Summary: The report notes areas in which the department satisfactorily administers programs as well as reveals a number of administrative processes and functions which need improvement to better meet the needs of Alaskans.

Key Findings for Administrative Functions

1. The department’s referral and placement policies for child and adolescent residential services are effective and efficient thanks in part to the 2005 Bring the Kids Home Initiative.
(Recommendation 5.3.5)

2. Abuse of prescription opioid narcotics is both a major behavioral health concern as well as a significant source of fraud and abuse in the health care system. Alaska’s current prescription drug monitoring law creates barriers that restrict DHSS and the Department of Law from accessing prescription drug data and using it to identify patient “doctor-shopping” and other prescribing practices that are potentially fraudulent or abusive.
(Recommendation 13.1.8)

3. The Department of Health and Social Services (DHSS or department) did not submit a list of 10 percent reductions in general funded budget. Instead, it offered a proposal for reductions drafted originally in response to the governor’s request for five percent and eight percent program reductions.
(Recommendation 7.1.2)

Key Recommendations for Administrative Functions

1. Reforming staffing policies and practices at the Alaska Psychiatric Institute (API), including more competitive hiring and retention efforts, could significantly improve the quantity and quality of care without increasing costs.
(Recommendation 2.4.1)

The state has a workforce shortage of qualified psychiatrists. This problem is accentuated at API by its sub-optimal personnel policies that maintain staffing levels in the short term, but ultimately hurt long-term workforce development and increase administrative challenges. For example, shortages both in psychiatrists and in psychiatric nursing staff have led API to establish mandatory staff overtime. This policy not only harms the hospital’s competitiveness in hiring and retention, but it also contributes to a worrying rise in workplace injury rates at the hospital. High turnover rates and physician vacancies subsequently force the hospital to contract with locum tenens (or temporary) agencies costing twice as much as a state-employed physician. The policy creates quality and continuity of care issues as well as budgetary inefficiencies. Overtime wages and locum tenens salaries are more expensive than regular wages and full-time salaries with benefits. By relying on mandatory overtime and locum tenens psychiatrists to staff API, the department experiences higher staffing costs and delivers a lower quality of care.

2. The department should develop a Medicaid behavioral health rate structure that covers provider costs, incentivizes quality, and minimizes administrative burden.
(Recommendation 3.0.8)

Since 2007, the department has funded a larger proportion of mental health and substance abuse services through Medicaid reimbursement rather than grant awards. However, the Medicaid reimbursement rates have not been updated since 2007 and are insufficient to cover the costs of needed services. DHSS supplements the Medicaid funding with state-funded grants. By revising rate structure, a greater share of the service costs will be paid for by federal funds.

3. The department should incorporate performance measures that are more appropriately outcome-oriented.
(Recommendation 4.3.4)

Outcome-oriented measures are well represented among the Division of Behavioral Health’s performance measures, but many rely on consumer perceptions of the quality of care rather than more objective indicators of recovery, such as the ability to secure stable housing or improved employment status. The department should revise the performance measures to include additional, more robust outcome-oriented measures along these lines.

4. The department should align the performance measurement for community providers, with the measures used in accreditation requirements as much as possible.
(Recommendation 4.3.6)

DHSS mandates that behavioral health service providers be accredited by a division-approved, private, non-State organization that assesses the provider for meeting best practice and quality of care standards. DHSS also requires behavioral health providers undergo additional evaluations by DHSS staff. Since providers are already required to be evaluated by certain quality indicators in the accreditation process, DHSS should match these accreditation measures within its performance management system. Holding providers to two separate sets of standards is confusing and costly, and places additional burdens on providers and the department.

5. The department should improve coordination efforts with the Department of Corrections (DOC) to ensure consistency in treatment programs and protocols for individuals exiting correctional facilities.
(Recommendation 5.5.5)

DOC is the largest provider of behavioral health services within Alaska. Developing coordinated behavioral health treatment programs available within the correctional system based on the same principles and using the same evidence-based practices as those services available within the community would provide continuous care for individuals exiting the correctional system. Continuity and minimal disruption of behavioral health care eases the reentry process and promotes a successful transition from the correctional system into the community.

Behavioral Health Improving Administrative Functions Findings Table
Finding NumberFinding
1.2.1The Division of Behavioral Health’s budget visualization includes all relevant information regarding cost, volume, and funding sources, but can be improved by reorganization of the information presented.
1.2.2The Division of Behavioral Health’s budget visualization presents the number of individuals served, cost of services provided, and funding sources used in a comprehensive manner that utilizes all space available.
1.2.4The Governor’s Amended Budget presents all necessary information at the appropriate level of detail.
2.1.1The Department has developed a clearly-articulated mission with well-defined goals and objectives to direct department, division, and program-level activities.
2.3.4Increasing reliance on Medicaid as the dominant source of funds for behavioral health services has led to disparate effects on youth and adult services, fostering different kinds of efficiencies and inefficiencies within the two systems.
4.1.1The Department has made significant strides in collecting the data necessary for effective measurement of behavioral health services.
4.1.2The Department’s progress in behavioral health performance measurement is consistent with the practices of state behavioral health agencies nationwide.
4.1.3Department behavioral health measures sufficiently demonstrate whether Prevention and Early Intervention (PEI) services are effective.
4.1.4Department measures do not sufficiently demonstrate whether community T&R services are effective.
4.1.5Department measures sufficiently demonstrate whether institutional behavioral health services are effective.
4.2.1Department measures demonstrate whether PEI services are efficient.
4.2.2Department measures do not demonstrate whether community Treatment and Recovery services are efficient.
4.2.3Department measures sufficiently demonstrate whether institutional behavioral health services are efficient.
4.2.4The Department’s measures of institutional behavioral health are consistent with nationwide best practices.
5.2.1Critical gaps in the continuum of care have prevented the Department from aligning its referral and placement policies with best practices for acute and sub-acute psychiatric care needs.
5.2.2The Department’s referral and placement policies and procedures for acute behavioral health care do not align with best practices. Chronic shortage of psychiatric hospital beds, lack of step-down services, and inappropriate utilization of acute care services have resulted in strict admission and utilization controls at the Alaska Psychiatric Institute that disconnect it from the community referral process.
5.2.3The Department’s referral and placement policies and procedures for child and adolescent residential services largely align with best practices.
5.2.4The Department’s referral and placement policies and procedures for community treatment and recovery services largely align with best practices.
5.2.5The Department’s referral and placement policies and procedures for early intervention services largely align with best practices.
5.3.2The Department’s policies and procedures for referrals between acute care services and long-term services and supports are not effective or efficient.
5.3.3The Department’s policies and procedures for referrals between acute care services and other community supportive services are not effective or efficient.
5.3.4The Department’s policies and procedures for referrals between acute care services and justice-involved services are not effective or efficient.
5.3.5The Department’s referral and placement policies for child and adolescent residential services are effective and efficient.
5.3.6The Department’s referral and placement policies and procedures for community treatment and recovery services are effective and efficient.
5.3.7The Department’s referral and placement policies and procedures for early intervention services are effective and efficient.
5.4.2Alaska’s vast geography impedes the Department’s ability to manage comprehensive behavioral health services efficiently.
6.1.1The consolidation of behavioral health administration within the Division of Behavioral Health (DBH) promotes more effective blending and braiding of funding services for behavioral health services.
6.1.2The organizational alignments facilitated by the Department’s Results-Based Accountability (RBA) framework provide an effective structure for necessary cross-divisional communication.
6.1.3Despite improvements in cross-divisional communication, deficiencies in care for specific subpopulations of shared interest, such as individuals with dementia, autism, and traumatic brain injury. (sic)
6.1.4The Department’s current information technology shared services model is inadequate to provide 24/7 support for acute behavioral health services.
6.1.5The Department should continue to develop division-level workgroups within the Department’s RBA core services structure to address the needs of neglected subpopulations.
6.2.1DBH’s organizational position within the Department promotes more efficient delivery of behavioral health services.
6.2.3The Division of Behavioral Health’s coordinated Medicaid and grant review process reduces auditing redundancy for both DHSS staff and behavioral health providers.
6.2.4The Department’s allotment of information technology (IT) resources specific to behavioral health enables DBH to support behavioral health service delivery more efficiently.
6.2.5The development of the Office of Integrated Housing & Services has improved the ability of DHSS to provide more efficient management of housing resources within the Department, but increased support and collaboration are needed.
6.3.1DHSS staffing for oversight of community behavioral health services is sufficient to support service delivery.
6.3.2Administrative staffing at API is consistent with average staffing patterns of state psychiatric hospitals nationwide.
6.3.4Overall administrative staffing is commensurate with the level of behavioral health service overseen by the Department.
7.1.1The Department did not respond to the Legislature’s request for proposed budget reductions in a timely fashion
7.1.2The Department did not submit a proposal of 10% reductions for the Legislature. Instead, it offered a proposal for reductions drafted originally in response to the Governor’s request for 5% and 8% program reductions. The total amount of proposed reductions for behavioral health services is well below 10%.
7.1.3In keeping with AS 44.66.020(c)(2), the proposed reductions represent a “good faith effort” because the Department identified General Fund expenditures for behavioral health services that could be reduced and refinanced through federal sources without compromising the Department’s ability to meet its mission in regard to behavioral health. Nevertheless, the Department’s submission was unresponsive to the specific terms of the statutory request.
7.2.1The Department’s proposed budget identifies approximately $1.9 million in budget reductions related to the delivery of behavioral health services.
7.2.2A review of each proposed impact shows that the cumulative consequences of the proposed budget reductions are unlikely to compromise the Department’s ability to meet its mission in regard to behavioral health.
8.1.1The Department’s use of information technology systems is consistent with standard practices across state mental health agencies nationwide.
8.1.2Costs incurred by the Department for information technology personnel and systems are reasonable in comparison to peer agencies in other states.
8.1.3The Department’s primary data platform for community-based services, AKAIMS, is capable of collecting metrics needed to support behavioral health programs and services.
8.1.4AKAIMS is administratively burdensome and requires double entry from many service providers, including API.
8.1.5Although AKAIMS’ EHR functionality provides considerable benefit to behavioral health providers who could not otherwise afford it, the use of AKAIMS as an EHR also impedes provider efforts to integrate behavioral health and primary care services.
8.1.6The data architecture underlying the AKAIMS system was designed for grant management and is structurally limited in its capacity to meet Medicaid billing requirements.
8.1.7Community behavioral health providers currently report data on multiple platforms, creating significant administrative challenges to accurate reporting and analysis.
8.1.8The Department adequately supports stakeholders implementing state-mandated behavioral health IT systems.
8.1.10The Department’s Grants Electronic Management System (GEMS) is effective at supporting behavioral health grant awards.
8.2.1The Department’s information technology systems have the capability to track and report on benefit recipients.
8.2.2Ad hoc tracking and reporting of benefit recipients is minimally effective.
8.2.3The Department’s ability to generate unduplicated counts of benefit recipients is uncertain and beset with administrative inefficiencies.
8.2.4The grant-funded system impedes the Department’s ability to report on costs of individual benefit recipients.
8.2.7The Department has effectively identified Medicaid eligible recipients of behavioral health services through AKAIMS.
9.1.1While a handful of state agencies throughout the country have assumed direct responsibility for treatment and recovery services, Alaska’s system of service procurement through non-state providers is the most appropriate option for the State’s public behavioral health system.
9.1.2Although the utilization of grant procurements by the Division of Behavioral Health (DBH) exceeds other divisions in the Department, both in the number and value of grants released, this method and scale of financing is consistent with state mental health agency practices nationwide.
9.1.3The grants and contracts management process was reformed approximately a decade ago from a process administered by each division to a centralized function administered within Finance and Management Services. The transformation has helped to streamline and standardize management of the Department’s grants and contracts.
9.1.5The Division recently implemented some of the grant administration “streamlining” recommendations drafted by the Division’s advisory boards and the Alaska Behavioral Health Association, which has improved the efficiencies of the grant management process.
9.1.6In an effort to stimulate service delivery and improve provider accountability the Department has recently begun a shift from procurement through grants to procurements through contracts.
9.1.7Although the transition from grant-based to contract-based financing is likely to improve the quantity and quality of many behavioral health services procured by DBH, grants remain an essential funding mechanism for providers of comprehensive services due to the flexibility these funds afford.
9.2.1The Department has taken a widely accepted approach in incorporating fees and matching funds into the overall grants and contract process.
9.2.2The fees involved in the Department’s grants and contracts are consistent with typical programmatic fees collected to support program operations.
9.2.3The Department’s grant and contract requirements adequately encourage providers to leverage third party insurance.
9.3.1The Department has established a fair and effective process that leverages technology and ensures competition, proper evaluation, and award.
9.3.2Grants are offered in both competitive and non-competitive solicitations. Most grants are procured as a competitive RFP, and non-competitive grants are procured using a waiver of competitive solicitation.
9.3.3Although competitive solicitations and performance based funding (PBF) are designed to improve quality by stimulating market competition, these processes are less effective in rural regions that cannot sustain multiple providers.
9.3.5The proposal evaluation process for grants and contracts promotes the Department’s objectives in selecting strong technical proposals that deliver value to the State.
9.3.6The Grants Electronic Management System (GEMS) provides all-encompassing grant administrative support and has served as a major improvement to the management process during the year in which it has been operational.
9.4.1The Department has established a structure for grant and contract monitoring that promotes accountability in overall management of its behavioral health grants.
9.4.2Providers consistently reported regular site visits by Division staff and frequent, supportive communication with state program managers.
9.5.1The Division’s non-adherence to the standard timelines of the Department’s grant cycle has resulted in administrative inefficiencies in the grant procurement process.
9.5.2The flexibility of grant requirements and the variety of service delivery methods they facilitate are substantial factors in the value and necessity of grant procurements, but the Department would ensure greater accountability of both providers and Division employees if grant requirements were defined more strictly.
11.1.1The department’s three behavioral health advisory groups provide adequate support and guidance regarding behavioral health issues.
11.1.2The joint meetings of AMHB and ABADA enable effective planning for a fully integrated behavioral health system of care.
11.1.3The independence of the advisory groups from the Department and other stakeholders enhances the importance of the advice provided.
11.2.1The guidance provided to the Department sufficiently incorporates consumer feedback and advocates for the needs to the boards’ constituencies.
11.2.2The co-location of AMHB, ABADA, and SPC staff and resources has allowed for a more economical use of departmental funding without detracting from the focus and specific division of labor of the separate advisory bodies.
11.2.3The close relationship between DBH and the advisory groups facilitates regular and systematic transfer of information, advice, and guidance, without diminishing the influence of non-departmental voices over planning and consumer advocacy.
11.3.1The review did not identify any significant areas of ineffectiveness or inefficiency requiring changes to advisory group organization or operations.
12.1.1The Department’s wide-ranging authority over health services creates strong potential for robust utilization tracking, but significant organizational challenges to data integration.
12.1.2The Department has traditionally monitored and managed utilization through its regional network of community behavioral health center (CBHC) grantees. This grant-based, regionalized service delivery system has contributed significantly to the Department’s effective collection of utilization data.
12.1.3The Department’s grant reporting requirements ensure effective collection of community utilization data.
12.1.4Lack of standardization in provider data reporting diminishes the efficiency of the Department’s utilization tracking.
12.1.5Flaws in AKAIMS’ data infrastructure have diminished the efficiency of utilization tracking until recently.
12.1.6Anticipated service delivery and payment reforms are likely to erode the effectiveness of CBHC-based utilization management, undermining the Department’s responsiveness to inappropriate utilization through traditional methods of oversight and intervention.
13.1.2The Medicaid Program Integrity (MPI) Section is the departmental unit with primary responsibility for identifying and reducing provider fraud, waste, and misuse. It has established a wide range of pre-payment and post-payment controls that have aligned the State with nationwide program integrity best practices.
13.1.4Overall responsibility for reducing and preventing fraud, waste, and misuse is currently decentralized among multiple state departments and DHSS program units. This diffusion of responsibilities has created challenges for the State in coordinating anti-fraud, waste, and misuse efforts.
13.1.6Lack of enrollment of some rendering provider types creates opportunities for providers to commit fraud.
13.1.7Abuse of prescription opioid narcotics is both a major behavioral health concern as well as a significant source of fraud and abuse in the health care system. Alaska’s current prescription drug monitoring law creates barriers that restrict DHSS and the Department of Law from accessing prescription drug data and using it to identify patient doctor-shopping and other prescribing practices that are potentially fraudulent or abusive.
13.1.8The department’s three behavioral health advisory groups provide adequate support and guidance regarding behavioral health issues.
13.1.9Substantial changes in behavioral health service delivery, such as mental health and substance abuse integration and the integration of behavioral health and primary care, have required significant revisions to the State’s Medicaid rules and regulations. Despite recent updates to the Medicaid regulations by DBH, ambiguities remain in the regulations for some behavioral health services that leave the program vulnerable to fraud, waste, and misuse.
Behavioral Health Improving Administrative Functions Recommendations Table
Recommendation NumberRecommendation
1.2.3Reorientation of the order of information on the budget visualization would improve communication of budget details.
1.2.5The use of visual aids in the Governor’s Amended Budget, such as bar graphs and tables, assists readers in comprehending and understanding the information presented. These could be further improved by standardizing the timelines used on these visual elements.
1.2.6The presentation of Department challenges and accomplishments in the Governor’s Amended Budget would be improved with a discussion of solutions, as well as an assessment of whether accomplishments meet Department goals.
1.2.7The Governor’s Amended Budget could be improved through the inclusion of an introduction and description of programs for each Results Delivery Unit (RDU) that would orient the reader to the detailed information that follows. The inclusion of historical and projection data would also facilitate evaluation of program elements over time.
2.4.1Reforming staffing policies and practices at API, including more competitive hiring and retention efforts, could significantly improve the quantity and quality of care without increasing costs.
3.0.3The Department should continue to promote greater capacity and utilization of peer support services.
3.0.8The Department should develop a Medicaid behavioral health rate structure that covers provider costs, incentivizes quality, and minimizes administrative burden.
4.3.1The Department should distinguish more clearly between measures of Division activities and the activities of funded providers.
4.3.2The Department should develop a consistent approach to measuring behavioral health performance across divisions.
4.3.3The Department should ensure continuity among program, division, and departmental-level evaluation of services, with appropriate degree of specificity and generality.
4.3.4The Department should incorporate performance measures that are more appropriately outcome-oriented.
4.3.5The Department should incorporate nationally recognized behavioral health treatment and recovery measures into the Department’s performance measurement strategy.
4.3.6The Department should align performance measurement of community providers, as far as possible, with measures used in accreditation requirements.
5.5.1The Department should implement a consistent and interoperable information technology solution for referrals across the behavioral health continuum of care.
5.5.5The Department should provide regional hospitals with a consistent screening tool and mapped interventions for individuals presenting with behavioral health-related emergencies.
5.5.6The Department should implement the recommendations presented in the State’s Recidivism Reduction Plan.
6.4.2The consolidation of grant and Medicaid review responsibilities can reduce costs and administrative burden on providers, but only if reorganization does not conflict with Medicaid administrative claiming processes or dilute the Department’s regulatory role.
8.3.2The Department should prioritize development of interoperability of data for all recipients of behavioral health services, from SDS to DBH to OCS.
8.3.3In the near term, the Department should transition all behavioral health providers across the continuum of care to data reporting through AKAIMS.
8.3.4The Department should develop clear and consistent priorities for data collection and incorporate these into the Minimum Data Set in AKAIMS.
8.3.5The Department should integrate AKAIMS and API data to the greatest extent possible.
8.3.6The Department should prioritize implementation of an accurate and complete Master Client Index.
9.3.4The Department should consider revising Medicaid regulations to increase non-grantee, private provider participation in Medicaid.
9.3.7Although the Department has produced user training videos for GEMS that have been praised by the provider community, it should also consider a user manual to accompany training videos to support instruction in rural communities with limited internet bandwidth.
9.4.3The Department should provide comprehensive training to all Division of Behavioral Health employees acting as grant and contract managers.
9.4.4The Department should improve the year-end report to focus more strongly on outcomes and performance metrics as opposed simply to dollar amounts or tasks accomplished.
9.5.3The Department should include a simple dashboard into the GEMS program that visually tracks program goals and percent completion. Although tracking for some qualitative measures may be difficulty, simple graphics demonstrating percent completion are useful in helping grantees to remain on track.
9.5.3The Department should include a simple dashboard into the GEMS program that visually tracks program goals and percent completion. Although tracking for some qualitative measures may be difficulty, simple graphics demonstrating percent completion are useful in helping grantees to remain on track.
9.5.8The Department should review the grant management process to ensure that grant administrative burden is commensurate with the size of the grant award.
12.2.2The Department should develop a consistent and transparent data analysis and reporting system, accessible throughout the Department that illustrates regular, monthly performance trends without reliance on ad hoc reporting.
12.2.3The Department should implement a uniform utilization reporting structure across the behavioral health continuum of care.
13.2.1The Department should strengthen Medicaid provider enrollment activities by requiring enrollment of all rendering provider types.
13.2.3The Department should streamline audit and investigation processes for providers by focusing resources on provider types that pose the greatest risk of overpayment, reducing audit cycle time and improving communication on audit status, and seeking a waiver of certain federal audit requirements.