Legislature(1995 - 1996)
04/11/1996 02:07 PM 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
April 11, 1996
2:07 p.m.
MEMBERS PRESENT
Representative Cynthia Toohey, Co-Chair
Representative Con Bunde, Co-Chair
Representative Gary Davis
Representative Norman Rokeberg
Representative Caren Robinson
Representative Tom Brice
Representative Al Vezey
MEMBERS ABSENT
None
COMMITTEE CALENDAR
CS FOR SENATE BILL NO. 193(L&C)
"An Act requiring insurance coverage for certain costs of birth;
and providing for an effective date."
- PASSED HCS CSSB 193(HES) OUT OF COMMITTEE
CS FOR SENATE BILL NO. 158(L&C) am
"An Act relating to pharmacists and pharmacies."
- PASSED HCS CSSB 158(HES) OUT OF COMMITTEE
CS FOR SENATE BILL NO. 259(HES)
"An Act extending the termination date of the Alaska Commission on
Aging; and providing for an effective date."
- PASSED OUT OF COMMITTEE
CS FOR SENATE BILL NO. 165(L&C)
"An Act relating to psychologists and psychological associates."
- PASSED HCS CSSB 165(HES) OUT OF COMMITTEE
PREVIOUS ACTION
BILL: SB 193
SHORT TITLE: MANDATORY INSURANCE FOR COSTS OF BIRTH
SPONSOR(S): SENATOR(S) SALO, Donley, Ellis, Duncan, Kelly, Pearce,
Zharoff; REPRESENTATIVE(S) Robinson, B.Davis, Finkelstein, G.Davis,
Navarre
JRN-DATE JRN-PG ACTION
12/29/95 2056 (S) PREFILE RELEASED - 12/29/95
01/08/96 2056 (S) READ THE FIRST TIME - REFERRAL(S)
01/08/96 2057 (S) LABOR & COMMERCE
01/16/96 2143 (S) COSPONSOR(S): DUNCAN
02/15/96 (S) L&C AT 1:30 PM BELTZ ROOM 211
02/15/96 (S) MINUTE(L&C)
02/21/96 2487 (S) L&C RPT CS 2DP 1NR SAME TITLE
02/21/96 2487 (S) ZERO FNS TO SB & CS (DCED,ADM,DHSS)
02/21/96 2487 (S) FIN REFERRAL ADDED
02/21/96 2498 (S) COSPONSOR: KELLY
02/27/96 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/07/96 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/12/96 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/12/96 2707 (S) FIN RPT 5DP 2NR (L&C)CS
03/12/96 2707 (S) PREVIOUS ZERO FNS (DHSS, ADM)
03/12/96 2707 (S) ZERO FN (DCED)
03/12/96 2718 (S) COSPONSOR(S): PEARCE, ZHAROFF
03/13/96 (S) RLS AT 11:00 AM FAHRENKAMP RM 203
03/13/96 (S) MINUTE(RLS)
03/22/96 2834 (S) RULES TO CALENDAR 3/22/96
03/22/96 2840 (S) READ THE SECOND TIME
03/22/96 2840 (S) L&C CS ADOPTED UNAN CONSENT
03/22/96 2841 (S) ADVANCE TO THIRD RDG FLD Y8 N11 E1
03/22/96 2841 (S) THIRD READING 3/25 CALENDAR
03/25/96 2868 (S) READ THE THIRD TIME CSSB 193(L&C)
03/25/96 2868 (S) PASSED Y17 N3
03/25/96 2868 (S) EFFECTIVE DATE(S) SAME AS PASSAGE
03/25/96 2869 (S) Sharp NOTICE OF RECONSIDERATION
03/26/96 2911 (S) RECONSIDERATION NOT TAKEN UP
03/26/96 2912 (S) TRANSMITTED TO (H)
03/27/96 3386 (H) READ THE FIRST TIME - REFERRAL(S)
03/27/96 3386 (H) HES, L&C
03/28/96 3465 (H) CROSS SPONSOR(S): B.DAVIS
03/29/96 3495 (H) FIRST CROSS SPONSOR(S): ROBINSON
03/29/96 3495 (H) CROSS SPONSOR(S): FINKELSTEIN,
G.DAVIS
04/01/96 3552 (H) CROSS SPONSOR(S): NAVARRE
04/11/96 (H) HES AT 2:00 PM CAPITOL 106
BILL: SB 158
SHORT TITLE: PHARMACISTS AND PHARMACIES
SPONSOR(S): SENATOR(S) MILLER
JRN-DATE JRN-PG ACTION
04/13/95 1025 (S) READ THE FIRST TIME - REFERRAL(S)
04/13/95 1026 (S) LABOR & COMMERCE
04/25/95 (S) L&C AT 1:30 PM FAHRENKAMP RM 203
04/25/95 (S) MINUTE(L&C)
05/02/95 (S) L&C AT 1:30 PM FAHRENKAMP RM 203
05/02/95 (S) MINUTE(L&C)
05/05/95 1524 (S) L&C RPT CS 3DP 2NR SAME TITLE
05/05/95 1524 (S) FISCAL NOTE TO SB (DCED)
05/05/95 1524 (S) ZERO FISCAL NOTE TO CS (DCED)
05/07/95 (S) RLS AT 1:00 PM FAHRENKAMP ROOM 203
05/07/95 (S) MINUTE(RLS)
02/21/96 2489 (S) RULES TO CALENDAR 2/21/96
02/21/96 2489 (S) ZERO FISCAL NOTE TO CS (FY97)(DCED)
02/21/96 2491 (S) READ THE SECOND TIME
02/21/96 2491 (S) L&C CS ADOPTED UNAN CONSENT
02/21/96 2492 (S) AM NO 1 ADOPTED UNAN CONSENT
02/21/96 2492 (S) AM NO 2 ADOPTED UNAN CONSENT
02/21/96 2492 (S) ADVANCED TO THIRD READING UNAN
CONSENT
02/21/96 2492 (S) READ THE THIRD TIME CSSB 158(L&C) AM
02/21/96 2493 (S) PASSED Y19 N- E1
02/21/96 2498 (S) TRANSMITTED TO (H)
02/22/96 2852 (H) READ THE FIRST TIME - REFERRAL(S)
02/22/96 2852 (H) HEALTH, EDUCATION & SOCIAL SERVICES
04/09/96 (H) HES AT 3:00 PM CAPITOL 106
04/11/96 (H) MINUTE(HES)
04/11/96 (H) HES AT 2:00 PM CAPITOL 106
BILL: SB 259
SHORT TITLE: COMMISSION ON AGING
SPONSOR(S): RULES BY REQUEST OF THE GOVERNOR
JRN-DATE JRN-PG ACTION
02/02/96 2282 (S) READ THE FIRST TIME - REFERRAL(S)
02/02/96 2282 (S) HES, FIN
02/02/96 2282 (S) FISCAL NOTE (ADM)
02/02/96 2283 (S) GOVERNOR'S TRANSMITTAL LETTER
03/08/96 (S) HES AT 9:00 AM BUTROVICH ROOM 205
03/08/96 (S) MINUTE(HES)
03/11/96 2685 (S) HES RPT CS 2DP 1NR NEW TITLE
03/11/96 2686 (S) PREVIOUS FN (ADM)
03/27/96 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/28/96 (S) FIN AT 8:30 AM SENATE FINANCE 532
03/28/96 2941 (S) FIN RPT CS 5DP 2NR NEW TITLE
03/28/96 2942 (S) ZERO FN TO CS (ADM)
03/29/96 (S) RLS AT 12:05 PM FAHRENKAMP RM 203
04/03/96 3045 (S) RULES TO CALENDAR 4/3/96
04/03/96 3046 (S) READ THE SECOND TIME
04/03/96 3047 (S) FAILED TO ADOPT FIN CS Y9 N10 E1
04/03/96 3047 (S) HES CS ADOPTED Y12 N7 E1
04/03/96 3048 (S) ADVANCED TO THIRD READING UNAN
CONSENT
04/03/96 3048 (S) READ THE THIRD TIME CSSB 259(HES)
04/03/96 3048 (S) PASSED Y19 N- E1
04/03/96 3048 (S) EFFECTIVE DATE(S) SAME AS PASSAGE
04/03/96 3053 (S) TRANSMITTED TO (H)
04/04/96 3634 (H) READ THE FIRST TIME - REFERRAL(S)
04/04/96 3635 (H) HES, FINANCE
04/09/96 (H) HES AT 3:00 PM CAPITOL 106
04/09/96 (H) MINUTE(HES)
04/11/96 (H) HES AT 2:00 PM CAPITOL 106
BILL: SB 165
SHORT TITLE: PSYCHOLOGISTS & PSYCHOLOGICAL ASSOCIATES
SPONSOR(S): HEALTH, EDUCATION & SOCIAL SERVICES BY REQUEST
JRN-DATE JRN-PG ACTION
04/25/95 1230 (S) READ THE FIRST TIME - REFERRAL(S)
04/25/95 1230 (S) HES, L&C
01/17/96 (S) HES AT 9:00 AM BUTROVICH ROOM 205
01/17/96 (S) MINUTE(HES)
01/18/96 2166 (S) HES RPT CS 4DP SAME TITLE
01/18/96 2166 (S) ZERO FISCAL NOTE TO SB & CS (DCED)
01/30/96 (S) L&C AT 1:30 PM FAHRENKAMP RM 203
01/30/96 (S) MINUTE(L&C)
01/31/96 2262 (S) L&C RPT CS 2DP 2NR SAME TITLE
01/31/96 2262 (S) PREVIOUS ZERO FISCAL NOTE (DCED)
02/02/96 (S) RLS AT 10:15 AM FAHRENKAMP RM 203
02/02/96 (S) MINUTE(RLS)
02/07/96 2324 (S) RULES TO CALENDAR 2/9/96
02/09/96 2359 (S) READ THE SECOND TIME
02/09/96 2359 (S) L&C CS ADOPTED UNAN CONSENT
02/09/96 2359 (S) ADVANCED TO THIRD READING UNAN
CONSENT
02/09/96 2359 (S) READ THE THIRD TIME CSSB 165(L&C)
02/09/96 2360 (S) PASSED Y19 N0 E1
02/09/96 2363 (S) TRANSMITTED TO (H)
02/12/96 2718 (H) READ THE FIRST TIME - REFERRAL(S)
02/12/96 2718 (H) HEALTH,EDUCATION AND SOCIAL SERVICES
04/02/96 (H) HES AT 3:00 PM CAPITOL 106
04/02/96 (H) MINUTE(HES)
04/04/96 (H) HES AT 3:00 PM CAPITOL 106
04/04/96 (H) MINUTE(HES)
04/09/96 (H) HES AT 3:00 PM CAPITOL 106
04/09/96 (H) MINUTE(HES)
04/10/96 3682 (H) ECD AND L&C REFERRAL ADDED
WITNESS REGISTER
BRUCE RICHARDS, Legislative Administrative Assistant
to Senator Judy Salo
Alaska State Legislature
Capitol Building, Room 504
Juneau, Alaska 99801-1182
Telephone: (907) 465-4940
POSITION STATEMENT: Presented Sponsor Statement for SB 193
JANET PARKER, Deputy Director
Division of Retirement & Benefits
Department of Administration
P.O. Box 110203
Juneau, Alaska 99811-0203
Telephone: (907) 465-4470
POSITION STATEMENT: Testified on CSSB 193(L&C)
STEVE LeBRUN, Senior Account Manager
Aetna Health Plan
Aetna Life Insurance Company
P.O. Box 91032
Seattle, Washington 98111-9132
Telephone: (206) 467-2803
POSITION STATEMENT: Testified on CSSB 193(L&C)
GAIL McGILL, Registered Nurse and Director
of Quality and Utilization Management
Columbia Alaska Regional Hospital
Anchorage, Alaska 99501
Telephone: (907) 264-1754
POSITION STATEMENT: Testified in support of CSSB 193(L&C)
JANET OATES, Representative
Providence Health System
P.O. Box 196604
Anchorage, Alaska 99519
Telephone: (907) 261-4946
POSITION STATEMENT: Testified on CSSB 193(L&C)
DR. RICHARD NIST, Obstetrician/Gynecologist
4120 Laurel
Anchorage, Alaska 99508
Telephone: (907) 563-6515
POSITION STATEMENT: Testified on CSSB 193(L&C)
GORDON EVANS, Lobbyist
Health Insurance Association of America
318 4th Street
Juneau, Alaska 99801
Telephone: (907) 586-3210
POSITION STATEMENT: Testified in opposition to CSSB 193(L&C)
NANCY WELLER
Division of Medical Assistance
Department of Health & Social Services
P.O. Box 110660
Juneau, Alaska 99811-0660
Telephone: (907) 465-3355
POSITION STATEMENT: Answered questions on CSSB 193(L&C)
JANET THURSTON
436 Valley View Drive
Fairbanks, Alaska 99701
Telephone: (907) 457-1164
POSITION STATEMENT: Testified on CSSB 193(L&C)
PAT SENNER, Executive Director
Alaska Nurses Association
P.O. Box 102264
Anchorage, Alaska 99510
Telephone: (907) 243-8044
POSITION STATEMENT: Testified in support of CSSB 193(L&C)
SCOTT CALDER
P.O. Box 75011
Fairbanks, Alaska 99707
Telephone: (907) 474-0174
POSITION STATEMENT: Testified on CSSB 193(L&C)
SENATOR JUDY SALO
Alaska State Legislature
Capitol Building, Room 504
Juneau, Alaska 99801-1182
Telephone: (907) 465-4940
POSITION STATEMENT: Prime sponsor of SB 193
ALISON ELGEE, Deputy Commissioner
Department of Administration
P.O. Box 110200
Juneau, Alaska 99811-0200
Telephone: (907) 465-2200
POSITION STATEMENT: Testified on CSSB 259(FIN)
ACTION NARRATIVE
TAPE 96-39, SIDE A
Number 001
The House Health, Education and Social Services Standing Committee
was called to order by CO-CHAIR CYNTHIA TOOHEY at 2:07 p.m.
Members present at the call to order were Representatives Toohey,
Davis, Rokeberg and Brice. A quorum was present to conduct
business.
CO-CHAIR TOOHEY announced the calendar for the meeting was CSSB 193
(L&C), "An Act requiring insurance coverage for certain costs of
birth; and providing for an effective date"; CSSB 158(L&C) am "An
Act relating to pharmacists and pharmacies"; CSSB 259(FIN), "An Act
extending the termination date of the Alaska Commission on Aging;
and providing for an effective date"; and if time allows, CSSB
165(L&C) "An Act relating to psychologists and psychological
associates."
CO-CHAIR CON BUNDE arrived at 2:09 p.m.
CSSB 193(L&C) - MANDATORY INSURANCE FOR COSTS OF BIRTH
Number 199
BRUCE RICHARDS, Legislative Administrative Assistant to Senator
Judy Salo, said Senator Salo introduced this legislation basically
to set some guide limits for the coverage on the cost of
hospitalization and medical care after birth. Senator Salo had
been contacted during the interim by a constituent who had been
told that her insurance would not cover an additional day beyond
the 24 hours following the birth of her child and she didn't feel
she was ready to go home. Senator Salo started doing some
checking and found this is not a huge problem in Alaska, but she
has been getting more and more calls since she introduced the
legislation. It is quite a large problem in the Lower 48 which is
where all Senator Salo's information came from. She had the
legislation drafted and basically what it does is require mandatory
coverage of hospitalization or medical care for 48 hours after a
vaginal birth and 96 hours after a caesarean section. It does not
mandate the patient to stay in the hospital if the patient wishes
to go home; it is purely a cost question of who is paying.
CO-CHAIR TOOHEY asked if the insurance companies charge for the 24
hours or for the actual time in the hospital?
MR. RICHARDS asked if she was referring to the time right after
birth.
CO-CHAIR TOOHEY said this legislation would allow for 48 hours
after a vaginal birth, but if the patient decided to stay only 24
hours, which is the patient's option, is that what the insurance
company charges for or do they charge for all 48 hours?
MR. RICHARDS said if a patient is in the hospital for only 24 hours
after the birth, that's what the insurance company charges for.
CO-CHAIR TOOHEY asked if there were any additional questions of Mr.
Richards. Hearing none, she asked Janet Parker to come forward to
testify.
REPRESENTATIVE CAREN ROBINSON arrived at 2:12 p.m. and
REPRESENTATIVE AL VEZEY arrived at 2:13 p.m.
Number 394
JANET PARKER, Deputy Director, Division of Retirement & Benefits,
Department of Administration, said she was available to answer
questions the committee might have regarding the fiscal note or how
this bill applied to the state health plan.
CO-CHAIR BUNDE noted there were three zero fiscal notes, yet this
bill would increase coverage and wondered who was going to pay for
that increased coverage?
MS. PARKER responded the division doesn't believe there will be
much increase at all for the state's plan; definitely not enough to
impact the premium. The state's plans are based on experience and
1.7 days is the average hospital stay for an uncomplicated vaginal
delivery. Based on that, currently more mothers are staying for
two days, but there are a lot of them going home after one day.
She commented it hasn't been a problem with the state's plan. In
her discussions with nurses at Aetna, they don't recall there being
a conflict with a doctor saying his/her patient needs another day
in the hospital. The division does not believe this legislation
will have an impact.
CO-CHAIR TOOHEY asked Ms. Parker if the division had received any
complaints?
MS. PARKER recalled having a complaint for someone who wanted to be
certified in advance for two days, but the state's plan only
certifies for one day. The nurses at Aetna will advise that an
individual can be certified for one day and to simply call if an
additional day is needed.
CO-CHAIR TOOHEY said she understood there is a difference in
delivery versus entry time. For example, some hospitals don't
start counting the time until the delivery takes place while others
start counting from the time a patient enters the hospital.
MS. PARKER commented that Bartlett Memorial Hospital in Juneau
actually does a delivery charge time and then starts the patient in
the hospital upon birth as far as staying as a patient. She noted
that hospitals bill from midnight to midnight on any hospital stay.
CO-CHAIR TOOHEY asked her to explain.
MS. PARKER said she walked into the hospital at ten minutes past
midnight and delivered her baby at 12:55 a.m. so her day didn't
start until the following day because the hospital counts from
midnight to midnight. On the other hand, if she had gone into the
hospital at 11:00 p.m., the hospital would have started the day and
charged for the full day if she had left at 10:00 the next morning.
CO-CHAIR TOOHEY asked if a mother delivers her child at 1:00 a.m.,
24 hours would be 1:00 a.m. the next day, so is that when the
mother would leave?
MS. PARKER replied no, she actually left about 36 hours later and
was charged one day by the hospital which was paid by the
insurance.
CO-CHAIR TOOHEY inquired who absorbs the rest of it?
MS. PARKER said the hospital bills from midnight to midnight, so
the hospital is absorbing it. The hospital doesn't charge for the
day of discharge.
CO-CHAIR TOOHEY asked if that was okay with the hospital?
MS. PARKER deferred the question to a hospital representative.
Number 678
REPRESENTATIVE GARY DAVIS said it appears there's a patient day -
midnight to midnight - but the legislation speaks specifically to
the period of time after child birth. He asked if that would be in
conflict with any hospital policies?
MS. PARKER said she didn't think so. She believed that Aetna uses
the guidelines of starting from the point of birth.
CO-CHAIR BUNDE observed that if a patient delivers her child at
1:00 a.m., conceivably a hospital could ask the patient to leave at
1:00 a.m. the following day.
MS. PARKER said she didn't think that would happen.
CO-CHAIR BUNDE said conceivably it could happen if they enforced
the 24 hours.
Number 765
REPRESENTATIVE ROBINSON said it was her understanding that this
legislation eliminates some of the red tape that occurs if a
patient needs to stay an additional day.
MS. PARKER didn't know if Aetna, with regard to the state's plan,
would change its procedure to check up and see if the patient needs
to be there. She views it more in the line that if managed care
came into Alaska and tried to do a 6-hour discharge after delivery,
it would be more of a protection. She reiterated she doesn't
believe there is a problem now. In her particular case, Aetna
certified an additional day for her and her baby because the doctor
thought the baby needed to stay in the hospital a while longer.
REPRESENTATIVE ROBINSON noted it was the local hospital board who
actually requested this legislation because of problems at Bartlett
Memorial Hospital.
Number 835
CO-CHAIR TOOHEY asked if the division had a specific criteria for
caesarean births?
MS. PARKER said the state does not, but Aetna does. She believed
that Aetna would certify three days at the start, and a person
could call for anything beyond that.
CO-CHAIR TOOHEY asked if the division intervenes when a problem
arises between a patient and the insurance company? If so, do they
win?
MS. PARKER said the division does intervene a lot and they don't
lose them all.
CO-CHAIR TOOHEY commented they do lose a certain amount of them,
however.
MS. PARKER said that was true and added they are not doctors.
CO-CHAIR TOOHEY said that was the statement she wanted to hear;
they aren't doctors and neither are the insurance companies.
Doctors are doctors and they make the final judgment.
Number 894
CO-CHAIR BUNDE said the fiscal note represents the state's policy
with Aetna and based on Ms. Parker's experience, it's not a problem
with Aetna if a doctor requests certification for a patient to stay
for an additional length of time. Therefore, this bill isn't
really needed and doesn't have an impact on the state employers who
are covered by the state program through Aetna. It may however,
have an impact on other businesses and other insurance programs.
MS. PARKER said she could not speak to what other companies are
doing.
CO-CHAIR BUNDE said the point he was getting at is that while there
will be no fiscal impact at this point to the state, there may well
be fiscal impact for private industry.
MS. PARKER said potentially yes.
CO-CHAIR TOOHEY asked if there were additional questions of Ms.
Parker. Hearing none, she asked Steve LeBrun to present his
testimony.
Number 973
STEVE LeBRUN, Senior Account Manager, Aetna Health Plan, Aetna Life
Insurance Company, said that SB 193 relates to the (indisc.) topic
given that (indisc.) delivery is the most frequent cause of
hospital admission in the United States. He said it's also true
that the trend for hospital length of stay for mothers and newborns
has been decreasing for many years. He said the committee had
already heard that not all mothers want to stay in the hospital and
that many would prefer to be at home with their families as soon as
they can. Nevertheless, Aetna understands this trend has raised
concerns, often based on anecdotal stories bubbling up from the
Lower 48. He believes everyone shares the goal of seeing that the
care and coverage needs of each individual mother and newborn are
recognized. Admittedly, coverage policies on payment criteria
from one health insurer to another may vary. In that regard, Aetna
would not be opposed to taking steps to avoid or weed out blatant
abuses as to where they exist or develop.
MR. LeBRUN said that Aetna Health Plan doesn't itself have a policy
which requires routine discharge of maternity patients from the
hospital after a one day stay. In pre-certifying hospital stays
for maternity, this is usually a process done months in advance of
the delivery date. Aetna does, in fact, generally pre-certify for
one day of hospitalization on the assumption of a routine,
uncomplicated delivery. However, after the birth has taken place
they will discuss with the attending obstetrician and pediatrician
and work with them if additional time in the hospital appears
appropriate and warranted, given the condition of the mother and
the newborn. In answer to a question, it is Aetna's standard up-
front certification for a caesarean section to allow for three days
essentially without question and then as with any confinement,
whether maternity related or otherwise, to then work with the
patient's physician to certify additional days as medically needed.
Aetna also agrees that medical decisions should be made by the
attending medical professional after consultation with their
patients and after an assessment of their medical condition.
Likewise, just for clarification, all of Aetna's benefit payment
decisions concerning maternity and maternity length of stay are
also made by medical professionals, either registered nurses or
physician (indisc.) reviewers; they don't use clerks or bureaucrats
or have any sort of blanket rule making.
MR. LeBRUN said Aetna doesn't want mothers and newborns discharged
from the hospital unless they meet appropriate guidelines. They,
in fact, use the guidelines that have been developed over time by
the American Academy of Pediatrics and the American College of
Obstetrics and Gynecology. Aetna has implemented those guidelines
in full, using the standards established by these groups. The
criteria included in these guidelines are fairly extensive and
include among other things, consideration that the mother has had
a full term, uncomplicated pregnancy, that infant growth is
appropriate, that development is normal, that lab screen tests have
been performed and there's been an assessment that the mother and
infant have been observed for sufficient time to ensure that both
are stable, the mother has received instruction in child care and
the social environment has been assessment, so from that
perspective it is appropriate and timely for her to go home or not
go home, and that the specific physical condition and status of
both mother and child has been attained prior to release.
CO-CHAIR TOOHEY commented that Mr. LeBrun had sent her the
guidelines for a 24-hour discharge following an uncomplicated
vaginal delivery and asked if she had his permission to distribute
that document to the committee.
MR. LeBRUN responded he had no problem with that. He noted the
guidelines are not Aetna developed guidelines; Aetna uses what he
thinks are the guidelines established by the medical review body.
CO-CHAIR TOOHEY referred to Mr. LeBrun's comment that decisions are
made by medical personnel and said she believes the only medical
personnel that should be consulted is the doctor who is caring for
the mother and the baby. She asked if Aetna gives paramount
consideration to them?
MR. LeBRUN said certainly, the attending physicians are in the best
position to assess the health status; therefore, they would be
looked to for advice and consultation.
CO-CHAIR TOOHEY asked how often does Aetna disagree and not allow
the physician's advice to carry any weight? Also, if a patient
signs out of a hospital AMA, meaning away without medical advice,
that carries a lot of weight; however, if Aetna determines a
patient needs to leave the hospital and will not pay for the
additional service, shouldn't there be a legal document which
states that Aetna is taking on the responsibility for that patient?
MR. LeBRUN said in answer to the first question, he didn't have
firm data with him on weights of acceptance or denial, other than
to say it would be the rare circumstance where there would be a
difference of opinion. Also, his involvement with the state
employees' plan as well as other plans, is that in this area in
working with Alaska facilities and providers, maternity lengths of
stay is not in any way a chronic ongoing issue. Regarding the
second question, he agreed there are some difficulties with the
concept, but Aetna's role is as a fiduciary of the health insurance
plan and it's in that role as administer of a health plan of
benefits, not as a care giver, that they are making a benefit
decision. Certainly, it is their hope and he thinks it's almost
always the case that Aetna's review for benefit coverage purposes
coincides with the physician's intent in that manner and that Aetna
is in agreement that items are medically needed and not just
convenient. Obviously, if a patient wants to stay and it's
primarily for convenience and not for a medical reason, it is
possible they may end up at odds with each other. Aetna does work
directly with attending physicians to fully understand the
patient's medical circumstances, but they can make an
individualized decision, when necessary.
CO-CHAIR BUNDE referenced a memorandum which indicated that if a
mother and newborn baby leaves the hospital within 24 hours, they
are eligible for a home care visit. However, if they stay in the
hospital longer than 24 hours, they lose the option for the home
care visit. He asked how this legislation would affect that
policy?
MR. LeBRUN said he wasn't aware that is Aetna's policy. He didn't
know of any hard and fast rule that would make home care visit
contingent on length of stay. Generally, he thinks there are many
cases where a home visit may not be necessary the next day, but he
wasn't aware of any blanket rule in that regard. He added that
Aetna has consistently promoted home health care visits as a good
quality cost effective alternative.
CO-CHAIR BUNDE said the conversation regarding the home care visits
had originated with Janet Keough of Aetna in Seattle and said he
would share the information with Mr. LeBrun, if he desired.
MR. LeBRUN reiterated that if it is the policy, he wasn't aware of
it. He said he would be happy to discuss the issue in his office
and confirm or clarify that issue for the committee.
CO-CHAIR BUNDE said he would appreciate that because to quote her,
"A mother and an infant discharged together within 24 hours of
birth qualify for a follow-up home visit. If the mother and child
are in the hospital longer than 24 hours after the birth, then a
home follow-up is not covered as a necessary medical expense."
MR. LeBRUN said he would follow up and provide comments back to the
committee.
CO-CHAIR TOOHEY asked if there were any questions of Mr. LeBrun.
Hearing none, she asked Gail McGill to testify.
Number 1464
GAIL McGILL, Registered Nurse and Director of Quality and
Utilization Management, Columbia Alaska Regional Hospital,
testified in support of CSSB 193(L&C). She said as a hospital with
an active maternal child unit, they strive to work with their
patients, physicians, nurse midwives and the payers in providing
the most cost effective quality care. If there is medical
necessity for the patient to stay, the insurance reviewers often
will extend the stay, but will provide a disclaimer that the bill
may not be paid by the insurer. Columbia Alaska Regional Hospital
supports the legislation as it provides the option for a 48-hour or
96-hour stay when it is determined to be in the patient's best
interest. As the length of stay for postpartum parents and infants
has dropped, they have seen an increase in the number of infants
brought into the emergency room and in the number of questions
phoned into the hospital about care of infants and mothers
recovering from the birth process. The shortened stay does not
provide the time for the physical and emotional recovery of the
mother and the adaptation of the newborn to the (indisc.) uterine
environment. The process of nursing a newborn is often not
established with the early discharge and new mothers may encounter
feeding problems without resources for solving them. It does
provide a difficult situation when a physician's assessment
indicates the best course of treatment is to provide continued
hospitalization for the mother, but the insurance policy is limited
and does not cover the additional stay. She said they recognize
the need for cost containment in health care, however they see the
need for safe relevant care in the most appropriate setting. The
attending physician or nurse midwife is the most appropriate
provider to determine when the mother and newborn are medically
stable enough to be discharged. They support the mother and infant
staying hospitalized on the order of a physician to be sure there
are no complications and that the recovery process is successfully
underway. They have begun a new program for home follow-up with
new mothers and infants through their home health agency, using
their experienced maternal child registered nurses. They will be
assessing the infants and providing any additional teaching which
may be necessary to ensure the safety and health of the newborn.
This is being provided as a continuation of the hospital visit.
They know that home visits are not the answer for all postpartum
patients, but will provide for early intervention of those newborn
or others who develop problems in the very early postpartum period.
She commented they would support amendments to this bill with
regard to home health services as well. She thanked the committee
for the opportunity to testify.
Number 1579
CO-CHAIR TOOHEY asked if Ms. McGill had found there was a
reluctance to accept a doctor's recommendation for a longer
hospital stay?
MS. McGILL said the staff had indicated sometimes there is but
often times if they can justify with the information, then the
insurance reviewers, who are usually registered nurses, state the
additional stay will be covered if there is medical indications.
CO-CHAIR BUNDE asked Ms. McGill if the maternity unit pays for
itself?
MS. McGill said she didn't know.
CO-CHAIR BUNDE said he had heard that maternity units were
expensive to operate and other services, such as a tonsillectomy,
are often padded to pay for maternity units. He felt this could
lead to patients being encouraged to stay longer.
CO-CHAIR TOOHEY asked if there were other questions of Ms. McGill.
Hearing none, she asked Janet Oates to testify.
Number 1645
JANET OATES, Representative, Providence Health System, said that
she agreed with Ms. McGill in that there is a bit of a problem.
They are aware of situations such as the one brought to Senator
Salo's attention that prompted the introduction of this
legislation. As Mr. LeBrun had mentioned, they can't say this is
the rule for a particular hospital; rather there are a variety of
plans and choices. In most cases, the employer is making a choice
among several different options offered by an insurance company, so
one insurance company could have a variety of ways and approaches
to providing maternity benefits and may include the length of stay.
Obviously, an employer in looking at an overall health plan, is
trying to stretch the dollars to provide the most coverage to all
employees. She added there are various ways the insurance
companies can (indisc.) take a hospital depending on the particular
plan that's being used; some are straight fee for service, some are
discounts, some are per diem rate, and they can all be from the
same insurance company. In the same way, the timing of when a
patient is charged can depend not on the hospital, but on the
particular plan - is it from the time of delivery or from the time
the person walks into the hospital.
MS. OATES said on the medical side, their doctors and nurses have
been concerned, and as Ms. McGill said 12 to 24 hours rarely allows
the physical and mental adjustment as well as the education needed
for mothers and newborns, especially in the area of breast-feeding.
In fact, when there has been a reluctance by an insurer to pay for
an additional stay, many times the hospital as a convenience to the
family, will allow them to stay longer. They do absorb the cost
and it does get cost shifted. Providence Health System likes the
language under Section 21.42.347(c) because it does allow some
flexibility. She believes there is a movement away from the very
rigid and expensively short stays in insurance plans even in the
Lower 48, because they've seen it hasn't worked. She thinks there
has been negative feedback from employees who complain to the
employer, who then change the benefit package. She is aware there
has been debate on whether this is something that needs to be
addressed by the legislature, but she believes they are comfortable
with this bill because there is flexibility in it and they support
the intent of it.
Number 1806
REPRESENTATIVE ROKEBERG said it was his understanding that
Providence has adopted what could be described as a miniature or
mini-managed care plan for their own employees. He asked Ms. Oates
what the maternity benefits of that plan were with regard to this
topic?
MS. OATES responded that it was so new - it began January 1, and
because she is so far removed from it, she hasn't looked at that
particular benefit. She suspected they would move more toward the
48 hours, but she couldn't confirm that. She offered to look into
that and provide information back to the committee.
CO-CHAIR TOOHEY called Dr. Richard Nist to testify from Anchorage.
Number 1853
DR. RICHARD NIST, Obstetrician/Gynecologist, testified from
Anchorage via teleconference. He is on the staff at both
hospitals, but he does almost all his work at the Providence
Hospital. He said there can be problems with short stays in the
hospital particularly with very young mothers who need extra time
just to guide them in the right direction of caring for newborn
babies. Alternatively, a mother who has gone through a prolonged
labor may be exhausted and may not be physically up to going home
at that point in time. He said it's difficult to place a standard
of 24 hours for discharge for normal vaginal deliveries and it
appears to him that it is important to be able to use some judgment
and have some flexibility with regard to mothers and newborns. He
has seen patients who have had tremendous hassles and problems with
their insurance company.
CO-CHAIR TOOHEY inquired if Dr. Nist, in his practice, feels this
legislation is warranted?
DR. NIST said he felt a lot of patients could go home after 24
hours and he didn't believe that mandating 48 hours is necessary.
He simply thinks it should be a medical judgment, but also with
some flexibility regarding the discharge. In other words, a
physician can't always find some medical reason that a patient
should not be discharged. For example, if a new mother is
exhausted, he wasn't sure that would fit into an insurance
company's standard. He affirmed that some flexibility is needed.
Number 2008
REPRESENTATIVE ROBINSON commented this bill does not mandate, it
just allows the option.
REPRESENTATIVE ROKEBERG asked Dr. Nist to comment "on the position
of the physician who would tend, particularly in OB/GYN, who
happened to be the most involuntary litigious portion of the
medical profession, wouldn't the tendency be to practice more
defensive medicine by tending to allow a patient who might
otherwise be discharged in 24 hours to stay an extra day?"
DR. NIST said on the litigious side of it, he thinks much more
involves the labor and delivery. He said he could certainly see
that a doctor could run into a patient that is somewhat abusive
about staying for 24 hours and the threat of potential litigation
would motivate a physician to allow the patient to stay longer.
Hopefully, that wouldn't happen and he thought it would be a rare
occasion. He feels quite strongly that physicians would not keep
patients hospitalized longer because of their fear of litigation.
CO-CHAIR BUNDE said he had heard a couple of comments in discussion
regarding babies who have gone home relatively quickly after
delivery, become jaundiced and had to go back to the hospital. He
asked if that happens to babies who stay in the hospital more than
24 or 48 hours? Also, is the going home early a factor in the
jaundice or is it just more likely to be caught?
DR. NIST said he didn't believe the fact that a baby goes home
early influences jaundice. He thinks the pediatricians can follow
up in the office. In his opinion keeping a mother longer than 48
hours would not prevent any of those problems and would simply add
to the cost.
CO-CHAIR TOOHEY announced that concluded the teleconference
testimony. She asked Gordon Evans to present his testimony.
Number 2142
GORDON EVANS, Lobbyist, Health Insurance Association of America,
said the Health Insurance Association of America (HIA) is a trade
association of commercial health insurance companies, but Aetna or
Blue Cross is not included in their membership. He said HIA is
opposed to Senate Bill 193 for a couple of reasons. First, because
it mandates coverage by the use of the language "shall provide."
State mandated benefits will ultimately result in increasing health
care costs and limit access to health care or quality care, and
this legislature just recently has gone on a mandated benefit
binge. In addition to this bill, there is mandated coverage for
cancer detection tests in the form of prostate testing for men and
pap smears for women, as well as the coverage for victims of
domestic violence. Because all of these benefits will be mandated
if they pass, the insurers will have to include that factor into
their underwriting considerations, which can only result in higher
premiums, especially for individual premiums. As was noted
earlier, with group insurance that coverage is usually negotiated
and will be included, so the increase would not be noticed that
much, but it would certainly reflect in an individual's policy.
MR. EVANS said that HIA believes that mothers and their doctors in
partnership with the health plan, can best determine when the
mother and her newborn are ready to leave the hospital safely.
They believe the legislature should not be making medical decisions
or embodying such decisions in law, especially since the decision
quite often varies according to individual circumstances. In a
way, their opposition to CSSB 193(L&C) would be just adding another
law on the books to cure what presently is a nonexistent problem in
this state. They realize there are some anecdotal problems, but it
is not prevalent. It has become obvious that the health care
industry is not getting across some key points they've been making
on this mostly emotional issue. First, this is not a debate about
covering medically necessary care; insurers will cover that. If it
is care that should be performed in the hospital and the doctor
confirms that, the insurance company will cover it for as many
hours as are needed. During the last decade, the health care
industry has made great strides in providing and delivering quality
health care at a reduced cost. One of the most noticeable ways in
which this has been achieved is by lowering the number of in-
patient hospital stays for a variety of illnesses, including
maternity length of stay. In fact the average length of stay for
maternity is not the result of a change in policy by insurance
companies, but rather as a result of the long trend of stated
declines. For example, the average length of stay for a vaginal
delivery was 4 days in 1970, 2.2 days in 1988 and 2 days or less in
1993. This decline is consistent with the decline for other
services which are also due to increasing medical knowledge and
advances in the patient care process. The real issue is how
insurers should cover care that is not medically necessary or is
given in an unduly expensive setting such as in the hospital versus
the home. Critics of early discharge programs fail to understand
that not paying for unnecessary care or in an unnecessary setting
is precisely what enables these insurers to offer the numerous
other services that managed care programs provide, such as well-
baby, dental and vision programs, all of which most people would
want up to a thousand dollar a day extra day's stay in the
hospital. No one wants a discharge program that jeopardizes the
health of the mother or the child. As he noted earlier, insurance
companies would not use early discharge programs if they were not
medically safe and if they were not used only when discharge is
safe. As a matter of fact, there is a lack of data to indicate
that discharge before 48 hours after a vaginal delivery and before
96 hours after a caesarean section delivery is harmful or unsafe to
the mother or baby. Other than isolated anecdotes of early
discharge problems here in Alaska, the advocates of these new
mandates such as proposed in SB 193 have provided no evidence that
insurance companies doing business in Alaska are systematically, as
a matter of practice, requiring mothers and newborns to be
discharged before they are medically ready to be discharged. In
fact, there is no evidence to suggest how long a hospital maternity
stay should be. No where in medical textbooks or guides will a
person find a magic number, such as 48 hours or 96 hours,
mentioned.
MR. EVANS said in summary, HIA believes that the services and
length of hospital stays for mothers and their newborns should be
determined on a case-by-case basis and on the medical necessity of
both mother and child as determined jointly by the mother and her
doctor and not by a legislative decision. He added that everyone
knows that maternity visits or hospital stays are one of the more
expensive stays. On a personal note, his daughter had a caesarean
section nearly three years ago.
TAPE 96-39, SIDE B
Number 001
MR. EVANS continued that the hospital bill was a little over $8,800
and she and her husband were uninsured at the time. He added that
Bartlett Memorial Hospital has been very good understanding and
they are still paying on it.
CO-CHAIR TOOHEY asked how long his daughter stayed in the hospital?
MR. EVANS responded she was there six days.
CO-CHAIR TOOHEY, speaking philosophically, said no one wants to
pass a mandate; this is very poor legislation in that it's a very
poor process for the state to have to go through. However, there
is a necessity for this; it wouldn't be done if this issue wasn't
coming to the forefront and needed. She noted that she had a
personal experience with the delivery of a newborn baby where the
parents were given such a hassle for staying one extra day and they
were denied by the insurance company.
MR. EVANS asked if the doctor had deemed it necessary.
CO-CHAIR TOOHEY responded affirmatively.
MR. EVANS said he couldn't speak to that situation.
CO-CHAIR TOOHEY said if it takes this kind of legislation to save
one baby and one mother, then it is important.
Number 057
CO-CHAIR BUNDE said he couldn't speak to Co-Chair Toohey's
experience, but he couldn't imagine a hospital throwing a patient
out. He supposed that if a person said they chose to stay or the
doctor requested they stay, the person may have to sign a
promissory note, like he did before he could take his daughter
home.
CO-CHAIR TOOHEY commented that when it comes to young parents who
don't have the money for an extended stay, generally the mother and
newborn infant will leave the hospital.
MR. EVANS commented that his daughter was 18 at the time and the
hospital didn't force her to leave.
Number 086
REPRESENTATIVE ROBINSON said this legislation does not mandate that
everyone stay in the hospital for 48 or 96 hours; it merely states
that it would be approved if the doctor and the patient believed it
was necessary.
MR. EVANS said that's why HIA believes it is unnecessary, because
their insurance companies have indicated they already do that.
REPRESENTATIVE ROBINSON questioned if that is true, why then did
the hospital board of the Bartlett Memorial Hospital come to her
and state that it is clearly a problem at Bartlett Memorial.
MR. EVANS said frankly, the hospital has a lot of empty beds and a
thousand dollars a day helps pay their bills.
REPRESENTATIVE ROKEBERG inquired how many insurance companies were
in the association represented by Mr. Evans.
MR. EVANS said about 95 companies and added the top five companies
such as Aetna, Principal and others are out of the group, but most
of the others are in.
REPRESENTATIVE ROKEBERG asked Mr. Evans if he was a member of the
Alaska Bar Association?
MR. EVANS responded yes.
REPRESENTATIVE ROKEBERG said, "Can I ask the same question I asked
before about the decision of a doctor where he felt there was a
potential for litigation arising out of this set of circumstances,
where he may be practicing preventive medicine as a result of this
particular law being enacted and choose to allow the patient to
stay over another day."
MR. EVANS stated he did not do personal injury type work, but he
knows of people that do and believes that is a correct answer. He
believes that if a patient advised her doctor that she was not
ready to go home, most doctors would give her that extra day. He
realized that insurance companies have to agree, but the insurance
companies have told him that it is usually extended if the doctor
says it is necessary.
REPRESENTATIVE ROKEBERG asked if Mr. Evans was aware of the vacancy
rate in hospital beds in the top five hospitals in the state of
Alaska.
MR. EVANS said he didn't have that information readily available.
CO-CHAIR TOOHEY said that wasn't the point. The point is - will
the insurance company pay for it. The hospital will absorb that
cost one way or another.
MR. EVANS interjected, "or pass it on."
Number 206
CO-CHAIR BUNDE said it had been acknowledged this legislation would
probably not impact the rates for the state of Alaska with Aetna,
but he questioned how it might impact rates for other insurers in
the state.
MR. EVANS said if it is a group policy, generally it is figured in
and negotiated over the entire price. If it is an individual
policy, the individual will pay for each little thing that is in
the policy. If something is mandated, it has to be there rather
than make it a mandated offering. The difference is that if it is
mandated, an insurance company has to provide that coverage. On
the other hand, if it is a mandated offering, the purchaser of the
policy has the right to select it if they so desire or turn it down
if they don't want it, depending on the cost.
CO-CHAIR BUNDE said in the case of a group policy in which this is
mandated, in his opinion 24 hours will become the norm because as
Representative Rokeberg had mentioned, there is some liability
involved if a patient is sent home earlier and as long as the
insurance company is paying for it, the patient will stay. He
noted however, that insurance companies aren't paying for it - the
people who buy the insurance are paying for it and that's why he is
curious about the impact on a company that isn't a huge insurer
like the state of Alaska.
MR. EVANS mentioned that most policies pay 80 percent, so people
will pick up 20 percent of the bill anyway, even with the state of
Alaska policy. He said it would have some impact on it but he just
couldn't say how much.
REPRESENTATIVE ROKEBERG asked if there was anyone available from
the Department of Health & Social Services to explain the fiscal
note.
Number 322
NANCY WELLER, Division of Medical Assistance, Department of Health
& Social Services, said the division operates the Medicaid program
which pays for 38 percent of the births in the state of Alaska.
She said this bill does not affect the Medicaid program because
they are not an insurance company.
REPRESENTATIVE ROKEBERG asked Ms. Weller to comment on the notation
in the fiscal note regarding the potential future impact of this
particular legislation if the division entered into managed care
type programs.
MS. WELLER said there could be some anticipated impact if they
entered into a capitated arrangement at some time in the future.
REPRESENTATIVE ROKEBERG asked if she had had the opportunity to
look at a managed care system to see what the impacts of this type
of legislation would be on in-patient hospital stays.
MS. WELLER said she had not. She added that the Medicaid program
currently covers 24 hours for a vaginal birth and 72 hours for a
caesarean birth. There is no pre-certification or authorization,
but if the patient needs to stay longer, they call the professional
review organization on contract with the division and the attending
physician explains the circumstances to the reviewer. An extended
stay is generally tied to medical necessity or often times
transportation problems because the Medicaid program covers so many
people from rural Alaska who have to fly in and the discharge time
is tied as much as possible with their plane time.
Number 410
CO-CHAIR BUNDE commented that a thousand dollars a day was an
expensive motel while waiting for an airplane. He inquired as to
how long a patient normally has to wait to catch the plane.
MS. WELLER said they usually don't keep people for days, but they
may need to stay for an additional half day because there is no
transportation to their community until the following day.
CO-CHAIR BUNDE asked Ms. Weller to confirm that 38 percent of the
births in Alaska are covered by Medicaid.
MS. WELLER said that was correct. She added the Medicaid program
covers pregnant women to 133 percent of the poverty level.
CO-CHAIR TOOHEY interjected it was federally mandated.
REPRESENTATIVE ROKEBERG assumed that dealing with such a large
number of births and if this legislation were to pass, the division
would have to change the guidelines to their utilization reviewer.
He questioned if that wouldn't have a fiscal impact on the state in
terms of Medicaid?
MS. WELLER replied no. She said the division feels they already
meet the requirement of this bill because it requires
hospitalization or other medical care. She added they cover all
pregnant women for 60 days following birth.
CO-CHAIR BUNDE pointed out that Ms. Weller had said that Medicaid
covers a 72-hour stay for a caesarean section, but this legislation
calls for 96.
MS. WELLER explained that it requires hospitalization or other
medical care; it doesn't require in-patient hospital care.
CO-CHAIR TOOHEY believed that office visits were covered under
that.
MS. WELLER interjected it would cover office visits or home health
care, whatever the doctor orders.
CO-CHAIR TOOHEY asked if there were other questions for Ms. Weller.
She noted there were two individuals wishing to testify via
teleconference from Fairbanks.
Number 482
JANET THURSTON testified via teleconference from Fairbanks that
based on the testimony given, newspaper articles and discussions
with people, she has come to three conclusions. First, the
problems associated with early discharge are related to poor
management, follow-up and access to health care. Secondly, this
legislation will not reduce infant mortality significantly in
Alaska and finally, this bill as worded will not change discharge
criteria. She said the initial case that prompted similar
legislation in Washington was a case in New Jersey in which a woman
had her baby, went home and the baby developed a rash and began
throwing up formula. She called the doctor several times and was
reassured that everything was okay. A nurse was supposed to come
to the home, but didn't and within hours her baby died from strep
B infection. Two significant problems with her management were
that she was not screened pre-natalist and was not informed to
return to the clinic and the visiting nurse program was poorly
coordinated. She said it is important for parents and people to
know this information so they understand it was not the time of
discharge that created the problem; it was the fact that she didn't
know she should return to the hospital or clinic. Strep B
infection can occur much later than 48 hours after birth. In fact
so can jaundice. She noted that most babies in Alaska who die do
so after 28 days of age. Alaska infant mortality problem is
associated with the high post-neonatal infant mortality rate that
exceeds national levels by 30 percent. Another issue to consider
is the significant problem of (indisc.) drug use. In 1989, a study
at the Fairbanks Memorial Hospital revealed 14 percent of women had
illicit drugs in their systems at the time of delivery. This study
when repeated in Anchorage, revealed a 16 percent rate of infants
exposed to drugs at birth. She asked what does that tell you about
the needs of mothers and babies in Alaska? To her, it says the
needs are not only in the hospitals, but in the communities as
well. Taxpayers are funding health care for mothers and babies.
A majority of care in the Interior is provided by government
sponsored health care - Medicaid funds 50 percent of obstetric
patients at Fairbanks Memorial Hospital and Champus funds beds at
(indisc.) community hospital and there are many other government
employed programs, so the question is "How can these dollars best
be spent?" There are many examples, at (indisc.) hospital,
certified nurse and midwives dropped the caesarean rate from 19
percent to 11 percent. Similarly, birth centers throughout the
country were developed as alternatives to home birth and developed
the early discharge system we see today, but unfortunately the
process was poorly understood by most people. This early discharge
program was never meant for all women. It emphasizes pre-natal
education, risk identification, referral and extensive home care.
She questioned why we are willing to pay $1,000 for a day in the
hospital, but not $5 on programs such as coordinated home care and
pre-natal education. Hospitals will not develop these programs
until they are reimbursed. She had several recommendations that
would be sent to the committee via facsimile. She concluded that
a 24-hour stay in the hospital won't do much good as mothers do not
receive the education and support they deserve. Education should
be given pre-natally and continue into home and into the community.
CO-CHAIR BUNDE said he shared Ms. Thurston's concerns about
education. Unfortunately, if it really worked, there would never
be a second FAS (fetal alcohol syndrome) birth.
CO-CHAIR TOOHEY asked if there were questions of Ms. Thurston.
Hearing none, she asked Pat Senner of Anchorage to testify.
PAT SENNER, Executive Director, Alaska Nurses Association,
testified from Anchorage that at the annual convention of the
Alaska Nurses Association in October 1995, the issue of postpartum
length of stay was raised and they decided to do some research to
see if it really was a problem in Alaska. They did identify some
problems and a lot of them related to education for mothers. They
found that mothers were not able to get babies to breast feed
properly, so they switched to formulas; mothers did not understand
the teaching that is given in the hospitals because it occurs too
soon after the child is born; and infants developing problems
postpartum that were not identified quickly. A hospital stay
should be viewed as a chance to educate people that may be lost in
the system later on. She felt that nurses have a different
definition than that of a physician of what may be medically
necessary. They believe that patients should have the option of
either a 48-hour length of stay or home visits by a maternal child
or lactation nurse postpartum. The early home health programs
started at the turn of the century actually had nurses visit every
mother in the home, not just particular ones. She concluded that
the Alaska Nurses Association supports CSSB 193(L&C).
CO-CHAIR TOOHEY thanked Ms. Senner for her testimony and asked
Scott Calder of Fairbanks to testify.
Number 765
SCOTT CALDER said this legislation may not be construed to require
hospitalization or medical care if the mother and the health care
provider agree that it is not necessary, which should address some
of the concerns raised about that issue. He thought it was fairly
well known that nurses, midwives and parents are often some of the
most important experts in the area of health and well-being of
children. He noted that in 1994 there was a Senate bill that was
drafted to put the services of a midwife at the top of the list of
services to be cut from Medicaid payments. It seemed to him that
placed a parent in the difficult position of not having the right
as a parent to choose to save the state or government money by
having Medicaid payments go to what is well known to be a more
economical and probably a better quality of service for some cases.
He thought this was an adequate piece of legislation, but he
doesn't feel it addresses the other important issues relating to
cost of birth.
Number 864
CO-CHAIR TOOHEY asked if there was anyone else wishing to testify
either via teleconference or in person. Hearing none, she closed
public testimony. She asked what the wishes were of the committee.
CO-CHAIR BUNDE distributed an amendment which would mandate the
offering of this coverage rather than mandating the coverage. The
amendment would delete "requiring" and insert "relating to" on page
1, line 1; delete "provide" and insert "offer" on page 1, line 6;
and delete "provide" and insert "offer" on page 1, line 10. He
made a motion to adopt Amendment 1.
REPRESENTATIVE ROBINSON objected for discussion purposes.
CO-CHAIR BUNDE explained that mandating the offering of the
coverage would allow people who are of child bearing age to buy
this coverage and people who are celibate wouldn't have to buy the
coverage. It would simply give people the option to purchase this
coverage.
REPRESENTATIVE ROKEBERG appreciated the intent of the amendment,
but wondered if a mere "offering" versus "provide" the coverage,
would allow the insurance company to make the differential within
their policy construction to make that an elective?
CO-CHAIR BUNDE said perhaps the insurance representative could
speak to that question, but it was his understanding that it would
allow the offering of the insurance and if a person wished to take
advantage of the offering, the person would then pay premiums.
Number 977
SENATOR JUDY SALO, Prime Sponsor, said at first glance she didn't
have any problem with the amendment, but she may after further
review or discussing it with the Department of Law. As she
understands the amendment, if maternity coverage is offered under
a policy, whether it be an individual or a group policy, then the
48 hours and the 96 hours "shall" be provided.
CO-CHAIR BUNDE reiterated he would like to hear Mr. Evans' comments
on the amendment.
MR. EVANS said this amendment would make it a mandated offering,
and as he stated earlier, the insurance companies do not oppose a
mandated offering because what that means is, for example, if a
male buys an insurance policy, he is covered for a mammogram
whether he wants it or not.
Number 1066
REPRESENTATIVE ROBINSON withdrew her objection.
CO-CHAIR TOOHEY asked if there was further objection. Hearing
none, Amendment 1 was adopted.
Number 1072
CO-CHAIR BUNDE made a motion to pass HCS CSSB 193(HES) out of
committee with attached fiscal notes and individual
recommendations.
REPRESENTATIVE ROKEBERG objected for the purpose of comment.
He expressed his concern regarding the zero fiscal note from the
Department of Health & Social Services. His concern relates to the
impact on the Medicaid payments from the state and the potential
impact on everyday practice of medicine in the state. Although he
appreciated the testimony from the department that we are paying
for it already, but the point in fact is, they have some guidelines
that Representative Rokeberg believed would have to be adjusted if
this bill were to pass.
CO-CHAIR TOOHEY asked if there were other comments.
REPRESENTATIVE ROKEBERG withdrew his objection.
CO-CHAIR TOOHEY asked if there were further objections. Hearing
none, HCS CSSB 193(HES) passed from the House HESS Committee.
CO-CHAIR TOOHEY turned the gavel over to CO-CHAIR BUNDE.
CSSB 158(L&C) AM - PHARMACISTS AND PHARMACIES
Number 1198
CO-CHAIR BUNDE announced the next order of business to come before
the House HESS Committee was CSSB 158(L&C) am. He asked Dave
Knight, staff to Senator Mike Miller to present the bill.
DAVE KNIGHT, Researcher for Senator Mike Miller, read the following
sponsor statement: "The passage of this legislation is necessary
to keep the practice of pharmacy in Alaska in step with national
standards and to afford the public the safety and protection it
deserves.
"Current statutes are antiquated and obsolete. For example,
investigative personnel within the Division of Occupational
Licensing have continually experienced difficulty in investigating
and processing complaints against licensed personnel and facilities
because of vague, inadequate or nonexistent language regarding
unprofessional conduct and disciplinary sanctions. Many of the
statutes are dated from the l970s and do not reflect the current
practice of pharmacy or changing nature of the profession.
"Using the Model State Pharmacy Act of the National Association of
Boards of Pharmacy as a template, this legislation reflects over
four years of work by the pharmacy community and is supported by
the Alaska Pharmaceutical Association and the Alaska Board of
Pharmacy."
MR. KNIGHT noted that Chris Corsey, member of the State Pharmacy
Association and Barbara Gabier from the Division of Occupational
Licensing were available to answer any questions.
REPRESENTATIVE ROKEBERG asked if there was a companion bill in the
House?
MR. KNIGHT responded no.
Number 1290
CHRIS CORSEY, President, Alaska Board of Pharmacy, said he was also
representing the Alaska Pharmaceutical Association and was one of
the original authors of the Model State Pharmacy Act. He echoed
Mr. Knight's comments in that the existing statutes and regulations
that govern the practice of pharmacy are antiquated. For example,
we require pharmacies to have reference texts which are no longer
published, we do not have a definition of the practice of pharmacy
in the Pharmacy Practice Act, we do not have a definition of
unprofessional conduct and we don't address the use of pharmacy or
recognize the use of pharmacy technicians which is an important
trend in the development of pharmacy practice, especially with the
effort to contain health care costs. The current statutes and
regulations are a compilation of small pieces of legislation,
mostly dating back to the (indisc.). He felt this legislation was
good for the public and the pharmacists themselves want a higher
standard and guideline by which to practice. This legislation
would move the practice of pharmacy into the 1990s and he urged the
committee to pass it. He noted the Division of Occupational
Licensing has recommended some minor changes and as President of
the Board of Pharmacy, he supports those changes.
CO-CHAIR BUNDE asked if there was someone available to speak to the
changes and pointed out the changes were reflected in the committee
substitute before the committee.
Number 1422
BARBARA GABIER, Program Coordinator, Division of Occupational
Licensing, Department of Commerce & Economic Development, said the
changes were minor concerns the division had with the existing
wording and the committee substitute before the committee would
clarify the wording. The division fully supports this legislation.
She commented she would be happy to go through each of the changes
if the committee so desired.
CO-CHAIR BUNDE asked if the changes were substantive in nature?
MS. GABIER responded no.
REPRESENTATIVE ROKEBERG inquired if this legislation had another
committee referral.
CO-CHAIR BUNDE responded it does not have another committee
referral.
Number 1495
REPRESENTATIVE ROKEBERG moved to adopt HCS CSSB 158, Version 9-
LS0525\R, Lauterbach, dated 4/9/96. Hearing no objection, the
House Committee Substitute was adopted.
Number 1515
REPRESENTATIVE ROBINSON made a motion to pass HCS CSSB 158(HES)
with individual recommendations. Hearing no objection, it was so
ordered.
CO-CHAIR BUNDE called an at-ease at 3:31 p.m. The meeting was
called back to order at 3:40 p.m.
CSSB 259(HES) - COMMISSION ON AGING
Number 1558
ALISON ELGEE, Deputy Commissioner, Department of Administration,
said as a part of her job duties, she sits as the department
designee on the Alaska Commission on Aging. She said the Alaska
Commission on Aging went through a sunset review last summer and
autumn under the normal course of business, and the legislative
audit group recommended that the commission be eliminated from the
sunset review process or alternatively have the commission extended
to the year 2003. The Senate considered this bill and was
uncomfortable with the extension of the commission and adopted a
termination date of the year 2000. She offered to answer questions
brought forward by the committee.
REPRESENTATIVE ROKEBERG asked if this was the one commission in the
state that looked after the elderly senior issues?
MS. ELGEE responded yes. She explained the commission which began
in 1981 was called the Older Alaskans Commission. The name was
changed in 1994 and it is a separate review board from the
Pioneers' Home Advisory Board. There is however, a reciprocal
relationship in that the Chair of the Commission on Aging sits on
the Pioneers' Home Advisory Board and likewise, the Pioneers' Home
Advisory Board Chair sits on the Commission on Aging. The
Commission on Aging, by statute, has no direct oversight or
responsibility for either the Pioneers' homes or the longevity
bonus program. The commission administers the federal programs
that come in under the Older Americans Act.
REPRESENTATIVE ROKEBERG asked if there was a federal mandate that
Alaska have a commission like this?
MS. ELGEE said there is a federal mandate that Alaska have a
designated unit on aging. The commission acts underneath that
state unit on aging because the entire Division of Senior Services
is, in fact, the designated unit. The commission does the grants
administration for the Older Americans Act funds.
REPRESENTATIVE ROKEBERG inquired if the commission were to sunset,
would that affect federal funds.
MS. ELGEE pointed out that if the commission were to be eliminated,
Alaska would continue to receive federal funds under the Division
of Senior Services, but the department would have to develop a
different process than the one currently being used for grant
review and the other programs administered by the commission.
REPRESENTATIVE ROKEBERG wondered if the Executive Director, at a
range 23, was necessary because there was a flow of business
activity that needed formal action.
MS. ELGEE said the commission employs a number of staff; the
Executive Director oversees those staff. They do the nutrition
transportation support services grants, review and monitor the home
and community based care grants, which include adult daycare
centers, respite care, care coordination, etc. She added this is
the unit that is, in essence, developing the home and community
based long-term care services for the state.
REPRESENTATIVE ROKEBERG asked if they were grant writers, not
implementers?
MS. ELGEE explained this unit does not write units; they review
grant applications coming in from senior centers.
REPRESENTATIVE ROKEBERG said he now understood and affirmed they
are the repository for the requests for grants from throughout the
state.
MS. ELGEE confirmed that.
Number 1800
CO-CHAIR BUNDE asked if there was any further testimony. Hearing
none, he closed public testimony on CSSB 259(HES).
Number 1807
REPRESENTATIVE ROKEBERG moved to pass CSSB 259(HES) out of
committee with accompanying fiscal note and individual
recommendations. Hearing no objection, it was so ordered.
CO-CHAIR BUNDE announced the next order of business was CSSB 165.
CSSB 165(L&C) - PSYCHOLOGISTS & PSYCHOLOGICAL ASSOCIATES
CO-CHAIR BUNDE announced there had been adequate public testimony
at previous hearings and closed public testimony at this time. He
asked Representative Rokeberg to present the amendments.
Number 1860
REPRESENTATIVE ROKEBERG said the original HESS committee had
appointed a subcommittee on CSSB 165(HES). The subcommittee came
up with an amendment which addresses some of the questions raised
in the committee hearing. He moved to adopt Amendment 1 for
discussion purposes.
REPRESENTATIVE BRICE objected for discussion purposes.
CO-CHAIR BUNDE asked Representative Rokeberg to speak to the
amendment.
REPRESENTATIVE ROKEBERG said, "In the interest of moving this bill
along, we did expedite the process and that's why I have permission
of the subcommittee members, because of the further referral and I
had some conversations with the various people involved in the bill
and came up with what I would call consensus changes to the
legislation before us, which is the Version G. The first part of
the amendment relates to page 3, line 10, and this particular
section of the amendment speaks to a concern that was raised about
the definition of psychological services. Previously, in statute,
the psychological associate license would specify areas or areas of
activities of competency and that would be specified on the
license. There was testimony that the scope of psychological
services was found in statute, but a review of the statute showed
that the definition was for -- to practice psychology, which was
all encompassing, and the only statutory definition, which is all
encompassing and really related particularly back to a psychologist
which is different, as we know from the testimony, than a
psychological associate." It was pointed out that existing
regulations 12 AAC 60.185, subsection (b) states, "The standards to
be adhered to a licensed psychologist and licensed psychological
associates rendering psychological services in the state are
`general guidelines for the providers of psychological services'
1987 edition of the American Psychological Association. General
guidelines for providers of psychological services is incorporated
by reference in this section." He explained that by adding the
words, "as defined in regulation" adopts the reference in
regulations which define the differential between a licensed
psychologist and a licensed psychological associate. Therefore,
the scope of work is more readily defined.
REPRESENTATIVE ROKEBERG said the second part of the amendment is
more substantive in form.
CO-CHAIR TOOHEY asked if there would be any reason to add "and
billed as such" following the insertion of "as defined in
regulation." She said the amendment defines the difference between
a psychologist and a psychological associate and it all comes down
to the fee for service.
REPRESENTATIVE ROKEBERG said he wasn't sure this section spoke to
that.
TAPE 96-40, SIDE A
Number 001
REPRESENTATIVE ROKEBERG said he appreciated Co-Chair Toohey's
position, but the scope of the work done by the subcommittee in the
time frame, really didn't speak to that particular issue and it
wasn't the intent of this amendment. The second part of the
amendment page 3, line 13, which deletes "and (2)." and inserts
",(2) and (4)." has a major substantive affect on this bill. He
referred to page 3, lines 1 and 2, which states, "(4) takes and
passes the objective examination developed or approved by the board
for psychological associates." He explained that by inserting (4)
into Section 6, it mandates that a person would have take and pass
an examination in order to receive a temporary license, which is
substantially different than the version of the bill that came
before the committee. The rationale is that, particularly given
the shortening of the period of supervision to a two year period,
a person has to pass an examination after graduating from an
accredited university, but before going into the public sector as
a psychological associate. Also, depending on what university
attended, a person may not have the proper academic background to
meet the requirements, so taking an examination is he feels the
responsibility of the state in determining the educational
background of the individual with a state license. It was his
understanding that the people who support this legislation, also
support this amendment.
Number 198
REPRESENTATIVE BRICE withdrew his objection.
CO-CHAIR BUNDE asked if there was further objection to Amendment 1.
Hearing none, Amendment 1 was adopted. He asked for the wishes of
the committee.
Number 228
REPRESENTATIVE ROKEBERG moved CSSB 165(L&C), Version G, as amended
with attached fiscal notes and individual recommendations. Hearing
no objection, it was so ordered.
ADJOURNMENT
CO-CHAIR BUNDE adjourned the House Health, Education, and Social
Service Committee meeting at 3:53 p.m.
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