Legislature(2019 - 2020)SENATE FINANCE 532

02/11/2019 09:00 AM HEALTH & SOCIAL SERVICES

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09:02:35 AM Start
10:21:06 AM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
-- Please Note Time & Location Change --
- Joint with Senate Finance -
Alaska Health Care Transformation Project Update
-- Testimony <Invitation Only> --
-- Teleconference Listen Only --
                 ALASKA STATE LEGISLATURE                                                                                       
                       JOINT MEETING                                                                                            
                 SENATE FINANCE COMMITTEE                                                                                       
   SENATE HEALTH and SOCIAL SERVICES STANDING COMMITTEE                                                                         
                     February 11, 2019                                                                                          
                         9:02 a.m.                                                                                              
9:02:35 AM                                                                                                                    
CALL TO ORDER                                                                                                                 
Co-Chair Stedman called the joint Senate Finance Committee                                                                      
and Senate Health and Social Services Committee meeting to                                                                      
order at 9:04 a.m.                                                                                                              
SENATE FINANCE COMMITTEE MEMBERS PRESENT                                                                                      
Senator Natasha von Imhof, Co-Chair                                                                                             
Senator Bert Stedman, Co-Chair                                                                                                  
Senator Click Bishop                                                                                                            
Senator Lyman Hoffman                                                                                                           
Senator Peter Micciche                                                                                                          
Senator Donny Olson                                                                                                             
Senator David Wilson                                                                                                            
Senator Bill Wielechowski                                                                                                       
SENATE FINANCE COMMITTEE MEMBERS ABSENT                                                                                       
Senator Mike Shower                                                                                                             
SENATE HEALTH and SOCIAL SERVICES COMMITTEE MEMBERS PRESENT                                                                   
Senator David Wilson, Chair                                                                                                     
Senator John Coghill, Vice Chair                                                                                                
Senator Gary Stevens                                                                                                            
Senator Cathy Giessel                                                                                                           
Senator Tom Begich                                                                                                              
ALSO PRESENT                                                                                                                  
Sandra Heffern, Executive Director, Effective Health                                                                            
Design; Scott Leitz, Senior Fellow, NORC at the University                                                                      
of Chicago.                                                                                                                     
PRESENT VIA TELECONFERENCE                                                                                                    
Lynne Snyder,  Ph.D., Principal  Research Scientist,  NORC at                                                                   
the University of Chicago.                                                                                                      
ALASKA HEALTHCARE TRANFORMATION PROJECT UPDATE                                                                                
Co-Chair  Stedman  introduced   the  members  of  the  Senate                                                                   
Finance Committee.                                                                                                              
Chair  Wilson introduced  the  members of  the Senate  Health                                                                   
and Social Services Committee.                                                                                                  
9:04:50 AM                                                                                                                    
Co-Chair  von Imhof  commented  that  healthcare  has been  a                                                                   
topic of  discussion in Alaska  for several years.  She noted                                                                   
that  some  committees  have been  researching  why  the  per                                                                   
capita costs  are so high in  Alaska. One of the  most recent                                                                   
studies  is  the  Alaska  Healthcare  Transformation  Project                                                                   
that  she  sits  on  along  with  Sandra  Heffern,  Elizabeth                                                                   
Ripley and others.  The project has a triple  aim: to improve                                                                   
population  health,  improve   the  patient  experience,  and                                                                   
lower  the per  capita cost  of  healthcare. The  hope is  to                                                                   
coordinate  patient care,  improve  primary care  utilization                                                                   
rather than using  the ER, change the way  healthcare is paid                                                                   
for  in Alaska  to provide  more  transparency, and  increase                                                                   
data analytics. She  said the project raised  $1 million last                                                                   
year  through the  state  and  private foundations  and  then                                                                   
hired  NORC  (National  Opinion  Research  Center)  with  the                                                                   
University  of Chicago  to help  with the  project. She  said                                                                   
the impetus  of the current meeting  is to check in  with the                                                                   
healthcare transformation team and NORC.                                                                                        
9:06:26 AM                                                                                                                    
Co-Chair Stedman  highlighted that  Senator von Imhof  is the                                                                   
budget  subcommittee chair  for  health  and social  services                                                                   
and some of  the most challenging pieces of  Alaska's current                                                                   
budget  concern  these issues.  He  noted that  this  meeting                                                                   
will  provide good  background before  the governor's  budget                                                                   
is published.                                                                                                                   
9:07:39 AM                                                                                                                    
SANDRA   HEFFERN,   EXECUTIVE  DIRECTOR,   EFFECTIVE   HEALTH                                                                   
DESIGN, ANCHORAGE,  stated that she and her  colleagues would                                                                   
present   a   brief   history  of   the   Alaska   Healthcare                                                                   
Transformation Project,  the current efforts, and  the future                                                                   
direction  of the  project. Salient  points  will be  briefly                                                                   
discussed,  and  a  more  in-depth   discussion  off-line  is                                                                   
available if there is interest.                                                                                                 
9:08:41 AM                                                                                                                    
Ms.  Heffern  reviewed  slide  2,  "History  of  Health  Care                                                                   
Reform Efforts in Alaska":                                                                                                      
     ? 2007 Health Strategies Planning Council                                                                                  
     ? 2009 Health Care Commission                                                                                              
     ? 2010 Medicaid Task Force                                                                                                 
     ? 2010 Affordable Care Act                                                                                                 
     ? 2014 Medicaid Reform Advisory Group                                                                                      
     ? 2016 SB 74 Medicaid Reform                                                                                               
She  discussed  the  past  efforts  and  how  healthcare  has                                                                   
transformed  in Alaska.  She  noted that  in  2007 under  the                                                                   
Palin   administration,   the  Health   Strategies   Planning                                                                   
Council  convened.  The  Council  created  a  list  of  seven                                                                   
     1.  Health cost for  all Alaskans  will consistently  be                                                                   
     below the national average                                                                                                 
     2.   Alaska   will   have   a   sustainable   healthcare                                                                   
     3.  All Alaskan  communities  will have  clean and  safe                                                                   
     water and wastewater systems                                                                                               
     4.  Quality   healthcare  will  be  accessible   to  all                                                                   
     Alaskans to meet their healthcare needs                                                                                    
     5.   Personal    responsibility   and    prevention   in                                                                   
     healthcare  will be top  priorities for government,  the                                                                   
     private sector,  tribal entities, communities,  families                                                                   
     and individuals                                                                                                            
     6.   Develop  and   foster   the  statewide   leadership                                                                   
     necessary  to   develop  and  support   a  comprehensive                                                                   
     statewide health and healthcare policy                                                                                     
     7.  Increase the number  of Alaskans  covered by  health                                                                   
She  described  how  the  work  of the  Council  led  to  the                                                                   
legislature establishing  the Health Care Commission  in 2010                                                                   
to  advise the  state on  policies for  improving health  and                                                                   
healthcare  for  all  Alaskans. The  Commission  was  charged                                                                   
with serving  as the state  health planning and  coordinating                                                                   
body  as   well  as  tasked   with  implementing   the  goals                                                                   
previously  established  by the  Health  Strategies  Planning                                                                   
Council. She  said the Commission  studied issues  related to                                                                   
healthcare   in   Alaska   and    reported   activities   and                                                                   
recommendations  to  the  legislature.   The  commission  was                                                                   
defunded in 2015 and is no longer active.                                                                                       
9:10:45 AM                                                                                                                    
She continued  that in  2010, Governor  Parnell convened  the                                                                   
Medicaid Task Force,  which was comprised of  legislators and                                                                   
state  administrators,  to  address the  growth  in  Alaska's                                                                   
Medicaid  program   and  budget.  The  Affordable   Care  Act                                                                   
(Obamacare) was  also established in 2010. She  discussed how                                                                   
the    following   years    were    spent   addressing    the                                                                   
implementation  of the  Affordable  Care  Act. That  included                                                                   
looking  at:  the  health market  and  the  health  insurance                                                                   
marketplace, whether  to expand Medicaid, and  individual and                                                                   
employer mandates.                                                                                                              
In  2014,  Governor  Parnell  convened  the  Medicaid  Reform                                                                   
Advisory Group which  was designed to develop  a proposal for                                                                   
reforming the  state's Medicaid  program. She noted  how this                                                                   
group  addressed:   the  stability   and  predictability   in                                                                   
budgeting, increasing  the ease and efficiency  of navigating                                                                   
the system  by providers,  and providing  whole care  for the                                                                   
patient   by   uniting   physical   and   behavioral   health                                                                   
She   said    that   in   2016   under    Governor   Walker's                                                                   
administration, Senate  Bill 74, the omnibus  Medicaid reform                                                                   
bill, became  law. Many  of the  legislators present  at this                                                                   
table  were instrumental  in the  passing of  that bill.  She                                                                   
stated  that  many  of  the  components  of  Senate  Bill  74                                                                   
including  telemedicine,  pharmaceutical   control  with  the                                                                   
prescription  drug   monitoring  program,  moving   toward  a                                                                   
coordinated  care  model  and behavioral  health  reform  are                                                                   
some of  the initiatives  that have  been implemented  or are                                                                   
currently  in progress.  She noted there  have been  numerous                                                                   
efforts for  health reform  and she  only discussed  the last                                                                   
12 years.                                                                                                                       
9:12:44 AM                                                                                                                    
She pointed out  that the Anchorage Economic  and Development                                                                   
Corporation  performs a business  confidence inventory  every                                                                   
year  (since 2010)  and  found that  the  main hinderance  to                                                                   
economic  growth  for business  development  is  the cost  of                                                                   
health  insurance. The  cost of  health insurance  correlates                                                                   
directly with the  cost of healthcare. She  noted that during                                                                   
the  2017 legislative  session  there  were many  discussions                                                                   
regarding the  issue of driving  down healthcare  costs while                                                                   
increasing quality  and increasing  access to healthcare  for                                                                   
9:13:57 AM                                                                                                                    
Ms.  Heffern   addressed  slide   3,  "What  is   the  Alaska                                                                   
Healthcare Transformation Project":                                                                                             
     A cross sectional collaboration of payers, providers,                                                                      
     policymakers and patient advocates working together to                                                                     
     transform Alaska's healthcare system.                                                                                      
She   stated  how   the  legislature,   administration,   and                                                                   
provider    organizations    were   brought    together    to                                                                   
collectively  discuss  the  issue of  healthcare  in  Alaska.                                                                   
From    those    discussions,     the    Alaska    Healthcare                                                                   
Transformation Project was developed.                                                                                           
9:14:45 AM                                                                                                                    
Ms.   Heffern   discussed  slide   4,   "Project   Management                                                                   
     ? Senator Natasha von Imhof                                                                                                
     ? Representative Ivy Spohnholz                                                                                             
     ? Elizabeth Ripley, Mat-Su Health Foundation                                                                               
     ? Kalani Parnell, Alaska Native Tribal Health                                                                              
     ? Becky Hultberg, Alaska State Hospital and Nursing                                                                        
     Home Association                                                                                                           
     ? Nancy Merriman, Alaska Primary Care Association                                                                          
     ? Mike Barnhill, Office of Management and Budget                                                                           
     Policy Director, State of Alaska                                                                                           
She discussed  why the  project was  different than  previous                                                                   
efforts which  have focused  primarily on Medicaid.  Medicaid                                                                   
is a  big part of Alaska's  healthcare system;  27-28 percent                                                                   
of the state's  population receives health  insurance through                                                                   
Medicaid.  However,  that  leaves  out about  70  percent  of                                                                   
Alaska's population.  She noted that Alaska has  a relatively                                                                   
small population  and when  efforts are  focused on  a single                                                                   
area,  significant cost  shifting can  occur. She  reiterated                                                                   
that this  was why employers  found health insurance  costs a                                                                   
hinderance  to  economic  growth.  She opined  that  not  all                                                                   
stakeholders impacted  by health reform were  brought to help                                                                   
with   previous  efforts.   She   relayed  her   longstanding                                                                   
experience  in  health  and  human  services  and  noted  the                                                                   
benefit  of having  new perspectives  brought  to the  table.                                                                   
The current  effort was  a public  private partnership  while                                                                   
previous  efforts were  mainly  driven  by government  (while                                                                   
government is  a part of the  current partnership, it  is not                                                                   
driven  by government).  She offered  her  belief that  these                                                                   
are the differences  from past efforts that will  lead to the                                                                   
success of this project.                                                                                                        
9:17:24 AM                                                                                                                    
Ms. Heffern addressed slide 5, "Vision":                                                                                        
     The  vision   for  Alaska's  healthcare  system   is  to                                                                   
     improve  Alaskan's health  while also enhancing  patient                                                                   
     and  health   professional's  experience  of   care  and                                                                   
     lowering the per capita healthcare growth rate.                                                                            
She noted  the project was  divided into phases.  The project                                                                   
began by bringing  stakeholders and policymakers  together to                                                                   
discuss what needed  to change within the  healthcare system,                                                                   
she said.  She stated  that from  those discussions  came the                                                                   
quadruple   aim  of   the   project:  the   overall   patient                                                                   
experience, the  provider's experience  of care, the  cost of                                                                   
care, and access to care.                                                                                                       
9:18:16 AM                                                                                                                    
Ms. Heffern discussed slide 6, "Guiding Principles":                                                                            
     ? Focus  on improving  individual and population  health                                                                   
     outcomes   (defined   holistically   including   mental,                                                                   
     behavioral, oral, vision and social health)                                                                                
     ? Health  coverage with common  basic benefits  for all.                                                                   
     There is  shared responsibility in reforming  and paying                                                                   
     for  coverage, with  everyone    individuals,  business,                                                                   
     insurers and governments  playing a role.                                                                                  
    ? Focus on whole person/integrated systems of care                                                                          
     ?  Use proven  healthcare  delivery practices  supported                                                                   
     by appropriate payment mechanisms                                                                                          
     ?  Seeking recognition  and ways  to incorporate  social                                                                   
     determinants of health in patients' care plans                                                                             
9:19:04 AM                                                                                                                    
Ms. Heffern addressed slide 7, "Goals":                                                                                         
     Healthy Alaskans:                                                                                                          
     ? The percentage of Alaskan residents with a usual                                                                         
     source of primary care will increase by 15% within                                                                         
     five years                                                                                                                 
     Healthy Economy:                                                                                                           
     ? Reduce overall per capita healthcare growth rate to                                                                      
     the greater of 2.25% or Consumer Price Index within                                                                        
     five years                                                                                                                 
     Everybody's Business:                                                                                                      
     ? Align all payers, public and private, towards value-                                                                     
     based alternative payment models with streamlined                                                                          
     administrative requirements within five years                                                                              
She  referenced  the  tag  line  "Healthy  Alaskans,  Healthy                                                                   
Economy,  Everybody's  Business" and  noted  that goals  were                                                                   
made for those  three specific areas. She spoke  to the first                                                                   
slogan,  "Healthy Alaskans."  She  noted  a national  survey,                                                                   
the  Commonwealth Scorecard,  showed 68  percent of  Alaskans                                                                   
have a  usual source  of primary  care (with  the best  state                                                                   
being at  89 percent, leaving  Alaska room for  improvement).                                                                   
She  discussed  the  second  goal,   "Healthy  Economy."  The                                                                   
Institute for  Social and  Economic Research (ISER)  released                                                                   
a report  in 2018  that stated,  Alaska's overall  healthcare                                                                   
spending  growth   rate  from   1991-2014  was   7.8  percent                                                                   
compared to  the United States  overall rate of  six percent.                                                                   
She  reminded the  committee that  Alaska's healthcare  costs                                                                   
are 38  percent higher  than the rest  of the United  States.                                                                   
She discussed  the last  bullet, "Everybody's Business."  She                                                                   
said that  since the Affordable  Care Act passed,  payment of                                                                   
value   versus  payment   of   volume  of   care  has   grown                                                                   
significantly   and  can   take   multiple  forms   including                                                                   
accountable care  organizations, global payments,  or bundled                                                                   
payments   for  care   improvement.  Alaska   is  unique   in                                                                   
geography and  region; therefore,  the goals were  created so                                                                   
the  state  would not  be  limited  to following  a  specific                                                                   
healthcare   model.  She  highlighted   that  providers   and                                                                   
practitioners  asked  for  a   focus  on  how  to  streamline                                                                   
administrative  requirements because  it  is recognized  that                                                                   
the added  cost of administration  does not equate  to better                                                                   
outcomes or better patient care.                                                                                                
9:21:46 AM                                                                                                                    
Ms.  Heffern   addressed  slide   8,  "Strategy   Development                                                                   
     ? Primary Care utilization                                                                                                 
     ? Payment Reform                                                                                                           
     ? Data Analytics                                                                                                           
     ? Coordinated Care                                                                                                         
     ? Social Determinants of Health                                                                                            
She  said  that  in the  second  phase  the  project  members                                                                   
created  strategy development  teams. A  group of 100  people                                                                   
met over  the course of four  months for three hours  a month                                                                   
to discuss areas  of question before making  recommendations.                                                                   
From those  five groups the  teams synthesized  the questions                                                                   
into four themes.                                                                                                               
She then discussed slide 9, "Themes":                                                                                           
     1. Alaska landscape       previous projects, pilots,                                                                       
     2. Meta-analysis/Synthesis of reports and studies                                                                          
     3. National landscape  what's happening in other                                                                           
     4. Spend/Cost analysis of Alaska healthcare                                                                                
She  recognized  that  in  the  last  10  years,  Alaska  has                                                                   
accomplished  a  lot  in healthcare  reform.  She  noted  the                                                                   
importance of observing  healthcare on the national  level to                                                                   
learn   how  other   states  have   accomplished  reform   in                                                                   
healthcare.  Lastly, it  was important  to  note what  Alaska                                                                   
was spending on healthcare and what the cost drivers were.                                                                      
9:23:28 AM                                                                                                                    
Ms. Heffern discussed slide 10, "Budget and Funding":                                                                           
     ? Governor's Budget $250,000                                                                                               
     ? Capital Budget $250,000                                                                                                  
     ? Foundations $120,000 Mat-Su Health Foundation                                                                            
     $250,000 Rasmuson                                                                                                          
     ? Other $130,000 Alaska Mental Health Trust, TBD                                                                           
She stated  that while  the strategy  development teams  were                                                                   
completing their  work, funds for the project  were collected                                                                   
to  support  the  research. She  thanked  the  committee  and                                                                   
members  present  last  year who  secured  $250,000  for  the                                                                   
project  in   the  governor's  operating  budget   under  the                                                                   
Department of  Administration. There was $250,000  in capital                                                                   
budget  appropriation,   $120,000  from  the   Mat-Su  Health                                                                   
Foundation, $250,000  from the Rasmuson  Foundation, $100,000                                                                   
from  the  Alaska  Mental Health  Trust,  and  an  additional                                                                   
$30,000 was  contributed by someone  who preferred to  not be                                                                   
identified. She  said $1 million  was selected  because other                                                                   
states  with  comparable  populations  used  that  amount  to                                                                   
pursue similar  efforts in  reforming healthcare.  She stated                                                                   
that  a  budget  was  developed,  scopes  of  work  were  put                                                                   
together,  and specific  contractors from  other states  were                                                                   
solicited. Five  entities responded  to the requests  for the                                                                   
scopes of work  and after scoring the responses,  NORC at the                                                                   
University  of Chicago  was selected  as  the contractor  for                                                                   
all four scopes.                                                                                                                
9:24:55 AM                                                                                                                    
Ms. Heffern introduced slide 11, "Four Scopes of Work":                                                                         
     NORC at the University of Chicago and University of                                                                        
     Alaska Anchorage                                                                                                           
She said  Mr. Leitz  with NORC  would provide  a synopsis  of                                                                   
their work.                                                                                                                     
9:25:42 AM                                                                                                                    
SCOTT  LEITZ,  SENIOR  FELLOW,  NORC  AT  THE  UNIVERSITY  OF                                                                   
CHICAGO, displayed  slide 12,  "About NORC at  the University                                                                   
of Chicago":                                                                                                                    
     NORC  at the University  of Chicago  is an  independent,                                                                   
     non-profit research  institution that  delivers reliable                                                                   
     data   and   rigorous   analysis   to   guide   critical                                                                   
     programmatic, business, and public policy decisions.                                                                       
He thanked  the committee  for the  privilege to update  them                                                                   
on the Healthcare  Transformation Project. He  stated that he                                                                   
served as the  project director and noted he  was accompanied                                                                   
by  his colleague  Lynne Snyder  via phone,  who would  speak                                                                   
later  in the  presentation. He  briefly  discussed slide  12                                                                   
and added  that NORC was established  75 years ago  and acted                                                                   
as an  independent entity affiliated  with the  University of                                                                   
9:27:14 AM                                                                                                                    
Mr.  Leitz  briefly spoke  to  slide  13 that  listed  NORC's                                                                   
office locations.                                                                                                               
9:27:22 AM                                                                                                                    
Mr. Leitz highlighted slide 14, "Research Areas":                                                                               
     Economics, Markets, and the Workforce                                                                                      
     Education, Training, and Learning                                                                                          
     Global Development                                                                                                         
     Health and Well-Being                                                                                                      
     Society, Media, and Public Affairs                                                                                         
He  noted  the   areas  of  research  NORC   participated  in                                                                   
including health  and well-being,  work related  to Medicaid,                                                                   
health  exchanges, and  private sector  healthcare. He  added                                                                   
that  they had  a variety  of clients  including federal  and                                                                   
state governments as well as private sector businesses.                                                                         
9:27:41 AM                                                                                                                    
Mr. Leitz  addressed slide  15, "About  University of  Alaska                                                                   
Anchorage: ISER":                                                                                                               
     The  Institute of  Social and  Economic Research  (ISER)                                                                   
     at the  University of Alaska  Anchorage has been  at the                                                                   
     forefront of  public policy research in Alaska  for more                                                                   
     than  half  a century.  ISER's  multidisciplinary  staff                                                                   
     studies  virtually all  the major  public policy  issues                                                                   
     Alaska   faces.   That  work   helps   Alaskans   better                                                                   
     understand    the   state's    changing   economy    and                                                                   
     populationand   the  challenges and  opportunities  that                                                                   
     come with change.                                                                                                          
He noted that  NORC has been working closely  with colleagues                                                                   
at the  University of  Alaska Anchorage.  He recognized  that                                                                   
by  working  with   a  team  that  brought   Alaska  specific                                                                   
knowledge   was  very   important  to   ensuring  that   NORC                                                                   
collectively  understood  the  context  and  history  of  the                                                                   
delivery system.  He said  NORC worked  closely with  ISER at                                                                   
UA and Ralph  Townsend (ISER Director) was  present today and                                                                   
available to answer any questions.                                                                                              
9:28:31 AM                                                                                                                    
Mr. Leitz  discussed slide  16, "About  University of  Alaska                                                                   
Anchorage: ICHS":                                                                                                               
     Institute  for Circumpolar Health  Studies (ICHS)  is an                                                                   
     applied  health research  institute  within the  College                                                                   
     of  Health  at  UAA.  The  focus  of  the  Institute  is                                                                   
     applied  health  research  and  evaluation  relevant  to                                                                   
     Alaskans.  Research  areas  of interest  include  health                                                                   
     disparities,   environmental   health,   rural   health,                                                                   
     healthcare systems, and social determinants of health.                                                                     
He mentioned that ICHS at the University of Alaska                                                                              
Anchorage was another partner that NORC has been working                                                                        
with during the project.                                                                                                        
9:28:54 AM                                                                                                                    
Mr. Leitz addressed slide 17, "Project Overview":                                                                               
     ?   Provide   the   Alaska   Healthcare   Transformation                                                                 
     Project,   Project  Management   Committee  (PMC)   with                                                                   
     objective information to:                                                                                                  
          ? Learn  from what has been done  already in Alaska                                                                 
          via   past   experiments    or   meta-analysis   of                                                                   
          ?  Learn from models,  structures, and  initiatives                                                                 
          in other states, and how to apply in Alaska                                                                           
          ? Understand  the drivers of the spending  and cost                                                                 
          of healthcare in Alaska                                                                                               
     ? Steered by  the PMC's vision, guiding  principles, and                                                                 
     goals, and topic areas of interest                                                                                         
He stated  that NORC was  selected to provide  the Healthcare                                                                   
Transformation  Project  with objective  information  related                                                                   
to  the  four main  themes  or  scopes  of work.  He  briefly                                                                   
discussed each point on slide 17.                                                                                               
9:30:12 AM                                                                                                                    
Mr. Leitz described slide 18, "Project Scope":                                                                                  
     ?  Four studies,  each  in response  to  a statement  of                                                                 
     work issued by  the PMC and focused on a  set of guiding                                                                   
     principles and topic areas.                                                                                                
          ?  Meta-Analysis. Identify  and assess  a group  of                                                                 
          Alaska-focused  reports  and  studies  issued  over                                                                   
          the past  decade (2008  to the present)  that focus                                                                   
          on  delivery system  reform related  to the  triple                                                                   
          aim  of improved health,  improved quality  of care                                                                   
          and  experience with  care  delivery (for  patients                                                                   
          as well  as the healthcare workforce),  and reduced                                                                   
          per capita costs.                                                                                                     
          ?  Alaska  Historical  Project Scan.  Identify  and                                                                 
          assess    selected     delivery    system    reform                                                                   
          experiments  in Alaska over  the past  decade (2008                                                                   
          to  the present), with  priority to  characterizing                                                                   
          regional innovation within the state.                                                                                 
He highlighted  that there  has been  a lot  of work  done on                                                                   
this issue,  so the  project was  not starting from  scratch.                                                                   
He  explained how  a  meta-analysis  looked across  the  data                                                                   
from  previous   studies  and   reports  and  used   research                                                                   
techniques  to find  common  themes threaded  throughout  the                                                                   
reports.  He said  the second  area of study  was the  Alaska                                                                   
historical  project scan  which  assessed former  experiments                                                                   
performed  in  Alaska,  regionally and  statewide,  to  glean                                                                   
knowledge  and information  to  help build  a more  efficient                                                                   
and effective healthcare system.                                                                                                
9:31:47 AM                                                                                                                    
Mr. Leitz described slide 19, "Project Scope (cont.)":                                                                          
     ? Four proposed studies continued?                                                                                       
          ?   National  Scan.   Develop   case  studies   for                                                                 
          selected   states  where  delivery   system  reform                                                                   
          relevant  to Alaska's five  key topics  of interest                                                                   
          offers lessons for prospective innovation.                                                                            
          ?  Drivers of the  Health Care  Costs and  Spend in                                                                 
          Alaska.  Review health care  spending in  the state                                                                   
          and  the  prospects  and limitations  of  available                                                                   
          data  sources  that  would support  a  fine-grained                                                                   
          analysis   of  cost   drivers  relevant   to  these                                                                   
          reforms.  Based on  this review,  prepare a  set of                                                                   
          estimates  of potential reform-related  savings and                                                                   
          a  draft roadmap with  proposed short-term  (within                                                                   
          one  year) and  long-term steps  that comprise  one                                                                   
          or more pathways to reform.                                                                                           
     ?  Dissemination-related  tasks.  Collaborate  with  the                                                                 
     PMC to  present or support  debriefings on  key findings                                                                   
     and the  roadmap, with  creation of high-impact  summary                                                                   
     materials (issue brief/fact sheet).                                                                                        
He said  NORC was  in the  process of  conducting a  national                                                                   
scan.  Each state  has its  own way  of accomplishing  health                                                                   
reform, so  NORC wanted  to look across  a variety  of states                                                                   
and see where  lessons learned may be applied  to help Alaska                                                                   
move  forward on  this  issue.  He noted  the  final area  of                                                                   
study, the drivers  of healthcare costs and  spend in Alaska.                                                                   
Under this scope  of work, NORC will be  reviewing healthcare                                                                   
spending  in the state  and find  data sources  to support  a                                                                   
more  finely  grained  analysis moving  beyond  cost  drivers                                                                   
relevant to  some of the reforms.  He said NORC would  do its                                                                   
best  to prepare  a  set of  estimates  on potential  reform-                                                                   
related savings  and develop a  draft roadmap that  will give                                                                   
logical next  steps for  health reform  in Alaska.  NORC will                                                                   
also  prepare several  materials that  will disseminate  some                                                                   
of the findings more broadly across the state.                                                                                  
9:32:59 AM                                                                                                                    
Mr. Leitz discussed slide 20, "Topic Areas of Focus":                                                                           
     Increasing primary care utilization                                                                                        
     Coordinating patient care                                                                                                  
     Changing the way healthcare is paid for in Alaska                                                                          
     Increasing data analytics capacity                                                                                         
     Addressing social determinants of health                                                                                   
He  noted  that   the  Project  Management   Committee  (PMC)                                                                   
identified five  areas of focus  that were key  components in                                                                   
achieving a successful reform system.                                                                                           
9:34:01 AM                                                                                                                    
Mr. Leitz discussed slide 21, "Timeline":                                                                                       
He said  the first  meeting was held  in November  2018 which                                                                   
involved  in-person visits  and an opportunity  to meet  with                                                                   
the PMC  to learn  more details about  the project.  He noted                                                                   
that   NORC's  work   began   with  the   meta-analysis   and                                                                   
historical scan  reports that were submitted and  reviewed in                                                                   
February 2019.  He said that  by March  2019, a draft  of the                                                                   
national scan  report and  cost report  would be reviewed  by                                                                   
the  PMC. A  final national  scan report,  based on  feedback                                                                   
from the  PMC, would be  completed by  the end of  March. The                                                                   
cost report  would be  reviewed in  April and then  finalized                                                                   
in May.  He said that the  final roadmap and report  would be                                                                   
finished in June, 2019.                                                                                                         
9:35:28 AM                                                                                                                    
Mr.   Leitz  discussed   slide  22,   "Overview  of   Project                                                                   
He noted  that the  historical project  scan and the  studies                                                                   
meta-analysis  were  important  first products  submitted  to                                                                   
the Project Management  Committee. Those reports  support the                                                                   
ongoing analysis  of what drives  healthcare costs  and spend                                                                   
as well  as provide  relevant elements  of the national  scan                                                                   
regarding Alaska.                                                                                                               
9:36:10 AM                                                                                                                    
Mr. Leitz addressed slide 24, "Meta-Analysis: Methods":                                                                         
     ?  Conduct  a systematic  review  to  identify  relevant                                                                 
     peer-reviewed and grey literature;                                                                                         
     ?  Extract  and  compile  quantitative  and  qualitative                                                                 
     data in a database; and                                                                                                    
     ? Develop  a report  that explores commonalities  across                                                                 
     the  identified reports  and studies,  analysis of  gaps                                                                   
     in  understanding   related  to  limitations   of  these                                                                   
     documents,  themes  that characterize  available  public                                                                   
     comments,  and a  summary of  policy, programmatic,  and                                                                   
     system redesign changes based on our review.                                                                               
He noted that  he would briefly discuss the  methodology that                                                                   
NORC  used  to produce  the  study  results within  the  four                                                                   
scopes  of work.  After,  he would  ask  his colleague  Lynne                                                                   
Synder  to  help  him  discuss  the  findings  of  the  meta-                                                                   
analysis  and historical  scan. He highlighted  that  as seen                                                                   
from  the  previous  timeline,  the  national  scan  and  the                                                                   
healthcare  costs and  spending  reports  were not  complete,                                                                   
but he would give a flavor of what they were looking at.                                                                        
He reiterated that  a meta-analysis was taking  a deeper look                                                                   
at  the  reports  that  have  been  produced  in  the  state,                                                                   
whether  in  peer  review journals  or  grey  literature.  He                                                                   
explained  that an example  of grey  literature was  a report                                                                   
produced  by a foundation,  the legislature  or state  agency                                                                   
that  was related  to  the healthcare  system  in Alaska.  He                                                                   
said  that  NORC  conducted  a  systematic  review  of  those                                                                   
reports   and  extracted   and   complied  quantitative   and                                                                   
qualitative   information   across    those   reports.   They                                                                   
developed  a report  that explored  the commonalities  within                                                                   
all  the   reports,  analyzed   the  gaps   in  the   current                                                                   
healthcare  system,   and  characterized  themes   that  keep                                                                   
reoccurring across the system and reports which gave                                                                            
insight on where to start with the reform process.                                                                              
9:37:53 AM                                                                                                                    
Mr. Leitz noted slide 25, "Meta-Analysis: Methods":                                                                             
     ?   Systematically  searched   peer-reviewed  and   grey                                                                 
     literature   for   Alaska-based  reports   and   studies                                                                   
     related to five topic areas                                                                                                
     ? Submitted  list of reports and studies  on November 5,                                                                 
     ? Developed database of reports and studies                                                                              
     ? Identified key themes from reports and studies                                                                         
     ?  Developed  final  report, submitted  on  February  7,                                                                 
9:38:30 AM                                                                                                                    
Mr. Leitz discussed slide 27, "Alaska Historical Project                                                                        
Scan: Methods":                                                                                                                 
     ?  Refine  a definition  of  health  reform  experiment,                                                                 
     services,  and outcomes to  guide scan of  reforms since                                                                   
     ?  Gather  and  analyze  qualitative  data  on  selected                                                                 
     ?  Develop a  report that  identifies regional  patterns                                                                 
     and gaps in  experiments across the topics  of interest,                                                                   
     compares   experiment   features   and   outcomes,   and                                                                   
     presents  conclusions  regarding  policy,  programmatic,                                                                   
     and system design recommendations for Alaska.                                                                              
9:39:02 AM                                                                                                                    
Mr. Leitz discussed slide 28, "Alaska Historical Project                                                                        
Scan: Methods":                                                                                                                 
     ? Identified  Alaska-based  experiments, focused  on the                                                                 
     five topic areas                                                                                                           
    ? Submitted list of experiments on November 5, 2018                                                                       
     ?   Searched   peer-reviewed    and   grey   literature,                                                                 
     including newspapers                                                                                                       
     ? Conducted interviews with stakeholders                                                                                 
     ? Organized information on the experiments                                                                               
     ? Submitted final report on February 7, 2019                                                                             
He said  that the PMC provided  feedback to NORC on  the list                                                                   
of experiments and  reduced it to approximately  11 different                                                                   
experiments  to  focus  on.  NORC   preformed  an  exhaustive                                                                   
review  of any  peer review  and  grey literature,  including                                                                   
newspapers,  to gain  more information  on the  effectiveness                                                                   
of those experiments and how well they worked in Alaska.                                                                        
Mr. Leitz discussed slide 30, "National Scan: Methods":                                                                         
     ? Develop a  list of states involved in  relevant health                                                                 
     reform models to inform in-depth analysis;                                                                                 
     ?  Gather  and  analyze   data  on  relevant  models  in                                                                 
     selected  states,  especially   those  with  all  payers                                                                   
     claims databases; and                                                                                                      
     ?  Develop a  report  that systematically  analyzes  and                                                                 
     compares  the  state health  reform  models,  identifies                                                                   
     what is known  about model results related  to costs and                                                                   
     other  outcomes,  and  presents   conclusions  regarding                                                                   
     policy,     programmatic,      and     system     design                                                                   
     recommendations for Alaska.                                                                                                
     Draft Report: March 1, 2019                                                                                                
     Final Report: March 29, 2019                                                                                               
9:40:58 AM                                                                                                                    
Mr. Leitz  discussed slide 31,  "National Scan:  Case Studies                                                                   
     ? State Characteristics                                                                                                  
     ? History of and Impetus for Health Reform                                                                               
     ?  Overview  and  Implementation  of the  Health  Reform                                                                 
     ? Details and Mechanics of Initiative                                                                                    
     ? Incorporation of Social Determinants of Health                                                                         
     ? HIT, Data Analytics, All-Payers Claim Database                                                                         
     ? Results, Lessons Learned, Next Steps                                                                                   
     ? Considerations for Alaska                                                                                              
He mentioned  that slide 31 showed  a list of what  the seven                                                                   
case studies would include.                                                                                                     
He briefly referred  to slide 32 which depicted  a map of the                                                                   
United  States   and  listed  the  seven  states   that  were                                                                   
   square4 Arkansas                                                                                                             
   square4 Colorado                                                                                                             
   square4 Maryland                                                                                                             
   square4 New Mexico                                                                                                           
   square4 North Carolina                                                                                                       
   square4 Oregon                                                                                                               
   square4 Washington                                                                                                           
9:42:11 AM                                                                                                                    
Mr. Leitz reviewed slide 33, "National Scan: State Health                                                                       
Reform Approach":                                                                                                               
     ?   Arkansas       Health   Care   Payment   Improvement                                                                 
     ? Colorado  The Colorado Framework                                                                                       
     ?   Maryland      All-Payer   Rate-setting  System   for                                                                 
     Hospital Services                                                                                                          
     ?  New Mexico     Centennial Care  and  Medicaid-related                                                                 
     reforms and initiatives                                                                                                    
     ? North  Carolina    Medicaid Transformation  and Social                                                                 
     Determinants of Health                                                                                                     
     ? Oregon  Oregon Action Plan for Health                                                                                  
     ? Washington  Healthier Washington                                                                                       
He noted  that slide 33  listed the specific  reforms studied                                                                   
for  each   state.  He   stated  that   NORC  was   asked  to                                                                   
investigate  these  reforms  and   then  see  how  they  were                                                                   
relevant to Alaska.                                                                                                             
9:42:50 AM                                                                                                                    
Mr. Leitz discussed slide 35, "Spend and Cost of                                                                                
Healthcare: Methods":                                                                                                           
     1) Review of Spending and Data                                                                                             
     ? Prepare  a review of  health care spending  in Alaska,                                                                 
             Identifying  gaps  in data  source  availability                                                                   
          that constrain a comprehensive accounting;                                                                            
            Identify  sources of  additional data  to address                                                                   
     2) Summarize  extant knowledge  on potential  sources of                                                                   
     cost savings;                                                                                                              
          ?  integrate  findings from  all  project tasks  to                                                                 
          understand   constraints   to   implementation   of                                                                   
          reforms in Alaska                                                                                                     
          ?  make considerations  regarding policy,  program,                                                                 
          and system redesign in the state;                                                                                     
     ? Develop  a report  that presents  a draft roadmap  for                                                                 
     possible  pathways   to  reform  in   Alaska,  including                                                                   
     recommendations for both short- and long-term steps.                                                                       
     ?   Revise   roadmap   and   disseminate   findings   in                                                                 
     coordination with  the PMC, incorporating  feedback from                                                                   
     the Steering Committee.                                                                                                    
     ? Final Report, May 2019                                                                                                 
He  said that  the methodology  for  the scope  of spend  and                                                                   
cost of  healthcare had  two work streams.  The first  was to                                                                   
review  available  data  pertaining   to  spending  and  cost                                                                   
within Alaska.  The second was  to summarize what  is already                                                                   
known on the potential sources of cost savings.                                                                                 
(He skipped slide 36)                                                                                                           
9:44:48 AM                                                                                                                    
Mr.  Leitz  reviewed slide  37,  "Alaska  Spend and  Cost  of                                                                   
Health  Care:  Revision  of  Roadmap   and  Dissemination  of                                                                   
    ? Meet with PMC to review draft report and roadmap                                                                        
     ?  Upon  PMC  approval,   coordinate  with  the  PMC  to                                                                 
     solicit  feedback from  the  strategic development  team                                                                   
     and convening groups                                                                                                       
     ? Iterative process with PMC to develop final report                                                                     
     ? In-person and virtual working visits                                                                                   
     ?   Create   high-impact,    visually-oriented   summary                                                                 
     materials (fact                                                                                                            
     sheet/short  issue  brief)   and  materials  to  support                                                                   
     debriefings that                                                                                                           
     PMC would schedule                                                                                                         
     ? Potential Follow-on steps:                                                                                             
          ? Survey payers to understand what data exist and                                                                   
          can be obtained for improved study on payment                                                                         
          ? Obtain and analyze data to further understand                                                                     
          cost drivers                                                                                                          
          ? Engage stakeholders in structured process to                                                                      
          refine analyses and generate recommendations;                                                                         
He  explained   that  even   though  producing   reports  was                                                                   
informative,   the  goal   of   the  roadmap   was  to   take                                                                   
information  and figure  out how  to best  implement it.  The                                                                   
roadmap  would  be based  on  the  four  scopes of  work  and                                                                   
through  an  iterative  process   between  NORC  and  PMC,  a                                                                   
roadmap will be  developed that has concrete  information for                                                                   
moving forward.                                                                                                                 
He said  that this was a  broad overview of the  project, but                                                                   
he wanted to  discuss the two reports that  were submitted to                                                                   
the  PMC  last  week concerning  the  meta-analysis  and  the                                                                   
historical  project scan.  He said Dr.  Snyder would  discuss                                                                   
the remaining slides.                                                                                                           
9:46:20 AM                                                                                                                    
LYNNE SNYDER,  PH.D., PRINCIPAL  RESEARCH SCIENTIST,  NORC AT                                                                   
THE  UNIVERSITY OF  CHICAGO (via  teleconference),  displayed                                                                   
slide 39, "Meta-Analysis: Methods":                                                                                             
    ? Reviewed 75+ reports related to five topic areas                                                                        
     ? Analyzed information by:                                                                                               
          ? Topic Area                                                                                                        
          ? Geography                                                                                                         
          ? Population                                                                                                        
          ? Payer                                                                                                             
          ? Service                                                                                                           
She   introduced  herself   and   mentioned   her  areas   of                                                                   
expertise. She discussed  how the meta-analysis  began with a                                                                   
long list  of studies  and reports  that have been  published                                                                   
in  the last  decade dealing  with health  reform in  Alaska.                                                                   
Nearly   300  reports   were   identified   for  the   social                                                                   
determinants  of health  section alone.  She stated that  the                                                                   
NORC  team divided  into  three groups  and  began the  meta-                                                                   
analysis process.                                                                                                               
   • ICER analyzed the payment reform and data analytics                                                                        
   • ICHS (Institute for Circumpolar Health Studies)                                                                            
     analyzed the social determinants of health                                                                                 
   • NORC analyzed the primary care utilization and                                                                             
     coordinated care (primary and coordinated care were                                                                        
     merged into one discussion)                                                                                                
She stated  that the three  teams tailored their  approach to                                                                   
data collection  and analysis  to reflect the  different ways                                                                   
in which studies  and reports were presented  for each topic.                                                                   
She  said  a narrative  was  developed  to explain  what  the                                                                   
teams learned about the five topics.                                                                                            
9:48:28 AM                                                                                                                    
She  explained that  NORC took  two  approaches to  interpret                                                                   
the  findings. For  the  topics  of primary  and  coordinated                                                                   
care  and  the  social  determinants   of  health.  A  matrix                                                                   
synthesized   key   finding  by   theme   including   region,                                                                   
population, or  a certain social determinant  like addiction.                                                                   
She added that  there was a draft of considerations  for data                                                                   
analytics  and payment  reform  that was  statewide in  scope                                                                   
and related  to public  or commercial  payers. She  explained                                                                   
that along  with the report,  NORC submitted  a free-standing                                                                   
appendix (available  in Excel and Word) of  the meta-analysis                                                                   
findings  that  noted  the  objectives  reach  report,  study                                                                   
design,   population   served   and  payer,   data   sources,                                                                   
conclusions,   and,   where  available,   information   about                                                                   
9:49:33 AM                                                                                                                    
Ms. Snyder highlighted slide 40, "Meta-Analysis: Summary":                                                                      
     ? Primary Care/Coordinated Care                                                                                          
          ? Promising models (evaluation): patient-centered                                                                   
      medical home, improved screening, telehealth &                                                                            
          ECHO    (specialty    co-management),    behavioral                                                                   
          health, CCI ED diversion program, Strong Start                                                                        
          for Mothers (national evaluation)                                                                                     
     ? Data Analytics:                                                                                                        
          ? Available data sources: CMS, commercial,                                                                          
          private; prospects for APCD                                                                                           
          ? Approaches to regional analysis                                                                                   
     ? Payment Reform                                                                                                         
          ? Cost-shifting (state to federal)                                                                                  
          ? Movement from fee-for-service toward value-                                                                       
          based purchasing: managed care, capitation                                                                            
          ? Challenge of low-volume, aligning payers                                                                          
          ? Promising models: bundled care, FQHC Advanced                                                                     
          Primary Care (national evaluation)                                                                                    
     ? Social Determinants of Health                                                                                          
          ? Landscape of needs                                                                                                
      ? Promising models (evaluation): Housing First                                                                          
She   noted   that   information    found   through   program                                                                   
evaluations  and  peer  review publications  on  primary  and                                                                   
coordinated care  was very limited.  She said that  there was                                                                   
more information  about what Alaska  needed in  health reform                                                                   
than  what actually  worked. Most  of the  reform data  since                                                                   
2008  was  unevaluated.  She said  39  reports  were  studied                                                                   
relating  to primary  and coordinated  care and  16 of  those                                                                   
reports were peer  review journal articles and  the rest were                                                                   
grey  literature.   She  listed  the  promising   models  for                                                                   
primary and coordinated care.                                                                                                   
        o The  Nuka  System  of  Care  and  similar  patient-                                                                   
          centered medical home models                                                                                          
        o Screening   to   improve  prevention   of   chronic                                                                   
        o Telehealth  delivery  of services  that extend  the                                                                   
          reach of primary and specialty care and support                                                                       
          providers in the field (for example, through the                                                                      
          ECHO model of specialty co-management)                                                                                
        o Integration   of   behavioral    health   that   is                                                                   
          preceding with the recent section of the 1115                                                                         
        o The   diversion   of    patients   from   emergency                                                                   
          department visits and into primary care through                                                                       
          Medicaid's Coordinated Care Initiatives                                                                               
        o Sharing  of  electronic health  record  information                                                                   
          across emergency departments                                                                                          
        o Improved  maternal  and  child health  through  the                                                                   
          Strong Start for Mothers initiative                                                                                   
She  noted that  the reports  and studies  reviewed for  this                                                                   
project  included  reform  in   both  tribal  and  non-tribal                                                                   
delivery  systems. Reform  within the  Department of  Defense                                                                   
and  Veterans   Administration  delivery  systems   were  not                                                                   
within the scope this study.                                                                                                    
She emphasized  that for  data analytics,  there was  a focus                                                                   
on  healthcare cost  rather than  data  concerning access  to                                                                   
care  or quality  of care.  She  noted that  the report  gave                                                                   
considerations  for working  with cost  data, for  conducting                                                                   
regional   analysis  of   costs,   and   for  exploring   the                                                                   
feasibility  of an all  payers claims  database (APCD)  which                                                                   
would enable  analysis  of utilization  and costs by  drawing                                                                   
on claims of  multiple payers. The report describes  key data                                                                   
sources that  were used to  analyze current healthcare  costs                                                                   
which included:                                                                                                                 
        o The center for Medicare and Medicaid services                                                                         
        o Medicare research files                                                                                               
        o The center's  national health expenditure  accounts                                                                   
         that allow for comparisons across states                                                                               
        o Three  national  and   commercial  insurance  claim                                                                   
        o Alaska state datasets that enable analysis of                                                                         
          cost as well as provider behavior and decisions                                                                       
9:52:18 AM                                                                                                                    
She noted that  a review of major payment  reform initiatives                                                                   
in  the  last  decade  were  included   in  the  report.  The                                                                   
discussions  focused   on  recent  developments   related  to                                                                   
pricing   transparency,   regulation  of   pharmacy   benefit                                                                   
managers and of  insurance reimbursement. She  said there was                                                                   
a trend  of reduced  spending accomplished  by cost  shifting                                                                   
from state  to federal  government. The  key example  was the                                                                   
reinsurance  of the  health insurance  marketplace under  the                                                                   
section 1332 waiver.  There is some movement  from a fee-for-                                                                   
service format  toward value-based  purchasing with  interest                                                                   
in  Anchorage's  upcoming  united   health  demonstration  of                                                                   
Medicaid   managed   care   health  plan.   She   noted   the                                                                   
considerable challenges to reform in Alaska:                                                                                    
        o Fragmented delivery systems                                                                                           
        o The small number of commercial payers                                                                                 
        o The low volume outside of Anchorage and Southeast                                                                     
       o The result in difficulty in aligning payers                                                                            
She  added  that  under  Senate  Bill  74,  there  were  some                                                                   
promising  models   supported  by  federal   one-time  grants                                                                   
including  multiple  initiatives   of  bundled  payments  for                                                                   
episodes of  care as well  as the federally  qualified health                                                                   
center advanced primary care model.                                                                                             
She  stated that  for  the topic  of  social determinants  of                                                                   
health  there  was   a  focus  on  needs  assessment   and  a                                                                   
consideration of non-medical influences on health and well-                                                                     
being. She  noted that NORC's  findings aligned to  the goals                                                                   
for health  set out by the  Healthy Alaskans  2020 initiative                                                                   
due  to its  broad-based consensus-oriented  process.  NORC's                                                                   
approach  was  to review  the  prior  work  done by  ICHS  to                                                                   
better   understand   the   health   influences   that   were                                                                   
meaningful to  Alaska's residents. She highlighted  that this                                                                   
revisioning  of social determinants  emphasized what  factors                                                                   
were  impacting   Alaskan's  health.  The   teams  considered                                                                   
factors  on  an  individual  level such  as  age  and  ethnic                                                                   
identity  as well  as those  related  to individual  behavior                                                                   
such  as  addiction  and  diet/exercise/nutrition   and  then                                                                   
considered   factors   related    to   social   relationships                                                                   
specifically  concerning  Alaska's  high  suicide  rates  and                                                                   
trauma  and how  each of  these  impact the  need for  health                                                                   
services. She noted  that their scale identifies  a number of                                                                   
factors  on the  neighborhood,  community,  region and  state                                                                   
level   that   are  uniquely   impacting   Alaskan's   health                                                                   
including access  to clean water and access  to communication                                                                   
through  broadband and  fiber  optics as  well as  challenges                                                                   
that  are  shared  with  other  states  including  access  to                                                                   
quality  healthcare and  addressing  workforce shortages  (as                                                                   
seen  in other  states  with  large rural  populations).  She                                                                   
added  that   national  and  federal  economic   development,                                                                   
revenue  for  Alaska  programs  that come  from  the  federal                                                                   
government, and  related policies and programs  in healthcare                                                                   
have important influences  on Alaskan's health.  She said the                                                                   
NORC team identified  the number of needs to  be addressed by                                                                   
health  reform  related  to addiction,  trauma  and  suicide,                                                                   
food and water  security, and homelessness. For  example, the                                                                   
Housing   First   reform   demonstration    offers   improved                                                                   
9:56:13 AM                                                                                                                    
Ms. Snyder highlighted  slide 41, "Alaska  Historical Project                                                                   
Scan: Methods":                                                                                                                 
     ? Initial list of 30 health reform experiments ? PMC                                                                   
     identifies 11 for focus                                                                                                    
     ? Literature review to generate supplemental list of                                                                     
     reforms by topic area                                                                                                      
     ? 5 key informant interviews                                                                                             
     ? Analyzed information by:                                                                                               
          ? Topic Area                                                                                                        
          ? Geography                                                                                                         
          ? Population                                                                                                        
          ? Payer                                                                                                             
          ? Service                                                                                                           
She   explained  that   the  historical   project  began   by                                                                   
submitting a list  of 29 reforms that had  taken place within                                                                   
the  last decade.  She  noted  that all  the  Senate Bill  74                                                                   
experiments and  pilot programs  were considered  one reform.                                                                   
She  stated the  PMC advised  the  NORC team  to focus  their                                                                   
research  on  11  of  the  29  reforms.  She  said  that  the                                                                   
research identified  a larger  supplemental group  of reforms                                                                   
(almost 100)  in each topic  area which  was used to  fill in                                                                   
the  gaps on  understanding the  meaning of  reform for  each                                                                   
topic. She  added that they conducted  a small number  of key                                                                   
informant  interviews  and reviewed  state  specific data  of                                                                   
healthcare  prior to  2008 to  provide  background on  health                                                                   
reform in Alaska.                                                                                                               
She  explained  how  the  report  considers  the  set  of  11                                                                   
reforms  in  multiple  ways,  including  trends  in  Alaska's                                                                   
health since  the era  of hospital/clinic  buildings  and the                                                                   
population  growth that  began during  World War II.  Reforms                                                                   
to  address  workforce  shortages, to  bridge  Alaska's  long                                                                   
distances and  to assert self-determination and  autonomy are                                                                   
all  enduring  themes  in the  state's  health  history.  She                                                                   
stated  how these  themes  better explain  why  Alaska has  a                                                                   
complex  payer  environment and  multiple  delivery  systems.                                                                   
She said  that with  the limited  evidence available  for any                                                                   
one  reform, an  analysis of  a  group allowed  NORC to  make                                                                   
preliminary  observations about  trends. The report  includes                                                                   
a short  profile for each of  the 11 reforms and  an appendix                                                                   
highlighting  what could be  learned about experiment  goals,                                                                   
current status, results and lessons learned.                                                                                    
She  highlighted how  four reforms  were  statewide in  scope                                                                   
with three relating  to the Medicaid program  and one related                                                                   
to  capacity building  for  providers.  Another four  reforms                                                                   
are  located  in  and around  Anchorage  and  Mat-Su  Borough                                                                   
including  the Southcentral  Foundation Nuka  System of  Care                                                                   
and three demonstrations  funded by the Centers  for Medicare                                                                   
and  Medicaid Services  (CMS).  She  added that  two  reforms                                                                   
were located  in Southeast  Alaska, but  none of the  reforms                                                                   
were in  the northern or interior  regions of the  state. She                                                                   
said that  in terms of leadership,  most reforms were  led by                                                                   
tribal health  organizations or by providers  under agreement                                                                   
with  state agencies.  She stated  that  reform funding  came                                                                   
mostly from  federal entities  like the Centers  for Medicaid                                                                   
and Medicare services.                                                                                                          
She  discussed   how  population  reform   targeted  Medicaid                                                                   
enrollees, beneficiaries  of the Medicare program  and Native                                                                   
Alaskan residents.  She said that  validation was  lacking in                                                                   
terms of outcomes  of documented reforms. She  noted the team                                                                   
identified  program evaluations  or peer review  publications                                                                   
specific to  Alaska for six of  the 11 initiatives.  She said                                                                   
the  Southcentral  Foundation for  the  Nuka System  of  Care                                                                   
offered  the most  evidence of  effectiveness while  evidence                                                                   
of  other  reforms   was  limited  yet   promising.  Positive                                                                   
findings  are seen for  the complex  behavior initiative  and                                                                   
the  coordinated  care initiative  emergency  room  diversion                                                                   
program. She  said the Kodiak  Area Native Association's  use                                                                   
of electronic clinical  reminders have been shown  to improve                                                                   
screening  rates  for  preventive care  and  the  PeaceHealth                                                                   
Ketchikan  care   coordination  pilot  was   associated  with                                                                   
improved care processes for diabetes.                                                                                           
She  said  national  evaluation  findings  include  data  for                                                                   
Alaska  sites  for  three  reforms   including  the  advanced                                                                   
primary  care  practice demonstrations  for  health  clinics,                                                                   
bundled payments  for care improvement  and the  Strong Start                                                                   
Program for  Mothers and  Newborns. However,  generalizations                                                                   
from  national findings  to  local  sites were  unclear.  She                                                                   
highlighted  how the  pace of  reforms has  increased due  to                                                                   
Senate Bill  74 but  there were  many gaps concerning  topics                                                                   
of reform  because  regions, populations,  and outcomes  were                                                                   
not  included in  the  list of  11 reforms  (or  even in  the                                                                   
broader list  of 104). She added  that NORC did  not identify                                                                   
reforms related to  dental or vision care,  access to durable                                                                   
medical   equipment,  or   anything   related  to   long-term                                                                   
services  and  reports.  Reforms  are  limited  in  terms  of                                                                   
tested  payment models  and  delivery  system changes  listed                                                                   
outside of primary care, she said.                                                                                              
10:01:45 AM                                                                                                                   
Ms.  Snyder discussed  slide 42,  "Alaska Historical  Project                                                                   
Scan: Findings by Topic":                                                                                                       
     ? Primary Care Utilization and Coordinated Care                                                                          
          ? Patient-Centered Medical Home Models                                                                              
          ? Behavioral Health Integration with Primary Care                                                                   
          ? Emergency Department Utilization                                                                                  
          ? Care Coordination Systems                                                                                         
          ? Clinic-Based Reforms                                                                                              
     ? Payment Reform                                                                                                         
          ? State-wide payment reform tied to delivery                                                                        
          system reform                                                                                                         
          ? VBP: bundled payment models                                                                                       
     ? Data Analytics                                                                                                         
          ? Electronic health records                                                                                         
          ? Telemedicine                                                                                                      
         ? Data analytics to support care delivery                                                                            
She stated  that both the  meta-analysis and  history reports                                                                   
gave  similar  considerations  for further  work  related  to                                                                   
policy and programmatic  reforms and delivery  system change.                                                                   
In terms  of short-term and  long-term policy  changes, there                                                                   
are some recommendations for the next two reports.                                                                              
        o First is to build on the historical experience of                                                                     
          Alaska's  public  officials and  stakeholders  with                                                                   
          multi-sector  planning   coalitions  to  bring  all                                                                   
          parties to the table.                                                                                                 
        o Second is to continue to tap the comprehensive                                                                        
          set   of   recommendations  around   primary   care                                                                   
          developed  by the  Health Care  Commission and  use                                                                   
          it  as  a  launching  point.  It  is  important  to                                                                   
          acknowledge  that the  patient center medical  home                                                                   
          model, as  a delivery system approach,  may be tied                                                                   
          to   different   payment   reforms  and   may   not                                                                   
          necessarily  yield  substantial  cost  savings  but                                                                   
          there  may be improved  access to care  and quality                                                                   
          of care.                                                                                                              
        o Third is the importance of continued investment                                                                       
          in  communication  and   transportation  strategies                                                                   
          that  bridge Alaska's distances  and invest  in the                                                                   
          state's own  ability to deliver healthcare  for its                                                                   
          residents (for primary and specialty care).                                                                           
She  stated  that  regarding  programmatic  changes,  it  was                                                                   
important   to  identify  and   adopt  nationally   validated                                                                   
performance  measures  that  would be  meaningful  to  health                                                                   
reform in  Alaska while supporting  the state's  current data                                                                   
systems. She  added that  it was  important to consider  what                                                                   
measure of  access and  quality of  care were most  important                                                                   
for  reform to  expand considerations  beyond  that of  cost.                                                                   
She explained  that in terms  of system redesign  changes, it                                                                   
was  important to  acknowledge  the defining  characteristics                                                                   
of  healthcare delivery  in  the  state which  included  deep                                                                   
orientation towards  fee-for-service reimbursement.  She said                                                                   
a  lot can  be done  within a  fee-for-service  reimbursement                                                                   
framework. She  highlighted the importance of  respecting the                                                                   
powerful   dynamic   between    federal   and   state   level                                                                   
organizations and  a pull toward  local autonomy.  She stated                                                                   
it was important  to continue to realign  Medicaid purchasing                                                                   
with  federal reform  opportunities  through wavier  programs                                                                   
as  well  as  support  greater   coordination  across  health                                                                   
services   delivery   and   social    services   to   address                                                                   
contributions  of social  determinants of  health to  adverse                                                                   
health   outcomes.  She   thanked  the   committee  and   her                                                                   
colleagues  for  the  opportunity  to  present  some  of  the                                                                   
findings from the study.                                                                                                        
10:05:05 AM                                                                                                                   
Mr. Leitz thanked  the committee. He said this  concluded the                                                                   
presentation from NORC.                                                                                                         
10:05:14 AM                                                                                                                   
Ms. Heffern noted  that the Project Management  Committee was                                                                   
still evaluating  the two reports. They will  be available on                                                                   
their website which  is listed on the last  slide (slide 43).                                                                   
She highlighted  that NORC would  complete two  other reports                                                                   
regarding  the   national  scan   and  would  bring   forward                                                                   
recommendations  about the reform  structure that  has worked                                                                   
in  other   states.  The   cost  drivers   and  spending   on                                                                   
healthcare  in Alaska  will also  be a  topic of  discussion.                                                                   
She said  that from June  till the end  of the year,  the PMC                                                                   
will  work  on  an  implementation  plan  that  will  include                                                                   
policy  recommendations that  will  be brought  to the  state                                                                   
administration, the  legislature and the  federal delegation.                                                                   
She opined  that implementing some  of the reforms  that come                                                                   
out of this  project could use federal help.  She thanked the                                                                   
committee  the invitation  to present  this information.  She                                                                   
noted that the  process of a cross sector  collaboration like                                                                   
this project  takes a  long time.  She assured the  committee                                                                   
that the Healthcare  Transformation team was  being proactive                                                                   
in  addressing  the  cost  of   healthcare  in  Alaska  while                                                                   
looking at quality and access of healthcare.                                                                                    
10:08:04 AM                                                                                                                   
Senator  Hoffman noted  that many of  the communities  spread                                                                   
across Alaska  have limited  access to  healthcare. He  asked                                                                   
why   the   adequacies   and   efficiencies   of   healthcare                                                                   
facilities  in  rural  Alaska  were  not  addressed  in  this                                                                   
10:09:15 AM                                                                                                                   
Ms.  Heffern  answered   that  she  agrees  that   access  to                                                                   
healthcare  is issue  of concern  in Alaska.  She noted  that                                                                   
looking  at  the  capacity  of   what  was  available  within                                                                   
individual communities  was beyond the scope of  the project,                                                                   
but it may be  a topic discussed in the next  phase. She said                                                                   
the  current focus  was  to look  at  the overall  healthcare                                                                   
system  and note  where  the gaps  and  cost  drivers are  in                                                                   
order to  assess what policy decisions  need to be  made. She                                                                   
opined   that   if  access   to   healthcare   within   rural                                                                   
communities was addressed,  it would need to  move forward as                                                                   
a policy decision and include the cost.                                                                                         
10:10:12 AM                                                                                                                   
Senator Hoffman said  it was critical for Alaskans  in remote                                                                   
areas  to have  access  to  adequate healthcare  and  without                                                                   
access  it  would  be impossible  to  improve  healthcare  in                                                                   
Alaska.  He said that  a vast  hole was  created within  this                                                                   
review because the topic was not addressed.                                                                                     
10:10:45 AM                                                                                                                   
Co-Chair von Imhof  highlighted that Alaska is  unique due to                                                                   
its vast  geography, lack  of connected  road systems,  and a                                                                   
relatively  small population.  She commented  that there  was                                                                   
limited  healthcare access  even in Anchorage  in some  areas                                                                   
such as a burn  unit treatment or of a deep  brain tumor. She                                                                   
opined  that Alaska  may never  solve  certain issues  around                                                                   
this  topic because  of the  population  and geographic  size                                                                   
but  it  should be  a  topic  of discussion  to  decide  what                                                                   
Alaskans are willing to accept.                                                                                                 
10:12:10 AM                                                                                                                   
Senator  Micciche pointed  out the  seven states  highlighted                                                                   
on page 32 and  assumed they were not the result  of a random                                                                   
draw. He  asked why those seven  states were selected  and if                                                                   
there  was a  specific  state  (from that  list)  that had  a                                                                   
higher level  of success with  health reform or if  they were                                                                   
all at different stages of improvement.                                                                                         
10:12:45 AM                                                                                                                   
Ms.  Heffern  said  correct,  those  seven  states  were  not                                                                   
randomly  selected. She  noted  that Washington,  Oregon  and                                                                   
Colorado  were selected  because  of  previous  work done  to                                                                   
study  their reforms.  She briefly  stated  reasons why  each                                                                   
state was selected:                                                                                                             
        o Oregon has a coordinated care organization                                                                            
          structure that is bundled payments to each of the                                                                     
          coordinated care organizations.                                                                                       
        o Colorado has a regional collaborative care                                                                            
          organization structure (very similar to Oregon)                                                                       
          done  on a  regional  basis and  doesn't perform  a                                                                   
          shared savings or shared  risk while Oregon does.                                                                     
        o Washington has a very structured managed care                                                                         
          type system and are looking at accountable                                                                            
          communities of health.                                                                                                
        o Arkansas has restructured the health insurance                                                                        
        o New Mexico has a large indigenous population.                                                                         
        o Maryland has a payment structure it has performed                                                                     
          with their hospitals.                                                                                                 
10:14:15 AM                                                                                                                   
Senator  Giessel commented  that there  was effort to  change                                                                   
Alaska's healthcare  system. She opined that  every dollar in                                                                   
the healthcare industry  has a formidable opponent  to change                                                                   
due to  how the current system  makes huge amounts  of money.                                                                   
She  referred  to slide  30  and  asked  which of  the  seven                                                                   
states were  ones with  an all  payers claims database,  what                                                                   
it cost to develop  the database, how long it  took to set up                                                                   
the database, and how useful those databases have been.                                                                         
10:15:08 AM                                                                                                                   
Ms. Heffern  replied that  the spend  and cost report,  which                                                                   
will be  release in May,  will contain that  information. She                                                                   
said  the recommendation  to look  at the  all payers  claims                                                                   
databases  came from  the  healthcare  commission many  years                                                                   
ago.  She  agreed  that  every dollar  in  healthcare  has  a                                                                   
constituent  behind it.  Thus, the  effort to  bring all  the                                                                   
different  perspectives impacted  by health  reform into  the                                                                   
discussion.  These include  Premera,  Atena, Moda,  Medicaid,                                                                   
Medicare,  the union health  trusts, legislators,  Department                                                                   
of   Health   and  Social   Services,   and   Department   of                                                                   
10:17:03 AM                                                                                                                   
Senator Bishop  asked if 68  percent of Alaskans  are insured                                                                   
(slide 7).                                                                                                                      
10:17:23 AM                                                                                                                   
Ms.  Heffern answered  no; 68  percent  of Alaskans  identify                                                                   
that they have a usual source of primary care.                                                                                  
10:17:32 AM                                                                                                                   
Senator Bishop  asked if  that means  30 percent of  Alaskans                                                                   
are not insured.                                                                                                                
10:17:35 AM                                                                                                                   
Ms.  Heffern   replied  that   there  was  a   difference  in                                                                   
identifying  a  usual  source  of  primary  care  and  having                                                                   
health  insurance  coverage.  She  offered  her  belief  that                                                                   
close  to  14   percent  of  Alaskans  do   not  have  health                                                                   
insurance coverage.                                                                                                             
10:18:02 AM                                                                                                                   
Senator Coghill  commented that  he appreciated the  work put                                                                   
into this  project especially  the meta  data. He  noted that                                                                   
he previously  met with the  University of Fairbanks  and was                                                                   
pleased  to   find  out  they  were  performing   significant                                                                   
research  on the  social  determinants  and economic  impacts                                                                   
related to Alaskan's health.                                                                                                    
10:19:16 AM                                                                                                                   
Chair Wilson  commented that  he was  looking forward  to the                                                                   
final  reports and  the map being  released.  He said  he was                                                                   
hopeful  that this work  would stimulate  or provide  impetus                                                                   
for action going  forward. He asked what  subcontracting work                                                                   
ISER and  ICHS were  performing  and if their  role was  with                                                                   
just the meta-analysis or throughout the entire project.                                                                        
10:19:55 AM                                                                                                                   
Mr.  Leitz  replied that  they  were  involved in  the  meta-                                                                   
analysis and  historical scan but  also helped with  the cost                                                                   
and spend  portion of the report.  He stated that  NORC would                                                                   
also work with  ISER and ICHS to analyze the  impacts certain                                                                   
reforms have on overall costs.                                                                                                  
Co-Chair Stedman discussed the next day's agenda.                                                                               
10:21:06 AM                                                                                                                   
The meeting was adjourned at 10:21 a.m.                                                                                         

Document Name Date/Time Subjects
AHTP_LEG Senate_Feb 2019_FINAL.pptx SHSS 2/11/2019 9:00:00 AM
Alaska Health Care Transformation Project