Alaska DHSS Commissioner Adam Crum on the successful vaccine rollout and behavioral health

Adam Crum is the commissioner for the Alaska Department of Health and Social Services and has served as the commissioner since December 2018. In this Q&A, Crum discusses Alaska’s response to the COVID-19 pandemic, the vaccine rollout and the behavioral health system in Alaska. 

 

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Sydney Kurle: In December, Governor Dunleavy announced his intention to split the DHSS into two departments, this is obviously an evolving plan, but how has the feedback from legislators and the public informed the thinking around splitting the agency?

Commissioner Adam Crum: “It’s gone really well. We actually have our first legislative meeting on it this week in Senate Finance. Because the governor’s amended budget is coming out on Wednesday as well,  we’ll talk about what the plan looks like in terms of the size and scope and how the overall budget for FY ‘22 compares to FY ‘21. But we’ve done a number of town halls for employees. Each division has had at least one or two town halls, an opportunity for all employees to sign in on a zoom and talk with myself and my team and ask direct questions. And it’s gone really well, [we have] gotten employee buy in about where we are trying to go and it’s pretty exciting.

There is something I would like to correct, there was something called an OCS [Office of Children’s Services] bifurcation that’s proposed, and that has nothing to do with the executive order. It just happened to have discussions started on it at the same time as the executive order. With that, we have actually asked to enter into formal tribal consultation with all of our tribal partners. Anything with the proposed bifurcation of the OCS or realignment is going to be involved in this many months long process, while we work this out with stakeholders to make sure it’s the best thing for our kids and families. Everybody was confused on that [the OCS bifurcation not being related to the executive order], including there was a legislative hearing that addressed it, and they’re two separate issues. What we’re just letting everybody know is that the executive order is just simply taking four separate divisions and moving to a new department with the commissioners office and existing divisions stay, and that’s all it contemplates. It has nothing to do with any other proposed changes to OCS.”

SK: Bloomberg recently said that “Alaska is winning the Covid vaccine race,” and 16.5% of the Alaska population had received at least one dose, when I last checked. How did Alaska succeed where other states might not have, and what issues has the state had to overcome?

AC: “I actually think we’re at like 24% now, when it gets updated. Right out the gate what we really focused on was partnerships. We looked to partnering with our tribal health partners in Alaska, knowing that they have upwards of almost 200 clinics in the state, and we would need their help administering the vaccine, to make sure that was available in remote communities. 

We started planning early on with the limited information that we had about what the logistics look like of moving this [the vaccine] around. There was a lot of prep work that we had started in August, and we did as much as possible without having an EUA, without having the final logistics sheet. Where are the possibilities for ultra-cold storage in Alaska? What does it look like if for re-dispersing, as in the shipping comes into the state of Alaska and then we can resize and re-send that out in smaller batches. And we tried to plan as much as possible with that, and educating our community providers and partners just about what it means to administer the vaccine, the expectations around monitoring for at least 15 minutes for adverse reactions. And I think it was just that we had a very broad conversation. And I think that’s what really pushed it. For a state as big as we are, there are a lot of logistical challenges. It’s been pretty cool to see. We’ve had shots delivered by four-wheelers, dogsled, boats and small airplanes, you name it we’ve used the tool to move vaccines around the state.” 

SK: A current issue nationwide is equitable distribution of the vaccine, you kind of touched on it, but Alaska seems to be doing really well. How is the DHSS ensuring an equitable distribution of the vaccine, both racially and ethnically but also across rural and urban lines?

AC: “When the COVID pandemic started, Governor Dunleavy made sure that everyone on the health team was well aware of the 1918 Spanish Flu Pandemic, and what it did in decimating Alaska Native Populations. He spent 20 years living in rural Alaska and he has heard directly from family members and in-laws the stories of what it was like coming back to a village where everyone had died. We were very mindful throughout this to make sure that we had protection responses around Alaska Native villages and that tribal health care had all the support they needed.

When it came to working with tribal health partners on vaccine distribution, we knew they would get their own allotment from IHS, so the question we asked ourselves is what can we do as a state to help them as much as possible. That has been something that has been very important, because Alaska Natives are around 15% of our population and I believe they’re disproportionately high in the number of fatalities due to COVID. We wanted to make sure that they were taken care of, that they had the flexibility necessary in villages to give it to who’s important to them in each village. We have our guidelines from the state, but in each village it’s an individual choice about how it’s administered out. That was something we really looked at. 

When it comes to the urban setting, they have been tremendous partners. Between the Anchorage Municipality and ANTHC, they helped us work out who we have to vaccinate next, are there neighborhoods that don’t know they have access and evaluating any hesitancy towards the vaccine. What can we do to just educate, because in Alaska we’re not going to do a vaccine mandate. We just want people to actually understand the truth behind the vaccine. We’re just informing, so we find and inform leaders or community and cultural leaders, here is the information on this and answer the questions they have and build a level of trust that will help us make sure their folks and their areas have access to it. It’s just a very mindful plan to continue building that relationship.”

SK: There has been controversy in the legislature about Governor Dunleavy’s State of Emergency Declaration, so much so that the declaration expired yesterday. How is the new plan going to mitigate the spread of the virus while allowing Alaska to reopen?

AC: “So with the disaster declaration expired we lose a number of authorities. We lose the ability to do health orders, which are the requirements around pretravel testing, both into the state of Alaska, as well as into offroad villages. And we have kept the infrastructure in place and so we already have the contracts planned out into June which we can cancel at any time. But we have those planned out to remove the burden, to make sure people understand the importance of continued testing and put out guidelines changing “required” into “should.” And we did lose some other authorities with the rapid procurements aspects that are allowed under the Disaster Act. There is a function that we can use for emergency procurement that’s faster than standard procurement, but not as fast as the procurement we were working under. 

The Senate tried really hard, they had multiple committee meetings on this, to move this along. But when we saw the state of the House not being organized, the governor really pushed us, he goes “you guys need to come up with a backup plan so that Alaskans understand that we’re not going anywhere, that the response is still going to be intact as much as possible and we’re still going to be here for a measure of support.” As we move into the situation there are some items that we are still working out, because we have our typical federal allocation plan for the vaccine that was approved in October, we’ve got our next month already planned out for distribution. But beyond that, there is an item of concern that we’re still trying to work out with the department of law, as the governor mentioned in the release as we identify items that we find very glaring gaps that we need legislative help or authority to do a targeted bill, perhaps an uncodified law. We’re meeting with the governor on a regular basis to perhaps bring that [gap] forward to the legislature to give us some certain authorities to make sure that the response continues and that we still stay ahead of the game.”

SK: Alaska recently announced they met or improved upon almost half of their goals on their Healthy Alaskan score cards, but some of the Leading Health Indicators that did not show major improvement fall into the categories such as substance abuse, violence prevention, and Social determinants of health. What are some of the strategies being used by the DHSS to improve outcomes in those categories?

AC: “That’s going to all be primarily related to our 1115 waiver as that moves ahead, we have successfully implemented the administrative services organization, or the ASO, this summer, and we’ve got more and more providers that are signed into that [ASO]. With the 1115, it provides, I think, 23 more different services on the behavioral health side and treatment side, that can be billed against Medicaid. And the goal is to provide the correct level of service in the right location. So as this moves ahead we think it’s going to be one of our biggest avenues to attack those items. This is to make sure that the behavioral health continuum of care continues to get built up. Our primary tool to do so is the 1115 waiver. And making sure that providers are taken care of, they understand the process, educating them on what it means to be an 1115 provider in the broad array of services. Centralized services in Anchorage, Fairbanks and the Matsu are not going to work, because a lot of times with these individuals dealing with substance abuse and other behavioral health issues need rapid attention. So the more we can get providers set up, in the kind of boots on the ground aspect around Alaska, the better it will be for all Alaskans.” 

SK: How is the DHSS going to help organize the behavioral health delivery system to respond to the specific traumas of this pandemic?

AC: “Throughout this response the behavioral health team has done a fantastic job. That was another aspect that Governor Dunleavy made a very big highlight on, was to make sure that we take care of the overall holistic health of Alaskans. We set up a lot of items in advance, like multiple different care lines. We had lines for health care providers dealing with trauma of COVID patients coming in and having to intubate. We set up lines for connecting youth to local resources. Put together post-vention and prevention grants for communities that [the] behavioral health [team] reached out to try and help communities that may have suicide situations, an area that we were worried was possibly going to be a cluster, luckily there was not, and so we try to be very proactive in that [planning ahead]. The thing with the division of behavioral health is their job is to help facilitate and manage programs and connect providers to them, and they have done an outstanding job really stepping up in that space throughout the response. And as we look across the state, we’re seeing a lot more of local health care systems that are investing in that. A great example is North Sound Health Corporation, in the Nome area, they have done a great job of getting vocational contracts set up with psychiatrists and other behavioral health professionals to work in their area. So we’re trying to help groups like this, we give them a level of resources and support because this is not just at the state level, we need our local partners to continue to invest and we’re glad to see that this is happening around the state.”

SK: There have been a number of efforts to change Medicaid in the last few years. Is that now an efficient, effective safety net program for Alaskans?

AC: “The idea around the Medicaid program is you want to make sure it’s provided to the correct individuals, that way eligibility is monitored properly. One thing with the enhanced FMAP [Federal Medical Assistance Percentage] of 6.2% from CMS, is that if you get that FMAP you agree that you will not touch your eligibility rules during the public health emergency, which is primarily for the federal side. So as we look at this we’re just trying to make sure that the programs are set up, monitoring utilization and seeing what we can do throughout. So we’re going to continue to look at that, the enhanced FMAP has definitely been a benefit to the state as far as an increase of savings in general fund dollars. But as we look ahead to the future it’s about what we can do on a regionalized basis. We’re having some fantastic conversations with the hospital association, before COVID hit, about global-based budgets in certain areas of the state, and how do we move to value-based payment system, and so these are conversations we are going to continue to have to see if can transform health care in Alaska a little bit more.”

This interview has been edited for clarity and length.