ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  February 15, 2011 3:06 p.m. MEMBERS PRESENT Representative Wes Keller, Chair Representative Alan Dick, Vice Chair Representative Bob Herron Representative Paul Seaton Representative Sharon Cissna (via teleconference) Representative Charisse Millett MEMBERS ABSENT  Representative Bob Miller COMMITTEE CALENDAR  CONFIRMATION HEARING(S): Commissioner, Department of Health and Social Services William Streur - Juneau - CONFIRMATION(S) ADVANCED PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER WILLIAM STREUR, Acting Commissioner Office of the Commissioner Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Testified as appointed commissioner of Department of Health and Social Services. ACTION NARRATIVE 3:06:15 PM CHAIR WES KELLER called the House Health and Social Services Standing Committee meeting to order at 3:06 p.m. Representatives Keller, Dick, Herron, and Millett were present at the call to order. Representatives Seaton and Cissna (via teleconference) arrived as the meeting was in progress. ^CONFIRMATION HEARING(S): Commissioner, Department of Health and Social Services CONFIRMATION HEARING(S): Commissioner, Department of Health and  Social Services    3:06:35 PM CHAIR KELLER announced that the committee would consider the confirmation of the appointment of William Streur as commissioner of the Department of Health and Social Services. 3:07:26 PM WILLIAM STREUR, Acting Commissioner, Office of the Commissioner, Department of Health and Social Services (DHSS), said that he had been involved in health care for 33 years, 30 years of which were in the private sector. He pointed out that he had worked extensively with Medicaid. He stated that he moved to Alaska in 2003 and had been with the Department of Health and Social Services since 2007. 3:10:36 PM ACTING COMMISSIONER STREUR offered to answer each of the written questions which the committee had presented to him. [Included in members' packets] He read the first question [original punctuation provided]: A lot of focus over the years has been on the supply side of health care, cutting costs through reductions in reimbursements and/or services, requiring prior authorizations, etc. what is being done on the demand side to keep our beneficiaries healthy? He said that the demand side kept beneficiaries healthy and made sure that they had "the proper care at the right time, the right place, delivered to them." He commented that although it was a big part, prevention was not the only answer. He pointed out that the Division of Public Assistance provided services to help achieve its mission of protecting and promoting the health of the public. He listed six core public health priorities from the demand side: infectious disease and epidemic prevention and control; injury prevention, control, and emergency medical services; chronic disease prevention and control; access to early preventive services and quality health care; public health emergency preparedness and response; and protection to human health from environmental hazards. He read the second question [original punctuation provided]: Wellness and prevention programs have shown reductions in health care costs and other improvements of around $3 per every dollar spent, have we looked into these, and what are we doing in this area? ACTING COMMISSIONER STREUR, referencing the $3 for every $1 spent, advised that "the jury is largely out on this." He stated the necessity of determining which of the prevention programs actually worked. He directed attention to the success in curbing the adult smoking rates, resulting in 8000 fewer tobacco related deaths, and $300 million in averted health care costs. He noted that public health employees actively worked with communities and organizations to build sustainability in health systems and ensure access to quality health services. He established that the Division of Public Health engaged in activities to ensure emergency medical service personnel were qualified and properly trained, and provided medical and legal investigative work related to unanticipated sudden or violent deaths. He declared that the division worked with a variety of organizations and individuals to develop and implement health promotion strategies and community action plans for prevention and reduction of chronic diseases. He confirmed the effectiveness for reducing health risks and injuries by the promotion of healthy behaviors through education and community support. He endorsed the outreach programs to the high risk and disadvantaged people in need of services. He opined that the continuing efforts with "self inflicted health care issues," such as obesity and smoking, would reap rewards. He announced that these issues currently cost Alaska $600 million each year in health care, and an additional $1.9 billion in lost productivity. He explained his struggle to balance the demands for care, the growing budget, the increasing number of enrollees, and the funding for prevention activities. He suggested a slow movement toward prevention activity and away from treatment activity to showcase any success. 3:15:00 PM ACTING COMMISSIONER STREUR reported that professional staff within the Division of Public Health monitored and assessed health status through the collection and analysis of vital statistics, behavioral risk factors, disease and injury data, and forensic data from post-mortem exams. This information was used to improve the program services, develop healthy recommendations, and inform future public decisions. 3:16:05 PM ACTING COMMISSIONER STREUR read the third question [original punctuation provided]: Do we have data on the prevalence of various preventable chronic diseases in our Medicaid population, such as cardiac disease, type 2 diabetes and obesity? If we do, what disease/conditions are they? Are we doing anything to address them? He stated that in FY 2010, Medicaid covered 120,879 Alaskans with total payments of $1.172 billion for health care. He declared that respondents with chronic conditions represented 49.7 percent of active Medicaid recipients, with 86.5 percent of Medicaid payments. 3:17:13 PM CHAIR KELLER asked for a breakdown of the chronic diseases, by expense and prevalence. 3:17:46 PM ACTING COMMISSIONER STREUR replied that, in FY 2010, there were 5217 Alaskans with diabetes on Medicaid, with payments of $12,553,951; 1318 Alaskans with congestive heart failure, with payment of $5,687,000; and 6669 Alaskans with asthma, with payment of $5,521,000. He explained that Alaska had a case management contract to ensure that these individuals kept appointments and took medications. He reported that this case management contract saved Alaska $673,636, about 5 percent, for patients with diabetes; saved $591,300, about 10 percent, for individuals with congestive heart failure; and saved $427,000, about 7 percent, for asthmatic patients. He added that case management was now an electronic process, also resulting in savings. He opined that the Alaska Medical Home Program would also save money. 3:20:25 PM CHAIR KELLER asked if the community health centers would be a solution. ACTING COMMISSIONER STREUR offered his belief that a community health center pilot program, as well as a private health facility, could contract with the Alaska Medical Home Program, for "a gentle form of managed care." He opined that there would be a "steep learning curve to implement [Alaska] Medical Home, but I believe it works." 3:22:08 PM ACTING COMMISSIONER STREUR moved on to the next question [original punctuation provided]: What have you done to define Medical Necessary? He stated that Department of Health and Social Services and Department of Law had worked together to address this and determine a practical approach for Alaska. He stated that only a medical professional could determine "medical necessity." He agreed that the issues were complex and that analysis was not yet complete. He noted that other states were confronting a similar dilemma. 3:23:51 PM REPRESENTATIVE MILLETT asked for a time line to the Department of Law recommendation. She pointed to a current request to increase the federal poverty level designated for qualification to Denali KidCare. ACTING COMMISSIONER STREUR replied that he wanted a decision as soon as possible, possibly by March 15. He stressed the need for a solution to the expansion of Denali KidCare. 3:24:57 PM ACTING COMMISSIONER STREUR read the next question [original punctuation provided]: Could you also share your thoughts of how the department will ensure equitable service to the people who are most difficult to reach (I'm referring to those in the bush) and who may need the help the most? He offered his belief that Alaska had risen above all the other states for the range of services provided, and the ability to develop community health aides, dental health aides, and behavioral health aides, ensuring that services were available. He pointed out that the Alaska Native Tribal Health Consortium and telemedicine had connected with [rural] clinics and health aides. He referenced a DHSS program for a broad delivery of behavioral health service in rural areas. He stated that "to do good, we have to do well." He announced that the state had to work with its health partners to ensure the ability to provide services to the communities. He opined that Alaska would not have "a social worker in every village" but he emphasized that access to services needed to be developed. 3:28:13 PM ACTING COMMISSIONER STREUR stated that DHSS had been working to add Medicaid coverage for behavioral health aids. 3:29:19 PM ACTING COMMISSIONER STREUR read the next question [original punctuation provided]: What is the benefit of having Therapeutic Courts compared to regular courts? In regards to the recidivism rate. He stated that, in 2007, the Alaska Judicial Council had conducted a recidivism study of the felony therapeutic courts in Alaska compared to the non-therapeutic court participants with similar characteristics. He shared its findings: only 13 percent of the graduates of therapeutic courts were re-arrested in the first year, about one third that of the comparison group. He noted that only 6 percent of the therapeutic group was convicted of a new offense in the first year, about 25 percent that of the non-therapeutic group. He stated that therapeutic courts significantly lowered the recidivism rates, and he emphasized that the cost for a therapeutic court candidate was 10 percent that of an incarcerated person. 3:30:42 PM REPRESENTATIVE MILLETT asked if the tracking for therapeutic court recidivism extended beyond one year. 3:31:08 PM ACTING COMMISSIONER STREUR replied that there was tracking for multiple years, but that this data was only year to year. He offered to supply the additional longer term data. ACTING COMMISSIONER STREUR compared that the four year re-arrest rate for drug court participants was 29 percent and 17 percent for drug court graduates, compared to 41 percent for similar drug offenders who did not participate in drug court. He pointed to a similar study for DUI [Driving Under the Influence] court participants, who were also found to be "substantially less likely than comparable DUI offenders sentenced to probation to be arrested for a new DUI offense or any criminal offense within two years of entering the program." He stated that the longer term effect of drug court in Portland was a 30 percent reduction over five years. 3:32:33 PM ACTING COMMISSIONER STREUR read the next question [original punctuation provided]: With over $4 million dollars spent on suicide prevention our numbers are still the worst in the nation. Can you tell us of your plans for turning this around that's different from what's been tried in the past? He reflected on the [Alaska Statewide] Suicide Prevention Summit in 2010, and noted the priority by the Suicide Prevention Council to strengthen the communication partnerships between the stakeholders and the systems. He discussed the partnership between the Alaska Mental Health Board, the Suicide Prevention Council, DHSS, and the Alaska Mental Health Trust to design and launch the interactive web portal, stopsuicidesalaska.org, which would help individuals connect with community groups engaged in suicide prevention. He stated that this would address the gap of ongoing communication, which had been addressed at the summit. He directed attention to a comprehensive toolkit for community training and response which had been developed by the Suicide Prevention Council, DHSS, and the Alaska Native Tribal Health Consortium. He shared that the Suicide Prevention Council had worked to expand access to suicide prevention and intervention training, as well as mental health first aid training. He pointed to a need for continuous engagement with community members, as suicide was epidemic not episodic, observing that social media was an effective tool. He described the Iron Dog poster and the baseball card campaigns, and pointed out that each included the Suicide Prevention hotline phone number. He attributed the campaign successes to the inclusion of role models, as opposed to scare tactics. 3:37:57 PM CHAIR KELLER reminded the committee that its role was to determine whether to forward this nomination. 3:38:36 PM REPRESENTATIVE SEATON, describing the high percentage of full mouth reconstructions for children in rural Alaska, asked about targeting for rural dental problems. 3:40:18 PM ACTING COMMISSIONER STREUR confirmed his frustration for the inadequate use of the Early Periodic Screening, Diagnosis, and Treatment Program, the [Medicaid] dental program targeting children. He pointed to a lack of available dental professionals to ensure good dental care, stating that community dental health aides could expand and improve this service. He also emphasized the need for a change to the trend for sugared drinks in rural stores. He suggested a school meal program in conjunction with Department of Education and Early Development. He reflected that dental care was the most difficult care to access in rural Alaska. 3:42:27 PM REPRESENTATIVE SEATON, offering his support for the dental health aides, declared a need to ensure early preventative dental programs. He opined that dental problems could lead to other health problems, including depression. 3:44:31 PM ACTING COMMISSIONER STREUR offered to report back to the committee. 3:44:55 PM CHAIR KELLER agreed that committee time would be dedicated to that report. 3:45:11 PM REPRESENTATIVE CISSNA reflected that state government had a role in health issues for the 300 communities around Alaska. She asked for a list of health needs per community, and, from this list, she suggested formation of a "community mentorship." 3:47:13 PM ACTING COMMISSIONER STREUR agreed that a health check on the communities would be an admirable undertaking. 3:47:46 PM REPRESENTATIVE CISSNA asked if the current state technology could allow for statewide hearings "to get people throughout the state working on it and actually have it be something that the people help build." 3:48:28 PM ACTING COMMISSIONER STREUR replied that he would speak with Dr. Hurlburt for possible options. 3:49:15 PM REPRESENTATIVE HERRON asked if Acting Commissioner Streur had a plan or a timeline for strategies on Medicaid managed care or cost containment. ACTING COMMISSIONER STREUR replied that he had "bits and pieces in place to roll out." He expressed his desire to have the Medical Home program ready by early summer, and that the Enhanced Care Management Program was already in place. He spoke about care management, ensuring that patients receive the proper care, and case management, directing patients to the proper place. He pointed to some of the challenges of the Medicaid budget, surmising that there was "a whole lot to do." He emphasized the importance for getting the proper technology in place, but that it would not be accomplished until early 2012. He offered his belief that the data for detailed reports determining the exact care provided would be available soon. REPRESENTATIVE HERRON requested to be included in the Medicaid decision making process. CHAIR KELLER agreed, stating that House Health and Social Services Standing Committee had a huge responsibility. 3:53:48 PM REPRESENTATIVE MILLETT offered accolades to Acting Commissioner Streur from her senior constituency that both he and OCS were attentive to their needs. 3:55:19 PM CHAIR KELLER closed testimony. 3:56:00 PM REPRESENTATIVE DICK moved to forward the confirmation of William Streur to joint session for consideration as commissioner of Department of Health and Social Services. There being no objection, it was so ordered. 3:56:35 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 3:56 p.m.