Health

Officials tangle with Alaska operating budget's mystery Medicaid proposal

JUNEAU -- When Gov. Bill Walker talked Medicaid expansion, Republican expansion opponents talked Medicaid reform.

But when those opponents refused to let Walker's expansion proposal come to a vote in the Legislature, they also chose not to advance their own reform efforts, while criticizing the existing Medicaid system as "broken."

But they did pass one measure trying to limit Medicaid-funded travel for medical care, and state officials who manage the Medicaid travel program are now trying to figure out what, if anything, they need to do to implement it.

Buried in the 68-page operating budget passed at the end of this year's regular and special legislative sessions is what's known as "intent" language. That language would prevent the state from paying for Medicaid travel when "services can be provided in local communities."

Medicaid can cover travel costs from outlying communities to regional hubs such as Anchorage, Fairbanks and Juneau where more advanced services can be provided.

The language tells the state's Department of Health and Social Services that the Legislature wants it to pursue authority from the federal government to deny such travel. The federal government regulates and provides much of the funding for Medicaid.

The attempt to limit Medicaid travel may actually negate what could be, in some instances, a cost-saving measure.

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Alaska's high cost of providing health care has led Premera Blue Cross Blue Shield, the state of Alaska and others paying for health care to look Outside for cheaper treatment options as a way of holding down costs. They've found some dramatic savings by going out of state, even after providing travel costs and lodging for patients and even travel companions.

That's raised concerns among some Alaska hospitals and other providers, but the Alaska Hospital and Nursing Home Association says the travel provision didn't come from them.

"This is the first I've heard about that language in the operating budget," said Becky Hultberg, the group's executive director.

She said it may have been designed as a cost-cutting measure of some sort, but she didn't know where it originated.

When legislators use intent language instead of a bill to effect policy, it means no record is left of what the legislators were trying to accomplish. In this case, there's not even an official record of where the intent language came from.

A comparison of various versions of the bill that were passed indicate that the Medicaid travel provision originated in the House, not the Senate. The office of Sen. Pete Kelly, R-Fairbanks, who spearheaded a Medicaid reform bill focused on cost-cutting measures, said the provision was not part of its reform proposals.

The Department of Health and Social Services, which manages Medicaid, says it already provides services in local communities whenever it can, and isn't sure what sort of authority it's being told to seek from the federal government, or what it would do with that authority.

In answers to questions provided by public information officer Sarana Schell, department Health Care Services Division Director Margaret Brodie said the intent language appears to tell the state's Medicaid program to do what it is already doing when it approves Medicaid travel.

"The travel has to be medically necessary," in order to be approved for Medicaid travel, Brodie said.

She said the state, through its Medicaid administrator Xerox Corp., already tries to hold down travel costs by doing things like waiting for a public health nurse to visit the community or delaying travel until tickets are less expensive in cases of non-urgent care.

The state is already required to provide service locally where possible, Brodie said, but is making sure that Xerox is being diligent that the need for travel is appropriately documented.

Schell said the division has tracked the Medicaid travel language down to Rep. Dan Saddler, R-Eagle River, through information from the Legislative Finance Division, which assists legislators with drafting bills.

Saddler did not return calls over the last two weeks seeking confirmation and information about the intent language included in the budget. Saddler is vice chair of the House Finance Committee, which is where Medicaid expansion stalled in this year's Legislature.

Some large users of Medicaid-funded travel include residents of smaller communities that don't have advanced medical services. Some don't have any health care services at all.

In Southeast, state Medicaid services are already being provided locally whenever possible, and it is not clear what the legislative intent would accomplish, said a top health care provider.

"They're already denying travel if the service is provided in the region," said Leatha Merculieff, vice president for executive administration for the Southeast Alaska Regional Health Consortium.

The tribal health provider operates a dozen clinics in the region, along with a hospital in Sitka. In many of those communities, it is the only provider and offers services to both tribal and non-tribal patients, with about 30 percent of patients currently covered by Medicaid.

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For the Alaska Native Medical Center in Anchorage, many of the patients come from outlying villages, with some covered by Medicaid. It recently announced a 202-room patient housing facility adjacent to its Anchorage hospital for those needing long-term care in the city, such as for cancer treatment or high-risk pregnancies.

Executives there declined comment through spokesperson Michelle Weston on the legislative language.

Brodie said the intent language would apply to all Medicaid travel, whether from a village to Anchorage, or from Anchorage to Seattle.

"This applies to all Medicaid prior authorizations, regardless of where they originate in the state. The program covers the nearest available needed care in or out of Alaska. If travel is needed to access that care, then it is covered," she wrote.

But whatever the intent, the Alaska Department of Law says it believes that language is unconstitutional and unenforceable. Despite the Alaska Constitution restricting bills to single topics, legislators continually attempt to include such intent language to make policy.

But while intent language may be officially unenforceable in many instances, agency leaders know that the legislators who use it are likely to be in charge of their budgets in future years and it can't simply be ignored.

The Department of Law advised the Department of Health and Social Services that it may want to comply with the unenforceable language "as a matter of comity."

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