Richard Neubauer, MD, FACP, is the director of the new Providence Senior Clinic slated to open its doors in Anchorage on January 17, 2011. Dr. Neubauer is certified in internal medicine and has published nationally on that subject. He was in private practice in Anchorage for 15 years before serving in various leadership roles at Alaska Native Medical Center for the past 3 years. The new clinic will exclusively serve patients age 55 and older. In this interview Dr. Neubauer discusses how the clinic is very different than other clinics for seniors in Anchorage, and how it will be a part of the solution for the ever-increasing problem of the inability of seniors to access primary care in the state of Alaska. The Providence Senior Clinic will be utilizing an innovative patient-centered medical home model of care. This interview was recorded on November 18, 2010. It has been edited for length and clarity.

Links to selected topics
Background of the Providence Alaska Senior Clinic
Patients 55 years and older eligible to receive clinic services
Clinic attracts health practitioners across the age spectrum
Patient-centered medical home model provides coordinated, comprehensive care
Advisory board will help keep the focus patient-centered
Coordinated care of multiple medical problems is the distinguishing focus
The concepts behind clinic compatible with new federal health care legislation

Background of the Providence Alaska Senior Clinic

AHPR: Would you please tell us a bit about yourself and your position at Providence Hospital?

Neubauer: I was in private practice in Anchorage from 1982 to 2007 in general internal medicine. I took a job as chief of the Internal Medicine Department at the Alaska Native Hospital in 2007. I was in that position until September of this year when I came to Providence to start the Senior Care Center. So that is my Alaska background. Before that, I was in medical school at Yale University in Connecticut. I did my internship and residency in Ann Arbor at University of Michigan and then I did 2 years in the Indian Health Service in a place called Fort Washakie, Wyoming, before I came to Alaska, and when I first came to Alaska I spent about six months working in Juneau before I came to Anchorage.


AHPR: As a physician?

Neubauer: As a physician.

AHPR: Would you please talk a little bit about the history of the development of the Providence Alaska Senior Clinic?

Neubauer: For at least ten years there's been some discussion in the Anchorage medical community about finding some kind of solution to the growing problem of taking care of patients who are either in the Medicare age group or reaching that age group. The current project was really a kind of fortuitous coming together, for me at least, of me being available to do this and having Providence be interested in doing it, so at least from my perspective this is a really a great coming together of really three areas of interest for me.

One is finding solutions to the access to care problem for Medicare patients, at least for primary care services, which are really problematic in Anchorage, [two,] the use of electronic health records which I am very interested in, and [three,] the concept of a patient-centered medical home, which I'm also very interested in particularly because of my involvement with the American College of Physicians over the past ten years where that conversation nationally about finding better ways to do primary care has sort of evolved.

AHPR: Is the clinic currently open or what are its plans for opening?

Neubauer: It's not currently open and the plans for opening are January of 2011, which is coming pretty quickly and actually our tentative start date is January 17th.

AHPR: Where will it be located?

Neubauer: It's going to be located in suite B 314 on the Providence Hospital Campus. Back to selected topics list

Patients 55 years and older eligible to receive clinic services

AHPR: Who is eligible to receive services at the clinic?

Neubauer: The demographic for our clinic is going to be age 55 and above, so mostly Medicare age patients. We are anticipating probably 70% of the patients or so will be Medicare covered patients.

AHPR: Will you accept insurance other than Medicare?

Neubauer: Yes. We'll take patients, as I said, who are age 55 and above. The rationale for picking that age was that this is an age group where the problems that patients have are very similar to the Medicare age group. People are starting to have more medical problems, multiple medical problems, so that's one rationale. [There are] several others -- one was that there are practices in Anchorage that are limiting their patients in the age group, say 55-65 because they are afraid that as those patients age they will very soon become Medicare covered patients, and many practices are trying to limit their Medicare population. We feel like we're serving a demographic there that also has needs, and I think it's important that patients [and] people in general feel that when they reach 65 they are all of a sudden relegated to a special category that has to go somewhere else.


AHPR: In your clinic, what kind of providers will be available? In other words, if somebody is a patient at your clinic, what kind of health care professionals will they be seeing?

Neubauer: The initial staffing of the clinic is going to be with internal medicine physicians. I'm a general internist, the other physicians that we're currently recruiting or have recruited are also general internists, and we will have a nurse practitioner as well. Over time I would envision a spectrum of physicians. It is certainly conceivable that we might get a geriatrician, somebody whose special expertise is taking care of older patients. Family practice physicians would be another group that we might recruit, and more nurse practitioners and potentially physician's assistants as well. The idea is that we'll have a spectrum of different providers with different skill sets that would match the varying needs of the patients that we'll be seeing. Back to selected topics list

Clinic attracts health practitioners across the age spectrum

AHPR: I know that many clinics and hospitals have complained in Alaska that it is hard to recruit and retain physicians and other health care providers. Has that been a problem for the clinic?

Neubauer: Knock on wood, not so far! We've had interest from both older physicians, who are interested in migrating into this clinic, and we've also had interest from younger physicians coming out of training, so I'm very encouraged by that. I think it probably has to do with a couple of factors. One is that we're trying to structure the physician job so that it's an attractive job for people coming out of training. Another is that I think the patient-centered medical home concept is attractive to physicians. The idea that they'll actually be participating in something that as a model of care is very attractive, and I think the desire of physicians coming out of training to do good primary care of patients has been there for a long time, it's just that there have been obstacles to finding jobs that are attractive in that way for physicians. At least so far, the results that I've had since I've started working on this have been very encouraging. Back to selected topics list

Patient-centered medical home model provides coordinated, comprehensive care 

AHPR: That's heartening to hear that. I wonder if you could explain a little more what the patient-centered medical home model is and why it might be a benefit to both the providers and patients.

Neubauer: It's a fundamentally different model of care than what primary care has been in the past. The underlying concept is that the care will be coordinated, comprehensive, will use a variety of means to provide enhanced access to care so would take advantage of electronic health records; the potential for communicating between patients and providers by e mail, by telephone; using a spectrum of different providers in a team based approach with all the providers in the patient-centered medical home working as a team together to provide care that is up to the level of their expertise in providing care to the whole patient.

It's a way of leveraging all the different things that we know now, including electronic health records to provide care that's integrated, coordinated, comprehensive, better for patients. In our particular situation, we're going to be using the electronic health record system called EPIC, which is going to be used in both the inpatient setting at Providence Hospital and also in the outpatient setting. So the potential for coordination between all those different settings is really, really huge. So if a patient comes to the emergency department, they'll be able to see there the outpatient record of the patient. If a patient is hospitalized and transferred to an outpatient setting [they] will be able to the inpatient records, and vice versa.

AHPR: So those records are used Providence-wide, that kind of electronic record?

Neubauer: It's in the process right now of being put in place. Back to selected topics list

Advisory board will help keep the focus patient-centered

AHPR: I wonder if you could tell us a little bit about the advisory board that you're forming for this clinic. I appreciate being offered a position on it and I have accepted, by way of disclosure to our readers, but I wonder if you could tell us what the purpose of the board is? I mean to the best of my knowledge most clinics don't have advisory boards, so why would you choose to establish one for this clinic?

Neubauer: That actually was an idea of both Dr. Tom Hunt and mine. As we've both been talking about putting this clinic in place, the notion that this is a patient-centered endeavor is very strongly in both of our minds. We thought it would be really great to actually put together an advisory group that would not have any fiduciary responsibility for the clinic, but would be able to keep us on track as physicians to make sure that we really do make something that is patient-centered. For instance, if there are some things that we have limited resources to do, ask people that are going to be patients in the clinic or who could be patients in the clinic, "What's most important to you?" "What would you like to see?" "How would you like to see us use the resources best for things that are meaningful to the clientele?" So it's a concept that hopefully will bear fruit.


AHPR: Do you anticipate having some built-in quality monitoring or quality measures for the health care?

Neubauer: Thanks for asking that. That's a really important point and the answer is clearly, yes! The other thing that the electronic health record enables really is to be able to do just what you say and probably do it better than otherwise, so quality and safety are actually another built-in feature to the whole concept of a patient-centered medical home.

AHPR: How many patients will be able to be seen by the clinic? I ask that question as opposed to the need for example, in the town or in the state.

Neubauer: Just a rough estimate, and it may not be accurate, a rough estimate of the number of patients in the greater Anchorage area who would like to have better access to primary care services but can't find it, and who are in the Medicare age group I would say would be probably between 10,000 and 15,000 patients -- just from the numbers that I know of about how many Medicare patients there are in the state and so on. How many patients we can see in this clinic will be dependent on how many providers we have and how quickly we can ramp up the services for the clinic. I don't think we'll be able to meet the needs of all the patients who are out there that have a need, but I am hoping we can make a pretty good dent in the need that's out there. It is difficult to say what a reasonable panel size would be for physicians in this clinic. I'm hoping that with four or five providers in our clinic potentially by the end of the year we can start seeing a good number of patients. Back to selected topics list

Coordinated care of multiple medical problems is the distinguishing focus

AHPR: How will this senior clinic be different than other ones in town, other clinics that generally accept seniors? I'm thinking for example of the community health centers that see seniors with Medicare, and then there's Dr. Rhyneer's clinic, which I don't really know if it's open or not yet, but in any case it's a clinic that's been contemplated and even partially funded I think by the state. Is the clinic here at Providence going to be different?                    

Neubauer: The primary focus of the neighborhood health clinic is the uninsured, and as a federally qualified health center that really is the mission for the [Anchorage] Neighborhood Health Center. They have a great mission and they do a great job of filling that need and they have actually over the past few years taken a larger number of Medicare patients mainly because those patients have had great needs and haven't been able to find homes for their medical care in other settings.

We're different than the neighborhood health center by virtue of the primary focus of our effort is really to enhance access for the Medicare population and the population of patients who are reaching Medicare age. I think we'll actually help the neighborhood health center by taking away some of the burden that they've seen by taking away some of the Medicare population because they've been one of the only venues that have taken new patients in that age group.

The Medicare clinic that is being put together by Dr. Rhyneer and his group is a parallel effort to ours and as I said, I think the number of patients out there who have a need for primary care is more than either that project or ours could meet alone, so having parallel projects will be a very, very good thing. Dr. Rhyneer's model is a little bit different than ours. How exactly that will work out I'm not sure, but we've met together and I've tried to help as much as I could with what they're doing. We're not really in competition -- really we're more parallel efforts toward addressing the same problem.


AHPR: I understand; based on the last time I heard Dr. Rhyneer make a public presentation, that to make his clinic financially viable he'll be treating patients on the basis of one clinical presentation or diagnosis per visit, and I'm wondering if your clinic will have that same kind of limitation.

Neubauer: Well, the short answer is no. The whole concept that we're using, the patient-centered medical home, is one of comprehensive coordinated care as I've mentioned, and that model is very different. We're going to be basing this on being able to take care of and coordinate care for multiple medical problems so we don't have the same limitation. The funding and the fundamental financial models that the clinics are based on is very different.

My understanding of the clinic that Dr. Rhyneer has put together is that it is specifically trying to live within the [financial] means of Medicare, and that's why they made that model of care. In the instance of the Providence Clinic, it's really highly subsidized by Providence. The expectation is that the clinic is not going to make money or even break even in the first year of operation, and it's not clear how that will go in subsequent years either, but what is clear is that Providence is putting a lot of resources into this. It's highly subsidized by Providence and able to do a different kind of model because of that.   

AHPR: And if I may ask, why would Providence make the decision to open up a clinic that's going to need a lot of subsidies in order to work?

Neubauer: Part of the answer to that is that it is part of the charitable mission of Providence to do that. There are other considerations. One of them for instance is that if Medicare patients can't get primary care they often come to the emergency department for care. They come there much sicker than potentially they otherwise would be, and they also come there because they have nowhere else to go even if they have simple problems that could be taken care of in an office setting, or not necessarily simple problems, but problems that would certainly be amenable to an outpatient setting. If these patients have a place to go and don't have to go to the emergency department, then Providence doesn't have to build more emergency public resources. So there are both charitable and other reasons for doing this.

AHPR: Just out of curiosity, will Providence be monitoring the emergency department to see if there has been an actual impact on that age group as a result of opening up the new senior clinic? 

Neubauer: I'm sure they will be.

AHPR: I forgot to ask earlier: will this clinic be associated with a residency program?

Neubauer: That's certainly potentially possible, but not at first. We really need to ramp up the operation before we can start taking residents, but I certainly think that as a future vision that would certainly be appropriate. Back to selected topics list

The concepts behind clinic compatible with new federal health care legislation

AHPR: Let's say there is an interested potential patient out there. How will they know when you open and how would they go about making an appointment?

Neubauer: We actually have a wait list right now. Patients can call the Providence main telephone number [907.562.2211] and they'll take down their information and patients will be put in a queue. Once we're open, which as I mentioned is anticipated in January, we have a website that's on the Providence main web site for the clinic, and of course we'll have telephone access as well and I'm sure there will be publicity in the newspaper and so on about the opening of the clinic. I don't think we'll be hard to find.

AHPR: I'm assuming that the planning for this clinic predates the federal health reform legislation. I wonder: do you anticipate any particular impacts on the clinic, positive or negative, from the federal health reform legislation as it's going to be rolling in over the coming years?

Neubauer: You're right. The planning did predate the passage of the Affordable Care Act (ACA). I can see nothing but positive from the Affordable Care Act as far as this clinic goes. There are things in the Affordable Care Act that specifically address new models of delivering primary care; the patient-centered medical home is certainly one of those. There are pilot projects in the ACA regarding the patient-centered medical home idea. I can't see any limitation from ACA as far as this clinic goes. I think the only impacts will be positive ones.

AHPR: I think we've reached the end of my prepared questions. I wonder if you have any kind of final statement you'd like to make for our readers.

Neubauer: I think this is a really exciting project for me. It's a wonderful thing to be involved in. I think the elders of our society deserve great medical care and my aim is to make this not a place where people come because they have nowhere else to go, but a place to go because this is the best place to go.

AHPR: Thank you very much for the interview.

Neubauer: It's a pleasure. Back to selected topics list

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Ward Hurlburt, MD, MPH is the chief medical officer for the Alaska Department of Health and Social Services and director of the Division of Public Health, providing medical consultation to the department and overseeing all programs and services responsible for the protection and promotion of public health in Alaska. Dr. Hurlburt served more than 30 years with the U.S. Public Health Service. He also served as vice president, chief medical officer and a consultant for managed care organizations across the west. In this interview he describes the challenges he is facing as the chair of the Alaska Health Care Commission and a member of the Medicaid Task Force including a discussion of the Patient Protection and Affordability Care Act and Alaska's decision to join 21 other states in challenging its constitutionality. This interview was recorded on November 11, 2010. It has been edited for length and clarity.

Links to selected topics

A diverse medical practice background
Responsibilities and issues of the chief medical officer position
The role of the Alaska Health Care Commission
The intersection of health care and the Alaska economy
The impact of federal health care reform in Alaska
Alaskans benefit from collaboration among public health care programs

A diverse medical practice background

APHR: I wonder if you could give us a little bit of history about yourself. What are some of the key positions you have occupied in past decades prior to your current appointments?

Hurlburt: My first residency was one of the old general practice residencies. It was a one-year program. It antedated family medicine [and was] much more like preparation for missionary medicine. It was a one year program after rotating internship. Then in the days of the draft I had elected to come in to Public Health Service to fulfill my military obligation and because my father-in-law had been an Eskimologist. Both my father-in-law and my mother-in-law had been born in Greenland. He was Danish, the son of Danish Lutheran Missionaries and she was Greenlandic.

My wife was born in Copenhagen, but [her father] spent his life traveling in the Eskimo areas of the world so we picked out of a catalog Kanakanak, this place that was spelled the same way forwards and backwards. I asked for that assignment and received it, and we went there in 1961 with a one year-old son, and my wife about six months pregnant when we got there. We spent a couple years there in Kanakanak intending just to stay two years in the Public Health Service.

I actually got out and went to Thailand with a mission group, but [returned] in a little over a year and went back in the Public Health Service and went to Vietnam on a program the Public Health Service had in civilian hospitals over there, taking care of about half war-injured civilians and about half just general tropical surgical disease. Then subsequently, spent some time in the Southwest on Apache Reservations training as a general surgeon, and ended up spending more than 31 years in the Public Health Service. [I spent] about two thirds of that in Alaska, and the rest of it all at the Alaska Native Medical Center as a surgeon, as chief of surgery, as director of the hospital, and a couple of tours as a deputy area director, which in the days when the government operated that system all the service units, we called them, all the facility directors reported to me.


We did have another overseas assignment in Liberia for a couple years, where we had a party developing a model for a rural health care system for that country. There was a contract for USAID [United States Agency for International Development] we had with the Indian Health Service to do that. I spent a couple years as director of operations nationally for the Indian Health Service back in Rockville, a couple years down in Navajo as chief medical officer and the deputy area director there, but Alaska was always home. Then I retired in '93 from the Public Health Service and led what was called the Integrated Health Plan. I went to Utah where there was company called FHP, it was an insurance company, but also we had our own hospital, we had our own clinics, and about 150 physicians. It was just like being in the Indian Health Services as far as I was concerned, a staff model type program.

I came back to Alaska for a couple years on a contract working for Dick Mandsager, one of my predecessors in this job, but I had formerly been Dick's boss and at that time he was my boss. I had known Dick for a long time and that was working with the medical center in the final phase of the transition of that last piece of the Alaska Native Health Care System to be operated by the Native groups here when Alaska Native Tribal Health Consortium was started. I then left Alaska again and was with Group Health for a while in the Puget Sound area leading their staff model, or group model portion in the Puget Sound area with a couple of hospitals, a nursing home, the non-primary care physicians and clinics. I tried retirement once and failed, and worked for about the last five years before we came back for a company called Molina where we contracted with the state for over 300,000 Medicaid enrollees there throughout Washington state. [I] again came back up here in June of 2009 intending to retire, but Bev Wooley and Jay Butler had left the state and so I came back into this position here a year and a quarter ago now, and it's been absolutely fascinating and a great opportunity to be here. So that's kind of how I got where I am.

APHR: Wow! That's a really extraordinarily diverse background! It turns out you and I have something in common. I also did work out in Navajo Nation. I was employed by the University of New Mexico School of Medicine for number of years in the 1970s, and my job was to evaluate the development of Navajo Health Authority over a number of years.

Hurlburt: We were there 1979-81, lived in Gallup, office was in Window Rock. Back to selected topics list

Responsibilities and issues of the chief medical officer position

AHPR: In September of 2009 you were appointed to be Alaska's new chief medical officer and Public Health director. First, I wonder if you could please explain a bit about the chief medical officer position. What are the responsibilities of the chief medical officer and what are the top issues you are dealing with now in that position?

Hurlburt: The chief medical officer's position was a relatively new position that was in the Office of the Commissioner and really does not have defined duties. I think significantly as a money-saving measure a decision was made to combine that with the director of Public Health Division's position, which is more of a line function. So the chief medical officer's role really serves as an advisor and support to the commissioner, does have a department-wide and in some ways a statewide basis kind of as the lead medical person that the governor can call on and others can -- looking for somebody with a broad public health background, with a clinical background, but with a fairly undefined role. Prior to my taking the job there had been I think like the preparedness program, an emergency preparedness program had specifically been assigned to the chief medical officer, but largely was not a line function so that's that.

Then the director of the Public Health Division is at the deputy commissioner level, but because it's a position called "the chief medical officer," my counterpart being like Bill Stewart [and] Pat Hefley who are designated as deputy commissioners. There are three of us really that function at that level and we each have operational responsibility for the various components within our areas. The director of Public Health has the traditional public health functions like public health nursing, like epidemiology, what we call Women's, Children's and Family Health, the old maternal and child health kinds of things, and then some of the newer ones like chronic disease prevention, health promotion.

There are some functions -- every state government is different -- Bureau of Vital Statistics is a part of this division, [and so is] Certification and Licensing of assisted living homes for both children and adults is a part of that. The Emergency Medical Services, which usually is part of public health is there, the emergency preparedness is, so there is a fairly broad array of responsibilities in there. There was probably some controversy over combining those two jobs. My bias before I took it, and I'd say it's only been reinforced, is that it was a reasonable thing and a good thing. I had in my mind, my preference even though it's more work, my preference is to have those two roles combined.


AHPR: Well, clearly as director of Public Health your purview seems quite broad, maybe even overwhelming with all the different sections that you oversee. What are some of the key issues or challenges you are facing at this time in your role as director of the Division of Public Health?

Hurlburt: I'm blessed to have two absolutely outstanding deputies -- one here in Anchorage and one in Juneau -- and we've structured the divisions of each of the sections [so that they report] to one or the other of the deputies, and that's what makes it very doable I believe. There's a major focus that we have -- in fact this afternoon we're having a kickoff meeting on it -- a major focus that we're having is on our immunization rates. Our immunization rates, and we have rates by various age groups from newborns up through adults, but commonly you tend to focus on the two-year-olds looking at how well do you do in having your two-year-olds receive the recommended immunizations. We're about 67 percent on a statewide basis and that's not satisfactory. This is an issue and it involves public health nursing, it involves epidemiology, it involves Women's, Children's and Family Health to some extent, and certainly involves the private sector of health care here, because we're certainly not the only ones administering the immunizations.

You have what you call the concept of herd immunity in public health, and that means if you have enough of your population that are immunized you don't have to have 100 percent. Probably for most things if you have an 80 percent level you're doing reasonably well. Our goal would be to be at 90 percent. Where your level of immunization drops off like it did for pertussis [whooping cough] in California this year, you have a significant outbreak of pertussis and you have some deaths from that, so we are concerned that our rates are not as high as they should be. It's the kind of thing that probably every few years you have to say, "Okay we've slipped a little, we need to get back on top of it." We need to do better.

AHPR: Focusing specifically on the section of Women's, Children's and Family Health, in early June of this year as you're aware, Governor Parnell vetoed expansion of Denali KidCare. The proposed Denali KidCare expansion would've extended public health insurance to cover children and pregnant women from families with incomes up to twice the federal poverty level. Current allowances cover families earning 175 percent of the poverty level. The bill would've opened state health insurance to approximately 1,300 uninsured children and 225 pregnant women. Alaska is one of a handful of states that doesn't offer public health assistance for uninsured children at twice the poverty level. In other words, most states offer it to children who are at least twice or more the federal poverty level. In light of this, is the health of children of working Alaskan families who cannot afford health insurance being adequately protected?

Hurlburt: I believe the governor has a track record and I think a personal philosophy of being very supportive of families. That's why his whole priority of domestic violence and sexual abuse that really is his number two priority next to the economy of the state has been something that he's been really supportive of going back to his days in the state legislature. So I think as far as answering the specific questions: that is and has been a priority. He's also clearly very much on the pro-life side of the abortion issue, and it was a realization this would expand the number of abortions due to the decision of the Alaska courts -- which have said if you're going to provide care for women pregnant you have to provide abortion services -- and it was this issue that was going to expand the number of abortions that the state would be paying for that caused him to veto it. I think the whole underlying concept of providing more care for kids was something that he has been supportive of, but because of his own life values, because he comes from the conservative side of the Republican Party, it was something he felt he couldn't support and that was why he vetoed it. Back to selected topics list

The role of the Alaska Health Care Commission

AHPR: Thank you. The Alaska Health Care Commission was recently established in state statute with the passage of Senate Bill 172 to serve the state as a health planning and coordinating body responsible for providing recommendations to the governor and the legislature on a comprehensive state-wide health care policy and on strategies for improving the health of Alaskans. The bill was signed into law by Governor Parnell on June 23, 2010. As medical director for the Department of Health and Social Services you were reappointed as the chair of the commission. What role do you foresee the commission playing in the coming years and what issues in particular do you see the commission focusing on?

Hurlburt: I believe that there would not be a health care commission if we were not spending 18 percent of our gross domestic product on health care and if, according to Mark Foster's data, we were not spending $7.1 billion out of our $30 billion gross domestic product in Alaska, or about 23 percent on health care. I think cost is what's driving us to do this. When you look at other industrialized countries, we spend at least 50 percent more of our gross domestic product and of our dollar equivalents than any other industrialized country, and the people in those countries often live longer than Americans generally do, the babies die a little less, so I think cost is what's driving this and that's been very central to the discussions of the health care commission.

We talk about cost in terms of value, and that's of course a product of the cost and then what happens from that. I think that's going to underlie all of our discussions there, but then we have some other issues that we see in the papers, [for example we] frequently hear on the news the problems that our Medicare enrollees have getting access. We read there are a dozen or 13 primary care physicians in Alaska who will take new Medicare patients so we know we have an access problem particularly for that group there. As a part of cost we see our Medicaid costs continuing to go up and up at a very rapid rate and that squeezes the ability of the state do other things -- whether to provide education, build roads or support public health programs -- so I think cost is part of that.


The commission was expanded, adding some new members by the legislature, and the commission will need to form into a group. There have been previous groups, as I know you're aware, going back to Governor Steve Cowper's time when the first commission was appointed looking at the issues that we have. The commission represents providers from the Alaska State Hospital [and] Nursing Home Association, physician groups, behavioral health, public health sector, and so on. There are 11 voting members now on the commission. They will be looking at quality issues, access issues, cost issues, and prevention -- that's a part of the charge.

The legislation establishing commissions is fairly short, but it establishes various goals and then in a second section talks about the cost kinds of issues, and I think both the legislature and the governor's office are looking for advice. In talking with the members of the legislature that have been involved, like Mike Hawker, the chair of the House Finance Committee who is one of those claiming some paternity for establishing the commission, his hope and his vision is that the commission can help the state get a handle on health care costs, not only what the state pays out for Medicaid enrollees, employees, workman's comp and other things, but for what health care takes as a chunk of our whole state's economy.

AHPR: You mentioned the issue of value. My impression is that when we talk about value and health care we're talking about cost and quality. Will the commission be dealing much on the quality side of the health care issue here in Alaska?

Hurlburt: Yes, they will. I think that clearly they are not in a clinical kind of role to determine what quality is, but at the first meeting of the newly established commission we spent a significant amount of time talking about what's called evidence-based health care, evidence-based medicine. There was an article just in this morning's Washington Post I believe, talking about what's been talked about a lot -- that much of clinical medical practice is really not supported by high-grade scientific evidence. There are a number of things that define what high-grade is, but in one of the early commission meetings after Governor Palin set it up, they had an individual come and say probably a third of all health care is not really supported by high-grade evidence.

The article in this morning's paper again used that same kind of figure and translating that to dollars and pointed out that every year in this country we probably spend $800 billion on health care that's not supported by high-grade evidence. We're all a part of that. As a clinician I know I did things, absolutely believed I was right, it's what the experts recommended at the time, but we subsequently learned the evidence doesn't really support doing that. We've been working with the commission and becoming knowledgeable and educated about that concept and I would hope that the commission can play a role in fostering more incorporation of that.

On the payer's side it's done by incorporating into policies that you pay for things that the evidence supports. On the provider side, on the physician's side it becomes a part of your whole DNA or your makeup. There's always going to be the need for professional judgment because every patient is going to be a little different. It's not just making a physician an automaton following a set of algorithms, but incorporating the understanding of the use of the evidence in the decision-making that's being done in the clinical setting. Back to selected topics list

The intersection of health care and the Alaska economy

AHPR: Since we're talking about cost, are you involved either through the commission or in any other way with, I may not have the name correct; I believe it's called the Medicaid Cost Containment Task Force?

Hurlburt: I think it's going by Medicaid Task Force, but that's exactly it, and I think that the throwing in the words cost containment gets at why it exists. This was a new group ... [I have] attended one meeting. The commissioner worked with the governor's office and obtained their support to set up that task force. There are four members of the Senate, four members of the House, and four from the department, and I am one of the four from the department. We've had one meeting, but that group is charged with looking at Medicaid, which in the next fiscal year, FY12, Medicaid will be spending about $1.5 billion in this state and that's rapidly going up.

It's going up right now more than it has been for the past few years because there's been increased enrollment in Medicaid, and that's due to the downturn in the economy even here in Alaska where we've not been hit that badly as most states have, nevertheless we have been hit. It's going up because of the changes in the Patient Protection and Affordable Care Act and national health care reform, which is bringing more people into Medicaid. It's going up because the prices that providers charge continue to go up, and it's going up related to the increased enrollment. Like any group of people, if you've not had insurance and you [obtain] health insurance, you tend to go in and try to get some of your unmet needs met and that increases utilization. The utilization has been going up for the enrollees that have.

AHPR: Just parenthetically, I imagine that $1.5 billion does have a huge impact on the state's economy, not from the expenditure side but from the revenue side.

Hurlburt: It does. It does. The whole $7.1 billion that we spend in the state on health care goes somewhere. Some of that goes outside, but most of it stays here in the state and pays the money that physicians make, the hospitals make, that employees receive, so it is a factor in the economy. However, that $7.1 billion overall, it's not money that would just go in the bank and not be used. There is a trade-off so that if you're spending 23 percent of your state's economy or 18 percent nationally on health care, it does mean that you may not be able to repair the roads or rebuild the roads, or you may not be able to put as much money into education or do other things. So there are trade-offs, but yes, it's not new money that comes from nowhere. It does come from other trade-offs, but it does go to support the health care sector and all those who work in it, and does derive the benefit that if you develop a cancer and your surgeon is able to cut it out and save your life, that's clearly something of high benefit to you. Back to selected topics list

The impact of federal health care reform in Alaska

AHPR: I recall some time ago in a presentation I attended that you had mentioned you attended periodic meetings of a working group consisting of representatives of several DHSS departments and perhaps other individuals attempting to prepare for the impact on Alaska of federal health reform legislation. I wonder if you could talk about that.

Hurlburt: Yes, we did. With the signing in March by the president of the PPACA, the Patient Protection [and] Affordability Care Act, called Obamacare probably by those who don't like it so well, that with that, the state needed to deal with that. As you know, we are one of the 21 states I guess that have felt that the legislation was not constitutional. We've joined with twenty, with Florida taking the lead, on challenging the constitutionality of that, but nevertheless we've needed to be knowledgeable about what's in that and be prepared for that.

There is a lot of money associated with that. Much of it is for programs that have been ongoing already, so it's continuation grant kinds of things -- questions for instance for programs for our Women's, Children's and Family Health area -- so we have tried to systematically look at that act, look at the various sections of it, be knowledgeable about it, be aware of how it impacts on us and track that just so that we know, and so the governor's office knows, what's happening there. We have made several requests for funding under that act to the Department of Health and Human Services for example with the federal government and have received grants for that.

There have been three areas where there were potential grants that the government has not gone for here. Two of them relate to the Division of Insurance. One of them had to do with providing a million dollars in funding to each state that allowed you to look at what insurers were charging, to look at the insurance rates. There was a difference of opinion about whether or not we should go for that, but the decision was made not to because that particular grant, or potential grant, allowed only $50,000 dollars to be used for some data automation, which is what we really needed. In this state where we have relatively few insurers and Premera has 70+ percent of the commercial insurance business, we have the information needed already from them and can get it from the others. The reporting requirements were significant so we did not go ahead and request that.


The second one that we did not request, again in the Division of Insurance, had to do with establishing insurance exchanges, and there are some exchanges that operate around the country now. Massachusetts has one. Utah has an exchange. They're very different in those two states, but we and Minnesota decided because we were challenging the constitutionality of the whole law not to go at this time for that money. I don't think that [will have] any immediate impact on us.

The third one that we did not go for was a potential grant of a relatively small amount, I was told about $50,000, for "abstinence only" type education. That was in our department. We did not go for that because it required the matching of the funding and we did not have the funds to do it. The reporting requirements were fairly onerous and the program that we do support is a comprehensive program that already includes abstinence education along with sex education. [That is] the kind of program nationwide that has been shown to have the most successful results as far as reducing teen pregnancy rates, so that we were already having that as a part of our program. Those are the only three I believe that we have not gone for.

The governor's office has wanted to be kept aware of the potential sources of funding, not wanting to basically place themselves in a compromising position of challenging the constitutionality of the law on the one side and going for the money on the other. I think that the national administration has probably done some work to try to potentially embarrass the 20 states that are challenging the law and put them in an awkward position so there's probably some politics at play there, but so far I think where we've had programs ongoing and where it's been important for the state, the governor has been supportive of requesting the money there, and we've been able to do it in a way that doesn't compromise the legal position of the state.

AHPR: Thanks very much for the detailed explanation. You actually answered questions I haven't asked yet. Does that group that periodically meets, your working group, do they have a name?

Hurlburt: It was called the Alaska Patient Protection and Affordability Care Act Implementation Team. It went by APIT. There were various department members that were in that, some folks from other departments, but kind of just met and tried to track the act, get knowledgeable about the act and look and make sure that that we weren't just unaware of opportunities might be there for the state.

APHR: So are you implying that this group no longer meets?

Hurlburt: That group will be meeting probably on a monthly basis. They tend to be informal meetings, but to keep up communications. The intent would be that they would continue to meet probably on a monthly basis. There's not been a meeting for a while I don't believe unless I was out of town and missed one. Back to selected topics list

Alaskans benefit from collaboration among public health care programs

APHR: We actually are at end of the list of questions I have prepared. Do you have any final things you'd like to say to the readers of Alaska Health Policy Review about any of these issues or others of importance?

Hurlburt: Well, I have not worked for the state before and came on new. I'd actually been recruited in the past for this position and ended up deciding I was very happy what I was doing with the tribal health programs here and stayed there, but I've been impressed with a lot of the folks and a lot of things that happen here. The state of Alaska has a real resource -- I have, and to make a list sounds like you are excluding some people, but looking at our epidemiology section led by Doctor Joe McLaughlin, it is absolutely outstanding. Public health nursing has always probably been the most popular program the state's health department has. A lot of committed people do a really good job.

The two labs that we have, the virology lab in Fairbanks and the bacteriology and toxicology here, are both pretty new. The one in Fairbanks just opened up. It'll be two years ago next February. [These are] tremendous resources for the state with highly qualified, highly dedicated people, and I could go through each of our sections and say that. The H1N1 outbreak through our preparedness folks -- as I listen to my counterparts around the country -- we had one of the smoothest operations here because of the good collaboration with school districts, with local fire departments, with local medical providers, with the state and so on, so I'm impressed that there a lot of really good things for our state and our state citizens that happen here.

AHPR: I did just think of one last question if I may ask it. I appreciate what you're saying because there's a kind of a cultural theme that we hear occasionally in the media that kind of vilifies public employees, so I am heartened to hear the positive feelings that you have towards public employees in the state of Alaska.

Hurlburt: The vast majority of our folks have a real passion about what they do and why they do it.

AHPR: The one last question I wanted to ask you was: Can you talk about any kind of working relationship you may have in any of your capacities within the Municipal Department of Health and Human Services?

Hurlburt: Under our constitution, the state is responsible for public health throughout the state. In some states it's that way, in others the state health department is relatively small and you have county health departments. Within Alaska for public health nursing services, we have four contracts with what we call grantees: Norton Sound in Nome, Maniilaq and Kotezube, North Slope, Barrow, and Municipality of Anchorage. Norton Sound has given the state notice that next July 1st they will be returning the public health nursing program to the state to manage and we're working closely together on that.


With the municipality, we contract with them for public health nursing services. Each of the four grantees has been putting significant resources of their own into the program. Percentage wise, probably the municipality more than anybody else, and this is one of the things that's been causing a challenge for Mayor Sullivan over there as he has his real budget challenges so the legislature did provide the requested $1 million last year that went to the four grantees to reduce the amount. We will see that there will probably be a request in the next legislative session to try to make the grantees whole at a level consistent with the funding that the rest of the state receives.

Meantime, the Department of Health and Human Services with the municipality and we continue to work closely and collaboratively together. Being right here in Anchorage, it's easy to have good communications with them. You may have seen recently on the [news about a] program that they had related to health at the Mexican Consulate. The municipality took the lead on it and some of our public health nursing folks went in and helped with influenza immunizations and other things. Occasionally we'll look at an issue from a different perspective, but the working relationships are really quite good between us and the state and municipality here.

AHPR: That really was my last question, and thank you Dr. Hurlburt. Back to selected topics list

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Lawrence D. Weiss, PhD, MS, Editor
Angie Shephard, Transcription and editing
Jacqueline Yeagle, Newsletter design and editing

 
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