Legislature(2021 - 2022)ADAMS 519
04/09/2021 09:00 AM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| HB99 | |
| HB117 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 99 | TELECONFERENCED | |
| + | HB 117 | TELECONFERENCED | |
| + | TELECONFERENCED |
HOUSE BILL NO. 117
"An Act extending the termination date of the Board of
Certified Direct-Entry Midwives; and providing for an
effective date."
9:12:39 AM
REPRESENTATIVE DAN ORTIZ, SPONSOR, thanked the committee
for hearing HB 117. The bill extended the termination date
for the Board of Certified Direct-Entry Midwives to June
30, 2023. It was a 2-year extension at the recommendation
of the Division of Legislative Audit. The board was
comprised of 5 members: Two direct-entry midwives; one
physician licensed by the state medical board; one
certified nurse-midwife licensed by the Board of Nursing;
and one public member. Under the statute the board examined
and issued certificates and permits, established
regulations for the certification and practice
requirements, ordered disciplinary actions, and approved
curricula and standards for education, training, and
apprenticeships. The bill had a $21,800 fiscal note which
was covered with the revenues from licensing fees. He
relayed the list of available testifiers.
Representative LeBon asked why the extension was only for 2
years. Vice-Chair Ortiz deferred to the legislative
auditor, Kris Curtis, as she recommended a 2-year
extension.
9:14:47 AM
KRIS CURTIS, LEGISLATIVE AUDITOR, ALASKA DIVISION OF
LEGISLATIVE AUDIT, would review the legislative audit
report for the Board of Certified Direct-Entry Midwives.
She relayed that the Division of Legislative Audit
conducted a sunset review of the Board of Certified Direct-
Entry Midwives. She thought members had a copy of the audit
report, dated June 2020 in their packets. The purpose of a
sunset audit was to determine whether a board or commission
was serving the public's interest and whether it should be
extended. She read a portion of the report:
Overall, the audit concluded that the board served the
public's interest by conducting meetings in accordance
with state laws and effectively certifying midwives.
The board adopted regulatory changes to improve the
profession but failed to pursue statutory changes due
to concerns over related costs. Additionally, the
audit found the peer review process was not
effectively monitored by the board and improvements
were needed over the Division of Corporations,
Business and Professional Licensing's (DCBPL)
investigative process.
In accordance with AS 08.03.010(c)(8), the board is
scheduled to terminate on June 30, 2021. We recommend
the legislature extend the board's termination date
two years, to June 30, 2023, which is significantly
less than the eight-year maximum allowed in statute.
The reduced extension is due to an issue identified
during the audit that may impact the board's ability
to protect the public and the board's reluctance to
recommend statutory changes in the public's best
interest. The details of the issue are not included in
this report to preserve the confidentiality of an
ongoing investigation. The reduced extension reflects
the need for continued oversight.
Ms. Curtis directed members to turn to page 7 of the audit
showing the standard licensing statistics for the board. As
of January 2020, the board had 51 certified direct-entry
midwives and apprentice midwives. Page 8 contained a
schedule of fees. In FY 17 the fees were increased to
address a deficit. As a result, the occupation had one of
the highest, if not the highest, fee of any occupation.
Ms. Curtis directed members to page 9 which showed a
schedule of revenues and expenditures. It showed that the
board had a deficit of just over $19,000 as of January
2020. She indicated that at the time of the audit, DCBPL
management believed that the deficit would be fully
resolved by the end of FY 21.
Ms. Curtis indicated the division had three recommendations
for improvements beginning on page 11 of the report. She
read Recommendation 1:
The board should recommend statutory changes that
benefit the public. The board identified a need to
change certification statutes to align Alaska's
midwifery laws with national standards. However, due
to the legal costs involved with the project, the
board did not recommend statutory changes.
Ms. Curtis read Recommendation 2 on page 12:
DCBPL's chief investigator should ensure
investigations are completed timely. Three cases open
over 180 days from July 2016 through January 2020 were
evaluated by auditors. All three were found to have
unjustified periods of inactivity ranging between 54
and 114 days. It was also noted that supervisory
review of two of the three cases was not documented as
required by DCBPL procedures, indicating review did
not occur or did occur and was not documented.
According to DCBPL staff, the inactivity was the
result of turnover and competing priorities.
Ms. Curtis read Recommendation 3 on page 12:
The board should improve oversight of the peer review
process. The board delegated peer reviews to the
Midwives Association of Alaska's Action and
Accountability Committee. However, the board did not
establish procedures to provide assurance that reviews
were adequately completed. The board did not consider
the need for or importance of monitoring the peer
review process. According to AS 08.65.030(b), the
board may, by regulation, require a CDM undergo a
uniform or random period of peer review to ensure
quality of care. Inadequate monitoring of the peer
review process increases the risk that the reviews
will be deficient, which increases the risk to public
safety.
Ms. Curtis indicated the responses to the audit began on
page 23. The commissioner of the Department of Commerce,
Community, and Economic Development (DCCED) did not respond
to Recommendations 1 and Recommendation 3, as those
recommendations were directed to the board. In response to
Recommendation 2, the commissioner state that the
department was going to add a supervisory investigative
position to help with the caseloads. She noted the Chair's
response was on page 25. The Chair expressed disappointment
with the 2-year recommended extension. Regarding
Recommendation 1 the Chair believed that the board should
not be penalized for their fiscal responsibility, as it was
a way to reduce costs. In response to Recommendation 2, the
Chair concurred with the finding but stated that she
believed it should not have impacted the term of extension,
as the duty to investigate fell on the department. She
continued that regarding Recommendation 3, the Chair
concurred with the recommendation.
9:20:10 AM
Representative Josephson asked about the statutory changes
recommended by the auditor and why the board had not
approached the legislature for a change. Ms. Curtis
responded that it was their perception that it would be
costly. She noted in the department's response that
although they did not have comments on the recommendation,
they remarked that the cost associated with that type of
project was small.
Representative Josephson noted Ms. Curtis had mentioned
some statutory changes that should be made that the board
had identified. However, they lacked the resources to make
those changes. He wondered why they had not come to a
legislator for assistance. Ms. Curtis reported that it was
their perception that it would be costly. She noted in the
department's response that although they did not have
comments on the recommendation, they did not think there
would be many costs. There was only a small cost associated
with that type of project.
Representative Josephson noted that in 2014 Senator Kelly
[a previous Alaska Senator from Fairbanks] sponsored and
saw the passage of Senate Bill 156 []. He was a legislator
at the time and had some concerns with the bill. Although,
he voted for it. The bill stripped away the prescriptive
statutory authority for direct-entry midwives and gave them
the authority to writ the regulations that would define
their scope. He wondered if the legislature should be
concerned that if there was much disclosure about the case,
a person could be identified. He asked if the legislature
should be concerned about how direct-entry midwives
perceived their own scope of practice.
Ms. Curtis indicated she had to proceed with caution based
on the recommendation of Legislative Legal Services on her
answer. She reported that in the previous sunset audit she
had recommended to the legislature to consider alternate
forms of regulating the board. At that point, her concern
was that with such a small number of licensees and the
weight of investigations it would drive the costs so high
creating a barrier into the occupation. She feared that if
the fees were very high it would prevent people from
practicing or lead some of them to drop off. Four years
ago, she testified and made the recommendation, no action
was taken. In hindsight, the number of licensees only
decreased by 3 even with the high fees. A small number of
licensees created problems with fees. She would not
otherwise answer the representative's question directly.
9:23:51 AM
AT EASE
9:26:01 AM
RECONVENED
Representative Thompson had a question about the length of
time of investigations. He wondered if DCCED was
responsible for the investigations. Ms. Curtis responded
affirmatively. She indicated that there was designated
staff within DCBPL that did investigations.
Representative Thompson asked if the cost of the
investigations was the responsibility of the board. He
wondered if licensing fees would have to be raised to meet
those costs if necessary. Ms. Curtis indicated AS 08.01.065
required the department to adopt regulations to establish
the amount and manner of payment of application,
examination, license fees, and permit fees. The statute
required that it covered the cost of regulating the board.
Essentially, all occupations paid their way.
Representative Thompson asked about the length of time for
an investigation. He speculated that investigations were
taking 180 days. Ms. Curtis Deferred to Ms. Chambers, the
director of DCBPL.
9:27:58 AM
SARA CHAMBERS, DIRECTOR, DIVISION OF CORPORATIONS, BUSINESS
AND PROFESSIONAL LICENSING, DEPARTMENT OF COMMERCE,
COMMUNITY AND ECONOMIC DEVELOPMENT (via teleconference),
reported that all of the license investigations had the
same process. However, the investigations vary depending on
the type of suspected infraction. The department had 17
professional investigators to handle the case load. The
process prioritized the life, health, and safety cases. The
division had struggled for several years with keeping up
with some of the case work, especially for the low priority
cases that do not pose an immediate threat. She had been
working to overcome the delays where possible.
Ms. Chambers continued that much of the investigation
process relied on receiving documentation from the licensee
under investigation and from the complainant. Sometimes it
involved obtaining copies of sensitive and confidential
medical and hospital records which could take time to
process. She believed the division could improve on
documenting delays so that all parties could see that the
division was actively working the cases and the delays were
reasonable. It was an area the Division of Legislative
Audit had suggested DBCPL improve. She had put some new
standards in place and added staff to reach that goal.
9:30:52 AM
Representative Thompson suggested that since the
investigative fees were passed onto the board and license
holders, it might be helpful to have additional
investigators to expediate the investigations.
Ms. Chambers relayed that it was one of the things the
division did to help improve timeliness and documentation.
It was important to have adequate staff to support all of
the investigations. The division added an additional
supervisor in the previous few months. The division
currently had a chief investigator and three senior
investigators who report to the chief. The division could
certainly use additional investigators to improve quality
control as the complexity and volume of cases increased.
The downside was that the cost would be passed on to
licensees.
Ms. Chambers reported that for the last several years the
division had worked on some alternative methods that would
help spread the cost of investigations, similar to an
insurance policy, that would help smaller licensing
programs such as the Board of Certified Direct-Entry
Midwives (a program that only had about 50 licensees) from
having to bear huge costs. Currently, a fully fledged
midwives licensee paid about $3500 every 2 years for their
license. Even though they had made amazing strides, had
willingly accepted the responsibility, and worked through
their debt, they were only one major investigation away
from incurring additional debt and seeing the cycle
continue.
Ms. Chambers relayed that the division had worked to
propose legislation and legislation had been proposed in
the prior several years to change the scheme. However, it
would take a statutory change to make a change. She was
open to speaking with legislators who might be open to
hearing more.
Representative Thompson was happy to help with the
legislation. Ms. Chambers thanked Representative Thompson.
Representative LeBon clarified that his asking to be
recognized was relating to the copying of the document.
9:34:03 AM
Representative Rasmussen was curious about the 2-year
extension given that the reduced extension was cited as
being due to an issue identified during the audit that
might impact the board's ability to protect the public and
the board's reluctance to recommend statutory changes. She
assumed that midwives were primarily dealing with pregnant
mothers and babies. She thought 2 full cycles of births was
a little alarming given the reluctance to seriously address
the issues brought out in the audit. She asked Ms. Curtis
to speak to the 2-year recommendation versus a 1-year
recommendation.
Ms. Curtis responded that when the division did a sunset
audit it started on the year before it terminates. The
current audit was dated June 2020. By the time she reviews
the audit with the legislature it was a year later. She
indicated that 2 years was really the lowest term of
extension because of reporting times to the legislature.
Representative Wool was concerned with the timeliness of
investigations and the board being penalized due to a lack
of investigators within DCCED. He asked how many
investigators resided within the department.
Ms. Curtis would defer the number of investigators to Ms.
Chambers. However, she could speak to the representative's
question regarding whether there was merit in talking about
the number of investigators and the timeliness of
investigations. She clarified that the issue identified was
different than her recommendation. Her recommendation about
the timeliness of investigators was completely separate
from the issue she identified. She continued to explain
that more than half of the time she looked at investigative
function making similar recommendations. Timeliness was an
issue DBCPL was working on improving.
Ms. Chambers responded that the division had less than 20
investigators. She had a team of approximately 20
investigative staff. Three of them are paralegal and
administrative staff. She had fewer professional
investigators that supported the 43 different licensing
programs. She strived to train them and keep them focused
on particular areas in order to gain knowledge and
experience over time. She provided some examples. However,
all of the staff can float from program to program
depending on need. Direct-Entry Midwives have had a small
number of investigative cases but were typically of a
serious nature. She suspected that the investigator who
would be assigned to midwives would also be working on two
or three other healthcare programs at the same time to
ensure the division was using its resources efficiently.
Sometimes that could have a negative affect on the
division's effectiveness. The division tried to strike a
balance.
Co-Chair Merrick relayed that the committee had been joined
by Representative Edgmon.
Representative Wool was under the impression that only one
investigator was assigned to the Board of Certified
Direct-Midwives. He read from a letter from the board that
stated that they were not in a position to make activity
happen when DCBPL could not keep staff members or
prioritize midwifery investigations. He asked how long the
current midwifery investigator had been working with the
division and whether they had been a part of the audit from
the start.
Ms. Chambers indicated that there had been significant
turnover within the division. Earlier in the current year
three of the investigator positions vacant. She offered
that division was juggling prioritizing life, health, and
safety cases with much lower priority cases and the
experience of investigator. There had been turnover for the
specific investigator position during the period of the
audit. She also indicated that the investigator for the
midwifery board would also be working other programs
because of the necessity of the resources of the division.
Representative Wool thought the board's claim had some
merit. He questioned the costs related to the board audit.
He wondered the cost of licensing for a nurse compared to a
midwife. Ms. Chambers reported that typically a nurse or
physician license was about $200. She pointed out there
were more than 20,000 nursing licensees and 5,000 to 6,000
physicians, physician assistants, and paramedics that
shared in the cost of investigations. The midwifery program
had 50 licensees. Economy of scale played a large factor
based on how the law was written. The impact was much
greater on the smaller programs when there was a sizable
investigation. She relayed that her staff maintained
positive timekeeping. Therefore, boards and programs were
only charged for the time worked on their cases. If there
were delays, the board was not being charged.
9:44:10 AM
Representative Wool asked if the revenue from billable
hours by the investigative staff went to the department. He
understood economy of scale. He provided an example. He
wondered about a proposal to aggregate licensing and
creating a larger pool. A small board of a specialized
professional had a larger investigative burden. He asked
about the typical cost of an investigation for the
midwifery board. Ms. Curtis deferred to Ms. Chambers. Ms.
Chambers would be happy to submit a written response. The
cost of investigations varied greatly. Co-Chair Merrick
asked Ms. Chambers to repeat the dollar amount. Ms.
Chambers would like to submit dollar amounts in writing.
Representative Josephson asked how many investigators her
division had in FY 12 through FY 14. Ms. Chambers recalled
that the division had only added 1 or 2 investigators since
that time. The division would have had approximately 16
investigators. The division had not grown the investigative
section since then.
Co-Chair Merrick asked if Ms. Chambers had further
comments. Ms. Chambers thought she had covered most of the
information. She wanted to report that the board had been
working with the division and had seen a stronger and open
relationship between members of the board and management
within the division to make improvements since the audit.
She had witnessed the board taking the recommendations
seriously.
Co-Chair Merrick indicated the Board chair was available.
9:50:12 AM
BETHEL BUH-LYLE, CHAIR, BOARD OF CERTIFIED DIRECT-ENTRY
MIDWIVES (via teleconference), reported came on to the
board in March 202. She was grateful to Representative
Ortiz for sponsoring the board's sunset bill. As a new
member of the board, hearing of the board's deficits and
what it needs to do better had spurred members to work
diligently on doing so. The two audit reviews she believed
pertained to the midwifery practice were the statutory
changes and the peer review process.
Ms. Buh-Lyle reported the board revamped the peer review
process in June 2020 and was waiting for it to be finalized
through the regulatory process. It was rewritten such that
the board took back complete control of its peer review
process and gave the board authority to take disciplinary
actions as needed. The board had done audits on charts and
peer reviews since 2014 and found there had been sufficient
oversight.
Ms. Buh-Lyle spoke of statutory changes. One of the board
members had recently been rewriting the entire statutes to
align with international standards. She relayed that on the
prior Wednesday the board had a 3-hour work session going
line-by-line to bring the standards to the level of a
leader in the United States. The documents were headed to
the legal department for review. The board was pushing to
match the auditor's request.
Representative Rasmussen asked if the chair would describe
the midwife practice. She wondered what type of health and
safety issues might arise that would lead to a claim and an
investigation into their practice. Ms. Buh-Lyle responded
that the board's current regulations stated that midwives
must submit a chart for peer review on any transport of a
mother or baby. The issue had to result in a 9-1-1 call.
For instance, a baby might struggle to transition well
after birth. An ambulance transport would occur and even if
a baby was released within 12 hours, there were things
midwives were required to do. She provided another example
of an emergency warranting ambulance transport. Whether
there was a poor outcome, such as the death of a mother or
baby, midwives were required to submit the full chart for
peer review to ensure proper protocols were followed. In
the new peer-review process, the charts were sent to and
reviewed by the board.
9:54:54 AM
Representative Carpenter clarified that the statutes
currently being re-written seemed like a substantial
amount. The finding stated that the board needed to change
certification statutes. He had quickly referred to
AS 08.65.060 through AS 08.65.080 and noted there was not
much substance. He was curious what the board was rewriting
to accommodate national or international standards. He
wondered if she was only talking about certification
standards or about the entire midwifery profession.
Ms. Curtis elaborated that one of the criteria that the
auditor used was to evaluate whether a board was
recommending statutory changes in the public's interest.
The auditor looked at the board's annual reports. Each
annual report for 3 years they identified the need to
change the statutes to align their laws with national
standards. The auditor did not involve themselves with
which statutes needed to change. Rather, the auditor
considered that there was a need that they were not filling
due to concerns over increasing their licensing costs which
was not in the public's interest.
Representative Carpenter asked for clarity on risk. He
wondered if there was a list of statutes that needed to be
changed or were in question that needed to be rewritten.
Ms. Curtis responded that that recommendation had nothing
to do with the issue identified by the auditor that was
causing her to recommend a 2-year extension.
Ms. Buh-Lyle indicated that the statutes that the board was
looking at changing had to do with word usage. She relayed
that the board was proposing to change the word "certified"
to "licensed," a national standard. Changing the word would
allow for midwives to be paid by more insurance companies.
Women would like to be able to choose on a hospital birth.
However, some insurance companies would not pay a direct-
entry midwife because of the use of the word "certified."
The board was moving in the direction of the national
recommendations set by the North American Registry of
Midwives.
Co-Chair Merrick reviewed the agenda for the afternoon's
meeting.
HB 117 was HEARD and HELD in committee for further
consideration.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 117 Additional Document 3.19.21.pdf |
HFIN 4/9/2021 9:00:00 AM |
HB 117 |
| HB 117 Sponsor Statement version A.pdf |
HFIN 4/9/2021 9:00:00 AM SFIN 5/14/2021 1:00:00 PM |
HB 117 |
| HB 117 Sunset Review DLA 6.19.2020.pdf |
HFIN 4/9/2021 9:00:00 AM |
HB 117 |