Legislature(2015 - 2016)HOUSE FINANCE 519
03/23/2016 01:30 PM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| SB74 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 74 | TELECONFERENCED | |
| + | TELECONFERENCED |
CS FOR SENATE BILL NO. 74(FIN) am
"An Act relating to diagnosis, treatment, and
prescription of drugs without a physical examination
by a physician; relating to the delivery of services
by a licensed professional counselor, marriage and
family therapist, psychologist, psychological
associate, and social worker by audio, video, or data
communications; relating to the duties of the State
Medical Board; relating to limitations of actions;
establishing the Alaska Medical Assistance False Claim
and Reporting Act; relating to medical assistance
programs administered by the Department of Health and
Social Services; relating to the controlled substance
prescription database; relating to the duties of the
Board of Pharmacy; relating to the duties of the
Department of Commerce, Community, and Economic
Development; relating to accounting for program
receipts; relating to public record status of records
related to the Alaska Medical Assistance False Claim
and Reporting Act; establishing a telemedicine
business registry; relating to competitive bidding for
medical assistance products and services; relating to
verification of eligibility for public assistance
programs administered by the Department of Health and
Social Services; relating to annual audits of state
medical assistance providers; relating to reporting
overpayments of medical assistance payments;
establishing authority to assess civil penalties for
violations of medical assistance program requirements;
relating to seizure and forfeiture of property for
medical assistance fraud; relating to the duties of
the Department of Health and Social Services;
establishing medical assistance demonstration
projects; relating to Alaska Pioneers' Homes and
Alaska Veterans' Homes; relating to the duties of the
Department of Administration; relating to the Alaska
Mental Health Trust Authority; relating to feasibility
studies for the provision of specified state services;
amending Rules 4, 5, 7, 12, 24, 26, 27, 41, 77, 79,
82, and 89, Alaska Rules of Civil Procedure, and Rule
37, Alaska Rules of Criminal Procedure; and providing
for an effective date."
1:31:50 PM
Co-Chair Thompson noted that Commissioner Davidson was
present.
HEATHER SHADDUCK, STAFF, SENATOR PETE KELLY, referred to
the handout titled "SB 74 - Medicaid Reform Topic and
Section Reference" that she previously distributed to the
committee. She relayed that today's topics under discussion
were Emergency Room Management and Super Utilizers which
related to Section 29 and Section 31 of the bill. She
provided a brief overview of the bill sections. She pointed
to Section 29 that began on page 28, line 18. She
elaborated that the section mandated primary care case
management for certain Medicaid members, which was
currently optional. In response to Representative Wilson's
question from Monday's bill overview, she clarified that
primary care case management would not initially be
mandatory for all Medicaid users. She specified that the
provision applied to enrollees with high hospital
admissions. Over time the Department of Health and Social
Services (DHSS) could add other Medicaid populations. The
department believed that not all recipients required
intensive case management. The provision differed from the
sponsor's intent that every enrollee had an assigned
primary care provider. She furthered that DHSS already
engaged in primary care case management with the super
utlizer population that was mostly performed
telephonically.
Ms. Shadduck continued with Section 31 found on page 30,
line 18 that related to the collaborative, hospital-based
project to reduce inappropriate Emergency Room (ER) use.
She delineated that the project had been designed after a
successful model employed in Washington State. She shared
that the project was recommended in the report [Recommended
Medicaid Redesign And Expansion Strategies For Alaska] by
Agnew Beck (copy on file) and reminded the committee that
she provided two handouts related to the project titled
"Seven Best Practices" (copy on file) and "Washington State
Medicaid: Implementation and Impact of "ER is for
Emergencies" Program (copy on file).
1:35:20 PM
Representative Wilson asked whether statute change was
necessary to implement the programs. Ms. Shadduck replied
that DHSS was expressly seeking a statute change for
primary care case management, which did not give the
identified Medicaid population a choice to opt in to the
program. Representative Wilson asked whether the section
defined what would happen if the recipient chose not to
participate in the program. Ms. Shadduck responded in the
negative. She explained that the department would implement
the regulations related to Section 29. She read from an
email response from the department (copy on file):
Enrollment in this program would be voluntary from the
enrollee's perspective at first, except for those with
multiple hospitalizations. Over time, as the
department evaluates the effectiveness of the program
and identifies other groups of enrollees who could
benefit from this service, the department may phase in
mandatory participation for additional groups.
Ms. Shadduck ascertained that the enrollee would be
required to enroll in a primary care case management system
under the provision in Section 29. The enrollee would
initially have an option to choose their case manager.
Representative Wilson asked what would happen if the
recipient chose not to participate in the program. Ms.
Shadduck answered that the "teeth" was the word "shall" in
Section 29. Currently, DHSS did not maintain the ability to
force a person to enroll but the provision made enrollment
mandatory. She deferred to Margaret Brodie, (Director,
Division of Health Care Services, Department of Health and
Social Services) for further clarification.
1:38:33 PM
Representative Wilson was uncomfortable with changing from
"may" to "shall" and forcing her Medicaid constituents into
a program they might not want to participate in.
Co-Chair Neuman wanted to know how the new Medicaid reform
regulations would be enforced.
Ms. Shadduck pointed to the statute AS 47.07.030 (d) and
read the following:
The department may establish as an optional service a
primary care case management system in which certain
eligible individuals are required to enroll and seek
approval.
Vice-Chair Saddler wondered whether the new provision was a
requirement or an option. He asked whether the department
currently was using the optional authority. Ms. Shadduck
deferred the question to the department to answer later in
the presentation. She noted that the issue had been
discussed thoroughly last session as a part of Medicaid
redesign. She explained that optional services within
Medicaid could be made optional for a certain Medicaid
population. In addition, the state was able to choose the
optional services it wished to participate in, within its
Medicaid system. She offered that the difference made the
statute language was confusing.
Representative Gara shared that when he worked for the
Attorney General's office it was customary to contract
outside of the state in order to utilize fewer state
employees as a cost cutting measure and that it actually
resulted in higher costs. He declared that in some
instances hiring more department staff saved money. He
noted that the super utilizer issue was not new and
remembered discussing the issue with former DHSS
Commissioner Bill Streur about his attempts to address the
problem. He wondered why a hospital could not refer a
person to another provider when someone showed up at the
emergency room with a non-emergency room issue. Ms.
Shadduck answered that federal law required care for anyone
who went to the ER for treatment. She pointed to page 31,
lines 3 through 5 of the legislation and read the
following:
(4) a process for assisting users of emergency
departments in making appointments with primary care
or behavioral health providers within 96 hours after
an emergency department visit;
Ms. Shadduck related that the former provision established
the authority for ER's to refer individuals to other
providers. Some individuals did not know how to access
healthcare other than going to the emergency room.
Representative Gara referred to the timeframe of 96 hours
for an appointment and wondered why it did not also specify
"immediate if feasible." He thought that 96 hours was too
long a wait time for some non-emergency issues. Ms.
Shadduck believed the provision was based on what other
states had done and was based on the practicality of
obtaining primary care appointments. She deferred the
question to the department for further detail. She revealed
that the hospital association would be working with DHSS on
the project. Representative Gara noted that he would like
to see the timeframe amended in the bill.
1:45:30 PM
Representative Guttenberg referred to the handout titled
"Washington State Medicaid: Implementation and Impact of
"ER is for Emergencies" Program" (copy on file). He stated
that the super utilizers were the most difficult population
to deal with but the most cost effective when remedied. He
asked whether more information was available regarding how
to manage the super utilizer Medicaid population. Ms.
Shadduck answered that a tremendous amount of information
existed on the topic. She cited the Agnew Beck report she
mentioned earlier and noted that an extensive explanation
on the issue was provided beginning on page 69.
Representative Kawasaki asked what definition of super
utilizer the state was operating under. Ms. Shadduck
replied that the bill did not define the term. The
department would set the guidelines along with input from
the hospital association. The department would relay its
current definition later in the meeting.
Representative Gara referred to Section 31 and asked
whether the provisions applied to anyone who entered and ER
seeking care for non-emergency issues regardless if a
person was a super utilizer or not. Ms. Shadduck answered
in the affirmative. She elaborated that the sponsor worked
with Alaska State Hospital and Nursing Home Association
(ASHNHA) in developing the provisions. The consensus was
that the provisions applied to all super utilizers,
Medicaid or not.
Co-Chair Neuman referred to page 28, subsection (d) of the
legislation. He read from the bill:
(d) The department shall [MAY] establish as optional
services a primary care
case management system or a managed care organization
contract in which certain eligible individuals are
required to enroll and seek approval from a case
manager or the managed care organization before
receiving certain services. The purpose of a primary
care case management system or managed care
organization contract is to increase the use of
appropriate primary and preventive care by medical
assistance recipients, while decreasing the
unnecessary use of specialty care and hospital
emergency department services.
Co-Chair Neuman reported that the legislation also
addressed cost reduction. He surmised that the department
would be required to do something, but the costs were
unknown. He was concerned about department mandates in a
fiscal crisis and a time of budget cutting. He noted that
the DHSS budget was reduced in other areas. He requested
further information related to the costs of the reform
programs. Ms. Shadduck responded that the Senate Finance
Committee members and co-chairs had taken the fiscal notes
for the legislation very seriously and examined them
thoroughly. However, the committee recognized that the
department required adequate resources to carry out
Medicaid reform. She referred to the document titled "DHSS
Fiscal Impacts for CSSB074(FIN)am, version UA" (copy on
file) that was distributed to members and provided a 2 page
summary of fiscal impacts. She cited that the primary care
case management program would cost $30 thousand in FY 17
but, by FY 18 DHSS would save $722 thousand and the savings
would continue to grow. She offered that the Senate Finance
Committee chose programs that would provide "the biggest
bang for the buck" and strove to develop the most balanced
options mindful of the state's fiscal situation.
Co-Chair Neuman clarified that the House was a separate
body and needed to do its own due diligence. He requested
any backup information regarding cost analysis.
1:53:14 PM
Representative Wilson requested information from the
department concerning program mandates. Ms. Shadduck
responded that the department would answer the questions.
BECKY HULTBERG, ALASKA STATE HOSPITAL AND NURSING HOME
ASSOCIATION, provided brief remarks. She related that the
high cost of healthcare presented a challenge to the entire
nation. In particular, the high cost of Medicaid was
spurring innovation in other states attempting to lower
costs. Many of the projects implemented in other states
were different but shared the same themes. She reported
that the themes consisted of the recognition of the role of
behavioral health, primary care as the foundation for
healthcare reform, and finally payment reform, which
impacted the value and cost of the care. She believed the
journey through reform would be arduous and involve
patience and resources. She emphasized that the department
would need resources to help implement some of the
projects. She announced that ASHNHA wanted to be part of a
solution. The association believed that the best way to
help manage the challenges was for the providers to "be at
the table" together with the state. She spoke to the
important thematic elements beginning with behavioral
health. She communicated that behavioral health presented
the biggest challenges to the association's members. She
referenced Section 27 and offered that the legislation
framed a vision for change for the behavioral health
system. She recounted that the legislation called for a
system that was comprehensive, integrated, and evidence-
based. Second, she remarked that primary care would serve
as the "quarter back" of the healthcare team associated
with the primary care case management project. She
supported the elements of the legislation, which created
and enabled supports for primary care providers to
accomplish reform. Lastly, the fee for service model or the
"do more get paid more" system was a volume based system.
She remarked that people wanted a healthcare system based
on value not volume; i.e., high quality care at an
affordable cost. Transformation was imperative for the
underlying payment mechanism that rewarded volume. She
detailed that the project took a "baby step" down the
transformational path by introducing a "shared savings"
portion into the mix. She thought that the bill approached
the volume to value transition with pilot projects. She
believed the bill was the right step towards achieving
payment reform by enabling broad pilot projects. She
underlined that the three themes provided the backbone of
reform and that reform took time to implement and produce
savings. She recognized that the legislature was interested
in immediate savings. She communicated that through the
primary care case management project small savings were
realized immediately and grew larger over time. In
addition, the project greatly improved the quality of care.
2:01:30 PM
Ms. Hultberg continued by providing a brief background on
the project. She communicated that ASHNHA put forward the
ER project in 2014 through the Medicaid reform advisory
group process. The program was included in the department's
Medicaid redesign project last fall [2015]. The program was
built upon a proven model from Washington State that
included the implementation of the "Seven Best Practices in
Emergency Room Care." She listed the practices as follows:
1. Tracking the ER visits to reduce emergency department
(ED) shopping.
2. Implementing patient education efforts to redirect
care to the most appropriate setting.
3. Instituting an extensive case management program to
reduce inappropriate emergency department utilization
by frequent users.
4. Reducing inappropriate ED visits by collaborative use
of prompt visits to primary care physicians.
5. Implementing narcotic guidelines that would discourage
narcotic seeking behavior.
6. Tracking data on patients prescribed controlled
substances by widespread participation in the State's
prescription monitoring program.
7. Use of a Feedback loop by assessing and reassessing
the effectiveness of the program to ensure the steps
were working.
Representative Gara stated that the presentation topic was
only part of the picture and the other part was that Alaska
had the highest healthcare costs in the nation.
Vice-Chair Saddler referred to Ms. Hultberg's testimony
about behavioral health. He asked whether state laws,
regulations, insurance companies, and the entire healthcare
system was properly set up to "equalize" behavioral care
with medical care. Ms. Hultberg answered that she did not
have a broad enough knowledge base about other states laws
to answer the question. She qualified that ASHNHA supported
the "investment of resources" in behavioral health, which
often resulted in reduced costs. She felt that the
legislation set out a framework to move forward with
healthcare system improvements.
Vice-Chair Saddler spoke to "ancillary unexpected costs" to
the reform efforts regarding behavioral health improvements
benefitting the healthcare system and he invited any
discussion regarding "clear ideas" on how to improve
behavioral health care.
Representative Edgmon discussed that the legislation was
really about "healthcare reform" and asked whether the term
was a "proper distinction." Ms. Hultberg answered in the
affirmative. She elaborated that Medicare and Medicaid
drove reform because the programs provided a "significant
portion of payment;" especially for hospitals. Medicare was
moving towards value in an effort to control costs. Changes
to Medicare and Medicaid would ultimately impact the entire
healthcare system.
2:06:19 PM
Representative Wilson referred to a super utilizer tracking
system. She wondered how the tracking system would
function. Ms. Hultberg deferred to DHSS for the answer. She
noted that the program would be implemented for anyone who
utilized the ER. She presumed that identifying and tracking
super utilizers informed the project's savings estimates.
Representative Wilson asked whether a super utilizer
tracking system currently existed. Ms. Hultberg responded
that there would not be a tracking system. She explained
that medical records, created when a person used the ER
could be accessed by other ER departments for the purpose
of providing better care. She characterized the system as
an "information exchange." Representative Wilson provided
an example of a patient using various hospitals. She asked
for verification that the system would not create an
information network between hospitals. Ms. Hultberg
deferred the questions to the medical providers.
Representative Guttenberg noted that the healthcare costs
in Alaska were astronomical and continued to increase. He
wondered what would happen to the costs and the ability of
the hospitals to function if nothing was done.
Ms. Hultberg answered initially about healthcare costs on a
national level. She communicated that healthcare costs had
been increasing as a percentage of the gross domestic
product (GDP). The costs resulted in lost economic
productivity in other sectors. She voiced that increased
healthcare costs would have a similar effect statewide and
would interfere with a "functioning economy."
Co-Chair Neuman discussed super utilizers. He assumed that
the concept of having super utilizers going to primary care
providers sounded beneficial. He stated that tens of
thousands of individuals used the ER in Alaska. He asked
how many super utilizers there were in the state and
wondered whether the program was trying to fix a problem
that did not exist. Ms. Hultberg did not have the data on
hand, but noted it was available through the department and
hospital ED's. She deferred the question to DHSS and
providers. Co-Chair Neuman believed it was important to
"weigh" the problems throughout the discussion. He stressed
the importance of the committee's understanding of the
costs by determining the size of the problem and its
consequences.
2:12:58 PM
Co-Chair Thompson relayed that he had a report that showed
information related to super utilizers and would distribute
it to the committee.
CARLTON HEINE, PAST PRESIDENT, AMERICAN COLLEGE OF
EMERGENCY PHYSICIANS, ALASKA CHAPTER, JUNEAU, relayed that
beside his work in Juneau in emergency medicine he commuted
to Washington to work with the University of Washington
over the past six years and noted his familiarity with a
similar project there and offered his perspectives. He
explained that the federal Emergency Medicine Treatment and
Labor Act (EMTALA) mandated that any patient that went to
an ER for care had to receive a screening exam [triage} and
have any emergency conditions stabilized. A screening exam
always had to be carried out; therefore, "the value of
triage was not always effective." He added that another
provision in federal statute concerned "a prudent
layperson" that defined an emergency as what a prudent
layperson felt was a healthcare emergency. He exemplified
that if a person came into the ER with chest pain it
represented the prudent layperson's interpretation of
symptoms that brought the patient to the ER.
Mr. Heine appreciated the efforts of the legislature to
work on the Medicaid cost issue. He declared that changing
Medicaid in ways that did not reduce care and resources to
patients would be very hard and that achieving large
savings would be based on difficult decisions. He
delineated that a significant amount of money was spent on
certain areas of healthcare without much benefit and felt
efficient reform began there. He believed that the SB 74
was addressing those areas, particularly the ED super
utilizer program. Alaska's high volume ER users were
complicated and numbered in the thousands. The patients had
complex medical problems and almost all had behavioral
health or addiction issues. The individuals visited the ER
"because they did not know how to do things in a different
way." The current system was only "putting a band aid on
the problem" and the ED was aware the patient was not
receiving quality care. He surmised that a lot of money was
being spent and the patient's problems were not being
corrected.
2:18:46 PM
Mr. Heine related that 5 years ago the Washington state
Healthcare Authority directed its Medicaid program to cut
$30 million from its super utilizer population. Because of
EMTALA an ER could not merely limit the number of ER
visits. The ER physicians, hospital association, and the
Washington Medicaid office collaborated and created the
Seven Best Practices program as a solution. He shared that
the program implementation costs were low and Washington
saved $34 million in its first year. He highlighted that
the program produced a significant savings without much
investment while increasing the quality of care. The bill
attempted to design the program to fit Alaska's needs. He
addressed the key components of the legislation. One of the
key components of SB 74 was related to case management and
finding social work solutions to some of the problems.
Another important component was the information exchange.
He noted that the exchange was similar to the Washington
state ER specific Healthcare Information Exchange (HIE). He
explained that an ER patient would be checked against the
database and the information would help ED's determine
appropriate care for the individual. He favored that the
information was easily accessible, contained a limited
amount of data and was "quick and easy to use." He
commented that one of the misconceptions was that all of
the patients just needed primary care and voiced that the
problem was more complex. He provided examples such as the
patient who went to the ER because she was lonely and the
solution was to provide a cell phone, or the patient
provided transportation services because he was using the
ambulance to travel to the ER. Creative solutions that
helped the patients and the state save money was imperative
for success. He emphasized that the program would both save
money and improve the quality of care, which were arduous
solutions to find. He strongly supported of the bill.
2:23:48 PM
Representative Wilson wondered whether Washington had put
its Seven Best Practices program in statute. Mr. Heine
replied that some parts of the program were placed in
statute but other portions were voluntary.
Representative Gattis asked about the patient information
exchanges. She wondered whether patients had the same
access to information and if acute care centers were
considered to be an ER in terms of patient information
exchanges. Mr. Heine replied that some of the nuances on
how acute care was defined would depend on how the program
was set up. He noted that, in general privacy laws offered
some limited access. He offered that the information
accessible to the ER exchanges would be limited to ER
visits and not necessarily urgent care visits. The database
would be designed in a way that the information was shared
with the provider only if a patient met certain defined
criteria.
2:27:28 PM
Representative Gattis asked whether the patient had the
right to request a copy of the information. Mr. Heine
answered in the affirmative.
Co-Chair Neuman asked whether patients had the right to opt
out of the information exchange. Mr. Heine replied that a
signed release was necessary to access a person's full
medical record, but permission was not required regarding
whether a patient visited another ER. Co-Chair Neuman
discussed that some individuals may not want their personal
information in a database. He asked whether the federal
government had access to the information. Mr. Heine did not
believe anyone outside of the hospitals had access to the
information. Co-Chair Neuman wanted to understand how much
information about the patient was shared. Mr. Heine
responded that the database worked through the billing
information. The amount of information was limited to
number of visits and the facilities visited and would not
contain all of the medical record details. In addition, the
database did not produce the data unless some subjective
criteria had been met such as multiple visits. A signed
medical record release would be necessary in order for the
ER to access detailed records.
2:32:00 PM
Co-Chair Neuman assumed that the information would
"feedback through the federal government" for any federal
based medical program. Mr. Heine responded that anyone that
had access to the billing system would have access to the
data. Co-Chair Neuman asked for clarification. Mr. Heine
answered that the federal Health Insurance Portability and
Accountability Act (HIPAA) laws delineated the access
certain types of providers had to various parts of
patient's information. He communicated that providers had
access to complete medical records and billing companies
had only enough access to the medical information to do the
billing portion.
Co-Chair Thompson presented a hypothetical scenario where a
patient did not share the information regarding a CT scan
received during one of his multiple recent visits to
different ER's. The possibility then existed he could
receive another scan at great cost to the system. He
wondered what information was shared on the information
exchange. Mr. Heine commented that that instance was a
great use of the system. The system would show that the
patient had received a CT scan but not the results. Beside
cost reduction, the exchange offered added healthcare
benefits like knowledge that a patient recently received a
CT scan which protected the patient from added exposure to
harmful radiation.
Representative Munoz mentioned that Mr. Heine had been
active with the Front Street Clinic [public health clinic
in Juneau serving the homeless population] and wondered if
the clinic resulted in reduced ER visits. She also asked
whether he believed there was a role for public health in
reducing ER visits. Mr. Heine responded that the reason he
became involved in the clinic because the ER was the
population's only other access to healthcare. He was
convinced that if the clinic was not in existence ER visits
would increase. He described the homeless patient
population as a difficult population to care for when
finding providers other than ER's to deliver their
healthcare and the clinic helped save the system money.
Representative Munoz wondered whether he was working on the
problem with the public health system throughout the state.
Mr. Heine revealed that that was the reason he was
advocating the project today. He had begun discussions with
Ms. Hultberg several years ago on how to expand on the
ideas from Washington State for adoption in Alaska. He
wanted to pilot successful programs and expand them for use
in the entire state.
2:37:36 PM
Vice-Chair Saddler thought they were discussing a larger
issue and viewed managed care as an answer to super
utilizers and the healthcare system overall. He wondered
whether the hospital based ER reduction project described
in Section 31 was the same as the primary care project
found in Section 29 of the legislation. Ms. Hultberg
responded that the Sections described two distinct
projects. Vice-Chair Saddler asked whether Washington State
had enough primary care physicians to implement the Seven
Best Practices program. Mr. Heine answered that problems
existed because of a lack of primary care physicians. He
expounded that the solutions could be broad and complex and
were not purely based on primary care. Primary care follow
up within a certain defined timeframe was part of the
Washington program and was achieved. He understood that the
primary care system in the state was "fairly robust" and
the bottleneck would likely occur in behavioral healthcare
where the demand outstrips the supply of providers. Vice-
Chair Saddler asked whether additional liability protection
was needed for ER providers who triaged the patient "if the
emphasis under the super utilizer reduction became shoving
people off to primary care." Mr. Heine answered that the ER
would still be responsible for doing a medical screening
exam and provided any needed ER care. He stated that the
goal of the program was to intervene and prevent the
patient's next unnecessary visit to the ER. The program
wanted super utilizers to get the care they need without
visiting the ER. He did not anticipate any liability
problems. Vice-Chair Saddler asked what percentage of ER
visits was prevented according to the Washington State
data.
ANNE ZINK, PRESIDENT, AMERICAN COLLEGE OF EMERGENCY
PHYSICIANS, ALASKA CHAPTER, MAT-SU, responded that the data
showed a 10.7 percent reduction in super utilizers and
overall 14 percent decrease in low acuity visits.
Vice-Chair Saddler asked whether the Section 29 information
exchange provisions only captured ER visits or would the
health information exchange contain data on primary care
and urgent care visits as well.
2:41:44 PM
Mr. Heine answered that in Washington State only ER visits
would populate the database because the problem resided in
the excessive use of ED's. Vice-Chair Saddler pointed to
Section 29 related to the super utilizer reduction program
and understood that the program could either be designed
and implemented by the department or contracted out to a
managed care organization (MCO). He asked whether his
understanding was correct. Ms. Hultberg replied in the
affirmative. She deferred to the department for its
interpretation.
Representative Gara spoke to a federal law requiring ERs to
stabilize an individual before they were released. He asked
whether a flu or bad cold required stabilization. Mr. Heine
answered that if a person had a viral illness that not much
could be done; however, if a person had a febrile illness
like pneumonia he would prescribe antibiotics.
Representative Gara informed Mr. Heine that he did
significant work with underprivileged kids who did not have
knowledge of the medical system and went directly to the ER
for healthcare. He wondered whether there was an easier way
to send a non-emergency patient to another facility that
would save the system money. Mr. Heine answered that
nationally ED's had been researching "triage out
protocols." He detailed that an initial screening was
required to make any kind of treatment assessment, which
performed most of the initial triage which essentially
ruled out cost savings. Public education regarding
appropriate use of the ER was an important and challenging
mission. He referred to causing possible problems in the
reverse where individuals should have gone to the ER or
doctor and decided to wait. Representative Gara asked
whether the initial ER screening was avoidable.
2:48:03 PM
Mr. Heine answered that the EMTALA law made a solution
difficult.
Dr. Zink provided some examples of her experiences working
in an ER in an effort to clarify the issues. She referred
to a super utilizer in her ED that she had established a
care plan for. She notified the committee that she was
prohibited from sharing the plan with other ED's. She
contacted the patient's primary care provider in an attempt
to obtain better care for a patient. She furthered that the
patient had 32 CT scan within one year and continued to
experience abdominal pain. The provider informed DR. Zink
that Providence Hospital had a care plan for the patient
and the patient should not be going to other hospitals. No
one had been aware of the situation for three years. She
judged that the underlying cause of her problems was not
addressed by the current system. She remarked that the
provisions in the bill would allow the hospital access to
enough information to correctly care for the patient. The
bill allowed for better patient care and cost savings and
she strongly supported it. She provided another example of
a "frequent flyer" patient who would constantly visit the
ER as a way to calm her anxiety. She finally received the
proper mental healthcare she needed through the mental
health court subsequent to a trespassing violation. She
felt that if the patient had previous access to proper
behavioral healthcare, the situation could have been
avoided. She voiced that many patients visiting the ER
arrived because the social network failed. She believed
that a true honor in working in an ER was being a safety
net but if one area of healthcare was inadequate another
area ballooned. She felt privileged to perform triage and
help patients understand whether their issue was a
perceived or real emergency and that placing the burden of
"medical decisions" on the patient was a risk. She
supported working with systems that allowed the provider to
screen the patient and have access to a system that shared
information about the patient in order to provide
appropriate care. She revealed her frustration with a
system that allowed over utilization of the ER and did not
believe the problem would be solved without collaboration
between government, insurance providers, and providers. She
cautioned against creating bottlenecks when crafting a
solution. She stated that different problems existed in
different areas of the state and that by creating case
management plans for super utilizers each community could
identify its limitations and work in collaboration between
public and private entities to find solutions. She shared
that her care management organization in the Matanuska-
Susitna Borough (Mat-Su) included the State Troopers,
Mental Health Court, Mental Health Providers, hospitals,
and others. She emphasized that all members of the
organization agreed that the ability for the ER to access a
patient information database was helpful to all other
providers. She spoke of a violent high-risk patient that
had a healthcare plan. She wanted his information to be
available around the state in case he travelled so
providers would be informed and consistent care would be
provided. She illustrated the situation as a way to
describe the benefits of the legislation.
2:56:32 PM
Dr. Zink discussed the opiate addiction problem and seeing
the serious health problems resulting from opiate addiction
presenting in the ER. She believed there was a connection
between frequent ER users and mental and behavioral health.
She shared data on super utilizers from the Mat-Su Health
Foundation. In 2013, one hospital in the Mat-Su received 27
thousand visits, 4429 were visits from super utilizers and
56 percent of the patients had concurrent behavioral health
diagnosis. Mat-Su Regional Hospital super utilizers cost
$73.5 million for facility costs alone. She often felt like
she was blind and handcuffed and unable to deal with ER
patients due to the lack of accessible information about a
patient. She supported the ED component of the bill, which
allowed her to fully practice as an ER physician.
Representative Guttenberg referred to references made about
the relationship between super utilizers, the courts, and
troopers. He asked whether the courts had access to medical
records. Dr. Zink replied in the negative. She explained
that the patient chart notes she composed, which might
include a care plan was completely protected and only
shared via a patient's permission. The information was
split into "different bundles;" the diagnosis, age, and
other necessary bits of information were sent to billers,
or Medicaid and Medicare. The billing bundle never
contained the remaining information on the chart and was
never shared with troopers, mental health providers, etc.
She furthered that if a trooper brought a suicidal person
to the ER for treatment she would have access to his care
plan but not the troopers. Representative Guttenberg
provided a hypothetical scenario where a mentally ill
person was arrested and a judge questioned whether the
person had a care plan. He wondered whether a judge or
probation officer would have access to the person's care
plan. Dr. Zink answered that different care plans were
written by different providers. The state would decide what
care plans would be accessible. Washington State authorized
ER's to write care plans. She relayed that the Mental
Health Court in Wasilla asked participants to sign a HIPAA
agreement releasing their records to a hospital and allow
the hospital to share the information. The troopers would
not have immediate access without the patient's permission.
Representative Guttenberg asked for Dr. Zink's experience
with the therapeutic courts. Dr. Zink replied that she
became a member of a care coalition team in the Mat-Su that
included troopers and the therapeutic courts a few years
ago in attempts to address the issue. The court designed
the HIPAA form that allowed information sharing and she
discovered that numerous ER patients were involved in the
therapeutic court. She voiced that the hospital had been
moving forward with reform and was not waiting for the
legislature to act.
3:02:39 PM
Vice-Chair Saddler asked for more information regarding
record sharing and whose records would be shared. Ms. Zink
believed patient privacy was a shared concern. She related
that in Washington State a care plan on the database
expired after 2 years. Typically, the care plans in
Washington involved patient input. The majority of the
plans were agreed upon between the provider and the
patient. She emphasized that judging patients did not
create a solution and she worked with the patient to try to
find the underlying condition.
Co-Chair Thompson noted that department staff was available
for questions.
Representative Edgmon thought that the legislation's
approach created a better business model to provide the
resources to accomplish the "low hanging fruit" of reform.
He wanted to explore the idea further. He voiced that there
were many areas of reform addressed in the bill. He
believed that the reform situation was similar to the
Medicaid expansion discussion by the need for resources in
order to build a better business model that addressed all
areas of reform to administer the appropriate healthcare,
"at the right value." He asked whether Ms. Hultberg agreed
with his summation. Ms. Hultberg responded that there were
many moving parts and pieces to the legislation and she
characterized it as "dense." She communicated that the
sponsor attempted to find immediate areas of savings. The
ER super utilizer reduction was the one piece of SB 74 that
produced savings. Other provisions in SB 74 created the
building blocks of reform so that in the future the system
achieved higher performance. She indicated that
transforming a business model was hard. She voiced that
"disruptive change was happening in healthcare all across
the country." Enhancing primary care and achieving payment
reform would take time and investment and results would not
be seen for several years. The legislation attempted to
balance the needs involved in creating a better system;
invest in the long term and explore innovative ways to
create some near term savings.
3:07:58 PM
Representative Edgmon referred to behavioral health. He
wondered whether behavioral health had a uniform definition
or "differing aspects on how it was perceived." Dr. Zink
answered that when analyzing the Mat-Su health data the
team "struggled" with the definition and did not think a
universal definition existed. She explained how the ER
addressed the issue. The ED department and the Mat-Su
foundation defined a behavioral health diagnosis based on
the following aspects of mental health: substance abuse,
depression, suicidality, homcidality, or anxiety.
Co-Chair Neuman had read some of the information provided
by Mr. Heine and cited that 85 percent of patients had
serious mental health issues. He also referred to Ms.
Zink's testimony about the patient with mental illness who
was constantly utilizing the ER as a way to manage her
anxiety. He asked whether a managed care plan would have
stopped the behavior. Ms. Zink replied in the affirmative.
She reminded Co-Chair Neuman that she had received a
managed care program from the therapeutic courts and the
behavior stopped. The hospital had only seen the woman once
in the past year and not at all in the current year. She
spoke to the successes the individual had as a result of
the managed care plan. Co-Chair Neuman referred to Ms.
Zink's other example of the women who received 32 CT scans.
He thought that systems should already be in place to deal
with the issue. Ms. Zink answered that she completely
agreed and was frustrated every time something similar
happened. She elaborated that healthcare existed in "silos"
and that the ER was a fast paced environment where it was
difficult to spend the time to get all of the information.
The information sharing system proposed in the bill would
"push" enough information in front of her to request more
complete records if warranted.
3:11:56 PM
Representative Munoz believed there needed to be fiscal
restraint on the part of the hospitals as well. She thought
that 32 scans were outrageous. Ms. Zink answered that part
of the ER's obligation was to ensure there was not a life-
threatening problem and chest or abdominal pain was a
trigger for high cost intervention.
MARGARET BRODIE, DIRECTOR, DIVISION OF HEALTH CARE
SERVICES, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via
teleconference), relayed that the department began a
program for super utilizers over two years ago. The
department initially defined a super utilizer as a person
who used the ER more than five times in an 18 month period.
Currently, 5,155 individuals were enrolled in one super
utilizer program and 19 enrollees in a different type of
program. She detailed that the department employed a
private contractor called MedExpert for the larger program
which offered telephonic services statewide. The company
provided case management services over the phone and had
medical professionals available. The program was voluntary
and the enormous response was unexpected. The model was
geared towards serving large populations over large
geographical regions. The contractor established a health
baseline, resource utilization pattern, and determined
whether family or community support was available for each
enrollee. Medical professionals were telephonically
available for the enrollees to call anytime. MedExpert
staff worked with the individual and her providers to
ensure that the patient was receiving the right health care
in the right setting as well as providing follow up. The
contractor also brought in appropriate social service
agencies to assist enrollees with other aspects of life.
She revealed that the program had been underway for about
1.5 years and saved $6 million in general funds (GF) as a
result.
3:16:50 PM
Ms. Brodie continued that DHSS initiated a smaller second
program that involved "face to face" contact; which was
more costly; therefore, a much smaller program. She
communicated that the contractor employed for the second
program was Qualis Health and began in November, 2015. The
investment results were not yet available. Qualis Health
will eventually work with a total of 40 to 60 volunteer
enrollees within the next six months. The program consisted
of nurses, social workers, case workers, and a physician
consultant that provided an initial screening and
comprehensive assessment. The model required extensive
outreach to the communities, which began by engaging in
meetings with numerous stakeholders throughout the state.
She remarked on the Med Expert program, which offered
unique follow up by providing extensive information on the
enrollee's medical condition enabling the individual to
make better healthcare decisions for themselves. She spoke
to Vice-Chair Saddler's questions regarding the Washington
State's ER program and Medicaid. Within the first year of
the program's inception, the ER visits by Medicaid patients
declined by approximately 10 percent and visits resulting
in prescriptions of controlled substances fell by 25
percent for the Medicaid population.
Representative Kawasaki referred to Section 29 of the bill
and specified subsection d and read, "the department shall
establish as optional services a primary care case
management system". He wondered why the program had to be
optional. Ms. Brodie answered that currently the program
was optional because the initial super utilizer program
called the "Care Management Program" was considered a
"locked-in" program where a patient was locked into a
specified provider and pharmacy and Medicaid would not pay
for services if they were provided by another physician or
pharmacy; the program was very restrictive for individuals.
She indicated that the program's regulations required the
department to obtain complete medical records to prove a
patient was utilizing services much more than they should.
The bill's language, explicitly the use of "shall" allowed
the department to enroll a person based on over utilization
of services. She qualified that the department analyzed the
data to determine the causes of utilization and individuals
with serious conditions that required extensive care were
legitimate and ruled out. She maintained that the
department considered appropriate use and did not solely
rely on "statistical outliers" to enlist participants.
3:22:53 PM
Ms. Shadduck referenced page 28, subsection d, the
language, "shall establish as an optional service." She
recapped that the words "optional service" had to remain
listed in statue in the bill. She reminded the committee
that the legislature had to grant permission for any
optional Medicaid service. Certain Medicaid programs were
required by the federal government and some programs were
optional but Alaska required legislative approval for DHSS
to participate in an optional Medicaid service.
Representative Kawasaki referred to testimony by Ms. Brodie
about the super utilizer program being optional for the
patient and requested clarification. Ms. Brodie answered
that the super utilizer programs currently in place were
voluntary. She explained that many of the participants also
qualified for the mandatory care management program and by
volunteering for the super utilizer programs the patient
was participating in a less restrictive program than the
department's mandated program.
Vice-Chair Saddler noted that AS 47.07.030(d) referred to
optional services and the mandatory services were in
paragraph (b). He cited page 28, line 29 of the
legislation, and read, "shall require recipients with
multiple hospitalizations." He wondered who defined what
multiple was. Ms. Brodie answered that the department
established a definition of three or more visits by an
individual in a 12-month period; the number totaled over
12,600 Medicaid recipients. Vice-Chair Saddler asked
whether the department wanted the definition in statute
rather than regulation. Ms. Brodie answered that the
department would need flexibility to make changes to the
definition in the future. She related that other services
besides ER visits were being over utilized and the
department needed to determine and address that excessive
utilization over time. Vice-Chair Saddler stated the
following from the legislation, "the department shall
require recipients to enroll in a primary care management
system." He asked what would happen if a person refused to
enroll. Ms. Brodie answered that at that point the
department would determine whether the individual qualified
for the mandatory care management program. Vice-Chair
Saddler restated the question. Ms. Brodie responded that if
a patient would not enroll the state would not pay for any
Medicaid services but the patient was then eligible for
"fair hearing rights." She commented that most patients
would enroll.
3:28:46 PM
Vice-Chair Saddler wondered about the likelihood the
department would be challenged legally. He referred to page
28, lines 19 through 21 and noted that the bill allowed for
either DHSS to create a managed care system or to contract
with an existing MCO. He asked which was more likely and if
contracting with MCO's would even be an option in Alaska.
Ms. Brodie replied that the state would contract the
services out if contracting was less expensive and would be
the preferred option. The key was that the option had to be
affordable for the state. Vice-Chair Saddler asked whether
the MCO had to exist in Alaska. Ms. Brodie responded that a
company could be headquartered out-of-state but would have
to have a presence in state.
Representative Wilson deduced that if a recipient refused
to participate in a voluntary or mandatory program the
department would expel the individual from Medicaid and
cause the individual to go the ER for more costly care. Ms.
Brodie answered that the scenario was what currently
happened with super utilizers.
3:32:10 PM
Representative Wilson surmised that the only change in the
legislation was that both programs would be mandatory. She
believed the end result would be the same as what was
happening now because the person had no other option than
to go to the ER. Ms. Brodie responded that the difference
was in the number of individuals the program could serve;
the new definition for super utilizer adopting 3 or more ER
visits [in a twelve month Period] captured over 14 thousand
more people it could steer to the appropriate healthcare
provider. Representative Wilson stated that the department
could currently change program parameters without statute.
Ms. Brodie agreed. She detailed that the key was that the
locked in care management program was only designed to
serve a maximum of 300 people. Currently, over 14,000
people qualified. Representative Wilson surmised that the
department already had a program. She could not figure out
why statue was needed. Ms. Brodie answered that statue was
necessary because if a person chose not to participate he
could continue to over utilize services. She added that the
additional enrollees would overwhelm the program in a short
period of time. There would be 13,900 people who would
continue to over utilize services and Medicaid would be
required to pay.
Representative Wilson reiterated her concerns regarding
super utilizers that refuse to participate in the program
frequenting the ER. Ms. Shadduck replied that if a person
did not enroll the department could stop paying for
Medicaid benefits. She spoke to her personal experiences
working in Fairbanks with case management and related that
education helped participants learn how to use appropriate
services. She believed there would always be "outliers" who
would refuse case management enrollment but the state would
no longer pay the Medicaid benefits. She believed the
programs would sill save state GF money.
Co-Chair Thompson guessed that only a small number of
people would refuse to participate.
Representative Gara deduced that federal law required an ER
to provide care at its own expense. In addition, the use of
the word, "shall" in SB 74 authorized the state to cut off
Medicaid benefits upon participation refusal. Ms. Shadduck
replied in the affirmative. Representative Gara asked
whether there was any evidence to prove that visits to the
ER were diverted by providing behavioral health to super
utilizers. Ms. Brodie answered that the costs of super
utilizers had been reduced by approximately $2,400 per year
per person. She indicated that providers had up to one year
to bill for services so the specific data related to the
Medicaid expansion population was not yet known.
3:40:03 PM
Representative Gara relayed from personal experience that
there was an incentive for providers to steer patients to
use expensive medical "equipment." He wondered whether the
department had the authority to deny unnecessary imaging.
Ms. Brodie answered that prior authorization for physician
owned imaging was required by DHSS for the past three
years. She clarified that imaging service rendered at an ER
did not require prior authorization. Representative Gara
asked whether the department could enforce inappropriate
use of imaging by an ER. Ms. Brodie answered that the
department could determine inappropriate use by an ER
during its utilization review process within three to six
months after the event happened and would direct the
patient to the proper provider.
3:42:10 PM
Representative Gara hypothesized the scenario of ER abuse
of the Medicaid program through overutilization of imaging
services. He wondered whether the department could refuse
Medicaid payment to ED's for unnecessary imaging. Ms.
Brodie responded that ER's use of imaging was a medical
decision and the department was not qualified to make
judgements regarding medical decisions. Representative Gara
asked why the department could enforce private physician
overuse but not ER overuse. Ms. Brodie answered that it was
due to the fact that the ER did not have time to wait for
preauthorization paperwork in an emergent condition.
Representative Gara wanted to know what would happen when
the condition was not an emergency and the use of imaging
was abused by the ER. Ms. Brodie answered that ER doctors
were professionals and the department did not want to
second guess their decisions.
Representative Munoz asked what the state paid for a CT
scan. Ms. Brodie would follow up and provide the answers.
Vice-Chair Saddler referred to the "lock-out" program. Ms.
Brodie corrected that the mandatory care management program
was known as the lock-in program. Vice-Chair Saddler asked
whether the lock-in program differed from the Med-Expert
administered program. Ms. Brodie answered in the
affirmative. Vice-Chair Saddler asked whether the Qualis
Health run program was a third program. Ms. Brodie replied
in the affirmative. Vice-Chair Saddler asked whether any of
the described managed care efforts would be eliminated with
passage of SB 74. Ms. Brodie replied that DHSS viewed
passage of the bill as evolving the programs into the
reform efforts. Vice-Chair Saddler asked for more detailed
information about the three programs. Ms. Brodie agreed to
follow up.
3:46:52 PM
Representative Wilson asked for more information regarding
how many enrollees refused to participate in the case
management programs. Ms. Brodie replied that she would
follow up with the information.
CSSB 74(FIN) am was HEARD and HELD in committee for further
consideration.
Co-Chair Thompson addressed the meeting schedule for the
following day.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB74 Super Utilizers HFIN 032316 - WA State ER is for Emergencies Seven Practices.pdf |
HFIN 3/23/2016 1:30:00 PM |
SB 74 |
| SB74 -Super Utilizers HFIN 032316 - Washington State ER Project Study_5.4.15.pdf |
HFIN 3/23/2016 1:30:00 PM |
SB 74 |