Legislature(2003 - 2004)

04/29/2004 09:10 AM RLS

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
HB 543-MEDICAID AND PRESCRIPTION DRUGS                                                                                        
CHAIR ROKEBERG announced  that the final order  of business would                                                               
be HOUSE  BILL NO.  543, "An Act  relating to  medical assistance                                                               
coverage for  prescription drugs; and providing  for an effective                                                               
Number 306                                                                                                                      
REPRESENTATIVE  KOTT  moved  to   adopt  CSHB  543,  Version  23-                                                               
LS1835\Q, Mischel, 4/27/04, as the working document.                                                                            
REPRESENTATIVE BERKOWITZ objected for discussion purposes.                                                                      
Number 313                                                                                                                      
REPRESENTATIVE PEGGY  WILSON, Alaska State Legislature,  chair of                                                               
the  House   Health,  Education  and  Social   Services  Standing                                                               
Committee,  sponsor  of  HB  543,   explained  that  HB  543  was                                                               
introduced because  the Department of Health  and Social Services                                                               
is  currently in  the process  of implementing  a preferred  drug                                                               
list (PDL).   This limitation  on medical assistance  coverage is                                                               
being done as a cost  containment measure.  Representative Wilson                                                               
related that she has received  numerous complaints with regard to                                                               
how the  procedure is going  and the [Pharmacy  and Therapeutics]                                                               
committee was  accepting testimony.  Therefore,  this legislation                                                               
establishes procedures  with regard  to how the  committee should                                                               
conduct  its  business.    As the  session  has  progressed,  the                                                               
department has reviewed and addressed many of the concerns.                                                                     
CHAIR ROKEBERG  asked if it  would be a fair  characterization to                                                               
say that  Version Q  is the  result of the  effort and  work done                                                               
with  the department.   He  also asked  if Representative  Wilson                                                               
believes that  the provisions [eliminated] from  Version Q aren't                                                               
particularly necessary.                                                                                                         
REPRESENTATIVE  WILSON commented  that  a lot  of  hard work  and                                                               
compromise has resulted in this legislation.                                                                                    
Number 340                                                                                                                      
CHAIR  ROKEBERG  asked if  the  committee  provided for  in  CSHB                                                               
543(HES) is no longer necessary.                                                                                                
REPRESENTATIVE  WILSON   explained  that  changes  made   to  the                                                               
original   legislation  were   conforming   changes  to   provide                                                               
structure  and  guidelines  to  the  committee.    There  was  no                                                               
intention to slow the committee.                                                                                                
CHAIR   ROKEBERG   surmised   that   the   committee   to   which                                                               
Representative   Wilson  is   referring  is   the  Pharmacy   and                                                               
Therapeutic  Committee  of the  Alaska  Division  of Health  Care                                                               
REPRESENTATIVE  WILSON  added that  as  part  of the  process  of                                                               
reviewing  each classification  of drug,  there was  concern that                                                               
most states wait until the end  to do the drugs for mental health                                                               
patients  because those  patients are  a more  fragile clientele.                                                               
Therefore, the  idea was to wait  a year and allow  the drug list                                                               
to be used before implementing it with mental health patients.                                                                  
REPRESENTATIVE  McGUIRE   asked  if  Representative   Wilson  was                                                               
comfortable with the legislation before the committee now.                                                                      
REPRESENTATIVE WILSON  specified that she feels  much better with                                                               
regard to  the mental health  drugs because the  commissioner has                                                               
decided  to suspend  the committee  until this  fall in  order to                                                               
allow time for it  to work.  The mental health  drugs will be put                                                               
on   the   list  in   January,   which   is  what   she   wanted.                                                               
Representative  Wilson said  she feels  comfortable with  most of                                                               
the legislation, save the cost  containment aspect of this.  Cost                                                               
containment was  the primary  purpose of the  PDL to  begin with,                                                               
and therefore she  was concerned with regard to how  tight to tie                                                               
the commissioner's hands.  At this  point, much of this is in the                                                               
hands of the  physicians.  She indicated that  the physicians can                                                               
determine that the more expensive drugs are necessary.                                                                          
Number 402                                                                                                                      
REPRESENTATIVE McGUIRE  asked if under the  "medically necessary"                                                               
provision, the  physician would have the  discretion to prescribe                                                               
a brand name drug.                                                                                                              
REPRESENTATIVE WILSON  replied yes,  specifying that as  the bill                                                               
stands the  physician has the  ability to  do whatever he  or she                                                               
feels  is   necessary.    However,   she  highlighted   that  the                                                               
legislature will  have to  address this  again next  year because                                                               
the current  language doesn't provide  any "wiggle room"  for the                                                               
REPRESENTATIVE McGUIRE  recalled discussions last  year regarding                                                               
timelines  that  seemed  to  shift   and  change.    One  of  the                                                               
difficulties  with a  part-time legislature  is that  legislators                                                               
aren't around for the bulk of  the year.  Therefore, she said she                                                               
feels  most  comfortable with  this  method  and readdressing  it                                                               
later.  Representative McGuire  highlighted that cost containment                                                               
includes a  variety of  things.  For  instance, if  someone isn't                                                               
successfully  treated, the  noneconomic and  economic damages  to                                                               
communities are profound.  Therefore,  she expressed the need for                                                               
that to be considered in regard to cost containment.                                                                            
CHAIR ROKEBERG surmised  that the tension is  between the ability                                                               
for a physician to prescribe what he  or she feels is in the best                                                               
interest of the patient and the cost containment measures.                                                                      
REPRESENTATIVE WILSON agreed.                                                                                                   
CHAIR ROKEBERG  pointed out that  the legislation only  speaks to                                                               
the ability  of the physician  [to prescribe] and  doesn't really                                                               
contain any cost containment measures.                                                                                          
Number 437                                                                                                                      
PAT LUBY, Advocacy Director, AARP  Alaska, announced that AARP is                                                               
in total support  of the PDL the way it's  currently operating in                                                               
Alaska.     "Alaska   is  doing   everything  right,"   he  said.                                                               
Physicians, pharmacists,  and nurse practitioners  are developing                                                               
the PDL.   Just last week  Alaska became one of  the first states                                                               
to participate in bulk purchasing  of pharmaceuticals, which will                                                               
save some money.  Mr. Luby  emphasized that this isn't just about                                                               
saving  money, it's  also about  good pharmacology.   Alaska  has                                                               
also  signed  on to  participate  in  an evidence-based  research                                                               
project at  the University of Oregon.   There are three  of these                                                               
projects  throughout the  nation, and  AARP is  encouraging every                                                               
state  to sign  on  to  them.   In  the [evidence-based  research                                                               
project],  scientists,  free   of  pharmaceutical  company  sales                                                               
representatives and advertising, are  reviewing what are the best                                                               
drugs  for people  to use  in particular  categories of  illness.                                                               
Therefore, good  scientific information  can be used  with regard                                                               
to therapeutic  effectiveness.  Mr.  Luby acknowledged  that cost                                                               
savings   are   great,   but   pointed   out   that   therapeutic                                                               
effectiveness is really what is being looked.                                                                                   
MR. LUBY  said, "Alaska is doing  this right, we don't  need this                                                               
bill.   We should just continue  with what we're doing.   We will                                                               
save more  money if  we don't  have this  bill, there's  no doubt                                                               
about that."   Mr. Luby  stated that the intent  of HB 543  is to                                                               
slow the  PDL.  He  characterized HB 543  as a pharmacy  bill, an                                                               
industry  bill,  and  related  his   belief  that  those  in  the                                                               
pharmaceutical  industry  are  calling Representative  Wilson  to                                                               
complain.  He  guaranteed the committee that  AARP members aren't                                                               
calling and complaining.   Mr. Luby encouraged  the committee not                                                               
to forward HB 543 to the House floor.                                                                                           
REPRESENTATIVE  McGUIRE   cautioned  Mr.  Luby  with   regard  to                                                               
relating motives  of the sponsor, which  she knew to be  a person                                                               
who wouldn't  introduce legislation  for one  particular interest                                                               
group.    Furthermore,   Representative  McGuire  indicated  that                                                               
members  of the  legislature, the  penal system,  and the  health                                                               
care community share  concerns [which led to  the introduction of                                                               
this legislation].                                                                                                              
MR. LUBY  acknowledged that everyone has  his or her own  view of                                                               
this issue.  However, those  voicing concern in the House Health,                                                               
Education  and  Social  Services   Standing  Committee  were  the                                                               
pharmaceutical  companies.   The  pharmaceutical companies  don't                                                               
believe they  have a  fair shot at  the Pharmacy  and Therapeutic                                                               
Committee,  and  AARP  doesn't believe  they  should  because  an                                                               
individual  working   for  a  pharmaceutical  company   tries  to                                                               
represent that company and get  that company's drugs on the list.                                                               
What [the  state] needs is  a Pharmacy and  Therapeutic Committee                                                               
that  operates independently  based on  scientific research,  not                                                               
based on marketing strategies for pharmaceutical companies.                                                                     
Number 473                                                                                                                      
CHAIR  ROKEBERG posed  an example  in which  an individual  takes                                                               
Lipitor.  If the PDL formulary  didn't provide for that and there                                                               
were  other less  effective [drugs]  available, he  surmised that                                                               
the individual would be restricted from taking Lipitor.                                                                         
MR.  LUBY clarified  that physicians  are still  in the  driver's                                                               
seat.   If a physician says  that a particular medication  is the                                                               
best for a particular condition  in a particular individual, it's                                                               
permissible under the PDL.                                                                                                      
CHAIR ROKEBERG interjected that  the aforementioned is allowed in                                                               
the legislation.                                                                                                                
MR.  LUBY reiterated  that  such is  already  allowed [under  the                                                               
current PDL].                                                                                                                   
Number 484                                                                                                                      
CHIP  WAGONER,  Lobbyist  for Alaska  Association  of  Homes  for                                                               
Children, informed  the committee that the  Alaska Association of                                                               
Homes  for  Children  passed  a  resolution  in  support  of  the                                                               
Department  of  Health  and  Social  Services'  cost  containment                                                               
effort with regard  to the PDL.  The competing  interests are the                                                               
health  of the  patient  and controlling  state  costs.   Because                                                               
Alaska  has  an  aging  population,   Alaska  has  an  escalating                                                               
population  that needs  drugs.   He  related his  belief that  in                                                               
terms of growth,  the senior and/or disability  population is the                                                               
highest area of  growth for Medicaid.  Mr. Wagoner  turned to the                                                               
fiscal  note,  and expressed  concern  that  if the  fiscal  note                                                               
remains the  same with Version Q,  what was intended to  be a $20                                                               
million  savings will  turn into  a $10  million savings  for the                                                               
state.   To make up that  $10 million difference would  result in                                                               
cuts to  the Department  of Health  and Social  Services' budget.                                                               
Those who would be impacted by  such would be those served by the                                                               
Alaska Association  of Homes for Children,  which serves children                                                               
in state custody who are in residential homes.                                                                                  
MR. WAGONER  said he didn't believe  the solution is to  give the                                                               
physicians carte  blanche because that  would blow a hole  in the                                                               
concept  of cost  savings.   The  solution is  in the  provision,                                                               
which address  administrative procedures.  If  the administrative                                                               
procedures  are fair,  that  is provide  adequate  notice and  an                                                               
opportunity to  be heard by  the drug companies,  businesses, and                                                               
physicians, the  proper cost containment could  be achieved while                                                               
being fair and taking into account the health of the patient.                                                                   
Number 508                                                                                                                      
JOEL GILBERTSON,  Commissioner, Department  of Health  and Social                                                               
Services,   explained  that   Version   Q   would  restrict   the                                                               
department's ability  to adjust the authorization  system for the                                                               
PDL.    He  noted  that   the  committee  packet  should  include                                                               
information  with  regard to  the  growth  trends.   The  current                                                               
growth  trend for  fiscal  year  (FY) 2005  is  $134 million  for                                                               
prescription  drug expenditures  in  the Medicaid  program.   The                                                               
aforementioned  is  the  uninterrupted,  nonpreferred  drug  list                                                               
growth rate.   With the PDL, the  growth rate for FY  05 would be                                                               
about $114 million.                                                                                                             
COMMISSIONER   GILBERTSON  informed   the   committee  that   the                                                               
department  will begin  implementing a  PDL  at the  end of  May,                                                               
although  the mental  health drugs  have been  delayed until  the                                                               
beginning of next  year.  Version Q speaks to  one portion of the                                                               
PDL, the  authorization system.  The  authorization system allows                                                               
a prescriber  to prescribe a  nonpreferred drug, which is  a drug                                                               
that has  been peer reviewed  to be a drug  that is not  the most                                                               
effective  or the  most safe  in that  drug class.   Commissioner                                                               
Gilbertson explained that currently,  the department is requiring                                                               
that physicians  document that it's  medically necessary  for the                                                               
nonpreferred  drug  to   be  prescribed.    He   noted  that  the                                                               
authorization  systems  vary  across the  nation,  with  Alaska's                                                               
being one of  the least intrusive on a provider's  practice.  The                                                               
higher the  hurdle, the  more likely the  preferred drug  will be                                                               
prescribed versus the nonpreferred.                                                                                             
COMMISSIONER  GILBERTSON  pointed out  that  the  savings lay  in                                                               
providing  and prescribing  more  effective drugs  that are  more                                                               
cost efficient.   Savings also  lay in supplemental  rebates with                                                               
the pharmacy  manufacturers.   As Mr.  Luby testified,  Alaska is                                                               
joining the  first ever multi-state prescription  drug purchasing                                                               
pool.   Alaska will  be joining  Nevada, New  Hampshire, Vermont,                                                               
and  Michigan   in  forming   this  Medicaid   prescription  drug                                                               
purchasing pool.   There will be about one million  lives in that                                                               
pool, and  therefore the state  will be able to  negotiate better                                                               
prices with  the manufacturer.   The authorization system  in the                                                               
CS would  restrict the  state and require,  by statute,  that the                                                               
state  must always  maintain the  lowest level  of authorization,                                                               
which  is simply  a documentation  on the  prescription that  the                                                               
drug  is medically  necessary.   The state  intends to  begin the                                                               
program  with  the aforementioned.    Physicians  and the  Alaska                                                               
State  Medical Association  have been  notified that  the PDL  is                                                               
beginning and the first 14 drug  classes that will be included as                                                               
well as  the override system.   Commissioner Gilbertson  said but                                                               
[the  department]  believes  in   working  with  the  prescribing                                                               
community  that [the  department] needs  the ability  to increase                                                               
the  authorization  system going  into  the  future if  there  is                                                               
noncompliance with the PDL.   The aforementioned ability provides                                                               
[the  department] the  ability to  work with  the physicians  and                                                               
prescribers in order  to ensure compliance.  He  pointed out that                                                               
if  [the  physicians,  prescribers, and  department]  don't  work                                                               
constructively together,  the authorization  system will  have to                                                               
be  increased.   Cost containment,  he emphasized,  is the  money                                                               
that will  be used  to continue care  for the  children, seniors,                                                               
and disabled who receive services  from the department.  He noted                                                               
that the department has submitted a fiscal note for Version Q.                                                                  
Number 557                                                                                                                      
COMMISSIONER  GILBERTSON   turned  to   Representative  McGuire's                                                               
earlier comment  and said [the department]  agrees with reviewing                                                               
other areas of cost containment rather  than just one.  Last year                                                               
the  legislature included  language directing  the department  to                                                               
analyze other cost containment measures  before rushing to a PDL.                                                               
In fact,  the implementation of  the program has been  delayed to                                                               
address  concerns, such  as those  with regard  to mental  health                                                               
drugs.   Commissioner Gilbertson highlighted that  the department                                                               
is  expanding  provider  "lock-in"   to  ensure  that  individual                                                               
Medicaid  beneficiaries  go to  one  physician  and one  pharmacy                                                               
rather  than   to  multiple  providers  with   the  potential  of                                                               
receiving   conflicting   prescriptions.      Furthermore,   case                                                               
management services  have been expanded  such that a  much larger                                                               
segment of  the Medicaid population  [is covered].   He specified                                                               
that the Medicaid  population is comprised largely  of those with                                                               
chronic  conditions and  mental  illness;  these individuals  use                                                               
multiple services from  the department and a  high utilization of                                                               
prescription   drugs.     Commissioner  Gilbertson   said,  "Cost                                                               
containment is going on across  the department, this is one piece                                                               
of  it.   And we  think it's  a responsible  piece, and  for that                                                               
reason we do have concerns with the CS."                                                                                        
Number 570                                                                                                                      
REPRESENTATIVE   COGHILL   expressed   his   interest   in   cost                                                               
containment while allowing the physician  to prescribe the proper                                                               
medication  for  the  patient.     He  inquired  as  to  how  the                                                               
"medically  necessary"  language  requirement  would  impact  the                                                               
department.     He   further  inquired   as   to  the   increased                                                               
authorization anticipated if [Version Q] didn't pass.                                                                           
COMMISSIONER GILBERTSON explained that  [Version Q] would lock-in                                                               
the   initial   authorization   system  [requiring   that   every                                                               
prescription  outside the  PDL would  simply specify]  "medically                                                               
necessary" as  the sole override  system.  Noncompliance  means a                                                               
higher number  of prescriptions of  less effective and  less cost                                                               
efficient  drugs.     Commissioner  Gilbertson  noted   that  the                                                               
department has reviewed the  possibility of continuing "medically                                                               
necessary" on  the prescription while  requiring the  provider to                                                               
document  the reason  the  prescription  is medically  necessary.                                                               
The department  has provided suggestions  of valid  reasons, such                                                               
as contra indications, allergies,  failure of the preferred drug,                                                               
or  an already  existing regime  on  a nonprefered  drug that  is                                                               
effective.    Commissioner  Gilbertson  noted  that  if,  in  the                                                               
future,  the  department  sees   continued  prescribing  of  less                                                               
therapeutically  efficient  drugs,  physicians may  be  asked  to                                                               
specify the reason  the drug is medically necessary  on the drug.                                                               
The aforementioned isn't  very burdensome and there  is no actual                                                               
review done  by the state.   He  mentioned that some  states have                                                               
been  strong  with  regard  to the  authorization  system.    For                                                               
example, Michigan has over 95 percent compliance with its PDL.                                                                  
TAPE 04-3, SIDE B                                                                                                             
COMMISSIONER GILBERTSON remarked that there  are a broad range of                                                               
authorization systems and  Alaska is starting at  the simple end.                                                               
The  desire is  to work  with the  prescribers in  good faith  in                                                               
order to  have preferred drugs  prescribed and  work efficiently.                                                               
However,  [Version  Q]  doesn't   provide  the  [department]  the                                                               
ability to increase "it" if there is noncompliance.                                                                             
CHAIR ROKEBERG  asked if, under  Version Q, the  department could                                                               
provide the regulations to require the medical justifications.                                                                  
COMMISSIONER  GILBERTSON explained  that the  language "medically                                                               
necessary" alone and undefined, without  the cause of the medical                                                               
necessity,  is all  that's  required  to override  the  PDL.   He                                                               
acknowledged  that in  regulation the  terms "medical  necessity"                                                               
could be defined.  However, the  only way to review that would be                                                               
to review patient files, which the department isn't proposing.                                                                  
CHAIR ROKEBERG  surmised that the  department doesn't  believe it                                                               
has the authority under Version  Q to [require] the justification                                                               
[be written on the prescription].                                                                                               
COMMISSIONER GILBERTSON  replied no, not on  the prescription pad                                                               
CHAIR ROKEBERG  recalled that  there is an  issue with  regard to                                                               
what  a "brand  name"  drug is.    He asked  if  the language  in                                                               
[Version Q]  would be harmful  and disallow a prescription  for a                                                               
generic drug that isn't on the formulary.                                                                                       
COMMISSIONER GILBERTSON  confirmed that as currently  drafted the                                                               
override system is restricted to  brand name drugs, and therefore                                                               
a  physician couldn't  override with  a generic  drug.   There is                                                               
statute  which mandates  that when  a generic  drug is  available                                                               
prescribers  must  prescribe  it  unless  a  medically  necessary                                                               
override is provided.  The  aforementioned was a cost containment                                                               
measure.  This legislation would  continue that mandate, although                                                               
not in the situation in which  there is a generic override of the                                                               
PDL.  However, he noted that most generics will be on the PDL.                                                                  
CHAIR  ROKEBERG  asked  if additional  language  to  address  the                                                               
[generic override of the PDL] would be appropriate.                                                                             
COMMISSIONER GILBERTSON  indicated that  the language  would need                                                               
to clarify  that an override for  the PDL could be  for a generic                                                               
or a brand name drug.                                                                                                           
Number 565                                                                                                                      
CHAIR  ROKEBERG turned  to the  April 16,  2004, letter  from Dr.                                                               
Brodsky, which is in the  committee packet.  The letter specifies                                                               
that  effective May  19, 2004,  prescribers will  be required  to                                                               
provide  the  terms "medically  necessary"  or  "allergic to  the                                                               
preferred  drug"  as  medical   justification.    Chair  Rokeberg                                                               
related  his understanding  that  the department  wants to  start                                                               
that way, but have the flexibility to change that.                                                                              
COMMISSIONER GILBERTSON opined that  the department has worked in                                                               
good faith  with the  provider community  and the  drug industry.                                                               
When  concerns have  been raised,  the department  has tried  its                                                               
best to  accommodate those concerns.   One concern raised  by the                                                               
physicians  was  having  everyone  well versed  in  the  override                                                               
system  at the  start  of the  program.   He  explained that  the                                                               
override  system proposed  by the  department was  such that  the                                                               
terms "medically necessary" would  be written on the prescription                                                               
itself  as well  as  the reason,  such  as specifying  "medically                                                               
necessary,  adverse reaction  to X."   However,  some prescribers                                                               
expressed  concern  that  getting  to that  step  now,  which  is                                                               
different  than the  current override  system for  generic drugs,                                                               
isn't  something  that  the  entire  provider  community  can  be                                                               
educated on in  day one, and furthermore it  isn't something that                                                               
the entire provider community supports  up front.  Therefore, the                                                               
department agreed to accommodate  the provider community and work                                                               
with it  in good  faith to  ensure compliance with  the PDL.   As                                                               
dialogue continues  with the physician and  prescriber community,                                                               
the  department  believes  it  should  retain  the  authority  to                                                               
increase  the authorization  system  if  there is  noncompliance.                                                               
Otherwise, Alaska will experience  what has been experienced when                                                               
statutorily  restricted to  medically  necessary  language.   For                                                               
example,  in  Oregon  the  aforementioned  statutory  restriction                                                               
resulted in a 75 percent decline in expected savings.                                                                           
Number 546                                                                                                                      
REPRESENTATIVE  McGUIRE   inquired  as   to  the   percentage  of                                                               
physicians in Alaska who accept Medicaid patients.                                                                              
COMMISSIONER GILBERTSON answered between 55-60 percent.                                                                         
REPRESENTATIVE  McGUIRE  reminded   committee  members  that  the                                                               
["medically  necessary" language]  was  what she  offered to  the                                                               
senior  care  legislation  that passed.    She  further  reminded                                                               
committee members  that [prescribing a  drug outside the  PDL was                                                               
allowed] if  the medical reason  fell into four categories.   The                                                               
physicians  are concerned  because they  believe the  ["medically                                                               
necessary"  language requiring  the  reason to  fall within  four                                                               
categories] is overly  onerous and puts their  medical license on                                                               
the line.   Representative McGuire  announced her support  of the                                                               
legislation as  it is [Version  Q], which she characterized  as a                                                               
good starting point.   She highlighted that  every legislature is                                                               
free to change this.                                                                                                            
REPRESENTATIVE   McGUIRE   returned   to  the   issue   of   cost                                                               
containment,  and said  that within  the PDL,  one has  to review                                                               
experiments in other states as  well.  She highlighted that those                                                               
who take  psychotropic drugs  are the  poorest in  the community.                                                               
Therefore, if such individuals are  prescribed the wrong drug, it                                                               
could result  in an emergency  room visit for which  the hospital                                                               
or other  [insureds] pick up  the tab.   Furthermore, if  such an                                                               
individual commits a  crime, many others are picking  up the tab.                                                               
Representative  McGuire  encouraged  the committee  to  keep  the                                                               
language [in Version Q] as it is.                                                                                               
REPRESENTATIVE COGHILL  noted that  he will support  the language                                                               
[in Version  Q], although  he would  also support  the physicians                                                               
providing  an explanation  or  justification  [for prescribing  a                                                               
drug not on the PDL].                                                                                                           
CHAIR   ROKEBERG  remarked   that   he  tended   to  agree   with                                                               
Representative   Coghill.      Chair  Rokeberg   requested   that                                                               
Commissioner Gilbertson review Version  Q and perhaps bring forth                                                               
some  amendments  in  response  to some  of  the  issues  brought                                                               
forward by the committee.                                                                                                       
Number 498                                                                                                                      
REPRESENTATIVE BERKOWITZ withdrew his objection.                                                                                
There being no further objection,  CSHB 543, Version 23-LS1835\Q,                                                               
Mischel, 4/27/04, was before the committee.                                                                                     
Number 496                                                                                                                      
REPRESENTATIVE  McGUIRE moved  to  report CSHB  543, Version  23-                                                               
LS1835\Q,  Mischel, 4/27/04,  out  of  committee with  individual                                                               
recommendations  and the  accompanying zero  fiscal note.   There                                                               
being no  objection, CSHB  543(RLS) was  reported from  the House                                                               
Rules Standing Committee.                                                                                                       

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