Legislature(2021 - 2022)ADAMS 519

04/12/2021 09:00 AM FINANCE

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Moved HB 99 Out of Committee
-- Public Testimony --
Moved HB 117 Out of Committee
-- Public Testimony --
<Bill Hearing Canceled>
+ Bills Previously Heard/Scheduled 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."                                                                                                           
9:18:47 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                                                                    
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                                                                    
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                                                                    
     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                                                                    
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                                                                    
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                                                                    
9:44:57 AM                                                                                                                    
AT EASE                                                                                                                         
9:46:39 AM                                                                                                                    
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                                                                    
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                                                                    
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                                                                    
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                                                                                                                   
Co-Chair  Merrick reviewed  the schedule  for the  following                                                                    

Document Name Date/Time Subjects
HFIN HB117 Follow-Up Information from CBPL (4.12.21).pdf HFIN 4/12/2021 9:00:00 AM
HB 117
HB 117 Follow-up Midwoves Assoc 041021.pdf HFIN 4/12/2021 9:00:00 AM
HB 117