Legislature(2015 - 2016)CAPITOL 106

02/11/2016 03:00 PM HEALTH & SOCIAL SERVICES

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Audio Topic
03:04:43 PM Start
03:05:37 PM Presentation: Medicaid Redesign and Expansion Technical Assistance Initiative
05:04:42 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation: TELECONFERENCED
"Medicaid Redesign & Expansion" by Dept. of
Health & Social Services & Agnew::Beck Consulting
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                       February 11, 2016                                                                                        
                           3:04 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Paul Seaton, Chair                                                                                               
Representative Liz Vazquez, Vice Chair                                                                                          
Representative Neal Foster                                                                                                      
Representative Louise Stutes                                                                                                    
Representative David Talerico                                                                                                   
Representative Geran Tarr                                                                                                       
Representative Adam Wool                                                                                                        
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
All members present                                                                                                             
                                                                                                                                
OTHER LEGISLATORS PRESENT                                                                                                     
                                                                                                                                
Representative Dan Ortiz                                                                                                        
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
PRESENTATION:   MEDICAID   REDESIGN   AND   EXPANSION   TECHNICAL                                                               
ASSISTANCE INITIATIVE                                                                                                           
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
No previous action to record                                                                                                    
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
THEA AGNEW BEMBEN, Managing Principal                                                                                           
Agnew::Beck Consulting                                                                                                          
Anchorage, Alaska                                                                                                               
POSITION STATEMENT:  Presented a PowerPoint titled "Medicaid                                                                  
Redesign and Expansion Technical Assistance Initiative."                                                                        
                                                                                                                                
NORA LEIBOWITZ, Principal                                                                                                       
Health Management Associates (HMA)                                                                                              
Portland, Oregon                                                                                                                
POSITION STATEMENT:  Testified and answered questions during the                                                              
PowerPoint presentation.                                                                                                        
                                                                                                                                
SUSAN PANTELY                                                                                                                   
Milliman, Inc.                                                                                                                  
San Francisco, California                                                                                                       
POSITION STATEMENT:  Testified and  answered questions during the                                                             
PowerPoint presentation.                                                                                                        
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
3:04:43 PM                                                                                                                    
                                                                                                                                
CHAIR PAUL  SEATON called  the House  Health and  Social Services                                                             
Standing   Committee    meeting   to    order   at    3:04   p.m.                                                               
Representatives Seaton, Wool,  Talerico, Stutes, Vazquez, Foster,                                                               
and Tarr were  present at the call to order.   Also in attendance                                                               
was Representatives Ortiz.                                                                                                      
                                                                                                                                
^Presentation:   Medicaid   Redesign  and   Expansion   Technical                                                             
Assistance Initiative                                                                                                         
    Presentation: Medicaid Redesign and Expansion Technical                                                                 
                     Assistance Initiative                                                                                  
                                                                                                                                
3:05:37 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON announced that the  first order of business would be                                                               
a presentation  on the Medicaid Redesign  and Expansion Technical                                                               
Assistance Initiative.   He noted  that this presentation  was in                                                               
relationship to proposed HB 227  regarding Medicaid Reform, which                                                               
had substantial budget implications over the next several years.                                                                
                                                                                                                                
3:06:37 PM                                                                                                                    
                                                                                                                                
THEA  AGNEW BEMBEN,  Managing Principal,  Agnew::Beck Consulting,                                                               
offered  some  background  on  her  company  and  her  consulting                                                               
history.  She shared  that that she grew up in  the state and she                                                               
had been  working as a  consultant in Alaska  for 20 years.   She                                                               
said  that her  company  had worked  in  conjunction with  Health                                                               
Management Associates and Milliman, Inc. on this report.                                                                        
                                                                                                                                
NORA  LEIBOWITZ, Principal,  Health Management  Associates (HMA),                                                               
reported  that the  HMA team  were primarily  the subject  matter                                                               
experts, working  closely in discussions  with stake  holders and                                                               
the state, in development for the recommendations.                                                                              
                                                                                                                                
SUSAN PANTELY, Milliman, Inc., shared  that Milliman, Inc. was an                                                               
actuarial  consulting  firm,  and  they  had  provided  actuarial                                                               
analysis  for the  report.   She  noted that  Milliman, Inc.  had                                                               
consulted  with more  than half  the states  on Medicaid  and the                                                               
implications of the program.                                                                                                    
                                                                                                                                
MS.  BEMBEN  emphasized  that  the   project  timeline  had  been                                                               
intense,  beginning in  July, 2015,  and the  final reports  were                                                               
published  on  the  Department  of  Health  and  Social  Services                                                               
website  on January  22,  2016,  slide 2.    She  noted that  the                                                               
Agnew::Beck  report  included  an analysis  from  Milliman,  Inc.                                                               
although  the Milliman  report in  full had  been also  published                                                               
separately.                                                                                                                     
                                                                                                                                
3:09:56 PM                                                                                                                    
                                                                                                                                
MS.  BEMBEN directed  attention to  slide 3,  "Project Overview,"                                                               
and  reported  that  the  project  began  with  an  environmental                                                               
assessment lead  by HMA, which  compared the experience  of other                                                               
states  with Medicaid  Reform,  as  well as  an  analysis of  the                                                               
various federal  financing mechanisms available.   She added that                                                               
it  provided  an overview  of  some  of  the ongoing  reforms  in                                                               
Alaska.  She stated that the  next step was the most intense part                                                               
of  the process,  beginning with  a key  partner and  stakeholder                                                               
meeting  at which  the findings  of the  environmental assessment                                                               
were reviewed with subsequent discussion  for the needs and focus                                                               
of Medicaid  Reform in  Alaska.   She relayed  that this  was the                                                               
beginning of many  such meetings for the  iterative process which                                                               
analyzed potential  reforms.   She stated  that the  final report                                                               
included  not  only an  analysis  of  Medicaid reform  initiative                                                               
options, but also proposals for  some alternative coverage models                                                               
for  the  expansion  population.     The  final  report  included                                                               
recommendations  from  the  various reform  initiatives  and  the                                                               
action steps  necessary for reforms.   She shared that  the final                                                               
piece of  the contract was an  evaluation plan, which would  be a                                                               
set of measures as a companion to the ultimate reform package.                                                                  
                                                                                                                                
MS. BEMBEN moved  on to slide 4,  "Broad Stakeholder Engagement,"                                                               
noting that at  least 500 people had participated  on some level.                                                               
She stated  that there  were three key  meetings, intended  to be                                                               
joint work  sessions, with partners  from many  different sectors                                                               
which  interacted   with  the  Medicaid   program,  as   well  as                                                               
leadership  from the  Department of  Health and  Social Services.                                                               
She added  that some engagement  meetings with  specific sectors,                                                               
including  hospital  administrators, physicians,  tribal  health,                                                               
and community health  centers, were also convened.   She reported                                                               
that  they gave  more than  30 public  presentations, as  well as                                                               
webinars after  each key partner  meeting.  She pointed  to slide                                                               
5,  "Key Partner  Organizations"  which listed  some  of the  key                                                               
partner organizations engaged in the work sessions.                                                                             
                                                                                                                                
3:13:28 PM                                                                                                                    
                                                                                                                                
MS.  BEMBEN  shared  slide  6,   "Final  Report  Outline,"  which                                                               
included  an  executive  summary,  and  an  introduction  with  a                                                               
roadmap  for reform.    She  explained that  the  roadmap was  an                                                               
attempt to  lay out  the recommended  package with  the necessary                                                               
sequencing, the groundwork for the  reforms that would build over                                                               
time.   She added that  the background  section was a  summary of                                                               
the  environmental assessment  document, which  she described  as                                                               
similar  to  a  primer  for care  models  and  federal  financing                                                               
mechanisms  around  the  U.S.    She  described  the  recommended                                                               
foundational  reform  initiatives,  which included  primary  care                                                               
improvement, behavioral health access,  and data analytics and IT                                                               
infrastructure,  as  necessary  to be  implemented  first  before                                                               
other more comprehensive reforms.   She stated that the emergency                                                               
care  initiatives and  the  accountable  care organization  pilot                                                               
initiative  were  the  primary  tests  for  value  based  payment                                                               
reform.  She  declared that other topics had  been identified for                                                               
further  discussion  in  work  groups,  while  some  topics  were                                                               
explored  but  not recommended.    She  reported that  the  final                                                               
section provided  information on  the three options  for coverage                                                               
of  the Medicaid  expansion population,  as well  as an  appendix                                                               
containing the reference material.                                                                                              
                                                                                                                                
MS.  BEMBEN  described  slide  7,   "Final  Report:  Roadmap  for                                                               
Reform," and slide 8, "Goals  for Medicaid Redesign + Expansion."                                                               
She stated  that these were  the initial goals introduced  in the                                                               
Request  for Proposal  (RFP), considered  the goals  for Medicaid                                                               
redesign  and expansion.    She  shared that  the  goals were  to                                                               
improve outcomes  for enrollees,  optimize access to  care, drive                                                               
increased value, and provide cost  containment.  She allowed that                                                               
although  it was  difficult to  balance all  of these  goals, the                                                               
report had  attempted to do just  that and not focus  on one over                                                               
another.                                                                                                                        
                                                                                                                                
MS.  BEMBEN  addressed  slide 9,  "Alaska  Medicaid  Redesign:  A                                                               
Phased  Journey to  Peak Performance,"  sharing that  the graphic                                                               
was used  throughout the  report to  communicate the  journey and                                                               
its phased sequence for building capacity for further reform.                                                                   
                                                                                                                                
MS.  BEMBEN  described  slide   11,  "Final  Report:  Recommended                                                               
Package  of Reforms,"  stating that  its  main sections  included                                                               
Foundational System  Reforms, Paying  for Value,  Pilot Projects,                                                               
and Recommendations around Work Group topics.                                                                                   
                                                                                                                                
MS.  PANTELY  introduced  slide  12,  "Final  Round  of  Analysis                                                               
Included Actuarial  Analysis by  Milliman, Inc." which  was based                                                               
on claims  data from 2014 for  the Alaska program.   She reported                                                               
that statistical  models were used,  and estimates were  based on                                                               
already implemented national programs  as well as their knowledge                                                               
of  the   health  care  system.     She  acknowledged   that  any                                                               
characteristics and  known limitations of the  Alaska marketplace                                                               
were taken  into consideration and  weighed against  the national                                                               
programs.  Moving  on to slide 13, "Summary  of Actuarial Results                                                               
for Reform  Initiatives," she  said that  they would  address the                                                               
savings  or increased  cost for  each of  the listed  initiatives                                                               
over the  next five fiscal years.   She shared that  the baseline                                                               
was  the   assumption  for  spending   if  none  of   these  were                                                               
implemented; however, this was only  for the medical expenses and                                                               
would not match the DHSS budget.   She said that some populations                                                               
had been excluded,  including Medicare Part B, as  the target had                                                               
been on  a broader population for  ease of the projections.   She                                                               
pointed  out  that,  as  each of  the  initiatives  was  reviewed                                                               
separately,   the  total   would   not  reflect   the  cost   for                                                               
implementation of all as there could be some overlaps.                                                                          
                                                                                                                                
MS. BEMBEN added that the  actuarial analysis was specific to the                                                               
Medicaid  budget, and  did  not include  any  savings that  could                                                               
accrue to other parts of the state budget.                                                                                      
                                                                                                                                
MS.  PANTELY explained  that behavioral  health grants  and state                                                               
taxes were all outside the scope of this analysis.                                                                              
                                                                                                                                
3:21:35 PM                                                                                                                    
                                                                                                                                
MS.  BEMBEN shared  slide 14,  "Analysis of  Reform Initiatives,"                                                               
and explained  that the  RFP had  included instructions  for what                                                               
each  of  the  initiatives  needed   to  include.    She  listed:                                                               
description and  key features  of the  initiative, considerations                                                               
for  any   special  populations  relevant  to   that  reform,  an                                                               
actuarial  analysis  of  projected costs  and  savings,  relevant                                                               
experience   from   other   states,  potential   challenges   for                                                               
implementation, and the proposed  timeline and phases with action                                                               
steps  for the  department  when implementing  the  reform.   She                                                               
noted  that  those did  not  take  into  account whether  it  was                                                               
necessary  to secure  budgetary authority,  add staff,  or secure                                                               
other resources.                                                                                                                
                                                                                                                                
MS.  BEMBEN  described  the  first   of  the  three  foundational                                                               
initiatives,  Primary Care  Improvement,  slide 15,  "Recommended                                                               
Package of Reforms."   Every Medicaid enrollee  would be assigned                                                               
to a  primary care provider  whose role  would be to  monitor and                                                               
coordinate  the care  for that  enrollee.   Each enrollee  should                                                               
have an  annual health risk  assessment, separate from  an annual                                                               
exam, similar  to a  questionnaire to  identify higher  and lower                                                               
health needs and risks.   She reported that care management could                                                               
be helpful for  improving the health of those with  high risk and                                                               
high health  needs, although,  as it  was not  a great  return on                                                               
investment for  people without complicated  health needs,  it was                                                               
important to identify  those who would benefit.   She stated that                                                               
health homes  were a  state plan option  for a  coordinated whole                                                               
person care, as well as  coordination of home and community based                                                               
support.   It was  targeted for those  with higher  health needs,                                                               
chronic  health  conditions  or   severe  and  persistent  mental                                                               
illness.  She  added that it was recommended  that the department                                                               
contract with  an Administrative  Services Organization  (ASO) to                                                               
provide the additional capacity  for help with enrollee education                                                               
orientation,  build a  provider network,  provide data  analytics                                                               
and IT support, and administer the health risk assessments.                                                                     
                                                                                                                                
3:26:00 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR asked for the  reason to contract outside the                                                               
department, as  opposed to  utilizing existing  or new  staff who                                                               
had the institutional knowledge from working for the state.                                                                     
                                                                                                                                
CHAIR  SEATON   asked  that  the   immediate  questions   be  for                                                               
clarifications only.                                                                                                            
                                                                                                                                
MS. PANTELY  returned attention to slide  16, "Actuarial Results:                                                               
Primary   Care  Improvement   Initiative,"  which   reflected  an                                                               
increased  cost  in  the  first  few  years,  with  a  subsequent                                                               
decrease  over  the baseline.    She  shared  that there  was  an                                                               
assumption that all medical costs,  even in the first year, would                                                               
start to decrease.   The savings would increase over  time, as it                                                               
most often took time for the  programs to get off the ground, and                                                               
that   providers  learned   from  experience   and  became   more                                                               
efficient.   She pointed out that  the health home would  start a                                                               
few  years after  the other  programs, and,  as it  had a  higher                                                               
federal match, it would also project for a greater savings.                                                                     
                                                                                                                                
MS. BEMBEN  stated that the second  initiative, Behavioral Health                                                               
Access,  was  a companion  to  the  first initiative,  slide  17,                                                               
"Recommended Package of Reforms."   She suggested that DHSS apply                                                               
for a  Section 1115  waiver, an  application for  a demonstration                                                               
project to  propose an innovative  use of Medicaid  funding other                                                               
than that  under the  traditional program.   She noted  that this                                                               
waiver could  be approved for  a five year  demonstration period,                                                               
with  the potential  for a  three year  extension.   She reported                                                               
that this  would allow  DHSS to  contract with  an administrative                                                               
services  organization   to  bring  in  national   expertise  for                                                               
behavioral  health  systems management.    This  would propose  a                                                               
change   from  program   and  grant   management  into   contract                                                               
management.     She  stated  that  the   waiver  would  establish                                                               
standards of  care to allow  expansion of delivery  for substance                                                               
use and  mental health services.   She proposed that  DHSS remove                                                               
the requirement that providers be  a grantee to bill Medicaid for                                                               
behavioral health services and the  broader range of providers be                                                               
allowed  to bill  for Medicaid  services, effectively  broadening                                                               
and increasing the available work  force for additional services.                                                               
In the second year of  the demonstration period, they recommended                                                               
to amend  the waiver application  to include a federal  waiver of                                                               
the exclusion for Medicaid funding  of services within institutes                                                               
for mental  disease containing  more than 16  beds.   She pointed                                                               
out that the  other recommendations addressed gaps  in the crisis                                                               
response system.   She  stated that the  goal of  this initiative                                                               
was  to  remove  the  barriers for  accessing  behavioral  health                                                               
services to allow  them to be provided in  an integrated fashion,                                                               
early  on  in order  to  prevent  the  need  for so  much  crisis                                                               
service.                                                                                                                        
                                                                                                                                
3:31:58 PM                                                                                                                    
                                                                                                                                
MS. PANTELY  explained slide  18, "Actuarial  Results: Behavioral                                                               
Health Access  Initiative," which  reflected an increase  in cost                                                               
for the  five years of the  program with increased access  to the                                                               
professional  component and  the  associated prescription  drugs,                                                               
although  some in-patient  care would  be avoided  by moving  the                                                               
services to a more appropriate level of care.                                                                                   
                                                                                                                                
MS.  BEMBEN mentioned  that development  of  the proposed  health                                                               
homes would  provide a hub  for coordinated and managed  care for                                                               
people with high needs, as  a requirement would be for integrated                                                               
physical and behavioral health services within that home.                                                                       
                                                                                                                                
MS. BEMBEN moved  on to the third initiative,  Data Analytics and                                                               
IT infrastructure,  stating that it was   absolutely foundational                                                               
to  implementing  these  and more  comprehensive  reforms  later,                                                               
slide 19, "Recommended  Package of Reforms."   She explained that                                                               
the  initiative proposed  use of  the current  health information                                                               
exchange although  it currently lacked the  connectivity for full                                                               
utilization.    She  stated  that   the  important  part  of  the                                                               
initiative was  to connect hospitals, emergency  departments, and                                                               
providers  to the  health information  exchange and  to integrate                                                               
the  prescription drug  monitoring  state program  data base  for                                                               
greater accessibility to providers.   She shared that it was also                                                               
proposed to contract with a  data analytics firm to support value                                                               
based  care  in  order  to  extract  information  from  the  data                                                               
repository and  provide analytics  to the departments  for better                                                               
management of  utilization and  costs of the  program.   The data                                                               
analytics  firm would  also offer  support to  the providers  for                                                               
connection,  as not  all the  providers had  either a  mandate or                                                               
resources to  connect.   This information  sharing would  lead to                                                               
greater  opportunities for  improving care  and containing  costs                                                               
outside the tribal system, where it was already utilized.                                                                       
                                                                                                                                
MS.  BEMBEN discussed  Initiative  4: Emergency  Care, slide  20,                                                               
"Recommended  Package of  Reforms," which  she called  a pay  for                                                               
value  pilot project.   She  explained that  this was  a private-                                                               
public  partnership which  could be  implemented fairly  quickly.                                                               
She  said  that   a  lot  of  this  was  also   imbedded  in  the                                                               
aforementioned Initiative  3, as it was  about connection through                                                               
better IT  infrastructures for  better information  sharing among                                                               
the  different  departments,  in   order  to  reduce  preventable                                                               
emergency  department use  and better  facilitate follow-up  with                                                               
primary care  and behavioral health  providers.  She  stated that                                                               
this would link to Initiative 1  and the need for assignment of a                                                               
primary  care provider.   She  reiterated that  primary care  and                                                               
behavioral  health were  the  two most  needed,  most basic,  and                                                               
least  expensive forms  of care  offered.   She  added that  this                                                               
initiative created the connections  to previous initiatives.  She                                                               
pointed out that  this initiative also proposed  a shared savings                                                               
model:   when emergency room  use was  reduced, a portion  of the                                                               
savings would be  shared with the emergency rooms.   She reported                                                               
that this had been done successfully  in the states of Oregon and                                                               
Washington.                                                                                                                     
                                                                                                                                
MS. LEIBOWITZ added that there was  a reduction of $33 million in                                                               
emergency room costs  in the first year of  implementation in the                                                               
State of Washington.  She pointed  out that, although there was a                                                               
much bigger population, this was  notable for the savings and the                                                               
use of the shared savings model.                                                                                                
                                                                                                                                
MS. PANTELY  directed attention to slide  21, "Actuarial Results:                                                               
Emergency  Care  Initiative,"  which   depicted  an  increase  in                                                               
savings   for   every  year,   including   the   first  year   of                                                               
implementation.  She explained that  the primary savings resulted                                                               
from  a  reduction in  the  facility  outpatient, emergency  room                                                               
visits, 50 percent  of these emergency room  visits were replaced                                                               
with  an   office  visit  to  either   primary  care,  outpatient                                                               
psychiatric, or  a specialist.   She  noted that,  although there                                                               
were professional  charges associated  with these  office visits,                                                               
there were also professional charges  with emergency room visits,                                                               
and  therefore, there  was still  a savings.   She  addressed the                                                               
incentive  to  the  emergency  facilities  to  provide  a  shared                                                               
savings program.                                                                                                                
                                                                                                                                
3:41:11 PM                                                                                                                    
                                                                                                                                
MS.   LEIBOWITZ   described   Initiative  5:   Accountable   Care                                                               
Organizations Pilot, slide 22,  "Recommended Package of Reforms."                                                               
She  stated  that  the  accountable  care  organizations  were  a                                                               
mechanism  for providers  within  an area  to  come together  and                                                               
agree to share responsibility for  the cost and quality of health                                                               
care  for a  particular patient  population.   She said  this was                                                               
different from  the more traditional  full risk managed  care, as                                                               
what made  it unique  was less about  payment mechanism  and more                                                               
about being  provider driven.   The  provider community  were the                                                               
ones  to make  the changes  in the  way care  was provided.   She                                                               
explained that the proposal for  payment was the establishment of                                                               
shared savings, with  a target based on analysis  of prior claims                                                               
for  the  relevant population  and  then,  if services  could  be                                                               
provided and meet  the targets for quality of care  and access to                                                               
care for less than the target  amount, then the providers and the                                                               
state would  share in  that savings.   She  suggested that,  in a                                                               
later stage, there  could be shared losses  between the providers                                                               
and the  state.   She reported  that this  was different,  from a                                                               
financing perspective, than the full  risk model of a traditional                                                               
managed care organization.                                                                                                      
                                                                                                                                
MS. PANTELY described slide 23,  "Actuarial Results:  Accountable                                                               
Care Organizations Pilot Initiative,"  which reflected savings in                                                               
the first year  of implementation after the  providers formed the                                                               
organization.   The  savings were  generated  from efficient  and                                                               
appropriate services, with an  increase in preventative services.                                                               
She pointed out  that, as Alaska had a  smaller population, there                                                               
was not  the critical  population mass  necessary for  the larger                                                               
savings.                                                                                                                        
                                                                                                                                
MS. BEMBEN addressed slide 24,  "Recommended Package of Reforms,"                                                               
and  identified some  workgroup topics  for DHSS  to convene  and                                                               
guide:    expansion of  telemedicine  to  include the  non-tribal                                                               
health  providers;  Medicaid  business  process  improvements  to                                                               
bring  together  DHSS  experts   and  providers  to  discuss  the                                                               
administrative  burden  and   identify  other  necessary  process                                                               
improvements with suggested resolutions;  and continued work with                                                               
providers and stakeholders for ongoing Medicaid redesign.                                                                       
                                                                                                                                
3:47:48 PM                                                                                                                    
                                                                                                                                
MS.  PANTELY  shared  slide  25,  "Actuarial  Results:  Potential                                                               
Savings  from  a  Telemedicine Initiative,"  and  reported  that,                                                               
although there  was not a  specific telemedicine  initiative, the                                                               
analysis was  based on the implementation  of robust telemedicine                                                               
initiatives  in other  states.   She said  that this  had reduced                                                               
office  and emergency  room visits,  as well  as some  in-patient                                                               
visits,  and  replaced  them  with   telemedicine  visits.    She                                                               
reported that there were immediate  savings, which increased over                                                               
time as telemedicine use became  more prevalent.  She shared that                                                               
the  initiative  did  not  include  any  cost  changes  for  non-                                                               
emergency transportation, as it varied from state to state.                                                                     
                                                                                                                                
MS. LEIBOWITZ discussed slide  26, "Reform Initiatives Considered                                                               
but Not  Recommended."  She  spoke first about full  risk managed                                                               
care as  an option for  the expansion population,  reporting that                                                               
the big difference for accountable  care organizations was on the                                                               
structural side,  as more often  with full risk managed  care the                                                               
state  was contracting  with an  existing  insurance carrier  who                                                               
accepted full risk.   She compared factors in  Alaska, large land                                                               
mass  and small  population with  states such  as Wyoming  in the                                                               
lower  48 which  ad also  had discussions  for implementing  this                                                               
managed care, but  had decided not to move forward  with the full                                                               
risk program.   She pointed out  that it had not  been determined                                                               
that it  would never  work in Alaska,  but that  Alaska, instead,                                                               
needed to have some key  fundamental reforms and changes in order                                                               
to keep moving.                                                                                                                 
                                                                                                                                
3:52:47 PM                                                                                                                    
                                                                                                                                
MS. BEMBEN continued  discussion on slide 26, and  talked about a                                                               
dementia  care access  initiative  that had  been  brought up  by                                                               
stakeholders.   She  reported that  DHSS currently  had a  robust                                                               
process  looking at  its  1915  I and  K  options,  and that  the                                                               
dementia  access  analysis  should  be run  concurrent  to  these                                                               
options.                                                                                                                        
                                                                                                                                
MS. LEIBOWITZ  spoke about the  three other  initiatives included                                                               
on  slide  26  as  ways  to  pay  for  services  which  were  not                                                               
prioritized  for  analysis.    She  described  bundled  payments,                                                               
taking a  set of  services and  having a  payment for  the entire                                                               
package,  and  offered maternity  care  as  an example;  pre-paid                                                               
ambulatory and inpatient  health plans as a type  of managed care                                                               
for a set of services, but  more limited than a full risk managed                                                               
care;  health  savings  accounts,  and how  they  worked  in  the                                                               
Medicaid realm, noting that, although  savings were possible from                                                               
the use  of pre-tax money, this  was less meaningful for  a lower                                                               
income  population.   She shared  that this  had not  had a  huge                                                               
impact to  providing incentives relative  to the overall  goal of                                                               
getting  people to  use services  to manage  care.   She reported                                                               
that often, currently,  doctors did not even  collect co-pays, as                                                               
the patients could not afford these.                                                                                            
                                                                                                                                
3:57:23 PM                                                                                                                    
                                                                                                                                
MS. LEIBOWITZ  brought attention to "Alternative  Coverage Models                                                               
for Expansion Population," slide 27.   She addressed the options:                                                               
utilizing the  current Medicaid benefit package  with no changes;                                                               
establishing  an   alternative  benefit  package  based   on  the                                                               
benefits  provided  in  a  qualified health  plan,  such  as  the                                                               
commercial  coverage  offered  through the  federal  marketplace;                                                               
and,  the states  paying  an insurer  for  private coverage,  and                                                               
paying  for  the  individuals'  premiums  and  some  co-payments.                                                               
After analysis, they decided it  made the most sense for everyone                                                               
to have  the same current  Medicaid benefit package.   She shared                                                               
that there  was a  lot of feedback  from providers  regarding the                                                               
complexity  of   multiple  packages,  as  this   would  add  more                                                               
administrative work.   She  relayed that the  cost for  the third                                                               
option did not make it viable.                                                                                                  
                                                                                                                                
MS.  PANTELY  continued with  slide  28,  "Actuarial Results  for                                                               
Alternative Expansion Coverage Models,"  which compared the three                                                               
models.    The  first  option, the  current  alternative  benefit                                                               
program,  relied on  the  Evergreen report  and  updates of  more                                                               
recent  claims data.   The  second option,  based on  a qualified                                                               
health plan,  removed dental  coverage with  subsequent decreases                                                               
in cost, although estimates for  emergency room use did increase.                                                               
The third  option, the private  option, looked at  the individual                                                               
marketplace  on the  exchange which  had  been experiencing  very                                                               
high  increases,  and, based  on  knowledge  of the  market,  was                                                               
determined to  be more  expensive.  She  shared that  the federal                                                               
government  would pay  the same  amount  in any  option, but  the                                                               
State  of Alaska  would be  required to  assume the  rest of  the                                                               
costs.                                                                                                                          
                                                                                                                                
4:01:16 PM                                                                                                                    
                                                                                                                                
MS.  PANTELY discussed  slide 29,  "Actuarial Results:  Expansion                                                               
Option  1 Current  Alternative Benefit  Package," reporting  that                                                               
they started with the number  of newly eligible adults multiplied                                                               
by the projected  take up rate, and arrived at  the number of new                                                               
enrollees.  She  acknowledged that, as the take up  rate was very                                                               
hard to predict, it was left  constant after the first year.  The                                                               
cost  per  enrollee  was  determined   from  the  current  annual                                                               
Medicaid cost for members with  the same demographic mix.  Moving                                                               
on to slide 30, "Actuarial  Results: Expansion Option 2 Qualified                                                               
Health  Plan  Package,"  she  reported   the  use  of  a  similar                                                               
analysis,  although  this  option  removed  dental  services  and                                                               
increased the emergency room visits by  a small amount.  On slide                                                               
31,  "Actuarial  Results:  Expansion Option  3  Private  Coverage                                                               
Option," they  reviewed the insurance premiums  on the individual                                                               
market  and the  cost for  adding these  individuals.   Using the                                                               
assumption for  federal payment capped  at Option 1,  this option                                                               
reflected the cost to the State of Alaska.                                                                                      
                                                                                                                                
MS. PANTELY relayed  that the caveats on slides 32  and 33 stated                                                               
that these were  estimates, and, if the specifics  of the program                                                               
change, they should be reevaluated.                                                                                             
                                                                                                                                
MS.  BEMBEN concluded  with slide  34, "Next  Steps," and  stated                                                               
that  they   had  made  presentations  to   the  Medicaid  Reform                                                               
subcommittee  and  House  Health  and  Social  Services  Standing                                                               
Committee.  They would next  develop some evaluation measures for                                                               
the reform package.                                                                                                             
                                                                                                                                
4:04:55 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE STUTES  directed attention to slide  31, and asked                                                               
if there was  a cost evaluation if the state  did not include all                                                               
27 options currently provided.                                                                                                  
                                                                                                                                
MS.  BEMBEN  asked  for  clarification  that  this  was  for  the                                                               
expansion  population, and  replied  that they  had not  analyzed                                                               
that  as an  option, but  instead had  used the  current Medicaid                                                               
package.                                                                                                                        
                                                                                                                                
REPRESENTATIVE  STUTES   asked  if  the  analysis   on  slide  26                                                               
considered  all  the  infrastructure  involved  in  telemedicine,                                                               
including broadband.                                                                                                            
                                                                                                                                
MS.  PANTELY  replied  that  the  analysis  just  considered  the                                                               
medical expenses and did not include any necessary investment.                                                                  
                                                                                                                                
CHAIR  SEATON  suggested  starting  with  the  beginning  of  the                                                               
presentation for questions.                                                                                                     
                                                                                                                                
4:08:00 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  VAZQUEZ referenced  slide  12, and  asked if  the                                                               
data  analytics, mentioned  in the  Foundational System  Reforms,                                                               
considered the data in the MMIS system.                                                                                         
                                                                                                                                
MS.  BEMBEN said  that  the  purpose of  this  initiative was  to                                                               
better capture and analyze data  from providers, which was beyond                                                               
the claims data in the MMIS  system.  She explained that this was                                                               
seeking to  analyze other types  of data, not  accessible through                                                               
claims  data,  to  help  better  measure  improvement  in  health                                                               
outcomes and manage the program.                                                                                                
                                                                                                                                
MS. LEIBOWITZ  added that  part of the  effort to  improve access                                                               
and  control   costs  involved  utilizing  data   collection  and                                                               
analysis to  ensure that providers  were providing  the necessary                                                               
services in  an efficient  manner.  She  said that  these quality                                                               
measures were not  usually included in claims  data, but required                                                               
an additional  effort.   She explained that  the benefits  in the                                                               
analysis included  the federal requirement for  the ten essential                                                               
health  benefits to  be included  for Medicaid  recipients of  an                                                               
alternative  benefit package.    There  was a  limit  as to  what                                                               
services could be taken out of any model.                                                                                       
                                                                                                                                
4:11:37 PM                                                                                                                    
                                                                                                                                
CHAIR  SEATON  asked if  these  analytics  included the  e-health                                                               
network,  and how  it corresponded  to either  Medicaid or  other                                                               
primary care in the health system.                                                                                              
                                                                                                                                
MS. BEMBEN  replied that there  was not an actuarial  analysis on                                                               
the  data analytics  initiative  because there  was  not a  clear                                                               
picture  of  the  cost  for  the  necessary  improvements.    She                                                               
expressed agreement  that an increase  for connectivity  with the                                                               
health information exchange would  benefit other payers, as well.                                                               
She stated  that the third initiative  on slide 11 would  lay the                                                               
groundwork for an  all-payers claim data base, as,  in Alaska, no                                                               
provider had a huge market share.                                                                                               
                                                                                                                                
4:13:30 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE VAZQUEZ  asked if the statewide  prescription drug                                                               
monitoring  program   would  be   linked  with   the  information                                                               
exchange.                                                                                                                       
                                                                                                                                
MS.  BEMBEN explained  that the  current state  prescription drug                                                               
monitoring program  data base was  difficult to access,  not used                                                               
by every provider, and not up to date.                                                                                          
                                                                                                                                
CHAIR SEATON relayed  that there would be  a committee initiative                                                               
to fix that portion of the data base not serving its purpose.                                                                   
                                                                                                                                
REPRESENTATIVE VAZQUEZ questioned whether  all the providers were                                                               
using  the aforementioned  prescription  drug monitoring  program                                                               
data base.                                                                                                                      
                                                                                                                                
MS. BEMBEN opined  that she did not believe so,  but that she did                                                               
not have a precise number of users.                                                                                             
                                                                                                                                
4:15:10 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR asked if the  health information exchange was                                                               
the same as the e-health network.                                                                                               
                                                                                                                                
MS. BEMBEN said  that the health information exchange  was the IT                                                               
infrastructure,  and  that  DHSS currently  contracted  with  the                                                               
Alaska e-health network  to manage it and bring  on providers and                                                               
vendors.                                                                                                                        
                                                                                                                                
REPRESENTATIVE  TARR  asked if  the  public  face of  the  health                                                               
information exchange was the e-health network.                                                                                  
                                                                                                                                
MS. BEMBEN expressed her agreement  that the e-health network was                                                               
the organization  managing it, although the  providers would most                                                               
often  be accessing  information  from  other provider  platforms                                                               
through the information exchange.                                                                                               
                                                                                                                                
4:17:39 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON  opined that the  e-health exchange was  a voluntary                                                               
exchange  of data,  and  asked  if this  would  be required  with                                                               
Medicaid.                                                                                                                       
                                                                                                                                
MS.  BEMBEN   stated  that  they   did  recommend  for   DHSS  to                                                               
investigate this  as a requirement  for Medicaid providers.   She                                                               
opined that  there needed to be  some sort of incentive  to join,                                                               
as it was not simple or cost free.                                                                                              
                                                                                                                                
4:19:43 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  referred to slide  15, the idea  of contract                                                               
versus increase of staffing.                                                                                                    
                                                                                                                                
MS.  BEMBEN,  in  response  to  Representative  Tarr,  said  that                                                               
contracting  with an  Administrative Services  Organization (ASO)                                                               
offered  greater capacity  than currently  existed.   She pointed                                                               
out  that the  report  discussed the  possibility of  contracting                                                               
with an  ASO for  specific program wide  functions, such  as data                                                               
analytics.  She  noted that tribal health  organizations may want                                                               
to take  on certain functions  for their enrollees, as  there had                                                               
been an expressed  desire for more regional  management of health                                                               
services.  She suggested that an  ASO could devolve some of these                                                               
functions to  a regional  entity.   She expressed  agreement with                                                               
the  desire to  first  use local  capacity,  although there  were                                                               
things for which national expertise was very useful.                                                                            
                                                                                                                                
MS. LEIBOWITZ  stated that  it could be  difficult to  change the                                                               
entire structure of a department  immediately, so, while that was                                                               
happening  or  being  considered,  an  ASO  could  provide  those                                                               
functions.                                                                                                                      
                                                                                                                                
CHAIR SEATON  asked if a contract  with an ASO was  a recommended                                                               
reform, even  though the benefits  were only for those  that were                                                               
at high  risk and high  cost.  He questioned  whether identifying                                                               
those people  for primary care  and continuity of care  was where                                                               
the savings originated, and he asked for the projected outcome.                                                                 
                                                                                                                                
MS.  BEMBEN  referenced slide  15  and  stated that  the  primary                                                               
reason, a  fundamental assignment, was to  connect every Medicaid                                                               
enrollee with a  primary care provider, which she  declared to be                                                               
a critical step.   She explained that the  health risk assessment                                                               
was also  for every  enrollee, but the  value of  this assessment                                                               
was for its identification of  people with higher health needs or                                                               
risks.  She said those enrollees  could be referred to the higher                                                               
levels  of care  management, with  the possibility  for receiving                                                               
services from  a health home,  or, if  they were identified  as a                                                               
high utilizer of emergency room  services, they could be enrolled                                                               
in the DHSS current care  program.  She shared that conversations                                                               
with stakeholders  indicated that  there were some  pilot efforts                                                               
for this care  management, although it was  difficult to identify                                                               
those people  who would most  benefit.  She explained  that these                                                               
assessments would help DHSS identify  the higher health needs and                                                               
risks,  and  prevent  future  high  utilizers  with  better  care                                                               
management early on.                                                                                                            
                                                                                                                                
4:25:40 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE VAZQUEZ  offered her belief that  the savings from                                                               
this initiative would be even  higher than projected on slide 16.                                                               
She  declared that  it  was  also a  humanitarian  measure as  it                                                               
lessened suffering  while offering  support from providers.   She                                                               
stated her support for the primary care initiative.                                                                             
                                                                                                                                
MS. BEMBEN  replied that  a difficulty of  the health  system was                                                               
for  the  attempts to  create  better  linkages between  clinical                                                               
settings  and community  base settings.   She  acknowledged that,                                                               
although there  was a very  robust network of available  home and                                                               
community  based services,  the linkages  to them  were "tricky."                                                               
The primary  care initiative  included recommendation  for better                                                               
use of those supportive services at a lower cost.                                                                               
                                                                                                                                
4:28:41 PM                                                                                                                    
                                                                                                                                
CHAIR SEATON  asked whether the  cost savings depicted in  FY17 -                                                               
19, slide  16, was  the savings  from individual  care prevention                                                               
catching up to the initial implementation costs.                                                                                
                                                                                                                                
MS. BEMBEN directed attention to  "Total Change in Medical Cost,"                                                               
slide 16,  and noted that  the medical costs started  to decrease                                                               
in  the first  year because  of assignments  to the  primary care                                                               
providers  for care  management.   She said  that the  first year                                                               
expenses  were for  the  ASO  fees.   By  FY19,  the health  home                                                               
services would  be ready, would  receive a federal match  for the                                                               
first two  years, and would  accelerate savings in  medical costs                                                               
from  the care  management for  those with  higher health  needs.                                                               
She  pointed  out  that  although the  ASO  services  were  being                                                               
purchased, they would  help reduce the medical  costs and produce                                                               
a better net savings to the state.                                                                                              
                                                                                                                                
4:30:45 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR, referencing  global payment schedules, asked                                                               
if  that impact  was evaluated  in this  analysis and  whether it                                                               
could be  used as a Medicaid  reform tool for cost  savings.  She                                                               
offered  her understanding  that  a global  payment schedule  was                                                               
value based instead of volume based.                                                                                            
                                                                                                                                
MS.  BEMBEN asked  if this  was a  capitated payment,  and, after                                                               
acknowledgement,  she  relayed  that  they  did  look  at  these,                                                               
especially  when  reviewing full  risk  managed  care.   In  that                                                               
system, the  managed care organization would  receive a capitated                                                               
payment, one payment  per member per month and  would be required                                                               
to  meet quality  outcomes and  provide  the requisite  services.                                                               
She opined that this was similar  to "trying to climb Mt. Everest                                                               
right out of the  gate" as it was assuming a  lot of capacity and                                                               
infrastructure  that   may  not  yet   exist  in  Alaska.     She                                                               
recommended a sequence of reforms  that will build that capacity.                                                               
She  reminded that  accountable care  organizations were  another                                                               
means  for value  based  payments  as they  could  be piloted  in                                                               
Alaska.   In this  model, the providers  would come  together and                                                               
form an  organization, estimate  the total cost  of care  for the                                                               
population they  would contract to  serve, and then, if  the care                                                               
was provided at a lower cost  than the state, they would share in                                                               
the savings.  From this model, there  could be a shift to a share                                                               
in  the  losses if  the  cost  was  exceeded.   She  stated  that                                                               
providers  take on  all  the risk  with  capitated payments,  and                                                               
offered her belief that this  arrangement "would be best to build                                                               
up to,  and not  to jump  to right  away."   She shared  that the                                                               
discussions  with stakeholders  had not  reflected a  willingness                                                               
from providers to  join this model right now.   She reminded that                                                               
Medicaid  was just  a  portion of  their  patient population,  so                                                               
willingness to  do this for  Medicaid had to be  balanced against                                                               
their efforts for the other payers.   She pointed out that it was                                                               
not prevalent  in rural states  because the  dispersed population                                                               
did not offer the economy of scale.                                                                                             
                                                                                                                                
REPRESENTATIVE  TARR   asked  if   there  were   instances  where                                                               
capitated  payment and  global payment  schedules were  different                                                               
and not used interchangeably.                                                                                                   
                                                                                                                                
MS. LEIBOWITZ replied  that they were the same  idea.  Capitation                                                               
was the monthly payment per  person, states like Oregon had moved                                                               
its   managed  care   program  into   this,  whereby   there  was                                                               
responsibility  by  the  managed care  entities  for  everything,                                                               
including physical  health, behavioral  health, and dental.   The                                                               
annual payments  were increased by  a specified  rate, regardless                                                               
of annual expenses.  She  added that, for states with coordinated                                                               
care organizations which utilized  the global capitation payment,                                                               
it often  seemed like the  payment mechanism and  the accountable                                                               
care were linked in a causal  way.  She stated that the important                                                               
thing  for  driving  change   was  accountability,  ensuring  the                                                               
organizations  and  providers  were  changing the  way  they  did                                                               
business,  and not  given incentives  for providing  more volume,                                                               
but only for quality.                                                                                                           
                                                                                                                                
4:38:06 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  VAZQUEZ  addressed slide  16,  and  asked for  an                                                               
explanation to the acronym, PCCM.                                                                                               
                                                                                                                                
MS. BEMBEN  relayed that  PCCM was the  acronym for  primary care                                                               
case management.                                                                                                                
                                                                                                                                
REPRESENTATIVE VAZQUEZ  asked how  the after share  savings would                                                               
work.                                                                                                                           
                                                                                                                                
MS. BEMBEN replied  that the proposed initiative  did not suggest                                                               
any shared  savings, the  line was included  to allow  a standard                                                               
format for all the initiatives.                                                                                                 
                                                                                                                                
CHAIR SEATON  explained that there  was some confusion  about the                                                               
global  payment  model as  an  earlier  proposal by  the  Central                                                               
Peninsula Hospital had  referenced a global payment model.    The                                                               
bills proposed by  the House Health and  Social Services Standing                                                               
Committee required  the Department of Health  and Social Services                                                               
negotiate for  a model but  there was not an  exact specification                                                               
for construction.   He allowed that he had also  been confused by                                                               
the various definitions for the global payment model.                                                                           
                                                                                                                                
MS.  BEMBEN noted  that each  initiative had  to be  specifically                                                               
designed  to allow  for an  actuarial analysis.   She  offered an                                                               
example of  the accountable care  organization pilot, as  part of                                                               
the  recommendation  was  for  a  shared  savings  model.    This                                                               
recommendation was for continuation of  the fee for services, but                                                               
the accountable care  organization is paid a bonus  of the shared                                                               
savings payment if  costs are reduced for the state.   She shared                                                               
that part  of the  reasoning was  for an easier  lift out  of the                                                               
gate, yet specific enough to do  an analysis.  She allowed that a                                                               
capitated  payment was  a  viable  option.   She  noted that  the                                                               
recommendation had been as an  incentive to accountability, while                                                               
sharing the risk  for the cost, and that there  were many ways to                                                               
do this.                                                                                                                        
                                                                                                                                
4:41:52 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  STUTES asked  if there  were enough  providers in                                                               
Alaska  for assignment  to every  enrollee or  would Alaska  need                                                               
more medical professionals.                                                                                                     
                                                                                                                                
MS.  BEMBEN replied  that  they did  not have  a  good number  to                                                               
calculate  a  ratio.   She  noted  that  a broad  definition  for                                                               
primary  care  provider  included  advance  nurse  practitioners,                                                               
physician  assistants,  family  practice  and  internal  medicine                                                               
physicians, and  behavioral health  providers among others.   The                                                               
behavioral  health  initiative  recommended that  DHSS  recognize                                                               
additional  behavioral   health  provider  types  who   were  not                                                               
currently  recognized  or able  to  bill  Medicaid, in  order  to                                                               
create  the  necessary  workforce.   She  acknowledged  that  the                                                               
analysis still needed to be done.                                                                                               
                                                                                                                                
4:44:20 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  STUTES  commented  that  many  seniors,  Medicare                                                               
patients, were  having a difficult  time finding  physicians, and                                                               
expressed her  pleasure that  the "spectrum  is being  widened on                                                               
the providers."                                                                                                                 
                                                                                                                                
MS. BEMBEN said that an important  part of the initiative was the                                                               
proposal that DHSS  pay a per member per month  incentive for the                                                               
case management to  the primary care provider, as  it takes quite                                                               
a bit of time to coordinate care.                                                                                               
                                                                                                                                
4:45:38 PM                                                                                                                    
                                                                                                                                
CHAIR  SEATON directed  attention to  slide  17, and  read:   "In                                                               
second  year, amend  Section  1115 waiver  to  include a  federal                                                               
waiver  of  the  IMD  exclusion  for  residential  substance  use                                                               
treatment."   He asked  if there  was a  history for  these being                                                               
generally granted in  the second year and if  the modification of                                                               
the waiver was a normal process.                                                                                                
                                                                                                                                
MS.  BEMBEN offered  her belief  that the  proposal to  amend was                                                               
fairly new.                                                                                                                     
                                                                                                                                
MS. LEIBOWITZ  shared that the  provision in Section 1115  of the                                                               
Social Security Act  to ask for a waiver of  a portion of federal                                                               
law was a "fairly  well trod path, which is not  to say that it's                                                               
a simple path."   She reported that  this took a lot  of work and                                                               
documentation, but that the process  was well understood and that                                                               
the letter  from CMS indicating  interest should give  states the                                                               
sense that the federal government was interested in approving.                                                                  
                                                                                                                                
4:47:44 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR asked  if Section  1115 had  an eight  year,                                                               
lifetime limit.                                                                                                                 
                                                                                                                                
MS. BEMBEN  replied that the  purpose of  the waiver was  to test                                                               
innovative strategies,  so, if  during the  demonstration period,                                                               
this was shown to be a  good way to administer Medicaid services,                                                               
the state could continue.                                                                                                       
                                                                                                                                
MS. LEIBOWITZ expressed her agreement,  sharing that it was a way                                                               
to test something for a period of time.                                                                                         
                                                                                                                                
4:48:50 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  VAZQUEZ  asked  for clarification  that  although                                                               
there  was not  a commitment  beyond the  requested demonstration                                                               
period,  the ability  to change  during the  demonstration period                                                               
was very limited.                                                                                                               
                                                                                                                                
MS. BEMBEN,  in response  to Chair Seaton,  shared that  they had                                                               
received guidance  that Centers for Medicare  & Medicaid Services                                                               
(CMS)  had issued  expressing desire  to integrate  substance use                                                               
disorder treatment with other mental health services.                                                                           
                                                                                                                                
MS.  LEIBOWITZ, in  response  to  Representative Vazquez,  stated                                                               
that this was  intended to be a five year  period, and that there                                                               
were federal and state agreements  to ensure that extra money was                                                               
not being  spent than without  the waiver.   She stated  that she                                                               
was not entirely sure how a  smaller change would work as part of                                                               
a larger process.                                                                                                               
                                                                                                                                
REPRESENTATIVE VAZQUEZ  asked about possibilities other  than the                                                               
waiver  for residential  substance  use  treatment, pointing  out                                                               
that Alaska did not have enough infrastructure.                                                                                 
                                                                                                                                
MS. BEMBEN  said that  part of the  reason for  limited treatment                                                               
capacity was that  the number of residential  treatment beds were                                                               
limited in  order to be  allowed to  bill Medicaid.   She pointed                                                               
out that the cost of  residential treatment was very difficult at                                                               
that scale and  that Medicaid reimbursement was  not available to                                                               
facilities larger  than a specific  number of beds.   This waiver                                                               
asked that the bed limit be waived.                                                                                             
                                                                                                                                
REPRESENTATIVE VAZQUEZ  asked if  this was  a waiver  for federal                                                               
regulation or was it a federal statutory limit.                                                                                 
                                                                                                                                
MS.  LEIBOWITZ replied  that,  although it  was  in statute,  the                                                               
waiver would give permission "to ignore that piece of law."                                                                     
                                                                                                                                
REPRESENTATIVE  TARR asked  how the  Medicaid payment  rates were                                                               
estimated in  out years,  slide 18, noting  that the  payment was                                                               
often considered to be insufficient.                                                                                            
                                                                                                                                
MS.  PANTELY  replied  that  the estimates  used  were  from  the                                                               
Department of Health  and Social Services, with  the exception of                                                               
pharmacy which used industry standards of 5 - 7 percent.                                                                        
                                                                                                                                
4:55:47 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  VAZQUEZ  noted  that  there may  be  an  ultimate                                                               
savings  as  it was  acknowledged  that  there  was a  mind  body                                                               
connection.                                                                                                                     
                                                                                                                                
MS.  BEMBEN said  that a  lot of  evidence confirmed  this.   She                                                               
stated that the  medical costs for people with  mental illness or                                                               
substance  use were  much higher,  and if  the behavioral  health                                                               
conditions  can  be  addressed,  then the  medical  cost  can  be                                                               
lowered.  She  pointed out this did not include  savings to other                                                               
parts  of  state  government,  reminding  the  committee  of  the                                                               
connection between behavioral health issues and corrections.                                                                    
                                                                                                                                
4:57:31 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE VAZQUEZ expressed her  concern that the initiative                                                               
analysis did  not address the  payment error rate of  16 percent,                                                               
slide 19.                                                                                                                       
                                                                                                                                
CHAIR SEATON  pointed to the  fact that  this was on  the payment                                                               
side, and that  the e-health initiative dealt  with the exchange.                                                               
He asked to confine the  questions, acknowledging that these were                                                               
the recommendations.                                                                                                            
                                                                                                                                
CHAIR  SEATON  asked  if  Initiative  4  was  not  considered  or                                                               
recommended as it was outside the range of the RFP, slide 20.                                                                   
                                                                                                                                
MS. BEMBEN  emphasized that they  did recommend  this initiative,                                                               
and, in response to Chair Seaton,  stated that they did not do an                                                               
actuarial analysis on Initiative 3.                                                                                             
                                                                                                                                
5:00:05 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE VAZQUEZ  asked about the Oregon  study that showed                                                               
the expansion of  Medicaid brought an increase  in emergency room                                                               
visits.                                                                                                                         
                                                                                                                                
MS. LEIBOWITZ  asked if this was  the study of expansion  for the                                                               
program.                                                                                                                        
                                                                                                                                
REPRESENTATIVE VAZQUEZ  said that the  study looked at  the usage                                                               
of  emergency  rooms  with Medicaid  expansion  in  Oregon,  with                                                               
findings that the use increased.   She stated that there was also                                                               
some evidence of an increase in  New York because of the shortage                                                               
of Medicaid providers.                                                                                                          
                                                                                                                                
CHAIR  SEATON  pointed  out  that   this  was  a  private  public                                                               
partnership.   He  declared that  Alaska  currently had  expanded                                                               
Medicaid  and  that   this  was  a  discussion   on  reform,  not                                                               
expansion.     He  asked  to   confine  the  questions   to  this                                                               
recommended package of reforms.                                                                                                 
                                                                                                                                
5:01:38 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE WOOL asked if dental  was ever part of the package                                                               
or had it been opted out because of expense.                                                                                    
                                                                                                                                
MS. BEMBEN replied  that this was a reference to  option 2 of the                                                               
coverage models for the expansion  population.  She said that the                                                               
difference was that  option 1 would provide  the current Medicaid                                                               
benefit  package to  the expansion  population, whereas  option 2                                                               
provided  a  benefit  package modeled  on  the  Alaska  qualified                                                               
health  plan which  did  not  include dental  benefits.   In  the                                                               
analysis, there  was a decrease  in cost  because of the  lack of                                                               
dental  benefits,   although  they   estimated  an   increase  in                                                               
emergency  care for  dental  emergencies.   She  stated that  the                                                               
report  offered  quite  a  bit of  evidence  that  supported  the                                                               
advantages  for  providing  dental care  to  Medicaid  enrollees,                                                               
especially  in low  income populations,  as it  was an  important                                                               
preventative  care,  and  prevented  the  exacerbation  of  other                                                               
chronic conditions.   She stated  that the recommendation  was to                                                               
go with  option 1 and  keep dental  benefits, even though  it was                                                               
slightly more expensive than option 2.                                                                                          
                                                                                                                                
CHAIR SEATON asked that any further questions to be submitted.                                                                  
                                                                                                                                
5:04:42 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being no  further business before the  committee, the House                                                               
Health  and  Social  Services   Standing  Committee  meeting  was                                                               
adjourned at 5:04 p.m.                                                                                                          

Document Name Date/Time Subjects
Milliman Report - AK Medicaid Expansion Population.pdf HHSS 2/11/2016 3:00:00 PM
Medicaid Redesign
Estimated financial impact_redesign_Milliman actuarial Redesign.pdf HHSS 2/11/2016 3:00:00 PM
Medicaid Redesign
Redesign_Final_Report_ Jan-22-2016.pdf HHSS 2/11/2016 3:00:00 PM
Medicaid Redesign
Medicaid Redesign_AgnewBeck Presentation to House HSS_02112016.pdf HHSS 2/11/2016 3:00:00 PM
Medicaid Redesign