Legislature(2015 - 2016)CAPITOL 106
03/04/2016 12:30 PM House HEALTH & SOCIAL SERVICES
Note: the audio ![]()
and video ![]()
recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.
| Audio | Topic |
|---|---|
| Start | |
| HB227 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 227 | TELECONFERENCED | |
| + | TELECONFERENCED |
HB 227-MEDICAL ASSISTANCE REFORM
12:36:18 PM
CHAIR SEATON announced that the only order of business would be
HOUSE BILL NO. 227, "An Act relating to medical assistance
reform measures; relating to administrative appeals of civil
penalties for medical assistance providers; relating to the
duties of the Department of Health and Social Services; relating
to audits and civil penalties for medical assistance providers;
relating to medical assistance cost containment measures by the
Department of Health and Social Services; relating to medical
assistance coverage of clinic and rehabilitative services; and
providing for an effective date."
12:37:32 PM
CHAIR SEATON moved to adopt Amendment 5, labeled 29-LS1096\H.9,
Glover, 2/22/16, which read:
Page 7, lines 14 - 26:
Delete all material.
Renumber the following bill sections accordingly.
Page 7, line 31, through page 8, line 1:
Delete "provided to Indian Health Service
beneficiaries through the Indian Health Service and
tribal health facilities"
Insert "for recipients of behavioral health
services, as defined by the department by regulation"
Page 11, line 13:
Delete "sec. 12"
Insert "sec. 11"
Page 11, following line 27:
Insert a new bill section to read:
"* Sec. 17. The uncodified law of the State of
Alaska is amended by adding a new section to read:
IMPLEMENT FEDERAL POLICY ON TRIBAL MEDICAID
REIMBURSEMENT. (a) The Department of Health and Social
Services shall collaborate with Alaska tribal health
organizations and the United States Department of
Health and Human Services to implement changes fully
in federal policy that authorize 100 percent federal
funding for services provided to American Indian and
Alaska Native individuals eligible for Medicaid.
(b) In this section, "Alaska tribal health
organization" means an organization recognized by the
United States Indian Health Service to provide health-
related services."
Renumber the following bill sections accordingly.
Page 12, lines 6 - 7:
Delete "and the provisions of secs. 12(e), 12(f),
15, and 16"
Insert "the provisions of AS 47.07.036(e) and
(f), added by sec. 11 of this Act, and the provisions
of secs. 14 and 15"
Page 12, line 22:
Delete "sec. 16"
Insert "sec. 15"
Page 12, line 23:
Delete "sec. 18"
Insert "sec. 19"
Page 12, line 25:
Delete "sec. 16"
Insert "sec. 15"
Page 12, line 27:
Delete "Section 12(e) of this Act"
Insert "AS 47.07.036(e), added by sec. 11 of this
Act,"
Page 12, line 29:
Delete "added by sec. 12(e) of this Act"
Insert "of AS 47.07.036(e), added by sec. 11 of
this Act,"
Page 12, line 31:
Delete "Section 12(f) of this Act"
Insert "AS 47.07.036(f), added by sec. 11 of this
Act,"
Page 13, line 2:
Delete "added by sec. 12(f) of this Act"
Insert "of AS 47.07.036(f), added by sec. 11 of
this Act,"
Page 13, line 4:
Delete "Section 15"
Insert "Section 14"
Page 13, line 6:
Delete "sec. 15"
Insert "sec. 14"
Page 13, line 8:
Delete "sec. 16"
Insert "sec. 15"
Page 13, line 11:
Delete "sec. 12(e) of this Act"
Insert "AS 47.07.036(e), added by sec. 11 of this
Act,"
Page 13, line 14:
Delete "sec. 12(f) of this Act"
Insert "AS 47.07.036(f), added by sec. 11 of this
Act,"
Page 13, line 17:
Delete "sec. 15"
Insert "sec. 14"
Page 13, line 20:
Delete "17(a)"
Insert "16(a)"
REPRESENTATIVE TARR objected for discussion.
12:37:53 PM
TANEEKA HANSEN, Staff, Representative Paul Seaton, Alaska State
Legislature, explained that proposed Amendment 5 removed the
language that currently directed the Department of Health and
Social Services to apply for a 1115 waiver for tribal health,
and then directed the DHSS to collaborate with providers and the
federal government to fully implement the Centers for Medicare &
Medicaid Services (CMS) rule on this issue. She directed
attention to page 7 of the proposed bill, and noted that the
proposed amendment would delete Section 11, which previously
deleted statutory language conflicting with the 1115 tribal
waiver; as Amendment 5 removed the 1115 waiver from the bill, it
was no longer necessary to change the statutes as proposed in
Section 11. She pointed to page 7, line 31, Section 12, of the
proposed bill, which deleted "provided to Indian Health Service
beneficiaries through the Indian Health Service and tribal
health facilities" and inserted "for recipients of behavioral
health services, as defined by the department by regulation."
She declared that this was a change in direction for application
of the 1115 waiver from a tribal waiver to a behavioral waiver.
She explained that a new bill section, Section 17, would direct
the department to implement the federal policy on tribal
Medicaid reimbursement. She relayed that the remainder of the
amendment was re-numbering and re-naming as necessary.
12:40:06 PM
CHAIR SEATON acknowledged that the necessary contractual
agreements between tribal and non-tribal providers would require
a significant level of collaboration and that it may be a
worthwhile investment for the state to incentivize this
collaboration in order to ensure reception of the 100 percent
federal medical assistance percentage (FMAP). He asked if this
option existed in the proposed bill, or if it was necessary or
beneficial, to authorize the department to offer incentives.
JON SHERWOOD, Deputy Commissioner, Medicaid and Health Care
Policy, Office of the Commissioner, Department of Health and
Social Services, relayed that DHSS had some ability to
incentivize, although it would be useful to have language in the
proposed bill which made it clear that this was part of the
department's responsibility. He discussed similar language in a
previously proposed bill.
CHAIR SEATON expressed his concern that a shift of providers
included enough incentives and agreements. He asked if the
department had this same concern.
MR. SHERWOOD replied that the strength of the new policy was
that it did not require a shift of individuals to different
providers to achieve this 100 percent FMAP, if those providers
were willing to enter into agreements with each other, tribal
and non-tribal, around the coordination of care. He declared
that nothing else had to change, neither the providers nor the
payment rates. He pointed out that the state did not have any
direct control over these relationships.
12:43:36 PM
VALERIE DAVIDSON, Commissioner, Department of Health and Social
Services (DHSS), reported that the tribal policy change had some
additional requirements which the department had to demonstrate
to CMS, in order for the state to make the 100 percent claim.
She explained that a requirement for the referrals was that the
Indian Health Service (IHS) provider must maintain control of
the medical record and then electronically transfer information
through a health information exchange or some other means. She
noted the challenge: all of the savings from these
opportunities and partnerships go to the state while there was
more work for the tribal and non-tribal providers to start a
partnership. She affirmed this chance for incentives and
opportunities to participate on the health information exchange.
12:45:16 PM
CHAIR SEATON [moved to adopt] conceptual Amendment 1 to proposed
Amendment 5, which stated: on page 2, line 1, [of the proposed
amendment] following "Medicaid", insert "collaboration may
include incentives for providers to participate in contracts for
referrals".
REPRESENTATIVE VAZQUEZ objected for discussion.
REPRESENTATIVE VAZQUEZ asked for an explanation to the type of
incentives.
CHAIR SEATON explained that this was permission for contractual
incentives, or whatever DHSS could design to enhance the
collaboration and the contracts. He pointed out that he was not
detailing the incentives, but only wanted to make it clear in
the proposed bill that Department of Health and Social Services
had the authority to provide them. He noted that, unless
everyone wins, the state would not realize the cost savings.
REPRESENTATIVE TARR asked for clarification that the use of
"may" instead of "shall" made this permissive and not
proscriptive.
CHAIR SEATON expressed his agreement, although he stated that he
did not have a specific incentive to offer. He said that he
wanted to ensure that the department had the authority to enter
into conversations for incentives, so that the state would
recognize as much of the 100 percent FMAP as available.
REPRESENTATIVE VAZQUEZ asked about any incentives, other than
cost sharing.
CHAIR SEATON offered his belief that there had been discussion
for coordination with the e-health network. He reiterated that
he wanted to provide the department with the authority.
REPRESENTATIVE VAZQUEZ suggested asking DHSS what incentives
they had in mind.
COMMISSIONER DAVIDSON relayed that there had been mention of the
cost associated with participation in the health information
exchange for providers.
CHAIR SEATON asked if that would be a 90 [percent] - 10
[percent] [federal] match.
COMMISSIONER DAVIDSON expressed her agreement.
REPRESENTATIVE VAZQUEZ asked if that was the only incentive
envisioned.
COMMISSIONER DAVIDSON said yes but that any other ideas for
significant savings in federal match would be entertained, and
that the department "would appreciate the latitude to pursue
those opportunities."
CHAIR SEATON relayed that this conceptual amendment resulted
from discussions for the new policy and the potential roadblocks
that could limit it, and not from Department of Health and
Social Services, in order to make it as beneficial as possible
to the state.
12:51:47 PM
REPRESENTATIVE VAZQUEZ removed her objection to conceptual
Amendment 1. There being no further objection, conceptual
Amendment 1 to Amendment 5 was adopted.
12:52:39 PM
CHAIR SEATON returned attention to proposed Amendment 5.
REPRESENTATIVE VAZQUEZ read from page 7, lines [15 - 21}, of the
proposed bill.
The department, in implementing this section, shall
take all reasonable steps to implement cost
containment measures that do not eliminate program
eligibility or the scope of services required or
authorized under AS 47.07.020 and 47.07.030 before
implementing cost containment measures under (c) of
this section that directly affect program eligibility
or coverage of services. The cost containment measures
taken under this subsection may include new
utilization review procedures, changes in provider
payment rates, and precertification requirements for
coverage
REPRESENTATIVE VAZQUEZ asked why the proposed amendment would
delete this provision.
MS. HANSEN explained that this section was being removed from
the bill so that the language would remain in statute. She
directed attention to page 7, lines 21 - 26, which, in the
proposed bill, were being deleted from the statute. With the
proposed amendment, all of subsection (b) would remain in
statute.
REPRESENTATIVE VAZQUEZ relayed that she would have to look at
the statute.
CHAIR SEATON offered his understanding that, as Section 11 of
the proposed bill had a deletion, adoption of the proposed
Amendment 5 meant nothing would change in the current statute,
AS 47.07.036(b).
REPRESENTATIVE VAZQUEZ expressed her agreement.
REPRESENTATIVE TARR removed her objection. There being no
further objections, Amendment 5, as amended, labeled 29-
LS1096\H.9, Glover, 2/22/16, was adopted.
12:57:04 PM
CHAIR SEATON moved to adopt Amendment 6, labeled 29-LS1096\H.11,
Glover, 2/29/16, which read:
Page 8, line 27:
Delete "design and"
Page 9, line 1:
Delete "department shall design the managed care
system"
Insert "managed care system must be designed"
REPRESENTATIVE TARR objected for discussion.
MS. HANSEN explained that proposed Amendment 6 also reviewed
Section 12 of the proposed bill, and she directed attention to
the changes on pages 8 and 9. She stated that the purpose of
the proposed amendment was to allow greater flexibility for the
proposed demonstration project, so that the department did not
have to design the project but only had to implement it. She
shared that a local group on the Kenai Peninsula was interested
in a similar project.
CHAIR SEATON explained that this amendment would allow for a
request for proposal (RFP) without the need for a departmental
design of the demonstration project.
REPRESENTATIVE TARR expressed her appreciation for the wording
of the proposed amendment, as it allowed flexibility. She
removed her objection. There being no further objection,
Amendment 6, labeled 29-LS1096\H.11, Glover, 2/29/16, was
adopted.
1:00:46 PM
REPRESENTATIVE TALERICO moved to adopt Amendment 9, labeled 29-
LS1096\H.14, Glover, 3/2/16, which read:
Page 9, following line 9:
Insert a new subsection to read:
"(g) To the extent consistent with federal law,
the department may not increase provider payment rates
unless and until the department
(1) implements a demonstration project
under (e) or (f) of this section that results in a
cost savings of at least 10 percent for provider
payments as compared to provider payments for fiscal
year 2016 for the group or groups of medical
assistance recipients participating in the project;
and
(2) determines that implementation of the
payment model tested in the demonstration project for
all medical assistance recipients will save a minimum
of 10 percent of the amount spent for provider
payments in fiscal year 2016 for all medical
assistance recipients."
Reletter the following subsection accordingly.
Page 12, lines 6 - 7:
Delete "and the provisions of sec. 12(e), 12(f),
15, and 16"
Insert "the provisions of AS 47.07.036(e) - (g),
added by sec. 12 of this Act, and the provisions of
secs. 15 and 16"
Page 12, line 27:
Delete "Section 12(e) of this Act"
Insert "AS 47.07.036(e), added by sec. 12 of this
Act,"
Page 12, line 29:
Delete "added by sec. 12(e) of this Act"
Insert "of AS 47.07.036(e), added by sec. 12 of
this Act,"
Page 12, line 31:
Delete "Section 12(f)"
Insert "AS 47.07.036(f), added by sec. 12,"
Page 13, line 2:
Delete "added by sec. 12(f) of this Act"
Insert "of AS 47.07.036(f), added by sec. 12 of
this Act,"
Page 13, following line 3:
Insert a new subsection to read:
"(d) AS 47.07.036(g), added by sec. 12 of this
Act, takes effect only if the commissioner of health
and social services notifies the revisor of statutes
in writing under sec. 18 of this Act, on or before
January 1, 2017, that all of the provisions of
AS 47.07.036(g), added by sec. 12 of this Act, have
been approved by the United States Department of
Health and Human Services."
Reletter the following subsection accordingly.
Page 13, line 11:
Delete "sec. 12(e)"
Insert "AS 47.07.036(e), added by sec. 12 of this
Act,"
Page 13, line 14:
Delete "AS 47.07.036(f), added by sec. 12 of this
Act,"
Page 13, following line 16:
Insert a new bill section to read:
"* Sec. 25. If AS 47.07.036(g), added by sec. 12 of
this Act, takes effect, it takes effect on
the day after the date the commissioner of health and
social services notifies the revisor of statutes in
writing under secs. 18 and 21(d) of this Act."
Renumber the following bill sections accordingly.
Page 13, line 19:
Delete "21(d)"
Insert "21(e)"
REPRESENTATIVE TARR objected for discussion.
1:01:02 PM
REPRESENTATIVE TALERICO shared that there had been repeated
discussions for the potential of cost savings, pointing to
several different opportunities for payment structures. He said
that the proposed amendment was an incentive to move rapidly
forward, directing attention to the dates and figures in the
proposed amendment and noting that all of these had the
potential for adjustment. He asked for a list to what the
priorities were when there were reforms. He opined that the
committee had been "throwing quite a bit of weight towards the
department to do some things," which included the responsibility
to amend the state plan with these changes, noting that the
department was capable although this was "a reasonably heavy
lift for the department," as well as establish criteria in
several areas for pilot programs or demonstration projects,
including coordinated care, reduction of pre-term births, and
services and care through home and community based services. He
spoke about the need for payment reform, care management, work
force development, and innovative service delivery models. He
asked whether DHSS had established a priority list, and whether
they had sufficient resources. He declared the need for a
conversation regarding the priorities.
MR. SHERWOOD acknowledged that the points were well taken and
that this was "a heavy lift for the department." He directed
attention to the priority schedule in the fiscal notes for the
department to work toward. He declared that the department
takes the need for Medicaid reform very seriously. He pointed
to some "quick wins" which included refinancing using federal
funds to replace general funds for systems already in place,
including tribal policy, and 1915(i) and (k). He shared that
other reforms focused on bending the long term cost curve in the
Medicaid program by bringing in better practices to benefit the
entire health care system. He reported that this required
partnership with others in the health care system. He noted
that a target for payment reform was often projected to be about
2 percent which, although initially not the same volume as the
refinance programs, would grow these savings when projected over
time. He declared the understanding that the work needed to
begin immediately and the foundation needed to be laid. He
opined that the fiscal notes reflected payment reform, and that
most of this would occur in about two years. He expressed
appreciation for "making priorities clear because there are a
lot of things to be done in this bill."
REPRESENTATIVE TALERICO replied that this was what he had been
looking for, noting that even the fiscal notes were cumbersome.
He asked if there was anything the committee could do to provide
assistance to the Department of Health and Social Services.
1:10:53 PM
REPRESENTATIVE TARR asked if there could be any unintended
consequences from line 4 of proposed Amendment 9, noting the
difficulty for finding Medicare doctors. She pointed out that
not increasing the rates could lead to a shortage of providers
participating in the demonstration projects.
MR. SHERWOOD pointed to line 3 of the proposed amendment, "to
the extent consistent with federal law," reporting that new
federal regulations required proof that access was being
provided whenever there was a change in rate methodology. He
said that the extent the department could restrict rates was
"somewhat questionable." He acknowledged that the burden for
approval of a freeze would "increase substantially" and that it
may not be obtainable, even with extensive effort. He noted
that this could result in a diversion of resources away from
pursuit of the legislative goals, and could refocus providers on
aspects of the program that were less central to the reforms.
REPRESENTATIVE TARR asked if the federal regulations created an
additional burden.
MR. SHERWOOD replied that the department did not have a lot of
history with how the federal government would view this. He
pointed out that physical access was different than regulation
of access for adequate financial considerations to the
providers.
REPRESENTATIVE VAZQUEZ asked about the specific federal
regulation.
MR. SHERWOOD replied that he would research it.
REPRESENTATIVE VAZQUEZ asked how he could know that Alaska paid
well in compensation to Medicaid providers.
MR. SHERWOOD explained that the common measure was for a
percentage of Medicare paid to health professionals subject to
the fee schedule under Medicare Part B. He reported that,
typically, Alaska paid over the Medicare rate, at times more
than 30 percent, whereas most other states do not pay above the
Medicare rate. He share that one could also look at the high
percentage of providers participating in the program relative to
other states.
REPRESENTATIVE VAZQUEZ asked about the percentage of providers
participating in Medicaid.
MR. SHERWOOD replied that it varied by provider type, but was
generally in the 90 percentile.
1:17:56 PM
JEANNIE MONK, Alaska State Hospital and Nursing Home Association
(ASHNHA), stated that there was "a pretty good understanding of
the impact," although she expressed concern that freezing the
provider rates as an incentive to do something different may not
result in the desired incentives. She directed attention to
pilot projects that allowed providers to change the incentives
in order to provide better care at a lower cost. If the rates
are reduced or frozen, the resources would be reduced, as well.
She pointed out that under federal law, the Emergency Medical
Treatment and Active Labor law, hospitals must accept Medicaid
if a patient goes to the emergency room. She noted that
physicians did not have that same requirement, and therefore, a
rate freeze could result in providers no longer accepting
Medicaid. She stated that ASHNHHA would rather not have rates
frozen, as it would "be harmful to the effort at implementing
these projects." She reported that hospitals and nursing homes
received cost based reimbursement from the state, which meant
they were paid the actual cost for providing the services.
These rates were analyzed and a new rate developed every four
years, while in between these re-basing years, there would be
inflationary increases. She emphasized that freezing rates
meant no increase. She acknowledged that, although some
facilities could absorb this, facilities with a high percentage
of Medicaid patients were not able to shift cost to other
payers. She offered her belief that the questions for asking
about capacity and what would be done first were very good, as
there was "a lot of reform on the table." She pointed out that,
as reform takes more time than wanted or anticipated, it needed
to be managed "in a thoughtful way."
REPRESENTATIVE TARR opined that it was necessary to take the
opportunity to be diligent and that reform would be evident in
the next year.
1:22:21 PM
CHAIR SEATON mused that previously there had been permission for
coordinated care although there were not any incentives, even
though it had been allowed statutorily. He reminded the
committee of a previous change from "shall design" to offering
an RFP and contract from the department to those providers of
the services for what made sense. He expressed some concern
that global payment models would accept all the risk, and then
rates would be frozen until there was demonstration for money
saved. He pointed out that the savings could come from
coordinated care and improvement of the health care status, a
longer term commitment. He questioned whether, under this
proposed amendment, anyone would propose a global payment model
as it could be more risky. He expressed a concern that lower
cost had to be demonstrated prior to allowing a design to work.
1:25:55 PM
REPRESENTATIVE TALERICO stated that he would like to hear about
incentives to ensure that everyone "was on board" and "part of
the system," noting that this would take participation from
everyone. He declared that the providers had to be very
involved, and that Department of Health and Social Services
should not have to take all of the responsibility. He shared
that he was impressed with the variety of payment option
programs, declaring that it was critical to provide assistance
to DHSS and the providers when moving forward. He expressed his
concern for "a slow boat moving forward" as it was necessary for
the boat to have momentum all the time. He shared an anecdote
of color coding for momentum.
1:30:02 PM
REPRESENTATIVE TARR asked if the providers saw the changes
coming with an expectation for participation.
COMMISSIONER DAVIDSON replied that DHSS had heard a consistent
message from providers and beneficiaries that this was "a must
have" and that people were incentivized to make this happen.
She offered her belief that there were a sufficient number of
provisions in the proposed bill, outlined in the fiscal notes,
for savings. She declared that the challenge was for what
period of time and for which incentives and investments to
realize savings. She pointed out that with behavioral health,
people were not able to access the treatment programs and
services in the necessary ways to impact the costs to
corrections, public safety, child maltreatment, and emergency
departments. She suggested that these areas would need an
investment, although the savings may not be seen in DHSS. She
asked if DHSS would be hindered from moving forward if those
savings were not recognized in the department. She offered an
analogy that a ship had already been built, and although it was
not the most efficient ship with lots of builders and visions,
it was now necessary to streamline the ship to ensure that
everyone was moving in the same direction with the current.
1:34:30 PM
REPRESENTATIVE TALERICO withdrew proposed Amendment 9.
1:34:43 PM
CHAIR SEATON moved to adopt Amendment 7, labeled 29-LS1096\H.12,
Glover, 2/29/16, which read:
Page 8, line 2, following "42 U.S.C. 1396n":
Insert "designed to result in cost savings to the
state and"
Page 8, line 5, following "42 U.S.C. 1396n":
Insert "designed to result in cost savings to the
state and"
REPRESENTATIVE TARR objected for discussion.
MS. HANSEN explained that the proposed amendment was to Section
12 of the proposed bill, and would insert the phrase "designed
to result in cost savings to the state" and would apply to
applications for the 1915(i) and (k) options. She reminded the
committee that these options provided an opportunity to leverage
federal funds for services which the state already provided and
that the state had the ability to design the criteria, as well
as design and target the population already being served. She
stressed that this language emphasized that the intention for
these options was to generate cost savings.
REPRESENTATIVE TARR expressed her support.
REPRESENTATIVE VAZQUEZ objected.
REPRESENTATIVE TARR removed her objection.
REPRESENTATIVE VAZQUEZ repeated her robust opposition to the
1915 options, as there were not any studies to show the real
cost to the state. She declared that there were a lot of grants
and a lot of hype, but no economic study to show any savings.
She stated that this cost shifting to the federal government
relied on a specific FMAP, and it was unclear whether this match
would continue given the issues on the national level. She
stated that earlier testimony had indicated that many of those
people currently on the waiting list for the developmental
disabilities waiver would now qualify at a 50 percent federal
match. In light of the current fiscal situation, she opined
that "we oughta be more sure."
CHAIR SEATON pointed out that this proposed amendment required
the waivers, and was not a discussion for whether or not the
waivers should be had, which had already been addressed in a
previous amendment. He stated that this proposed amendment
inserted language that said it was necessary for the design of
the application of those waivers to result in a cost savings to
the state. The purpose was for the waiver process to be
constructed to result in a cost savings.
1:40:05 PM
REPRESENTATIVE VAZQUEZ maintained her objection because it
related to the implementation of the 1915 options, for which she
objected due to the lack of real data for saving money.
1:41:06 PM
A roll call vote was taken. Representatives Talerico, Tarr,
Foster, and Seaton voted in favor of Amendment 7, labeled 29-
LS1096\H.12, Glover, 2/29/16. Representative Vazquez voted
against it. Therefore, Amendment 7 was adopted by a vote of 4
yeas - 1 nay.
1:41:46 PM
CHAIR SEATON moved to adopt Amendment 8, labeled 29-LS1096\H.13,
Glover, 2/29/16, which read:
Page 9, line 14, following "other":
Insert "or between a provider and a recipient who
are physically separated from each other"
REPRESENTATIVE TARR objected for discussion.
MS. HANSEN explained that proposed Amendment 8 added to the
definition of telemedicine in Section 12, on page 9, line 14 of
the proposed bill, to include the option for being between a
provider and a recipient.
CHAIR SEATON shared that the proposed amendment was offered as
it was not thought that telemedicine was always between
providers as in many cases providers were not available. He
stated that the definition of telemedicine could be broad or
narrow.
REPRESENTATIVE TARR expressed her appreciation for telemedicine
in provider - patient relationships, and that it was necessary
to have a definition which did not prevent this. She asked
whether DHSS wanted this definition to be even broader, so as to
not limit any opportunities.
COMMISSIONER DAVIDSON relayed that DHSS did not have any
objection to the proposed amendment.
1:45:05 PM
REPRESENTATIVE VAZQUEZ stated her appreciation for the proposed
amendment, sharing that the definition did need to be expanded.
She suggested a need to reconsider the definition of provider to
include a department employee to allow for more flexibility.
MR. SHERWOOD reported that the department currently did some
assessment through telehealth, although a non-licensed host
affiliated with the provider was often at the site. He
questioned whether the language in the proposed amendment was as
critical as it would be if the language was being used more
broadly, although for consistency to align with future
definitions it would probably not interfere.
CHAIR SEATON asked whether this did not need to be expanded in
this section of the proposed bill because the definition for
tele-medicine meant the practice of health care delivery and did
not include re-assessments.
MR. SHERWOOD relayed that he was thinking of this connected with
the implementation of a demonstration project, such as a global
payment fee structure. He stated that it would not necessarily
relate directly to the activities in this demonstration project.
He acknowledged that he was unclear whether the language would
pertain more for provider projects and not for the
administration activities.
REPRESENTATIVE VAZQUEZ declared that the Department of Health
and Social Services had model telehealth regulations, which were
touted as "the best in the nation;" however, she stated, there
was not a statute in place. She asked if the regulations were
conforming with the intention of the proposed bill, declaring
that she wanted to make this statutorily capable.
MR. SHERWOOD replied that the department did not have an
objection to the access to telemedicine, but that he was unsure
whether the proposed bill would attain as broad of a result as
intended.
1:50:21 PM
CHAIR SEATON questioned whether subsection (g), page 9, line 12,
of the proposed bill, was specific only to the global payment
model defined in subsection (f), or whether it referred to all
of Section 12 of the proposed bill.
MR. SHERWOOD apologized for any misinterpretation of the
proposed bill.
CHAIR SEATON opined that the definition applied to the entire
Section 12.
CHAIR SEATON reminded the committee that, as Section 12 had
previously been amended "fairly heavily," a committee substitute
containing all the adopted amendments was necessary in order to
"see everything with the pieces, how they all fit together."
REPRESENTATIVE TARR removed her objection.
REPRESENTATIVE VAZQUEZ stated that she did not object to the
specific amendment; however, before final passage of the
proposed bill, she wanted to look at the regulations to see if
any further amendment was necessary for this particular section.
She reiterated that the department regulations were nationally
touted as "the model regulations on the subject."
MR. SHERWOOD expressed to Representative Vazquez, "you are
absolutely correct."
1:54:32 PM
There being no further objections, Amendment 8, labeled 29-
LS1096\H.13, Glover, 2/29/16, was adopted.
1:55:00 PM
CHAIR SEATON moved to adopt Amendment 10, labeled 29-
LS1096\H.15, Glover, 3/2/16, which read:
Page 2, following line 13:
Insert a new subparagraph to read:
"(C) collaborate with community mental
health clinics and drug or alcohol treatment centers
that receive state grants and that have historically
provided behavioral health services in the state to
expand the availability of behavioral health services
while maintaining quality and cost controls;"
REPRESENTATIVE TARR objected for discussion.
MS. HANSEN explained that proposed Amendment 10 added a new
subparagraph (C) to the intent language in Section 1 of the
proposed bill, which she read. She stated that this was a
further directive to the department that these reforms needed to
be continued in collaboration with the community health
providers which had been supporting that population.
REPRESENTATIVE TARR acknowledged that, although this was intent
language and did not have the entire force of law, this was "a
huge piece of what we're trying to accomplish with Medicaid
reform."
1:56:42 PM
CHAIR SEATON [moved to adopt] conceptual Amendment 1 to proposed
Amendment 10: on line 4, delete "receives" and insert "have
received." There being no objection, conceptual Amendment 1 to
proposed Amendment 10 was adopted.
1:58:27 PM
REPRESENTATIVE TARR removed her objection. There being no
further objection, Amendment 10, labeled 29-LS1096\H.15, Glover,
3/2/16, as amended, was adopted.
1:58:47 PM
CHAIR SEATON moved to adopt Amendment 11, labeled 29-
LS1096\H.16, Glover, 3/2/16, which read:
Page 6, following line 3:
Insert a new bill section to read:
"* Sec. 6. AS47.05.200 is amended by adding a new
subsection to read:
(f) After reviewing audit reports received under
this section, the department may collaborate with
medical assistance providers or provider entities to
provide or create educational information for medical
assistance providers regarding the most frequent
errors or overpayment types."
Renumber the following bill sections accordingly.
Page 10, line 21:
Delete "sec. 9"
Insert "sec. 10"
Page 11, line 13:
Delete "sec. 12"
Insert "sec. 13"
Page 12, line 6:
Delete "sec. 9"
Insert "sec. 10"
Page 12, lines 6 - 7:
Delete "and the provisions of secs. 12(e), 12(f),
15, and 16"
Insert "the provisions of AS 47.07.036(e) and
(f), added by sec. 13 of this Act, and the provisions
of secs. 16 and 17"
Page 12, line 21:
Delete "sec. 9"
Insert "sec. 10"
Page 12, line 22:
Delete "sec. 16"
Insert "sec. 17"
Page 12, line 23:
Delete "sec. 18"
Insert "sec. 19"
Page 12, line 24:
Delete "sec. 9"
Insert "sec. 10"
Page 12, line 25:
Delete "sec. 16"
Insert "sec. 17"
Page 12, line 27:
Delete "Section 12(e) of this Act"
Insert "AS 47.07.036(e), added by sec. 13 of this
Act,"
Page 12, line 28:
Delete "sec. 18"
Insert "sec. 19"
Page 12, line 29:
Delete "added by sec. 12(e) of this Act"
Insert "of AS 47.07.036(e), added by sec. 13 of
this Act,"
Page 12, line 31:
Delete "Section 12(f) of this Act"
Insert "AS 47.07.036(f), added by sec. 13 of this
Act,"
Page 13, line 1:
Delete "sec. 18"
Insert "sec. 19"
Page 13, line 2:
Delete "added by sec. 12(f) of this Act"
Insert "of AS 47.07.036(f), added by sec. 13 of
this Act,"
Page 13, line 4:
Delete "Section 15"
Insert "Section 16"
Page 13, line 5:
Delete "sec. 18"
Insert "sec. 19"
Page 13, line 6:
Delete "sec. 15"
Insert "sec. 16"
Page 13, line 8:
Delete "sec. 9"
Insert "sec. 10"
Delete "sec. 16"
Insert "sec. 17"
Page 13, line 10:
Delete "secs. 18 and 21(a)"
Insert "secs. 19 and 22(a)"
Page 13, line 11:
Delete "sec. 12(e) of this Act"
Insert "AS 47.07.036(e), added by sec. 13 of this
Act,"
Page 13, line 13:
Delete "secs. 18 and 21(b)"
Insert "secs. 19 and 22(b)"
Page 13, line 14:
Delete "sec. 12(f) of this Act"
Insert "AS 47.07.036(f), added by sec. 13 of this
Act,"
Page 13, line 16:
Delete "secs. 18 and 21(c)"
Insert "secs. 19 and 22(c)"
Page 13, line 17:
Delete "sec. 15"
Insert "sec. 16"
Page 13, line 19:
Delete "secs. 18 and 21(d)"
Insert "secs. 19 and 22(d)"
Page 13, line 20:
Delete "17(a), 18, 19, and 21"
Insert "18(a), 19, 20, and 21"
REPRESENTATIVE TARR objected for discussion.
MS. HANSEN explained that proposed Amendment 11 inserted a new
Section 6, on page 6, line 3, which she read, and then
renumbered the following sections accordingly.
CHAIR SEATON explained that, during the discussion of audits and
reporting requirements, it was decided to ensure that DHSS
informed providers of any mistakes made by similar provider
types, in order to avoid problems with future audits.
MR. SHERWOOD stated that the department had no objections.
2:01:14 PM
REPRESENTATIVE TARR removed her objection. There being no
further objection, Amendment 11, labeled 29-LS1096\H.16, Glover,
3/2/16, was adopted.
2:01:49 PM
CHAIR SEATON [moved to adopt] conceptual Amendment 1 to proposed
HB 227, page 11, line 11, delete the date, "February" and insert
"July".
REPRESENTATIVE TARR objected for discussion.
MS. HANSEN explained that this would change the report on cost
savings associated with waivers and options. She stated that
the current time line would only have allowed six months of
service to collect cost savings information, and twelve months
of payment information would be more worthwhile.
REPRESENTATIVE TARR, recalling that July 1 was the start date of
the new fiscal year, asked if that was too soon to have captured
a year of data.
MR. SHERWOOD expressed his agreement with Representative Tarr
that it was necessary to allow time for data to be submitted.
Generally speaking, July was the close-out of one fiscal year
with the start-up of a new fiscal year and budget, while the
federal fiscal year closed at the end of September. He declared
a preference for November to submit reports, as it allowed time
to finalize and review the claims data.
REPRESENTATIVE TARR stated her desire to ensure that the work
was diligent, and she asked if DHSS would object to a change to
November, 2018, for a progress report to keep the legislature in
the loop.
MR. SHERWOOD replied that, as long as there was an understanding
that some data may be incomplete the department could report on
the progress of activities for which they had information.
REPRESENTATIVE TARR asked if Chair Seaton was open to this.
CHAIR SEATON stated that, as numbers and results were not
expected in 2018, a status report would be acceptable.
REPRESENTATIVE TARR wanted to ensure that the state could
respond according to any federal changes.
REPRESENTATIVE VAZQUEZ stated support for the conceptual
amendment by Representative Tarr.
CHAIR SEATON expressed his agreement.
REPRESENTATIVE TARR removed her objection.
CHAIR SEATON withdrew proposed conceptual Amendment 1.
2:10:30 PM
CHAIR SEATON [moved to adopt] conceptual Amendment 2: on page
11, line 11, delete "February 1, 2019" and insert "November 1,
2018 and November 1, 2019" as the dates of the status reports to
the Alaska State Legislature. There being no objection,
conceptual Amendment 2 for proposed HB 227 was adopted.
2:11:20 PM
CHAIR SEATON directed attention to the written comments already
submitted, titled "House Bill 227 Amendments." [included in
members' packets]
MS. HANSEN shared that this was not a legally drafted amendment,
although there could be comments that the committee might want
to consider for a future amendment or project.
2:13:23 PM
JOCELYN PEMBERTON, Executive Director, Alaska Hospitalist Group,
stated that her group participated in BPCI (Bundled Project for
Care Improvement) with Medicare patients in Alaska. She asked
that consideration be given for an opportunity for local
physicians to be incentivized based on episodes of care. She
explained that this project, BPCI, determined total costs for
patients who originate at hospitals, based on historical data
associated to their diagnosis and care, and that incentivized
physicians to minimize the costs across the full continuum of
care with a shared savings arrangement that would benefit the
final cost to the state. She noted that the group offered
physician involvement around changing the financial incentives
for patient care.
CHAIR SEATON surmised that this would be included in Section 12
of proposed HB 227 and he asked if a bundled payment model would
come under an RFP for a coordinated care model.
REPRESENTATIVE TARR suggested that these other demonstration
projects were supposed to address this concept, expressing her
hope that this would be accomplished. She opined that this
sounded similar to the global payment schedule.
MS. PEMBERTON explained that although the two projects were
similar, the global payment schedule allowed the department to
pay an annual or a monthly cost for patients, whereas the
bundled payment schedule was more episodic and based on a
diagnosis. She explained that this was a stair step toward risk
sharing within the provider community. She acknowledged the
similarity, although slightly different. She offered the
perspective that the current language in the proposed bill was
broad, and that she wanted to bring the BPCI project to the
attention of the House Health and Social Services Standing
Committee as it was well defined by CMS, and could be
piggybacked with them with very few administrative requirements.
REPRESENTATIVE TARR asked for more time to better understand
this before consideration.
CHAIR SEATON relayed that the committee did not have to decide
on the projects, but only to see if this fit into the panoply of
demonstration projects to provide savings and better health that
had been included in the proposed bill. He expressed his
pleasure that more than one provider in Alaska had declared a
willingness to step forward to share some risk in the payment
models, as opposed to being strictly fee for service.
COMMISSIONER DAVIDSON complimented the committee for maintaining
broad and flexible language in the proposed bill so the
department could consider many models.
CHAIR SEATON relayed that this had been the goal.
MS. HANSEN suggested that the committee might find interesting
language relating to the percentage of local providers in the
aforementioned amendment comments and suggestions.
CHAIR SEATON stated that the adopted amendments would be drafted
into a committee substitute.
[HB 227 was held over.]
| Document Name | Date/Time | Subjects |
|---|---|---|
| CMS letter on tribal health_March 1 2016.pdf |
HHSS 3/4/2016 12:30:00 PM |
HB 227 |