Legislature(2013 - 2014)CAPITOL 106
02/13/2014 03:00 PM House HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HB269 | |
| HB281 | |
| Presentation: Fairbanks Resource Agency | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 269 | TELECONFERENCED | |
| *+ | HB 281 | TELECONFERENCED | |
| + | TELECONFERENCED |
HB 281-PRESCRIPTION WITHOUT PHYSICAL EXAMINATION
3:39:13 PM
CHAIR HIGGINS announced that the next order of business would be
HOUSE BILL NO. 281, "An Act relating to prescription of drugs by
a physician without a physical examination."
3:39:32 PM
REPRESENTATIVE LYNN GATTIS, Alaska State Legislature, declaring
"I think it's a relatively simple bill," read from a prepared
statement. She explained that proposed HB 281 would clarify in
statute that physicians would not be sanctioned for dispensing
or administering prescription medications without a physical
examination of the patient. She stated that this practice was
"called telemedicine. Telemedicine based medical care would be
delivered by primary care physicians within the State of Alaska.
Anyone needing medical care would be a candidate for this
system." She noted the benefits for a working mother with a
sick child, a rural homesteader, or an employee not able to take
the time from work. She stated that the proposed bill would
allow patients to obtain, through over the phone and on-line
consultations when physicians were able to diagnose an ailment,
any necessary prescription. She pointed out that the proposed
bill would not allow physicians to prescribe controlled
substances. She listed the benefits to include convenience to
patients, lower cost, immediate access, and higher productivity
for a healthier workforce. She noted that this would lead to
quicker access for primary care for rural residents. She
declared that telemedicine did not replace a relationship with a
primary care provider, although a telemedicine provider could be
designated as the primary care provider. This telemedicine
consultation would be considered a doctor-patient relationship.
She acknowledged the concerns for updates to patient background
information, stating that these would also be required prior to
telemedicine conferences.
3:43:34 PM
REPRESENTATIVE GATTIS, in response to Representative Tarr, said
that there would be testimony by individuals from other
participating states.
CHAIR HIGGINS pointed out that a requirement for health history
and informed consent was not included in the proposed bill. He
asked if there was an assumption for this to be conducted by the
physician.
REPRESENTATIVE GATTIS expressed her assumption that the doctor
would take the relevant information necessary for "good service
to me and back up their license."
CHAIR HIGGINS expressed his agreement that the medical
profession would ensure the proper documentation, although he
surmised that it would be prudent to include this in the
proposed bill.
3:46:09 PM
REID HARRIS, Staff, Representative Lynn Gattis, Alaska State
Legislature, shared that, as the medical community in Alaska was
tight knit, any questionable performance would be quickly
reviewed. Referencing paragraph (3), page 1, lines 12-14, of
the proposed bill, "the person consents to sending a copy of all
records of the encounter to the person's primary care provider,"
he offered his belief that a telemedicine provider would become
the primary care physician if the patient did not have a
physician, and the telemedicine provider would "take all your
information." He pointed out that this information would be
sent to an already existing primary care physician.
3:47:16 PM
REPRESENTATIVE SEATON pointed out that the proposed bill
required the physician to be in the State of Alaska. He asked
whether treatment by outside physicians would allow
prescriptions to be altered.
REPRESENTATIVE GATTIS replied that the proposed bill did not
address specialists or specialty care. She explained that
telemedicine offered consultation for relatively common issues,
such as respiratory illness, skin problems, and abdominal,
joint, and back pain.
REPRESENTATIVE SEATON, asking for clarification that Version 28-
LS1234\A of the bill was in front of the committee, questioned
where the aforementioned limitation to prescriptions was
mentioned in the proposed bill.
REPRESENTATIVE GATTIS explained that, although not mentioned
specifically in the proposed bill, telemedicine only allowed the
aforementioned care.
3:49:43 PM
CHAIR HIGGINS, referencing paragraph (3), page 1, lines 12-14,
of the proposed bill, asked who was required to send the forms,
and how would they know who to send the forms.
MR. HARRIS replied that, although the telemedicine provider
would be required to send the forms to the designated primary
care physician, the bill did not address a timeline for
transmission.
CHAIR HIGGINS noted that Teladoc was available to testify, and
he lauded its program. He asked about the procedures and
requirements for transfer of information with a program other
than Teladoc, as the proposed bill would allow consultation with
any telemedicine group.
REPRESENTATIVE GATTIS offered her belief that, as this was the
same situation with Instant Care, "we have that situation
already in place with our doctors."
CHAIR HIGGINS pointed out that the forms were filled out when a
patient attended Instant Care and Urgent Care.
REPRESENTATIVE GATTIS expressed her agreement, noting that this
was the same as filling out forms on-line. She stated "that's
really all this bill does, is it allows us to do it on-line, or
have it done over the phone. It's the same process that we go
to when we walk into a doctor's office, and tell them our health
history."
3:52:36 PM
REPRESENTATIVE TARR referenced the Alaska Federal Health Care
Access Network (AFHCAN), the telemedicine program for the Alaska
Native Tribal Health Consortium (ANTHC). She asked to better
understand what was already happening with telemedicine in
Alaska, and how the proposed bill would complement this program.
MR. HARRIS explained that AFHCAN was "a little bit different
than telemedicine." He explained that AFHCAN supplied a
provider and a medical cart to assist the patient while the
physician was on the other end of the phone. He said that the
proposed bill only specified the patient with the physician at
the other end. He relayed some complaints from rural areas that
the intermediate connection with the provider and the medical
cart, between the physician and the patient, was possibly not as
helpful as a direct connection with the physician.
REPRESENTATIVE GATTIS stated that "this relatively simple bill"
clarified in statute that physicians may not be sanctioned for
dispensing or administering prescription medications without a
physical examination of the patient, and "quite frankly, that
already happens right now." She offered her belief that many
people already called their physician with their problems and
symptoms, and requested prescriptions. She stated that the
proposed bill "clarifies and keeps them out of hot water."
3:54:46 PM
REPRESENTATIVE SEATON asked if the proposed bill restricted
doctors from out of state, specifically Veterans' Administration
or Indian Health Service physicians.
MR. HARRIS replied that, as military and ANTHC doctors had a
federal exemption which allowed them to operate, the proposed
bill would clarify this for an in-state doctor.
3:56:14 PM
CHAIR HIGGINS opened public testimony.
HENRY DEPHILLIPS, Corporate Chief Medical Officer, Teladoc,
described Teladoc as the oldest and largest telehealth company
in the United States. Describing the telemedicine industry, he
stated that he would clarify if there was something specific to
Teladoc which did not apply to the rest of the industry. He
said that the concept of telemedicine was comparable to a doctor
reference, if your primary care physician was not available. He
reported that Teladoc was the oldest in the telemedicine
industry, operating for 12 years, and that about 15 million
Americans were covered in a telemedicine program through their
employer or their health insurance company. He shared that more
than 500,000 consultations had taken place throughout the United
States, and to date, there had not been any liability issues.
He noted the telemedicine programs features which were different
than traditional cross coverage, and included: no DEA
controlled substances were allowed; a limited number of
diagnosis were treated, primarily common, uncomplicated medical
problems that were usually recurrent for the patient; the
treatments were straightforward; and, the majority of
prescriptions were generic, falling into three classes,
antibiotics, anti-allergy medications, and inhalers. He offered
his observations for the telemedicine industry, noting that
there had been internet scam offerings in the late 1990s, which
had allowed for prescriptions to DEA controlled substances. He
reported that many state medical boards had then implemented a
"prior in-person visit requirement," which entailed a physical
examination. He opined that this requirement had stopped the
scams. He explained that there was then a realization for the
similarity of cross coverage consultations with telephonic
encounters, both without the prior in-person visit. Therefore,
as regulations for exceptions became necessary, emergency
situations and cross coverage were exempted. At this point,
attorneys for the industry ascertained that telemedicine was a
cross coverage service, and was subject to that exemption. He
reported that the Alaska State Medical Board had disagreed with
this interpretation which leads to the current proposed
legislative solution. He offered his belief that the Alaska
State Medical Board had concerns that the care of Alaskans would
move to doctors outside of Alaska. He shared that the Teladoc
business model called for Alaskan care to be performed by
physicians licensed and living in Alaska. He spoke about the
perception that, if there was not a prior in-person physical
exam, the quality of care would be compromised. He declared
that the data argued against this perception, as the common,
uncomplicated medical problems had not had any liability issues.
He reported that telemedicine providers usually covered the
liability insurance for the consulting doctors, and the premiums
were at the lowest levels, Class I. He reminded the committee
that telephonic diagnosis and treatment had occurred for many
years in the cross coverage situation. He pointed to the three
take home points in the Rand Corporation telemedicine study
which was recently published in Health Affairs. The first point
reported was that people without the option for telemedicine
made emergency room visits for a non-emergency problem about 25
percent of the time. The second conclusion of the study was
that telemedicine was especially valuable for people without an
established relationship with a primary care physician. The
third conclusion was that the cost for medical care was reduced
with telemedicine. He noted that improved access and cost were
two important issues in Alaska. He explained that the proposed
bill would curtail intervention by the Alaska State Medical
Board with telemedicine. In response to an earlier question, he
noted that the telemedicine industry had worked in conjunction
with the Alaska State Medical Association to arrive at the
language in the proposed bill. He responded to a question
regarding medical history, and expressed his agreement that
although the telemedicine industry needed oversight and
structure, this should be a similar standard to that applied to
the in-person setting. He offered his belief that there was not
a legal or regulatory requirement for a copy of the record to be
sent to the primary care physician, but he emphasized that it
was good medical practice. He questioned whether it was
necessary to legislate the requirement in the telemedicine
environment.
4:05:29 PM
CHAIR HIGGINS mentioned that there was a standard of care to
which physicians were held responsible, which included an intake
form, a consent form, and a health history. He pointed out
that, although this was not written, obeying the standard of
care was necessary.
DR. DEPHILLIPS expressed his agreement, and stated that the
standard of care should be applied in all settings.
CHAIR HIGGINS suggested that the use of telemedicine needed to
be further reviewed, as the savings to Medicaid could be
substantial. He pointed out that the Alaskan Native
Corporations had offered telemedicine for many years, and that
it was working. He stated that the public sector "should be
able to do the same thing." He expressed his appreciation for
the proposed bill to further the conversation.
4:06:51 PM
REPRESENTATIVE TARR, reflecting on the use of emergency rooms
for non-emergency visits by patients who did not have a primary
care provider, asked how people could learn about the option for
the use of telemedicine.
DR. DEPHILLIPS opined that there would soon be "direct to
consumer telemedicine, there are some start-up companies that
are starting to go there." However, the majority of
telemedicine programs were sponsored by health care plans and
employers. He reported that Teladoc had about 1,750,000
Medicaid recipients, as well.
4:08:36 PM
REPRESENTATIVE TARR asked if the proposed bill would allow
Medicaid recipients to enroll.
DR. DEPHILLIPS offered his understanding that the proposed bill
would allow physicians in Alaska to enroll in a telemedicine
program, and be compensated by Alaskans not already enrolled in
a federal program. He clarified that telemedicine was already
allowed in the federal programs, and could not be regulated by
the Alaska State Medical Board. The proposed bill would allow
patients not in a federal program to have these same
opportunities. He shared that there was discussion for adding
telemedicine to the Alaska Medicaid program, allowing for
increased access and cost savings. He pointed out that it was
necessary for passage of the proposed bill, as it would offer
regulatory cover for Alaska physician licenses.
4:10:11 PM
REPRESENTATIVE SEATON asked for an explanation for the operation
of the telemedicine program.
DR. DEPHILLIPS explained that, for the sponsored primary care
model, a person would pick up the telephone and talk with a
customer service intake representative, who would collect the
appropriate information and medical history. The same process
could be conducted on line. He shared that, during the request
process, it was important to know the age of the patient and
where you were calling from, so the appropriate licensed
physician could respond. He pointed out that it could be
required for the patient to fill out the medical history and for
the doctor to review this before contact with the patient. He
explained that the physician would receive and review the
consultation request, and would contact the patient, by
telephone audio video, which had to be a Health Insurance
Portability and Accountability Act (HIPAA) compliant, secure
platform. The physician would communicate in real time with the
patient for as long as necessary to conclude with either a
treatment plan or a reference for an in-person consultation,
which resulted about 4 percent of the time. He pointed out that
there was not any financial incentive for a referral. He stated
that Teladoc hired highly trained, highly qualified physicians,
and then empowered them to make the best decisions for each
patient.
4:12:32 PM
REPRESENTATIVE SEATON asked if a patient would get the same
physician on a follow up call.
DR. DEPHILLIPS replied that, as the Teladoc program did not want
to interfere with any existing relationships with primary care
physicians, Teladoc did not allow any choice for physician,
similar to an emergency room or Urgent Care visit. He noted
that, however, some telemedicine programs did allow selection of
a physician.
REPRESENTATIVE SEATON directed attention to page 1, line 10 of
the proposed bill, and read: "the physician is located in this
state and available to provide follow-up care." He asked how
this was satisfied if the initial physician was not available
for the follow up care.
DR. DEPHILLIPS replied that there was a 72 hour window after the
initial telemedicine consultation for direct contact between the
patient and the same physician. He offered his belief that,
with a physician in Alaska, the patient could directly contact
the physician. The telemedicine industry was designed to get
patients over the acute problem, and then back in touch with
their primary care physician. He offered his belief that the
proposed bill allowed this continued "safety valve" contact in
Alaska, as these licensed telemedicine physicians resided in
Alaska.
REPRESENTATIVE SEATON expressed concern for the aforementioned
wording, and suggested a change to read: "follow-up care is
provided through the telemedicine group." He compared the
telemedicine program to his neighborhood clinic, where he was
served by whichever doctor was available. He opined that, even
though the telemedicine model would not allow for the same
physician, that physician would often become the primary care
physician, hence the wording on page 1, line 10 of the proposed
bill needed to change.
4:18:23 PM
DR. DEPHILLIPS suggested viewing the telemedicine service
industry as a physician cross coverage service. He recommended
not to put any additional burden on the telemedicine industry
that was not put on an in-person doctor. He reminded the
committee that each telemedicine doctor had access to the
medical records from the patient's previous visit.
REPRESENTATIVE SEATON noted that the state did not have a
statute requiring the prescribing doctor to be available for
follow-up, whereas the proposed bill did state this.
CHAIR HIGGINS, directing attention to page 1, line 10, of the
proposed bill, suggested to delete "and available to provide
follow up care;" which would maintain the current state standard
for all the physicians.
REPRESENTATIVE SEATON offered his belief that this specified
something that could not always be accomplished.
4:21:04 PM
REPRESENTATIVE PRUITT asked to research the intent of the bill
drafter, and the intended definition of "available."
DR. DEPHILLIPS shared that the language for paragraphs (1), (2),
and (3) was drafted collaboratively with the Alaska State
Medical Association, and he suggested discussion with the
drafter.
4:22:31 PM
The committee took an at-ease from 4:22 p.m. to 4:25 p.m.
4:25:27 PM
CHAIR HIGGINS announced that the committee intended to hold the
proposed bill.
DR. DEPHILLIPS explained that the intent of the follow up care
provision in the proposed bill, page 1, line 11, was to allow
the opportunity to obtain medical attention if there was a
problem. He shared that this could either be re-contact with
the telemedicine provider or the primary care physician.
CHAIR HIGGINS stated the desire of the committee to hear from
the Alaska State Medical Board, the bill drafter, and the Alaska
State Medical Association.
REPRESENTATIVE SEATON asked whether anyone with prescriptive
ability, including a physician's assistant, would also be
included.
4:28:22 PM
CHAIR HIGGINS left public testimony open, and stated that
proposed HB 281 would be held over.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 269 - Bill version A.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/25/2014 1:30:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB 269 - Sponsor Statement.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB281A.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Sponsor Statement.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Support DOLWD Census Data.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Support SB80 Teladoc.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 SB 80 |
| HB281 Telemed Defined.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281-DCCED-CBPL-02-06-2014.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Support Teladoc.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB 269 - Letter of Support, Alaska Native Medical Ctr..pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB 269 ASMA Letter .pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB269 Fiscal Note DCCED-CBPL-02-06-2014.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB269 Fiscal Note Law-Civ-02-07-14.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB281Fiscal Note-DCCED-CBPL-02-06-2014.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB 269 - Letter of support - United Way, 2.11.14.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB 269 - Legal Opinion, DOL 8.19.13.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB 269 - Legal Opinion, Legislative Legal Services 1.13.14.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB 269 - Support AK Mission of Mercy information.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB269 - Dental Society bullet points.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| ASL Presentation 2132014.pdf |
HHSS 2/13/2014 3:00:00 PM |
|
| HB281 Support Rand Press Release.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Support Rand Study.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| CS HB 269 - Bill version U.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| CS HB 269 - Differences version A to U.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB 269 - Sectional Summary.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB 269 - Leg Legal Opinion 2 13 14.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB 281 Letter of Support.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 ASMB Opposition.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |