Legislature(2015 - 2016)HOUSE FINANCE 519

03/23/2016 01:30 PM House FINANCE

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Audio Topic
01:30:54 PM Start
01:31:50 PM SB74
03:49:10 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
Super Utilizers/Emergency Room Management
+ Bills Previously Heard/Scheduled TELECONFERENCED
CS FOR SENATE BILL NO. 74(FIN) am                                                                                             
     "An   Act  relating   to   diagnosis,  treatment,   and                                                                    
     prescription  of drugs  without a  physical examination                                                                    
     by a  physician; relating to  the delivery  of services                                                                    
     by  a  licensed  professional counselor,  marriage  and                                                                    
     family    therapist,     psychologist,    psychological                                                                    
     associate, and  social worker by audio,  video, or data                                                                    
     communications;  relating to  the duties  of the  State                                                                    
     Medical  Board;  relating  to limitations  of  actions;                                                                    
     establishing the Alaska  Medical Assistance False Claim                                                                    
     and  Reporting  Act;  relating  to  medical  assistance                                                                    
     programs administered  by the Department of  Health and                                                                    
     Social Services;  relating to the  controlled substance                                                                    
     prescription database;  relating to  the duties  of the                                                                    
     Board  of  Pharmacy;  relating to  the  duties  of  the                                                                    
     Department   of  Commerce,   Community,  and   Economic                                                                    
     Development;   relating  to   accounting  for   program                                                                    
     receipts; relating  to public record status  of records                                                                    
     related to  the Alaska  Medical Assistance  False Claim                                                                    
     and   Reporting   Act;  establishing   a   telemedicine                                                                    
     business registry; relating  to competitive bidding for                                                                    
     medical assistance  products and services;  relating to                                                                    
     verification  of  eligibility   for  public  assistance                                                                    
     programs administered  by the Department of  Health and                                                                    
     Social  Services; relating  to annual  audits of  state                                                                    
     medical  assistance  providers; relating  to  reporting                                                                    
     overpayments    of    medical   assistance    payments;                                                                    
     establishing  authority to  assess civil  penalties for                                                                    
     violations of medical  assistance program requirements;                                                                    
     relating  to seizure  and  forfeiture  of property  for                                                                    
     medical  assistance fraud;  relating to  the duties  of                                                                    
     the   Department  of   Health   and  Social   Services;                                                                    
     establishing    medical     assistance    demonstration                                                                    
     projects;  relating  to   Alaska  Pioneers'  Homes  and                                                                    
     Alaska Veterans'  Homes; relating to the  duties of the                                                                    
     Department  of Administration;  relating to  the Alaska                                                                    
     Mental Health Trust  Authority; relating to feasibility                                                                    
     studies for the provision  of specified state services;                                                                    
     amending Rules  4, 5, 7,  12, 24,  26, 27, 41,  77, 79,                                                                    
     82, and 89,  Alaska Rules of Civil  Procedure, and Rule                                                                    
     37, Alaska Rules of Criminal Procedure; and providing                                                                      
     for an effective date."                                                                                                    
1:31:50 PM                                                                                                                    
Co-Chair  Thompson  noted  that  Commissioner  Davidson  was                                                                    
HEATHER  SHADDUCK, STAFF,  SENATOR PETE  KELLY, referred  to                                                                    
the  handout  titled "SB  74  -  Medicaid Reform  Topic  and                                                                    
Section Reference"  that she  previously distributed  to the                                                                    
committee. She relayed that  today's topics under discussion                                                                    
were  Emergency Room  Management and  Super Utilizers  which                                                                    
related  to Section  29  and  Section 31  of  the bill.  She                                                                    
provided a brief overview of  the bill sections. She pointed                                                                    
to  Section  29  that  began   on  page  28,  line  18.  She                                                                    
elaborated  that  the  section mandated  primary  care  case                                                                    
management   for  certain   Medicaid   members,  which   was                                                                    
currently optional.  In response to  Representative Wilson's                                                                    
question  from Monday's  bill overview,  she clarified  that                                                                    
primary  care   case  management  would  not   initially  be                                                                    
mandatory  for all  Medicaid users.  She specified  that the                                                                    
provision   applied   to   enrollees  with   high   hospital                                                                    
admissions. Over  time the Department  of Health  and Social                                                                    
Services (DHSS)  could add  other Medicaid  populations. The                                                                    
department  believed   that  not  all   recipients  required                                                                    
intensive case  management. The provision differed  from the                                                                    
sponsor's  intent  that  every   enrollee  had  an  assigned                                                                    
primary  care  provider.  She furthered  that  DHSS  already                                                                    
engaged  in  primary care  case  management  with the  super                                                                    
utlizer    population    that     was    mostly    performed                                                                    
Ms. Shadduck  continued with  Section 31  found on  page 30,                                                                    
line 18  that related  to the  collaborative, hospital-based                                                                    
project  to reduce  inappropriate Emergency  Room (ER)  use.                                                                    
She delineated  that the project  had been designed  after a                                                                    
successful model  employed in  Washington State.  She shared                                                                    
that the project was recommended  in the report [Recommended                                                                    
Medicaid Redesign  And Expansion  Strategies For  Alaska] by                                                                    
Agnew Beck  (copy on file)  and reminded the  committee that                                                                    
she  provided two  handouts related  to  the project  titled                                                                    
"Seven Best Practices" (copy on  file) and "Washington State                                                                    
Medicaid:   Implementation  and   Impact  of   "ER  is   for                                                                    
Emergencies" Program (copy on file).                                                                                            
1:35:20 PM                                                                                                                    
Representative  Wilson  asked  whether  statute  change  was                                                                    
necessary to  implement the  programs. Ms.  Shadduck replied                                                                    
that  DHSS  was  expressly  seeking  a  statute  change  for                                                                    
primary  care  case  management,  which  did  not  give  the                                                                    
identified Medicaid  population a  choice to  opt in  to the                                                                    
program.  Representative Wilson  asked  whether the  section                                                                    
defined  what would  happen if  the recipient  chose not  to                                                                    
participate in  the program. Ms.  Shadduck responded  in the                                                                    
negative. She explained that  the department would implement                                                                    
the  regulations related  to Section  29. She  read from  an                                                                    
email response from the department (copy on file):                                                                              
     Enrollment in this program would  be voluntary from the                                                                    
     enrollee's perspective at first,  except for those with                                                                    
     multiple   hospitalizations.   Over    time,   as   the                                                                    
     department evaluates  the effectiveness of  the program                                                                    
     and  identifies other  groups  of  enrollees who  could                                                                    
     benefit from this service, the  department may phase in                                                                    
     mandatory participation for additional groups.                                                                             
Ms.  Shadduck   ascertained  that  the  enrollee   would  be                                                                    
required to enroll in a  primary care case management system                                                                    
under  the  provision  in Section  29.  The  enrollee  would                                                                    
initially  have  an option  to  choose  their case  manager.                                                                    
Representative  Wilson  asked  what   would  happen  if  the                                                                    
recipient  chose  not to  participate  in  the program.  Ms.                                                                    
Shadduck answered that  the "teeth" was the  word "shall" in                                                                    
Section 29. Currently, DHSS did  not maintain the ability to                                                                    
force a person  to enroll but the  provision made enrollment                                                                    
mandatory.  She  deferred  to  Margaret  Brodie,  (Director,                                                                    
Division of  Health Care Services, Department  of Health and                                                                    
Social Services) for further clarification.                                                                                     
1:38:33 PM                                                                                                                    
Representative Wilson  was uncomfortable with  changing from                                                                    
"may" to "shall" and forcing  her Medicaid constituents into                                                                    
a program they might not want to participate in.                                                                                
Co-Chair Neuman wanted  to know how the  new Medicaid reform                                                                    
regulations would be enforced.                                                                                                  
Ms. Shadduck  pointed to  the statute  AS 47.07.030  (d) and                                                                    
read the following:                                                                                                             
     The department  may establish as an  optional service a                                                                    
     primary care  case management  system in  which certain                                                                    
     eligible individuals are required to enroll and seek                                                                       
Vice-Chair Saddler wondered whether  the new provision was a                                                                    
requirement or  an option. He  asked whether  the department                                                                    
currently  was using  the optional  authority. Ms.  Shadduck                                                                    
deferred the question  to the department to  answer later in                                                                    
the  presentation.  She  noted   that  the  issue  had  been                                                                    
discussed  thoroughly last  session  as a  part of  Medicaid                                                                    
redesign.  She  explained   that  optional  services  within                                                                    
Medicaid  could  be made  optional  for  a certain  Medicaid                                                                    
population. In  addition, the state  was able to  choose the                                                                    
optional services  it wished to  participate in,  within its                                                                    
Medicaid system.  She offered that  the difference  made the                                                                    
statute language was confusing.                                                                                                 
Representative  Gara  shared that  when  he  worked for  the                                                                    
Attorney  General's  office  it was  customary  to  contract                                                                    
outside  of  the  state  in order  to  utilize  fewer  state                                                                    
employees as  a cost  cutting measure  and that  it actually                                                                    
resulted  in   higher  costs.  He  declared   that  in  some                                                                    
instances  hiring  more  department staff  saved  money.  He                                                                    
noted  that  the  super  utilizer  issue  was  not  new  and                                                                    
remembered   discussing   the   issue   with   former   DHSS                                                                    
Commissioner Bill  Streur about his attempts  to address the                                                                    
problem.  He  wondered why  a  hospital  could not  refer  a                                                                    
person to  another provider  when someone  showed up  at the                                                                    
emergency  room   with  a  non-emergency  room   issue.  Ms.                                                                    
Shadduck answered that federal  law required care for anyone                                                                    
who went  to the ER for  treatment. She pointed to  page 31,                                                                    
lines  3  through   5  of  the  legislation   and  read  the                                                                    
     (4)  a   process  for  assisting  users   of  emergency                                                                    
     departments  in making  appointments with  primary care                                                                    
     or behavioral  health providers  within 96  hours after                                                                    
     an emergency department visit;                                                                                             
Ms. Shadduck  related that the former  provision established                                                                    
the  authority  for  ER's  to  refer  individuals  to  other                                                                    
providers.  Some  individuals did  not  know  how to  access                                                                    
healthcare  other   than  going   to  the   emergency  room.                                                                    
Representative Gara  referred to  the timeframe of  96 hours                                                                    
for an appointment and wondered  why it did not also specify                                                                    
"immediate if  feasible." He thought  that 96 hours  was too                                                                    
long  a  wait  time   for  some  non-emergency  issues.  Ms.                                                                    
Shadduck  believed the  provision  was based  on what  other                                                                    
states  had  done  and  was based  on  the  practicality  of                                                                    
obtaining  primary  care   appointments.  She  deferred  the                                                                    
question to the department  for further detail. She revealed                                                                    
that the hospital association would  be working with DHSS on                                                                    
the project.  Representative Gara  noted that he  would like                                                                    
to see the timeframe amended in the bill.                                                                                       
1:45:30 PM                                                                                                                    
Representative  Guttenberg referred  to  the handout  titled                                                                    
"Washington  State Medicaid:  Implementation  and Impact  of                                                                    
"ER is for  Emergencies" Program" (copy on  file). He stated                                                                    
that the super utilizers  were the most difficult population                                                                    
to deal with  but the most cost effective  when remedied. He                                                                    
asked whether  more information was available  regarding how                                                                    
to  manage  the  super  utilizer  Medicaid  population.  Ms.                                                                    
Shadduck answered  that a  tremendous amount  of information                                                                    
existed on  the topic. She  cited the Agnew Beck  report she                                                                    
mentioned earlier  and noted  that an  extensive explanation                                                                    
on the issue was provided beginning on page 69.                                                                                 
Representative  Kawasaki  asked  what  definition  of  super                                                                    
utilizer  the  state  was   operating  under.  Ms.  Shadduck                                                                    
replied  that  the  bill  did   not  define  the  term.  The                                                                    
department would  set the guidelines  along with  input from                                                                    
the  hospital association.  The department  would relay  its                                                                    
current definition later in the meeting.                                                                                        
Representative  Gara  referred  to   Section  31  and  asked                                                                    
whether the provisions applied to  anyone who entered and ER                                                                    
seeking  care  for  non-emergency  issues  regardless  if  a                                                                    
person was  a super utilizer  or not. Ms.  Shadduck answered                                                                    
in the  affirmative. She elaborated that  the sponsor worked                                                                    
with  Alaska State  Hospital  and  Nursing Home  Association                                                                    
(ASHNHA)  in developing  the provisions.  The consensus  was                                                                    
that  the   provisions  applied  to  all   super  utilizers,                                                                    
Medicaid or not.                                                                                                                
Co-Chair Neuman referred  to page 28, subsection  (d) of the                                                                    
legislation. He read from the bill:                                                                                             
     (d) The department shall [MAY] establish as optional                                                                       
     services a primary care                                                                                                    
     case management  system or a managed  care organization                                                                    
     contract  in  which  certain eligible  individuals  are                                                                    
     required  to  enroll  and seek  approval  from  a  case                                                                    
     manager  or   the  managed  care   organization  before                                                                    
     receiving certain  services. The  purpose of  a primary                                                                    
     care   case   management   system   or   managed   care                                                                    
     organization  contract  is  to   increase  the  use  of                                                                    
     appropriate  primary  and  preventive care  by  medical                                                                    
     assistance    recipients,    while    decreasing    the                                                                    
     unnecessary   use  of   specialty  care   and  hospital                                                                    
     emergency department services.                                                                                             
Co-Chair   Neuman  reported   that   the  legislation   also                                                                    
addressed cost  reduction. He  surmised that  the department                                                                    
would  be  required to  do  something,  but the  costs  were                                                                    
unknown.  He was  concerned about  department mandates  in a                                                                    
fiscal crisis  and a time  of budget cutting. He  noted that                                                                    
the DHSS  budget was  reduced in  other areas.  He requested                                                                    
further  information  related to  the  costs  of the  reform                                                                    
programs.  Ms. Shadduck  responded that  the Senate  Finance                                                                    
Committee members  and co-chairs had taken  the fiscal notes                                                                    
for  the  legislation  very   seriously  and  examined  them                                                                    
thoroughly.  However,  the  committee  recognized  that  the                                                                    
department   required  adequate   resources  to   carry  out                                                                    
Medicaid reform.  She referred to the  document titled "DHSS                                                                    
Fiscal  Impacts for  CSSB074(FIN)am,  version  UA" (copy  on                                                                    
file) that was distributed to  members and provided a 2 page                                                                    
summary of fiscal  impacts. She cited that  the primary care                                                                    
case management  program would  cost $30  thousand in  FY 17                                                                    
but, by FY 18 DHSS would  save $722 thousand and the savings                                                                    
would continue to grow. She  offered that the Senate Finance                                                                    
Committee  chose programs  that would  provide "the  biggest                                                                    
bang for the  buck" and strove to develop  the most balanced                                                                    
options mindful of the state's fiscal situation.                                                                                
Co-Chair  Neuman clarified  that  the House  was a  separate                                                                    
body and  needed to do  its own due diligence.  He requested                                                                    
any backup information regarding cost analysis.                                                                                 
1:53:14 PM                                                                                                                    
Representative   Wilson  requested   information  from   the                                                                    
department   concerning  program   mandates.  Ms.   Shadduck                                                                    
responded that the department would answer the questions.                                                                       
BECKY  HULTBERG,  ALASKA  STATE HOSPITAL  AND  NURSING  HOME                                                                    
ASSOCIATION, provided  brief remarks.  She related  that the                                                                    
high cost of healthcare presented  a challenge to the entire                                                                    
nation.  In  particular,  the  high  cost  of  Medicaid  was                                                                    
spurring  innovation in  other  states  attempting to  lower                                                                    
costs.  Many of  the  projects implemented  in other  states                                                                    
were  different but  shared the  same  themes. She  reported                                                                    
that the themes consisted of  the recognition of the role of                                                                    
behavioral  health,  primary  care  as  the  foundation  for                                                                    
healthcare  reform,   and  finally  payment   reform,  which                                                                    
impacted the  value and cost  of the care. She  believed the                                                                    
journey  through   reform  would  be  arduous   and  involve                                                                    
patience and  resources. She emphasized that  the department                                                                    
would  need   resources  to  help  implement   some  of  the                                                                    
projects. She announced  that ASHNHA wanted to be  part of a                                                                    
solution.  The association  believed  that the  best way  to                                                                    
help manage the  challenges was for the providers  to "be at                                                                    
the  table"  together  with  the state.  She  spoke  to  the                                                                    
important  thematic   elements  beginning   with  behavioral                                                                    
health.  She communicated  that behavioral  health presented                                                                    
the  biggest challenges  to the  association's members.  She                                                                    
referenced  Section  27  and offered  that  the  legislation                                                                    
framed  a  vision  for  change  for  the  behavioral  health                                                                    
system.  She recounted  that the  legislation  called for  a                                                                    
system  that was  comprehensive,  integrated, and  evidence-                                                                    
based. Second,  she remarked that  primary care  would serve                                                                    
as  the "quarter  back" of  the  healthcare team  associated                                                                    
with  the   primary  care   case  management   project.  She                                                                    
supported  the elements  of the  legislation, which  created                                                                    
and  enabled   supports  for   primary  care   providers  to                                                                    
accomplish reform. Lastly, the fee  for service model or the                                                                    
"do more  get paid more"  system was a volume  based system.                                                                    
She remarked  that people wanted  a healthcare  system based                                                                    
on  value  not  volume;  i.e.,   high  quality  care  at  an                                                                    
affordable  cost.  Transformation  was  imperative  for  the                                                                    
underlying  payment  mechanism  that  rewarded  volume.  She                                                                    
detailed  that  the project  took  a  "baby step"  down  the                                                                    
transformational  path  by  introducing a  "shared  savings"                                                                    
portion into the  mix. She thought that  the bill approached                                                                    
the  volume to  value  transition with  pilot projects.  She                                                                    
believed  the  bill was  the  right  step towards  achieving                                                                    
payment  reform  by  enabling   broad  pilot  projects.  She                                                                    
underlined that  the three themes  provided the  backbone of                                                                    
reform and  that reform took  time to implement  and produce                                                                    
savings. She recognized that  the legislature was interested                                                                    
in  immediate savings.  She  communicated  that through  the                                                                    
primary  care case  management  project  small savings  were                                                                    
realized  immediately   and  grew   larger  over   time.  In                                                                    
addition, the project greatly improved the quality of care.                                                                     
2:01:30 PM                                                                                                                    
Ms. Hultberg  continued by providing  a brief  background on                                                                    
the project.  She communicated that  ASHNHA put  forward the                                                                    
ER  project in  2014  through the  Medicaid reform  advisory                                                                    
group process. The program was  included in the department's                                                                    
Medicaid redesign project last  fall [2015]. The program was                                                                    
built  upon  a  proven  model  from  Washington  State  that                                                                    
included the implementation of the  "Seven Best Practices in                                                                    
Emergency Room Care." She listed the practices as follows:                                                                      
   1. Tracking the ER visits to reduce  emergency department                                                                    
     (ED) shopping.                                                                                                             
   2. Implementing patient  education  efforts  to  redirect                                                                    
     care to the most appropriate setting.                                                                                      
   3. Instituting an extensive  case  management program  to                                                                    
     reduce inappropriate emergency department utilization                                                                      
     by frequent users.                                                                                                         
   4. Reducing inappropriate ED visits by  collaborative use                                                                    
     of prompt visits to primary care physicians.                                                                               
   5. Implementing narcotic guidelines that would discourage                                                                    
     narcotic seeking behavior.                                                                                                 
   6. Tracking  data  on   patients  prescribed   controlled                                                                    
     substances by widespread participation in the State's                                                                      
     prescription monitoring program.                                                                                           
   7. Use of a  Feedback loop  by assessing  and reassessing                                                                    
     the effectiveness of the program to ensure the steps                                                                       
     were working.                                                                                                              
Representative Gara  stated that the presentation  topic was                                                                    
only part of the picture and  the other part was that Alaska                                                                    
had the highest healthcare costs in the nation.                                                                                 
Vice-Chair  Saddler  referred  to Ms.  Hultberg's  testimony                                                                    
about  behavioral  health.  He  asked  whether  state  laws,                                                                    
regulations, insurance companies,  and the entire healthcare                                                                    
system  was properly  set up  to "equalize"  behavioral care                                                                    
with medical  care. Ms. Hultberg  answered that she  did not                                                                    
have a broad  enough knowledge base about  other states laws                                                                    
to answer the question.  She qualified that ASHNHA supported                                                                    
the "investment  of resources"  in behavioral  health, which                                                                    
often  resulted   in  reduced  costs.  She   felt  that  the                                                                    
legislation  set  out  a  framework  to  move  forward  with                                                                    
healthcare system improvements.                                                                                                 
Vice-Chair Saddler spoke to  "ancillary unexpected costs" to                                                                    
the reform efforts  regarding behavioral health improvements                                                                    
benefitting  the  healthcare  system   and  he  invited  any                                                                    
discussion  regarding  "clear  ideas"   on  how  to  improve                                                                    
behavioral health care.                                                                                                         
Representative  Edgmon discussed  that  the legislation  was                                                                    
really about "healthcare reform"  and asked whether the term                                                                    
was  a "proper  distinction." Ms.  Hultberg answered  in the                                                                    
affirmative.  She  elaborated  that  Medicare  and  Medicaid                                                                    
drove reform  because the  programs provided  a "significant                                                                    
portion of payment;" especially  for hospitals. Medicare was                                                                    
moving towards value in an  effort to control costs. Changes                                                                    
to Medicare and Medicaid  would ultimately impact the entire                                                                    
healthcare system.                                                                                                              
2:06:19 PM                                                                                                                    
Representative Wilson referred to  a super utilizer tracking                                                                    
system.  She   wondered  how   the  tracking   system  would                                                                    
function. Ms. Hultberg deferred to  DHSS for the answer. She                                                                    
noted that the  program would be implemented  for anyone who                                                                    
utilized the ER. She presumed  that identifying and tracking                                                                    
super  utilizers informed  the project's  savings estimates.                                                                    
Representative  Wilson   asked  whether  a   super  utilizer                                                                    
tracking  system currently  existed. Ms.  Hultberg responded                                                                    
that there  would not  be a  tracking system.  She explained                                                                    
that  medical records,  created when  a person  used the  ER                                                                    
could be  accessed by other  ER departments for  the purpose                                                                    
of providing  better care. She  characterized the  system as                                                                    
an  "information exchange."  Representative Wilson  provided                                                                    
an example of  a patient using various  hospitals. She asked                                                                    
for  verification  that  the  system  would  not  create  an                                                                    
information   network   between  hospitals.   Ms.   Hultberg                                                                    
deferred the questions to the medical providers.                                                                                
Representative  Guttenberg noted  that the  healthcare costs                                                                    
in Alaska  were astronomical  and continued to  increase. He                                                                    
wondered what would  happen to the costs and  the ability of                                                                    
the hospitals to function if nothing was done.                                                                                  
Ms. Hultberg answered initially  about healthcare costs on a                                                                    
national level.  She communicated that healthcare  costs had                                                                    
been  increasing  as  a percentage  of  the  gross  domestic                                                                    
product  (GDP).   The  costs   resulted  in   lost  economic                                                                    
productivity  in other  sectors. She  voiced that  increased                                                                    
healthcare costs  would have a similar  effect statewide and                                                                    
would interfere with a "functioning economy."                                                                                   
Co-Chair Neuman  discussed super utilizers. He  assumed that                                                                    
the concept of having super  utilizers going to primary care                                                                    
providers  sounded  beneficial.  He   stated  that  tens  of                                                                    
thousands of  individuals used  the ER  in Alaska.  He asked                                                                    
how  many  super  utilizers  there were  in  the  state  and                                                                    
wondered whether  the program  was trying  to fix  a problem                                                                    
that did  not exist. Ms. Hultberg  did not have the  data on                                                                    
hand, but noted it was  available through the department and                                                                    
hospital  ED's.  She  deferred  the  question  to  DHSS  and                                                                    
providers.  Co-Chair Neuman  believed  it  was important  to                                                                    
"weigh" the problems throughout  the discussion. He stressed                                                                    
the  importance  of  the committee's  understanding  of  the                                                                    
costs  by  determining  the  size of  the  problem  and  its                                                                    
2:12:58 PM                                                                                                                    
Co-Chair Thompson relayed  that he had a  report that showed                                                                    
information related to super  utilizers and would distribute                                                                    
it to the committee.                                                                                                            
CARLTON   HEINE,  PAST   PRESIDENT,   AMERICAN  COLLEGE   OF                                                                    
EMERGENCY PHYSICIANS,  ALASKA CHAPTER, JUNEAU,  relayed that                                                                    
beside his work in Juneau  in emergency medicine he commuted                                                                    
to  Washington to  work with  the  University of  Washington                                                                    
over the  past six  years and noted  his familiarity  with a                                                                    
similar  project  there  and offered  his  perspectives.  He                                                                    
explained that the federal  Emergency Medicine Treatment and                                                                    
Labor Act  (EMTALA) mandated that  any patient that  went to                                                                    
an ER for care had to  receive a screening exam [triage} and                                                                    
have any  emergency conditions stabilized. A  screening exam                                                                    
always  had to  be  carried out;  therefore,  "the value  of                                                                    
triage  was not  always  effective." He  added that  another                                                                    
provision   in   federal   statute  concerned   "a   prudent                                                                    
layperson"  that  defined an  emergency  as  what a  prudent                                                                    
layperson felt  was a  healthcare emergency.  He exemplified                                                                    
that  if a  person  came  into the  ER  with  chest pain  it                                                                    
represented  the   prudent  layperson's   interpretation  of                                                                    
symptoms that brought the patient to the ER.                                                                                    
Mr.  Heine appreciated  the efforts  of  the legislature  to                                                                    
work on the  Medicaid cost issue. He  declared that changing                                                                    
Medicaid in ways  that did not reduce care  and resources to                                                                    
patients  would  be  very  hard  and  that  achieving  large                                                                    
savings   would  be   based  on   difficult  decisions.   He                                                                    
delineated that a  significant amount of money  was spent on                                                                    
certain areas  of healthcare without  much benefit  and felt                                                                    
efficient reform  began there.  He believed  that the  SB 74                                                                    
was  addressing  those  areas,  particularly  the  ED  super                                                                    
utilizer  program.  Alaska's  high   volume  ER  users  were                                                                    
complicated and numbered in the  thousands. The patients had                                                                    
complex  medical  problems  and almost  all  had  behavioral                                                                    
health or  addiction issues. The individuals  visited the ER                                                                    
"because they did  not know how to do things  in a different                                                                    
way." The  current system  was only "putting  a band  aid on                                                                    
the  problem" and  the  ED  was aware  the  patient was  not                                                                    
receiving quality care. He surmised  that a lot of money was                                                                    
being  spent  and  the patient's  problems  were  not  being                                                                    
2:18:46 PM                                                                                                                    
Mr.  Heine related  that 5  years ago  the Washington  state                                                                    
Healthcare Authority  directed its  Medicaid program  to cut                                                                    
$30 million  from its super utilizer  population. Because of                                                                    
EMTALA  an  ER could  not  merely  limit  the number  of  ER                                                                    
visits.  The ER  physicians, hospital  association, and  the                                                                    
Washington  Medicaid  office  collaborated and  created  the                                                                    
Seven Best Practices  program as a solution.  He shared that                                                                    
the  program implementation  costs were  low and  Washington                                                                    
saved $34  million in  its first  year. He  highlighted that                                                                    
the  program produced  a  significant  savings without  much                                                                    
investment while  increasing the  quality of care.  The bill                                                                    
attempted to  design the program  to fit Alaska's  needs. He                                                                    
addressed the key components of  the legislation. One of the                                                                    
key components of  SB 74 was related to  case management and                                                                    
finding  social  work solutions  to  some  of the  problems.                                                                    
Another  important component  was the  information exchange.                                                                    
He noted  that the  exchange was  similar to  the Washington                                                                    
state ER specific Healthcare  Information Exchange (HIE). He                                                                    
explained that  an ER patient  would be checked  against the                                                                    
database  and  the  information would  help  ED's  determine                                                                    
appropriate  care for  the individual.  He favored  that the                                                                    
information  was  easily  accessible,  contained  a  limited                                                                    
amount  of  data  and  was  "quick  and  easy  to  use."  He                                                                    
commented that  one of  the misconceptions  was that  all of                                                                    
the patients  just needed primary  care and voiced  that the                                                                    
problem was more  complex. He provided examples  such as the                                                                    
patient who  went to the ER  because she was lonely  and the                                                                    
solution  was  to  provide  a cell  phone,  or  the  patient                                                                    
provided transportation  services because  he was  using the                                                                    
ambulance  to  travel to  the  ER.  Creative solutions  that                                                                    
helped the patients and the  state save money was imperative                                                                    
for success. He emphasized that  the program would both save                                                                    
money and  improve the quality  of care, which  were arduous                                                                    
solutions to find. He strongly supported of the bill.                                                                           
2:23:48 PM                                                                                                                    
Representative  Wilson wondered  whether Washington  had put                                                                    
its  Seven  Best Practices  program  in  statute. Mr.  Heine                                                                    
replied  that  some parts  of  the  program were  placed  in                                                                    
statute but other portions were voluntary.                                                                                      
Representative  Gattis asked  about the  patient information                                                                    
exchanges.  She  wondered  whether  patients  had  the  same                                                                    
access  to  information  and  if  acute  care  centers  were                                                                    
considered  to be  an  ER in  terms  of patient  information                                                                    
exchanges. Mr.  Heine replied  that some  of the  nuances on                                                                    
how acute care  was defined would depend on  how the program                                                                    
was set up.  He noted that, in general  privacy laws offered                                                                    
some  limited  access.  He   offered  that  the  information                                                                    
accessible  to  the ER  exchanges  would  be limited  to  ER                                                                    
visits and not necessarily  urgent care visits. The database                                                                    
would be designed  in a way that the  information was shared                                                                    
with  the provider  only if  a patient  met certain  defined                                                                    
2:27:28 PM                                                                                                                    
Representative  Gattis asked  whether  the  patient had  the                                                                    
right  to  request a  copy  of  the information.  Mr.  Heine                                                                    
answered in the affirmative.                                                                                                    
Co-Chair Neuman asked whether patients  had the right to opt                                                                    
out of  the information exchange.  Mr. Heine replied  that a                                                                    
signed  release  was necessary  to  access  a person's  full                                                                    
medical record,  but permission  was not  required regarding                                                                    
whether  a  patient  visited  another  ER.  Co-Chair  Neuman                                                                    
discussed that some individuals  may not want their personal                                                                    
information  in a  database. He  asked  whether the  federal                                                                    
government had access to the  information. Mr. Heine did not                                                                    
believe anyone  outside of the  hospitals had access  to the                                                                    
information. Co-Chair  Neuman wanted to understand  how much                                                                    
information  about   the  patient  was  shared.   Mr.  Heine                                                                    
responded  that  the  database worked  through  the  billing                                                                    
information.  The  amount  of  information  was  limited  to                                                                    
number of  visits and the  facilities visited and  would not                                                                    
contain all of the medical  record details. In addition, the                                                                    
database  did not  produce the  data unless  some subjective                                                                    
criteria  had been  met such  as multiple  visits. A  signed                                                                    
medical record release  would be necessary in  order for the                                                                    
ER to access detailed records.                                                                                                  
2:32:00 PM                                                                                                                    
Co-Chair   Neuman  assumed   that   the  information   would                                                                    
"feedback through  the federal  government" for  any federal                                                                    
based medical program. Mr. Heine  responded that anyone that                                                                    
had access  to the billing  system would have access  to the                                                                    
data.  Co-Chair Neuman  asked for  clarification. Mr.  Heine                                                                    
answered that  the federal Health Insurance  Portability and                                                                    
Accountability  Act  (HIPAA)   laws  delineated  the  access                                                                    
certain  types   of  providers  had  to   various  parts  of                                                                    
patient's  information. He  communicated that  providers had                                                                    
access  to complete  medical records  and billing  companies                                                                    
had only enough access to  the medical information to do the                                                                    
billing portion.                                                                                                                
Co-Chair Thompson presented a  hypothetical scenario where a                                                                    
patient did  not share the  information regarding a  CT scan                                                                    
received  during  one  of  his  multiple  recent  visits  to                                                                    
different  ER's.  The  possibility  then  existed  he  could                                                                    
receive  another  scan  at  great cost  to  the  system.  He                                                                    
wondered  what information  was  shared  on the  information                                                                    
exchange.  Mr.  Heine commented  that  that  instance was  a                                                                    
great  use of  the system.  The system  would show  that the                                                                    
patient had received  a CT scan but not  the results. Beside                                                                    
cost  reduction,  the   exchange  offered  added  healthcare                                                                    
benefits like  knowledge that a patient  recently received a                                                                    
CT scan which  protected the patient from  added exposure to                                                                    
harmful radiation.                                                                                                              
Representative  Munoz  mentioned  that Mr.  Heine  had  been                                                                    
active with  the Front Street  Clinic [public  health clinic                                                                    
in Juneau  serving the homeless population]  and wondered if                                                                    
the clinic  resulted in  reduced ER  visits. She  also asked                                                                    
whether he  believed there was  a role for public  health in                                                                    
reducing ER visits.  Mr. Heine responded that  the reason he                                                                    
became  involved  in  the  clinic because  the  ER  was  the                                                                    
population's  only  other  access   to  healthcare.  He  was                                                                    
convinced that if the clinic  was not in existence ER visits                                                                    
would   increase.   He   described  the   homeless   patient                                                                    
population  as  a  difficult population  to  care  for  when                                                                    
finding  providers   other  than   ER's  to   deliver  their                                                                    
healthcare  and the  clinic helped  save  the system  money.                                                                    
Representative Munoz wondered whether  he was working on the                                                                    
problem with the public health system throughout the state.                                                                     
Mr.  Heine  revealed  that  that   was  the  reason  he  was                                                                    
advocating the project today. He  had begun discussions with                                                                    
Ms.  Hultberg several  years ago  on  how to  expand on  the                                                                    
ideas  from  Washington State  for  adoption  in Alaska.  He                                                                    
wanted to pilot successful programs  and expand them for use                                                                    
in the entire state.                                                                                                            
2:37:36 PM                                                                                                                    
Vice-Chair  Saddler thought  they were  discussing a  larger                                                                    
issue  and  viewed  managed  care  as  an  answer  to  super                                                                    
utilizers  and the  healthcare system  overall. He  wondered                                                                    
whether the  hospital based  ER reduction  project described                                                                    
in  Section 31  was the  same  as the  primary care  project                                                                    
found  in  Section  29  of  the  legislation.  Ms.  Hultberg                                                                    
responded   that  the   Sections   described  two   distinct                                                                    
projects. Vice-Chair Saddler  asked whether Washington State                                                                    
had enough  primary care physicians  to implement  the Seven                                                                    
Best  Practices program.  Mr. Heine  answered that  problems                                                                    
existed because  of a  lack of  primary care  physicians. He                                                                    
expounded that the solutions could  be broad and complex and                                                                    
were not purely  based on primary care.  Primary care follow                                                                    
up  within  a certain  defined  timeframe  was part  of  the                                                                    
Washington program and was achieved.  He understood that the                                                                    
primary care  system in  the state  was "fairly  robust" and                                                                    
the bottleneck  would likely occur in  behavioral healthcare                                                                    
where the  demand outstrips the  supply of  providers. Vice-                                                                    
Chair Saddler asked  whether additional liability protection                                                                    
was needed for ER providers  who triaged the patient "if the                                                                    
emphasis under  the super utilizer reduction  became shoving                                                                    
people off to primary care."  Mr. Heine answered that the ER                                                                    
would  still be  responsible for  doing a  medical screening                                                                    
exam and  provided any  needed ER care.  He stated  that the                                                                    
goal  of  the  program  was to  intervene  and  prevent  the                                                                    
patient's  next unnecessary  visit  to the  ER. The  program                                                                    
wanted super  utilizers to  get the  care they  need without                                                                    
visiting  the  ER.  He  did  not  anticipate  any  liability                                                                    
problems.  Vice-Chair Saddler  asked what  percentage of  ER                                                                    
visits  was  prevented  according to  the  Washington  State                                                                    
ANNE   ZINK,  PRESIDENT,   AMERICAN  COLLEGE   OF  EMERGENCY                                                                    
PHYSICIANS, ALASKA CHAPTER, MAT-SU,  responded that the data                                                                    
showed  a  10.7 percent  reduction  in  super utilizers  and                                                                    
overall 14 percent decrease in low acuity visits.                                                                               
Vice-Chair Saddler asked whether  the Section 29 information                                                                    
exchange  provisions only  captured ER  visits or  would the                                                                    
health  information exchange  contain data  on primary  care                                                                    
and urgent care visits as well.                                                                                                 
2:41:44 PM                                                                                                                    
Mr. Heine answered  that in Washington State  only ER visits                                                                    
would populate  the database because the  problem resided in                                                                    
the  excessive use  of ED's.  Vice-Chair Saddler  pointed to                                                                    
Section 29  related to the super  utilizer reduction program                                                                    
and  understood that  the program  could either  be designed                                                                    
and implemented  by the  department or  contracted out  to a                                                                    
managed  care  organization  (MCO).  He  asked  whether  his                                                                    
understanding  was  correct.  Ms. Hultberg  replied  in  the                                                                    
affirmative.  She   deferred  to  the  department   for  its                                                                    
Representative Gara spoke to a  federal law requiring ERs to                                                                    
stabilize an individual before they  were released. He asked                                                                    
whether a flu or bad  cold required stabilization. Mr. Heine                                                                    
answered that if a person had  a viral illness that not much                                                                    
could be  done; however, if  a person had a  febrile illness                                                                    
like    pneumonia    he   would    prescribe    antibiotics.                                                                    
Representative  Gara   informed  Mr.   Heine  that   he  did                                                                    
significant work with underprivileged  kids who did not have                                                                    
knowledge of the medical system  and went directly to the ER                                                                    
for healthcare. He wondered whether  there was an easier way                                                                    
to  send a  non-emergency patient  to another  facility that                                                                    
would  save  the  system  money.  Mr.  Heine  answered  that                                                                    
nationally   ED's   had   been   researching   "triage   out                                                                    
protocols."  He  detailed  that  an  initial  screening  was                                                                    
required  to make  any kind  of treatment  assessment, which                                                                    
performed  most  of  the initial  triage  which  essentially                                                                    
ruled   out  cost   savings.   Public  education   regarding                                                                    
appropriate use of  the ER was an  important and challenging                                                                    
mission.  He referred  to causing  possible problems  in the                                                                    
reverse  where individuals  should have  gone to  the ER  or                                                                    
doctor  and  decided  to  wait.  Representative  Gara  asked                                                                    
whether the initial ER screening was avoidable.                                                                                 
2:48:03 PM                                                                                                                    
Mr.  Heine answered  that  the EMTALA  law  made a  solution                                                                    
Dr. Zink  provided some examples of  her experiences working                                                                    
in an  ER in an effort  to clarify the issues.  She referred                                                                    
to a  super utilizer in  her ED  that she had  established a                                                                    
care  plan for.  She  notified the  committee  that she  was                                                                    
prohibited  from  sharing  the  plan with  other  ED's.  She                                                                    
contacted the patient's primary  care provider in an attempt                                                                    
to obtain better care for  a patient. She furthered that the                                                                    
patient  had 32  CT scan  within one  year and  continued to                                                                    
experience abdominal  pain. The  provider informed  DR. Zink                                                                    
that Providence  Hospital had  a care  plan for  the patient                                                                    
and the patient  should not be going to  other hospitals. No                                                                    
one had  been aware  of the situation  for three  years. She                                                                    
judged that  the underlying  cause of  her problems  was not                                                                    
addressed  by  the current  system.  She  remarked that  the                                                                    
provisions in  the bill would  allow the hospital  access to                                                                    
enough information  to correctly  care for the  patient. The                                                                    
bill allowed  for better patient  care and cost  savings and                                                                    
she strongly  supported it. She provided  another example of                                                                    
a "frequent  flyer" patient who  would constantly  visit the                                                                    
ER as  a way to calm  her anxiety. She finally  received the                                                                    
proper  mental  healthcare  she needed  through  the  mental                                                                    
health  court subsequent  to  a  trespassing violation.  She                                                                    
felt  that if  the  patient had  previous  access to  proper                                                                    
behavioral  healthcare,   the  situation  could   have  been                                                                    
avoided.  She  voiced that  many  patients  visiting the  ER                                                                    
arrived  because the  social  network  failed. She  believed                                                                    
that a  true honor in  working in an  ER was being  a safety                                                                    
net but  if one  area of  healthcare was  inadequate another                                                                    
area ballooned.  She felt privileged  to perform  triage and                                                                    
help  patients   understand  whether   their  issue   was  a                                                                    
perceived or real  emergency and that placing  the burden of                                                                    
"medical  decisions"   on  the  patient  was   a  risk.  She                                                                    
supported working with systems  that allowed the provider to                                                                    
screen the patient  and have access to a  system that shared                                                                    
information   about  the   patient  in   order  to   provide                                                                    
appropriate  care.  She  revealed  her  frustration  with  a                                                                    
system that allowed  over utilization of the ER  and did not                                                                    
believe the  problem would  be solved  without collaboration                                                                    
between government, insurance  providers, and providers. She                                                                    
cautioned  against  creating  bottlenecks  when  crafting  a                                                                    
solution.  She stated  that  different  problems existed  in                                                                    
different  areas of  the  state and  that  by creating  case                                                                    
management plans  for super  utilizers each  community could                                                                    
identify its  limitations and work in  collaboration between                                                                    
public and  private entities to  find solutions.  She shared                                                                    
that  her care  management  organization  in the  Matanuska-                                                                    
Susitna  Borough  (Mat-Su)   included  the  State  Troopers,                                                                    
Mental  Health Court,  Mental  Health Providers,  hospitals,                                                                    
and  others.   She  emphasized  that  all   members  of  the                                                                    
organization agreed that the ability  for the ER to access a                                                                    
patient  information  database  was  helpful  to  all  other                                                                    
providers.  She spoke  of a  violent high-risk  patient that                                                                    
had  a healthcare  plan. She  wanted his  information to  be                                                                    
available  around   the  state  in  case   he  travelled  so                                                                    
providers  would be  informed and  consistent care  would be                                                                    
provided.  She  illustrated  the   situation  as  a  way  to                                                                    
describe the benefits of the legislation.                                                                                       
2:56:32 PM                                                                                                                    
Dr. Zink  discussed the opiate addiction  problem and seeing                                                                    
the serious health problems  resulting from opiate addiction                                                                    
presenting in  the ER. She  believed there was  a connection                                                                    
between frequent ER users and  mental and behavioral health.                                                                    
She shared  data on super  utilizers from the  Mat-Su Health                                                                    
Foundation. In 2013, one hospital  in the Mat-Su received 27                                                                    
thousand visits,  4429 were visits from  super utilizers and                                                                    
56 percent of the  patients had concurrent behavioral health                                                                    
diagnosis.  Mat-Su Regional  Hospital  super utilizers  cost                                                                    
$73.5 million for facility costs  alone. She often felt like                                                                    
she  was blind  and handcuffed  and unable  to deal  with ER                                                                    
patients due to  the lack of accessible  information about a                                                                    
patient. She supported  the ED component of  the bill, which                                                                    
allowed her to fully practice as an ER physician.                                                                               
Representative Guttenberg referred  to references made about                                                                    
the relationship  between super  utilizers, the  courts, and                                                                    
troopers. He asked whether the  courts had access to medical                                                                    
records.  Dr. Zink  replied in  the negative.  She explained                                                                    
that  the  patient chart  notes  she  composed, which  might                                                                    
include  a  care  plan was  completely  protected  and  only                                                                    
shared  via  a  patient's permission.  The  information  was                                                                    
split  into "different  bundles;"  the  diagnosis, age,  and                                                                    
other necessary  bits of information  were sent  to billers,                                                                    
or  Medicaid   and  Medicare.   The  billing   bundle  never                                                                    
contained  the remaining  information on  the chart  and was                                                                    
never shared  with troopers,  mental health  providers, etc.                                                                    
She furthered  that if a  trooper brought a  suicidal person                                                                    
to the  ER for treatment she  would have access to  his care                                                                    
plan  but   not  the  troopers.   Representative  Guttenberg                                                                    
provided  a  hypothetical  scenario  where  a  mentally  ill                                                                    
person  was  arrested and  a  judge  questioned whether  the                                                                    
person  had a  care plan.  He  wondered whether  a judge  or                                                                    
probation  officer would  have access  to the  person's care                                                                    
plan.  Dr.  Zink answered  that  different  care plans  were                                                                    
written by different providers.  The state would decide what                                                                    
care plans would be  accessible. Washington State authorized                                                                    
ER's  to  write care  plans.  She  relayed that  the  Mental                                                                    
Health Court in  Wasilla asked participants to  sign a HIPAA                                                                    
agreement releasing  their records  to a hospital  and allow                                                                    
the hospital  to share the  information. The  troopers would                                                                    
not have immediate access  without the patient's permission.                                                                    
Representative  Guttenberg asked  for Dr.  Zink's experience                                                                    
with  the  therapeutic courts.  Dr.  Zink  replied that  she                                                                    
became a member of a care  coalition team in the Mat-Su that                                                                    
included  troopers and  the therapeutic  courts a  few years                                                                    
ago in  attempts to  address the  issue. The  court designed                                                                    
the  HIPAA form  that  allowed information  sharing and  she                                                                    
discovered that  numerous ER patients  were involved  in the                                                                    
therapeutic  court. She  voiced that  the hospital  had been                                                                    
moving  forward with  reform  and was  not  waiting for  the                                                                    
legislature to act.                                                                                                             
3:02:39 PM                                                                                                                    
Vice-Chair  Saddler  asked  for more  information  regarding                                                                    
record sharing and  whose records would be  shared. Ms. Zink                                                                    
believed patient  privacy was a shared  concern. She related                                                                    
that  in  Washington  State  a care  plan  on  the  database                                                                    
expired  after  2  years.  Typically,   the  care  plans  in                                                                    
Washington  involved  patient  input. The  majority  of  the                                                                    
plans  were  agreed  upon  between   the  provider  and  the                                                                    
patient.  She  emphasized  that  judging  patients  did  not                                                                    
create a solution and she worked  with the patient to try to                                                                    
find the underlying condition.                                                                                                  
Co-Chair Thompson noted that  department staff was available                                                                    
for questions.                                                                                                                  
Representative   Edgmon  thought   that  the   legislation's                                                                    
approach  created a  better business  model  to provide  the                                                                    
resources to  accomplish the "low hanging  fruit" of reform.                                                                    
He wanted to explore the  idea further. He voiced that there                                                                    
were  many  areas  of  reform  addressed  in  the  bill.  He                                                                    
believed  that  the  reform situation  was  similar  to  the                                                                    
Medicaid expansion  discussion by the need  for resources in                                                                    
order to  build a better  business model that  addressed all                                                                    
areas of  reform to  administer the  appropriate healthcare,                                                                    
"at the right  value." He asked whether  Ms. Hultberg agreed                                                                    
with his  summation. Ms. Hultberg responded  that there were                                                                    
many  moving parts  and pieces  to the  legislation and  she                                                                    
characterized  it  as  "dense." She  communicated  that  the                                                                    
sponsor attempted  to find immediate  areas of  savings. The                                                                    
ER super utilizer reduction was the  one piece of SB 74 that                                                                    
produced  savings. Other  provisions  in SB  74 created  the                                                                    
building blocks of  reform so that in the  future the system                                                                    
achieved    higher   performance.    She   indicated    that                                                                    
transforming  a business  model  was hard.  She voiced  that                                                                    
"disruptive change  was happening  in healthcare  all across                                                                    
the country."  Enhancing primary care and  achieving payment                                                                    
reform would take time and  investment and results would not                                                                    
be  seen for  several  years. The  legislation attempted  to                                                                    
balance  the needs  involved in  creating  a better  system;                                                                    
invest  in the  long  term and  explore  innovative ways  to                                                                    
create some near term savings.                                                                                                  
3:07:58 PM                                                                                                                    
Representative  Edgmon  referred  to behavioral  health.  He                                                                    
wondered whether behavioral health  had a uniform definition                                                                    
or "differing  aspects on  how it  was perceived."  Dr. Zink                                                                    
answered  that when  analyzing the  Mat-Su  health data  the                                                                    
team "struggled"  with the  definition and  did not  think a                                                                    
universal  definition  existed.  She explained  how  the  ER                                                                    
addressed  the  issue.  The ED  department  and  the  Mat-Su                                                                    
foundation defined  a behavioral  health diagnosis  based on                                                                    
the  following aspects  of mental  health: substance  abuse,                                                                    
depression, suicidality, homcidality, or anxiety.                                                                               
Co-Chair Neuman  had read some  of the  information provided                                                                    
by  Mr. Heine  and cited  that  85 percent  of patients  had                                                                    
serious  mental  health  issues.  He also  referred  to  Ms.                                                                    
Zink's testimony  about the patient with  mental illness who                                                                    
was  constantly utilizing  the ER  as  a way  to manage  her                                                                    
anxiety. He  asked whether  a managed  care plan  would have                                                                    
stopped the  behavior. Ms. Zink replied  in the affirmative.                                                                    
She  reminded  Co-Chair  Neuman  that  she  had  received  a                                                                    
managed  care program  from the  therapeutic courts  and the                                                                    
behavior stopped. The hospital had  only seen the woman once                                                                    
in the  past year and  not at all  in the current  year. She                                                                    
spoke to  the successes  the individual had  as a  result of                                                                    
the  managed  care plan.  Co-Chair  Neuman  referred to  Ms.                                                                    
Zink's other example of the  women who received 32 CT scans.                                                                    
He thought that  systems should already be in  place to deal                                                                    
with  the  issue.  Ms. Zink  answered  that  she  completely                                                                    
agreed  and  was  frustrated every  time  something  similar                                                                    
happened. She elaborated that  healthcare existed in "silos"                                                                    
and that  the ER was a  fast paced environment where  it was                                                                    
difficult to spend  the time to get all  of the information.                                                                    
The information  sharing system proposed  in the  bill would                                                                    
"push" enough  information in front  of her to  request more                                                                    
complete records if warranted.                                                                                                  
3:11:56 PM                                                                                                                    
Representative  Munoz believed  there  needed  to be  fiscal                                                                    
restraint on the part of  the hospitals as well. She thought                                                                    
that 32 scans  were outrageous. Ms. Zink  answered that part                                                                    
of the ER's  obligation was to ensure there was  not a life-                                                                    
threatening  problem  and  chest  or abdominal  pain  was  a                                                                    
trigger for high cost intervention.                                                                                             
MARGARET   BRODIE,  DIRECTOR,   DIVISION   OF  HEALTH   CARE                                                                    
SERVICES,  DEPARTMENT OF  HEALTH  AND  SOCIAL SERVICES  (via                                                                    
teleconference),  relayed   that  the  department   began  a                                                                    
program  for  super  utilizers   over  two  years  ago.  The                                                                    
department initially  defined a  super utilizer as  a person                                                                    
who used the ER more than  five times in an 18 month period.                                                                    
Currently,  5,155 individuals  were  enrolled  in one  super                                                                    
utilizer program  and 19  enrollees in  a different  type of                                                                    
program.  She  detailed  that   the  department  employed  a                                                                    
private contractor  called MedExpert for the  larger program                                                                    
which  offered telephonic  services  statewide. The  company                                                                    
provided  case management  services over  the phone  and had                                                                    
medical professionals  available. The program  was voluntary                                                                    
and  the enormous  response was  unexpected.  The model  was                                                                    
geared   towards  serving   large  populations   over  large                                                                    
geographical  regions. The  contractor established  a health                                                                    
baseline,  resource  utilization   pattern,  and  determined                                                                    
whether family  or community support was  available for each                                                                    
enrollee.   Medical    professionals   were   telephonically                                                                    
available  for  the  enrollees to  call  anytime.  MedExpert                                                                    
staff  worked  with  the individual  and  her  providers  to                                                                    
ensure that the patient was  receiving the right health care                                                                    
in the  right setting  as well as  providing follow  up. The                                                                    
contractor  also  brought   in  appropriate  social  service                                                                    
agencies  to assist  enrollees with  other aspects  of life.                                                                    
She revealed  that the program  had been underway  for about                                                                    
1.5 years  and saved $6 million  in general funds (GF)  as a                                                                    
3:16:50 PM                                                                                                                    
Ms. Brodie  continued that DHSS  initiated a  smaller second                                                                    
program  that involved  "face to  face"  contact; which  was                                                                    
more  costly;   therefore,  a  much  smaller   program.  She                                                                    
communicated  that the  contractor employed  for the  second                                                                    
program was Qualis  Health and began in  November, 2015. The                                                                    
investment  results were  not yet  available. Qualis  Health                                                                    
will  eventually work  with a  total of  40 to  60 volunteer                                                                    
enrollees within the next six  months. The program consisted                                                                    
of  nurses, social  workers, case  workers, and  a physician                                                                    
consultant   that   provided   an  initial   screening   and                                                                    
comprehensive  assessment.  The   model  required  extensive                                                                    
outreach  to the  communities, which  began  by engaging  in                                                                    
meetings  with numerous  stakeholders throughout  the state.                                                                    
She  remarked  on  the Med  Expert  program,  which  offered                                                                    
unique follow  up by providing extensive  information on the                                                                    
enrollee's  medical  condition  enabling the  individual  to                                                                    
make better  healthcare decisions for themselves.  She spoke                                                                    
to Vice-Chair  Saddler's questions regarding  the Washington                                                                    
State's ER  program and Medicaid.  Within the first  year of                                                                    
the program's inception, the ER  visits by Medicaid patients                                                                    
declined by  approximately 10  percent and  visits resulting                                                                    
in  prescriptions  of  controlled   substances  fell  by  25                                                                    
percent for the Medicaid population.                                                                                            
Representative Kawasaki  referred to Section 29  of the bill                                                                    
and specified  subsection d and read,  "the department shall                                                                    
establish  as   optional  services   a  primary   care  case                                                                    
management system".  He wondered why  the program had  to be                                                                    
optional.  Ms. Brodie  answered that  currently the  program                                                                    
was  optional because  the  initial  super utilizer  program                                                                    
called  the  "Care  Management  Program"  was  considered  a                                                                    
"locked-in"  program  where  a  patient was  locked  into  a                                                                    
specified provider  and pharmacy and Medicaid  would not pay                                                                    
for services if  they were provided by  another physician or                                                                    
pharmacy; the program was  very restrictive for individuals.                                                                    
She indicated  that the  program's regulations  required the                                                                    
department  to obtain  complete medical  records to  prove a                                                                    
patient was  utilizing services much more  than they should.                                                                    
The bill's  language, explicitly the use  of "shall" allowed                                                                    
the department to enroll a  person based on over utilization                                                                    
of services. She qualified that  the department analyzed the                                                                    
data to determine the causes  of utilization and individuals                                                                    
with serious  conditions that  required extensive  care were                                                                    
legitimate   and  ruled   out.  She   maintained  that   the                                                                    
department  considered appropriate  use and  did not  solely                                                                    
rely on "statistical outliers" to enlist participants.                                                                          
3:22:53 PM                                                                                                                    
Ms.  Shadduck   referenced  page   28,  subsection   d,  the                                                                    
language,  "shall establish  as  an  optional service."  She                                                                    
recapped  that the  words "optional  service" had  to remain                                                                    
listed in  statue in  the bill.  She reminded  the committee                                                                    
that  the  legislature  had  to  grant  permission  for  any                                                                    
optional  Medicaid service.  Certain Medicaid  programs were                                                                    
required by  the federal government  and some  programs were                                                                    
optional but  Alaska required legislative approval  for DHSS                                                                    
to participate in an optional Medicaid service.                                                                                 
Representative Kawasaki referred to  testimony by Ms. Brodie                                                                    
about  the super  utilizer program  being  optional for  the                                                                    
patient  and requested  clarification.  Ms. Brodie  answered                                                                    
that  the super  utilizer programs  currently in  place were                                                                    
voluntary. She explained that many  of the participants also                                                                    
qualified for  the mandatory care management  program and by                                                                    
volunteering  for the  super utilizer  programs the  patient                                                                    
was  participating in  a less  restrictive program  than the                                                                    
department's mandated program.                                                                                                  
Vice-Chair Saddler  noted that  AS 47.07.030(d)  referred to                                                                    
optional  services  and  the   mandatory  services  were  in                                                                    
paragraph  (b).   He  cited   page  28,   line  29   of  the                                                                    
legislation,  and  read,   "shall  require  recipients  with                                                                    
multiple  hospitalizations." He  wondered  who defined  what                                                                    
multiple  was.  Ms.  Brodie  answered  that  the  department                                                                    
established  a definition  of  three or  more  visits by  an                                                                    
individual  in a  12-month period;  the number  totaled over                                                                    
12,600   Medicaid  recipients.   Vice-Chair  Saddler   asked                                                                    
whether  the department  wanted  the  definition in  statute                                                                    
rather  than  regulation.  Ms.   Brodie  answered  that  the                                                                    
department  would need  flexibility to  make changes  to the                                                                    
definition in  the future. She  related that  other services                                                                    
besides  ER   visits  were  being  over   utilized  and  the                                                                    
department needed  to determine  and address  that excessive                                                                    
utilization  over   time.  Vice-Chair  Saddler   stated  the                                                                    
following  from  the   legislation,  "the  department  shall                                                                    
require recipients  to enroll in  a primary  care management                                                                    
system." He asked  what would happen if a  person refused to                                                                    
enroll.  Ms.   Brodie  answered  that  at   that  point  the                                                                    
department would determine  whether the individual qualified                                                                    
for  the  mandatory   care  management  program.  Vice-Chair                                                                    
Saddler restated the question.  Ms. Brodie responded that if                                                                    
a patient would  not enroll the state would not  pay for any                                                                    
Medicaid  services but  the patient  was  then eligible  for                                                                    
"fair  hearing rights."  She  commented  that most  patients                                                                    
would enroll.                                                                                                                   
3:28:46 PM                                                                                                                    
Vice-Chair  Saddler   wondered  about  the   likelihood  the                                                                    
department would be challenged  legally. He referred to page                                                                    
28, lines 19 through 21 and  noted that the bill allowed for                                                                    
either DHSS to  create a managed care system  or to contract                                                                    
with an existing MCO. He asked  which was more likely and if                                                                    
contracting with  MCO's would even  be an option  in Alaska.                                                                    
Ms.  Brodie  replied  that  the  state  would  contract  the                                                                    
services out if contracting was  less expensive and would be                                                                    
the preferred option. The key was  that the option had to be                                                                    
affordable for  the state. Vice-Chair Saddler  asked whether                                                                    
the MCO had to exist in  Alaska. Ms. Brodie responded that a                                                                    
company could  be headquartered out-of-state but  would have                                                                    
to have a presence in state.                                                                                                    
Representative Wilson  deduced that  if a  recipient refused                                                                    
to  participate  in a  voluntary  or  mandatory program  the                                                                    
department  would expel  the  individual  from Medicaid  and                                                                    
cause the individual to go the  ER for more costly care. Ms.                                                                    
Brodie  answered  that  the   scenario  was  what  currently                                                                    
happened with super utilizers.                                                                                                  
3:32:10 PM                                                                                                                    
Representative Wilson  surmised that the only  change in the                                                                    
legislation was  that both programs would  be mandatory. She                                                                    
believed  the end  result  would  be the  same  as what  was                                                                    
happening now  because the person  had no other  option than                                                                    
to go  to the ER.  Ms. Brodie responded that  the difference                                                                    
was in  the number of  individuals the program  could serve;                                                                    
the new definition for super  utilizer adopting 3 or more ER                                                                    
visits [in a twelve month  Period] captured over 14 thousand                                                                    
more  people it  could steer  to the  appropriate healthcare                                                                    
provider. Representative  Wilson stated that  the department                                                                    
could currently  change program parameters  without statute.                                                                    
Ms. Brodie  agreed. She detailed  that the key was  that the                                                                    
locked  in  care management  program  was  only designed  to                                                                    
serve  a  maximum  of 300  people.  Currently,  over  14,000                                                                    
people  qualified. Representative  Wilson surmised  that the                                                                    
department already had  a program. She could  not figure out                                                                    
why statue was  needed. Ms. Brodie answered  that statue was                                                                    
necessary because  if a person  chose not to  participate he                                                                    
could continue to over utilize  services. She added that the                                                                    
additional enrollees would overwhelm  the program in a short                                                                    
period  of time.  There  would be  13,900  people who  would                                                                    
continue  to over  utilize services  and  Medicaid would  be                                                                    
required to pay.                                                                                                                
Representative  Wilson  reiterated  her  concerns  regarding                                                                    
super utilizers  that refuse to  participate in  the program                                                                    
frequenting the  ER. Ms. Shadduck  replied that if  a person                                                                    
did  not  enroll  the  department   could  stop  paying  for                                                                    
Medicaid  benefits. She  spoke to  her personal  experiences                                                                    
working in  Fairbanks with case management  and related that                                                                    
education helped  participants learn how to  use appropriate                                                                    
services. She believed there would  always be "outliers" who                                                                    
would refuse case management enrollment  but the state would                                                                    
no  longer  pay  the  Medicaid benefits.  She  believed  the                                                                    
programs would sill save state GF money.                                                                                        
Co-Chair  Thompson  guessed  that  only a  small  number  of                                                                    
people would refuse to participate.                                                                                             
Representative Gara deduced that  federal law required an ER                                                                    
to provide care at its own  expense. In addition, the use of                                                                    
the word, "shall"  in SB 74 authorized the state  to cut off                                                                    
Medicaid benefits  upon participation refusal.  Ms. Shadduck                                                                    
replied  in  the   affirmative.  Representative  Gara  asked                                                                    
whether there was  any evidence to prove that  visits to the                                                                    
ER  were diverted  by providing  behavioral health  to super                                                                    
utilizers.  Ms.  Brodie answered  that  the  costs of  super                                                                    
utilizers had been reduced by  approximately $2,400 per year                                                                    
per person. She indicated that  providers had up to one year                                                                    
to bill  for services  so the specific  data related  to the                                                                    
Medicaid expansion population was not yet known.                                                                                
3:40:03 PM                                                                                                                    
Representative  Gara relayed  from personal  experience that                                                                    
there was  an incentive for  providers to steer  patients to                                                                    
use expensive  medical "equipment." He wondered  whether the                                                                    
department had  the authority  to deny  unnecessary imaging.                                                                    
Ms. Brodie  answered that prior authorization  for physician                                                                    
owned  imaging  was required  by  DHSS  for the  past  three                                                                    
years. She clarified that imaging  service rendered at an ER                                                                    
did  not require  prior  authorization. Representative  Gara                                                                    
asked  whether the  department  could enforce  inappropriate                                                                    
use  of imaging  by  an  ER. Ms.  Brodie  answered that  the                                                                    
department  could  determine  inappropriate  use  by  an  ER                                                                    
during its  utilization review process  within three  to six                                                                    
months  after  the  event  happened  and  would  direct  the                                                                    
patient to the proper provider.                                                                                                 
3:42:10 PM                                                                                                                    
Representative Gara  hypothesized the  scenario of  ER abuse                                                                    
of the  Medicaid program through overutilization  of imaging                                                                    
services. He  wondered whether  the department  could refuse                                                                    
Medicaid  payment  to  ED's  for  unnecessary  imaging.  Ms.                                                                    
Brodie  responded that  ER's use  of imaging  was a  medical                                                                    
decision  and  the  department was  not  qualified  to  make                                                                    
judgements regarding medical  decisions. Representative Gara                                                                    
asked  why the  department could  enforce private  physician                                                                    
overuse but not ER overuse.  Ms. Brodie answered that it was                                                                    
due to the  fact that the ER  did not have time  to wait for                                                                    
preauthorization   paperwork  in   an  emergent   condition.                                                                    
Representative Gara  wanted to  know what would  happen when                                                                    
the condition  was not an  emergency and the use  of imaging                                                                    
was abused  by the ER.  Ms. Brodie answered that  ER doctors                                                                    
were  professionals  and  the department  did  not  want  to                                                                    
second guess their decisions.                                                                                                   
Representative  Munoz asked  what the  state paid  for a  CT                                                                    
scan. Ms. Brodie would follow up and provide the answers.                                                                       
Vice-Chair Saddler  referred to the "lock-out"  program. Ms.                                                                    
Brodie corrected that the  mandatory care management program                                                                    
was known  as the lock-in program.  Vice-Chair Saddler asked                                                                    
whether  the lock-in  program differed  from the  Med-Expert                                                                    
administered   program.   Ms.   Brodie   answered   in   the                                                                    
affirmative.  Vice-Chair Saddler  asked  whether the  Qualis                                                                    
Health run program  was a third program.  Ms. Brodie replied                                                                    
in the affirmative. Vice-Chair Saddler  asked whether any of                                                                    
the described managed care efforts  would be eliminated with                                                                    
passage  of  SB 74.  Ms.  Brodie  replied that  DHSS  viewed                                                                    
passage  of  the bill  as  evolving  the programs  into  the                                                                    
reform efforts.  Vice-Chair Saddler asked for  more detailed                                                                    
information about  the three programs. Ms.  Brodie agreed to                                                                    
follow up.                                                                                                                      
3:46:52 PM                                                                                                                    
Representative Wilson  asked for more  information regarding                                                                    
how  many  enrollees  refused to  participate  in  the  case                                                                    
management  programs.  Ms.  Brodie replied  that  she  would                                                                    
follow up with the information.                                                                                                 
CSSB 74(FIN) am was HEARD  and HELD in committee for further                                                                    
Co-Chair Thompson addressed the meeting schedule for the                                                                        
following day.