Legislature(1995 - 1996)
03/05/1996 02:04 PM House HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HB 480 - PHYSICIAN ASSISTANTS Number 1422 REPRESENTATIVE GENE THERRIAULT, Sponsor, read the following sponsor statement: "House Bill 480 is intended to clarify the process that is currently in place for granting physician assistants the authority to practice in the state, and to prohibit unfair insurance discrimination against physician assistants. "The bill would change current language in AS 08.64.107, dealing with the regulations for physician assistants, from `The board shall adopt regulations regarding the registration of physician assistants...' to `The board shall adopt regulations regarding the licensure of physician assistants...' This would more accurately reflect the actual requirements a physician assistant must meet before he or she can practice in the state under AS 08.64.170. Under AS 08.64.170, a physician assistant must be licensed to practice medicine under the supervision of a licensed physician. Because state regulations require this credentialed process that is in essence licensure, references in state statute should be changed to more accurately reflect the high standards that must be met to practice as a physician assistant in Alaska. "In addition, this bill would prohibit unfair discrimination against physician assistants under group health insurance policies. It states that if an insurance policy covers the type of services that a physician assistant is licensed to perform, then the policy must cover those services when they are performed by a physician assistant, and may not discriminate against physician assistants by excluding their services, while covering other providers who perform the same services." REPRESENTATIVE THERRIAULT said he had been in contact with physician assistants (PAs) in his area for the last year or two over a number of issues. Some of the issues have been dealt with through regulations, however, this particular issue of licensure cannot be dealt with through regulation. There is an inconsistency in the statutes that can only be cleared up by legislation. With regard to the nondiscrimination, he was requesting that the physician assistants be added to the existing list of providers. He said that representatives from the major health insurance providers had indicated that for the most part that coverage is provided and those payments are made. Number 1574 REPRESENTATIVE VEZEY said he didn't understand the motivation for this legislation. REPRESENTATIVE THERRIAULT explained that the process physician assistants go through is more akin to a licensure, rather than a registration. He referred to a letter from the Medical Board in which they recommend the change in statute to more accurately reflect the process that physician assistants go through to practice in the state of Alaska. That change in wording means something to the health care providers and the insurance providers. REPRESENTATIVE VEZEY said he understood the physician assistants wanted the wording change from registration to licensure, but he failed to understand the importance of that. He asked if Representative Therriault was saying that insurance companies won't pay a registered health care provider, only a licensed health care provider. REPRESENTATIVE THERRIAULT responded there had been instances where a health care provider was denied payment because they were in a registered classification rather than a licensured classification, by the strict wording of the statute. However, the process by which they go through to perform the services in the state is more akin to licensure. REPRESENTATIVE VEZEY asked if Representative Therriault could identify who was denying payment. REPRESENTATIVE THERRIAULT said there were people signed up to testify who could speak to specific instances. Number 1666 CO-CHAIR BUNDE asked if this portion of the bill would be more or less a semantic change in that nurses, doctors and dentists are licensed, but physician assistants are registered. REPRESENTATIVE THERRIAULT said that was his understanding. Number 1690 CO-CHAIR TOOHEY said she thought it was semantics. She is a registered nurse, but holds a nursing license. Number 1724 JOHN RILEY, Chairman, Legislative Affairs Committee, Alaska Academy of Physician Assistants, testified from Anchorage that the Academy was supporting HB 480 to reserve access to the primary health care services that are provided by physician assistants throughout the state of Alaska. He said in the past, PAs were in general reimbursed by insurance carriers for services provided. However, recently some federal insurance carriers have denied reimbursement for PA-provided services because PAs weren't considered to be licensed in the state. Section 1 of HB 480 is an attempt to address that problem. If private insurance companies followed suit, PAs would be unable to provide many services to the Alaskan public in (indisc.) instances. Section 4 is an attempt to ensure that private carriers will continue to reimburse for PA provided services. He emphasized that is the only intent of this bill; it is only an attempt to ensure that the positive impact of PAs have had in Alaskan's health care in the last 20 years will continue. Number 1795 CO-CHAIR BUNDE said there were two major sections; Section 1 would bring the description of the certification process in line with other medical professionals in that PAs would then be licensed. MR. RILEY said that even though it is just a semantic change, that wording has been used by some federal carriers to deny reimbursement for PA services. CO-CHAIR BUNDE verified that the purpose of Section 4 was because the Academy wanted the statute to indicate physician assistant fees would be covered by insurance. MR. RILEY concurred and said the reason that both these sections were included is because simply changing Section 4 would not have the effect on the federal carriers due to federal waivers from state law. CO-CHAIR TOOHEY offered to give the committee an update on federal Blue Cross/Blue Shield, who insures the federal employees in the Park Service. She had talked with the Washington, D.C. Branch of the Blue Cross/Blue Shield Office just that morning and they hoped to have a change in their policy by the end of the week. She said they realized it was just a very small section of the employees in Alaska that were not being covered by PAs and they were willing to look into that issue. MR. RILEY interjected there was another federal carrier; the government employees health association had the same issue. Additionally, there are some concerns because other companies who are not federal rely on the use of the term "licensed provider," so the problem may not be solely confined to the federal carriers. Number 1932 REPRESENTATIVE VEZEY commented that federal agencies are exempt from any statute written by the Alaska Legislature and do not have to accept medical care in Alaska. Number 1960 JEANNE CLARK, President, Alaska Academy of Physician Assistants, said that HB 480 would change the language in current statute from registration to licensure. This change would accurately reflect the stringent credentialing process that currently a physician assistant goes through to become authorized to provide medical services in the state. The State Medical Board has supported this change and this request for legislation. She noted this will in no way change the collaborative plan that is required with a physician who supervises the physician assistant to provide these services. In addition, HB 480 would prevent insurance companies from not reimbursing services provided by physician assistants as a class of providers. Currently, many companies reimburse for services provided by a physician assistant that do not specify the term "physician assistant" in their policy. Experience in other states has shown that because the language is not specified, companies have stopped reimbursement or have refused to recognize PAs as providers of medical services. She stated that recently, several companies had refused to reimburse for services provided by PAs in Alaska. Section 4 of HB 480 would prevent discrimination against reimbursement of physician assistants as a class who provides medical services in this state. CO-CHAIR BUNDE referred to the previous question regarding the insurance companies who specifically refused to reimburse for physician assistant services and asked if she was aware of who those companies were. MS. CLARK responded there have been some federal programs that have not reimbursed, but she knew they were exempt from the state. There have been other carriers, specifically in her practice that have refused to reimburse for services that she provided to a patient. She had copies of other examples with her. Physician assistants who provide medical services under physician supervision continue to work to improve access and provide cost effective medical care. She believes the changes in HB 480 would continue to achieve these objectives, especially with the changes that are occurring with different carriers coming in to the state and with the development of managed care plans. Number 2095 CO-CHAIR TOOHEY expressed her concern with Section 4 of HB 480. She felt it was particularly important that the medical society be given a chance to respond whenever any medical problem is discussed involving nurses, doctors, chiropractors, etc. She added the society was given the opportunity to provide feedback on Sections 1-3, but they had no knowledge of Section 4. Co-Chair Toohey asked the medical society for their thoughts regarding Section 4 and apparently they are split down the middle on whether it should be allowed or shouldn't be allowed. The reason for PAs is to give a cheaper cost to the community that is paying the bill, either the patient or the insurance company and that's why the insurance companies are involved in this. It is her belief that if a person sees a physician assistant at the doctor's office, the charge should be less than if the patient had been seen by the doctor. She asked what is to prevent a physician from having 15 physician assistants throughout a city, not involved with the patients at all and charging for a physician's visit for each of the PAs? She questioned if the insurance company is obligated to pay a doctor's visit fee when the patient was seen by a physician assistant. She thought it was not and said she would not pay a physician's rate when she had been seen by a physician assistant. Co-Chair Toohey thought the bill needed to be amended until the medical community had an opportunity to discuss the issue. She had no problem with Sections 1-3 of the bill. There is no difference in the education of a licensed PA and a registered PA, but she thought Section 4 should be brought before the medical community, who are responsible for physician assistants. MS. CLARK remarked that the language regarding the licensure is cited in the federal register and in the Health Care Finance Administration's regulations. She said that is one of the biggest reasons for the change in wording because that's where the insurance industry is getting their direction to make policy. With regard to Section 4, she said the medical society had not indicated to the Alaska Academy of Physician Assistants that they were not in agreement with that section. She said there hadn't been an objection raised in the past, and didn't see any problem with getting their feedback. CO-CHAIR TOOHEY reiterated that she had checked with the medical community and they are split right down the middle. They have some major concerns with Section 4 because they are ones responsible for physician assistants. She read from a letter from Leslie Haywood as follows: "The medical board had not taken a position on the entire bill, just the registered licensed portion." Ms. Haywood also indicated there was no limit to the number of PAs a physician can sponsor. Co-Chair Toohey added the medical society also takes that position. Number 2316 MS. CLARK remarked that John Riley had spoken with a member of the Alaska State Medical Association who said the association could not make a statement positive or negative on this bill until it was discussed with their delegates the following weekend. Mr. Riley indicated the physician member he spoke with understood what the intentions were of HB 480. CO-CHAIR BUNDE commented that further information was anticipated from the medical community. TAPE 96-21, SIDE B Number 001 REPRESENTATIVE VEZEY reiterated that he failed to see that the difference between registered and licensed was anything more than semantics. He remarked the problem was so small, was it really worth the risk of changing the statute. Often times, additional problems are created when the statute is changed. He asked if Ms. Clark was aware of any private providers of medical coverage who are not recognizing physician assistants as health care providers, especially in the context of the absence of a physician in the community. MS. CLARK replied yes, she personally had an experience and she had letters from other physician assistants who had been denied in the past. REPRESENTATIVE VEZEY asked which companies were involved? MS. CLARK responded private, small insurance companies. CO-CHAIR BUNDE noted there were two from Aetna. MS. CLARK said it may seem like a small problem now, but other states are having major problems. The Academy wants to do something about it before it becomes a major problem involving access to health care for certain individuals in the state. REPRESENTATIVE VEZEY again asked Ms. Clark for the name of the entity that is causing the problem. CO-CHAIR BUNDE interjected there were two from Aetna, one from Met Life and one from the Government Employees Hospital Association (GHEA). REPRESENTATIVE VEZEY clarified that GHEA was exempt from state statutes and regulations. MR. CLARK said this was really not controlled by Blue Cross/Blue Shield. Based on their research on the national level, it is controlled by the government employees' benefits committee which is headed by Senator Stevens. It is the government employees' regulations that state it has to be a licensed practitioner. Number 156 CATHERINE REARDON, Director, Division of Occupational Licensing, Department of Commerce & Economic Development, testified that the department supports the change from registration to licensure and had submitted a zero fiscal note. She thought the Division of Insurance could more appropriately address the questions regarding Section 4. She said it is true that we can't regulate the federal government; therefore, this is basically adapting to their terminology. Within the occupational licensing statutes, licensure is the most common term, but there are some programs where certification or registration are used. The medical board has voted to support the change from registration to licensure and she hoped the committee would see fit to do so, also. CO-CHAIR TOOHEY asked if Ms. Reardon was going to address Section 4? MS. REARDON referenced the previous concerns that had been expressed regarding the number of PAs a doctor could have working under his/her supervision and the billed rates and said this is the case currently. Section 4 does not permit that to happen in a way that can't occur at the present time. In other words if a doctor wants several PAs working under his/her supervision or charges a physician's rate, that currently is the doctor's right. The Division of Occupational Licensing doesn't regulate fees. She pointed out that SB 100, which was introduced last year, contained the same wording as in Section 4, so the medical community would have been aware that the proposal existed previous to HB 480 being introduced. Number 299 REED STOOPS, Lobbyist, Aetna Life & Casualty, said the letter distributed to committee members which indicated that Aetna didn't pay a physician assistant claim actually says the only reason the claim wasn't paid was because the bill was submitted directly by the physician assistant and not through the supervising physician. He stated Aetna does pay those bills when submitted through the supervising physicians. He asked if this bill was enacted would it obligate Aetna or any other insurance company to change the procedure to make payment directly to a physician assistant or is the licensing statute, which places the physician assistant under the supervision of a physician, the guiding statute? While it may not be a major issue, he thought it was one that needed to be clarified. Number 347 CO-CHAIR TOOHEY cited a hypothetical situation where she as a stockholder of Aetna is very concerned that Aetna is paying the proper fee for the proper services. She is also a recipient of a state contract. She asked if her insurance company would pay the same rate for services provided by a PA as services provided by an MD? MR. STOOPS said it was his understanding the physician assistant is billed at a lower rate; therefore, that is the rate that is being paid. He did not know if the supervising physician gets some payment for the supervisory capacity. He added that he would discuss the issue with representatives from Aetna who were due in town the following day. CO-CHAIR TOOHEY noted that Ms. Clark indicated she is on a salary and the insurance company is billed by the physician. The issue raised is there is nothing in law that states a physician assistant should be paid less than a doctor. Physician assistants don't require the education of a doctor, but they do perform a vital function in the state. Co-Chair Toohey thought it would be detrimental if they charge physician fees for physician assistant services. Number 455 MS. CLARK said with regard to payment for services, "If services are provided - I take care of you, I charge a fee for the service I provide to you. I am given the authority to take care of you through the statutes currently. That bill is sent in to the insurance company with the name of the provider who provided that service, the physician assistant. Then it goes to your insurance company. Now, if your insurance company has negotiated with your employer and the employee to give a lower rate, I mean that's between those three entities." She commented that is not what they are looking for in this bill; they want physician assistants to be recognized as a provider of medical services. CO-CHAIR BUNDE asked if she, as a physician assistant who provides treatment, bills the insurance company directly? MS. CLARK said her services are billed through the physician or through the clinic she works for. CO-CHAIR BUNDE clarified that the clinic bills under the doctor's name and then whatever the doctor bills the physician assistant's time out at, the doctor has the right to bill the physician assistant's rate according to the group policy at either a PA rate or an MD rate. MS. CLARK said that was right. For example, in her current practice in Fairbanks, the physician is a participating provider in Blue Cross/Blue Shield of Washington/Alaska and accepts whatever Blue Cross/Blue Shield pays for services. If she provides the service, the rate billed is discount. That has been negotiated with the people who bought the service of the insurance company. CO-CHAIR BUNDE asked if a group policy doesn't address physician assistants, is it possible that a physician could bill a PA's work at the MD rate. MS. CLARK said it's a fee for service; it's the service that's being provided and that's what is being billed. CO-CHAIR BUNDE gave an example of Group Policy A which says that an insurance company will pay for physician assistants at a certain rate and for physicians at a certain rate. The physician assistant provides service and the clinic employing the physician assistant bills out the PA's time at the agreed upon rate. On the other hand, Group Policy B does not address physician assistants, it only addresses physicians. The physician employs the physician assistant and the service is provided by the physician assistant, but the physician bills at the physician rate, not at a lesser rate. MS. CLARK emphasized that would be based on what the policy pays. CO-CHAIR BUNDE said but if there is only one rate to bill, that is the rate billed. MS. CLARK said it depends on what the terms are of the policy. CO-CHAIR BUNDE interjected that when an employer is negotiating a group policy, it is incumbent upon that employer to negotiate a policy that addresses a rate differential between services provides by an MD and services provided by a PA. MS. CLARK commented that is done a lot in the industry. CO-CHAIR BUNDE noted that if it isn't done, then the physician has a right to bill at the physician rate according to the policy. REPRESENTATIVE ROBINSON referred to the term "service provided" and said if she went to a physician assistant or a physician and had a throat culture, that would be the service that was provided and that is what would be charged for. MS. CLARK said national statistics indicate that charges provided by a physician assistant are less than a physician's rate. CO-CHAIR TOOHEY questioned what rate she would be charged if she went in for a throat culture and paid cash? MS. CLARK said it's the price for the service provided. CO-CHAIR TOOHEY said that is what is being addressed under Section 4 and that is what she objects to because there is no delineation. CO-CHAIR BUNDE said HB 480 would be held in committee for another hearing.
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