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 371 Sponsor Statement.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 371 Sectional Analysis.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 371 Version A.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 344 CPH Letter of Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| Michael Collins Nursing App_Redacted.pdf |
HHSS 2/29/2024 3:00:00 PM |
Governor's Appointee |
| Michael Collins Nursing Resume_Redacted.pdf |
HHSS 2/29/2024 3:00:00 PM |
Governor's Appointee |
| HB 371 Fiscal Note DOH-PHAS.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 344 Presentation.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 371 Presentation.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 343 VOA Alaska Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 343 |
| HB 343 AKBHA Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 343 |
| HB 343 ASD Support Letter.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 343 |
| HB 371 ACOG letter of support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 344 AHHA Letter of Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 344 Aids Assoc. Letter of Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 344 ANTHC Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 371 AHHA Letter of Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 344 Trust LOS Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 371 Alaska AWHONN .pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 371 CJA Letter of Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 343 Providence Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 343 |
| HB 343 Trust LOS 2.26.24.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 343 |
| HB 371 MCDR Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 371 |
| HB 344 Angel Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 344 |
| HB 343 ACSA Letter of Support.pdf |
HHSS 2/29/2024 3:00:00 PM |
HB 343 |