03/01/2007 03:00 PM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HJR10 | |
| HB100 | |
| Presentation: Strengthening Families | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| += | HB 100 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| += | HJR 10 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
March 1, 2007
3:05 p.m.
MEMBERS PRESENT
Representative Peggy Wilson, Chair
Representative Bob Roses, Vice Chair
Representative Anna Fairclough
Representative Paul Seaton
Representative Sharon Cissna
Representative Berta Gardner
MEMBERS ABSENT
Representative Mark Neuman
COMMITTEE CALENDAR
HOUSE JOINT RESOLUTION NO. 10
Relating to reauthorization of federal funding for children's
health insurance; and encouraging the Governor to support
additional funding for and access to children's health
insurance.
- ADOPTED FISCAL NOTE;
MOVED CSHJR 10(HES) OUT OF COMMITTEE 02/27/07
SPONSOR SUBSTITUTE FOR HOUSE BILL NO. 100
"An Act relating to exempting certain air ambulance services
from insurance regulation and requiring certain air ambulance
services to provide services."
- HEARD AND HELD
PRESENTATION: STRENGTHENING FAMILIES
- HEARD
PREVIOUS COMMITTEE ACTION
BILL: HJR 10
SHORT TITLE: MEDICAL ASSISTANCE FOR CHILDREN
SPONSOR(s): HEALTH, EDUCATION & SOCIAL SERVICES
02/15/07 (H) READ THE FIRST TIME - REFERRALS
02/15/07 (H) HES, FIN
02/27/07 (H) HES AT 3:00 PM CAPITOL 106
02/27/07 (H) Moved CSHJR 10(HES) Out of Committee
02/27/07 (H) MINUTE(HES)
03/01/07 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 100
SHORT TITLE: AIR AMBULANCE SERVICES
SPONSOR(s): REPRESENTATIVE(s) COGHILL
01/16/07 (H) READ THE FIRST TIME - REFERRALS
01/16/07 (H) HES, L&C
02/15/07 (H) SPONSOR SUBSTITUTE INTRODUCED
02/15/07 (H) READ THE FIRST TIME - REFERRALS
02/15/07 (H) HES, L&C
02/22/07 (H) HES AT 3:00 PM CAPITOL 106
02/22/07 (H) <Bill Hearing Canceled>
03/01/07 (H) HES AT 3:00 PM CAPITOL 106
WITNESS REGISTER
REPRESENTATIVE JOHN COGHILL
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Testified as prime sponsor of SSHB 100.
KATHLEEN MCLERON, Health Program Manager
Division of Public Health (DPH)
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Testified on SSHB 100, and responded to
questions.
SHELLY DEERING, Alaska Director
Clinical Operations
Airlift Northwest
Juneau, Alaska
POSITION STATEMENT: Testified on SSHB 100, and responded to
questions.
PAUL HARRIS, General Manager
Guardian Flight, Inc.
Fairbanks, Alaska
POSITION STATEMENT: Testified in support of SSHB 100, and
responded to questions.
TOM BAILEY, Manager
Providence, Air Medical Services
Anchorage, Alaska
POSITION STATEMENT: Testified in opposition to SSHB 100, and
responded to questions.
LINDA HALL, Director
Division of Insurance
Department of Commerce, Community, & Economic Development
(DCCED)
Anchorage, Alaska
POSITION STATEMENT: Testified in support of SSHB 100, and
responded to questions.
SHARLI HAYTER
Critical Care Incorporated (CCI)
Ketchikan, Alaska
POSITION STATEMENT: Testified in support of SSHB 100, and
responded to questions.
LEIF WILSON, President
Director of Operations
40-Mile Air, Medivac Service
Tok, Alaska
POSITION STATEMENT: Testified in opposition to SSHB 100
CLAUDIA SHANLEY, Systems Reform Administrator
Office of Children's Services (OCS)
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Co-presented the Strengthening Families
Through Early Care and Education program, and responded to
questions.
SHIRLEY PITTZ, Coordinator
Early Childhood Comprehensive Systems Plan (ECCS)
Office of Children's Services (OCS)
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Co-presented the Strengthening Families
Through Early Care and Education program, and responded to
questions.
LUPITA ALVAREZ, Director
Juneau Montessori School
Juneau, Alaska
POSITION STATEMENT: Participated in the Strengthening Families
Through Early Care and Education Program, and responded to
questions.
ACTION NARRATIVE
CHAIR PEGGY WILSON called the House Health, Education and Social
Services Standing Committee meeting to order at 3:05:34 PM.
Representatives Seaton, Roses, Gardner, and Cissna were present
at the call to order. Representative Fairclough arrived as the
meeting was in progress.
HJR 10-MEDICAL ASSISTANCE FOR CHILDREN
3:05:34 PM
CHAIR WILSON announced that the first order of business would be
to consider HOUSE JOINT RESOLUTION NO. 10, Relating to
reauthorization of federal funding for children's health
insurance; and encouraging the Governor to support additional
funding for and access to children's health insurance.
[Note: HJR 10 was moved from committee at the February 27,
2007, regular meeting, and held pending the adoption of the
fiscal note.]
3:06:28 PM
REPRESENTATIVE SEATON moved to adopt the zero fiscal note for
HJR 10. There being no objection, it was so ordered.
HB 100-AIR AMBULANCE SERVICES
3:07:10 PM
CHAIR WILSON announced that the next order of business would be
SPONSOR SUBSTITUTE FOR HOUSE BILL NO. 100, "An Act relating to
exempting certain air ambulance services from insurance
regulation and requiring certain air ambulance services to
provide services."
3:07:24 PM
REPRESENTATIVE JOHN COGHILL, Alaska State Legislature, presented
SSHB 100, as prime sponsor. He explained that this bill arose
because an air ambulance service wishes to provide a
subscription Medivac service that under current law may only be
offered by a non-profit entity. He went on to say that a
subscription service differs from insurance. Furthermore, he
said that SSHB 100 stipulates that subscription air ambulance
services may not deny emergency service to any person. He
explained that the bill allows market dynamic forces to work, as
the service provider is able to offer a desired service to
customers. He referred to previous testimony before this
committee from one provider who objects to certain provisions in
the bill, and noted that today's testimony will cover other
aspects of the business. He suggested that the state move
slowly in this new area, however, he opined that persons should
have the benefit of entering a service agreement at whatever
level they may choose. He said a level playing field will allow
providers to enter at the service level they desire.
3:12:37 PM
CHAIR WILSON stipulated that testimony will be taken today, but
the intent is to hold the bill in committee.
REPRESENTATIVE COGHILL expressed his openness for amendment
suggestions.
3:13:07 PM
REPRESENTATIVE GARDNER referred to the sponsor's allusion to
there being six air ambulance providers, in Alaska, and said
that she has documentation indicating that there may be as many
as 18.
REPRESENTATIVE COGHILL replied that the numbers may vary
depending on the type of aircraft and certification that the
provider holds, and he speculated that forthcoming testimony
would clarify the numbers.
The committee took a brief at ease from 3:14 to 3:16.
3:16:14 PM
KATHLEEN MCLERON, Health Program Manager, Division of Public
Health (DPH), Department of Health and Social Services (DHSS),
explained that her division "credentials" air medical services
for the health department. She said that there are 19 air
certificates issued in the state to 14 different agencies. She
explained that five are Native health organizations, two are
hospital-based services, two are borough or government agencies,
four are privately owned services, and one is a military
organization.
3:17:26 PM
REPRESENTATIVE COGHILL established that the bill concerns
carriers who operate for profit, therefore a description of the
differentiation between profit and non-profit services would be
in order.
3:17:42 PM
MS. MCLERON explained that DPH does not review certification
based on an organization's profit or non-profit status. She
explained that there are three levels of service certification:
Medivac, critical care or ambulance, and specialty aero-medical
transport teams. The certification requirements differ for each
level, and require different staff, equipment, and aircraft.
Other organizations, such as the Federal Aviation Administration
(FAA), also require that carriers meet certain aircraft
requirements. The DPH limits itself to ensuring that agencies
comply with state statutes and regulations.
3:19:59 PM
REPRESENTATIVE SEATON asked how many carriers are within the
three service classifications.
MS. MCLERON responded that currently certified services include:
ten critical care or ambulance, eight Medivac, and one specialty
transport team. Several organizations hold more that one
certificate, therefore there are 19 certificates for 14
agencies, she said. She explained in response to a question,
that AS 18.08.082 authorizes the DPH to write regulations, and
that the three levels of service are contained in these
regulations. In further response, she noted that there is a
small variation in the number of providers and type of
certifications issues. One service is currently considering a
consolidation from two levels of certification to one, and that
one out-of-state provider chose not to renew certification. She
went on to say that overall the numbers are reasonably stable.
3:22:23 PM
REPRESENTATIVE GARDNER asked whether Alaskans are well served by
air ambulance providers, and whether this bill would improve the
services offered.
MS. MCLERON stated her understanding that DHSS is not taking a
position on this bill. She said that currently air ambulance
services are available in rural areas to transport patients to
urban, and out of state, medical centers. Recalling her past
personal experience, as a certified flight paramedic in Point
Barrow, she offered that clinic workers are well aware of the
services available for patients.
REPRESENTATIVE GARDNER questioned if the effect of SSHB 100
would be to improve access to necessary medical services, or
serve to address a business model.
MS. MCLERON reiterated that DHSS is not taking a position on the
bill because it is viewed as addressing a business model. The
governing statute, and regulations, stipulates that a service
employ the appropriate medical personnel, administration,
equipment, and aircraft. An applicant meeting these
requirements will be credentialed, she said.
3:24:59 PM
SHELLY DEERING, Alaska Director, Clinical Operations, Airlift
Northwest, paraphrased from a statement, which read as follows
[original punctuation provided]:
I'm a critical care flight nurse and manage our
medically related operations in Alaska.
Airlift Northwest was created in 1982 after a house
fire in Sitka claimed the lives of five children for
whom no air medical transport service could be
obtained to fly them to a burn center. After 25 years
and 55,000 patients, we remain southeast Alaska's
premiere nonprofit air medical service. We're the
only service with dedicated medical Learjet's in both
Ketchikan and Juneau. We have 14 nurses and pilots
who live and work in each community. It has been our
honor and privilege to serve Alaska patients and their
families.
I'm here today to express concerns about SSHB 100.
This legislation seeks to provide Alaskans with the
ability to participate in subscription or membership
programs for air medical transportation. This type of
program offers a discounted medical service for a fee.
Rarely will insurance cover all the costs of air
medical transportation. Under a subscription program,
the patient's co-pay, or the amount not covered by
insurance or Medicare, will be covered through the
membership fee.
We are concerned, however, that SSHB 100 could have
some serious, unintended consequences. In fact, it
could jeopardize some of the state's air medical
programs. Currently Alaska has 16 state certified air
medical service providers - some cover rural areas and
others cover the state as a whole. Membership
programs can result in a competitive environment in
which smaller providers would be at a distinct
disadvantage. They may not have the resources
necessary to set up a viable program. Conceivably,
some could be driven out of business leaving areas of
the state without adequate service.
It's important to remember, too, that subscription
programs are like every other health care program.
When one person pays less than the actual cost of
service, which occurs when they purchase a
subscription, another person pays more.
Unfortunately, this differential pricing is the
reality of our health care system.
I'd also like to call your attention to Section One of
this bill which requires that organizations offering
subscription programs "may not deny emergency medical
services to any person." On the surface, this would
seem like an admirable policy. But if it is
interpreted broadly, patients will suffer. The
problem lies in the definition of emergency.
For example, if a person falls in Juneau and breaks a
hip, that is an emergency - one that can be treated
effectively at Bartlett Regional Hospital. However,
under Section One, the person could call their air
ambulance membership provider and request to be taken
to Anchorage. Not only will this drive up the cost of
treatment, it could take an aircraft out of service
when it is needed for a much more serious emergency.
We also are concerned that this legislation would
exempt subscription programs from any type of
insurance regulation. We believe that subscription
programs are a form of insurance. To get
clarification on this, we presented the question to
Alaska Insurance Commissioner Linda Hall in a meeting
on February 9. We are still waiting to get guidance
from the Commissioner or her staff. We've checked
several times with her office since that meeting and
haven't been able to get a response.
If subscription programs are made available, they
should be regulated to assure that Alaskans receive
adequate protection when they purchase a membership.
Let me give two examples of what can happen without
regulation.
First, some companies require that patients fly only
with them in order to receive their membership
benefits. This could result in harm to a patient.
For example, a person who has suffered a heart attack
may receive treatment at a local hospital to help
dissolve a clot. Sometimes this procedure doesn't
work and the only alternative is advanced cardiac
intervention at another hospital accessible only by
air. If an aircraft is not immediately available from
the company that sold the patient a membership, that
person may have to wait for hours for their
"subscription program" to transport them. The longer
the delay, the more heart muscle that can be destroyed
-- having long-term effects on a patient's health.
Second, some companies try to sell subscriptions to
Medicaid recipients or people who receive benefits
from the Indian Health Service. These patients don't
need a subscription program because co-payments are
not required from them. If they are persuaded to buy
a membership, they are purchasing coverage they don't
need. Companies who sell to Medicaid or IHS [Indian
Health Services] beneficiaries are, in essence,
praying on people who can least afford the cost.
Regulation is needed to prevent this.
Washington State recently passed legislation to exempt
membership programs from insurance regulation, with
minimal consumer protection. Already revisions are
being considered. Airlift Northwest provides
memberships in Washington and we voluntarily formed a
reciprocity agreement with another flight program that
provides the same level of quality service. It is
also the only other flight program in Washington. We
did this to assure that our membership holders are not
delayed in getting the care they need.
So if you do decide to move ahead with this
legislation, we urge you to consider safeguards to
protect Alaskans. In addition to regulations to
prevent the situations I just described, companies
selling memberships should be required to obtain a
surety bond from a company licensed to do business in
Alaska in an amount equal to the funds to be
subscribed and also to maintain adequate reserves
based on the subscription fees. Without this
regulation, a company can come into a state, sell
memberships, and then leave without ever providing
service to patients. This protection is needed
especially when a company offers lifetime memberships.
Companies should also be required to comply with all
state and federal regulations regarding billing and
reimbursement for participants.
People require air medical transportation when they
are critically ill or injured. This is a time for
them and their families that is filled with stress and
anxiety. Those of us who practice in this field want
the best possible care for our patients. We hope you
will carefully consider this legislation and not pass
something that could ultimately be to the detriment of
patients - not to their benefit.
3:31:40 PM
REPRESENTATIVE SEATON asked if a patient, who has purchased a
subscription for service, would have to use the class of carrier
covered by the subscription service, regardless of the medical
condition necessitating the air ambulance service.
MS. DEERING responded that the patient would have to decide
whether to pay the extra cost, if the patient chose to fly with
a carrier with whom they do not have a subscription.
3:33:08 PM
REPRESENTATIVE ROSES asked about the turnover rates for air
ambulance service providers.
MS. DEERING said that during her time in Washington State, she
experienced the loss of one service provider. She stated that
she is not aware of a service provider leaving the Southeast
Alaska area.
REPRESENTATIVE ROSES expressed concern regarding the
consequences of a subscription service provider going out of
business or leaving the state. He opined that there may need to
be some type of guarantee that a service will be available when
needed.
REPRESENTATIVE WILSON noted that doctors certainly provide
guidance to patients in emergency medical situations requiring
air-lift services.
3:35:33 PM
PAUL HARRIS, General Manager, Guardian Flight, Inc., testified
in support of SSHB 100. He explained that Guardian Flight's air
medical ambulance service is based out of Fairbanks. It is
Alaska's largest air medical carrier; providing service
throughout the state. It is his understanding that subscription
services are a common business practice in other states. The
provider's reputations, and the need for services, are the
deciding factors of whether to enter into a subscription
contract. The number of air medical service providers has been
fairly stable for the last ten years. He opined that SSHB 100
allows any air ambulance provider the option to sell memberships
or subscriptions for air ambulance services. In response to
concerns regarding continuity of services should a provider
cease operations, he noted that a lifetime membership subscriber
would be aware that any business could be terminated. He said
that the customer/business relationship is important. Guardian
Flight provides a service to the people of Alaska at the lowest
possible cost, and he relayed that the idea of offering a
subscription service was developed as a means to improve the
system. A subscription service allows people to plan for the
future possibility that they, or a family member, may need
emergency air medical services. He drew a comparison between a
subscription service and a pre-burial service: both are a means
for planning ahead to minimize stress at a difficult time. Mr.
Harris said he thought it was fair to allow all air medical
service providers the chance to sell subscriptions. He
suggested that the courts would not look favorably upon a
provider selling subscriptions in areas they did not serve.
3:41:11 PM
REPRESENTATIVE ROSES observed that air ambulance services are
vital in Alaska. He said that he is not concerned with the
integrity of the providers, but he noted that it may only take
one aircraft crash to force a company out of business. He asked
what Guardian Flight would plan to charge for a flat fee
subscription, and how many subscribers are anticipated.
MR. HARRIS replied that an annual fee of $50.00 per individual,
and $75.00 for a family, would be charged, and estimated sales
of 100,000 subscriptions.
REPRESENTATIVE ROSES calculated $2.5 million in subscription
fees, and asked what a person with insurance, but no
subscription, would pay out of pocket for a medical service
flight.
MR. HARRIS noted that insurance policies provide variable
payment amounts. However, in 2006, Guardian Flight provided
about 1,100 Medivac flights at a cost range of $6,000 to $55,000
each. He said that most insurers pay 80 percent of that cost
and explained that a flight to Portland, Oregon, or Seattle,
Washington, could cost $48,000 to $50,000.
REPRESENTATIVE ROSES estimated that a patient with a co-pay of
20 percent, charged $6,000 for a Medivac, is responsible for
$1,200. A provider receiving $2.5 million in subscription
payments could, he theorized, transport 2,500 people for the
amount of money collected through subscriptions. He related to
this to the co-pay aspect of insurance coverage.
MR. HARRIS revealed that Guardian Flight had uncollectible, or
underfunded, service fees, in 2006, totally $2.3 million.
3:45:37 PM
MR. HARRIS responding to a member's question, stated that
Guardian Flight responds to every service request, including
calls from clinics, hospitals, or rural emergency medical
service systems.
REPRESENTATIVE GARDNER inquired about contracts from particular
hospitals, or agencies, to provide flight service on a routine
bases.
MR. HARRIS replied that there are preferred provider contracts.
3:46:53 PM
REPRESENTATIVE SEATON asked how a subscription service would
work if a patient needed transport from a different area of the
state, and whether the subscription agreement specifies which
areas are serviced.
MR. HARRIS explained that Guardian Flight has the ability to
service the entire state, and will respond regardless of the
subscriber's location. He noted that regulatory limitations,
such as certain FAA requirements, may affect the arrival time.
Guardian Flight informs the patient/doctor of the arrival time,
to allow them the option of alternative arrangements.
REPRESENTATIVE SEATON asked whether the patient is responsible
for the full cost of the service, in the absence of insurance
coverage.
MR. HARRIS replied yes.
3:49:17 PM
CHAIR WILSON said that she has had occasion to request Medivac
services, and has never been asked whether the patient has
insurance.
MR. HARRIS said that the non-profit agency, Critical Care, Inc.
(CCI), [Ketchikan, Alaska], offers memberships for Medivac
services.
3:50:19 PM
REPRESENTATIVE CISSNA opined that the high cost of a Medivac in
some rural areas is very expensive and constitutes a financial
burden to the communities. Some organizations are working to
provide medical services to areas that are lacking.
MR. HARRIS said that in the Tanana Chiefs area, the Council of
Athabascan Tribal Governments (CATG), has contracted with
Guardian Flight to provide medical services to seven
communities, and with another air carrier to service other
areas. He explained that two Guardian Flight doctors travel to
the seven communities to hold clinics three times a week. The
doctors are on contract with CATG, and Guardian Flight provides
the air support. However, if the patient is a Tanana Chiefs
client, they would use a Tanana Chief's service provider.
Guardian Flight has facilitated membership payments for CCI,
forwarding the necessary paperwork.
3:55:16 PM
REPRESENTATIVE FAIRCLOUGH asked if a definition of air ambulance
service is in state statute.
MR. HARRIS said statute requirements exist for each level of
certification of air medical services.
REPRESENTATIVE FAIRCLOUGH asked whether statute allows Guardian
Flight to solicit memberships.
MR. HARRIS replied that membership solicitation is restricted to
non-profit agencies; however, he understands that SSHB 100 will
allow for-profit businesses to seek memberships/subscriptions.
3:56:57 PM
REPRESENTATIVE FAIRCLOUGH asked if there are defined EMS
(emergency medicals service) boundaries in Alaska.
CHAIR WILSON offered that the services know their boundaries,
and the circumstances may dictate whether a patient is
transferred, at a given point, or carried non-stop to the
regional hospital.
REPRESENTATIVE CISSNA interjected that the state manages the
EMS.
3:58:00 PM
MS. MCLERON said there are no limits as to where an air medical
service is allowed to operate. She explained that some choose
to service only a defined area, or patient population, while
others provide state wide services. She reiterated that the
governing statutes, and regulations, set forth certification
requirements. In response to Representative Fairclough's query,
she noted that "air ambulance" is not defined in statute. The
governing regulations, AS 7 AAC 26.999, define Medivac services,
critical care air ambulance, and specialty aero medical
transport teams.
REPRESENTATIVE FAIRCLOUGH stated that the specific criteria
exists for the licensing requirement of the air ambulance
services, and asked about the defined areas that are established
in municipalities as EMS response areas.
MS. MCLERON confirmed, that specific, municipality EMS areas are
adhered to, and described the boundaries in Anchorage.
Regarding the air medical arena, she clarified, it is "market
driven;" there is not a certificate of need (CON) restricting
service areas. To a follow-up question, she said that Medicaid
regulations are not her purview. Receiving credentials from the
department means that the provider is meeting state standards,
and she explained the standards for a Medivac service.
4:01:09 PM
REPRESENTATIVE FAIRCLOUGH referred to page 1, line 8, Sec. 2. AS
21.03.021, and asked if this statement allows air ambulance
services to be exempt from insurance regulation.
MS. MCLERON declared that DHSS is not taking a stance on SSHB
100, and said that Sec. 2 appears to cover insurance.
4:01:51 PM
REPRESENTATIVE SEATON stated his understanding that SSHB 100
would allow private air ambulance services to use the same
subscription model, which is now limited for use by non-profit
agencies. He asked whether allowing wide spread use of this
model would diminish the existing community air medical
services.
MR. HARRIS responded that it comes down to what the market will
bear. Speaking specifically to the bill, he said that Guardian
Flight has found the non-profit model to be beneficial, creating
a symbiotic relationship for marketing purposes, as well as
meeting the needs of the communities. The non-profit
organization supports free hospital and EMS training, which is a
critical component to the air medical services system.
4:05:23 PM
TOM BAILEY, Manager, Providence, Air Medical Services, stated
opposition to SSHB 100, paraphrasing from a prepared statement,
which read as follows [original punctuation provided]:
I'm the manager of Providence Alaska Medical Centers
Air Ambulance Service, LifeGuard Alaska. LifeGuard
Alaska is a rotor and fixed wing air ambulance service
providing emergence medical transports, and specialty
transports throughout Alaska and have done so as a
dedicated service since 1986, touching the lives of
over 25, 000 Alaskans and non-Alaskans from premature
infants to adults. I would like to go on the record
first to thank representative Coghill for his efforts
in trying to decrease the cost risks for those
Alaskans with grave illnesses or injuries but would
also like to share with you my concerns with the bill
as written. Most people who have been seriously ill
understand that the costs can be astronomical and in
some cases people have put their own outcomes in
jeopardy as a result of trying to cut corners, or base
decisions on economics verses the path with the
greatest likelihood for a positive outcome. A
potential example of this is the patient who is in an
isolated village or community and having a heart
attack and belongs to a subscription for an air
ambulance that is not available for maybe hours and
chooses to wait verses allowing the use of another
provider and either succumbs to the heart attack or
loses so much heart muscle that he becomes a cardiac
cripple , and then is dependent on the government for
care throughout the rest of his life. In the case of
a trauma patient who chooses to wait for the next
available subscription flight he or she would reduce
the likelihood of a positive outcome. In this case
the golden hour of trauma kicks in which indicates
that if his or her chance of survival due to injuries
is 50% after one hour it decreases to 25% or two hours
12.5% etc. Again the desire to save expenses could
potentially result in death or long term disability.
There is also a potential for abuse of the service
which could leave those most in need of the service
waiting for the next available aircraft.
In addition to potential harm to the patient I believe
the question exists regarding the legality of a
membership program for the coverage of patients who
are Medicare, IHS [Indian Health Services], or
Medicaid eligible. Coverage for these patients
already exists. In the case of the Medicaid patient
there is no co-pay and by subscribing to a membership
they in essence are being charged a co-pay that they
one, are not legally required to pay and two, the
provider is not legally allowed to charge for. As you
are probably aware a large majority of rural Alaskan
natives are Medicaid eligible and there would be
little if any benefit to them, and if subscribed to a
membership program would be paying much needed money
for a service they are already covered for. In the
case of the Medicare and IHS patient I believe there
is question enough to research issues with anti-kick
back legislation.
Another issue in regard to the consumer is lack of
protection to the consumer in the event the provider
of service goes out of business or leaves the state.
The consumer has then paid for a service that they
will not receive without the protection of a refund.
I would also like to point out that I am not
personally aware of any service in the state of Alaska
in an emergency situation that asks for proof of
insurance or benefit coverage before transporting a
seriously ill patient. In fact it is the last thing
on our minds. As a provider for the citizens of
Alaska Providence writes off millions of dollars in
charitable care every year [sic], and LifeGuard Alaska
in particular operates at a loss to provide this much
needed service. I do not believe this bill will
benefit the providers or the majority of those
provided for.
4:10:40 PM
REPRESENTATIVE CISSNA inquired what regular services are
provided by Guardian Flight, to the Yukon Flats area.
MR. HARRIS responded that Guardian Flight primarily transports
doctors to the area, but also provides Medivac services.
4:14:17 PM
REPRESENTATIVE SEATON asked whether the practice of selling
subscriptions to persons eligible for Medicaid or Indian Health
Services (IHS), should be considered illegal.
MR. BAILEY opined that charging a Medicaid patient a service
subscription fee, is essentially the same as a co-pay, and the
legality of this is questionable.
4:15:33 PM
LINDA HALL, Director, Division of Insurance, Department of
Commerce, Community, & Economic Development (DCCED), stated
support for SSHB 100. She explained that the intent of this
bill does not address the provision of ambulance services, or
health insurance, but deals with subscriptions for air ambulance
services. She opined that perhaps a misunderstanding of Chapter
87, Title 21, has occurred. Only two entities in Alaska are
governed by Chapter 87, titled Hospital and Medical Service
Corporations: Premera Blue Cross and Vision Service Plans. The
division does not regulate an agency based on its status as a
profit, or not-for-profit, organization. The exclusions in
Chapter 87 are specific to that chapter, and do not exclude an
agency from being governed by Title 21. The bill does not
interfere with the provision of air ambulance services. She
observed that SSHB 100 is modeled after legislation passed in
Washington State. Following a 27 state survey, the Office of
the Insurance Commissioner found that air ambulance memberships,
not service, were considered insurance under Washington State
statute. She further described the result of that finding, and
the limiting effect it has had on air ambulance services in the
San Juan Islands. The air ambulance providers were informed
that their service was considered a product, and required them
to become insurers in order to continue operating. She said,
"To become an insurer is a very onerous process." Many of the
services were discontinued, based on that ruling. "Our
definition of insurance is broad," she said, and read the
definition [source not cited]:
Insurance means a contract where by ... one undertakes
to indemnify another or pay or provide a specified or
determinable amount or benefit upon determinable
contingencies." ... That could cover a myriad of
activities, all of which [the division has] the
ability to say are insurance. ... For [the division]
to regulate somebody selling an insurance product,
they have to become an insurer. ... To be an insurer
in Alaska, you have to have a specified by statute
amount of statutory capital and surplus. Minimum ...
to start an insurance company is $2 million dollars:
$1 million in capital, $1 million in surplus. ... You
get a certificate of authority, which says now you're
an insurer, ... you also get to have an annual audit
by your CPA ... $10,000 roughly. ... You also get to
have [the division] come in and do a financial exam
every three years, ... conservative[ly] $30,000. ...
If we say this air ambulance membership is an
insurance product, which we probably can under our
statute, then we have to make that air ambulance
company selling the membership an insurance company.
... The bills intent is merely to say that these
subscriptions are not insurance; it's not to impact
whether you have ambulance service.
MS. HALL noted that none of the states surveyed, in the
Washington study, have reported any consumer complaints, and she
stated that should a complaint arise, it would be directed to
the Division of Fraud, Department of Law.
4:23:31 PM
REPRESENTATIVE GARDNER clarified that SSHB 100 establishes
statute to stipulate that the sale of air ambulance
subscriptions does not constitute the sale of insurance. She
asked whether that will preclude the state from imposing
regulation, or providing statutory insurance laws to protect the
consumer, and what happens if someone purchases a lifetime
contract from a service provider whose business does not prove
viable.
MS. HALL offered that a restriction could be imposed on lifetime
memberships, and she pointed out that the consumer protection
office is available to enforce consumer protection laws.
4:25:24 PM
SHARLI HAYTER, Critical Care Incorporated (CCI), stated support
for SSHB 100, and described CCI as a non-profit organization
dedicated to providing support for education, training, and
research for Alaska's medical personnel. The organization is a
member supported service, and all members receive "the critical
care advantage": a no balance bill for Medivac services
received, if the services are provided by Guardian Flight. She
reported that 100 percent of donations received by CCI are
allocated for funding medical education and research.
REPRESENTATIVE SEATON requested clarity regarding the
subscriptions sold by CCI, and how the subscriptions relate to
the air ambulance services fees, which are collected directly
from patients.
MS. HAYTER stated that CCI does not sell subscriptions. She
said, "People donate to us and we call them members."
Additionally, CCI also solicits direct donations.
4:29:19 PM
REPRESENTATIVE GARDNER asked whether subscribers would receive
priority service should two medical emergencies occur and only
one Guardian Flight airplane is available.
MS. HAYTER answered that Guardian Flight will respond wherever
they are needed, without question. If a flight is not
available, the patient is immediately informed of the situation.
4:30:09 PM
LEIF WILSON, President, Director of Operations, 40-Mile Air,
Medivac Service, stated opposition to SSHB 100, and cautioned
that a membership service "effectively strips the local provider
from their ability to choose the Medivac service that is most
suited to the needs of the patient, for the particular problem
that exists, at that time." He described a recent situation, in
which a patient held a membership for a Medivac service based
out of Fairbanks. The patient insisted on waiting the 3-4 hours
that it would take for the service provider to arrive in Tok,
rather than use the local Medivac service. The response time
for 40-Mile Air is 30 minutes, and the ability to deliver a
patient to a regional hospital in less time than it would take
for one of the regional services to be dispatched to the Upper
Tanana area. Additionally, the subscription carrier service may
be weathered out, due to the lack of a precision landing
facility in Tok. Weather that does not allow for an aircraft to
land does not prohibit take-off, thus 40-Mile Air has the
advantage. He stressed the need for the local medical services
to have the option of utilizing a special service flight.
4:35:15 PM
CHAIR WILSON closed public testimony, and stated that the bill
would be held for further discussion.
^PRESENTATION: STRENGTHENING FAMILIES
4:35:50 PM
CHAIR WILSON announced that the final order of business would be
a presentation on Strengthening Families.
4:36:39 PM
CLAUDIA SHANLEY, Systems Reform Administrator, Office of
Children's Services (OCS), Department of Health and Social
Services (DHSS), stated that this presentation is being brought
on request of the committee chair, and is based on a jointly
attended National Conference on State Legislators meeting, held
recently in Chicago, Illinois. She described the Strengthening
Families Through Early Care and Education (SFTECE) program as a
national movement.
4:38:01 PM
SHIRLEY PITTZ, Coordinator, Early Childhood Comprehensive
Systems Plan (ECCS), Office of Children's Services (OCS),
Department of Health and Social Services (DHSS), introduced
herself.
MS. SHANLEY explained that this is a child abuse and prevention
program facilitated through early care and learning programs.
She presented slides, and paraphrased from an accompanying
prepared statement, which read as follows [original punctuation
provided]:
The ongoing interaction between early experience and
genetics affects the architecture of the maturing
brain and the function of the immune system.
As it emerges, the quality of that architecture
establishes either a sturdy or a fragile foundation
for all the learning behavior, and health that follow.
Nurturing and responsive interactions build healthy
brain architecture that provides a strong foundation
for learning behavior, and health.
When protective relationships are not provided
persistent stress results in the activation of
physiological systems that can disrupt brain
architecture by impairing cell growth and interfering
with the formation of health neural circuits.
Research on the biology of stress helps explain some
of the underlying casual mechanisms for differences in
learning, behavior, and physical and mental health
that are associated with poverty, maltreatment, and
discrimination.
Positive Stress is moderate, and short lived.
Tolerable Stress could disrupt brain architecture but
is buffered by supportive relationships that help the
child to facilitate adaptive coping skills.
Toxic Stress is a strong and prolonged activation of
the body's hormonal stress management systems in the
children without the buffering protection of adult
support.
MS. SHANLEY presented statistics, slide 8 [page 2], titled
"Reports of Harm by Age Group Federal Fiscal Year 2006," which
indicated that the birth to five year old category is the most
vulnerable age, comprising 35 percent of the total survey. She
described the two pronged approach to the issue, as she
continued paraphrasing from the prepared statement, which read
as follows [original punctuation provided]:
[The approach is to provide] universal and coordinated
access to prenatal care, primary health services, and
early care and education options to support families,
facilitate child well-being, and detect problems in
health or learning that can benefit from early
intervention.
[Additionally,] targeted and early provision of
service for children experiencing toxic stress to
reduce disruptions of the developing nervous and
immune systems that can lead to later impairments in
learning behavior and both physical and mental health.
To alter children's outcomes, it is necessary to
increase protective factors, and decrease risk
factors.
4:43:22 PM
MS. PITTZ, relayed that the inception of the SFTECE project was
at the Center for the Study of Social Policy (CSSP). This
agency, located in Washington, D.C., is focused on addressing
child abuse prevention, as well as early childhood education.
In 2001, the CSSP was seeking a strategic approach to child
abuse prevention that was: systematic, national in scope,
reached large numbers of very young children, and would have an
impact long before the abuse or neglect occurred. To facilitate
a paradigm shift, the center explored how child abuse efforts
have been addressed, and how they could be addressed, as set out
in slide 12, [page 2]. The old ideas included "at risk
labeling" of families and "highlighting bad parents." The new
idea calls for exploration of the protective factors approach to
build buffers, which include: going where the kids already are,
utilizing programs already in place; universal, implementation
of a none stigmatizing, educational approach; and acting before
anything bad happens. The hypothesis that the center arrived at
was that early care and education programs could be central
because they offer: daily contact with parents and children;
uniquely intimate relationships with families; a universal
approach of positive encouragement, and education for families;
and can serve as an early warning, and response system, at the
first sign of trouble. She presented slide 14 [page 3] titled
"New Child Abuse Prevention Framework" and stressed that the
intention is to implement a strength based approach, utilizing
hard evidence and research, and that everyone involved be
engaged in evidence based practices. She relayed that the
center looked for exemplary early care and education programs to
discover what protective factors are currently being practiced.
The protective factors compiled, indicated strategies which:
facilitate friendships, and mutual support, among the parents
through social events, support groups, and volunteer
opportunities; strengthen parenting through direct contact with
the parents, and by conducting home visits; respond to family
crisis; link families to services and opportunities, as well as
job training programs and educational opportunities; and value
and support parents involvement in the program.
4:50:12 PM
REPRESENTATIVE GARDNER stated that all of the qualities listed
fit the description of programs such as Head Start. It would
seem, she opined that this approach already exists, and asked if
there was a need to "reinvent something that has been around for
several decades."
MS. SHANLEY, responded that Head Start does fit this
description, however, establishing the evidence base is
important.
4:51:30 PM
REPRESENTATIVE CISSNA interjected her understanding that Head
Start financial support is waning, despite its effectiveness.
MS. SHANLEY declined to comment on the current status of the
Head Start programs.
4:52:10 PM
MS. SHANLEY stated that the model programs, observe and respond
to the early warning signs of child abuse and neglect. Quality
early child care and education programs allow time for staff to
observe situations, make determinations, and request assistance
if necessary. As a result, an early warning system is imbedded
in the program.
MS. SHANLEY, presented slide 18 [page 3], titled "Early care and
education programs can serve several critical roles for young
parents," which establishes the model program as: a primary
source of information, and support, for young families; a
gateway to outside services, or supports, such as health or
mental health services, transportation, education, housing, and
jobs; the key early warning system when families or children are
in trouble.
4:54:47 PM
MS. PITTZ provided the names, credentials, and affiliations of
the 11 member leadership teams representing the SFTECE program
in Alaska [slide 20, page 4]. She paraphrased the goals for
Alaska, slides 21 and 22 [page 4], which read as follows
[original punctuation provided]:
To highlight and expand the valuable role that early
care and education programs play in their efforts to
prevent child abuse and neglect.
To actively engage the early care and education
community in becoming key stakeholders in carrying out
child abuse and neglect prevention strategies.
To enhance collaboration between the Office of
Children's Services, Child Protection Program staff
and the early care and education community statewide.
To link early care and education and child protection
programs systems change efforts into a cohesive plan
for statewide implementation.
4:57:01 PM
MS. PITTZ named the five SFTECE pilot programs located in
Anchorage, Fairbanks, Juneau, and Dillingham, respectively
representing Boys and Girls Clubs, RurAL CAP Child Development
Center, Open Arms, Juneau Montessori School, and the Bristol Bay
Head Start Program. Further, she described each programs
operation, including ages and numbers of children served. In
the first year, the pilot programs each: completed pre and post
self-assessments, developed implementation plans, attended
orientation and training, participated in monthly "Learning
Network" teleconferences, and received mini-grants of $10,000.
She explained the self assessment, and how it was graded to
identify improvement areas in the programs.
5:00:57 PM
LUPITA ALVAREZ, Director, Juneau Montessori School, described
the steps and experience of the school joining the SFTECE
program. Although many of the goals were already being
accomplished by Juneau Montessori, room for improvement was
discovered in the process. The improvement opportunities were
capitalized on by the teachers including: offering parenting
classes; providing family support and social gatherings; and
facilitating intimate relationships between teachers and
parents. She reported that as these tools were implemented, the
program began to evolve. The sense of community, that had been
established, was strengthened, and families began to participate
more fully in activities. With the children arrive at 7 a.m.
and attending until 5:30, the bulk of their day is at the
school, thus involving the extended family in the classroom is
important. The other area of focus was the utilization of
mental health services. Children with special needs were
identified, and the families directed to the appropriate
professional care. She stated that this proved to be very
valuable to the families. The process also discovered children
and families who require special assistance, but do not qualify
for services; causing children to fall through the cracks. At
least the parents were informed, she said, and better able to
address the situation. Overall, she reported that it has been a
learning experience and the community response has been good.
5:08:07 PM
CHAIR WILSON asked how long it took for the parents to become
engaged, and participatory, beyond dropping off and picking up
their child.
MS. ALVAREZ stated that each family presents a unique situation,
however, the parent teacher conferences proved to be very
engaging.
5:09:33 PM
CHAIR WILSON addressed the presenters who had been Head Start
teachers, prior to their involvement in SFTECE, and asked how
this would effect their approach if they were still with Head
Start.
5:10:10 PM
MS. SHANLEY cited the recent advances for understanding the
early development of the child's brain, and said SFTECE offers
opportunities for prevention work that did not exist ten years
ago. Additionally, support of the family has been brought to
the forefront.
5:10:40 PM
CHAIR WILSON speculated that this program is an effective
vehicle to help parents know how to respond to their children,
in an age appropriate manner.
MS. PITTZ stressed that the success of the program revolves
around the relationship that is established between the parents
and the care givers.
5:12:10 PM
ADJOURNMENT
There being no further business before the committee, the House
Health, Education and Social Services meeting was adjourned at
5:12 p.m.
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