Legislature(2021 - 2022)ADAMS 519
04/12/2021 09:00 AM FINANCE
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HOUSE BILL NO. 117 "An Act extending the termination date of the Board of Certified Direct-Entry Midwives; and providing for an effective date." 9:18:47 AM REPRESENTATIVE DAN ORTIZ, SPONSOR, reintroduced the bill that would extend the Board of Certified Direct-Entry Midwives. He summarized that committee members had heard the bill the previous week where there had been good discussion. He was available for any questions. He listed others available for questions. Representative Johnson referenced the audit recommendation for the board to improve oversight of the peer review process. She asked how the board intended to improve oversight. BETHEL BELISLE, CHAIR, BOARD OF CERTIFIED DIRECT ENTRY MIDWIVES, ANCHORAGE (via teleconference), answered that the board had already begun the process to completely revamp the peer review method. She explained the process that had been in place since 2014. She detailed that a committee of midwives unaffiliated with the board received charts of any outcome listed in statutes and regulations including the death of the mother of a baby, an emergency transport of any kind, or if a midwife went outside regulations. For example, if a midwife attended a woman at a home birth and the baby was being delivered breached, the midwife was required to call 911. She elaborated that if emergency responders did not arrive, the midwife may deliver the baby and was then required to submit the chart. Ms. Belisle reported that the board had removed the entire committee and had brought the entire peer review process back to the board. She explained that any midwife who had a birth under the aforementioned categories, was required to submit the chart to the board for review. The updated process gave the board the ability to provide discipline as needed or to send the case to investigation if outside the board's regulation. She elaborated that currently when the board received charts, it reviewed paperwork to determine whether a midwife had followed procedures, obtained signed consent, and protected the public interest. The board had moved from a peer review committee back to a board review. She shared that the process was in the final stage with legal to ensure it was up to the state standard. Representative Johnson she asked if in the peer review process the board was taking responsibility for monitoring and addressing any problems. She asked how the process would differ from the former review by a peer review committee. She asked if the board would have more ability to directly address issues. Ms. Belisle replied that the old committee was called an action accountability committee. The only thing the committee could do was determine whether a midwife had or had not followed procedures. She elaborated that if the committee determined a midwife had not followed procedures, the chart was sent to investigation. Under the new process, the board would receive the charts for review. The board would also be able to tell someone under review they needed more education on a specific issue. She expounded that in a scenario where there was no death of a mother or baby. She explained that the board could determine there had been numerous pink flags that the midwife should have identified earlier. The board would have the ability to discipline by requiring more education, a fine, or accountability under another midwife. 9:24:28 AM Representative Wool looked at the two-year extension recommendation. He noted that an audit took one year. He asked if two years was enough time to realize changes and see the impacts. Ms. Belisle replied in the affirmative related to the peer review portion. She detailed that the peer review change should be completed in 2021. The board had already begun a process to change the statutes to align with national standards. She stated that while the board may not get all the way through the process, she believed the auditor would be able to see the board had made significant changes and that it was on a trajectory to meet the changes that would meet or exceed the national standard. Representative Wool looked at the biennial $3,800 license fee for a midwife. He wondered at what point a fee would become cost prohibitive and result in the loss of practicing midwives. He noted that fewer practicing midwives would mean a higher fee. He asked if the license fee was currently at the top end of affordability. Ms. Belisle responded in the affirmative. She reported that as the license fee had increased to the current amount in recent years, the number of licensed midwives had stayed fairly static at 40. She confirmed that the fee was cost prohibitive. She considered the $3,800 fee and relayed that a Medicaid payment for a birth was about $3,400. She explained that for midwives without large practices it was difficult to stay licensed due to the high license fee. She did not believe the fee could go any higher. 9:27:00 AM Representative Wool provided a hypothetical scenario where an additional investigation may require the board to raise fees due to the cost. He thought the current number of midwives was around 50, but he noted Ms. Belisle had listed the number at 40. He was concerned an increased fee may decrease the number of licensed midwives from 40 to 30. He asked if the number of midwives had been increasing up until the past several years. Ms. Belisle confirmed there were 40 licensed direct-entry midwives and 10 licensed apprentices. She relayed the apprentice fee was $850 for a two-year license. She stated that practicing midwives had selected the profession as their career path and would work diligently to maintain the fees. She shared that she would not leave her practice merely because it got more expensive. She noted it was a difficult procedure to move forward to think about a potential investigation. She was happy the board was taking over the peer review process and was hopeful it would decrease the likelihood of an investigation due to increased oversight by the board. 9:28:54 AM Representative Wool referenced Ms. Belisle's statement that the number of midwives was remaining flat. He asked if the population of midwives had typically increased in the past. He asked about the license fee in Washington, Oregon, and California. Ms. Belisle answered that the number of midwives in Alaska had been relatively flat for the past ten years. She shared that when she received her original license in 1999, her license had been number 25. She noted that license numbers had changed, and the number of midwives had fluctuated over time. The number of licensees was remaining flat, particularly because some of the education requirements in regulation had changed, which made it harder for women in Alaska to become midwives. She reported that the license fee in Oregon was $600 every two years. She did not know the fee in Washington. Representative Johnson asked about the peer review process. She looked at the audit recommendation to move the peer review process under the board. She noted that the documents did not mention the board's plan to have the process brought back to the board. She asked when the process would be brought back to the board. 9:30:40 AM Ms. Belisle answered that the board had started the process to change its regulations for the new peer review in March 2020. She believed the process had been slowed down due to COVID, but it was currently under review by legal. She relayed that the process was not part of the original audit. She noted she was not the original chair of the board and the information had not been given to the auditor at the time the audit had been performed. Representative Johnson asked about the timeline. Ms. Belisle believed the process should be done by October. Co-Chair Merrick OPENED public testimony. MADI GRIMES, PRESIDENT, MIDWIVES ASSOCIATION OF ALASKA, JUNEAU (via teleconference), shared that she lived and worked in Juneau had had been a licensed midwife for seven years. She spoke in support of the bill and certified direct-entry midwives. She referenced a document titled "Midwifery in Alaska" located in members' packets (copy on file). She read from prepared remarks: Certified direct-entry midwives have been licensed in the State of Alaska for nearly 30 years. In that time more Alaskan constituents are accessing midwifery care every year and we see the demand for home and birth center births grow. Midwives are trained through an accredited education program and are focused on providing individualized care to low-risk individuals. We are integrated in the larger healthcare system and refer high-risk clients to physicians when the need arises. Our goal as a midwifery group is to provide the highest quality care while ensuring the safest outcomes possible. Midwife-led care has been found to reduce the risk of costly complications and interventions, such as cesarean births, preterm births, and low birth weight incidents. This cost savings can be directly tied back to the state cost savings as approximately 30 percent of families receiving midwifery care are Medicaid recipients. Some of the supporting documents in your packet include an epidemiology report outlining the demographics and outcomes of Alaskan families as well as a couple studies showing the cost savings and safety outcomes of families who receive midwifery care. Highlighting the Strong Start study run by the Centers for Medicare and Medicaid Innovation - this study shows a savings of $2,000 per pregnant person that receives prenatal care with a midwife regardless of their ultimate location of birth. An interesting footnote in that study is that we actually had three Alaskan birth centers participate in this study group furnishing data. Our association supports the passing of House Bill 117. Thank you. 9:34:21 AM Co-Chair Merrick CLOSED public testimony. Co-Chair Merrick asked the Legislative Finance Division (LFD) to discuss the fiscal note. SABRINA JAVIER, ANALYST, LEGISLATIVE FINANCE DIVISION (via teleconference), reported that LFD had no issues with the fiscal note put forward by the Division of Corporations, Business and Professional Licensing (CBPL). She was available for questions. Representative Wool referenced the $21,800 designated general fund cost in the fiscal note. He asked if the cost was paid by the board and if it was the standard process. He asked if it would be the process going forward for all boards. Ms. Javier answered that the receipt supported services code 1156 was essentially treated like general fund program receipts. The department could not spend the $21,800 for FY 22 and FY 23 unless it collected the funds. The fiscal note was asking for authority to use the funds. 9:36:07 AM Representative Josephson referenced the $21,800 outlined on page 2 of the fiscal note. He asked for verification that the expenses were typical and should not increase the (already very high) annual fee for a licensee. He surmised the cost was a reflection of life in the division and the costs it absorbed for the board. Ms. Javier responded in the affirmative. She elaborated that the expenses the department had put forward reflected a projection and request for spending authority. Representative Josephson provided his understanding of what would take place if the board extension were five years instead of two years. He surmised four years would go by and the legislature would not know, but the agency would be requiring the payment of $21,800 from the licensees. Ms. Javier noted that the division may be able to better answer the question. She explained that if the program were going to extend for the next five years, the fiscal note would show the $21,800 in receipt supported services for the next five years. She elaborated that the fiscal note would give the division authority to collect the fees to fund the program. 9:38:10 AM Representative LeBon looked at the expenses summarized in the fiscal note. He observed that about $20,000 was indicated for travel for five board members and staff to attend four board meetings per year. He asked if one or two of the meetings could be held via videoconference or if there was a requirement to meet in person. Ms. Javier deferred the question to the department. SHARON WALSH, DEPUTY DIRECTOR, DIVISION OF CORPORATIONS, BUSINESS AND PROFESSIONAL LICENSING (CBPL), DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT (via teleconference), asked Representative LeBon to repeat the question. Representative LeBon restated his question. Ms. Walsh answered that the department encouraged Zoom meetings to reduce some of the fiscal costs. She noted the decision was up to the board. She relayed that the board's annual report to the department projected any travel for the year, which had to be approved by the division director. She detailed that some boards had a statutory requirement to meet in person (e.g., the medical board), but most did not. She did not believe the board under discussion had a requirement to meet in person. Co-Chair Merrick asked Ms. Belisle if the board had considered meeting electronically. Ms. Belisle answered that the board had not met in person for several years. She expounded that all of the meetings in the past 1.5 years had been via Zoom. She noted there had been no travel for a minimum of two years. Representative LeBon wondered why the licensing fees were so high when the board was not traveling. Representative Wool calculated that the 40 licensed midwives and 10 apprentices brought in $160,000 every two years or $80,000 annually. He remarked that $20,000 went to travel. He was surprised the fiscal note had not been reduced to reflect there had been no travel in recent years. He thought reducing the amount for travel would provide the board with more funding to spend on any investigations. He thought perhaps it would lower the license fee. 9:42:59 AM Ms. Javier responded that if the board were doing more Zoom meetings and did not incur the $20,300, the funding would sit as hollow authority. She did not know how it would impact the licensee fees. Representative Wool highlighted the vast cost difference between the two board extensions discussed by the committee during the meeting. He noted the fiscal note for the first board was $2,300 whereas the fiscal note for the midwifery board exceeded $20,000. He remarked that a layperson would question why one board was spending ten times the amount spent by another board. He thought it would be in the best interest of the board and CBPL to make the numbers more accurate. 9:44:57 AM AT EASE 9:46:39 AM RECONVENED Co-Chair Merrick asked the Division of Legislative Audit to address the committee. KRIS CURTIS, LEGISLATIVE AUDITOR, ALASKA DIVISION OF LEGISLATIVE AUDIT, highlighted that the legislation was a board extension bill. She elaborated that the licensing function would remain with the division if the board were not extended. She clarified that the fiscal note only reflected the cost of continuing the board itself and did not reflect the cost of licensing the entire occupation. She stated that board members were not compensated but often they were paid per diem, which was coded to travel even if there was no actual traveling. She did not know whether it was the case for the midwifery board. Representative Wool understood that per diem was not travel. He remarked that a board member doing a Zoom call from home did not incur the cost of lodging and meals. He thought per diem was directly relatable to hotels and meals while traveling. Ms. Curtis answered that there were five categories including personal services, travel, services, commodities, and capital projects that showed up as codes in budgetary documents. She explained that per diem was part of the travel code. She thought there could be amounts budgeted under travel that was used for something other than airfare or hotel. Co-Chair Merrick asked if a stipend could be used as another term for per diem. Ms. Curtis replied in the affirmative. Representative Wool surmised that the increment in the fiscal note was coded travel, but it could reflect a board member being paid to attend a board meeting, whether in their living room or a conference room in Anchorage. Ms. Curtis agreed. She believed the department was responsible for drafting the fiscal note and could provide more explanation on the reason for budgeting $20,000 per year for a board meeting four times. 9:49:38 AM Ms. Walsh answered that travel was estimated at $20,300 based on five board members and one staff attending four meetings per year. She added that the amount did not necessarily reflect what the board would do. She expounded that if board members wanted to travel, the amount provided an idea of the cost. Co-Chair Merrick asked if [midwifery] board members received a stipend for attending a board meeting electronically. Ms. Walsh answered that board members received $16 per day if they chose to submit the paperwork. Representative Wool considered that board members received $16 per day to attend a meeting from home [or elsewhere]. He asked if board members also received per diem or any other portion of the $20,000 if there was no travel. He thought it would be more in the board's interest to show a lower fiscal note. He suggested it may be beneficial to lower the amount if the board was not using the hollow receipt authority. 9:51:37 AM Representative Edgmon thought another way to look at the fiscal note was that the money not spent would be lapsed to the subsequent year. He clarified that the amount in the fiscal note was merely a budget item for a maximum of five members and four meetings. He asked whether the funds could lapse to the FY 23 budget if not expended. Ms. Javier responded that the CBPL allocation had language in the operating budget allowing the division to carry forward receipt supported services authority. Representative Edgmon referenced the license fees coming in from 40 midwives and 10 apprentices in the amount of $3,800 and $850, respectively. He asked if the approximately $50,000 per year from fees came into the department via language in the operating budget. Ms. Javier answered that there was conditional language in the numbers section of the budget allowing for the funds to be carried forward. Representative Thompson referenced the audit and observed that the board was in a deficit situation. He assumed if the board did not spend the $20,000 on travel, its deficit would be reduced. Ms. Javier asked Representative Thompson to repeat his question. Representative Thompson repeated his question. Ms. Javier confirmed that it was her understanding. 9:55:01 AM Representative Johnson considered the audit recommendation for the board to update the peer review process. She stated her understanding the board was transitioning to having peer reviews done by the board. She thought the previous peer review process was perhaps not carried out to the level auditors preferred. She asked if the auditors had recommended a board review. She asked if there had been a recommendation on how to update the review process. Ms. Curtis answered that the audit recommendation was very general. The audit had found the board did not have internal controls over monitoring the peer review process it had delegated to the Midwife Association of Alaska's action accountability committee. The board had delegated the process and had not been overseeing it or monitoring it, which increased the risk of deficiency and to public safety. The audit recommendation was for the board to improve its monitoring of the process. She understood the board had taken over the review process. She had no comment on the change until the Division of Legislative Audit was able to review the updated process. 9:56:59 AM Co-Chair Foster MOVED to REPORT HB 117 out of committee with individual recommendations and the accompanying fiscal note. There being NO OBJECTION, it was so ordered. HB 117 was REPORTED out of committee with a "do pass" recommendation and with one previously published fiscal impact note: FN1 (CED). 9:57:26 AM AT EASE 10:00:05 AM RECONVENED Co-Chair Merrick reviewed the schedule for the following meeting.
|HFIN HB117 Follow-Up Information from CBPL (4.12.21).pdf||
HFIN 4/12/2021 9:00:00 AM
|HB 117 Follow-up Midwoves Assoc 041021.pdf||
HFIN 4/12/2021 9:00:00 AM