Alaska Health Policy Review

The Alaska Health Care Commission convened for the first time on February 27 and 28 in Juneau. The commission was created in the Department of Health and Social Services by Governor Sarah Palin's administrative order #246 on December 4, 2008. The commission consists of seven voting members appointed by the governor, three nonvoting members, and an executive director.

The purpose of the commission is to "provide recommendations for and foster the development of a statewide plan to address the quality, accessibility, and availability of health care for all citizens of the state." By January 15, 2010, the commission will submit a report of its activities, and its recommendations to the governor and the Legislature.

This is a summary of some of the highlights of those meetings. Over the course of the two days, present commission members exchanged introductions, shared information, and established procedures. Most interestingly during the first day of meetings, members discussed some of their guiding principles and tried to identify priority issues for the commission's immediate consideration.

A Few Guiding Principles

Ryan Smith of Soldotna has been chief executive officer of the Central Peninsula General Hospital since 2006. He fills a commission seat "designated for the Alaska State Hospital and Nursing Home Association". Smith presented the Hospital Association's principles for reform based on national reform efforts. The four guiding principles were:

continuing to improve health care quality and efficiency
establishing health care accountability
improving and expanding health care access
strengthening public and private health care programs

Smith also presented the results of a Kromer Group public opinion survey conducted in Southeast Alaska. Key health care concerns of individuals were identified as:

care close to home
low costs
good quality

The general sentiment of those surveyed was summarized as, "I don't mind paying for health care, but I can't afford what's available now."

Keith Campbell is a retired hospital administrator and national leader of the American Association of Retired Persons (AARP). He fills a commission seat representing health care consumers. Campbell stressed the importance of learning from other state health reform efforts and system overhauls. In particular, he asked commissioners if research into California, Oregon, Iowa, Massachusetts, and Vermont attempts at comprehensive health policies was available.

Representative Wes Keller of Wasilla has represented the Wasilla area in the Alaska State House of Representatives since 2007. Keller was "appointed by House Speaker Mike Chenault to fill a non-voting seat representing the House on the commission". Keller said, " ... what makes me love Alaskans is that we're very individualistic and independent, but the fact is that our health care is not individualistic and independent, but comes from a pool. What I do to my body might very well affect your bottom line. That's something culturally that's hard for Alaskans to swallow."

Jeff Davis has served nine years as president of Premera Blue Cross Blue Shield of Alaska, and previously was Premera's vice president of network development in Alaska, Washington and Oregon. He represents Alaska's health insurance industry on the commission. He identified Blue Cross/Premera's public policy principles as the following:

everyone deserves to obtain appropriate care
a person is obliged to figure out how to finance care
people should have a choice of coverage
the government should subsidize those who can't afford care and should regulate the industry

He stressed that the private market was the best engine of innovation, adding, "we should research what works."

Davis noted the unacceptable rates of failed care or redundant care that drive up costs as an opportunity for change. He raised the question of why people don't take advantage of accessible care or find out what's available to them. Davis asked, "Have we stigmatized public assistance?"

The Commission's Priorities

On the second day the commission met, the discussion focused on establishing priorities. According to Palin's executive order, the duties of the commission are to:

1. serve as the state health planning and coordinating body;
2. consistent with state and federal laws, provide recommendations for and foster the development of a:

A. comprehensive statewide health care policy;
B. strategy for improving the health of Alaskans that includes

i.   encouraging personal responsibility in prevention and healthy living for all residents of the state
ii.   a reduction in health care costs for all residents of the state to be below the national average;
iii.   access in communities of the state to safe water and wastewater systems;
iv.   the development of a sustainable health care workforce in the state;
v.   quality health care being accessible for all residents of the state; and
vi.   increasing the number of residents of the state who are covered by health care insurance

3. submit a report to the Governor and the Legislature on or before January 15, 2010 regarding the commission's recommendations and activities.

The broadly detailed duties of the commission made for wide-ranging round table talks. Considerable time was spent trying to figure out how the body was to proceed given the large scope of the project handed to them by the governor.

As a starting point, the group acknowledged that the state lacks a cohesive statewide health plan. One of many problems identified as a result of this is the lack of comparative data for cost and quality. Measures of cost and quality being developed are only in infancy -- and at the moment, very expensive. It's difficult to discern cost savings that are more likely to appear in the long term. Furthermore, since Alaska currently requires no mandatory reporting, it is hard to issue health grades such as found with Washington health clinics, where physicians worked together to define quality measures and a system for reporting and recording data.

Underlying all the discussion was the need to bring down cost and to address the issue of access to health care. Other important issues the commission believed they should address included:

coordinating services and standardizing practices
regulation
access
reform
listening and responding to the needs of individual Alaskans.

With cost, access to care, and the six areas identified as requiring strategies for improving care identified in the governor's order in mind, the commission began to narrow its focus on three key issues to address in the near future: capitalizing on federal dollars, the present shortage of health care providers, and consumer responsibility.

Capitalizing on Federal Dollars

Conversation throughout the day was speckled with mention of capturing funds in the federal stimulus package. The consensus was that it was still too early to tell precisely how much money might be available, what programs might qualify for funding, or what steps will be required in order to obtain funding. Commission members did point to health information technology as a potential area for receiving funds. This included both pooling consumer information and the creation of a health records database.

The need for new Alaska mini COBRA laws to help continue health insurance for the recently unemployed was identified as one specific change needed to receive new federal funds.

The Workforce Issue

Addressing the shortage of health care providers in Alaska was identified as a target for immediate strategizing for a solution. Pediatrics, internal medicine, and family care were three areas named as especially in need. Possible solutions to the problem posed were increasing loan forgiveness and repayment programs, and offering monetary incentives to attract primary care providers to remote areas of the state.

Dr. Larry Stinson, the commissioner appointed to represent Alaska health care providers, drew attention to importance of where students conduct their residencies. "Where you train, you stay," he said, and noted a 75 percent retention rate of students in the WWAMI program who had residencies in Alaska.

Consumer Responsibility

Commission members agreed that people taking better care of themselves is the most cost-effective way to lower health care costs. According to Commission Chairman Dr. Jay Butler, personal lifestyle choices account for 50 percent of determining a person's health. Linda Hall is the director of the Division of Insurance in the Department of Commerce, Community and Economic Development, a "non-voting representative of the executive branch." She encouraged the commission to make personal accountability and prevention high priorities. Dr. Stinson noted that he would be happy if he received as little as 10 percent compliance with his patients.

How do you help Alaskans take control of their health? Possible methods involved promoting physical education and health education in school, with hints that the school year might even need to be expanded to allow for instilling vital information and healthy habits.

Dr. Butler held out hope for the future of virtual education, but online remedies to curbing health care costs may take some time to materialize. As noted the day beforehand, for what data is out there, only two to five percent of patients access online information. Finding ways to encourage the public to take advantage of available information, Commissioner Ryan Smith called, "almost a health behavior issue."

As far as the allure of incentives go (commission members reiterated this belief repeatedly on both days), valuable information and the promise of good health can't compete with the appeal of money. A wide-array of money incentives, either in practice or for consideration, were proposed, including:

cash for filling out wellness surveys
consumer credits for demonstrating a reduction in health risks
physician rewards for patients reducing health risks
a PFD-like payout for good health behavior

Related Matters

The commission also took time to consider proposed legislation. Two bills currently in the legislative hopper, HB 25 and HB 75, both propose to create different, long-term commissions. HB 25 would establish the Alaska Health Reform Policy Commission in the Department of Health and Social Services. HB 75 would establish the Alaska Health Commission.

These bills would establish a commission resembling the current one. The number of commission members would increase, however, and their duties would both expand and become more narrowly defined. It is unclear how and if these proposed commissions would carry forward the work of the current commission.

It was decided that the current commission should not declare support for any one particular bill because of the likelihood that bills will change substantially or might never pass into law. Several members noted that the legislative process would invite a far greater number of voices lobbying for different interests into the process, whereas the current commission's membership is small. A subcommittee was created to review HB 25 and 75. The subcommittee will report to the full commission and then members will perhaps draft recommendations that would provide legislators help in crafting legislation.

Commission members will meet again in either late April or May. Chairman Jay Butler, M.D., expressed pleasure over how well the commission had cohered during this initial meeting and over how much ground had already been covered. There was the shared optimism echoed from time to time by different members that if changes to the state health care system produced even small savings, those savings over time translate into billions of dollars.

Gavel to Gavel Alaska, a service of KTOO-TV Juneau, provides complete audio recordings of the Health Care Commission meetings online. Click on their "Live/Archived Audio" link, and enter February 27 and 28 into the calendar. More information on the Alaska Health Care Commission is available online.

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