MCHB 2006 Federal/State Partnership Meeting

The Future of State MCH and Medicaid Partnerships

October 15-18, 2006

STEPHANIE BIRCH: Good morning. I'd like to thank James and the Bureau for inviting the Title V Director to come and talk a little bit about what I think can be our role in moving SCHIP reauthorization along as well as implementing some of the programs around DRA.

So, in Alaska, first I want to try to frame a little bit of what those of us in Alaska face when looking at opportunities to work together with collaborative partner such as Medicaid. Alaska is unique and although you can't see this quite so clearly, it's a very large state, sorry Texas, we sort of out rank you a little bit here. But we have some very unique attributes now I think delivering healthcare in Alaska can be very challenging.

We only have 17,000 miles of roads in Alaska. The majority of our population is--our population size is around 626,000 and half of which live in Anchorage, which is not the state capital. Our state capital resides along the panhandle there on the east side, and you have to fly into it, you can't drive. We have folks that are in villages, the size of a 150 to 100 people and then all the way into smaller sub-regional areas of the state. Our healthcare delivery system is really quite unique and poses, I think, along with the challenges, poses some interesting opportunities for us. We have several partners. The Federal IHS State, Department of Defense Partners. None of our hospitals are actually owned by the corporations that reside in the state, they're all owned by outside corporations. We have different levels of service including community tribal health aids, public health nurses who deliver some EPSDT services. We have federally qualified health centers, private providers, sub-regional health clinics that are owned by IHS native corporations. We have private practice groups in urban centers with only really those residing in five communities. We import services for specialty services, particularly for children from other states. And then we export our care outside to states such as Washington, Oregon, and Utah. This has quite an impact on our cost. In FY '03, we spent $14 million of Medicaid money flying Medicaid eligible beneficiaries around to receive services, and an additional $10 million to take Medicaid beneficiaries outside the State of Alaska. So $24 million just in air and transportation, ground transportation and hotel costs.

We also have a unique setting in terms of payers. We have virtually no Manage Care. We have a few preferred provider agreements primarily with some of the larger corporations and they're pretty much urban based i.e., Anchorage. And approximately 50 percent of the children in Alaska qualify for Medicaid as payer source.

I was fortunate, I think, to be recruited into the State of Alaska to begin to work on a relationship with Medicaid back in 2001, and I always find it to be a bit curious that many of the other states sometimes don't even talk to their Medicaid folks because I was hired primarily for the reason to do some outreach around ESPDT. Now, this was back in the time when we had a very forward thinking governor who had done an amazing job in terms of developing our SCHIP Program, and we were at a time where we could really put this out and be very pro-active in terms of outreach, and that unfortunately was very short lived. And with the change of administration, some other things happened.

Our focus at that time was really educating Medicaid beneficiaries about the benefits of the EPSDT, and treating it really as a benefit package. And also, I decided to have our group really take the framework of helping our Medicaid beneficiaries become better patients, so that physicians would see them as a group of patients, not necessarily somebody there with an entitlement program.

We continued on into 2003, and as many of you know, with our administrative change, we had a huge reorganization of our Department of Health and Social Services, which affected our MCH program. And in fact, our MCH program was dismantled. The staff and the programs were divided and put into five different divisions of the Division of Healthcare Services, and my colleagues and staff were actually placed over in Medicaid. The Medicaid division was interested in having me because of my healthcare financing background. And although it took a while to sort of gain some ground again, I think we have very unique opportunity that was presented to us at the time. I will say for MCH, in terms of losing its identity, it was really quite a crisis for us and it taught me a lot about how you can't necessarily have your program dependent upon the people, because very quickly, you can lose your identity, and so, we had to really do a lot of hard work to really get out and validate, and demonstrate how important programs for women and children and families were and put a different spin on it.

We very quickly realized that we had something to offer the Medicaid folks that they didn't have and that was data, and data analysis capacity and we had clinicians. The Medicaid staff, I have to say, and the last card, just fabulous, fabulous people and really want to do right thing. But interestingly, and maybe this is different in other states, our Medicaid staff really had no clinical background. So we brought in advance practice staff, a pediatrician, clinical nursing staff and those staff with laboratory background. And we quickly became very assertive in offering services and knowledge that we had to help work with them and that included some consultation in our regulations. We assisted them in updating fee schedules, some of which had not been updated in 15 years, especially around audiology. And I particularly, you know, selfishly began to look at what can we do to better improve the services for children in our state.

So we looked at upgrading the lab schedules for the lab services around, especially around newborn metabolic screening, as we got into tandem aspect. And then, DME for those of you who aren't familiar as durable medical equipment, we have had a real deficit in having specialized equipment for kids with special healthcare needs. And so, working with the families, in particular in the community, identified specialized equipment that Medicaid really should be paying for and they fully intended to, but they didn't really know what was really best. So we did a huge rewrite of all the regulations around DME.

We also provided a tremendous amount of data. And despite the fact of having been in the department for years and years and years, they were totally unaware of some of the outcome data that we could provide for them. And many times without asking, I would show up in a meeting with the data as they were talking about the bunch of kids that they were going to have to sustain. Our program, our MCH program right now is about $8.4 million, much smaller than they had then when we had been a larger section. The Medicaid program in Alaska is a billion dollars. And so, my little part was very insignificant. But I was able, because of my background in cost finance and cost analysis, to demonstrate to them how one small change could really make a huge impact, and later on cost them a lot of money, especially around prenatal care.

I also kind of inserted myself in some of the discussions that were happening with some of the providers outside, in terms of care. Because we are still what I call "land of the fee," we basically provide a fee-based service--payment service for Medicaid. There's a lot of interests especially in hospitals and healthcare organizations out state side to get our business. And in my caveat to some of that business was really to become a much more sensitive and more customer-based for our families that traveled outside, especially around those with kids with special healthcare needs.

So as we moved into reorganizing and helping to demonstrate that, it perhaps was not a very wise decision to have dismantled MCH and organized us. My comment to my Medicaid colleagues was, "Show me the money. We'll continue to work together, but what can you do to help provide some long-term sustainability?" And so, I've convinced them to help fund some of our staff. In fact, they pay for half of my position and Medicaid became a pair of data. And in return, we've continued to offer them regulatory support and assistance in planning. We also were fortunate to receive TA support from HRSA and hosted Johnson Consulting to come up and work with us to foster some increased cooperation between state Title V and Medicaid, and some of our partner organizations, especially around EPSDT.

These were just a few of the priorities that we came up with, many more than, I think, Kay wanted us to. And we had long discussions of how we're really going to implement them, but we reassure Kay, we actually are moving ahead in several of them. And I think what it helped us realize it is that there were other partners out there who also have money that we could really work on some kind of unique opportunities around cross funding and including parental engagement.

And then finally, I want to stress the opportunity if it comes to pass, that MCH director should pick up on and that's participating as one of the states if your chosen in a very unique opportunity around that sponsored, I believe annually, around with the state legislative--excuse me--the National Council of State Legislators, the Governor's Association, AMCHP and then ASTO.

I led a team. I was fortunate enough to lead the team that went to Denver this last summer with the theme of using limited health dollars wisely. And that really helped to frame the discussion in terms of preparing increments for the coming year. For more state you have to help fund their MCH programs. The Commission of Health came along. We had Medicaid director. I had several legislators, both in the House and Finance committees, who would participate in that. And as a result of that, I think they heard about and they were able to hear me sort of constantly talk about some of the outcomes that we were experiencing in the Maternal and Child Health world.

So my two slides are take away messages for you. And you know, I think it's time for us as state Title V if you haven't had a relationship with Medicaid, now's the time to really kind of get in there and dig in. Get to know your Medicaid staff, one on one. Find out what payments work, be familiar with what your DME regulations are, familiarize yourself with the statutes and regulations, invite Medicaid staff to your meetings, we have Medicaid participants in our EHDI and newborn metabolic screening advisory committees and any time we have an opportunity, even if I think it's only remotely reflective of what they might be involved in, I encourage them to come along. Include them in the distribution of your publications. Weigh in on your regulations, most states when you have a new reg package that's going to come out--