ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  January 22, 2015 3:04 p.m. MEMBERS PRESENT Representative Paul Seaton, Chair Representative Liz Vazquez, Vice Chair Representative Neal Foster Representative Louise Stutes Representative David Talerico Representative Geran Tarr Representative Adam Wool MEMBERS ABSENT  All members present COMMITTEE CALENDAR  OVERVIEW: DEPARTMENT OF HEALTH AND SOCIAL SERVICES - HEARD PREVIOUS COMMITTEE ACTION  No previous action to record WITNESS REGISTER VALERIE DAVIDSON, Commissioner Designee Office of the Commissioner Department of Health and Social Services (DHSS) Juneau, Alaska POSITION STATEMENT: Presented a power point overview of the Department of Health and Social Services. JAY BUTLER, MD, Chief Medical Officer/Director Division of Public Health Central Office Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Answered questions during the overview of Department of Health and Social Services. JON SHERWOOD, Deputy Commissioner Medicaid and Health Care Policy Office of the Commissioner Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Answered questions during the DHSS overview. ACTION NARRATIVE 3:04:07 PM CHAIR PAUL SEATON called the House Health and Social Services Standing Committee meeting to order at 3:04 p.m. Representatives Seaton, Vazquez, Tarr, Wool, and Talerico were present at the call to order. Representatives Foster and Stutes arrived as the meeting was in progress. 3:05:28 PM CHAIR SEATON announced that the first order of business would be for each committee member to introduce themselves and share a brief account of their interest for participation on the House Health and Social Services Standing Committee. REPRESENTATIVE TARR said that she was interested in Vitamin D and improving health outcomes, as her interests included mental health, substance abuse treatment, and child sexual abuse prevention. REPRESENTATIVE VAZQUEZ explained that she had a "passion for health care," noting that she had an MBA in health care services administration. She looked forward to working on improvement of outcomes, and she expressed her support for prevention. REPRESENTATIVE WOOL reported that his family were all in the health industry, and that he was a consumer of health care. He expressed concern for the difficulty in obtaining health care and health care insurance. REPRESENTATIVE FOSTER shared his success with his personal health since regularly taking Vitamin D. He noted that his primary interest was for directing attention to the villages across the state. REPRESENTATIVE TALERICO reported that, as he had 43 distinct communities in his district, he had an interest in telemedicine for the delivery of health care services. CHAIR SEATON shared his interest for better health outcomes relative to the expense, and that he wanted to ensure improvement to the health of Alaskans, with a focus on improving basic health. He declared that this would have a positive impact on all budgets. He pointed out that the Department of Health and Social Services had a myriad of responsibilities. He stated that he would like to make upstream changes, instead of waiting until the conditions were downstream and required expensive treatments. He emphasized that the committee mantra would be prevention. REPRESENTATIVE STUTES said that she wanted to learn about ways to keep Alaskans healthy and to participate in keeping Alaskans healthy. ^OVERVIEW: DEPARTMENT OF HEALTH AND SOCIAL SERVICES OVERVIEW: DEPARTMENT OF HEALTH AND SOCIAL SERVICES  3:12:12 PM CHAIR SEATON announced that the next order of business would be an overview by the Department of Health and Social Services. 3:14:02 PM VALERIE DAVIDSON, Commissioner Designee, Office of the Commissioner, Department of Health and Social Services (DHSS), shared that she had been an early childhood teacher and she believed strongly in early childhood opportunities. She stated that the sooner there were good relationships between children and health care providers, the better the experiences later in life. She reported that she had worked for the past 15 years in the Alaska Tribal Health system, including the past 8 years with the Alaska Native Tribal Health Consortium (ANTHC), which was statewide. She shared that the Yukon-Kuskokwim Health Corporation in Bethel was very innovative for providing health care services. She offered an overview of the department, slide 2, "Alaska Department of Health and Social Services Organization Chart." She moved on to slides 3 and 4, "Executive Leadership," and introduced those in attendance. COMMISSIONER DAVIDSON, in response to Representative Tarr, explained that the Division of Behavioral Health was now aligned with the Division of Public Assistance. 3:22:37 PM COMMISSIONER DAVIDSON directed attention to slides 5 and 6, "Health & Social Services," noting that Department of Health and Social Services had eight divisions. She introduced each division and its director. 3:25:31 PM CHAIR SEATON, referencing the Divisions of Public Assistance and Senior and Disability Services, asked which division was responsible for public assistance to seniors. COMMISSIONER DAVIDSON replied that all public assistance programs were housed under the Division of Public Assistance. 3:26:04 PM COMMISSIONER DAVIDSON, addressing slide 7, stated that the vision for the department was to ensure that "Alaska individuals, families, and communities really are safe and they are as healthy as possible." She listed the three main priorities of the department: health and wellness across the life span; health care access, delivery, and value; and safe and responsible individuals, families, and communities. She stated that this focus for priorities included core services, and she acknowledged that the budget was linked to results based accountability. She reported that the former commissioner had done a good job ensuring that the budgets aligned with the departmental priorities, which she opined was not an easy task. She stated that data was still incoming and there would be further alignment. 3:27:29 PM CHAIR SEATON asked if there were plans for accomplishing the priorities and the goals, as the committee wanted to ensure there was a "mechanism to accomplish each one of those goals." He stated that the current position of health care in Alaska did not have an enviable ranking in the US. COMMISSIONER DAVIDSON, in response, directed attention to slides 8 - 11, "Areas of primary focus (4)." She explained that the first focus was to provide access to health care for Alaskans, which included a commitment to Medicaid expansion, as there were more than 40,000 Alaskans who did not have access to health care and would be eligible. She declared that, in the short term, it was important to get individuals as healthy as possible during this period when the federal government offered a 100 percent match to Medicaid. She explained that the longer term goal recognized that there were changes necessary to the Medicaid program, both the current and expanded recipients, in order for its delivery to be as efficient as possible. She acknowledged that there were significant systems challenges to enroll individuals in the Medicaid expansion. She referenced the two system conversions, which included the eligibility information system for Medicaid and other public assistance, which was a year late in coming on line and was experiencing a backlog. She explained that the other major system change was to the Medicaid payment system, now called the Medicaid Management Information System (MMIS). She reported that this system also had significant challenges for accuracy and timeliness of claims payments to providers. Noting that, in order to proceed responsibly, it was necessary to ensure the systems were running sufficiently, she shared her anticipation for a July start date to Medicaid expansion, even as this could mean an aggressive push to meet this goal. 3:33:09 PM REPRESENTATIVE STUTES asked whether the Department of Health and Social Services (DHSS) was going to work with the Department of Corrections (DOC) for mental health evaluation to inmates as, she opined, there was a disconnect between the two services. She suggested this could alleviate the burden on the penal system. COMMISSIONER DAVIDSON in response, expressed her agreement with early intervention opportunities in order to forego the construction of another prison. She reported that there was a recidivism effort which included both departments, as well as the Alaska Court System and local communities. She stated that the correction system was filled with people "who wouldn't be there if we provided adequate alcohol or other substance abuse treatment," declaring that these were resources that were very well spent. She compared that this was the same as with Medicaid expansion, as behavioral health services were covered. She pointed out that, as the Patient Protection and Affordable Care Act required behavioral health parity, this was an opportunity to interrupt that cycle in corrections and child welfare issues. She opined that too often the focus was too late and that earlier intervention could stop the cycle. She reported that there would be savings for DOC as inmates were eligible under Medicaid expansion for health care costs outside the facility. She declared that the challenge was for timing, to ensure that people could be enrolled and receive services. She pointed out that there were also some short term savings with Medicaid expansion, including catastrophic coverage, which was currently paid out of the general fund. For a longer term strategy, as Medicaid was $1.7 billion of the DHSS budget of $2.7 billion, she offered her belief that it was necessary to review the use of Medicaid services in Alaska and design a program that worked for Alaska. 3:38:12 PM COMMISSIONER DAVIDSON shared that there were current opportunities to realize savings, including funding projects for long term care facilities and skilled nursing facilities, so care for elders could be provided closer to home. She reported that there was a 100 percent match for these services, if three requirements were met: an Indian Health Service (IHS) beneficiary, an Alaska Native, or a Medicaid beneficiary at an IHS facility. She clarified that this was already available and would continue under the Medicaid expansion. She referenced Senate Bill 61 which looked at the prospects for Alaska to leverage opportunities and partnerships with the tribal health system to recognize savings. She listed the long term care services and behavioral health services for residential, home, and community, as two of these opportunities. She mentioned the super utilizer program, which focuses on reducing the use of emergency departments. Although Medicaid beneficiaries often made use of emergency departments, DHSS was working with these recipients to better manage their care through a primary care provider. She acknowledged that the emergency room had become the first resort for people without medical coverage, resulting in a significant bill for uncompensated care. She suggested that Medicaid expansion could teach people more appropriate ways to access health care. She allowed that DHSS was open to suggestions for change, and she was looking at the experiences of other states for best practice models. 3:44:27 PM REPRESENTATIVE FOSTER asked whether there were any transitional costs to the state during the Medicaid expansion and its initial 100 percent payment by the federal government. COMMISSIONER DAVIDSON explained that Medicaid expansion allowed states to be reimbursed at 100 percent during 2014, 2015, and 2016. For the next three calendar years, 2017, 2018, and 2019, the federal match would transition from 95 percent, to 94 percent, and then to 93 percent. In 2020, this would transition to a 90 percent federal match, where it would remain. Directing attention to the transition costs for Alaska, she informed the committee that there was an administrative match for 50 percent of cost, as well as a 90 percent match for systems improvement and changes. COMMISSIONER DAVIDSON, in response to Representative Foster, said that the budget, including transition costs, would be provided soon after the governor's budget statement, though she opined that this would be less than anticipated. 3:47:53 PM CHAIR SEATON asked for more information regarding the enrollment system. COMMISSIONER DAVIDSON said that the first phase of the enrollment system, the Medicaid determination, had been delayed a year. She noted that the second phase, including Temporary Assistance to Needy Families (TANF) and food assistance, would go live after that. She said that mandatory overtime requirements were about to be implemented to ensure that individuals would be enrolled and to diminish some of the backlogs. She offered that more progress had been made with the enrollment system than the payment system, noting that litigation had begun against Xerox by the former administration. She reported that the contract with Xerox required an administrative hearing, which would be heard by an administrative law judge in February. She reported that the state had hired an independent consultant to review the work by Xerox and write an independent assessment for the program. She noted that Xerox had submitted a performance improvement plan, which was being reviewed. She offered her belief that the situation was direr than she had realized, and that Department of Health and Social Services would be more transparent regarding the problems with these systems. She opined that the public deserved to be more aware of the backlog and the situation, and that the department should be accountable for fixing the systems. She reported that the providers were working with the health care services to ensure that workarounds were in place to guarantee payment. CHAIR SEATON expressed his disappointment in the rollout for the program, and for the lack of dual accounting. He said that his office had contacted the State of Massachusetts when researching the problems with Xerox, as that state had incorporated the same system. He reported that Massachusetts had the same problems. He asked if the problems in Massachusetts had been resolved. COMMISSIONER DAVIDSON acknowledged that other states had contracts with Xerox, although, she opined, as other states were managed care states, it was not necessary to have the capability to process as many claims as Alaska. She stated that other states were also in litigation with Xerox. She pointed out that the systems in other states were designed to do very different things. 3:54:35 PM COMMISSIONER DAVIDSON, directing attention back to the areas of primary focus, slide 9, "Child welfare/keeping our children safe," and reported that more than 2400 Alaskan children were in out of home placements, more than at any previous time. She expressed concern for the resources and the programs to prevent this. COMMISSIONER DAVIDSON moved on to the third area of primary focus, slide 10, "Tribal and Federal Partnerships." She stated that it was necessary to have this out front and center to enhance the State of Alaska's relationships and partnerships with tribal organizations and the federal government, including the federal Departments of Interior and Health and Human Services, to make sure that barriers which are standing in the way of progress are removed. She pointed out that Alaska Native children comprised between 17 - 20 percent of the state population, but comprised 60 percent of the children in out of home placements. She declared that, as neither the state nor the federal agencies could solve this problem alone, it was time for the focus to change from who was providing the service to what was being done for the children, and who could do what to help get there. She acknowledged the work between Office of Children's Services and the tribal organizations, but opined that it was necessary to be more aggressive for leveraging these partnerships and opportunities. She declared that tribal organizations had been ready for this for a long time. She offered her belief that the commitment to the children should be the focus beyond those ideas for the right solution, noting that trust building only happened over time. 3:59:28 PM CHAIR SEATON asked whether there were particular barriers to the legislature or to the administration in working on this partnership. COMMISSIONER DAVIDSON replied that although there were some agreements with the Tanana Chiefs Conference for better tribal - state partnership, there were challenges for getting them information, especially about child welfare cases. She allowed that there would be some administrative discretion although the governor had agreed to work across departments to address these issues. She suggested that it was necessary for clarity in the statutes to help remove any of the barriers. She offered to relay more in-depth information. She concluded with slide 11, "Improving the health status of Alaskans," and declared that this was the focus. 4:01:43 PM JAY BUTLER, MD, Chief Medical Officer/Director, Division of Public Health, Central Office, Department of Health and Social Services, shared his background in public health care, noting that he had worked for the past five years with the Alaska Native Tribal Health Consortium. Directing attention back to slide 11, "Improving the health status of Alaskans," he reported that 28 percent of Alaskan adults and 17 percent of children were obese, defined as having a body mass index (BMI) over 30. He pointed out that obesity was most likely a primary driver for the increased rates of Type 2 diabetes, which affected almost 5 percent of Alaskans. He noted that the teenagers were the age group with the biggest increase in obesity in the past 15 years. He shared that diabetes could be managed, as well as prevented, through healthy behaviors such as weight control and healthy diet. He suggested that healthy behaviors could be influenced by making the healthy choice the easy choice. He pointed out that preventive maintenance was very necessary. He stated that education was also an important influence on behaviors, and that the power of education was profound. He noted that the only eradication of a disease had been for small pox, through vaccination, and he offered an anecdote of a current educational campaign to eradicate another disease. 4:09:50 PM DR. BUTLER discussed the reduction of tobacco use, noting that use was down to 20 percent in Alaska, with huge progress for the prevention of smoking. He suggested that this change was a result of both education and a change of the social norms. REPRESENTATIVE TARR asked about any focus on e-cigarette use. DR. BUTLER replied that there was great interest, although there was a lot that was still not known. He noted that tobacco use overlapped with e-cigarette and marijuana use. He reported that e-cigarettes had been touted as nicotine prevention tools, although they were not currently FDA approved for overcoming nicotine addiction. He expressed his concerns with the flavors and the marketing of e-cigarettes, comparing it to the smokeless products. CHAIR SEATON asked if the Department of Health and Social Services was letting it be known that the sale of nicotine delivery products to minors was illegal. DR. BUTLER replied that the legislation was an important deterrent, although he was not aware of the enforcement. He reported that the illegal sale of tobacco products was an educational issue. In response to Chair Seaton, he agreed that the illegal sale of nicotine delivery systems to minors should also be part of the educational curriculum. 4:16:07 PM DR. BUTLER announced that the department desired to reduce the abuse of alcohol and other drugs, as 25 percent of Alaskan adults reported binge drinking. He declared that it was important to realize that this was not just a personal health decision, but that impairment also affected the health of others. He offered examples of injuries from motor vehicles, as well as injuries to the fetus from fetal alcohol spectrum disorder. He moved on to address opioid drug abuse with the increase of opioid prescriptions, possibly due to a lack of understanding for pain management. He declared that this would be a priority for the Alaska Health Care Commission during the upcoming year. REPRESENTATIVE WOOL asked about a centralized data base for opioid prescriptions. DR. BUTLER replied that that was a recognized best practice, and it was used in Alaska. REPRESENTATIVE TARR offered her belief that the funding was scheduled to cease last year, and there had not been any legislation to extend the funding. COMMISSIONER DAVIDSON expressed agreement that funding had been discontinued but that, as the department had felt it was "sufficiently important for the health of Alaska, it was being continued through an agreement with another department. REPRESENTATIVE VAZQUEZ asked if this data base was different than the data base for the over-utilization of prescription drugs. 4:20:41 PM JON SHERWOOD, Deputy Commissioner, Medicaid and Health Care Policy, Office of the Commissioner, Department of Health and Social Services, in response to Representative Vazquez, said that this was a different program, was available to all health care providers and pharmacies, and was not limited to Medicaid. REPRESENTATIVE TARR asked for clarification that the provider had to access the information from the data base, and whether any of the program management had changed, especially as it was not on a real time basis. MR. SHERWOOD explained that the program was now under the Department of Commerce, Community & Economic Development. As administration of the data base was not in the DHSS responsibility, he was not aware of the specifics. REPRESENTATIVE VAZQUEZ asked if the prescription data base was used by DHSS. MR. SHERWOOD opined that DHSS did not have access to the data base, although he was not absolutely certain. He relayed that it was intended for use by providers when prescribing. REPRESENTATIVE VAZQUEZ asked if this lack of access was because of statutory restraints. MR. SHERWOOD offered his belief that the statute did not identify DHSS as a user of the data base, although he would like to confirm this. CHAIR SEATON asked that Mr. Sherwood provide that answer to the committee. REPRESENTATIVE VAZQUEZ asked how many individuals were in the Lock-In program, and how its use had constrained expenses over the past five years. She asked whether the settlement with legal services regarding the Lock-In program was still in effect. MR. SHERWOOD replied that he would research that and send the information to the committee. CHAIR SEATON asked for a status update, specifically to how the system was working. REPRESENTATIVE VAZQUEZ requested a copy of the legal settlement. She opined that Lock-In was a good cost containment measure as it prevented over utilization by recipients. CHAIR SEATON asked for an outline of the Lock-In program. REPRESENTATIVE WOOL asked if the data base tracked the physician or provider as well as the recipient. MR. SHERWOOD replied that he was unsure and agreed to get the information back to the committee. CHAIR SEATON asked for a more comprehensive description of the prescription data base program, as well. 4:27:43 PM DR. BUTLER directed attention back to slide 11, and discussed the now legal use of marijuana. He stated that the Division of Public Health wanted to reduce any adverse health effects from this legalization, and do what was best for Alaska. He stated that DHSS would learn lessons from legalization in other states. He listed some of the short term effects from marijuana legalization to include an increase in Colorado for emergency room visits by children from THC ingestion, and an increase in burns during extraction of THC. He expressed concern with the medical literature on long term effects, particularly for heavy use in adolescents. He shared that the department was reviewing regulations with marijuana. He allowed that the bigger question for all drug use was why people needed to self-medicate. He mentioned the data on adverse childhood experiences and those effects on health in later life. He reported that research was working to reduce these later health effects. He said that almost 25 percent of hospitalization injuries were alcohol based. DR. BUTLER relayed that injuries were the leading cause of premature death in Alaska, and the outcome could be influenced during the golden hour of field management and transport to a certified trauma center. He reported that there were now two Level 2 trauma centers in Alaska, as well as 15-16 Level 4 centers. 4:33:47 PM CHAIR SEATON asked about other strategies for prevention of injuries. DR. BUTLER, in response, mentioned the "Kids Don't Float" program, which encouraged the use of personal floatation devices. He pointed to the white flotation coats program, which were made to look like a traditional whaler's coat, as the whalers were the traditional leaders in a community. He cited education and regulations for the use of seat belts and helmets. He spoke of the tragic injuries from domestic violence, and, although not a traditional part of public health, he deemed it was necessary for DHSS to recognize and address this problem. 4:35:57 PM DR. BUTLER stated that immunizations had made a big difference in the health of Alaskan children and that Alaska was doing well for ensuring vaccinations for school age children. However, he noted that some vaccination rates lagged, especially for the immunizations of two year olds. He shared that access to vaccines was often a challenge. He noted that Alaska was looking at models for a return to the universal vaccine program, and he mentioned the Alaska vaccine assessment program. This program would allow the purchase of vaccines at wholesale prices for substantial savings to providers and third party payers. He offered his belief that Alaska would be the tenth state to use this model for vaccine purchases. CHAIR SEATON asked whether the state program for purchasing, warehousing, and distributing vaccines was currently in place. DR. BUTLER replied that the remaining funding allowed to forward fund the first year purchases, and then continue to buy in bulk. He explained that much of the country had direct to provider distribution, but that the state had convinced the federal government that Alaska had a better understanding for distribution logistics in an Arctic environment. 4:39:10 PM DR. BUTLER discussed the prevention and control of infectious diseases, noting that this health threat would continue as it dealt with another biologic system that was able to continuously change. He offered his belief that there was not a high risk for Ebola in Alaska, as the department monitored the return of the very small volume of travelers from affected areas. He noted that DHSS continued its work with hospitals in Alaska and Washington State for management planning in case of Ebola. He mused that Ebola brought back the conversation about readiness for serious infectious diseases. 4:41:33 PM REPRESENTATIVE FOSTER asked about inadequate sewage and water quality and its role with infectious diseases, and whether Department of Health and Social Services would have any role with this. COMMISSIONER DAVIDSON replied that the Centers for Disease Control and the ANTHC had reviewed the impact on infants and communities without adequate sanitation facilities. These findings indicated that there were 11 times greater likelihood for hospitalization from respiratory infections and 5 times more likely from skin infections. She clarified that these infants required a medivac from the rural community to the hospitals. She relayed that this equated to hospitalization for one in three infants from the community in any year. She explained that the challenge was for some public health benefit programs to continue in other state departments during times of significant budget contractions. She offered a personal anecdote of her daughter's bouts with respiratory disease. She pointed out that adequate sanitation facilities programs were matched by federal funding. She declared that there was a link between adequate sanitation facilities and public health and the health status of communities. DR. BUTLER declared that it was necessary to consider what could realistically be accomplished for the 25 percent of the state population who did not have the proper sanitation facilities. He emphasized that it was important to use engineering models to look for ways to provide these services. He referenced the diseases associated with a lack of running water, pointing out that these were not waterborne diseases. He noted the challenge to supply adequate wash water for personal hygiene, comparing this to the absolute minimum World Health Organization standard for refugee camps. He declared the need for opportunities for people to wash in rural Alaska. 4:48:27 PM DR. BUTLER moved on to discuss the prevention of infant deaths, reporting that today's death rates were about tenfold lower due to immunization, improved standards of living, and increased protection in the first year of life. He discussed implementation of the Healthy Alaskans 2020 action plan. He said that it was necessary to programmatically address these health challenges in order to make a difference. He explained that the Healthy Alaskans program was a collaboration between the State of Alaska and the Alaska Native Tribal Health Consortium to connect with communities, identify some of the priorities for improving health, determine what could be done to make those improvements, and then measure the impact. He relayed that the plan's outcome was for 25 measures with useable goals and included specific outcomes such as reducing cancer mortality, reducing the proportion of Alaskans living below the poverty line, and improving the high school graduation rate. 4:51:33 PM DR. BUTLER expressed his pleasure in hearing of the interest in prevention, stating that health care had really been disease care. He enthused that prevention was an emphasis of the Alaska Health Care Commission in defining how health care was provided. He offered his thoughts on Vitamin D, citing thousands of studies for its health outcomes which included the prevention of falls and fractures in the elderly, as well as prevention of colon, breast, and prostate cancer, cardio vascular disease, stroke, diabetes, and depression. He allowed that there were still a lot of questions for the public health opportunities, and that association did not necessarily prove causation. He pointed out that there were more than 1500 clinical trials assessing Vitamin D, and, as he was a pragmatist, he asked what this would mean for Alaska. He shared that the vital trial, involving more than 25,000 Americans, was very well conducted and, because of its size, offered many analyses. He lauded the potential for flu prevention with an over the counter supplement. CHAIR SEATON reflected on some of the earlier trials which only offered once a week or once a month Vitamin D dosage, noting that recent research showed that daily dosage was necessary to affect soft tissue. Other studies examining the effect on cancer and other disease had shown that Vitamin D may prove ineffective if dosages were only taken a few times each month. 4:58:57 PM COMMISSIONER DAVIDSON acknowledged the work of the HSS transition team which brought together more than 250 Alaskan volunteers to offer ideas for improvement to the delivery of services, slide 12, "Looking to the future." She directed attention to the five recommendations listed on the slide and said that these would all be evaluated for possible implementation. CHAIR SEATON stated that the committee would review Medicaid expansion, including reviews of the Arizona criteria and the Tennessee model for cost sharing with the health care providers to implement the program. 5:01:55 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 5:01 p.m.