ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  February 8, 2011 3:04 p.m. MEMBERS PRESENT Representative Wes Keller, Chair Representative Alan Dick, Vice Chair Representative Bob Herron Representative Paul Seaton Representative Sharon Cissna Representative Bob Miller Representative Charisse Millett MEMBERS ABSENT  All members present COMMITTEE CALENDAR  PRESENTATION(S): CHILDREN'S JUSTICE ACT TASK FORCE - HEARD ALASKA HEALTH CARE COMMISSION - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER DR. CATHY BALDWIN-JOHNSON, Chair Alaska Children's Justice Act Task Force Anchorage, Alaska POSITION STATEMENT: Presented a PowerPoint, "Alaska Children's Justice Act Task Force." JARED PARRISH, Director Alaska Surveillance of Child Abuse & Neglect (SCAN) Division of Public Health Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Testified and answered questions during the PowerPoint, "Alaska Children's Justice Act Task Force." DEBORAH ERICKSON, Executive Director Alaska Health Care Commission Office of the Commissioner Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Presented a PowerPoint, "Alaska Health Care Commission's 2010 Report." DR. WARD HURLBURT, Chief Medical Officer/Director Division of Public Health Central Office Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Testified and answered questions during the overview of the Alaska Health Care Commission's 2010 Report. ACTION NARRATIVE 3:04:40 PM CHAIR WES KELLER called the House Health and Social Services Standing Committee meeting to order at 3:04 p.m. Representatives Keller, Millett, Miller, Cissna, and Dick were present at the call to order. Representatives Seaton and Herron arrived as the meeting was in progress. ^PRESENTATION(S): Children's Justice Act Task Force PRESENTATION(S): Children's Justice Act Task Force    3:05:19 PM CHAIR KELLER announced that the first order of business would be a presentation by the Children's Justice Act Task Force. 3:05:48 PM DR. CATHY BALDWIN-JOHNSON, Chair, Alaska Children's Justice Act Task Force, presented a PowerPoint, "Alaska Children's Justice Act Task Force." [Included in members' packets.] Pointing to slide 1, "Introduction," she reported that the Task Force had been founded in 1999 to "evaluate how our system responds when there are concerns for child abuse and neglect." She stated that the Task Force mandate was to make recommendations for improvements to the system, and to provide an annual update to the legislature. She declared that the Commission received population based federal funding. DR. BALDWIN-JOHNSON moved on to slide 2, "Update," and indicated that the update included: child maltreatment data in Alaska, gaps in our laws, costs to our state, and the 2010 Task Force projects. 3:07:55 PM DR. BALDWIN-JOHNSON explained slide 3, "Some Issues Identified." She emphasized the rising concerns: an ongoing need for education, the wide variation to interpretation of laws and policies across Alaska, the gaps in our laws, sexual exploitation of children via the Internet, and child sex trafficking in Alaska. 3:08:23 PM REPRESENTATIVE DICK asked her to elaborate on child sex trafficking in Alaska. DR. BALDWIN-JOHNSON replied that minors were being lured into prostitution and sexual activity. REPRESENTATIVE MILLETT asked if there were any statistics. DR. BALDWIN-JOHNSON replied that this was being studied to better understand how large a problem it had become. REPRESENTATIVE MILLETT asked to clarify if these children were runaways, or had a lack of supervision, and how did this happen without parental knowledge. DR. BALDWIN-JOHNSON, in response, indicated there were a number of factors, which included runaways, difficult family situations, and not enough adult supervision. She acknowledged that there was a need to gather much more information. REPRESENTATIVE MILLETT asked if the task force was working in concert with the Office of Children's Services (OCS). 3:10:57 PM DR. BALDWIN-JOHNSON confirmed that a small task force had been established to address the issue, and would be invited to address the legislature. REPRESENTATIVE CISSNA pointed to the growing problems of homeless youth and outmigration from rural Alaska. CHAIR KELLER asked who had identified child trafficking as an issue. DR. BALDWIN-JOHNSON stated that it was identified by people working with Anchorage Police Department and the FBI. 3:13:56 PM REPRESENTATIVE CISSNA opined that the problem was with "not looking after our kids" and she suggested that this be addressed in the "big picture." DR. BALDWIN-JOHNSON, furnishing slide 4, "2010 Projects," listed ongoing distribution of the mandated reporter CD, sponsorship in collaboration with the Alaska Children's Alliance to the 2010 Alaska Child Maltreatment Conference, and scholarships for Alaskans working in the field as ways to address the need for further education. She referenced the link to NETSMARTZ on the task force website, which was an educational site about preventing child sexual exploitation via the internet. She affirmed that the Multidisciplinary Team Guidelines, on the task force website, addressed the wide variation for interpretation on laws and policies. 3:16:37 PM JARED PARRISH, Director, Alaska Surveillance of Child Abuse & Neglect (SCAN), Division of Public Health, Department of Health and Social Services, established that the data was collected by the SCAN program. He directed attention to slide 6, "Public Health Surveillance," and said that this was an important issue for Centers for Disease Control and Prevention (CDC). He noted that, as no single agency had jurisdictional responsibility for all child maltreatment, the public health surveillance was an ongoing collection and unification of the existing data sources. This more comprehensive picture of child maltreatment in Alaska would lead to a standardized public health definition, accounting for areas not covered by jurisdictional regulations, and allowing for measurement of the true magnitude and impact. It would also identify risk and protective factors, and offer recommendations based on the comprehensive data. He shared slide 7, "Case Designation," which defined the tiers of abuse: confirmed, suspected, or potential and the definition for each. 3:19:29 PM MR. PARRISH moved on to slide 9, "Maltreatment-related child deaths," and stated that, from 2000 - 2008, approximately 20 percent of child deaths, 0-9 years of age, were maltreatment related; among Alaska Native children, this increased to 25 percent. He declared that the rates for maltreatment related child deaths were almost 4 times higher for Alaska Native than for non-native. MR. PARRISH supplied slide 11, "Research in Alaska Indicates:" He identified the seven factors statistically related to maltreatment, and noted that 80 percent of maltreated children had two or more of the risk factors. He reported that these risk factors provided targets for prevention funding. 3:21:13 PM MR. PARRISH indicated slide 12, "Maltreatment-Any Type," and clarified that this was sexual abuse, physical abuse, and neglect. He reported: In 2008, approximately 12,400 children were the potential victims of at least one incident of maltreatment. Among the children experiencing maltreatment, 24 percent had at least one incident confirmed. 3:21:47 PM REPRESENTATIVE SEATON requested to return attention to slide 11, and asked for clarification that a family receiving public aid was a greater risk factor than maternal domestic violence or sexual assault. MR. PARRISH replied that these were associative, not causal, indicators. REPRESENTATIVE MILLER asked for an explanation to the headings "aOR" and "95%CI." MR. PARRISH explained that "aOR" was the "adjusted odds ratio" and that "CI" was confidence interval, which reflected the percentage range of confidence for the adjusted odds ratio. 3:23:16 PM MR. PARRISH returned to slide 12, stating that as many as 34 children a day were maltreated in Alaska. MR. PARRISH continued with slide 13, "Maltreatment-Neglect," and stated that, in 2008, "almost 9000 children were the potential victims of at least one incident of neglect. Among the children experiencing neglect, 25 percent had at least one incident confirmed." He emphasized that 25 percent was the "tip of the iceberg." He pointed out that this was as many as 25 children each day. 3:24:55 PM MR. PARRISH provided slide 14, "Maltreatment-Physical Abuse," and stated that "2700 children were the potential victims of at least one incident of physical abuse in 2008. Among the children experiencing physical abuse, 22 percent had at least one incident confirmed." 3:25:17 PM MR. PARRISH, in response to Representative Cissna, said that he would supply a matrix defining maltreatment and neglect. He replied that each agency had a separate definition for neglect. DR. BALDWIN-JOHNSON added that neglect meant a failure to meet a child's basic needs, such as nutritional, medical, emotional, and educational neglect. She noted that neglect did not include abuse, but that maltreatment included both abuse and neglect. 3:27:14 PM MR. PARRISH, returning attention to slide 14, stated that physical abuse could affect as many as seven children each day. MR. PARRISH concluded with slide 15, "Maltreatment-Sexual Abuse," stating: In 2008, almost 2000 children were the potential victims of at least one incident of sexual abuse. Among the children experiencing sexual abuse, 16 percent had at least one incident confirmed. REPRESENTATIVE DICK asked how to define a potential victim. MR. PARRISH defined a potential victim as having at least one incident of sexual abuse. He pointed out that a child could have multiple incidences of sexual abuse each year. 3:28:40 PM DR. BALDWIN-JOHNSON said that confirmed instances were much lower as many times there was not the corroborating evidence to prosecute. 3:29:17 PM REPRESENTATIVE DICK asked for further clarification. DR. BALDWIN-JOHNSON explained that a valid OCS report, or a medical code that identified sexual abuse, defined a potential victim. She shared that a confirmed incident had to go to court. 3:29:52 PM MR. PARRISH stated that potentially five children a day were sexually abused in Alaska. 3:30:21 PM DR. BALDWIN-JOHNSON, indicating slide 16, "Gaps in our laws Abusive Head Trauma," spoke about abusive head trauma and stated that if the child did not die, the highest criminal charge was Assault 1, which had limited penalties. She said that children were included with adults under the physical assault laws. DR. BALDWIN-JOHNSON offered slide 17, "Gaps in our laws Torture," pointing out the difficulty to find charges for the torture of children. DR. BALDWIN-JOHNSON referred to slide 18, "Gaps in our laws," and pointed out that multiple forms of physical abuse to children only result in a charge of Assault 1. DR. BALDWIN-JOHNSON directed attention to slide 19 and slide 20, "Gaps in our laws: sexual abuse," and reported that sexual abuse of a five year old carried the same charge as a 19 year old having consensual sex with a 14 year old. She announced that foster siblings could not be charged with incest or sexual abuse of a minor if there was less than a four year age difference. 3:33:46 PM CHAIR KELLER confirmed that the committee members would deliberate the legislation proposals. 3:34:29 PM DR. BALDWIN-JOHNSON brought attention to slide 21, "What does this cost?" and observed that there were both short and long term costs for medical and mental health care, as well as for the child protection and criminal justice systems. 3:35:05 PM DR. BALDWIN-JOHNSON explained that the Adverse Childhood Experiences Studies, slide 22, "Turning Gold Into Lead," recognized the link between "bad things happening to children and the adults that they become..." She directed attention to the chart on slide 23 which graphed the rising costs in health care. 3:36:04 PM DR. BALDWIN-JOHNSON stated that slide 24, "Direct Annual Costs of Child Abuse & Neglect in the US," revealed costs totaled more than $33 billion. Slide 25, "Indirect Annual Costs," showed that costs for juvenile delinquency and adult criminality exceeded $70 billion. 3:37:01 PM DR. BALDWIN-JOHNSON emphasized this total cost of more than $103 billion, as shown on slide 26, "Total Annual Cost of Child Abuse and Neglect in the US," and shared that the annual cost in Alaska was more than $500 million, as shown on slide 27. DR. BALDWIN-JOHNSON turned to slide 28, "What are we willing to pay to keep kids safe?" She reported on a child maltreatment survey in the state of Georgia which had shown a willingness by each citizen to pay $150 to help reduce the number of deaths from child maltreatment. She asked what Alaskans were willing to pay to keep kids safe. DR. BALDWIN-JOHNSON summarized slide 30, "In Juneau:" and asked for ongoing support for the governor's initiative, "Choose Respect," and to ensure that the related data and program development include children. She summarized slide 31, "In your community," and asked for support to the local Child Advocacy Centers and for support to any child maltreatment prevention programs. 3:38:47 PM DR. BALDWIN-JOHNSON asked the committee for assistance, slide 32, "2011 Alaska CJATF Projects," with legislative support to the Task Force, and with passing laws which hold offenders accountable and prevent future victimization. She endorsed the search for more information on child trafficking and child on- line sexual exploitation. DR. BALDWIN-JOHNSON shared slide 33, "Remember:" and asked that legislators remember: During this legislative session, here in Alaska, about 3000 children are likely going to be maltreated, 450 sexually abused, 630 physically abused, 2200 neglected, and the price tag to our state during this 90 days exceeds $123 million. 3:39:54 PM REPRESENTATIVE DICK asked where to look for a definition of neglect. He asked if this definition could become intrusive into people's private lives, with respect to government imposed immunizations. DR. BALDWIN-JOHNSON replied that refusing immunizations was not a form of neglect in Alaska. She emphasized that the conditions under which some children live in Alaska were appalling. 3:41:07 PM DR. BALDWIN-JOHNSON, in response to Chair Keller, explained that the mandated reporter training CD was developed for statewide distribution, and was also available on the website. REPRESENTATIVE SEATON clarified that the neglect statute was a statewide standard and was not the community standard for a village. 3:43:01 PM REPRESENTATIVE CISSNA reflected that this was now a generational problem, and that kids were not being taken care of. She opined that foster care could not replace the family. 3:45:38 PM DR. BALDWIN-JOHNSON replied that this had been a topic of discussion. She offered her belief that the Office of Children's Services (OCS) was making efforts to keep children safer in their own homes. She agreed that foster care was not usually the first choice, but there may be no other alternative. She opined that the solutions were complicated, as they involved a cultural shift for the value of children, which would be multi-tiered. She confirmed that as more data was uncovered, the risk factors could be better identified, and prevention solutions could be developed. She advocated for better laws to hold people accountable, and to prevent further victimization. 3:48:13 PM REPRESENTATIVE HERRON asked if the Task Force had contacted the administration about proposed legislation. DR. BALDWIN-JOHNSON replied that they had not yet spoken with the administration. 3:48:46 PM CHAIR KELLER declared that the role of government was to take care of the most vulnerable. He challenged the task force to contact HHSS and ask for children's advocates. He requested more information and updates about the child advocacy centers. 3:50:15 PM The committee took a brief at-ease. ^Alaska Health Care Commission Alaska Health Care Commission    3:52:54 PM CHAIR KELLER announced that the final order of business would be a presentation by the Alaska Health Care Commission. DEBORAH ERICKSON, Executive Director, Alaska Health Care Commission, Office of the Commissioner, Department of Health and Social Services, presented a PowerPoint, "Alaska Health Care Commission's 2010 Report." [Included in members' packets] She directed attention to slide 2, "A Brief History of Health Reform Attempts in Alaska," and listed the groups and organizations which addressed these issues. She stated that each had provided findings and recommendations. MS. ERICKSON offered slide 3, a graph of the 1993 legislative task force projections of health care expenditures. She opined that these cost concerns had lead to the establishment of the current Alaska Health Care Commission. She said that 2005 health care expenditures were more than $5.5 billion, and that Institute of Social and Economic Research (ISER) consultants had projected 2010 expenditures to be more than $7 billion. MS. ERICKSON referring to slide 4, "Significance of Health Care to SOA," listed Medicaid expenses to be about $1.4 billion of the $7.3 billion in the state operating budget. The Medicaid expenses were comparable to the entire operating budget of the Department of Education and Early Development, and twice that of the Department of Transportation & Public Facilities. She pointed out that these Medicaid operating expenses did not include other health care expenses incurred by state government. 3:59:19 PM CHAIR KELLER asked about the level of detail in the ISER study. MS. ERICKSON replied that it would show spending for health care by major payers in 2010, and the factors driving the increases in costs. 3:59:47 PM REPRESENTATIVE CISSNA asked if social disparity had been considered. 4:01:01 PM MS. ERICKSON replied that social factors to health care costs would be discussed later. 4:01:35 PM MS. ERICKSON provided slide 5, "Alaska Health Care Commission." She said that the Alaska Health Care Commission was convened under a 2009 administrative order by Governor Palin, and was established in statute in 2010. The bill added four additional voting members to the Commission, and included a transition clause to provide for continuity by retaining the former members. 4:03:42 PM MS. ERICKSON stated, as shown on slide 6, "Alaska Health Care Commission," that the purpose of the Commission was: "to foster the development of a statewide plan to address quality, accessibility and availability of health care for all citizens of the state." The main duties listed in the statute were "for the commission to serve as the state's health planning coordinating body and to foster the development of both the comprehensive state wide health care policy and also a strategy for improving the health of all Alaskans." MS. ERICKSON discussed slide 7, "Membership," and stated that there were 11 voting members designated from the health care industry, the Division of Veterans' Affairs (VA), and consumers. She pointed out that the Chair was the Chief Medical Officer of Department of Health and Social Services. 4:05:11 PM MS. ERICKSON moved on to slide 8, "5-Year Strategic Planning Process," and listed the five parts of the process: develop vision, describe current state, build foundation, design transformation policies, and measure progress. Once the vision was developed, each of the other four parts had an annual goal. 4:06:14 PM MS. ERICKSON, summarizing slide 9, "Develop Vision," stated the vision: Alaska's health care system produces improved health status, provides value for Alaskans health care dollar, delivers consumer and provider satisfaction, and is sustainable. She listed the goals: increase access, control costs, improve quality, and make the system more prevention-based. MS. ERICKSON provided slide 10, "Describe Current State," and explained that the 2009 report had an appendix with a description of the current system, an explanation of service finance, and an overview of the impact on Alaska from the Patient Protection Affordable Care Act (PPACA). She added that, in 2011, the Commission was planning an analysis of the current conditions. 4:10:22 PM DR. WARD HURLBURT, Chief Medical Officer/Director, Division of Public Health, Central Office, Division of Public Health, Department of Health and Social Services, offered three reasons for a Health Care Commission, cost, cost, and cost. He said that the costs of health care now exceeded 18 percent of gross domestic product. He compared this cost in the United States to the other 37 industrialized countries in the world, which each spent between 8 - 12 percent of its gross domestic product for health care. He reported that, from 1991 - 2005, the cost of living in Alaska increased 38 percent, while health care costs increased 100 percent. He stated that health care expenditure was $7.1 billion in Alaska, about 23 percent of the state gross domestic product. DR. HURLBURT directed attention to slide 12, "Describe Current State" and discussed that Medicaid would cost Alaska about $1.5 billion in the upcoming fiscal year, an average of $13,000 for each of the 110,000 enrollees. He pointed out that, although the majority of enrollees were young women and children, the high costs were for those individuals with "life issues, like drug use." 4:15:50 PM DR. HURLBURT pointed to slide 13, "Differences in Medicaid Fees, 2009," and explained that the comparative costs of Alaska Medicaid fee schedules were more than 2.5 to 3 times those of Washington and Oregon. He referenced the comparative workers' comp fee schedules for Alaska, Washington, and Hawaii, which also reflected the much higher costs in Alaska. He reported that an actuarial firm and the VA were both reviewing the reasons for the high medical costs in Alaska. 4:18:18 PM DR. HURLBURT referred to slide 14, "Determinants of Health" and slide 15, "Chronic Disease accounts for," and said that the leading cause of death for ages 1 - 44 years was unintentional injuries. He noted that infectious disease had been a high cause of death, but that "diseases of choice" were now higher. He shared that although Alaska ranked first in education against smoking, a much bigger problem was now obesity. CDC had estimated the direct medical cost related to the complications of obesity to be $300 billion each year, which he extrapolated to a cost for Alaska of $800 million each year. He pointed to diabetes as the most notable complication of obesity, and that, in 2003, CDC estimated that children born in this decade had a 33 percent risk of developing diabetes, while almost 8 percent of the population had diabetes. He reported that 33 percent of Americans were overweight, which lead to a 13 percent increase for expectation of premature mortality; another 33 percent were obese, which lead to an increase of 40 - 80 percent. He listed the complications of diabetes to include blindness, loss of kidney function, dialysis, loss of limbs, and heart attack, and he stressed the huge economic. He opined that the challenge to overcome obesity would be greater than that of smoking. He applauded the efforts of the Anchorage schools to combat obesity rates. He summarized that chronic diseases accounted for the majority of health care costs and that the economic impact could be devastating. 4:24:48 PM DR. HURLBURT, in response to Chair Keller, said that Milliman, a large national actuarial firm, would be a good choice for studying the reasons for the increased health rates. 4:25:58 PM CHAIR KELLER asked when this would be available. MS. ERICKSON replied that the VA would release the report later in the year. CHAIR KELLER asked if the report would specify the fee differences between workers' comp and Medicaid. MS. ERICKSON replied that the request was for an analysis and comparison of the methodologies of the health care payers in Alaska, which she assumed would include Medicaid, Workers' Comp, private insurance, and TRICARE fee schedules. REPRESENTATIVE HERRON asked about the three contracts to be proposed: actuarial, Medicare, and health status. MS. ERICKSON agreed that the three contracts would be in place, although ISER was just finishing up a study on the economic impact of the PPACA on Alaska. She reported that there was a contract with ISER for an analysis on health care spending in Alaska, and a contract with a health care actuarial firm for a comparison of pricing, the cost of providing Medicare in Alaska, and any inequities with reimbursement for Medicare versus primary care. 4:28:52 PM REPRESENTATIVE CISSNA reiterated her earlier question about social disparities. DR. HURLBURT replied that social disparities had not been a major focus of the Health Care Commission, though it was a focus of the federal government. He noted that Alaska Natives were the largest non-white population and he confirmed that standards for Alaska Natives were not yet to the US all races standards. He noted that the Alaska Tribal Health System was doing a better job on child immunizations than the rest of state. He stated his aspiration to be in the top 90 percentile for child health care. He referenced studies which indicated that the Alaska Tribal Health System was about 33 percent underfunded. He pointed out the collaboration between the health care systems in Alaska. 4:34:07 PM REPRESENTATIVE CISSNA stated that her visitations around Alaska had revealed an out migration from its rural areas. She expressed that it's the "whole well-being picture that's got to be looked at." She stressed the need for immediate work on this. 4:36:38 PM MS. ERICKSON, indicating slide 16, "Analysis of Current Conditions (planned for 2011)," pointed to the formula for costs to health care, and explained that the cost for total expenditures was equal to the price for the process multiplied by the utilization. She confirmed that the analysis would include a cost analysis, a price comparison study, and a health status assessment. In response to Representative Cissna, she noted that underlying health status and utilization would be reviewed in accord with social determinants. 4:38:00 PM MS. ERICKSON presented slide 17, "Health Care Transformation Strategy," and explained the strategies for transforming Alaska health care. She explained the need to build the foundation by ensuring a strong health care workforce, deploying health information technology, and maintaining strong statewide leadership. The health care strategies were built around this foundation. Referring to slide 18, she relayed that in 2009, the focus was on primary care intervention and patient centered medical home models; in 2010, the focus was on evidence based medicine; and for 2011, the strategic study would be for price and quality transparency, and value driven purchasing. REPRESENTATIVE DICK asked about the relative cost of malpractice insurance to the cost of health care. MS. ERICKSON replied that malpractice reform was one of the strategies for increasing value, which the commission was going to study in the future. She pointed to the Alaska Health Care Commission's 2009 report, which included a national estimate for the effect of malpractice on health care costs and an explanation of Alaska laws regarding malpractice. She confirmed that there had been a malpractice reform effort in 2005. 4:42:58 PM CHAIR KELLER opined that Alaska liability laws were in good shape. REPRESENTATIVE SEATON remarked that even with malpractice reform, there had not been any lowering of Alaska insurance rates. He pointed out that the malpractice premium which doctors paid had remained the same, but that they received a rebate at the end of the year, the value of which was not passed on to the consumer. He asked for a further review. He referred to slide 20, "Potential System Design Policies for Enhanced Prevention," asked if any of the policies had been implemented, and questioned why prevention was not more of a focus. 4:45:38 PM MS. ERICKSON, in response to Representative Seaton, said that a duty of the Alaska Health Care Commission was to develop a strategy for improving the health of Alaskans. She shared that a 2009 recommendation from the Commission was to explore opportunities for support of healthy lifestyles. She directed attention to slide 27, "Status of 2009 Recommendations." She clarified that the recommendations from the Commission were standing recommendations for the future, and that it would report each year on the full body of recommendations relative to what had happened in the state. Returning attention to slide 27, she indicated that the governor's "Choose Respect" initiative, the Childhood Obesity Collaborative, and the Alaska Food Policy Council were 2010 activities which supported healthy lifestyles. She stated that the report included major policies and organizational activities undertaken in the health care industry during the year. 4:50:21 PM REPRESENTATIVE MILLETT asked why substance and alcohol abuse was not addressed by either the 2009 recommendations or the governor's initiative. 4:51:19 PM MS. ERICKSON, in response to Representative Millett, said that the 2009 prevention recommendation was a very generic policy suggestion. She said there were no new initiatives, but that behavioral health would be addressed in the 2011 health status report. She noted that the StopSuicideAlaska web portal was a new behavioral health initiative. REPRESENTATIVE SEATON, referring to the use of checklists in hospitals, asked if the Alaska Health Care Commission had focused on procedures as a means to improving health. DR. HURLBURT replied that the Commission was trying to deal with broader scope issues, not with specifics of clinical practice. 4:55:17 PM REPRESENTATIVE SEATON asked to see that the recommendations, even though not specific, were followed. 4:55:48 PM DR. HURLBURT referred to slide 33, "New 2010 Recommendations," and declared that these recommendations dealt primarily with the use of evidence-based medicine. He announced that this dealt with quality and cost savings, and he embraced the suggestions for follow up. 4:57:03 PM CHAIR KELLER asked Representative Seaton for more information on his statement about malpractice rates. REPRESENTATIVE SEATON asked Dr. Hurlburt if that information was available. CHAIR KELLER offered for his staff to contact the Director of the Division of Insurance for this information. 4:58:29 PM REPRESENTATIVE DICK offered his belief that high health care costs were a direct result of what the health care providers thought they could charge. 4:58:59 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 4:59 p.m.