Legislature(1993 - 1994)
08/31/1993 09:00 AM House HES
| Audio | Topic |
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES
STANDING COMMITTEE
WORK SESSION
August 31, 1993
9:00 a.m.
MEMBERS PRESENT
Rep. Cynthia Toohey, Co-Chair
Rep. Pete Kott
Rep. Bettye Davis
Rep. Irene Nicholia (via teleconference)
Rep. Tom Brice (via teleconference)
MEMBERS ABSENT
Rep. Con Bunde, Co-Chairman
Rep. Gary Davis, Vice-Chairman
Rep. Al Vezey
Rep. Harley Olberg
OTHER LEGISLATORS PRESENT
Sen. Johnny Ellis
Sen. Dave Donley
Sen. Suzanne Little (via teleconference)
Rep. Joe Sitton (via teleconference)
Rep. Jim Nordlund
COMMITTEE CALENDAR
Work Session: Proposed Regulations on State Lab Fees
WITNESS REGISTER
DR. PETER NAKAMURA, Director
Division of Public Health
Department of Health & Social Services
P.O. Box 110610
Juneau, AK 99811-0610
Phone: (907) 465-3090
Position Statement: explained and defended fees
DR. KATHERINE KELLEY, Chief
Section of Laboratories
Division of Public Health
Department of Health & Social Services
3256 Hospital Drive
Juneau, AK 99801
Phone: (907) 586-3586
Position Statement: presented detailed history of how
regulations were adopted, what sort of
comments were received, how fees work
REP. JOE SITTON
Alaska State Legislature
Dimond Courthouse, Room 609
Juneau, AK 99801
Phone: (907) 465-2327
Position Statement: questioned fees and their public health
impact
CHARLES F. TEDFORD
Radiological Physicist
Division of Public Health
Department of Health & Social Services
320 West Willoughby Street, Suite 101
Juneau, AK 99811
Phone: (907) 465-3019
Position Statement: explained tube fees, defended
inspection system
MARGARET ERICKSON
Seward General Hospital
P.O. Box 265
Seward, AK 99664
Phone: (907) 224-3845
Position Statement: expressed concern with tube fees,
advocated moving radiological
inspector's office to Anchorage
TONI LEE, Lab Supervisor
Family Medical Center
HC 60, Box 3140
Delta Junction, AK 99737
Phone: (907) 895-5100
Position Statement: expressed concern with lab fees, their
effect on patient participation in
public health process
SHELIA NORDALE
Central Peninsula General Hospital
P.O. Box 866
Soldotna, AK 99669
Phone: (907) 262-4404
Position Statement: concerned about effect of fees on
hospital operations and collection of
public health data
JOAN BENNET SCHRADER
Coalition of Labor Women
Mount Redoubt Chapter
P.O. Box 1587
Kenai, AK 99611
Position Statement: opposed to fees, insistent on full
state funding
SEN. SUZANNE LITTLE
Alaska State Legislature
State Capitol, Room 7
Juneau, AK 99801
Phone: (907) 465-2828
Position Statement: expressed concern over infrequent
radiological testing, uncertainty as to
need for fee increases
TERRY SCHMIDT, Lab Supervisor
State Health Laboratory
Fairbanks, AK 99701
Phone: (907) 474-7017
Position Statement: representing self, questioned amounts
of lab fees
JENNIFER GARCIA
P.O. Box 110518
Anchorage, AK 99511
Phone: (907) 276-5222
Position Statement: expressed concern over fees and
privatization trend
HEATHER FLYNN
Abused Women's Aid in Crisis, Inc.
100 West 13th Avenue
Anchorage, AK 99501
Phone: (907) 279-9581
Position Statement: explained shelter's dependence on
Neighborhood Health Services and state
labs
JEANNE WOLF
Municipality of Anchorage
Department of Health & Human Services
Anchorage, AK
Phone: (907) 343-4605
Position Statement: expressed concern over effect of fees,
need for publicity of fee waivers
JAN WELLS
Municipality of Anchorage
Department of Health & Human Services
Anchorage, AK
Phone: (907) 343-4605
Position Statement: stated fear of cost shifting and effect
of fees on high quality of state labs
WILLIAM GALLANGER
664 West 34th Avenue, #425
Anchorage, AK 99503
Phone: (907) 562-5276
Position Statement: representing self, concerned with fees
and priority for tests
SALLY GUINEY
Petersburg General Hospital
P.O. Box 1244
Petersburg, AK 99833
Phone: (907) 772-4291
Position Statement: mammography fee too high, inspections
ought to be combined
SUSAN KERNES, President
Board of Directors
Kachemak Bay Family Planning Clinic
P.O. Box 984
Homer, AK 99603
Phone: (907) 235-5194
Position Statement: opposed fees, recommended consolidation
into one state lab
KIM SMITH
Kachemak Bay Family Planning Clinic
P.O. Box 2742
Homer, AK 99603
Phone: (907) 235-3436
Position Statement: listed specific public health concerns,
noted importance of accessibility
DAN FIEBELKORN
Southern Peninsula Hospital
P.O. Box 4333
Homer, AK 99603
Phone: (907) 235-8101
Position Statement: expressed concern that HIV tests would
no longer be confidential, and that
fees would hurt rural areas more
MARY JEFFERSON
Bartlett Memorial Hospital
9351 Miner Drive
Juneau, AK 99810
Phone: (907) 586-8417
Position Statement: specified some fees which shouldn't be
charged, likely problems with billing
DONALD NOVOTNEY
Bartlett Memorial Hospital
1120 Timberline Court
Juneau, AK 99810
Phone: (907) 586-8413
Position Statement: worried over charges for Hepatitis-B
tests, said use of private labs to save
money and time likely
TONY BELL
Municipality of Anchorage
Department of Health & Human Services
Sexually-Transmitted Diseases Clinic
525 `L' Street, #107
Anchorage, AK 99501
Phone: (907) 343-4611
Position Statement: concerned with fees' effect on
confidentiality, collection of data,
public use of labs
HAROLD JOHNSON, M.D.
Anchorage Neighborhood Health Center
1217 East 10th Avenue
Anchorage, AK 99501
Phone: (907) 257-4600
Position Statement: concerned with fees as compared to
private labs, inquired if doctors would
decide finally for whom to waive fees
GEORGE M. HANSEN, D.D.S.
Alaska Dental Society
Anchorage, AK
Phone: (907) 567-7518
Position Statement: opposed increase on per-tube
inspection, questioned entire
inspection program
KAY LAHDEMPERE
Municipality of Anchorage
Department of Health & Human Services
525 `L' Street
Anchorage, AK
Phone: (907) 343-4624
Position Statement: supported keeping tests in state labs,
keeping fees low to account for client
hardship
PATRICIA HONG
Alaska Nurses Association
237 East 3rd Avenue, #3
Anchorage, AK 99501
Phone: (907) 274-0827
Position Statement: supported prevention, including
testing, over mere treatment of illness
MELINDA EVANS, M.D., M.P.H.
Center for Health & Counseling
University of Alaska Fairbanks
Health & Social Services Building
Fairbanks, Alaska 99775
Phone: (907) 474-7043
Position Statement: opposed fees, listed problems expected
ELMER LINDSTROM
Special Assistant to the Commissioner
Department of Health & Social Services
P.O. Box 110601
Juneau, AK 99811-0601
Phone: (907) 465-3030
Position Statement: explained department's budgeting
REP. JIM NORDLUND
Alaska State Legislature
Dimond Courthouse, Room 608
Juneau, AK 99801
Phone: (907) 465-4968
Position Statement: criticized fees
SHARLANE DONALSON, Lab Supervisor
Crossroads Medical Center
P.O. Box 5
Glennallen, AK 99588
Phone: (907) 822-3203
Position Statement: exposed flaw in fee schedule,
questioned revenue generating potential
SUZANNE OLSON, Health Lab Supervisor
Center for Health & Counseling
University of Alaska Fairbanks
Health & Social Services Building
Fairbanks, AK 99775
Phone: (907) 474-7043
Position Statement: opposed fees, questioned how they were
calculated
DAN RITTER, Manager
State Health Lab
Fairbanks, Alaska 99775
Phone: (907) 474-7017
Position Statement: representing self, opposed fees
VICKI MARIE COLACICCO, Director
Public Health Nursing
Norton Sound Regional Hospital
P.O. Box 966
Nome, AK 99762
Phone: (907) 443-3221
Position Statement: opposed fees and cost shifting
DONNA HURDLE
Planned Parenthood of Alaska
406 West Fireweed Lane
Anchorage, AK 99503
Phone: (907) 272-4822
Position Statement: requested specification of which
sexually-transmitted diseases allow for
waivers
CARMEN DIEZ CANSECO-MALLIJUDI
3150 Seawind Drive
Anchorage, AK 99516
Position Statement: opposed charging lab fees, called
policy short-sighted
FRANK L. PAULS, M.D.
3431 Cottonwood Street
Anchorage, AK 99508
Phone: (907) 274-9930
Position Statement: opposed fees as likely to result in
further cuts in general fund support of
state labs
ROSE TANAKA, Manger
Public Health Lab
Division of Public Health
Department of Health & Social Services, Anchorage
P.O. Box 110610
Juneau, AK 99811-0610
Phone: (907) 465-3090
Position Statement: representing self, opposed fees
ACTION NARRATIVE
TAPE 93-68, SIDE A
Number 002
CHAIR CYNTHIA TOOHEY called the meeting to order at 9:00
a.m. and noted members and other legislators present. She
announced the calendar, namely consideration of regulations
proposed by the Department of Health & Social Services to
charge fees for services at state laboratories and for
radiological safety testing.
CHAIR TOOHEY noted that the meeting was being
teleconferenced to Juneau, Fairbanks, Bethel, Nome, Delta
Junction, Glennallen, Soldotna, Valdez, Cordova, Seward, and
Homer. She stated that hearings had been held on July 30
regarding the proposed regulations, but concerns expressed
to her and other legislators had led to the House HESS
Committee hearing on the same matter. She stated that the
Division of Public Health would consider testimony from this
hearing as it implemented its new regulations and outlined
the history of the regulations in question.
Number 067
DR. NAKAMURA, Director, Division of Public Health,
Department of Health and Social Services, began his
testimony by stating the importance of public health
independent of the process of health care reform. He
explained that the state's labs are an integral part of the
public health system, which is maintained by the state and
federal governments. He noted that funds were essential to
providing public health services, including lab services,
and when funds are not available several options exist:
altering the manner of services provided, either in quality
or quantity; or generating resources to maintain a level of
services. Fees are an attempt to do the latter, he said.
Number 113
REP. BRICE noted that the need for general fund monies for
the state laboratory program hadn't arisen in Health &
Social Services (HSS) Finance Subcommittee meetings, or if
it had been brought up it wasn't addressed. Rep. Brice
inquired what the status of lab funding had been at the time
the HSS Finance Subcommittee was doing its work.
DR. NAKAMURA responded that the initial cuts to the
division's budget had come in 1993, which caused the
division to consider where funds could be raised to replace
the lost general fund monies. Various programs were looked
at and lab services were considered a potential source for
an estimated $264,000.
Number 129
DR. KATHERINE KELLEY confirmed this amount at Dr. Nakamura's
request.
Number 130
DR. NAKAMURA finished by explaining that though the division
did not specifically request general funds for the labs,
they were at that time dealing with budgetary shortfalls
that extended into FY '94.
Number 135
DR. KATHERINE KELLEY, Chief of Public Health Laboratories
for the Division of Public Health, Department of Health and
Social Services, announced that she would be using an
overhead projector, prompting Rep. Brice to ask that the
materials she would display be transmitted to him via
facsimile.
Number 144
CHAIR TOOHEY responded that the information would be sent up
after the presentation.
Number 145
DR. KELLEY began by describing the state's public health lab
system: operating labs in Anchorage, Fairbanks, and Juneau;
the office of radiological health; and the chief's office.
She noted that some sort of public health lab had been
available since territorial days with a varying array of
services provided. She stated that in the past ten years
services at the public health labs had been reduced by
transferring them to other agencies or eliminating them.
Transferred services include all environmental testing
(except water microbiology in Juneau), the PSP program
(transferred to the Department of Environmental
Conservation), and the DWI program moved in 1987 (at which
time drug testing by public health labs was completely
eliminated).
Number 180
DR. KELLEY indicated that a quality assurance program had
been dropped, too, and the motivation for these changes had
been the budget. The labs were funded entirely from the
general fund, and the initial cuts in FY '93 led to an
effort to shift federal funds to cover the labs costs.
Federal funds include Medicare and Medicaid, which cannot be
billed selectively; every one must be billed for a service
if Medicare and Medicaid will pay for it. This led to
development of a schedule of fees that Dr. Kelley stated
seemed conservative to the division. This would have
yielded an estimated $260,000 for half of FY '93. Dr.
Kelley said that in order for the labs to bill legally,
regulations must specify for what services they would bill
and in what exact amounts. The review of all Health &
Social Services regulations would provide an opportunity for
all the divisions to evaluate their receipts and modify fees
charged, but a comprehensive fee schedule is time-consuming.
Number 219
DR. KELLEY continued by stating that concerned parties knew
of the proposed fee increases by the time the July 30
meeting was announced, and she had tried to give as much
advance notice as possible. She reflected that the public
notice format does not attract much attention, operating
within a certain bureaucratic framework. She said she
appreciated the fact that many persons sincerely felt they
had not received adequate notice.
Number 236
DR. KELLEY displayed an overhead transparency illustrating
the public notice process and a summary of the verbal
comments from the July 30 meeting with written comments
received through August 18. These comments were divided
into categories of concern: cost of fees and impact on care
(27 comments); epidemiological impact (17 comments); and
concerns about specific fees and how they would be collected
in situations of high public health concern (no number).
DR. KELLEY mentioned for Rep. Brice's benefit that the
transparency she was currently discussing was in the file in
his possession.
Continuing with categories of concern, DR. KELLEY listed
possible privatization of public health labs and efficiency
of public health labs compared with the private sector;
regulations and the notice process; the amount of detail in
regulations and the guidance they provide; billing and
payment of fees; and the decision-making process on
implementation including waivers and discounts. Fifteen
comments were received on radiological fees.
DR. KELLEY noted that there was a lot of misunderstanding
about the proposed fees and that fees were calculated in
accordance with a system derived from the Centers for
Disease Control and the public health lab directors using a
standard lab accounting system common in the private sector.
The cost of lab time is the base unit for the system.
DR. KELLEY cited the proposed fee documentation,
specifically the charts on pages 14-19 comparing costs of
public fee schedules at private labs doing business in
Alaska (based on FY '92 figures). Dr. Kelley pointed out
that she was aware that public fee schedules do not
represent all prices charged for services by labs, given
some contractual arrangements. She explained how she had
gone through the fee schedule and marked the fees that were
higher, roughly equal, or lower than the proposed state
fees, calculating that for the 68 state public health lab
fees for which comparable private data existed 57% were
lower, 24% were about the same, and 19% were higher than the
private fees. She listed the procedures for which the
proposed state fees were higher, describing these as time-
consuming and/or rare.
Number 389
DR. KELLEY addressed the epidemiological impact of the
proposed fees, noting that the major concern she was aware
of was the waiver language in the regulations. She
recommended reading the regulations, most importantly the
sliding fee scale section which mentions health services but
not labs, because it was not the division's intent to use
the sliding scale for lab services. She explained that
waivers were intended to apply to lab fees, then read how
the waivers would help provide necessary public health
information when an outbreak occurred, as fees for testing
for it would be waived.
Number 441
CHAIR TOOHEY asked DR. KELLEY if she considered TB or HIV an
ongoing epidemic.
DR. KELLEY responded that these diseases were ongoing
epidemics but not outbreaks, which are clusters being
investigated in order to find the source and bring in
necessary medical services to stop the spread of a disease.
She then pointed out that a waiver could be granted if the
lab service was necessary to detect a sexually-transmitted
or communicable disease that would pose a health risk to the
general public. She said this was an example of a long-
term, ongoing effort to control, say, HIV.
Number 462
REP. BRICE asked DR. KELLEY if removal of the term
"sexually-transmitted" meant such diseases would be covered
by the term "communicable."
DR. KELLEY responded in the affirmative.
Number 470
CHAIR TOOHEY noted that REP. BETTYE DAVIS joined the
meeting.
Number 474
DR. KELLEY spoke of the third justification for waiving a
fee, which states that the inability to pay will not result
in denial of services. She noted that this provision was
not only regulatory but present in the enabling statute.
She cited page 8, mentioning free screening and pre- and
post-test counseling as services that must be offered free
of charge in the interest of public health, which she
interpreted as meaning HIV testing would be offered for
free. She said that the Department of Law had instructed
the writers of the fee schedule that unless a service has a
fee associated with it, no fee could be charged under any
circumstances; HIV and TB are listed in the schedule to
allow for the possibility of charging for testing in a
specific situation, such as a contract research project.
Number 530
CHAIR TOOHEY reiterated that she wanted to know if the labs
would charge for TB and sexually transmitted diseases.
DR. KELLEY responded that no fees would be charged when the
tests were in the interest of public health.
CHAIR TOOHEY asked how they defined the interest of public
health.
DR. KELLEY stated that that was "the tough one." With TB,
she said, the labs would take direction from the Section of
Epidemiology.
Number 550
REP. BRICE mentioned that many concerns were based on the
definition of public health, especially if said definition
depended on funding levels, and a drop in funding levels
could make some tests less important to the public health
than they should be. He asserted his desire for a stronger,
clearer definition of public health in order to allow for
better guidelines.
DR. KELLEY responded that in her thirty-year career in
public health she had experienced constant grappling with
the definition of public health and she didn't think she
could answer the question once and for all, but the Alaskan
definition was the relevant one and the public health
meeting in Fairbanks in September would be an excellent
forum to define public health.
Number 590
REP. SITTON said he agreed with Rep. Brice that the state
underfunds public health, and asked Dr. Kelley why so few
federal funds were available for state labs.
DR. KELLEY responded that traditionally public health labs
had not received direct funding from the federal government,
even from the mother agency, the Centers for Disease
Control. Dr. Kelley said that the majority of federal funds
were grants to the program element housed in the Section of
Epidemiology, which was generous in assisting public health
labs with the federal funds available to them. She noted
that while labs had not been well-funded federally, she had
written a grant application for equipment replacement to
reduce the diagnosis time for TB, and the labs had received
$38,000. Dr. Kelley stated that she expected no federal
funding in the coming year.
Number 660
REP. SITTON commented that without dealing with the
specifics of the fee schedule, nothing is more cost-
effective than prevention, and any fee interfering with
prevention defeated the main purpose. He stressed the
imperative of adequately funding public health, and
expressed his concern with the Division of Public Health's
quarter-million dollar budget cuts every year.
CHAIR TOOHEY mentioned that the division had not had its
funding reduced at least since 1988 and these reductions had
not originated in the legislature.
Number 683
REP. SITTON responded that he had thought he had seen a
$254,000 operations reduction in the last year.
CHAIR TOOHEY said that it must have been an inter-agency
reallocation, as the legislature had not cut it. She then
asked DR. KELLEY to finish up her testimony.
TAPE 93-68, SIDE B
Number 028
DR. KELLEY spoke about the privatization concerns raised at
the July 30 meeting, and tests that would be shifted to the
private sector. She asserted that these concerns were
common to every one involved in public health who want just
to survive and not to compete. She stated that she hoped
the waiver system was comprehensible, and if there were
questions, she would answer them if possible.
DR. KELLEY mentioned concerns about the efficiency of the
public health labs, not for quality, but for fiscal
efficiency, given bureaucratic constraints. She accepted
that the state health labs were not fiscally efficient
compared with those in the private sector, and she had so
stated at the July 30 meeting.
DR. KELLEY mentioned that billing would be direct to a
third-party payer if one existed, and the labs would collect
a minimum of information above that currently collected from
providers; three or four simple questions would be asked
regarding a patient's insurance status, and the policy
number if insured. She said providers would decide if
patients needed to use the waiver option due to an inability
to pay.
Number 070
CHAIR TOOHEY clarified her earlier comment on the budget's
not having been reduced, stating that the lab budget had not
been reduced. She continued, saying that a major concern
she had heard was whether or not one would have to lie in
order to get a test fee waived.
Number 084
CHARLES TEDFORD, Radiological Health Specialist, Division of
Public Health, Department of Health and Social Services,
addressed three questions about the radiologic health
program. Mr. Tedford noted that there were 1265 x-ray tubes
in the state at many different medical offices, a majority
being dental. He stated that there were 29 or 30
mammography units, spread out individually except for
concentrations of three in Anchorage and Juneau. Mr.
Tedford noted that proposed fee increases were from $20 to
$50 on dental tubes; from $30 to $80 for medical units; and
$1500 for mammography inspections.
MR. TEDFORD noted three issues arising when considering
fees: cost by number of inspections and related expenses;
total departmental expenses; and comparison with other
states (asserting that Alaska was more expensive than other
states due to travel and other factors). He said that
presently the program had $140,000 and one person, and that
it ought to have $250,000 and three persons. He stated that
the fees covered 25-50% of actual costs excluding
mammography; the federal contribution to the mammography
figure was probably $1200, which Alaskans probably would not
pay. He said the mammography program would be transferred
to the Food & Drug Administration on October 1, 1994, though
it may still be administered by the state's radiological
health officer. He mentioned the operator licensing
inspector who accompanied him on inspections as an example
of additional expenses to mammography.
CHAIR TOOHEY asked MR. TEDFORD if he considered equipment
manufacturer's contract tests valid.
MR. TEDFORD noted that that question had been raised at the
July 30 hearing, and a radiologist had stated that he was
inspected four times a year; this duplication comes from
different sources requiring inspection.
Number 174
MR. TEDFORD mentioned a recent study requested by Governor
Hickel on radiological threats in response to events at Fort
Greely and Point Hope, citing the top recommendation: the
state ought to revise and implement the existing x-ray unit
inspection program to ensure that x-ray units are inspected
and that the frequency inspections recommended protects
public health; the greatest exposure for most Alaskans to
radiation comes from diagnostic x-rays used in medical and
dental facilities; inspection of x-ray machines and
correction of deficiencies is the most effective way to
minimize unnecessary exposure; and inspections in Alaska are
far behind schedule.
Number 198
MR. TEDFORD noted the question of why mammography fees were
so much higher than for other machines, answering that they
required much longer inspections due to Medicare funding
requirements. He noted the question of why the radiological
inspector was situated in Juneau when most units requiring
inspection were elsewhere, and answered that most programs
of this sort were located in state capitals and relocating
the inspector would have only a very small effect on costs.
He mentioned the issues of how often inspections were
required and how frequently they occurred; if other
qualified individuals could perform inspections and submit
reports; if inspections could be conducted by mail; and what
qualifications an inspector needed.
Number 248
CHAIR TOOHEY thanked MR. TEDFORD and asked for the SEWARD
TELECONFERENCE SITE to present testimony.
Number 256
MARGARET ERICKSON, Head of the Radiology Department at
Seward General Hospital, stated that the hospital's greatest
concern was the increased cost of inspection, largely
because of travel costs. She endorsed the idea of moving
the radiological inspector's office to Anchorage for cost
savings before adoption of the $1500 fee.
Number 274
CHAIR TOOHEY thanked Ms. Erickson for her testimony and
noted for the record the arrival of Rep. Jim Nordlund. She
then asked for the DELTA JUNCTION TELECONFERENCE SITE to
present testimony.
Number 282
TONI LEE, Laboratory Supervisor, Family Medical Center,
commented that the proposed lab fees would be a problem in
her area due to an influx of low-income persons and
increased dependence on state labs. She mentioned
difficulty in getting patients to submit insurance
information or documentation of inability to pay, and state
labs' history of intervention in epidemics before they
start. Ms. Lee expressed her belief that it is harder to
get someone to pay for a procedure that does not affect him
or her directly.
Number 299
SHELIA NORDALE, Central Peninsula General Hospital,
Soldotna, stated that charging fees for services could
restrict accessibility to health care by the poor and if
persons avoided testing for sexually transmitted diseases or
TB, waiting until their condition became critical, greater
expense would result than that incurred by screening and
early treatment. She said that if state labs began
charging, the hospital would likely start sending its tests
to a reference lab, which would delay collection of data for
epidemiological purposes. Ms. Nordale noted that if state
labs charged a retail price, it might increase health care
costs for consumers.
Number 324
CHAIR TOOHEY thanked MS. NORDALE for her testimony and asked
for the next witness.
Number 327
JOAN BENNET SCHRADER, Coalition of Labor Union Women, Mount
Redoubt Chapter, Kenai, spoke of the taxpayers' having paid
for a modern lab that was badly needed and her group's
concern over the status of public health in the state. Ms.
Schrader asked for a series of conveniently timed public
meetings to discuss this issue and mentioned that labs on
the Kenai Peninsula had to choose between testing for HIV
and testing for TB. Ms. Schrader asked the legislature to
fund clinics at a level that would eliminate fees, and
characterized this as a responsibility.
Number 362
CHAIR TOOHEY pointed out to Ms. Schrader that the statute
allowing for regulations charging fees dated from 1986,
though the fees themselves were more recent.
The Chair then recognized REP. BRICE.
Number 370
MS. SCHRADER interrupted, claiming that her group recognized
the point made by Chair Toohey, but by accepting
responsibility as taxpayers and voters, they knew that the
law had sometimes to be amended or changed.
Number 375
REP. BRICE asked for Ms. Schrader's address.
Number 380
SEN. LITTLE said she was appalled to hear Mr. Tedford say
that some radiological units had not been inspected in ten
years, and asked him to verify that she had heard him
correctly. She inquired as to the type of units having gone
uninspected.
MR. TEDFORD stated that he would have to check records to
provide the exact units, but they were of all types, in
isolated areas. He said he would provide the information
after checking the record, though he remembered a number in
the seven-year category. Mr. Tedford asserted the need for
more staff to conduct inspections.
Number 401
DR. KELLEY stated that the radiological testing program was
a one person office, and x-ray inspections were but a part
of his job, which included providing expert advice to the
Governor and others on radiation. She added that it had
taken over two years after the last radiological physicist
retired to recruit a replacement.
REP. NICHOLIA stated that she thought it would be wise to
move the radiological testing person to Anchorage to improve
access to rural areas.
Number 431
CHAIR TOOHEY asked SEN. LITTLE if she had further
commentary.
SEN. LITTLE responded that she was certain this was an area
requiring change, better performance, and heightened
efficiency in addressing public health needs. She stated
she was unconvinced that higher fees were the answer, but
ensuring the inspection of radiological equipment more
frequently than once a decade was necessary.
Number 444
CHAIR TOOHEY asked the FAIRBANKS TELECONFERENCE SITE to
present testimony, suggesting that REP. SITTON and REP.
BRICE speak.
REP. BRICE mentioned that Rep. Sitton had intended to speak
but he had to leave. Rep. Brice stated he would let persons
who had come to testify present their testimonies.
Number 456
TERRY SCHMIDT, Lab Supervisor, State Health Laboratory,
Division of Public Health, Department of Health and Social
Services, spoke as an individual. He referred to page 45 of
the proposal where lab services were allocated $2.2 million
for FY '92. He subtracted radon monitoring and radiological
testing costs to arrive at a figure of $2.1 million for lab
services.
MR. SCHMIDT mentioned the figures used to determine the
work-time unit from page 77, stating that horizontal
addition of those numbers yielded a figure of almost $3.5
million, indicating that the total cost used to calculate
fees exceeded the actual appropriation by $1.4 million. Mr.
Schmidt said the cost of tests and the resultant proposed
fees were inflated by 63%. He questioned the work-time unit
for individual tests, citing his prior day's lab experience
setting 170 hepatitis-b tests, which he processed the
following morning. Mr. Schmidt noted that the proposed fee
was based on a lab work-time of ten minutes for a single
hepatitis-b test, and the official time he calculated of
1700 minutes (just over 23 hours) was much greater than the
two and a half hours it actually had taken him.
MR. SCHMIDT hypothesized that the figures were determined
based on small numbers of tests being done, though large
batches were common. He stated his belief in the efficiency
of the labs, but it was unreasonable to expect tests to be
sent to the labs if overcharging occurred. He noted that
the cost estimates accounted for having to set up a billing
system that would require four new positions, leasing a
computer at a cost of $300,000, and paying for office space.
Number 527
MR. SCHMIDT emphasized that revenues from fees would
probably not exceed the costs of implementing the fee
schedule. He stated that the labs' approximate budget
request for FY '94 was $2.9 million, which he divided by the
state's population to arrive at a cost per person of $5.30,
or just over $21 for a family of four. Mr. Schmidt stated
his belief that the labs provided a level of service to each
Alaskan.
Number 541
CHAIR TOOHEY asked for persons present at the meeting in
ANCHORAGE to testify next.
Number 562
JENNIFER GARCIA, Anchorage, stated that she had testified at
the July 30 hearing on the proposed regulations and many of
her concerns had since been addressed. She said she felt
privatization was coming to the state lab system and
wondered whether the public sector could bid for components
of the work, such as insurance billing. Ms. Garcia stated
that she thought billing would involve fourth and fifth
parties after the third party, that it would be expensive,
and that it was not a task to which lab technicians were
accustomed.
Number 600
HEATHER FLYNN, Executive Director of Abused Women's Aid in
Crisis (AWAIC), Anchorage, told how the shelter received
weekly services via a federal grant and the Neighborhood
Health Center. She said a registered nurse visited weekly
to tend to cuts and bruises, but women coming to the shelter
were often unable to get basic health services. Ms. Flynn
said the Neighborhood Health Center provided blood analysis,
urological analysis, gynecological tests, and other services
to which women at the shelter often haven't had access in a
long time, intervening at a much better point than if the
conditions were allowed to go untreated. She said a lot of
children were helped by the shelter through such procedures
as well baby checks, immunizations, and other treatment of
common ailments. She praised the Neighborhood Health
Center's contributions to the shelter's operations,
mentioning her awareness that the Center used state labs for
all the shelter's tests. Ms. Flynn expressed concern that
paperwork generated by the proposed regulations would take
funds from actual lab work, and pointed out that persons
leaving her shelter continued to rely on the Neighborhood
Health Center or the Municipal Health Department.
Number 669
JEAN WOLF, Municipal Department of Health & Human Services
Community Health Services Division, Anchorage, stated that
she had testified at the July 30 hearing and she felt more
comfortable after hearing Dr. Kelley's remarks. Ms. Wolf
expressed lingering concern for some clients unable to pay
for services. Her first concern was perception, based on
her experience with federal parental notification rules,
that publicity could deter persons from coming in for tests
merely because they would think they would have to pay until
the were seriously ill. Ms. Wolf stated that good
information needed to go out to the public regarding fees,
and she would like an agreement that if the fee system
turned out not to work, the issue could be revisited in
order to make the system work better.
Number 721
CHAIR TOOHEY clarified that statute signs bearing the
message that one would not have to pay if one could not
afford it would be posted at all lab sites. She said she
felt this was a very important message.
TAPE 93-69, SIDE A
Number 001
MS. WOLF noted that having signs up at clinics would make no
difference if persons failed to come to those locations.
She stated that there had been a reduction in public health
service funding at the municipal level, with more tasks
being done by fewer persons.
CHAIR TOOHEY recognized JAN WELLS.
Number 022
JAN WELLS, TB Control Community Health Nurse Supervisor for
the Municipal Department of Health & Human Services,
Anchorage, said she was reassured by Dr. Nakamura and Dr.
Kelley's statements that necessary public health work could
be done without charging for lab tests. She said she was
still concerned at hearing of cost shifting at the state
Department of Health & Social Services as this had happened
with Medicaid and Medicare. Ms. Wells stated that in
seeking payment for services that had been publicly funded,
the focus of those services might shift due to staffing
constraints. She praised the quality of state labs and
expressed her hope that the system, of which all were proud,
would be maintained in spite of fees.
Number 045
CHAIR TOOHEY called WILLIAM GALLANGER to testify.
WILLIAM GALLANGER, Anchorage, stated that he worked in lab
services but was representing himself at the hearing, though
he felt he represented many lab workers and their concerns.
He said based on his handling of TB work, he would like to
maintain the quality of lab services, and the fee schedule
would limit the availability of health care. He said that
in Alaska private labs often hadn't the resources to provide
testing for low income persons. Mr. Gallanger told a story
about an immigrant to the U.S.A. who was in Alaska but three
days, displayed TB symptoms, and came into contact with
approximately 200 persons while staying at the Brother
Francis Shelter. He made the point that if all 200 persons
had needed to be tested, it would have stressed the clinic,
lab, and hospital involved to the point of sending specimens
to an Outside reference lab. Mr. Gallanger expressed hope
that given the speed and efficiency of state labs, the
legislature would prioritize which tests would remain
available for no fee in order to protect rural areas likely
to be impacted harder than Anchorage.
Number 097
CHAIR TOOHEY asked Dr. Kelley if she would like to address
Mr. Gallanger's concerns.
DR. KELLEY stated that the example situation would come
under the outbreak or emergency category, and that skin
tests would be done prior to lab tests.
Number 109
CHAIR TOOHEY called for the PETERSBURG TELECONFERENCE SITE
to present testimony.
Number 110
SALLY GUINEY, Lab Director and Radiologist, Petersburg
General Hospital, stated that $1500 was too high a fee for
mammography, noting that a Seattle physicist was performing
annual inspections for them for Medicare certification at a
cost of $2500. She said that in addition to this, they paid
for Medicare and state inspections of other radiological
equipment. Ms. Guiney asked why mammography and general
tube inspections couldn't be combined to reduce costs,
perhaps inspecting all tubes in a community on one visit.
Ms. Guiney stated that the hospital often used the Juneau
state lab for confirmation of work, not for primary testing.
She then asked what the fees would be for specimens sent for
identification, pointing out a discrepancy between two
different figures for a parasitology test.
DR. KELLEY said the fee would be $19.75 for parasitology,
and confirmation tests would be charged back.
Number 159
CHAIR TOOHEY asked SUSAN KERNES at the HOMER TELECONFERENCE
SITE to testify.
SUSAN KERNES, President, Kachemak Bay Family Planning Clinic
Board of Directors, identified herself as underinsured, and
stated that public health was a part of government's duty to
maintain public safety. She said the public health system
was in place to monitor and react to general public well-
being, a mission that would be undermined by fees that could
force family planning clinics to shut. Ms. Kernes explained
that the clinic received many reproductive health services
at low cost or free from state labs and charged low fees to
clients. She commented on a study by a New York consultant
assessing the sometimes unsafe, crumbling lab
infrastructure, which recommended centralization as the way
to go. She noted that the study suggested closing the three
main labs due to inadequate physical plant. She recommended
creating a new state of the art facility to serve the entire
state, as well as possibly in terms of accuracy, speed and
efficiency.
CHAIR TOOHEY recessed the meeting for five minutes.
Number 205
KIM SMITH, Kachemak Bay Family Planning Clinic, testified
from Homer that cervical cancer and genital warts were
considered public health issues. She said 27 pap smears had
been done at four clinics in July and August and the average
client's income was $918.15 per month. She asserted the
importance of these critical procedures to women and her
desire to see them remain available. Ms. Smith proposed, in
reference to HIV, that the health of an entire community
often depended on the health status of its least advantaged
member, indicating that health care must be obtainable.
Number 227
CHAIR TOOHEY recognized DAN FIEBELKORN in Homer.
DAN FIEBELKORN identified himself as Lab Director at South
Peninsula Hospital, and said he had been in health care
service in Alaskan labs for twenty years and he truly
appreciated state labs. He stated the need to keep billing
in the hospital, which would not happen in cases of
inability to pay, resulting in violation of HIV test
confidentiality as information was released. He indicated
that borderline cases would probably go to reference labs,
using staff time and funds, leading towards privatization
which would have a greater negative impact rurally.
Number 250
CHAIR TOOHEY asked DR. KELLEY to respond.
DR. KELLEY stated that there was no plan to charge for HIV
testing in the normal course of events, making fears of
billing information leaking into the insurance system
unfounded. She said she shared the reference lab concern,
anticipating the loss of some data. She cited studies from
other states where fees had been implemented showing a
return to 80-90% of the pre-fee workload after a year with
fees.
Number 270
CHAIR TOOHEY asked if anyone in ANCHORAGE wishing to testify
had a time constraint.
MR. FIEBELKORN asked Dr. Kelley how cases where a patient
was able to pay for an HIV test would be handled, as no
specific provision exempted such persons from billing.
DR. KELLEY answered that HIV testing was listed only to
allow for the possibility of billing at some future point,
which would be impossible were it not listed. She said
future information would address the matter.
Number 295
CHAIR TOOHEY called witnesses to the table, then recognized
MARY JEFFERSON and DONALD NOVOTNEY at the JUNEAU
TELECONFERENCE SITE.
MARY JEFFERSON said she was Lab Manager at Bartlett Memorial
Hospital and listed four concerns: that fees not be charged
for epidemiological activity, such as stereotyping organisms
for CDC; that fees not be charged for TB monitoring, which
was proposed excepting that funding developments could alter
this; that Bartlett would shop for the cheapest and quickest
lab, reducing the state's access to information; and that
billing would be hard in labs without computers. Ms.
Jefferson noted that lab workers in Alaska are uncommon, and
that adding billing to their appointed duties would increase
stress on the profession.
Number 350
DONALD NOVOTNEY said he was Infection Control Practitioner
at Bartlett Memorial Hospital, and explained that his job
was to protect employees. He cited Occupational Safety &
Health Administration requirements for occupational exposure
control with HIV and hepatitis-b, noting that although HIV
tests were to remain free, there might be charges for
hepatitis tests. He mentioned that state labs had a ten-day
return time, and price differentials would necessitate
shopping. Mr. Novotney noted that he would prefer to keep
the money in Alaska if speed and cost were comparable. He
said that he would like to see duplication of services
eliminated.
Number 389
CHAIR TOOHEY thanked Mr. Novotney for his testimony and
asked TONY BELL to speak.
TONY BELL said he was a Nurse Practitioner who had been at
an STD Clinic for thirteen years. He listed his concerns:
that the definition of public health was related to waiver
of fees for certain procedures based on the availability of
funds; that confidentiality be maintained; that word of fees
would deter persons from testing despite public notice of
the waiver system; that collection of data not be impaired;
and that more paperwork would be detrimental to clinical
efficacy.
Number 425
CHAIR TOOHEY pointed out that by law clinics must notify the
Division of Public Health of suspected TB or sexually
transmitted disease infection.
MR. BELL responded that identification had to be by number
and not by name.
DR. NAKAMURA noted that the regulations allowed for
providers to exercise judgment in order to maintain good
public health practices.
Number 447
CHAIR TOOHEY called DR. HAROLD JOHNSON to speak.
HAROLD JOHNSON said he was Family Physician and Medical
Director of the Anchorage Neighborhood Health Center, and
that information he had heard at the day's hearing allayed
his fears, which were the viability of state labs facing
competition with lower fees (his annual fees at proposed
state levels would be $120,000 versus $90,000 with a private
contractor), and the loss of epidemiological information as
free testing ended for many persons and procedures.
CHAIR TOOHEY asked DR. KELLEY to address these issues.
DR. KELLEY stated they would be dealt with in the final
recommendations to the Commissioner of Health & Social
Services.
DR. NAKAMURA added that most decisions would remain in the
hands of providers and that the division did not want to
have to decide.
Number 525
DR. JOHNSON asked if a provider would decide finally if a
person could pay.
DR. KELLEY told him he was correct.
Number 553
CHAIR TOOHEY called DR. GEORGE HANSEN from the Alaska Dental
Society, who expressed his and the Society's opposition to
any increase in fees for inspection of dental x-ray
machines. He noted his lack of expertise in radiology, but
also his twenty-five years using dental x-ray equipment. He
said dentists agreed to testing of machines initially to
comply with federal law and offer the best possible service
to patients, and the fee of $20 had been thought reasonable
given the nature of the machines and their use.
Number 570
DR. HANSEN explained dentists' experiences with inspectors,
and voiced his belief that inspections probably ought to be
regularly timed and less labor-intensive. He stated that
dental x-rays were being considered inaccurately with
medical devices, and the proposed fee increase was unwise as
it would be paid by patients.
Number 639
CHAIR TOOHEY thanked DR. HANSEN for his testimony and noted
that she had a letter from a DR. HIBSCHER that she would
like to have included in the record.
The Chair then called for KAY LAHDEMPERE.
KAY LAHDEMPERE, Public Health Nurse Manager, Municipal
Family Planning Clinic, said she had been with the clinic
since 1966. Ms. Lahdempere said she had worked extensively
with state labs, and that tests ought to continue to go to
state labs. She thanked Drs. Nakamura and Kelley for their
sensitivity on the issue, noting her lab was charged with
serving low-income and teen-aged patients. She noted three
items: use of Outside labs, consistency of epidemiological
reporting, and clients' hardships.
CHAIR TOOHEY asked Ms. Lahdempere to limit her testimony to
the allotted time.
MS. LAHDEMPERE noted problems in using Outside labs, and the
chlamydia rate among persons aged fifteen years and younger
was 25%, necessitating reasonable fees.
TAPE 93-69, SIDE B
Number 011
PATRICIA HONG, President, Alaska Nurses Association,
reminded the committee that nurses nationally supported
prevention and health promotion programs over treatment.
She noted that health promotion and disease prevention
required surveillance which could not occur if fees were
prohibitive. She stated that she didn't want to see a shift
to illness care only, but hoped Alaska's focus on prevention
would persist.
Number 022
CHAIR TOOHEY recognized REP. BRICE, and asked the FAIRBANKS
TELECONFERENCE SITE to testify.
REP. BRICE introduced DR. MELINDA EVANS of the Center For
Health & Counseling at the University of Alaska Fairbanks.
DR. EVANS described the Center's duty to provide primary
care and counseling to students who did not budget, and thus
could not pay for, health care. Dr. Evans said students
would not be able to pay for tests, and that in spite of the
testimony she had heard, she feared the fees would impair
her ability to track illnesses on campus. She proposed that
the fees could end up costing the state more if an outbreak
resulted, and she asserted that data collection on illnesses
was essential to provision of public health. She said that
private physicians and clinics did not always report data to
the state.
DR. EVANS stated that current practice was not to bill
Medicaid, that no system was in place to determine waiver
eligibility, and that increased paperwork would result. She
pointed out a flaw in the revenue estimates for the proposed
fees - that reduced demand would result from increased
prices, yielding less total revenue. She defined public
health as an investment in the population, and pointed to
erosion of support for this investment through reduced
services. She also said she was unsure if the Center would
be considered a private or public provider.
Number 065
CHAIR TOOHEY asked ELMER LINDSTROM, Special Assistant to the
Commissioner of Health & Social Services, to speak briefly.
Number 068
MR. LINDSTROM described the department's budgeting and the
effect formula funding of some programs and of mental health
trust income account funding had on other agencies in the
department. He said the Division of Public Health's budget
relied on two strategies to make up for lost general funds:
seeking federal grants, and Medicaid refinancing (also known
as cost shifting). The use of the latter strategy lead to
confusion over whether or not reductions had occurred. Mr.
Lindstrom noted that the aforementioned consultant's report
on lab consolidation was very important and needed to be
considered at Dr. Nakamura's upcoming public health
conference.
Number 123
DR. NAKAMURA noted that the conference was legislative, not
his, and that Rep. Sitton had taken the lead on getting the
conference together.
Number 130
REP. NORDLUND stated fees were dubious public policy, and as
the fees had resulted from prior legislative action, it was
the legislature's job to appropriate supplemental monies.
CHAIR TOOHEY noted for the record that SEN. DONLEY arrived
at the meeting. She then called for SHARLANE DONALSON at
the GLENALLEN TELECONFERENCE SITE to testify.
Number 145
SHARLANE DONALSON identified herself as Lab Supervisor at
Crossroads Medical Center, complimented state labs, and
noted that the epidemic policy needed work in order to
determine when an epidemic started and whether or not
surveillance testing was necessary. She questioned at what
point waivers for testing would apply to all epidemic
victims. She said the fee schedule was flawed in that it
assumed all cultures would be positive and would require
full work-ups, when in reality many were negative. Ms.
Donalson said she had a computer at her facility, but she
disagreed that a few simple questions would provide enough
insurance information due to the complexity of third-party
billing and insurers' demands for diagnostic codes.
Number 207
CHAIR TOOHEY asked DON RITTER and SUZANNE OLSON to testify.
SUZANNE OLSON said she was Lab Supervisor at the Health
Center at UAF, and when she had heard of impending fee
increases, she had not been alarmed and expected the
increases to be minimal. She stated that the proposed fees
were surprisingly high and that she would probably get lab
service from other labs at a more reasonable cost, though
this was not her desire. Ms. Olson expressed her wish that
careful attention be paid to lab workers' concerns, and that
the erroneous method of calculating fees be addressed.
Number 234
DON RITTER said he was speaking as a private citizen, and
that the state had a moral and ethical obligation to provide
for public health, and fees would ultimately jeopardize the
public health infrastructure.
Number 252
REP. NICHOLIA mentioned significant opposition in District
36 to increased lab fees, and said there had been a
hepatitis epidemic, and mentioned other dangerous diseases.
Number 273
VICKI MARIE COLACICCO, Director of Public Health Nursing at
Norton Sound Hospital, commented on her need to establish a
billing position in order to recoup lost general fund monies
from Medicaid, which would require the loss of a nursing
position. She noted the difficulty of distinguishing
between the inability and the unwillingness to pay. She
stated that TB and hepatitis were endemic in her region and
the need for surveillance made deciding whether or not to
waive fees difficult. Ms. Colacicco questioned the language
allowing fees to be raised or changed at the discretion of
the commissioner.
Number 317
DONNA HURDLE, Executive Director of Planned Parenthood, said
all costs for non-profit providers were significant, meaning
use of private labs would occur if necessary. She noted her
need for a list stating exactly which sexually-transmitted
diseases allowed for waivers. Ms. Hurdle stated that every
one had a different means of determining ability to pay, and
even in low-income groups there was a great variety of
circumstances.
Number 345
CHAIR TOOHEY stated that each provider's definition of
ability to pay was the deciding one.
Number 352
CHAIR TOOHEY asked if anyone on the teleconference network
wanted to testify. There was no response.
Number 366
CARMEN DIEZ CANSECO-MALLIJUDI said that as a health educator
she viewed collection of data as essential to health
promotion, disease prevention, and cost containment. She
mentioned Alaska's problem with cervical cancer in Natives,
and that cutting costs by raising fees was short-sighted.
Number 385
DR. FRANK PAULS stated that he had expressed his views in
writing to the commissioner. He then told the committee how
he had come to Alaska in 1938 to establish the first
territorial lab in Juneau and had retired as chief of the
Section of Labs in 1979. He said that the hearing showed
concern, and that the idea of charging fees could lead to
the legislature's viewing state labs as a source of revenue,
with fees' being raised to a point of self-sufficiency. He
stated that this development would result in the loss of a
public service.
Number 445
CHAIR TOOHEY asked for a last time if anyone else wanted to
testify.
ROSE TANAKA, Manager of the Public Health Lab in Anchorage,
representing herself, recognized the need to look at other
funding alternatives than fees, including consolidating labs
and flat fees for services.
Number 468
CHAIR TOOHEY announced that public testimony was closed and
indicated for the record that four minutes remained of
meeting time. She thanked the department and the interested
public. She welcomed written testimony and adjourned the
meeting.
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