Legislature(2009 - 2010)CAPITOL 106
02/19/2009 03:00 PM House HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| Presentations: Medicaid Reform | |
| Cooperative Efforts in Medicaid Reform | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
February 19, 2009
3:11 p.m.
MEMBERS PRESENT
Representative Bob Herron, Co-Chair
Representative Wes Keller, Co-Chair
Representative John Coghill
Representative Bob Lynn
Representative Paul Seaton
Representative Sharon Cissna
MEMBERS ABSENT
Representative Lindsey Holmes
COMMITTEE CALENDAR
PRESENTATION: MEDICAID REFORM
- HEARD
PRESENTATION: COOPERATIVE EFFORTS IN MEDICAID REFORM
- HEARD
PREVIOUS COMMITTEE ACTION
No Previous Action to Record
WITNESS REGISTER
JERRY FULLER, Project Director
Office of Program Review
Office of the Commissioner
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Testified and answered questions on
Medicaid Reform.
JON SHERWOOD, Medicaid Special Projects
Office of the Commissioner
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Testified and answered questions on
Medicaid Reform.
VALERIE DAVIDSON, Senior Director
Legal and Intergovernmental Affairs
Alaska Native Tribal Health Consortium
Anchorage, Alaska
POSITION STATEMENT: presented a Power Point titled "Tribal
Medicaid Reform Initiative."
ACTION NARRATIVE
3:11:49 PM
CO-CHAIR WES KELLER called the House Health and Social Services
Standing Committee meeting to order at 3:11 p.m.
Representatives Keller, Seaton, Cissna, Coghill, and Lynn were
present at the call to order. Representative Herron arrived as
the meeting was in progress.
^Presentations: Medicaid Reform
3:12:16 PM
CO-CHAIR KELLER announced that the first order of business would
be a presentation on Medicaid Reform.
3:14:21 PM
JERRY FULLER, Project Director, Office of Program Review, Office
of the Commissioner, Department of Health and Social Services
(DHSS), described the history of the long term care forecast for
Medicaid. He offered that the forecast model was initiated for
both a 3-5 year review and a 20 year review. He noted that the
forecast indicated that the Medicaid budget would quadruple in
20 years. He reported that medical inflation and increased
demand as the population aged were the primary reasons for the
budget increase. He observed that the Pacific Health Policy
Group was hired to review the Medicaid program and make
recommendations to control this cost increase.
3:17:33 PM
MR. FULLER said that the review established that long term care
was a major cost and suggested a search for ways to increase
federal support funds. He defined long term care to include
nursing homes, residential and community based services,
personal care, and pioneer homes. He noted that the review also
suggested for DHSS to work more closely with the Alaska Tribal
Health organizations for Medicaid managed care. He described
the Federal Medical Assistance Percentage (FMAP) as the federal
contribution percentage for Medicaid services, currently at 51
percent, with an increase to 57 percent after the stimulus
package. He reported that Medicaid paid 100 percent for
American Indians and Alaska Natives who received service through
the Tribal Health organizations.
3:21:53 PM
MR. FULLER observed that two years ago the legislature
appropriated $2 million dollars to review 13 recommendations
from the Pacific Health Policy Group. He stated that designated
grants were given to Alaska Native Tribal Health Consortium
(ANTHC) to review and develop a sustainable long term health
care system. He went on to discuss behavioral health services
and endeavors with the Center for Medicaid Services (CMS) for a
narrow array of services to treat and prevent substance abuse.
He recounted that a McDowell Group report ascribed the cost from
substance abuse to be $750 million.
MR. FULLER shared that Pacific Health Policy Group was
investigating the potential for a waiver from CMS for substance
abuse. He also noted that Pacific Health Policy Group was
researching for the most effective array of provider services
for substance abusers.
3:26:34 PM
REPRESENTATIVE CISSNA noted that behaviors were all correctable
with treatment or relearning. She asked if the provider
services could be expanded to include depression.
3:27:47 PM
MR. FULLER agreed that the service array would include mental
health services, as substance abuse was very often a co-
occurring disorder.
3:29:16 PM
CO-CHAIR KELLER asked about a timeline for the report from
Pacific Health Policy Group.
3:29:31 PM
MR. FULLER responded that most of the research was to be
finished by early to mid April, and he looked forward to a
report by the end of the session. He mentioned that legislative
approval was necessary for the department to implement a budget
neutral waiver.
3:32:03 PM
REPRESENTATIVE SEATON asked, since Alaska's population was
aging, if the increased cost for end of life health care was
being addressed.
3:33:27 PM
MR. FULLER responded that this was part of the long term care
plan. He advised that a properly constructed case management
system could intervene earlier in a person's life to avoid the
high costs at the end. He offered an example of the Wyoming
Medicaid program that had "decent" results.
3:35:27 PM
REPRESENTATIVE SEATON noted that care management had a reduced
expenditure, but that there could still be substantial expense
at the end of life unless this was also managed.
3:37:07 PM
JON SHERWOOD, Medicaid Special Projects, Office of the
Commissioner, Department of Health and Social Services (DHSS),
recounted that once people were eligible for Medicare, it was
the primary payer of acute and primary care. He said that
Medicaid paid for most of the long term care. He shared the
challenge of making sound investments in long term care while
the effects were also in acute and primary care expenditures.
He noted that much of the care for end of life should happen
under the Medicare program. He allowed that Medicare was best
suited for urban places.
3:39:47 PM
REPRESENTATIVE LYNN observed that rationing health care was a
moral issue.
3:41:01 PM
MR. FULLER disclosed that palliative care was included in the
Oregon priority of services. He offered his belief that the
country was not ready for a serious discussion about the moral
issues of health care.
3:42:13 PM
REPRESENTATIVE CISSNA referred to a chronic care study which
stated that controlling the severity of chronic disease would
lower the long term cost. She suggested that the hospice
program in Alaska was not fully developed.
3:45:44 PM
MR. FULLER opined that there was no control over managed long
term care until Medicaid and Medicare were funded together.
3:46:47 PM
CO-CHAIR KELLER talked about the preventive aspect of managed
care.
3:47:59 PM
MR. FULLER expanded on the recommendation from the Pacific
Health Policy Group to work with tribal organizations to
configure tribal health care as managed care. He cited that
Alaska did not have any private managed care. He allowed that
tribal health care approximated a pre-natal through death
managed care system. He said that Pacific Health Policy Group
did not understand tribal health care systems. He noted that
managed care required infrastructure, which both the state and
the Alaska Tribal Health care lacked. He suggested that the
Alaska Tribal Health care organization needed more services,
which would allow better use of the FMAP payment for services.
He said that federal funding was flat, and had not kept up with
either inflation or population growth. He said that
reimbursement did not cover the costs. He reported that a close
look at the reimbursement methodologies was required to assist
the tribal health service to expand their Medicaid services. He
referred to Senate Bill 61 as a means to look at doing things
differently.
3:54:43 PM
CO-CHAIR KELLER asked who produced the long term forecast.
MR. FULLER explained that the Lewin Group reported in 2006, and
DHSS updated the forecast each year. He said that DHSS had made
significant changes in order to decrease some of the costs.
3:57:33 PM
CO-CHAIR KELLER said that state spending still showed an
increase. He referred to the "Progress report on Alaska
Medicaid reform" handout. [Included in the members' packets.]
He pointed out that the nine projects listed on the report were
not reflected in the latest DHSS forecast.
MR. FULLER referred to ongoing and completed programs that had
made a difference.
CO-CHAIR KELLER asked if the expenditure results of Senate Bill
61 were incorporated in the DHSS update.
MR. FULLER allowed that a number of reports were not included.
3:59:14 PM
REPRESENTATIVE CISSNA asked if any studies existed regarding the
habits of senior citizens, as Alaska was the leader of habit
forming conditions.
4:00:34 PM
MR. FULLER said that he was not aware of any such study.
MR. SHERWOOD explained that Senate Bill 61 was focused on ways
to make Medicaid more sustainable and that much of the bill
centered on long term care, as Alaska's senior population was
only exceeded by Nevada. He shared that the Medicaid program
projected a shift from care for children to service for the
elderly and disabled. He stated that DHSS was reviewing the
rate setting methodology so that home and community based
program rates were more in balance with the provider costs. He
explained that some health care providers were public entities,
such as government or tribal providers. He said that the state
match to Medicaid for public entities, and any increase to the
rate, could be met by certifying public expenditures. He shared
that one advantage of working with tribal partners to increase
services to its beneficiaries was that there was no increase in
the state match.
4:05:43 PM
CO-CHAIR KELLER asked how many Medicaid providers there were in
Alaska.
MR. SHERWOOD replied that he was unsure, but that it was in the
thousands, and he shared that there were 356 different in-home
and community based providers.
4:06:26 PM
CO-CHAIR KELLER asked to know the number of both active and
qualified providers.
4:06:41 PM
MR. SHERWOOD stated that DHSS had hired HCBS Strategies to help
develop a long term care plan. He declared that the report,
"Alaska Long Term Care Plan," was a most comprehensive report,
and he shared some of the suggestions: improve the method of
matching people with the needed services, develop the aging and
disability resource center as one stop shops, explore changing
the new personal care program to a cash and counseling model,
and provide more support for cognitive impairments. He
mentioned a new federal option for certain targeted groups with
benchmark plans to be provided with a mix of services for
limited managed care plans.
4:11:13 PM
REPRESENTATIVE COGHILL asked that Mr. Sherwood explain the
process to change a waiver.
4:11:24 PM
MR. SHERWOOD said that it required a statement of legislative
intent.
REPRESENTATIVE COGHILL clarified that the application had to be
made through the state plan.
MR. SHERWOOD agreed that, along with the statement of intent, a
federally approved amendment or waiver of the state plan was
necessary. He said that this could take from a few months to
much longer, dependent on the prior approvals for other states.
4:13:26 PM
MR. SHERWOOD, in response to Representative Coghill, said that
DHSS would anticipate a significant time frame, probably longer
than 6 months.
4:13:59 PM
REPRESENTATIVE COGHILL noted that this could not be done in this
budget cycle.
MR. SHERWOOD offered his appreciation of the clarification. He
expressed the necessity for thoughtful implementation, as the
inadvertent consequences could be substantial.
4:14:43 PM
REPRESENTATIVE CISSNA asked when was the last waiver change.
MR. SHERWOOD said that the service mix for the current waivers
was about the same as approved in 1993. He explained that
clearer service definitions were done a few years ago.
4:17:02 PM
MR. FULLER stated that conversations regarding the best waiver
would continue with Medicare and Medicaid. He highlighted that
the long term goal for DHSS was to make the system more
efficient and cost effective. He said that the focus was on
people and dollars.
4:19:08 PM
MR. SHERWOOD summarized that some cognitive impairments might
not qualify for home and community based services. He shared
that consultants had suggested several federal funding sources
which included: Medicaid funding for cognitive impairments of
patients in the pioneer homes, technical procedural changes for
the waivers, and review of the state funded pioneer home payment
assistance program. He shared that another recommendation was
for DHSS to involve stake holders in the sustainable planning
process of a long term care strategy. He summarized that Senate
Bill 61 included prior authorization of drugs, step therapy for
drugs, a review of the pharmacy reimbursement for compliance
with federal requirements, and a re-appraisal of the personal
care program. He stated that it was important to coordinate all
DHSS efforts with Alaska Tribal Health.
^Cooperative Efforts in Medicaid Reform
4:25:44 PM
CO-CHAIR KELLER announced that the final order of business would
be a Power Point presentation titled "Tribal Medicaid Reform
Initiative." [Included in members' packets.]
4:25:51 PM
VALERIE DAVIDSON, Senior Director, Legal and Intergovernmental
Affairs, Alaska Native Tribal Health Consortium (ANTHC),
presented the Power Point and spoke about slide 3, "Alaska
Tribal Health System." She explained that tribal health was a
voluntary affiliation of more than 30 tribes and tribal
organizations and noted that it was often the only health
service in a community.
4:27:17 PM
MS. DAVIDSON pointed to slide 4, a map of Alaska showing Alaska
Tribal Health System locations, and slide 5 "Economic Impact."
She reported that tribal health employed more than 7,000 people
statewide, and that it was often the only health provider in
rural areas.
4:27:55 PM
MS. DAVIDSON referred to slide 6, "Alaska Native Demographics,"
and noted that Alaska Natives represented 20 percent of the
population. She offered slide 7, "ATHS Service Population,"
which reflected the Alaska Native population distribution. She
spoke quickly about the major health issues for Alaska Natives,
slide 8, "Alaska Native Health Status."
4:28:27 PM
MS. DAVIDSON noted that slide 9, "Medical Care Service Levels,"
explained the multi tiered health care delivery system.
4:29:07 PM
MS. DAVIDSON examined the Alaska map on slide 10, "Referral
Patterns." She spoke about the importance for access to care
which was mentioned on slide 11, "Village-Based Medical
Services."
4:31:20 PM
MS. DAVIDSON skipped slide 12, and explained the role of the
"Alaska Native Tribal Health Consortium," slide 13.
4:32:03 PM
MS. DAVIDSON spoke briefly about the "Alaska Native Medical
Center," shown on slide 14, slide 15, and slide 16. She pointed
out that Alaska Tribal Health Service was also a public health
agency, slide 17, "Community Health Services," and shared that
wellness and prevention activities reduced the need for primary
care.
4:32:56 PM
MS. DAVIDSON observed that many people believed that the federal
government paid for Indian Health Services (IHS), but that
funding only paid for 51 percent of the basic health care
services, as shown on slide 19, "Sustainability Issues."
4:33:58 PM
MS. DAVIDSON explained the funding level gaps which restricted
some services noted on slide 20, "Rationed Health Care." She
said that the wait period for the limited number of "Residential
Treatment Centers," slide 22, was between six to nine months.
She pointed to slide 23, "Authority to bill," and explained the
reimbursement sources for IHS.
4:35:02 PM
MS. DAVIDSON pointed out the FMAP savings for the State of
Alaska when Medicaid patients used the IHS facilities, as shown
on slide 24,"Alaska benefits."
4:35:50 PM
MS. DAVIDSON moved on to slide 25, "Medicaid Information," and
read that 40 percent of Alaska's Medicaid population was Alaska
Native. She pointed out that most of the non-tribal provider
payments were for long term care, behavioral health, and
hospital services, as IHS had historically not funded any of
these.
4:37:13 PM
MS. DAVIDSON read slide 26, "Pacific Health Policy Group
Report," and stated that there was both a financial and a
quality of service interest to enhance the tribal provider
capacity, especially for long term care.
4:37:41 PM
MS. DAVIDSON explained slide 27, "Legislature authorized SB 61,
Tribal Medicaid Demonstration," which provided resources for an
ANTHC statewide and regional study of several focus areas, which
included long term care, behavioral health service and financial
infrastructure, to establish model delivery systems.
4:38:51 PM
MS. DAVIDSON, in response to Co-Chair Herron, shared that both
the state and the ANTHC were mindful to not rush in and develop
service delivery systems faster than either tribal health was
able to absorb or the state was able to implement. She offered
her belief that a quarterly evaluation should be required for
the first two years to review the reimbursement levels, the
obstacles, and the necessary changes.
MS. DAVIDSON referred back to the Power Point presentation and
slide 28, "Long-Term Care." She pointed out that it was not
just for the elderly as there were people with disabilities who
also required long term care. She observed that there were home
and community based services which allowed independent living
for as long as possible. She explained one recommendation that
was for a short term pilot project at three existing sites of
home and community based services. She said the project would
see what was working and what needed to be changed to ensure
that the programs were sustainable. She suggested that this
would lead to an expanded state wide comprehensive system plan.
She said that there would always be a need for residential
services. She observed that the study identified bed needs at
the sub regional level, which was especially important for
traditional lifestyle communities.
4:45:13 PM
MS. DAVIDSON moved on to slide 29, "Behavioral Health," and
explained some of the lessons learned from the tribal health
program, which included a focus on integrated behavioral health
and on primary care.
4:48:10 PM
MS. DAVIDSON said that an adequate system of care was dependent
on regulatory and program support, and workforce development.
4:48:29 PM
MS. DAVIDSON identified slide 30, "Other Services & System
Efficiencies," and explained the importance of care
coordination. She noted that in October and November more than
371 patients had been diverted from Alaska Native Medical Center
to Providence Hospital in Anchorage. She stated that
implementation of electronic health records and health
information exchanges would improve the system efficiency.
4:50:08 PM
MS. DAVIDSON, in response to Co-Chair Herron, explained that
Alaska Native Medical Center had to pay for patients who did not
have alternative resources. She emphasized that for the tribal
health system to be sustainable there must be systems of care
that worked in a variety of places. She quickly discussed slide
32, "Sustainability Issues," and slide 33, slide 34, and slide
35, "Sustainability Issues: Energy Crisis," and noted the
increase of infectious diseases as financial pressure forced
overcrowding in homes without adequate sanitation facilities.
4:53:12 PM
MS. DAVIDSON advised that alcohol and substance use was also a
problem. She shared that the energy crisis was increasing the
demand for care and decreasing the ability for clinics and
hospitals to provide the care. She reported that every major
tribal health organization had to implement cost cutting
measures.
4:55:02 PM
MS. DAVIDSON returned to slide 31, "Managed Care Feasibility,"
and explained the difference between a managed care organization
and managing the care of Alaskans. She pointed to the benefits
from implementing wellness and prevention activities, looking at
cost based reimbursement structures, expanding capacities, and
improving efficiencies.
4:57:40 PM
CO-CHAIR HERRON requested a graph that showed the tribal cost
when a patient was referred out of the Alaska Tribal Health
system.
4:58:46 PM
MR. FULLER announced that it was extremely important for the
state and tribal organizations to work together. He summarized
that the committee could expect more discussion of choices for
long term general fund savings and tribal sustainability. He
noted that the Medicaid program needed to look at maximizing the
FMAP for reimbursement to public providers.
5:01:45 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 5:01 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Alaska Medicaid Reform.doc |
HHSS 2/19/2009 3:00:00 PM |
|
| ANTHC SB 61 for HSS final 2_09.ppt |
HHSS 2/19/2009 3:00:00 PM |
SB 61 |