Legislature(2017 - 2018)SENATE FINANCE 532
02/27/2018 09:00 AM FINANCE
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SENATE BILL NO. 108 "An Act relating to the State Medical Board; relating to the licensing of physicians, osteopaths, and podiatrists; and providing for an effective date." 9:03:32 AM SENATOR CATHY GIESSEL, SPONSOR, discussed the presentation, "SB 108 State Medical Board" (copy on file). 9:03:51 AM Senator Giessel highlighted Slide 2, "Purpose": 1. Streamline Physician Licensing 2. Need for office assistants 9:04:26 AM Senator Giessel discussed Slide 3, "Streamline MD licensing": Section 1, 2, 8, 9, 10 State Medical Board to write regulations to delegate to EXECUTIVE ADMINISTRATOR: 1. review applications and grant license if requirements are met 2. review applications and issue temporary license if requirements are met 3. grant certification if requirements are met 4. spells out prohibitions to this delegated authority 9:06:28 AM Senator Giessel discussed Slide 4, "Streamline MD licensing": Section 10, 11 1. Allows another person, designated by the board, to help the Executive Administrator to issue temporary license. 2. Outlines when this could happen Senator Giessel stated that this change was urgently needed and widely supported. 9:08:20 AM Senator Giessel highlighted Slide 5, "Medical Assistants - Unlicensed Assistive Personnel": Medical Assistants trained in "routine medical tasks" Section 3 authorizes delegation to unlicensed person prohibits delegation of pain management or opioid related activities Senator Giessel offered a brief history of the role of medical assistance in practice. 9:10:31 AM Senator Giessel addressed Slide 6, "Medical Assistants - Unlicensed Assistive Personnel": Section 6 adds unlicensed assistive personnel, performing delegated routine medical duties to exception under "License to practice medicine, podiatry, or osteopathy" Section 13 adds "medical assistants" to definition of "medical professional" under Title 12 Criminal Procedure Senator Giessel stated that only licensed medical professionals could access the state's pharmaceutical database. 9:12:18 AM Senator Giessel looked at Slide 7, "Certified Medical Assistants - NEW entity": Why? Prescription Drug Monitoring Program (PDMP) prohibits access by any unlicensed person envisioned clinician delegate "look up" before prescribing Problem No licensed people in MD clinic, other than the MD Frequent need to check on PDMP Solution Alaska's Community Colleges training programs for CMA National exams for Certification Done in most other states. Washington State is one example 9:14:17 AM Senator Giessel discussed Slide 8, "CMA (Certified Medical Assistant) Process defined": Section 4 Certification - process will be defined in regulation Section 5 Title "CMA" and limits its use Section 12 Penalty for practicing without license as CMA Senator Giessel addressed Slide 9, "Urgent need for SB 108": Efficient, expeditious and effective licensing of MDs Legal clarity for delegation of "routine medical duties" to unlicensed assistive personnel (medical assistants) More legally stringent delegated activities to licensed entity, Certified Medical Assistant 9:14:29 AM Senator Giessel discussed Slide 10, "Urgent need for SB 108": These changes needed this session Support State Medical Board (requested) Department of Commerce No opposition 9:15:10 AM Senator Stevens asked how long the temporary license would last and whether it removed the responsibility to precure a permanent license. Senator Giessel replied that the temporary license was time-limited. She deferred to Ms. Stovern. 9:15:50 AM Co-Chair MacKinnon wondered whether medical assistants were licensed in other states. Senator Giessel replied that other states recognized certified medical assistants, which was why the national exams were available. 9:16:13 AM Senator von Imhof looked at the fiscal note, which reflected that professional licensing programs were funded by receipt supported services to fund the two new full-time positions that the bill would create, which meant that the expense would be paid by the health professionals that were involved with the board. Senator Giessel replied in the affirmative. 9:16:51 AM Co-Chair MacKinnon wondered whether the structure of the bill was understood by the entire committee. 9:16:55 AM Senator Olson asked how the bill would affect heath corporations in rural Alaska. Senator Giessel responded that she had not heard from specific native corporations or native health organizations. She imagined that if Anchorage was experiencing issues then rural areas must be as well. 9:18:06 AM Senator Olson wondered about continuing medical education (CME) requirements for medical assistants. Senator Giessel deferred to Ms. Stovern. 9:18:31 AM Senator Olson asked whether other professionals working under the per view of the medical board would be affected by the bill. Senator Giessel replied that physician's assistants were affected, because they delegated to unlicensed assisted personnel and needed to access the PDMP. 9:19:23 AM Co-Chair Hoffman wondered whether the legislation would increase the number of certified medical assistants in the state. Senator Giessel replied that it was hard to predict whether the numbers would grow but that it was a growing field of work. 9:20:32 AM Senator von Imhof read from the sponsor statement: The bill provides for physician delegation of specific, routine activities to unlicensed personnel working in physician offices. Senator von Imhof assumed that the "specific, routine activities" would be within the parameters of their training and would be spelled out in regulation. Senator Giessel replied in the affirmative. 9:21:33 AM Senator Micciche spoke to concerns that had been voiced by the American Association of Medical Assistants (AAMA) about confusion surrounding certified medical assistants. Senator Giessel said that she had been in communication with the association and had clarified with them the importance of the bill. She stated that the association could bring other concerns to the Board of Medicine. 9:22:13 AM Co-Chair MacKinnon noted that there was a letter in the packet from the AAMA that offered suggestions on what initials to give certified medical assistants (copy on file). Senator Giessel stated that she was aware of the letter and had instructed the AAMA to communicate with the Board of Medicine. She asserted that she was carrying the legislation on behalf of the board and would not change any aspects of the bill unless the board agreed. 9:22:50 AM Co-Chair MacKinnon wondered how many other states recognized certified medical assistants through licensure programs. She asked whether the final licensure of a doctor coming into the state had to be approved by the board, and after that happened, would a list of physicians officially approved to practice in the stat be approved by the board. Senator Giessel deferred the question to Ms. Stovern. 9:24:20 AM Co-Chair MacKinnon understood that a "clean" application would not go before the board, but a questionable application would go before the board for further scrutiny. Senator Giessel shared that it would be up to the board how they wanted to review applications approved by the executive administrator. She said that the issue was not discussed in the bill. 9:25:02 AM FRED PARADY, DEPUTY COMMISSIONER, DEPARTMENT OF COMMERCE, COMMUNITY, AND ECONOMIC DEVELOPMENT, spoke in support of the legislation. He shared that the workload of the medical board had dramatically increased due to telemedicine. He stated that in 2015, the backlog reached 6 months in application processing time due to the volume of applications received. He relayed that in FY17, the division processed 22 percent more medical licenses and 31 percent more nursing licenses than in FY16. He related that to date in FY18, more licenses had been received than the entirety of the previous fiscal year. He shared that the department had worked to streamline the application process for health care professions. He said that a comprehensive examination of the application process had been done to identify areas of friction, or "rubs." He relayed that 27 rubs had been identified, which had been evaluated individually to determine whether the issue served a public safety purpose, met a public safety need, or whether the process was outdated or obsolete. He explained that a three-pronged approach had been initiated to implementing solutions to streamlining the licensure process. The areas of friction were split in three areas: small changes through board regulations, improvements in technology, and changes to statute that would allow the department to more effectively administer programs. He concluded that legislative support of the bill was the final step in ensuring Alaska's health care facilities were able to stay open, while remining fully staffed and able to serve the public in a timely fashion. 9:32:10 AM DEBORA STOVERN, EXECUTIVE DIRECTOR, ALASKA STATE MEDICAL BOARD, ANCHORAGE (via teleconference), stated that under current statute only the board was authorized to grant licenses, the board also had the authority to delegate to her the authority to approve applications for temporary permits, curtesy licenses, and resident permits. She said that because the board only met four times per year, temporary permits allowed applicants with complete files to practice until the next board meeting, when files would be considered by the board for approval of a permanent license. She said that a temporary permit was time-limited to 6 months and could not be extended. She related that as part of the licensing streamlining project that Mr. Parady spoke to, the board had taken actions to improve application processing, including; in office efficiencies, changes to application requirements, the inclusion of participation in programs offered by the Federation of State Medical Boards, the adoption of regulation for an expedited temporary permit. She anticipated that once the legislation passed, the board would continue to delegate the approval authority to the executive secretary as well as the licensing supervisor, for the issuance of the expedited temporary permits. She said that once an expedited file was complete, it would be referred to the executive secretary for approval of the permeant license. Any application with derogatory or adverse information, discrepancies, or questions and concerns would require a board review for approval of temporary or permanent license, as appropriate. She related that under the legislation much of the temporary licensure would be at the discretion of the board. She spoke to the CME question posed by Senator Olson. She said the licensing program required that assistants maintain their national certification, which meant they had to complete continuing medical education. She anticipated that the board would require something similar with certified medical assistants. 9:37:11 AM Senator Stevens wanted a guarantee that no one would be given a temporary license that did not have the necessary medical background. Ms. Stovern responded that temporary permits were issued on a checklist that had been developed by the board and delineated all of the requirements for licensure. She said that the process ensured that all requirements were met, and all credentials were in place before temporary permits were issued. The board would be tasked with further developing that checklist for the enhanced process. 9:38:33 AM Senator Stevens wanted assurances that the public would be safe. Senator Olson commented that he understood Senator Stevens's concerns but that he had witnessed a lack of service in rural areas of the state due to the lack of streamlining in the permitting process. 9:40:16 AM Co-Chair MacKinnon felt it was important to note that Senator Olson was a doctor. Senator Olson said he was first licensed as a medical doctor in 1984 and had practiced in rural Alaska throughout his career. He added that he had been on the medical board from 1995, until he was elected to office. 9:41:50 AM Senator Micciche asked whether the bill would speed up the permitting process without reducing the credential requirements. Ms. Stovern replied yes. She said that the board considered that the credentials had been reviewed for the issuance of a temporary permit and took that into consideration when granting a permanent license. 9:43:58 AM Senator Micciche reiterated concern that requirements would be reduced at the risk of public safety. 9:44:31 AM Co-Chair MacKinnon understood that Senator Micciche was requesting assurances that there would be no changes in requirements for permanent licensure in the state. Ms. Stovern replied that the requirements would not be changed. 9:44:47 AM Senator Stevens requested further information on the backlog of 290 applications. Ms. Stovern said that there was not currently a huge backlog. She related that there had been an influx in application due to increased telemedicine. She felt that once streamlining efficiencies were implemented the application processing time would be significantly reduced. She relayed that there were some delays in the process that were outside of the boards control. She stated that once an application was received by her office it took approximately one to three weeks to issue a temporary license. She said that current backlogs were related to missing documents and credentials in files. 9:47:53 AM Senator Stevens felt that a 6-month extension would take care of the current backlog. Ms. Stovern responded in the affirmative. 9:48:42 AM DOCTOR DANNY ROBINETTE, CHIEF MEDICAL OFFICER, FOUNDATION HEALTH PARTNERS, FAIRBANKS (via teleconference), understood the concern about credentials. He encouraged keeping the diligent process intact and not changing the standards. He stressed the importance of a streamlined process for granting privileges to candidates. He related that he had lost candidates to other states because the licensing process had taken too long. He expressed strong support for the legislation. 9:50:49 AM Senator Stevens wondered how the bill would help with efficiency of licensure. Dr. Robinette thought that granting authority to the director would save waiting for the next board meeting for a clean candidate. 9:51:48 AM Senator Stevens surmised that if an individual had been given a 6-month extension, but at the end of the 6 months the file was not complete, he would be denied the opportunity to continue to work in the state. Dr. Robinette agreed. 9:52:23 AM Vice-Chair Bishop asked how much it cost to vet applicants. Dr. Robinette answered that, including the cost of hiring temporary staff to manage the workload, the cost was several hundreds of thousands of dollars. The cost of recruiting an individual physician was between $30,000 and $50,000. 9:53:41 AM Vice-Chair Bishop remarked that the hospital would spend time vetting the individual, as would the board. Dr. Robinette agreed, and believed that both vetting opportunities should exist, he thought that anything that could be done to streamline the vetting would be helpful. 9:54:33 AM 9:54:55 AM Co-Chair MacKinnon CLOSED public testimony. 9:55:02 AM AT EASE 9:55:19 AM RECONVENED 9:55:22 AM Co-Chair MacKinnon directed attention to the fiscal note. 9:55:39 AM Vice-Chair Bishop discussed the fiscal note from the Department of Commerce, Community and Economic Development (DCCED). He read from the analysis: One full-time Records and Licensing Supervisor is needed to implement this program. Currently, one existing Records and Licensing Supervisor is spread among numerous programs; only part of that position's time is dedicated to medical programs. As a result of the addition of the certified medical assistant license type, the workload related to medical programs supports a dedicated Records and Licensing Supervisor. If the bill passes the following expenses will be incurred: Personal Services: $177.8 (2 full-time positions) Travel: $1.5 (1 training session per year) Services: $10.0 (annual legal review) $5.0 (annual investigations) $4.5 (regulations project in the first year) $30.0 (annual core services & allocated costs) Supplies: $20.0 (set up for new employees in the first year) $2.5 (postage in the first year) $1.0 (office supplies) Professional licensing programs within the Division of Corporations, Business and Professional Licensing are funded by Receipt Supported Services, fund source 1156 Rcpt Svcs (DGF). Licensing fees for each occupation are set per AS 08.01.065 so the total amount of revenue collected approximately equals the occupation's actual regulatory costs. 9:57:42 AM Co-Chair MacKinnon asked whether Ms. Stovern had comments pertaining to the AAMA and their concerns with CMAs in Alaska. Ms. Stovern replied that the board had not considered the concerns. 9:58:54 AM Co-Chair MacKinnon spoke again to the letter from Donald A. Balasa, Ms. Davis, MBA, CEO and Legal Counsel for the AAMA. She asked Senator Giessel to speak to her credentials. Senator Giessel shared that she had been a registered nurse in Alaska since 1974, and Advanced Nurse Practitioner since 2000. She relayed that she had served on the Board of Nursing from 2002 to 2010, five of those years she served as chair of the board. She said that the issue raised by the AAMA was trivial, as opposed to the legislation, which would address a critically urgent matter. 10:01:07 AM Senator Olson asked whether Senator Giessel had received letters of support of opposition from physician groups. Senator Giessel said that she had not received letters from the Alaska State Medical Association or the Association of Physicians and Surgeons. She reminded the committee that the Board of Medicine had written the bill. Co-Chair MacKinnon announced that amendments were due by 5pm the following day. SB 108 was HEARD and HELD in committee for further consideration.