Alaska Healthcare Fall 2017

M O R R I S

P U B L I S H I N G

INSIDE: Physicians' initiative tackles cost through coordinated care, 8 State gets waiver to continue reinsurance program, 10 First blood test for breast cancer detection reaches Alaska, 12 In health care, a good price (or any price) is hard to find , 14 State program shows success recruiting health workers, 17 Premera cuts rates further for 2018 - 26 percent, 18 Central Peninsula Hospital moves forward on detox facility, 19 Senators welcome delay on healthcare vote to lobby for Alaska, 20

G R O U P

F A L L

2 0 1 7

Wynd Counts, MD

Katie Ulmer, ANP

Wendy Cruz, MD

Migel Hadley, ANP

Kristina Eaton, MD

Jennifer Feeney, ANP

Rhianne Christopherson, ANP

~Taking care of Alaska’s women, since 1994~ Specializing In: Minimally Invasive and Robotic-Assisted Surgeries Prenatal Care

Gynecology

Infertility

Contraception

NEW PATIENTS WELCOME 2741 DeBarr Road, Suite C-205 (907) 279-2273 * Fax (907) 258-7705 www.wcakobgyn.com

Preferred Providers with:

Blue Cross

Multiplan

Aetna

Cigna

Tricare

K a t i e U l m e r , A N P M i g e l H a d l e y , A N P J e n n i f e r F e e n e y , A N P R h i a n n e C h r i s t o p h e r s o n , A N P

W y n d C o u n t s , M D W e n d y C r u z , M D K r i s t i n a E a t o n , M D

2 7 4 1 D e B a r r R o a d , S u i t e C 2 0 5 A n c h o r a g e , A l a s k a 9 9 5 0 8 T e l ( 9 0 7 ) 2 7 9 - 2 2 7 3 F a x ( 9 0 7 ) 2 5 8 -­‐ 7 7 0 5 w w w . w c a k o b g y n . c o m

Women’s Care of Alaska is an all-­‐female medical practice, of Obstetrics and Gynecology that has been providing comprehensive care, to the women of Alaska, since 1994. Our group is currently composed of three physicians and four nurse practitioners. We recently moved into a new, much larger office, that was designed with the comfort of our patients, in mind; we created an environment that is warm and inviting not only for our patients, but for their families, as well.

At Women’s Care of Alaska, we provide you with some of the best obstetrical care in Alaska. Our expertise encompasses both low and high risk pregnancies, starting with preconceptional counseling, all the way through post-­‐partum care; in addition, we have in-­‐office ultrasound and testing capabilities. Our obstetric care is tailored to individual needs and wants, while continually providing safe care for mom and baby.

Our physicians are some of the busiest gynecologic surgeons in Alaska, especially when it comes to minimally-­‐invasive and robotic procedures; all of our surgeons are robotically trained. We perform surgeries for evaluation and treatment of pelvic pain, bleeding issues, pelvic prolapse and incontinence, to name a few. We strive for a minimally-­‐invasive approach in surgery, so our patients may have much faster recoveries, with less pain.

Other services provided include the management of infertility, family planning, health maintenance annual exams, urinary concerns, sexual dysfunction, menstrual irregularities, and menopause. In addition to our medical services, our practice will also bill your insurance company. We are preferred providers with Blue Cross, Aetna, Cigna, Multiplan and Tricare.

We are accepting new patients, and we look forward to providing Alaska’s women with the best medical care, we have to offer.

PAI D ADV E R TI SME N T

Providing the right care, at the right time, in the right place for our people.

ANMC staff provide culturally sensitive, patient-and-family-centered care every day. Our staff are known for going above and beyond in their work, serving our people with compassionate, innovative care.

ANMC has been Alaska’s only MagnetŽ-recognized hospital for nursing excellence since 2003, which acknowledges high quality patient care, nursing excellence and innovations in professional nursing practice.

Magnet recognition is the gold standard nursing excellence.

As a Level II Trauma Center, ANMC has provided the highest level of trauma care in Alaska since 1999. We were also Alaska’s first Comprehensive Pediatric Emergency Center, providing the best and latest innovations in care for our pediatric patients.

Interested in joining our team? Visit www.anthc.org/careers.

301 Arctic Slope Ave. Ste. 350 Anchorage, AK 99518 P: 907-561-4772 F: 907-563-4744 www.alaskajournal.com Publisher Deedie McKenzie (907)335-1245 Deedie.mckenzie@morris.com Managing Editor Andrew Jensen (907)275-2165 editor@alaskajournal.com Advertising Director Jada Nowling (907)275-2154 Jada.nowling@morris.com Regional Circulation Manager Doug Munn (907)335-1232 doug.munn@peninsulaclarion. com Production Matthew Wilkinson (907)523-2233 matthew.wilkinson@morris.com Account Executive Ken Hanni (907)275-2155 Kenneth.hanni@morris.com Account Executive Ryan Estrada (907)275-2114 Ryan.estrada@morris.com

INDEX Page Physicians' initiative tackles cost through coordinated care 8 State gets waiver to continue reinsurance program 10 First blood test for breast cancer detection reaches Alaska 12 In health care, a good price (or any price) is hard to find 14 State program shows success recruiting health workers 17 Premera cuts rates further for 2018 - 26 percent 18 Central Peninsula Hospital moves forward on detox facility 19 Senators welcome delay on healthcare vote to lobby for Alaska 20

The good physician treats the disease; the great physician treats the patient who has the disease.

William Osler

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7

Physicians’ initiative tackles cost through coordinated care

By Tim Bradner For the Journal of Commerce An Anchorage-based physicians’ initiative is aiming at improving health and reducing medical costs through a coordinated care program, mainly by reducing reliance on hospital emergency rooms for routine or non-emergency problems.

The goal is to steer patients toward more effective care, typically through primary care and better use of specialists, reducing the burden on hospital emergency rooms, the most expensive form of health care.

Alaska Innovative Medicine, or AIM, formed four years ago by six Anchorage physicians and Jocelyn Pemberton, a medical administrator, now has an active caseload of about 270 and has helped about 5,000 patients since the project started in January 2015.

Premera Blue Cross Blue Shield helped inspire the initiative and remains a strong supporter, Pemberton said. Most of the patients being assisted are Blue Cross members with costs paid through their health insurance.

“This all started four or five years ago in discussions within the physician community about how to improve the health care system and reduce waste through collaboration,” Pemberton said.

The founders were Anchorage physicians Jeremy Gitomer, Noah Laufer, Eric Miknich, Kathy Hurlburt, Tim Bateman and Terry Lester, along with Pemberton.

“We created the concept of clinically-driven care coordination out of these discussions,” she said. “The idea was to provide a multi-disciplinary approach that would allow us to be flexible and match the needs of each patient. The social worker or the case manager often takes the lead with the patient and can pull in resources as they are needed.

“We are not a clinic, although we have an office for our staff to meet with patients who aren’t comfortable with a home visit.”

Most of AIM’s work is with patients in their home setting after they have met with them in the hospital at discharge.

“Our role is to help coordinate the patient’s integration back into the primary care system from the hospital and to ensure the continuity of the care,” Pemberton said.

The belief is that coordinated care, compared with ad hoc visits to emergency rooms or medical specialists, will lead to more effective care and in the long run, lower costs.

Pemberton said it is physicians’ referrals that generate the bulk of new patients for AIM because they have an established relationship and trust with the patient.

In this, the group has a ready-made referral network of physicians who work in Southcentral Alaska hospitals through The Hospitalist Group, a collaborative of about 80 physicians contracted to provide in-hospital service. Pemberton is also CEO of the Hospitalist Group.

In addition to the hospitalists, there are 49 local primary care physicians now participating with AIM. The idea of coordinated care — the right care at the right time — has long been talked about in Alaska’s health care community but has never been actually done, at least in a formal way.

In other states managed care is done through health maintenance organizations, or HMOs. These organizations are

The clinical team at Alaska Innovative Medicine from left, Kristi Davis, administrator, case supervisor Cheryl Becker and clinical manager Ted Paprocki. (Photo/Tim Bradner/For the Journal)

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typically led by insurers and are aimed mostly at lowering costs.

HMOs are not allowed under Alaska laws.

What’s different about AIM’s approach, Pemberton said, is that it is led by physicians focused on health care rather than insurance companies who are concerned more with costs and the bottom line, at least in the minds of many consumers.

The difference has led to a higher level of trust for AIM’s approach among those being served, Pemberton believes. The evidence for this, she said, lies in “call back” rates, or phone inquiries from patients, a kind of rough consumer satisfaction indicator.

Phone calls from patients in managed-care HMOs typically average about 15 percent to 20 percent but average 85 percent to 90 percent for AIM, when there is a physician referral.

Premera Blue Cross, which is a nonprofit insurance company, has supported AIM’s project from its inception because it believes the coordinated care approach in sound and will improve health for its members, said Jim Grazko, Premera’s CEO for Alaska.

Premera steers members it believes can be helped by coordinated care to Alaska Innovative Medicine and also shares claims data, which documents medical experience.

“We sometimes see a high degree of emergency room use.

There are always times when people do need the ER but also times when it is not really necessary. We try to deflect some of that to more appropriate care,” typically primary care but also specialists, Grazko said.

“We’re talking about people who are at their most vulnerable

Alaska Innovative Medicine CEO Jocelyn Pemberton, left, and Administrator Kristi Davis.

Gigi Rygh, left, and Emily Splinter-Felton, right, are social workers on the Alaska Innovative Medicine team. (Photos/ Tim Bradner/For the Journal)

state, facing a medical emergency or actually in the hospital. It’s important to have an advocate at that point to help people navigate the system.”

Pemberton said, “We do a lot of medication counseling. Our goal is to help a patient understand a health plan and how to navigate the system, but we can help with calls to physicians to get follow-up care. If there are problems getting appointments, we can help.”

Having physicians (through AIM) make calls can often open doors to get appointments or get patients in earlier to see specialists, she said. AIM’s engagement also varies with the individual.

“Some patients need just one visit to go over the health plan but we’ve been involved for as long as two years with others,” she said.

There have been surprises, however.

“When we started we thought the needs would be mostly clinical,” she said. “What we found, though, is that most of our needs have involved social workers,” for health issues related to lifestyle and behavior.

If there are mental health issues, referrals are made to providers in those fields.

“Our support is in getting the patient to recognize that he or she needs help, then help get it,” Pemberton said.

One area where a real need has been identified is when patients travel out-of-state for medical procedures and need support integrating back into the provider system at home.

“Many out-of-state hospitals have good support systems while patients are there, but once people are discharged and headed home it’s ‘you’re on your own,’” she said. “AIM can provide that transition help.”

Pemberton said it may be too early to demonstrate cost savings but there is substantial anecdotal evidence that some ER visits are being avoided.

One indicator of that such intervention can save money comes from the state Department of Health and Social Service Medicaid Services Division, which launched an intervention service two years ago for state Medicaid recipients identified as high-ER

users, and who volunteered for special assistance.

Margaret Brodie, director of the state Medicaid division, said the state program resulted in $6.6 million in savings last year and $8.6 million in savings are projected this year. The comparison is with what was estimated to have been spent in ER visits.

At this point the state program is at a preliminary level involving telephone consultations of Medicaid recipients who volunteer with a registered nurse mainly reminders about medication and appointments. Brodie said the department program also includes nurses who make home visits for a small number of people who need special assistance.

The state is now looking at ways to expand its program with more intensive care coordination, Brodie said.

“We’ve all learned a lot over the last two to three years (with AIM’s program) and our goal now is to widen the number of people being served with these kind of services,” Grazko said.

Coordinated care, involving integration of health services, is well established in the Alaska tribal health organizations — Southcentral Foundation’s “Nuka” system of integrated care is now recognized nationally — but the idea is in its infancy outside the Tribal system.

It is also done at a smaller scale in places like Juneau’s Bartlett Hospital, which contracts with social workers to bring behavioral expertise into the hospital.

A formal physician-led coordinated care model like that developed by AIM is a first for Alaska, at least outside the tribal health system, Pemberton believes.

“We’re an experiment,” she said. “Our idea was to start it and demonstrate its success.”

“We’re talking about people who are at their most vulnerable state, facing a medical emergency or actually in the hospital. It’s important to have an advocate at that point to help people navigate the system.”

Tim Bradner is co-publisher of Alaska Legislative Digest and a contributor to the Journal of Commerce. He can be reached at timbradner@gmail.com.

9

State gets waiver to continue reinsurance program

By Naomi Klouda Alaska Journal of Commerce The 23,000 Alaskans in the individual insurance market will see premiums decrease by at least 21.6 percent and by as much as 26.5 percent in 2018 after the state received an innovation waiver under the current Affordable Care Act. While the U.S. Senate debated changes to the ACA, also known as Obamacare, the State of Alaska was approved for a five-year waiver that will allow it to continue the reinsurance program passed by the Legislature in 2016 using $55 million in premium fees to help the lone individual insurance company left in the state hold rates down.

From 2018 to 2022, Alaska’s insurance market will be stabilized with $332 million in federal appropriations, it was announced July 11 by the Centers for Medicare and Medicaid Services and the U.S. Treasury Department.

“Today’s approval will temporarily stabilize Alaska’s individual insurance market, which only has one carrier and has experienced a 203 percent increase in insurance premiums since the Affordable Care Act began,” said CMS Administrator Seema Verma.

Premera Blue Cross-Blue Shield of Alaska is currently the only insurance company offering plans through the Alaska healthcare exchange and had 16,732 customers as of May 31.

Its 2017 rate increase was 7 percent compared to a projected 42 percent thanks to the $55 million reinsurance program. The company has said it lost about $7 million over the first three years under the ACA from 2014-16.

The Alaska Reinsurance Program, or ARP, is a state-operated program that covers claims in the individual market for people with one or more of 33 identified high-cost conditions in order to help stabilize premiums for healthier participants.

The state projected that the ARP will reduce premiums by 20 percent in 2018, and an additional 1,460 households currently uninsured may purchase coverage when it is more affordable.

In September, Premera announced a rate cut of 26.5 percent, a greater cut than the initial rate decrease of 21.6 percent announced in August, after calculating that Cost Sharing Reduction payments would continue.

Section 1332 waivers present an opportunity for states to develop solutions that help bring down costs and increase coverage choices for Americans faced with unaffordable premiums, high deductibles, and reduced competition in the insurance market brought on by the ACA. Verma acknowledged the national struggle to obtain coverage on the exchanges where providers are seeking significant premium increases and 40 percent of counties are left with one or no insurance provider.

CMS held up Alaska’s approach as a creative solution other states could pursue in a national news conference announcing a long-awaited decision after the state applied for it in December.

Division Director Lori Wing-Heier was out of town and was unavailable to comment on the announcement.

Because some 90 percent of Premera’s individual market customers qualify for at least some income-based subsidy from the federal government, lower premiums reduce the size of those individual subsidies.

From left, Tennessee Department of Commerce and Insurance Commissioner Julie Mix McPeak, Washington State Insurance Commissioner Mike Kreidler; Alaska Division of Insurance Director Lori Wing-Heier; Insurance Commissioner of Pennsylvania Theresa Miller and Oklahoma Department of Insurance Commissioner John Doak, testify during a Senate Health, Education, Labor, and Pensions Committee hearing on the individual health insurance market for 2018 on Capitol Hill in Washington, Wednesday, Sept. 6, 2017. (AP Photo/ Manuel Balce Ceneta) CMS stated that the second-lowest cost silver plan premium will be reduced, resulting in the federal government spending less in premium tax credits.

In its waiver application, the state projected the reinsurance program would save the federal government more than $48 million in 2018 alone.

“Based on these projections, CMS and the U.S. Department of the Treasury are approving the request,” CMS said in its announcement.

Randy Pate, deputy administrator of CMS and director of the Center for Consumer Information and Insurance Oversight said the total 2018 outlay will be $59 million, with $11 million of that required to come from the state.

According to the approval letter, the state Legislature must reauthorize the ARP by September and appropriate sufficient funds for the 2018 calendar year. The ARP and the premium fees that funded it were only approved for 2017 when passed last year.

Gov. Bill Walker’s office issued a statement lauding the announcement. The waiver stabilizes Alaska’s individual health insurance market, bringing in approximately $332 million to the Alaska Reinsurance Program over the next five years, according to the governor’s office.

“I thank the Trump Administration, members of the Legislature, and the congressional delegation for their efforts,” the governor said. “I especially thank Division of Insurance Director Lori Wing-Heier for proposing this innovation for Alaska, which has also served as a model for other states.”

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First blood test for breast cancer detection reaches Alaska

By Naomi Klouda Alaska Journal of Commerce

Dr. Karen Barbosa, a Breast Fellowship-trained surgeon in Anchorage, has begun using BioZorb in lumpectomies.

After a lump is removed, the surgeon inserts the device, a spiral the size of a walnut and six little titanium clips, that is implanted in the area where the lump was removed. It acts as a scaffold for reconstructive surgery and reduces the amount of radiation needed during treatment. (Photo/Courtesy/BioZorb)

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Blood tests let patients know if they have a vitamin B deficiency. Blood testing provides windows into whether a person has diabetes. But until recently, no blood test could tell if a person has breast cancer.

New technology available for the first time in Alaska should help ease anxiety for women tested for breast cancer by providing clearer answers during cancer screening. Dr. Karen Barbosa at Alaska Breast Care Specialists on the Alaska Regional Hospital campus is the first in the state to offer the proteinbased blood test for detecting breast cancer.

Barbosa also introduced to Alaska patients another technology called BioZorb, which is used during a lumpectomy.

She is the only accredited Breast Fellowship Trained Surgeon in Alaska, which means she has achieved a unique specialization and expertise in the treatment of breast cancer from detection to radiation/chemotherapy and surgery.

“I’m really excited to bring these new technologies to Alaska,” she said. The technology is “so cutting edge, even many doctors don’t know this exists. We want to get the technology not only out to patients, but to let doctors know it exists.”

Patients can make an appointment to have their blood drawn at Alaska Breast Care Specialists. The Videssa testing is then completed at a Provista Diagnostic lab, which also handles the billing and gives the results in 5 to 7 days. So far, only a handful of patients at Barbosa’s clinic have had the test.

“It’s that new,” she said.

Here’s the problem with current testing. For patients with abnormal or difficult-to-interpret mammograms, breast imaging has known limitations. Benign breast disease can mimic the appearance of cancer, increasing false positives and breast density can obscure cancers increasing false negatives.

This can lead to uncertainty about whether or not immediate follow-up is needed, patient anxiety and unnecessary downstream procedures contributing to increased healthcare costs, according to Provista Diagnostic, which provides the Videssa testing.

Nonetheless, Barbosa recommends her patients do the imaging tests or mammograms, in addition to the Videssa Breast blood test. The test detects the current status, but doesn’t predict future risk.

The test was developed by advancement in understanding protein biomarkers in the blood. It detects and analyzes multiple types of tumor protein biomarkers for improved cancer detection.

Unlike other liquid biopsy technologies, such as circulating tumor cells and cell-free DNA, breast cancer proteins are more abundant in the blood, offering a more effective approach for cancer detection, according to information published by Provista Diagnostics.

“In a nutshell, the Videssa test is looking at protein levels in your blood for Bi-Rads 3 or 4, which would suggest a biopsy,” Barbosa said.

A low protein signature indicates you likely don’t have cancer.

Therefore, no biopsy is necessary. A high protein signature (BiRads 3-4) means it’s important to follow up, but is not conclusive for cancer.

“Every case varies,” she said.

Barbosa also is using BioZorb, a device used in lumpectomies.

After a lump is removed, the surgeon inserts the device, a spiral the size of a walnut and six little titanium clips.

“This does several things from a cosmetic standpoint,” said Liz Dowling, the communications director for BioZorb through

Dr. Karen Barbosa at Alaska Breast Care Specialists on the Alaska Regional Hospital campus is the first in the state to offer the protein-based blood test for detecting breast cancer. (Photo/Courtesy/Dr. Karen Barbosa)

Dowling &Dennis Public Relations in San Francisco.

A “divet” is implanted in the area where the lump was removed. It acts as a scaffold for reconstructive surgery.

“Radiation is the next step after a lumpectomy, but with BioZorb implanted, the radio oncologist can target exactly where the cancer is so the patient doesn’t need as much radiation,” Dowling said. “The clips are the only things that stay.

After a year the coil is absorbed by the body, like sutures. So when a radiologist does a scan, they can see where the cancer was removed (by the remaining clips’ placement). And they can check it much more carefully.”

Barbosa has used the BioZorb technology about six months longer than she has used the blood testing. She found out about the technologies at specialized cancer conferences out of state in 2015-16 and signed on to use them in her practice.

Most of all now, Barbosa is eager to share the technology with not only her patients, but the larger Alaska health community, she said.

Naomi Klouda can be reached at naomi.klouda@alaskajournal. com.

13

In health care, a good price (or any price) is hard to find

By Jenny Gold Kaiser Health News A recent story about why Northern California is the most expensive place in the country to have a baby began as a tip from an obstetrician. Dr. Sarah Azad told me that insurers were paying her just a third of what they pay doctors employed by large hospital systems in her town of Mountain View, Calif.

Unfortunately, she explained, she could speak only in general terms. She couldn’t share her actual payment rates with me because she was barred from doing so by a gag clause in her contracts with insurers.

So, I called the insurers who pay her, and the hospital systems that employ most of the other obstetricians in Mountain View.

They all had the same answer: It would be illegal for them to tell me the dollars and cents.

As it turns out, the vast majority of contracts between doctors or hospitals and insurance companies are subject to a gag clause, which prohibits either party from disclosing negotiated rates.

That means it’s almost impossible for consumers, researchers or journalists to find actual, accurate numbers, despite the fact that cost differentials among doctors can be so stark. And it’s particularly problematic for the growing number of people who have insurance plans with deductibles that can run more than $10,000 for a family.

The underlying problem of our health care system — beyond the corrosive partisan politics — is its high cost. I have long understood that the lack of price transparency is one reason our system stays so expensive. It was a surprise, though, to find out that this opacity is cemented by legally binding contracts.

Think about what this would look like for a mundane purchase, say, a gallon of milk. Advertisements and price tags would disappear, so you couldn’t compare prices at different stores. And you wouldn’t even know how much you had paid for the milk until you got a bill in the mail weeks or months later. On top of that, the store and the dairy farmer would be barred from telling a journalist or an economist what you had paid.

It’s absurd, but I wasn’t going to let the absurdity kill my story.

I started by asking all of the health policy analysts, researchers and economists I could find, “How can I find these rates, by physician, for an uncomplicated vaginal delivery?” Everyone told me the same thing: You can’t get that.

I searched online, but most of the websites claiming to offer health price transparency offered only “average costs” for specific services in your area. Not much help if you’re trying to compare the costs of individual doctors.

Next, I asked Castlight, a “transparency tool” that gathers payment data and allows employees of certain companies to estimate the costs of their medical care. But Castlight told me that as a journalist, I wasn’t allowed to have access to the exact pricing information of individual providers. It, too, was subject to the gag clause.

So I turned to the consumers who might have access to those tools. I asked friends and colleagues, and put out social media requests: Would anyone be willing to share the information from the cost estimators they got from their employers or insurers? I found a few willing sources and was able to mine the results of their inquiries to find out the basic cost differentials between independent doctors and those employed by large systems, including Sutter Health.

In this Aug. 5, 2010, file photo, a pharmacy tech poses for a picture with prescription medication at a pharmacy in Edmond, Okla. More than a dozen websites and apps are vying to help U.S. consumers find the lowest prices for prescription drugs by comparing prices and searching for deals, similar to the way Expedia looks for cheap airfare or Bankrate.com looks for low mortgage rates. (Photo/Sue Ogrocki/ Associated Press)

Unfortunately, these estimators are difficult to use and often provide incomplete data. And when I tried to confirm that information, I ran up against the gag clauses again.

Finally, I found out about a health data company called Amino that was willing to send me the claims data it had been gathering. At last! The Holy Grail! It had hundreds of claims for vaginal births performed by obstetricians in the Bay Area.

KHN data correspondent Sydney Lupkin helped me decipher a Medicare provider database to determine where each doctor worked. In cases where the doctor’s employment status was unclear, I called the health system or physician directly. We then calculated the median billing amount, on average, for a routine vaginal birth for each health system.

Weeks of digging and data analysis confirmed the imbalance Dr. Azad had told me about at the start of my quest. The few independent doctors left in the Bay Area receive a median amount of $2,408.45 for a routine vaginal delivery, which includes prenatal and postnatal visits. That compares with $5,238.13 for the same bundle of services provided by Stanford physicians and $8,049.84 when the doctors are employed by University of California-San Francisco — a fourfold difference.

Hard data, hard won.

The database we built gave us a strong sense of the cost variation between doctors who work at other health systems and those who have remained independent. But it did not include enough claims from the largest hospital system in the region, Sutter Health. For Sutter, I used the data from the online cost estimators, and found that obstetricians employed by the system are reimbursed about $6,452 for a vaginal delivery.

It’s no accident that data on physician costs are so hard to find. Its inaccessibility allows hospitals to keep raising their prices. It’s simply not in their interest for the public to know how much they’re charging. And insurers don’t want other doctors or hospitals to see the high prices they’ve agreed to pay, for fear they would demand the same.

In the end, all of us — through our insurance premiums and our taxes — pay a price for non-transparency.

Kaiser Health News (KHN) is a national health policy news service.

It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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16

State program shows success recruiting health workers

By Tim Bradner For the Journal of Commerce A seven-year-old program to recruit funds, 34 percent by health provider medical professionals to Alaska led by employers and the remainder from the the Department of Health and Social Alaska Mental Health Trust Authority.

Services has resulted in 254 physicians, The only state money currently involved behavioral specialists, dentists and is for the cost of administration, which other professionals coming to or staying is a federal requirement. in Alaska to work.

A second, state-led program, “SHARP Most were recruited for rural and 2” was launched in 2012, and quickly small communities, which is where became a nationally known model. It shortages are most acute. was funded 75 percent with Alaska The state program is called general fund dollars and 25 percent SHARP, short for the tongue-twisting with health care employers, Sewell said.

Supporting Health Access (through SHARP 2 included other professionals loan) Repayment Program, and it helps such as pharmacists, physician graduating health professionals handle assistants, nurse practitioners and mountains of student loan debt. registered nurses along with dental That can be towering by the time hygienists and clinical social workers. of graduation. Robert Sewell, who Alaska needed them all. The manages SHARP for the state, recalls Legislature agreed with that and passed one recent psychiatry graduate packing House Bill 78 unanimously in 2012. The $900,000 in education debt. largely state-funded SHARP 2 was not “It will be hard to pay that off in a restricted to primary care. person’s lifetime,” he said.

However, state general funds are A seven-year-old program to recruit Debt loads of $150,000 to $450,000 now tight and new applications under medical professionals to Alaska led by the are common.

SHARP 2 are not longer being accepted, Department of Health and Social Services Alaska has shortages in almost every Sewell said. “SHARP 3,” the new has resulted in 254 physicians, behavioral field in the health professions, and the program component that will involve no specialists, dentists and other professionals state has always had a tough enough state funds is now taking shape, and will coming to or staying in Alaska to work. time attracting medical professionals, be announced this year.

(Photo/File/Alaska Journal of Commerce) particularly to small communities Tom Chard, executive director of the where climate and remoteness add Alaska Behavioral Health Association, challenges. chairs the health professionals’ advisory board for SHARP and Sewell said he heard officials at the Alaska Native Tribal is an enthusiastic backer of the program.

Health Consortium say the rural health organizations they work “We have the demand (for health services) but we don’t have with are short 120 physician assistants, and that’s not including the supply (of medical personnel). SHARP helps fill that void,” the facilities like the Southcentral Foundation in Anchorage. It’s Chard said. just one example, he said.

“The program is pretty targeted, and we find we get a lot of Shortages in the health care professions are a nationwide quantitative data and a lot of other information. It’s one of the problem, however, and to attract medical graduates Alaska few programs where we can really connect the dots,” in dealing must compete with other states, many who can offer lucrative with the problem of shortages, he said. financial packages as inducements.

Kathy Craft, director of the Alaska Health Workforce Coalition “When you’re packing that kind of debt you have no choice and also on SHARP’s advisory committee, said SHARP is one of but to look to who can make you a decent deal,” Sewell said. several tools being used to address the workforce problem in Some states are offering incentives under various programs health care. that help with loan repayments but that may also pay cash in One other is “grow your own,” through initiatives like the bonus payments, both of which Alaska has done.

University of Alaska Anchorage’s successful nursing programs.

Alaska is a relative latecomer to this competition but the state “But in many specialties, we’ll have to import from out-ofis now geared up, although budget shortfalls have put a crimp in state. SHARP has definitely boosted our workforce, with people part of the program that was state-funded. being placed in all parts of the state,” she said.

However, funding for this is likely to be replaced with more “One advantage of the pending SHARP 3 is that it will have the money from health care employers, who have always chipped flexibility for employers to work with an applicant and a funding in, Sewell said, along with possible funds from other private foundation to put together a tailored package,” Craft said. contributors.

The initial program, which still exists, began in 2010 with “SHARP 1,” focusing on primary care medical professionals and Tim Bradner is co-publisher of Alaska Legislative Digest and a including physicians, dentists and behavioral health specialists. contributor to the Journal of Commerce. He can be reached at Currently, SHARP-1 is funded 50 percent with federal timbradner@gmail.com.

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Premera cuts rates further for 2018 – 26 percent

By Mark Thiessen Associated Press Alaskans buying health insurance on the individual market will see a decrease of 26.5 percent in rates next year, the sole insurer in the state announced Tuesday.

Alaskans had been paying some of the highest premiums in the nation.

Premera Blue Cross Blue Shield attributed the decrease to a significant reduction in the use of medical services and the state’s establishment of a program to address high claims separately, called reinsurance.

Premera’s announcement “shows that my team’s out-of-the box thinking in creating the Alaska Reinsurance Program — approved by the Legislature — has paid off,” Alaska Gov. Bill Walker said in an email statement.

“It also supports a need for Congress to fully examine the impacts of any changes to the Affordable Care Act, which enabled

the creation of this program,” said Walker, an independent who favors a bipartisan approach to healthcare overhaul.

The decrease could mean nearly $200 a month more in the pockets of Alaskans who buy on the individual market.

For example, a 40-year-old nonsmoker living in Anchorage on the company’s lowest level plan with a deductible of $5,250 would see insurance rates drop from $703 a month this year to $526 a month next year, Premera spokeswoman Melanie Coon said.

“We think it is showing that our market is becoming somewhat stable,” said Lori Wing-Heier, director of the Alaska Division of Insurance.

“We’re hopeful it will attract another insurer or two back into Alaska,” she added.

The president of Premera’s Anchorage office said it was too soon to assume the lower rates are the start of a trend.

“However, we believe the state’s reinsurance program without question has contributed to a more stable and affordable individual health insurance market,” Jim Grazko said in a statement.

It’s the first time the average rate has decreased under the current federal health care law in Alaska, where high health care and premium costs have been an ongoing concern. Rate increases had previously been as high as 40 percent, but stabilized a bit in 2017, which saw a 7 percent increase.

There is a chance next year’s rate could still change.

Premera said the current decrease assumes federal costsharing reductions will remain in place. They are included in the current bill being considered to replace President Barack Obama’s health care bill, but the Trump administration doesn’t

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support them, Wing-Heier said.

If those subsidies were to be stripped out, the decrease would be closer to 22 percent.

But in July, Premera Blue Cross Blue Shield filed insurance rates for 2018 in a preliminary prediction of 21.6 percent decrease for customers on individual Affordable Care Act compliant plans. The 26 percent As predicted by the Centers for Medicare and Medicaid services when Alaska received a Section 1332 “innovation waiver” on July 11, Alaskans on the individual market exchange were to see a significant percent decrease in 2018.

From the Alaska Journal: The waiver will provide for $48.9 million in federal funds to the Alaska Reinsurance Program, or ARP, which when combined with $11 million in state funds allowed Premera to lower its rates next year.

The five-year waiver will send about $332 million to the ARP. The ARP was created by the Legislature in 2016 and with $55 million in funds collected from every insurance policy sold in the state, Premera was able to reduce the 2017 rate increase

from 42 percent to 7 percent.

The reinsurance program was initially funded by the state for 2017 with $55 million in fees collected from insurance policies.

A Section 1332 “innovation waiver” under the Affordable Care Act granted to Alaska will have the federal government paying about 80 percent of the cost, or $49 million, with the state kicking in $11 million for 2018.

The waiver helps the pool of insured. It came out of the state’s reinsurance program that committed state insurance tax dollars ahead of time to prevent costs from increasing for Premera customers.

“For Alaska’s 20,000 people — that’s not a big pool,” Coon said. “There were not enough healthy people, and by that, I mean people who are healthy and pay insurance but don’t use it to offset the high medical costs of those who were sick.”

The funds aren’t “new money” but rather the amount that would have been paid anyway through individual subsidies that 90 percent of Alaskans on the exchange receive.

Central Peninsula Hospital moves forward on detox facility

room.

The detox facility won’t be an inpatient, residential facility — rather, it will provide supervision and assistance so people can safely detox, said Bruce Richards, the director of external affairs and marketing for Central Peninsula Hospital.

“We’re only talking a few days to possibly a week for people who are withdrawing from whatever the substance of their addiction is,” he said. “It’s not like a residential treatment; it’s withdrawal services.”

Though the property has been assessed at $703,900, the owners accepted an offer of $500,000 from the borough, according to the purchasing agreement submitted to the Kenai Peninsula Borough Assembly. Because the borough owns the hospital’s land and assets and leases them to a nonprofit operating board, the assembly has to approve some of the hospital’s bond issuances and withdrawals from its Plant Replacement and Expansion Fund. The hospital has asked for $750,900 from the fund, with $240,900 allotted for remodeling the building for hospital use, according to a memo from Land Management Office Marcus Mueller to the assembly.

The interior needs some work to be livable and up to code, according to a letter from Richards to the borough.

“The scope of the project will include: code requirements identified in the building report, new paint and flooring, casework, minor remodeling (for configuration), signage, furniture fixtures equipment (FF&E), information technology costs for hospital associated operations, and security system completion,” the letter states.

The new facility would be the second related to addiction treatment on Tyee Street owned by Central Peninsula Hospital.

The assembly approved funding for the hospital to purchase a building close by on Tyee Street for a transitional housing facility, which provides affordable longer-term housing for patients coming out of addiction treatment.

In the past year, more facilities have opened in the central Kenai Peninsula area for those seeking help to recover from addiction or to stay sober. Two sober-living homes have opened in Soldotna in the past year, and several town halls hosted by the community organization Change 4 the Kenai in May 2016 drew more than a hundred people to talk about addiction openly.

However, some people have also expressed concern about the sober living homes in neighborhoods or near other community

By Elizabeth Earl Peninsula Clarion Central Peninsula Hospital is moving forward with plans to build a detox center in Soldotna.

The hospital received a grant from the Alaska Department of Health and Social Services in January to provide treatment for substance abuse disorders. The first year of the three-year grant will provide the hospital with $500,000, then $1 million in each of the subsequent years, if the grant is still available and the hospital reapplies in cycle.

The plans are still up in the air for the particulars of precisely what services will be available at the center, but the hospital has zeroed in on a building to house the program: 354 Tyee Street, a facility currently owned by Kenai Peninsula Housing Initiatives that previously housed people with psychiatric or cognitive disabilities.

The six-bed, six-bathroom facility would provide medical assistance for people withdrawing from substances like alcohol or opioids. Not only is Alaska one of the top states in alcohol consumption per capita, the national crisis of prescription opioid and heroin abuse has hit the state hard in the past few years, with health care providers like Central Peninsula Hospital seeing a large number of people either currently using or withdrawing from use of substances in its clinics and emergency room. The hospital’s residential substance abuse facility, Serenity House, is the only facility of its kind on the peninsula and has limited

19

facilities. Richards said if someone in the hospital’s planned facility had an issue, the hospital would take care of it. But the fact that the people are seeking help is a sign that they are ready to deal with their addiction problems, he said.

“I think that alone is cause that shows that these are people trying to get better,” he sai.

When the borough’s Healthcare Task Force finalized its recommendations in 2016, one of the six focus areas it identified was for widespread substance abuse. The idea of a detox facility surfaced in September, about a month before the group finalized its recommendations, arising from input from public and private health care providers and social services around the peninsula.

Kenai Peninsula Borough Mayor Mike Navarre said the

building is a good purchase for the borough and even if the program has to close down, it could be used for other services.

With the state’s fiscal situation, the grants could be at risk, but Richards said that with national attention on the opioid addiction issue, he thought the state and federal government would maintain funding.

“I believe it’s going to get that sort of attention for some time into the future,” he told the assembly’s Finance Committee at its April 4 meeting. “As we all know, there has been a huge epidemic going on with the opioid crisis. It’s taken center-stage, even in Juneau in the middle of a budget deficit year.”

The assembly will consider the funding request at its April 18 meeting, which will take place in Seward.

Senators welcome delay on healthcare vote to lobby for Alaska

By Naomi Klouda Alaska Journal of Commerce A delayed vote on overhauling the U.S. health care system buys time for U.S. Sens. Lisa Murkowski and Dan Sullivan to negotiate on key provisions for Alaska over the July 4 recess.

Neither of the Alaska senators issued an official statement after Sen. Mitch McConnell, R-Ky., saw that he did not have the necessary 50 votes to pass his legislation repealing and replacing the 2010 Affordable Care Act. Through spokesperson Karina Petersen, Murkowski called the delay a “good thing.”

“It’s a good step to take more time. She has said we need to do it right and not rush this. Now she can continue to vet the bill,” Petersen said, adding that her phone hasn’t quit ringing.

Murkowski’s moderate standing places her as a swing vote courted by both President Donald Trump and McConnell. The national media is clambering to know how Murkowski will vote, she said.

This also buys Murkowski negotiating credits — her vote in exchange for key changes.

“She is looking at the Medicaid portion — those with Medicaid and those who came in under Medicaid expansion — (wanting) that they continue to be covered and not have the rug pulled out,” Petersen said.

The Congressional Budget Office rated the Senate’s health care bill as potentially causing 22 million to become uninsured.

About 15 million of those would be people who choose not to buy insurance because of the repeal of the individual mandate; others could lose coverage through loss of Medicaid eligibility or reduction in premium subsidies.

That is an important score, Murkowski says, but it’s not the only one she is considering.

According to the latest figures provided by the Alaska Department of Health and Social Services 185,139 Alaskans receive Medicaid services. That’s 25 percent of the state’s population. Previous to the Medicaid expansion funds accepted

by Gov. Bill Walker, there were 33,945 fewer people covered that now are added to Medicaid rolls.

Keeping Alaska’s adjustment at 138 percent of poverty level

is another must-have provision, Murkowski and Sullivan have said. Without that adjustment, fewer people will qualify for federal subsidies.

The bill, as currently written, also would phase out additional federal funding 31 states and Washington, D.C., receive, and Alaska is one of them. When then-Gov. Sean Parnell objected in 2010 to expanding Medicaid in Alaska through funds offered during the President Obama administration, he did so on the belief Alaska would be left holding the bag if the law ever changed.

That’s exactly what the Senate version does. It ramps down payments to states from 90 percent in 2020 to 50 percent by 2025.

“We want to keep what’s worked for some Alaskans under the ACA — keep coverage for preexisting conditions,” Sullivan said in a video statement.

But he’s also “relentlessly focused on educating leaders” about “how big of an outlier Alaska is as it relates to healthcare and insurance costs.”

The first of Sullivan’s three goals is to stabilize the market.

One insurer on the individual market is not sustainable, he said.

He wants to protect the “thousands who receive subsidies” but also the thousands who don’t “and they are being wiped out financially.” And thirdly, he wants to see a sustainable, equitable path forward.

In a statement issued June 27, Sullivan said he supports waiting until after the July 4 recess to vote. He also “appreciates being invited to the White House with my colleagues for a very productive meeting with President Trump and Vice President Pence” on June 27.

“Like most one-size-fits-all approaches from Washington, D.C., the Affordable Care Act is not working for many Alaskans,” he said. “Premiums and deductibles have skyrocketed for the middle class. The director of Alaska’s Division of Insurance (Lori Wing-Heier) said that our market is in ‘chaos.’ The current situation in the healthcare market in Alaska and nationally is not sustainable. Something has to be done, and it has to be done

20

President Donald Trump talks with Sen. Joni Ernst, R-Iowa in the Cabinet Room of the White House in Washington, on June 13, alongside, from left, Sen. Rob Portman, R-Ohio, Sen. John Thune, R-S.D., and Sen. Lisa Murkowski, R-Alaska. Murkowski and fellow Alaska Sen. Dan Sullivan are key votes on the Senate’s healthcare bill and are using that leverage to lobby for improvements in the bill for the state. (Photo/Susan Walsh/AP)

soon.”

Sullivan wanted to get rid of the employer or individual mandate, as well.

The Senate version does change how the mandate is handled.

Insurance carriers have said they favor some kind of carrot to incentivize Americans not to wait to get coverage.

McConnell agreed to a penalty for Americans who let their insurance lapse for 63 days or more. Under the new provision, those who go without insurance will be “locked out” of getting coverage for at least six months after they sign up.

This “lockout period” would, in theory, create an incentive for people to have insurance all the time, instead of waiting until they’re in the ambulance.

Alaska’s only individual market insurer, Premera Blue Cross Blue Shield, favors moves that help with market stability.

Premera Alaska President Jim Grazko expressed concern about the earlier draft that lacked any kind of mandate.

“We are encouraged that the Senate bill includes funding for reinsurance as well as more funding for subsidies than the House bill to help lower income families,” said Steve Kipp, vice president of corporate communications.

That’s important for Alaska because Premera’s rates climbed

only 7 percent rather than 42 percent in 2017 because of a reinsurance program approved by the Legislature last year that included $55 million from the state collected through a levy on all plans sold in Alaska.

Grazko felt the Senate version offered “slight” improvements over the House. But income will be a big factor in determining subsidies, coupled with age. Premera’s criteria list is to ensure coverage for as many people as possible to increase Alaska’s pool and bring costs for all customers down. They also want people who can’t afford insurance to receive the subsidies for commercial health care coverage.

With so many variables still in the air, Premera must calculate its 2018 rates by mid-July and file with the Alaska Division of Insurance.

“We are currently working on those,” said Melanie Coon, Premera senior communications manager.

As of June 27, Division of Insurance Director Lori Wing-Heier said she was still analyzing the 140-page bill.

“At this point, it’s hard to say what impacts there will be to those in the insured market,” she wrote in an email. “We continue to work very closely with Sen. Murkowski and Sen. Sullivan on the intent of the bill and what its impact will be on Alaska.”

21

Do you know what two of the most common phrases are that I hear in my office? “It’s not that bad, yet” or “I’ll just wait until it gets worse.” However, studies show that sooner, rather than later, is the time to address any hearing concerns. The ears are often overlooked, as hearing loss is a “silent disability.” We can’t look at someone and know they have hearing loss. We may notice the side effects of one’s hearing loss, often after it has been present for an extended period of time. Once a friend or loved one’s hearing loss is evident you might notice increased communication errors, frustration on both the listener and speaker sides of the conversation, reluctance or refusal of not wanting to attend social gatherings, and even cognitive decline.

Did you know the auditory cortex, which performs the brain’s hearing functions, is like other muscles in our body and needs regular “exercise?” It is stronger and more effective when used regularly. Untreated hearing loss can shrink cortex size and weaken neural pathways, decreasing brain volume in key sensory areas. This directly correlates to the 25-year study which shows that untreated hearing loss is associated with quicker cognitive decline in older adults. The good news, is that by treating the loss, whether it’s a mild or a more significant loss, we can lessen the progression. We can lessen it so much so that there is no difference in cognitive decline between those using hearing instruments and those with normal hearing.

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