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October 20, 2009 Vol 3, Issue 20


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Interview with Anchorage Mayor Dan Sullivan
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Discussion with Rep. Wes Keller
Discussion with Deputy Commissioner Bill Streur
AHPR Staff and Contributors
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From the Editor

Dear Reader,

Today is soapbox day. I am compelled to stand on the digital soapbox and talk about "personal responsibility." Among legislators, administrators, commentators, and policy wonks, when the conversation turns to problems in our health care system and the need for health reform, suddenly the conversation is inundated with exhortations of "personal responsibility."  It sounds something like this, "If people would stop smoking, eat less, drink less, get off the couch and exercise more, then they would be healthier and the cost of health care would go down." Who can argue with that? The implication is this: if people get sick and need health care, it is probably their own fault because they did not take "personal responsibility." The problem is not in the system, it is in individuals.

Yes and no. In fact, I would say mostly no. Here is an analogy. Someone is driving around town and they accidentally crash their car into a light post.  Why did they crash? One could argue that they failed to take "personal responsibility" for safe driving. Blame assigned. Problem solved. No need to look further.

However, if we do decide to investigate a little more carefully, the tidy little blame-the-victim package starts to unravel. Did the car have a manufacturing defect or a faulty repair that contributed to the crash? Were the tires properly manufactured? Was the intersection properly deiced and sanded? Did a child or a drunk dash out in front of the car? Did another person run a red light? Was the intersection properly designed and maintained? Was there a huge pothole due to a lack of funding for adequate road maintenance, or a chunk of metal debris in the street?

Did legislators exercise their "governing responsibility" by allocating sufficient funds and resources for construction, repairs, and maintenance of safe roads? Did they enact sufficiently strong policies to restrict cell phone usage among drivers, and to restrict the sale and use of alcohol, particularly by drivers? Have the schools taken "educational responsibility" for promoting a culture of safe driving among their students and staff? Do automobile manufacturers exercise "manufacturers' responsibility" by spending billions of dollars a year to promote a culture of fast, high risk driving to sell more cars? Do fast food retailers assume "food vendors' responsibility" when they spend billions researching and advertising foods drivers are most likely to buy and eat while driving, despite the known hazards?

Was it just a matter of "personal responsibility," and how far does that perspective get us in understanding the social, cultural, political, and commercial contributions to the collision?

Back to "personal responsibility" in health issues. An individual buys a pack and lights up a cigarette. One way to look at it is that it is a matter of "personal responsibility." However, billions of dollars a year are spent in research and marketing backed by legions of industrial psychologists and sociologists and pharmacologists who have one goal in mind: to make sure that people will purchase and smoke cigarettes, and that they will do it daily, decade after decade. The whole point of this massive effort is to subvert "personal responsibility."

Food manufacturers research, produce, and package sugary, salty, fatty foods with long shelf lives to be profitably sold by mini-marts, gas stations, and fast food outlets that have proliferated on every corner across the nation. All media are saturated with billions of dollars of scientifically engineered advertising designed to encourage endless consumption of these commodities. The targeted and desired result of these efforts is to extinguish the vestigial role of "personal responsibility" in the consumption of food.

The health insurance industry maximizes profits by selling health insurance to healthier populations who are less likely to use it, denying health insurance to those who are more likely to use it, denying the claims of the desperately ill who do use it, and selling "high deductible" health insurance policies to low-income families who will be forced into bankruptcy before they ever see the first health insurance dollar. In this commercial environment the role of "personal responsibility" is largely irrelevant.

The concept of "personal responsibility" in the absence of a discussion about the responsibility of government, industry, the regulatory agencies, and elected officials is a diversion from serious analysis. Everyone needs access to high quality health care. Sound public policies based in socio-economic analysis can get us there. Jumping to the blame-the-victim ideology of "personal responsibility" will not.

OK. I feel better now.

In this issue, we eavesdrop on a discussion about health policy and the Cato Institute by Representative Wes Keller, a practical discussion about the state's current role in the provision of health care by Deputy Director Bill Streur, and we interview the new mayor of Anchorage, Dan Sullivan, who discusses health issues and pushups. As always, your comments and suggestions appreciated.

Lawrence D. Weiss PhD, MS
editor, AHPR
ldweiss@gmail.com
Interview with Anchorage Mayor Dan Sullivan

Mayor Dan Sullivan
Anchorage Mayor Dan Sullivan was sworn in as mayor on July 1, 2009. Prior to that, he was Anchorage Assembly member, 1999-2008, and chair, 2006. He is founder and co-owner of McGinley's Pub in downtown Anchorage, which opened in 2006. He also owns Sullivan & Associates (1986-present), a firm specializing in government relations and business development consultancy. In this interview, the mayor discusses the municipality's relationship with the Anchorage Neighborhood Health Center, the city's role in maintaining the health of Anchorage residents, his considerable ability to do pushups, and more. The interview was conducted October 16, 2009, in the mayor's office. It has been lightly edited for length and clarity.

AHPR: Mayor Sullivan, conceptually, what in your view is the legitimate or desirable role municipal government should play in terms of the health and safety of residents and visitors to Anchorage?

Sullivan: You know that's a great question. The municipality doesn't just have a role; it has an obligation. And, we look at public safety, for example, and we think in terms of your police and your fire, but public safety also includes having a healthy city. For example, everybody right now has concern about the H1N1 virus. It's a legitimate role of city government to ensure that its citizens are safe from a pandemic of any kind. Being in the vaccination business to help prevent mass flu outbreaks, I think is a legitimate purpose of government. Certainly, any catastrophic sort of reaction or relief, or provisions -- all legitimate roles of government to play.

I think as the city has matured, we've gotten to where we probably have expanded services. Oftentimes they're a function of the state, but I think modern cities realize that they can deliver things on a local level maybe more efficiently and perhaps more comprehensively. So they've assumed some of the roles that were traditionally state functions, and I think we've done that here in Anchorage as well. There's a legitimate role, obviously, for a good, viable health department and I think we've got a good one.

AHPR: You have the Anchorage Health and Human Services Commission, and as I said by way of full disclosure, I am on it. It is made up of volunteers from this community, appointed by the mayor, who are for the most part, experts in their various health fields. In your view, what role should the health commission play vis-à-vis health-related policies established by the municipality?

Sullivan: You know, the health commission is really no different than a lot of our other boards and commissions. We have them in place to literally provide good, solid, sound advice to the policymakers. Typically, the commissions don't make policy, but they give the advice that develops policy. And that's why you try and get those commissions staffed with people that really do have expertise in various fields. So, it really serves as a great guiding body for myself and the municipal manager as we try and develop policies that affect 280,000 people. We want good advice, and that's what the commission does. It provides good advice, [but] not always good advice. What I mean by that is, it doesn't mean we always agree or we'll go exactly down the path that's recommended by a board or commission. It's a sounding board, and you weigh that against other advice you might be getting from other sectors in the community. It's good to help develop policy.

AHPR: There are tens of thousands of Anchorage residents who lack regular access to most health care providers in the city, because they have no health insurance, inadequate health insurance, or otherwise they cannot afford to pay for health care. For these residents, the Anchorage Neighborhood Health Center is probably the most significant safety net provider of primary care. To what extent is the municipality of Anchorage supporting or working with the Anchorage Neighborhood Health Center?

Sullivan: That's a great question, and I know the health center is moving, or has moved, or about to move. I guess they've got a piece of land that they're looking at relocating on. The way the city can help is like we do with other non-profit groups. We can be supportive through grants. If there is heritage-banked land, for example, a group like that needs, we can support that way. And we recognize that the service they provide is a valuable one. So, I think the city has had a good relationship that will continue under my administration.

AHPR: My understanding was that the land that they're moving to is city land.

Sullivan: You know, that all happened before I came on board so I'm not sure of all the details on the land. I've been here 90 days, and I'm not sure of the particulars of that particular deal.

"Not only to deal with how do you get back-up power, but what do you do with the health consequences? ... When there's heat out, you have the potential for people to use space heaters wrongly. You have elderly and sick people who, all of sudden, if they're cold, are in danger."

AHPR: Recently, you announced that Anchorage may be subject to natural gas cutbacks, or outages, if we have a particularly cold winter. That could have dire health consequences for many thousands of ill, handicapped, elderly, and low-income residents of the city. And also, by the way, I wrote a memo to some of my colleagues regarding some of things we can expect [in the event of gas outages or cutbacks] such as more house fires, and more carbon monoxide poisonings as people turn to alternative means of heating.

And at the same time, you've announced some substantial cutbacks in funds allocated to the Department of Health and Human Services. And it appears as though there may be even more cuts in coming years. So, in the event of some large-scale disaster such as a gas stoppage, an earthquake, or a more deadly version of H1N1 - like was discussed in today's [Anchorage Daily News] paper -- will the MOA have the capacity after these cutbacks, to keep the people safe?

Sullivan: Sure. Well, first of all, you've got to understand that when you've got a budget shortfall, number one: your budget has to balance. You don't have a choice, that's the law. So when you have revenues not meeting your expenditures, you have to make cuts. Every department took cuts. It was across the board. It certainly just wasn't in Health and Human Services. So, we relied on each department manager to determine what areas in their department they felt that they could cut back on and still provide the level of service that is necessary for a community our size. We're confident that each department head did do that. You know, we've got a balanced budget; we spread the pain, again, across many different sectors across the city. We're confident that if there is a disaster, we'll be adequately prepared to handle it.

Keep in mind, one of the things we're doing that hadn't been done before we came into office, was we put together now, a master plan for what happens if the gas does go out. Two of the last three winters, it's gotten to the point that the deliverability was in question. When we got into office, we were surprised that there had been no coordinated effort. So that was our first priority, to make sure that our municipal manager -- who used to be garrison commander for the Army in Alaska and who is very well versed in emergency preparedness -- got all the utilities, the major users, the emergency service providers, the producers, all together in the same place at one time, to put together that master plan.

Not only to deal with how do you get back-up power, but what do you do with the health consequences? Are we prepared to deal with just exactly the situations you mention? When there's heat out, you have the potential for people to use space heaters wrongly. You have elderly and sick people who, all of sudden, if they're cold, are in danger. So, we have started that master planning and are far more, I guess developed with it than it had ever been done in Anchorage before. So we're confident that, not only are we planning for worse case scenarios, that we can respond adequately. So that's one of the roles of the city. Again, it comes back to that public safety umbrella, that we're going to maintain public safety in Anchorage, even in a disaster.

"The municipality's role ... is to provide the infrastructure that allows people to take advantage of healthy opportunities. ... We've got all the elements that allow people to make those good healthy choices. The other role the municipality can play is education. ... There's no lack of opportunity to have a healthy lifestyle. It's all here for us."

AHPR: What is your long-term vision for the role that the municipality can play in the improvement of the health of city residents and visitors, and what additional policies and resources may be necessary to do that, to implement that?

Sullivan: The municipality's role in that is to provide the infrastructure that allows people to take advantage of healthy opportunities. We have a world-class trail system. We have more parkland per capita than any city in the United States. We've got all the elements that allow people to make those good healthy choices. The other role the municipality can play is education. I don't like laws that mandate that people go do things. I mean, I don't think that's our role of government. But you can certainly educate people about the opportunities: how to stay healthy, and let them know that these facilities are available to everyone. There's no lack of opportunity to have a healthy lifestyle. It's all here for us.

And then, it comes down to a matter of personal choice. So, what we've said is we're going to maintain our facilities as a top priority. We're probably not going to be building any new edifices anytime soon, in Anchorage, because the budget is not going to let us do it. But we're going to maintain the things we have, our parks, our trails, our rec centers -- all those things that are available to the public to have a healthy lifestyle. You combine that with the education component, I think that's our role.

AHPR: You place education as the centerpiece; it sounds like, of your vision. Do we have adequate infrastructure for health education?

Sullivan: Well, you know you've got a school district that deals with 50,000 kids, and that's where it needs to start. It needs to start with that youth education. Build healthy lifestyles when they're young, and people tend to maintain it through a lifetime. So I think we have that built-in infrastructure. And [we are] partnering with the school district. I'm real pleased to see, for example, the school district is going to reintroduce swimming into the grade schools. I think that's a great start on getting that healthy lifestyle developed. When we were in school, you and me, years ago, P.E. [physical education] was mandatory from junior high on through high school. You had to have P.E., and they dropped that. We would like to encourage the school district to bring that back. The mayor can't make the school district do certain things, but working cooperatively and maybe using our bully pulpit a little bit, we can get people moving that direction.

I'm a guy who grew up as a very active young guy. I was a basketball player, and we used to walk and ride our bikes everywhere, and nobody drove us places.  Obviously we've lost that a little bit [in] America, not just in Anchorage. We need to get back to that, and it starts when they're young. You've got to get people moving at a young age.

AHPR: Well, I'm not young anymore, but my hair's a bit wet because I just got out of the swimming pool before coming here.

Sullivan: Good man! And I don't play basketball anymore except shooting in my driveway, but I'm a tennis player and I get on the treadmill, and I need to get on the treadmill a little bit more.

AHPR: Now you're on a different kind of treadmill.

Sullivan: This job, I must admit, so far has not been conducive to the lifestyle that I like to lead, which is, you know, much more active. It's funny, we were just talking with my secretary, Betty, that we're going to start scheduling, instead of going to lunch, I'm going to go have a "workout lunch" on a regular basis and get back into the swing of things, because you can't talk a big game if you're not going to live it.

"We need a healthy mayor, and I've always been one to want to lead by example. And if I'm going to talk about a healthy community, I've got to be the epitome of it. That being said, I'd bet I could do more push-ups than anyone you know."

AHPR: Right, we need a healthy mayor.

Sullivan: We need a healthy mayor, and I've always been one to want to lead by example. And if I'm going to talk about a healthy community, I've got to be the epitome of it. That being said, I'd bet I could do more push-ups than anyone you know.

AHPR: Certainly more than me! (Laughter) You know, again, on that question of health education, do you see a role for your public health department in health education? You mentioned the school districts, but ...

Sullivan: Oh absolutely. They do it now. If you look at some of the information they disseminate, I think they're very much involved in health education on a daily basis.

AHPR: The reduction of obesity in the public is a high-priority issue for the municipal Health and Social Services Commission. For example, public transit and parks are two public entities that are part of the obesity solution, walking to and from bus stops and recreating in nearby parks, which you've already mentioned. How do you view the role of the municipality in relationship to the reduction of obesity in the town's population?

Sullivan: I think we kind of touched on it. It's our job to maintain good facilities, provide that infrastructure so people don't have a lack of opportunity, and I think that's a great role for the city to play. We've got great parks, great trails, great rec centers -- there's just no lack of opportunity -- and at a young age, if you can convince kids that this is the right thing to do, then we've done our part, I think. One of the problems I see with people using transit -- walking to the bus stops of course -- [is that] we're a winter city, and sometimes it's pretty darned cold. A lot of people aren't going to stand out there at a bus stop.

Should we have heated bus stops? Should we do a better job clearing them? It may be something we can do down the road, but right now, transit has about one percent ridership. They say the best cities with the best transit get to about two percent. So [public transportation is] never going to be the solution to fitness. But I would encourage people, that if they're not getting out and about enough, walk to that bus stop, and walk everywhere, in fact.

AHPR: We had heard, going back to what has been important in the recent past to the Health and Social Services Commission, that there was serious consideration being given to a new health department building. The current building seems to be, really literally, falling apart. Can you elucidate us on whether, if, or when there is going to be a new building?

Sullivan: We have had that on our legislative priority list for a number of years, because the cost of it is such that we'd like to see the state participate, particularly since we are doing functions through our health department that might be traditional state functions. So we'd love to see them share in some of the cost of a new building. Obviously, with tight financial times now, we may be looking to stretch a few more years out of the existing facility. But as the economy starts to recover, we may see people more willing to support a bond issue that maybe is matched by state money. I think we're all in agreement that we probably need a new facility. It's just, we may have to get a couple more years out of this one.

AHPR: Thank you. And here's what I'm sure is going to be your favorite question. Is there anything else you would like to say to the readers of Alaska Health Policy Review?

Sullivan: That's a great question. You know, get off your behinds, quit eating and get out and walk. Get away from that computer monitor. It's a nice day outside, it's a beautiful fall, there's no excuse for not having an active lifestyle in Alaska. I talked about leading by example, once we get a little more settled in, I actually wanted to do a mayor's fitness challenge, if you will, or be part of that education campaign by being at the forefront of it. Going and visiting schools and visiting different employee groups, or whatever, and just trying to encourage that healthy lifestyle. It probably won't happen for a few months, but as I said, once we get settled in, I'd like to lead that effort.   

AHPR: I wonder if I could make a suggestion.

Sullivan: Absolutely.

" ... I've been one by one, visiting all my departments. In fact, I've had an amazing reaction. ..."We've never ever seen the mayor before, in any administration." So, they appreciate the fact that you come by and find out who they are, where they work, what they do, and so far the reaction has been great."

AHPR: Since I have this opportunity to talk with you. At the same time, there are a lot of people in this town, who really can't get out and run around, who are very inhibited in terms of their ability to do physical movement. Maybe at the same time, you could also visit the neighborhood health center, your own health department, you know, to really focus on that aspect of it too, the actual delivery of health care, which is sort of the other half of physical fitness and prevention.

Sullivan: Sure, when you say visit them, I've been one by one, visiting all my departments. In fact, I've had an amazing reaction. Because as I've gone literally to department by department, people have said, "We've never ever seen the mayor before, in any administration." So, they appreciate the fact that you come by and find out who they are, where they work, what they do, and so far the reaction has been great. I actually wanted, in the first 60 days, to have visited every municipal facility, and we got so caught up in fixing the 2009 budget we weren't able to do it. We're scheduling at least twice a week, I get out, I see people doing their jobs for the city, and telling them how much I appreciate them.

AHPR: And I bet you walk there.

Sullivan: I absolutely do not. (Laughter) But, in the building, I mean, down the stairs, up the stairs. But I haven't walked over to Project Management on Tudor lately.

AHPR: I'm looking forward to that media event where you challenge people to do push-ups. [Laughter]

Sullivan: Absolutely, the Mayor's Push-Up Challenge.

Erkmann: [Communications Director Sarah Erkmann] You cross-country ski.

Sullivan: A little bit, a little bit. In the winter my thing is skating. We go down to the lagoon, and it's just been so great for the last decade to have Conoco Phillips sponsor the clearing of the lagoon, and the barrels, and it's just great. So I've found that you know, I was just doing indoor recreation in the winter. And, come on, it's Alaska.

Erkmann: You've got to get out in the winter, or you go nuts, I think.

Sullivan: Yeah, so we went to Play it Again Sports, bought some skates, and it's awesome down there.

AHPR: Well, I have no further questions to trouble you with.

Sullivan: I appreciate your coming.

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Discussion with Representative Wes Keller

Wes KellerRepresentative Wes Keller was a featured speaker at the September 10, 2009 Alaska Primary Care Association Fall Conference and Legislative Summit. You may have missed his presentation, but we were there with digital recorder in hand, taped it, typed it, and present it here for your edification. Representative Keller is probably best known in health policy circles because he is co-chair of the House Health and Social Services Committee, and a non-voting member of the Governor's Health Care Commission.  However, he also serves in various capacities on several other committees, and he is a member of the Governor's Council on Disabilities and Special Education. In this presentation Representative Keller embraces Cato Institute health policy, extols "personal responsibility," rails against government intervention, and is compelled to admit that he is not Representative Don Young. This transcript has been lightly edited for length and clarity.

Moderator Shelley Hughes: We want to welcome some honored guests who have taken time out of their busy schedules to come talk to us about their views about what's happening in the health care policy world. And we're very honored to have Representative Keller here. Representative Keller has been working in the Legislature for ten years. He was chief of staff to Senator Dyson, and now he serves District 14, which is out in the Mat-Su, the Wasilla area, and he is also the co-chair of the House Health and Social Services committee. So he's very pertinent to the work that we do. He has been in Alaska for 40 years, is that correct? And, he has a background in construction, he's a pilot, he's a grandfather, he's just a great overall guy and we're real happy to have him here today. And, so we're going to give you the mic.  

Keller: Before I start, I got a fun story to tell you. This summer, I had a meeting up in Fairbanks. I got on the Alaska Airlines plane and sat toward the back. I typically carry a pilot manual and bring that on with me to read it. The flight attendant started -- I don't want to say 'pandering' --  but, you know, a lot of smiles, two bags of peanuts, coffee refills, and extra soft drinks. And then she came back after a while and she says, "Hey, I was in your office and you had my picture up." You know it's nice, and I couldn't remember, I was scrambling to recollect. And she got back to work and then she came to me and said, "Listen, I'd really like to get your picture taken. So, if you don't mind, come back in the galley, and we'll get the stewardesses here, the flight attendants, and they'll take your picture."

So I went back there, and they got a picture of me with two flight attendants, smiles, you know and all. You see representatives don't get that kind of treatment. Our constituents know us pretty well. So usually, you get tomatoes, and you get a lot of, pressure. But this was going on and on. It was pretty nice. I never thought too much about it. But, I knew I didn't have to get used to it or anything, I'd just kind of enjoy it for a while.

Anyway, I went to get off the plane when I got to the back door, she stuck her hand out, she said "Have a nice day, Mr. Young." [laughter from audience] That's when I get noticed, for a younger Don. You know he looks pretty intelligent and sophisticated.

Actually, I'm pretty humbled to talk to you, and you won't find things I say loaded with content. It's an informal group. I'm sure we can give and take, and stop me if you have something. I'm humbled to speak to this noble group. I've chosen my words -- it's flattery -- but noble is the right word, because inherent in, and intrinsic in the health care career is altruism. You know, the definition is unselfish regard, devotion, goodwill, care of others. It's just part of the definition of who you are. So, it's easy for me to call you noble. It's okay to look out for yourself on the pay end of the scale. But, there is that element of altruism in health care that makes me proud to come here to talk to you, and to say thank you for your service.

If we were just sitting and talking over coffee, and I asked you "Are you healthy, or are you not healthy?" How would you just think about it if we were to sit and talk, and how you would respond to that? "I'm healthy," or "I'm not healthy," "yes" or "no." If I was sitting there I'd say, "Hey, why are you healthy? Why are you not healthy? Give me some reasons. Let's talk here a little bit. What would you attribute your good health to, what would you attribute your bad health to?"

And we talk about it. Get some answers in your mind. Think about it as if we were talking about it, okay? And I'm going to guess that some of you, maybe most of you, would have a spiritual atonement in your response: "God blesses me," "I was made this way," you know, whatever. Another factor that would come up would be chance [or] genetic selection. "I was born this way and I'm grateful I'm healthy," or "I'm not healthy because I inherited this," or whatever.

Another aspect, maybe, to the discussion would be, "Well, I eat right, I exercise, I run three miles a day before breakfast." Or, "I am not healthy because I've eaten too much over my life," or whatever. So, those [are the] three things that I thought of: the spiritual, the relational, and of course, just the chance thing.

But I'll bet you, that none of you are sitting there thinking that government is one of the reasons I'm healthy. If government came to your mind, it was not on the list. I'll bet you it wasn't the correct one. Of course it's a factor: sanitary systems, clean water, clean air -- things that happen in government do have an effect on our health, but, we don't think of it as the primary thing. So, if that's the case, then it's kind of fascinating to me.

By the way, your timing for this meeting is fantastic. I'm sure all of you went to last night's [speech about health reform by] Obama like they did. I mean, it's a thing of irony of us holding our breath waiting for the federal government to come up with something that fits this noble, altruistic element of who we are. There's a contradiction there, or an irony, or whatever you want to call it. We're holding our breath and there's not even a bill, just a lot of discussion. There's a number of bills, but I mean nothing is nailed down very well. We're hearing things -- it is such a fascinating time to be involved in health care. The last couple of days, it just blows your mind to listen to some of the things that are being said. "Coverage for everybody," you know, both, all sides of the aisle, that's what we want. "Anyone should be able to choose," you know, keeps it private care, "health care costs will fall," just like everything else the government is involved in, focus on the cost.

" ... The other thing that's really fascinating is both sides are calling the other side liars. ... Who would think we would see the day that everybody is standing there pointing, and hollering out loud, you know 'Liar, liar.'"

I think President Obama said last night that Americans spend 1.5 times what everybody else does in the world on our health care. The irony, again, to me, [is that] it just seems odd we would spend so much more. We were already spending high, and we would expect that cost crisis to fall. And then, not one dime more on the deficit. These are some of the things we're hearing. The deficit won't increase, and yet the CBO is saying up to $9 trillion, I think they're saying now, of the total costs if everything in all the bills was taken, paid for, you're talking $9 trillion.

And this is a big deal, this is bigger than Social Security, this is bigger than Medicare. It's a big, big deal that's being decided on right now in our culture. It's going to affect us, especially the people in this room, huge, big time. The waste and fraud thing: It is fascinating, to me, that came up again, but there's no specifics on how to recover it. But the point is that there's supposed to be a huge number there that is going to, again, pull the costs down. I don't get it.

There was a comment last night, not to reveal my prejudices or biases or anything here, but you know, "not one dollar will be taken from the Medicare trust fund," remember that?  Not one dollar will be taken from that. It's bankrupt, there's nothing there. You know, this whole thing is modeled after Medicaid/Medicare. I point this all up not to attack what's going on, more to just say, hey, we're in a fascinating [time]. This calls on our whole culture. You're going to be affected big time, in what happens this fall. And I think it's a really a big deal, it's a really interesting time to be involved in health care.

And then you have the veterans. That's a government system, right? Ask them, how they like their care, it's a perfect example. You got seniors, now, denied the right of the voucher thing that's implicit in the proposal, for the voucher thing, you know they could take the money and go take, buy their health care wherever they want. That seems to be out of the question.

The other thing that's really fascinating is both sides are calling the other side liars. You heard last night on the TV, there was a Republican in Congress who stood up and said, "Liar." And now, today he's apologizing. You probably haven't heard the news yet, but he's apologizing now for being out of line. But it isn't just that. You had David Axelrod who said, you know, that talking point, the lies and distortions there of people that are proposing the proposals. Then the Article 26: Lies about HR 3200 that was in the Annenberg report recently. "The five biggest lies about health reform," that was in Newsweek a couple of weeks ago. You would think we're living in a foreign country. Who would think we would see the day that everybody is standing there pointing, and hollering out loud, you know "Liar, liar." We're seeing the outside of the realm of cerebral discussion here of what we should do and where we should go.

Well in conclusion, there is a point. I'm not trying to get you mad at me; I'm not trying to start a fight. I realize that there are some, at least in this room that would really like to see the health reforms in Congress go through, and I respect that. But I encourage you to evaluate your personal life and the way you look at health care, based on the altruistic part in you. It's okay to admit it: "I'm in this business because I like to look out for other people, I want to make life better for my neighbors." If we focus on that, talk about that, and not be afraid of that one, then that gives us a common ground where we can all go together and, in fact, make Alaska the most healthy group of people in the United States of America.

I know this isn't quite what Shelley [Hughes of the Alaska Primary Care Association] had in mind, but I can't and I won't do any predictions about what sessions are going to be about in health care. There's too much here, going up in the air, you know, being danced around. The Denali KidCare, SCHIP [State Children's Health Insurance Program], it's meaningless if something passes, that's similar to what some of the things I've seen. So, it would be kind of ridiculous to waste a lot of time. I know, it's in Representative Herron's and my committee, health care, and I don't know where it's going to go, and what it's going to do. But we're working on it, but we all got to kind of hold back here until we see what happens on the federal level.

The Alaska Health Care Commission -- I'm an ex officio member of that -- we're kind of in the same boat.  We're learning, we're poised to make some recommendations to the governor and to the Legislature, but the context keeps changing, so we don't know what the recommendation should be. Medicaid rate review, in a way, it's the same thing. You know, so many things that become a moving target. I guess I would expect, maybe some legislation coming up because of the CMS [Centers for Medicare and Medicaid Services] hold on the waiver, Medicaid waivers for personal care attendants. But you know I've been talking to the department and we've gone over the training material that they're using for the assessment and looking at their new hires, and what they're doing there. They're doing a lot, and I really kind of think that maybe that one will kind of even out, and maybe we won't even see anything then.

But, it is true that at some level, the Legislature is on hold until we see what happens at the federal level. And maybe that's not all bad. The product is focusing on the real issue here, and that is making life healthier for our fellow Alaskans and our communities. I'll stop there. But if anyone has any comments, or wants to ask a question, or anything like that, feel free. I'll be very happy...yes?

Audience Member: You've made it pretty clear what you don't like, and you've made it pretty clear what you think the government can't do. What I'd really be interested in hearing now, in your opinion, is health reform in any way needed, and if so, what are the principals that you espouse for health reform?

"You ask what we should do. My personal opinion is we should come up with a uniquely American solution, and that is look at free market, and look at personal responsibility. That's what it's all about. Let individuals choose what they do with their health care dollar."

Keller: I really appreciate that, because if I'd gotten out of here without talking about it ... You see it's easy to be a naysayer. You could say things are wrong all day long. The answer to your question is I believe that the U.S. has one of the finest health care systems in the world. No question about that. I think that we need reform, and we need it bad. The reason is because of the costs. Cost is increasing, and we've all seen the charts. I'm sure you know they're going off the scale. We need reform. Too many people lack health insurance -- that's one of the huge challenges that is in front of us. It costs too much and the quality of care is uneven. In one place someone might get better care than another place.

So we have to do reform. You ask what we should do. My personal opinion is we should come up with a uniquely American solution, and that is look at free market, and look at personal responsibility. That's what it's all about. Let individuals choose what they do with their health care dollar. I think what has to happen is -- I really do, I really hope this happens -- is that the existing bills get taken off the floor and they start over. They go back and get their heads together, both sides of the aisle, and they come up with some new proposals, and I hope that some of the elements of that proposal have to do with a person's control of their own health dollar.

I'm going to do some reading. This is from the Cato Institute, and I think you would respect their perspective on this, but that's where they start, and then they continue on. And they want to move away from the employer-based system, and that makes sense. You know, people who have employer-based insurance, there's all kinds of problems with that. One is the cost is very hard to determine, then of course you've got the uneven care. One employer chooses to care at one level, and another employer chooses to do it at another level. Again, if we could somehow get the individuals to have an individual-based system insurance, why not? Why not buy insurance across state lines, for example? Why not be able to shop around, and see what's going on?

Of course, HSAs, Health Savings Accounts -- my son has three, some of the finest looking grandkids you ever saw, and a beautiful wife -- we were talking about this the other day. About 2-3 years ago he started putting money in an HSA, and he isn't wealthy, he doesn't even have a really high-paying job. In fact I think this fall they're going to the Philippines on a mission. But then again, he uses his health savings account, and he was saying, "Boy, it really hurt to go in there and draw twenty-five hundred bucks this fall to get my kids teeth straightened out." He says, "It's kind of cool, because I didn't take it all. The rest is mine." You know, and they've got major HSAs. I'm sure you all know, but they have a major coverage thing, but anyway they have to pay things like teeth. He was just really impressed with how good it was working for them. They're young, they're healthy, and of course, that gets into the area where [HSAs] are being criticized. They figure it isn't so great for the old and the sick, but it's better for the young and healthy. The principal is individual-based, individually-owned, responsible for their own care.

Another one is to just increase the competition out there. Hard to do in Alaska, I know it's unique up here. Hard to get insurance companies up here, but, again, the health insurance buying across state lines nationwide may be a big deal. Medical licensing laws, they suggest that you know, the nurse practitioners, physicians assistants, their medical care people, midwives, whatever -- let them do more. They're capable of it. Expand it so that licensing will allow them to do more. Another thing they suggest, and I thought it was fantastic, is let licenses go from state to state so that there can be a little bit more competition with what the medical professionals do. Then of course we talk about working on the Medicare voucher system that could be able to pay a senior citizen a voucher, to say go shop for your care. What it does is, again, is leaves the person in charge of their health care dollar.

So, anyway, that's a long-winded answer to your question. I do commend to you the Cato Institute studies on this and recommendations, and there are many more out there. And, by the way, I don't pretend to be a health care professional like you here. I'm not. When I said I was humbled to speak to you, I mean it. I've had some background in it. Like Shelley said, I worked for Senator Dyson as a HSS [Health and Social Services] committee aide for ten years, but that's it. So what I've picked up is from the government end of the scale. So I'm shopping for ideas just like you. Thanks for the question.

"I always get really squirmy when the government gets involved in allotting, setting rates, and all that kind of thing. It gets confusing, and that's our problem. It's how we got where we are."

Audience Question: Where do you see community health centers moving into the health care reform?

Keller: I think they are fantastic. When [Shelley Hughes] first started explaining what they were to me, I said "You've got to be kidding -- can't turn anyone away?" I'm a little uneasy about the sliding scale on the Medicare/Medicaid payments. I don't know where it's going to go. I always get really squirmy when the government gets involved in allotting, setting rates, and all that kind of thing. It gets confusing, and that's our problem. It's how we got where we are. America's based on this free-market idea that I've just been talking about. The free market, I think is what produced the Mayo Clinics. You go stand in front of the Mayo Clinic you see people coming from all over the world. It's a fantastic system, and you know we do have really good health care in this country.

But once we get involved at the government level -- I'm going to say us politicians -- [we] fall into this trap of thinking one of the reasons you're healthy is because we're here making the laws and regulations to make you healthy. Maybe it's a bigger trap for us as politicians than it is health care professionals. So community health centers, I like that. My personal experience with people I've met working there [is that they] are dedicated, that's why I had no problem coming to this group and calling you "noble," because I see people that care, and I appreciate that. You have to, to be in that business. It's great, as far as what's going to come for community health centers...again, we don't know. This is all up in the air, depending on what's going to happen at the federal level.

Audience Member Question: Are you saying that you think that maybe the health reform won't be including health centers as much as we think? Do you think that we're in the ballpark with them, with reform, that they're going to use part of our principals, or our...?

Keller: I think all that I'm saying is that probably the change in the reform is big, is what I'm saying. It's a big deal, so I don't know how it's going to effect [community health centers]. The way things are set up now, it looks really good for community health centers. It is a stopgap, and that is what's there. I wonder if the numbers were given for the uninsured, I wonder how that takes into account what community health centers do. I get puzzled on that, because if anybody can go to a community health center, I see just the awareness is coming up. I didn't know what a community health center was until a few years ago, and I worked in HSS [the Department of Health and Social Services]. That's probably a reflection on me more than anything else, but the point is, I don't know how it's going to turn out in the wash with support.

Audience Member Question: I just want to say, Representative Keller, as one individual, it's been a privilege to listen to you expand, and not try to paint us a pretty picture. It meant a lot to me to hear that we are in turmoil, we are in a mess, and we don't know what the answer is. I liked what you said, and I believe the same way that, my God, we ought to erase it and start over. Right now it's like the foxes and the chickens. Thank you for coming.

Keller: It will be different tomorrow, with the changes.

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Discussion with Deputy Commissioner Bill Streur

William Streur
William J. Streur is deputy commissioner for Medicaid and Health Care Policy in the Alaska Department of Health and Social Services. We caught up with him September 10, 2009, at the Alaska Primary Care Association Fall Conference and Legislative Summit. He addressed in a clear and straight forward manner a long list of issues given to him by APCA leadership.  These ranged from veterans' health issues, to reimbursement mechanisms, to the Frontier Extended Stay Clinic, and beyond. We recorded and transcribed his address at the conference and provide it here to you, slightly edited for length and clarity.

Moderator Shelley Hughes: I'll just give you a little background on this great man up here [at the podium]. He is the deputy commissioner over the Medicaid and Health Care Policy part of the department, and he has been serving for two years in his position. Prior to that, he was director of [the Division of] Health Care Services at the department, and prior to that, he was involved with First Health Services Corp., the senior director of Alaska Operations -- a big responsibility. So overall, he's had 25 years of working in health care and with Medicaid, including managing -- I thought this was interesting -- a behavioral health system and establishing a Medicaid HMO in Michigan. So he has quite a broad background.   

Streur: I want to thank you for allowing me out here today. It's great to see what you do. I came up from Soldotna, about two hours ago, driving up, and [the commissioner] flew down over the top of me, to get down there. We both have to be on the panel tomorrow, so it's going to be a wild trip back tonight, later. I bring his regrets, because you are an essential and huge part of what we do. And I think going forward is going to be even more significant. I also bring his thanks for all you do. He and I spoke about it, and it was kind of a tossup. I came up and he didn't.

I just want to start out and say, 'Wow,' because these are exciting times. I did catch excerpts of last night, and I'm not going to argue with Wes about anything that he said because so much of it was right on. These are exciting times, but these are going to be awful challenging times -- probably the most challenging times that I've had in my years of experience in health care. I started out in the military, back in 1975, post-Vietnam working in health care and I've been struggling through it ever since. It's been interesting. We have the stimulus package that we're dealing with. That is both a blessing and a curse as far as I am concerned. I think that it is such a two-edged sword. We're going to build all this infrastructure, we're going to build all  [these] capabilities of our system, and I'm worried [about] what's going to happen in five years. This balloon is going to burst, and are we going to be left holding the bag on so many issues?

But we have short-term opportunities from it, and [maybe] we can take that opportunity -- take the money, if you will -- and run and develop some system that's not dependent going forward. We can develop infrastructure, we can develop site capabilities, [and] and we can expand what we need to expand. One of the big things that I'm working on right now is health information technology and health information exchange, electronic health records. There's going to be millions and millions of dollars available to the state of Alaska for that. As Charlie Huggins, Senator Huggins, put it during legislative hearings last year, he asked me, "Bill if you had a chance to get 25 million dollars to pay for something that's going to happen anyway, what would you do?" That's what it came down to, rapidly. So, the next two years you're going to see significant changes in our capabilities under health information technology -- that covers the entire gamut.

"It's huge, but we need to promote community care. We need to promote the right care in the right place at the right time for the right amount of money, and we aren't doing that."

Health reform -- Representative Keller talked about that briefly. I don't know what it's going to do. I would think after almost thirty years in health care that I would have it figured out by now, but every time I go to bed at night, I wake up the next morning with another idea or another fear on what's going to happen, and I think all of us are faced with that. Well, one of the things that's obviously going to come out of that is higher quality and care coordination. Doing things smarter -- we're doing things well, but now we need to do them smarter. And there are smarter ways. One near and dear to my heart now is the Frontier Extended Stay Clinic, and I'll get into that shortly.

It's huge, but we need to promote community care. We need to promote the right care in the right place at the right time for the right amount of money, and we aren't doing that. I'm as guilty as anybody in that I've been in this job for a couple of years now, and you need to give me a little slack because this is my first bureaucracy job. I was on the private side of health care until this. It's been a learning curve, and it's been a steep learning curve, let me tell you. Things don't move the way they move in the private sector.

One of the things I feel we have to focus on is quality of care issues. I don't know that all of you can determine that, but I can't look at the $1.2 billion that I spend in Medicaid and say that we are really doing the best that we can. I don't even know if we're doing mediocre. That's going to be a challenge for us. So I think the next few years of that stimulus money, if we can begin to focus on that, and begin to look at the right care, at the right place, at the right time -- we're going get to go a long way.

Linking of providers in the communities -- I am forever amazed of the fact that we can have two significant providers, and only two significant providers in the community, and they aren't getting along. We need to promote that. I see the heads nodding; there is recognition with that. I don't know what capability I'm going to have with that under Governor Parnell but I think that's one of the things that we need to move forward on. We don't have the luxury of being able to operate independently anymore. If we are going to improve access in the hospitals in the community, and the community health centers in the community, they need to be hand-in-glove. And, frankly, you're not. Yes, and I just delivered the same message down in Soldotna, so you aren't getting picked on. It's something that needs to occur. We have finite resources; we have finite dollars in the communities. And for a few years we're going to get some latitude, but it's going to dry out.

Promoting innovation -- the Frontier Extended Stay Clinics. I was a little askance at that, or I looked at it a little askance when I first saw it. Then I went out and visited, and saw what it can be and what it can do in communities. And those [clinics], I can't wait for you to get open.

Audience Member: We are!

Streur: Well, open and billing, because it's a tremendous opportunity for communities that are more than 75 miles from another hospital and off the road system. They're going to move forward, they're going to be exciting, and I'm looking forward to it.

Expanded dental care -- I want to continue to expand dental care opportunities, and that, you know, that includes a variety of areas, and I'll touch on that a little later as well.

" ... we have a lot of vets returning from Iraq and Afghanistan and going back to the village and not being able to get the necessary health care that they need unless they buy a plane ticket and fly into Anchorage."

Telehealth -- visiting communities and seeing how telehealth can work in the rural health centers, in the tribal clinics -- it's staggering. A study I recently read said that 40 percent of all travel can be eliminated by having effective telehealth efforts. I spent $40 million a year; I spent $40 million last year on transportation for 100,000 Medicaid recipients. You can do the math yourself, that's a lot per recipient. If I can cut out 40 percent of that, that's about $16 million that I'd have for other areas that we can focus on. That's an issue of being smarter.

Veterans' services -- I'm retired military vet, and there's nothing I'd like better than to have some choice in how I'm going to get my veterans' medical services. We need to promote that in the state of Alaska. I have friends that work with the military family life program, and we have a lot of vets returning from Iraq and Afghanistan and going back to the village and not being able to get the necessary health care that they need unless they buy a plane ticket and fly into Anchorage. Getting those services out of the communities where you all operate, and getting paid for it on top of it, is very important going forward. So the pilots that we do have in place now I think we need to continue to promote to make that a regular part of what the vets have.

Varied payment schemes -- I think the majority of you are paid under some form of encounter rate, for your services. One of the things I'm encountering is that if I want to get you to deliver an H1N1 vaccination right now I have to pay you an encounter rate for that. I'm not stingy, but I come out of the private sector where we don't do it that way. We need to figure out a way for you to be able to do that, and for you to have the option to do that with some of the services. In the dental services in particular, that I think can be delivered ultimately through the community health centers, rural health centers, federally-qualified health centers, we need to do that. Medical home -- Marilyn [Marilyn Walsh Kasmar, executive director of Alaska Primary Care Association] and I are going to get medical home off the ground this year. I don't know how we're going to do it, but we are going to get it off the ground this year. That's a challenge to you as well.

Audience Member: We're on it! We're actually very excited about working on it this year.

Streur: It's the right thing to do, and you need to figure out a payment scheme, need to figure out how we're going to do it. We need to co-op people to do it. The Southcentral Foundation evidently has a program that is working, and we need to figure out whether we can do what we [want to] do because I think it's the right way to deliver health care in our communities. Right now one thing I can guarantee is that I don't have care that's coordinated very well. We're not a primary care-driven system, and we need to get there.

Just a few other points that Shelley [Shelley Hughes, government affairs director, Alaska Primary Care Association] wrote in her crib sheet that she sent me: the Medicaid Management Information System, the new MMIS, how you all get paid through submitting your bills. I have staff back east right now and will be back for the better part of next week to determine if we can make a time line that I promised to the governor's office -- I think everybody under the big guy -- that we would deliver on time and on budget, and I'm scared skinny that we're not going to make it. I know there were a lot of cynics out there when I was saying it. Getting these vendors to deliver software on time, it's just amazing. Particularly when they use offshore development. Offshore development falls out of space sometimes. I think that's what we've got in this case. It's just I hope to have more to move forward, but that's more than a little bit scary.

Increasing Denali KidCare eligibility -- I'd love to see it, but I think one of the things that we've got is misconceptions about what we're covering -- kids that otherwise could and would have insurance, and that's a cheap way to do it. We're going to have some of those; we already have some of those, even at current levels of 150 percent of poverty level. But if we take it to 200 percent and have co-pays and deductibles, and we have premiums -- I can't handle it right now. There's no way that I can add 10,000 kids to the system and be able to collect checks from 2,000 families to do that. So we need to figure out an effective way to do it and yet meet the needs of legislators who are concerned about that. My big thing is a co-pay. That way when they get in the physician's office, the provider has an ability to determine whether or not they're going to try to collect that co-pay or deliver the service. If you deliver the service for free right now, and you can get 80 percent of it, or 90 percent of it, and hope that the person will participate with you and play the game, that's probably a better way to go. Premiums and deductibles? I may retire at my age before that happens.

Enhanced Medicaid dental prevention benefits -- that's one where I think we can work with you all to provide some of these services [such as] dental coverage and policy changes that support topical fluoride, and other topical applications, increased use of sealants, enhanced early dental screening on educating the public on diet and baby bottle syndrome. There's no reason that it's a part of a regular visit, or an EPSDT [Early Periodic Screening, Diagnosis, and Treatment Program, the child health component of Medicaid] visit with you all that we couldn't incorporate all that through a separate payment system. That's one thing that would be an add-on to the existing encounter rate. Plus, we'd have healthier people, healthier kids, out of it.

More EPSDT, Well-Child visits -- across the state we have about an average of maybe 50 percent -- low of 11 percent, high of 56 percent in the metropolitan areas -- success with on time well-child visits, and we've got to bring that up. Most other states are 65 percent or more, and working with all of you to do that I think is an effective way. I'm not saying that the visits aren't occurring; I'm saying that they're probably being written up as a sports physical or something like that, that's a little easier. It's not that hard to take that sheet and fill it out and get the credit for it. We get the credit then too, and plus it's a healthier population that we end up with.

PACE program -- I don't know how many of you are familiar with PACE, but that's the program to give all-inclusive care to the elderly. I'm hoping that we'll be able to get a pilot project off the ground this year, put some smiling out here, because if I can get two pilots rather than one pilot, then we can do some experimenting on things.

Everybody talks about the boondoggle that we've received from the stimulus-funding package. For Medicaid, we got an extra $120 million, I think, for this year. Well, that came out of the general fund to do that. We basically had a wash this year. We didn't benefit in terms of extra money, we just benefited in terms of being able to save general funds on that for this year.

" ... Right now we don't have enough providers out there to meet the demand that's out there. We don't know about the quality, we don't know about the right way to deliver the system ..."

I've already talked about Medicaid reimbursement for the veterans. That's a very important program. Having met with some of the vets that are coming back -- those that live out in the villages, those that live outside the urban Anchorage bowl area -- it's tough for them to get care, and a lot of them need care.

Those are the big things that I wanted to focus on. What the program is going to look like moving forward, I don't know. A lot of it is going to end up with what comes out of the feds on this whole issue around health reform. Universal health care, masking that it's health reform, something about it that's bothered me a bit. That's only the tip of the iceberg. It's one thing to get coverage, it's another thing to have an adequate provider system out there, to get more people utilizing services because of the coverage. We all utilize more services when we're covered, and you're going to have more demand. Right now we don't have enough providers out there to meet the demand that's out there. We don't know about the quality, we don't know about the right way to deliver the system, and I could [go] on and on and on about all the components that need to be involved in health reform. I consider that the tip of the iceberg and, if this is universal health care of some sort ... I heard Joe Biden this morning on the TV saying that the new goal deadline that was July 1, is now going to be by Thanksgiving, and tomorrow, and tomorrow, and tomorrow. So, with that, I don't want to spend a whole lot more time, but with that I'd like to get your input on what I need to do, what we need to do, at the state to work more closely with you going forward. Yes, sir?

Audience Member: I'm glad you're here. We've talked a few times. But [I want to comment on] one of the problems on your statistics on EPSDT, and I brought this up with Medicaid rate with you. Most of we who are "tribal," as you say, get the Medicaid encounter right. How the state counts their EPSDT visits is basically through the fee-for-service of their staff coding. At Southcentral, we basically took your EPSDT coding system and integrated into our encounter form and process it through. For the third year in a row that I've brought this up is you don't get to count them because they're under the physician encounter rate, instead of pulling your stats using a procedure or the code that describes the procedure instead of looking at the provider.

That yearly report you pull out, and I think the report you reported EPSDT on is the 415, or something like that. If you go into the CMS website, it's got the 415, which is the EPSDT report, and it's by state, for Utah and Alaska. But if they would, instead of rely on the provider type, which is the EPSDT provider or the EPSDT clinic, or the fee-for-service, they're probably missing 3000 to 5000 EPSDT visits a year, minimally, maybe 6000. I know we do 2,800 -- and none of them counted in that report. I get them because I do an EPSDT cost report. But they're not in your yearly report on Medicaid usage because they're under an encounter rate, not under EPSDT. If they would do a pull based on those ICD-9 codes, you might be able to get to that 60 percent. And I'm hearing 'yeah, yeah,' going about it this way, which the more you got, the more you get, is I'm guessing is how that goes.

And another thing, and this is a personal anecdote. My father, a teacher, who is semi-retired, but teaches part-time with the University of Kentucky Dental School. He wanted to come up here and donate services for three months a year, mainly to see his grandchildren, but he would practice dentistry part-time and go into rural areas at no cost. He could not even get some time in front of the licensing board to get a provincial license. Now, my father is almost 70 but he still practices part-time. He teaches dentistry at the University of Kentucky, which is one of the better dental schools I think, in the country, but he can't even get an application for provincial license to come donate services. The licensing boards really have a grip, and sometimes we're not thinking about providing care but providing a market. So I think maybe someone needs to kind of look at the licensing boards, maybe ...

Audience Member: Some of us, it takes six months to get a license, and that's not just dental, that's medical or other behavioral health, also.

Audience Member: The one thing, if I might add, the one thing that's kind of saved Indian Health is under our federal employees we bring in, they're exempt. As long as they're licensed in one state, they can come to an Indian Health facility. That out, that at least helps us do it.  That's probably one of the reasons why we have a big dental department and an ophthalmology department, but I don't know how non-Indian Community Health Centers recruit ...

Audience Member: Because we partner with Indian Health. I might have them for a couple of months, and then they get their license and then we get them back.

Audience Member: We recruit for about a year in advance, and the minute we've got a contract signed, which is usually signed within, by eight months before the provider starts, we say, "Get your license." Two of our last four providers submitted their paperwork, and eight months later they still don't have their license. Both of them worked for us for a month before they got their license ...

Audience Member: I remember when I lived in Sand Point, and worked with Chris Devlin for some years, I would recruit as far as upstate New York to get providers. I spent a fortune on bringing them in temporarily -- spending huge amounts of money.

Streur: Let's talk about that offline sometime, because I'd like to get the information on that and maybe give it to Ward [Ward B. Hurlburt MD MPH, chief medical officer; director, Division of Public Health] and see if we maybe can't break that loggerhead.

Audience Member: How are we doing on changing the pace of the payoff for behavioral health for licensed counselors, for all those things? We just merged. That's one of the issues I know you talked about that with Stan [?]. How's that moving forward?

Streur: I had thought that that had been done. I thought that behavioral health had picked it up, but I was just reappraised by Stan that that's gone nowhere, when he was up a couple of weeks ago. I contacted four states that are currently doing it, and they are sending me their regulations, but I haven't received them yet.

Moderator Shelley Hughes: [Mr. Streur], I also have some research for you, which I'll give you on that subject that I just did last weekend. It talks about what other states are doing, and might be helpful. I have a copy of that for you.

Audience Member: Would that require just an emergency, like reg change?

Streur: We can do an emergency reg on it, if we need to. But it's not the state that's the problem, it's primarily the federal, from what I understand, that's the problem. Some states have gotten around it by writing either a regulation or by getting a waiver. I did get one e-mail saying that we have a waiver for it, and I'll send it to you. I haven't received it. I'll also call into Kim Sibilisky's [executive director Michigan Primary Care Association]. Some of you may know Kim. He has been around as long as I have, and I worked with him in Michigan in the early days of rural health centers.

Audience Member: It's a little frustrating. We have two master's-level licensed school-certified behavioral health counselors. One's a licensed marriage family therapist, and one's a licensed professional counselor. Between them they have over 40 years of experience, and we can't bill for them.

Audience Member: Ouch.

Streur: It's not unique; you need to know.

Audience Member: I am aware of that.

Audience Member: It's everywhere.

Streur: It is everywhere. I have a friend who's a master's-level psychologist, and she can't bill what a brand new MSW can bill. Sir, in the back?

Audience Member: You mentioned an expansion of dental services and other items. How about vision-related stuff? Is that something that we can do at our health centers in the state, something the governor's budget can accommodate?

Streur: I think if you have the capabilities to do the vision exams and things, that is definitely something that can be looked at. It's just having the capabilities to do it. Vision is a little different than the topical dental stuff that I was talking about, because there is a precedent in dental. In vision there is not.

Audience Member: You mean, a precedent like ... ?

Streur: There's a precedent at the end that topical administration is a billable code. We just haven't allowed it in the state before, and other states have allowed it for years.

Moderator Shelley Hughes: We'll take one more question.

Audience Member: I really want to thank you for your support for the Frontier Extended Stay Clinic program. I think, under your leadership, we are so excited about being able to get Medicaid reimbursement as well as Medicare reimbursement. And there's four, well, all the Alaskan clinics are represented here now. I just want you to know that we're going to be ready in probably a month to start billing Medicare, and hopefully Medicaid too at the same time. I'm just wondering if you have any idea for the other clinics in the room who might meet the eligibility requirements? At what point might we look at expanding it within the state of Alaska to allow other clinics?

" ... People are asking about the HIE, Health Information Exchange, Health Information Technology, where we are with that.  ... I'm hoping that by December 1 we have a state-designated entity in place ... "

Streur: I think at least part of that is going to depend on the feds, and whether they'll allow us to expand the project. If they won't, we have to sit down with the four of you that aren't moving forward, and say, "Okay, how can we set this up with Medicaid only?" I won't go outside the rules right now. Mark [?] and I had that discussion last time we were in Washington D.C., and the rules are what, 75 miles from a hospital...

Audience Member: Seventy-five miles from a hospital or not on the road system.

Streur: ...or not on the road system. As long as we follow those rules, I don't have any problem with doing that. We have the capability to do it, it makes perfect sense and having been in Klawock and seeing, being able to touch and feel what it really looks like -- I was like, "Whoa, this is good."

May I do one quick thing? People are asking about the HIE, Health Information Exchange, Health Information Technology, where we are with that. We did an RFLOI, Requests for Letters of Interest. We have fourteen respondents, so, there's lots of interest out there in doing it. We had just a few that were qualified, however, because it requires a board to be in place, you know, those things. But we did have more than one that was qualified. So, we are going with an RFP process. In the meantime, our letter of intent went out in the mail yesterday, and electronically to the Office of the National Coordinator to apply for the $20 plus million of money that's available. What we'll do is we'll issue an RFP, in the meantime we'll submit a plan, that's due to the Office of the National Coordinator by October 15. We'll issue an RFP for a state-designated entity, the entity that will manage it, and we'll have to put a board in place made up of five providers, the community insurance carriers, and the university, as outlined in Senator Paskvan's Senate Bill 133. I'm hoping that by December 1 we have a state-designated entity in place, and we're moving forward with that -- both with electronic health record assistance to entities that qualify, and also to begin to get our own health information exchange in place so people can talk and communicate with each other on records.   

Moderator Shelley Hughes: It is an exciting time. Lots is happening and you're doing a lot for us and with us in the state. I also want to thank you too, because I know under your section there in the department, there's a new state loan repayment program -- a federal grant received, and partnership with that. We got behind that, supported that, and provided a letter of support, so we're just happy that that's happening too. You're doing a lot, and we need to stay in touch and be in good communication with you. I think that we can get a lot done, and help you with your goals. We really need to give this fellow a round of applause.

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AHPR Staff and Contributors

Lawrence D. Weiss, PhD, MS, Editor
Kelby Murphy, Senior Policy Analyst
Jacqueline Yeagle, Newsletter design and editing

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