Legislature(2005 - 2006)CAPITOL 106
03/17/2005 03:00 PM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HB193 | |
| HB185 | |
| HB156 | |
| HB151 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 151 | TELECONFERENCED | |
| *+ | HB 156 | TELECONFERENCED | |
| *+ | HB 185 | TELECONFERENCED | |
| = | HB 193 | ||
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
March 17, 2005
3:04 p.m.
MEMBERS PRESENT
Representative Peggy Wilson, Chair
Representative Paul Seaton, Vice Chair
Representative Tom Anderson
Representative Vic Kohring
Representative Lesil McGuire
Representative Sharon Cissna
Representative Berta Gardner
COMMITTEE CALENDAR
HOUSE BILL NO. 193
"An Act relating to the licensing, regulation, enforcement, and
appeal rights of ambulatory surgical centers, assisted living
homes, child care facilities, child placement agencies, foster
homes, free-standing birth centers, home health agencies,
hospices or agencies providing hospice services, hospitals,
intermediate care facilities for the mentally retarded,
maternity homes, nursing facilities, residential child care
facilities, residential psychiatric treatment centers, and rural
health clinics; relating to criminal history requirements, and a
registry, regarding certain licenses, certifications, approvals,
and authorizations by the Department of Health and Social
Services; making conforming amendments; and providing for an
effective date."
- HEARD AND HELD
HOUSE BILL NO. 185
"An Act relating to immunization of postsecondary students for
meningitis; and providing for an effective date."
- MOVED HB 185 OUT OF COMMITTEE
HOUSE BILL NO. 156
"An Act relating to the membership of the Alaska Commission on
Aging; and providing for an effective date."
- MOVED CSHB 156(HES) OUT OF COMMITTEE
HOUSE BILL NO. 151
"An Act relating to provider responsibility for ocular
postoperative care; and providing for an effective date."
- MOVED CSHB 151(HES) OUT OF COMMITTEE
HOUSE BILL NO. 13
"An Act relating to reimbursement of municipal bonds for school
construction; and providing for an effective date."
- SCHEDULED BUT NOT HEARD
PREVIOUS COMMITTEE ACTION
BILL: HB 193
SHORT TITLE: LICENSING MEDICAL OR CARE FACILITIES
SPONSOR(S): RULES BY REQUEST OF THE GOVERNOR
03/02/05 (H) READ THE FIRST TIME - REFERRALS
03/02/05 (H) HES, JUD, FIN
03/15/05 (H) HES AT 3:00 PM CAPITOL 106
03/15/05 (H) Scheduled But Not Heard
03/17/05 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 185
SHORT TITLE: POSTSECONDARY STUDENT IMMUNIZATION
SPONSOR(S): REPRESENTATIVE(S) CHENAULT
02/28/05 (H) READ THE FIRST TIME - REFERRALS
02/28/05 (H) HES, FIN
03/17/05 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 156
SHORT TITLE: COMMISSION ON AGING
SPONSOR(S): REPRESENTATIVE(S) HOLM
02/18/05 (H) READ THE FIRST TIME - REFERRALS
02/18/05 (H) HES, FIN
03/17/05 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 151
SHORT TITLE: RESPONSIBILITY FOR CARE AFTER EYE SURGERY
SPONSOR(S): LABOR & COMMERCE BY REQUEST
02/14/05 (H) READ THE FIRST TIME - REFERRALS
02/14/05 (H) HES, L&C
03/01/05 (H) HES AT 3:00 PM CAPITOL 106
03/01/05 (H) Scheduled But Not Heard
03/08/05 (H) HES AT 3:00 PM CAPITOL 106
03/08/05 (H) Heard & Held
03/08/05 (H) MINUTE(HES)
03/17/05 (H) HES AT 3:00 PM CAPITOL 106
WITNESS REGISTER
RICHARD MANDSAGER, M.D., Director
Division of Public Health
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Provided information on HB 193 and
testified in support of HB 193.
STACIE KRALY, Attorney
Senior Assistant Attorney General
Department of Law
Department of Labor & Workforce Development
Juneau, Alaska
POSITION STATEMENT: Provided information on HB 193 and
testified in support of HB 193.
ERICH DELAND, Staff
to Representative Mike Chenault
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented HB 185 on behalf of
Representative Mike Chenault and answered questions.
BARBARA COTTING, Staff
to Representative Jim Holm
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented HB 156 on behalf of
Representative Jim Holm and answered questions; suggested
changes to HB 156.
LINDA GOHL, Executive Director
Alaska Commission on Aging
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Provided information on behalf of the
Alaska Commission on Aging.
STEVE ASHMAN, Director
Division of Senior and Disability Services
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Provided information on behalf of the
Division of Senior and Disability Services.
WAYNE HAGERMAN, O.D.
Sitka, Alaska
POSITION STATEMENT: Testified in opposition to HB 151.
CARL ROSEN, M.D.
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 151.
ERIK CHRISTIANSON, O.D.
Ketchikan, Alaska
POSITION STATEMENT: Testified in opposition to HB 151.
WILLIE SHIELDS, M.D.
Washington
POSITION STATEMENT: Provided his opinions regarding eye care
and offered relevant information pertaining to HB 151.
BOB FORD, M.D.
Chehalis, WA
POSITION STATEMENT: Testified in opposition to HB 151.
SAM TRIVETTE
Juneau, Alaska
POSITION STATEMENT: Testified in opposition to HB 151.
FRANK BICKFORD
Alaska Society of Eye Physicians Surgery
Juneau, Alaska
POSITION STATEMENT: Testified in support of HB 151.
MICHAEL BENNETT, O.D.
Juneau, Alaska
POSITION STATEMENT: Testified in opposition to HB 151.
ACTION NARRATIVE
CHAIR PEGGY WILSON called the House Health, Education and Social
Services Standing Committee meeting to order at 3:04:42 PM.
Representatives Kohring, Anderson, and Gardner were present at
the call to order. Representatives Seaton, Cissna, and McGuire
arrived as the meeting was in progress.
HB 193-LICENSING MEDICAL OR CARE FACILITIES
CHAIR WILSON announced that the first order of business would be
HOUSE BILL NO. 193 "An Act relating to the licensing,
regulation, enforcement, and appeal rights of ambulatory
surgical centers, assisted living homes, child care facilities,
child placement agencies, foster homes, free-standing birth
centers, home health agencies, hospices or agencies providing
hospice services, hospitals, intermediate care facilities for
the mentally retarded, maternity homes, nursing facilities,
residential child care facilities, residential psychiatric
treatment centers, and rural health clinics; relating to
criminal history requirements, and a registry, regarding certain
licenses, certifications, approvals, and authorizations by the
Department of Health and Social Services; making conforming
amendments; and providing for an effective date."
3:06:02 PM
RICHARD MANDSAGER, M.D., Director, Division of Public Health,
Department of Health and Social Services, (Department),
introduced the slide entitled, "PUBLIC HEALTH: Protecting and
Promoting the Health of All Alaskans, HB 193, a Bill to
Consolidate DHSS Licensing, Certification, and Background Check
Functions." He showed slide number 2 and explained:
The existing statutory and regulatory environment ...
that the Department deals with all kinds of programs
and facilities that range in size from major
hospitals, like Providence, to small family owned
assisted living homes, to hospice, to ambulatory ...
surgery centers, to foster families - there's this
whole range of licensing and certification activities
that the Department does. And, two years ago the
Governor with "administrative order 108" ... began the
centralization process of bringing the certification
and licensing activities together into one place and
separating them from the parts of the Department that
pay for services ... there is some degree of
separation of the licensing and certifying from the
paying part of the organization. As we've started
down that journey, it has become very apparent that
these programs have all grown up independently ...
with their own sets of statutes ... regulations ...
appeal processes and they are sometimes similar ...
many times with different steps. So, the first real
purpose here is an administrative simplification and
cohesion question about what makes sense ... for the
Department across all of these entities to make them
as similar as possible ... in terms of cost of
certification and licensing ... even though there's a
theory that we can bring together and centralize this
licensing function ... the training of staff to be
able to interact with more than one type of program is
really markedly decreased ... We're aiming for a day
... when one person could go prepared to do two or
three activities rather than three separate people
going in on three separate plane trips into that
[rural] community. To get there, requires us ... to
try to get to much more standardized and simplified
rules on the state side ... on the provider side, many
providers have multiple types of programs and for them
to keep track of separate program rules ... is an
administrative cost ...
DR. MANDSAGER described a past situation where a provider in a
supported living home was misappropriating funds collected from
a resident. He explained that the state does not demand a
license or background check for [supported living homes] and
there was little that the state could do in terms of recourse.
He said that in Alaska there is a "nurse aid registry" and three
nurse aids were found by investigative agencies to be
mistreating residents in a nine month period and after the
mandatory reporting period, two had not been entered into the
registry; one case had involved physical violence. He pointed
out that timeliness issues in the current process need to be
improved. He added that many personal care attendants work for
more than one agency and are required to have separate
background checks with each agency. He offered that doing this
once for all agencies could be more efficient. Dr. Mandsager
reviewed which department divisions and service providers would
be affected, and what would be standardized by HB 193.
3:18:20 PM
REPRESENTATIVE GARDNER stated that Representative Kohring and
she have constituents that are involved in the health care field
and provide services to people at home, and they have inquired
as to the development of a database that would allow for the
detection of people who have been accused of fraud with Medicare
billing. She explained that there is no legal way to inform
other agencies that this has occurred with a past employee. She
asked if the registry [mentioned by Dr. Mandsager] would include
fraud allegations.
STACIE KRALY, Senior Assistant to the Attorney General,
Department of Law, said that she understood the theoretical
concept behind the abuse registry to include a finding of fraud
in that context if the individual had, in fact, been terminated
for fraudulent billing activities. She explained that the idea
[for the abuse registry] is to create a civil registry that
would include all types of instances that a prospective employer
would want to know about, before hiring.
REPRESENTATIVE GARDNER said that there are gray areas that would
include there being no record of offensive behavior. She opined
that many employees [in assisted living homes, or acting as care
providers] are minimally skilled and move from agency to agency
for a variety of reasons; it seems that there is the possibility
for "low-grade" violations to escape prosecution in many
instances, which would provide little or no information on the
registry.
3:21:31 PM
MS. KRALY said that Representative Gardner brought up a good
point and that ultimately, what is envisioned is a mechanism, to
notify the state for the basis of the termination and provide
them with some type of hearing. She highlighted that this is a
process that benefits both parties so that one cannot be taken
advantage of.
3:23:42 PM
DR. MANDSAGER said that the [Division of Public Health] is
looking for ideas of how to make this [registry] have the best
value at a reasonable cost and accomplish all of the things
mentioned.
REPRESENTATIVE GARDNER inquired as to care providers
participating in the process [of using the registry] and asked
whom they should contact for more information.
DR. MANDSAGER offered himself as a contact.
3:24:31 PM
REPRESENTATIVE SEATON opined that there should be a hearing
process that defines limitation on liability for the employer
and provides information on past employees [that have committed
offenses of some kind]. He said that there may be difficulty in
the creation of a registry if employers could face lawsuits from
past employees.
3:26:22 PM
MS. KRALY referred to HB 193 and said:
On page 13, section 47.32.170, there's an immunity
section, subparagraph C, which addresses the liability
and the criminal history check but we should probably
look at that with respect to the abuse registries, as
well ... We appreciate that comment, and we'll take a
look at that.
REPRESENTATIVE KOHRING inquired as to the description of this
legislation as an "efficiency measure."
DR. MANDSAGER said that he hopes that as the population grows
and more providers come online, that the staff required to serve
will remain the same and demonstrate efficiencies over time.
3:28:20 PM
REPRESENTATIVE KOHRING inquired as to Dr. Mandsager's perception
of the medical industry in terms of streamlining regulatory
processes.
DR. MANDSAGER said that he is also troubled by the
aforementioned question which concerns regulatory
simplifications in a heavily regulated industry.
REPRESENTATIVE MCGUIRE asked, "are there any new categories that
did not previously require licensure?"
DR. MANDSAGER said that one of the amendments that is being
worked on relates to the list on page 2, of HB 193. He
explained:
I have a concern ... as the medical industry ...
evolves ... and develops more free standing services
outside of hospitals, how do we have a list that
includes some kind of a statement that there could be
developed a checklist or criteria against which when
the risks of a population is high enough, that they
would then be brought into a licensed and regulated
environment ... more and more services are leaving
hospitals and going into stand alone types of service
delivery. At the other end of the extreme ... there's
... "supported living homes" that aren't regulated ...
"assisted living home" starts at [page] 25 and there's
a set of criteria that are listed ... if a person is
... providing housing and food services or assisting
with activities of daily living, this would ... say
that you need to be licensed as an assisted living
home. Right now, there are ... places out there that
are choosing not to be licensed ... this will try and
make it more clear what the break point is at which
you need licensure or don't ... the staff would need
the background check, as minimum, as this bill were to
go into place ...
3:32:26 PM
DR. MANDSAGER said that the Division of Public Health is working
on a series of amendments [for HB 193].
REPRESENTATIVE GARDNER inquired as to the issue of employment
and a record of termination [within the registry]. She then
asked if [Alaskan Statute] "47.05.20" is part of HB 193.
MS. KRALY explained that the first statutory cite in
subparagraph C should be "47.05.310" and then it should be
"47.05.320" and those are the statutes of reference on page 27,
of HB 193. Under "Article 3" of the bill, the new sections
under "47.05", which creates the "Criminal History; Registry"
process and how the background check can occur.
3:36:17 PM
REPRESENTATIVE SEATON mentioned the testimony from the Alaska
State Hospital and Nursing Home Association, (ASHNHA), and its
liability concerns. He inquired as to what has been done to
prevent liability issues and if these concerns have been
addressed, overall.
DR. MANDSAGER said, " ... as we envision this in statute, we
need to make sure that there are steps in place either in
statute or ... in regulation to make it clear that the
Department is ready to do such an action ... you can't expose
frail elderly ... to risk, before they're moved out to another
facility ... or another provider is brought in to manage the
facility."
MS. KRALY clarified that the bill was drafted in an effort to
bring the 12 statutory provisions into one umbrella process, in
an effort to serve a wide spectrum of entities. Currently, if
there is a situation of immediate risk in a nursing home, a
temporary manager must be contacted to go through a series of
court processes, she related. When there is an assisted living
home with an individual at risk, she said, the individual would
be removed and the due-process hearing would occur later. She
clarified that the instances that ASHNA had mentioned in their
letter would be dealt with using the temporary manager, and
court process, because from a legal and management standpoint,
it would not be plausible to take over a large institution.
3:40:43 PM
REPRESENTATIVE SEATON inquired as to the "taking over" of
smaller assisted living homes if they are found to be "at risk"
situations.
MS. KRALY it would all be laid out through regulation, and more
often than not, a resident would be removed before a "home" was
"taken over."
CHAIR WILSON mentioned the "Position Paper on House Bill 193
Offered by Rod Betit, President of ASHNHA," and inquired as to
the Department addressing the concerns that were listed.
DR. MANDSAGER said that the current regulations allow for
gradation within the assisted living situations. The balance
point between a nursing home and a "level 3" in a pioneer home,
for example, is the discussion point. In light of the function
pioneer homes have, he opined that in order to continue that
level of home-based, social service, kind of care, rather than
medical care, regulation opportunities will have to be created.
CHAIR WILSON commented on the slow physical deterioration of
individuals within care facilities and the adaptation of
different forms of care that evolve.
DR. MANDSAGER stated that one major issue concerns fire
marshals. In a pioneer home, a fire marshal would require that
people be able to readily get out and if someone had physically
deteriorated to a certain level [where they could not readily
get out], then that person would have to move to another
facility.
3:45:19 PM
REPRESENTATIVE CISSNA commented that she would like to stay
informed as Dr. Mandsager and others make more decisions and
modifications on HB 193.
DR. MANDSAGER opined that in reality, HB 193 is unlikely to pass
this legislative session. He advocated for moving through the
process, making modifications, hearing concerns, and coming back
next year with a clearer version of HB 193.
REPRESENTATIVE MCGUIRE opined that, in many instances, language
within HB 193 is unqualified. She referred to page 14, line 22,
and said that this section was a very broad "access to
information" clause. She encouraged Dr. Mandsager to spend time
looking at HB 193 and qualifying sections that are lacking
specific information.
DR. MANDSAGER explained that the advantage of having introduced
the bill is it is now public and can be inspected from many
points of view. He said he hopes that there will be meeting
over the summer and fall and then, HB 193 can be acted on next
winter.
MS. KRALY clarified:
The genesis of this section 1, which is a centralized
licensing and related administrative procedures, 99
percent of that is current law. It's just been cut
and pasted and cleaned up ... to create one,
centralized licensing statute. If you look at most of
it, it's not pulled out of the pie in the sky type
thoughts, we're currently using these statutes - it
just pulls it into one ... we took the best of the
best, we felt and we cleaned up the problems that we
see we've envisioned in enforcing and advising the
department and created this centralized panel, there
are questions and issues and we knew there would be -
but just so that's clear, we tried to take what was
good and make it a little bit better.
[HB 193 was held over.]
HB 185-POSTSECONDARY STUDENT IMMUNIZATION
3:52:53 PM
CHAIR WILSON announced that the next order of business would be
HOUSE BILL NO. 185 "An Act relating to immunization of
postsecondary students for meningitis; and providing for an
effective date."
ERIC DELAND, Staff to Representative Mike Chenault, presented
the sponsor statement for HB 185 on behalf of Representative
Chenault. He described how a man in Alaska, age nineteen, was
overcome with a meningococcal disease and became brain dead
within several hours of the onset of symptoms. He informed that
meningococcal disease has a 15 percent mortality rate. What
this bill tries to do, he related, is remove the exemption so
that post-secondary institutions shall provide information about
viral and bacterial meningococcal diseases and their risk. He
said that the students shall also sign a document stating that
they have received this information and can have the option of
immunization. He emphasized that there is no requirement for
immunization in HB 185. He said that the Center for Disease
Control, the American Academy of Physicians, and the American
Academy of Pediatrics recommend immunizations for post-secondary
students.
CHAIR WILSON commented that immunization requirements concerning
meningococcal disease are required for some groups of people but
that there are known exemptions. She offered religious beliefs
as an example of an exemption.
MR. DELAND explained that the passage of HB 185 will enable
post-secondary students to receive information about
meningococcal disease. He said that post-secondary students
live in high-risk environments for the spread of meningococcal
disease
CHAIR WILSON clarified that this bill does not require
immunization of students.
MR. DELAND stated that it requires post-secondary schools to
provide information pertaining to meningococcal disease and
information about immunization.
REPRESENTATIVE GARDNER asked if there are various types of
meningococcal disease.
MR. DELAND said that meningococcal disease can be viral or
bacterial. He informed that there are many different strains.
REPRESENTATIVE GARDNER inquired as to the effectiveness of the
immunization for all of the types of meningococcal disease.
MR. DELAND stated that the immunization is effective, regardless
of the strain of meningococcal disease.
REPRESENTATIVE KOHRING inquired as to the necessity of passing
HB 185 and creating statute around this issue. He asked if
schools are informed about meningococcal disease.
MR. DELAND said that most schools around the country are
requiring immunizations but it is not required in Alaska.
REPRESENTATIVE KOHRING asked if schools in Alaska know that
meningococcal disease is a problem.
MR. DELAND opined that schools should know [about meningococcal
disease] and the purpose of HB 185 is to provide necessary
information so that students can make a decision regarding
immunization.
REPRESENTATIVE KOHRING inquired as to the distribution of
letters to schools as an attempt to inform, as opposed to
creating legislation.
MR. DELAND clarified that HB 185 is related to post-secondary
schools.
REPRESENTATIVE KOHRING offered that the letters be distributed
to post-secondary schools. He expressed his uncertainty of
creating a bill to inform students of a disease.
MR. DELAND restated that not all institutions provide
information on meningococcal disease.
REPRESENTATIVE KOHRING inquired as to the cost associated with
the distribution of information.
MR. DELAND explained that there is a [health] packet handed out
to new students at post-secondary schools and this information
would be included in that packet.
3:59:05 PM
REPRESENTATIVE MCGUIRE said, "We're requiring that information
be given but we're not requiring immunization?"
MR. DELAND said that is correct.
REPRESENTATIVE MCGUIRE asked why immunization is not required.
MR. DELAND said that the reasons are similar to those brought up
by Chair Wilson. He described the issues concerning religious
beliefs, and opined that each individual should make their own
decisions [to immunize].
REPRESENTATIVE MCGUIRE related that, in her experience,
immunizations were required when attending school.
CHAIR WILSON clarified that there are other exemptions. She
commented that some people don't believe in immunizing their
children, and that, based on her experience as a school nurse
for many years, there are many reasons why people choose not to
be immunized.
4:00:35 PM
REPRESENTATIVE MCGUIRE inquired as to the number of states that
require immunization [of meningococcal disease].
RICHARD MANDSAGER, M.D., Director, Division of Public Health,
Department of Health and Social Services, stated that there are
two varieties of meningococcal vaccine for this organism, for
Neiserria meningitidis. He explained that this is the kind of
meningitis that makes people fearful. He said:
somebody gets sick with flu symptoms and can be dead
in a few hours. Thankfully, it's very rare. There is
a small, increased risk if you are a freshman in a
college dorm or in the military, and that's where the
epidemics back ... during WWII, were first recognized.
A couple things have changed this winter, the American
Council on Infectious Practices has just changed its
recommendations about the vaccine for Neiserria
meningitidis ... and is now recommending, because
there is a new vaccine available this winter, that all
people ... get it ... within a few years, this is
going to be common practice for most kids entering
post-secondary institutions ... colleges already
include it in their information ... we in the
[Department of Health and Social Services] are fairly
neutral on this bill for some of the reasons that
Representative Kohring just stated ... there's a small
number of post-graduate colleges in this state and
couldn't we persuade them to voluntarily include [a
letter] rather than have a statute, given the fact
that immunization practices over the next five years,
most kids, by the time they go off to college, are
going to be immunized already with a new vaccine.
Your question is specifically how many states have
requirements for either information or vaccination or
nothing, most have moved to ... either requiring
information or requiring immunization and there's a
mixture across the country but it's going to change
fairly quickly now with the change in immunization
practices. We are a universal immunization state and
we don't have to include this vaccine because of the
vaccine for kids which is the federal program ... as
long as we remain a universal vaccine state, all of
our kids in this state will be offered, and the only
kids that won't be immunized will be the families that
choose not to get vaccinated, but it will get joined
into the requirement for school attendance over this
next year ... I recognize the ... interest in the
bill, but the timing is interesting given the change
in vaccine as to how necessary it is, given it's going
to happen, anyhow.
4:04:06 PM
REPRESENTATIVE MCGUIRE expressed her belief that if [the
legislature] makes a fundamental policy shift to require
immunizations, then that should be the law created. She
inquired as to the requirements of immunizations at the local
level for students, before entering school.
DR. MANDSAGER said that over this next year, because Alaska is a
"universal vaccine state", the Department will be putting up
proposed regulations that [meningococcal disease vaccine] will
get added to the schools for students in grades K-12. He opined
that over the next six months the [meningococcal disease
vaccine] will be added in; the [Department of Health and Social
Services] will have to put out regulations proposing to amend
the mandatory vaccine policies for schools and, if that happens,
over the next few years all of the teenagers are going to get
vaccinated.
REPRESENTATIVE MCGUIRE clarified that the [meningococcal disease
vaccine] will be a requirement for students in grades K-12.
REPRESENTATIVE SEATON stated that HB 185 deals specifically with
post-secondary students. He asked if regulations proposed by
the state will apply for post-secondary schools.
DR. MANDSAGER said that the state has no authority to regulate
immunization in post-secondary schools.
REPRESENTATIVE GARDNER inquired as to the document mentioned in
HB 185 where the student's immunization status is recorded. She
asked how long this document would be kept and by whom.
MR. DELAND said that the document would be kept while the
student was attending that institution, by the institution.
4:07:18 PM
REPRESENTATIVE MCGUIRE moved to report HB 185 out of committee
with individual recommendations and the accompanying fiscal
notes.
REPRESENTATIVE GARDNER objected. She said that if this bill
were to pass, she anticipates repealing it when regulations are
revised. She said that she is not in favor of passing a bill
that may not be needed.
CHAIR WILSON reminded Representative Gardner that the new
regulations would apply to grades K-12, and HB 185 is dealing
with post-secondary schools.
A roll call vote was taken. Representatives Anderson, McGuire,
Seaton, Cissna, and Wilson voted in favor of reporting HB 185
out of committee. Representative Gardner voted against it.
Representative Kohring was absent for the vote. Therefore, HB
185 was reported from the House Health, Education and Social
Services Standing Committee by a vote of 5-1.
4:09:52 PM
HB 156-COMMISSION ON AGING
CHAIR WILSON announced that the next order of business would be
HOUSE BILL NO. 156 "An Act relating to the membership of the
Alaska Commission on Aging; and providing for an effective
date."
BARBARA COTTING, Staff to Representative Jim Holm, presented HB
156 on behalf of Representative Holm. She explained that within
the committee packet, the sponsor statement, sectional analysis,
and her comments are addressed to the committee substitute
because the original bill had suggested changes.
4:11:04 PM
REPRESENTATIVE SEATON moved to adopt the proposed committee
substitute (CS) for HB 156, Version 24-LS0615\F, Mischel,
3/2/05, as a work draft. There being no objection, Version F
was adopted.
MS. COTTING explained that in 2003, Governor Murkowski issued an
executive order that transferred the Alaska Commission on Aging,
(ACoA), from the Department of Administration to the Department
of Health and Social Services. In 2004, she related,
Representative Holm sponsored HB 394 which put that change into
statute; it also changed the "sunset" date from 2004 to 2008.
She said that HB 156 makes a change in compliance with the
wishes of the ACoA. She pointed out that at the ACoA February
2005 quarterly meeting, what was requested was that a vacancy be
filled by a senior services provider, regardless of age, and
that the provider be a recipient of a division of senior and
disabilities grant under the senior grant program. She added
that the ACoA felt strongly that the expertise that would be
provided would be a good thing for the ACoA. She requested that
the committee insert the phrase, "regardless of age" in HB 156,
on page 1, line 11, after "senior services provider."
REPRESENTATIVE GARDNER inquired as to who would be included in
the pool of "grant recipients" mentioned.
4:14:13 PM
LINDA GOHL, executive director, Alaska Commission on Aging, said
there's a variety of services under the senior grant program,
including nutrition, transportation support services, in-home
services for home and community based care, chore respite, and
Alzheimer's support services.
REPRESENTATIVE GARDNER asked if the people who administer the
aforementioned programs obtain the grants.
MS. GOHL said grant recipients could be project coordinators or
a board member for a non-profit organization; they are people
providing direct services as part of an agency. She explained
that the ACoA was asked, prior to the meeting, to consider this
seat being a provider seat and they thought it would be
beneficial to the community, as well as to the providers,
beneficiaries, and stakeholders.
4:15:53 PM
STEVE ASHMAN, Director, Division of Senior and Disability
Services, said that under statute, the recipients of grants have
to be a 501(c)3, a municipal government, or a "tribal
government."
REPRESENTATIVE GARDNER inquired as to the "ethics act."
MS. GOHL said that the ACoA is no longer receiving grant
proposals, reviewing grant proposals, making recommendations for
grant awards, nor involved in any way in the grant award
process.
REPRESENTATIVE GARDNER clarified that there aren't conflicts
with grant recipients.
MS. GOHL said that is correct. She continued:
The Department has essentially taken over that
function, within the Division of Senior and Disability
Services and the centralized grants and contracts
administration unit, and then the Commissioner [of the
Department] or his designee is the only individual who
is actually signing grant awards ... there could be a
potential conflict ... when the [ACoA] works on the
state plan of services that has to be produced every
two to three years and submitted to the federal
government in order to receive continuing funds under
the Older Americans Act, we have to do a formula
allocation which is a geographic allocation for how
the grant awards will be distributed throughout the
state and there's different criteria and elements and
factors that make up this chart of how the awards and
the total funds will be allocated, and there could be
a potential conflict if this provider were in an area
that was going to see a loss, perhaps, or a gain in
funding in their geographic area ... the commission
discussed any potential ... conflicts of interest ...
and they decided during the February meeting that they
would ask the individual to refrain from voting.
4:19:15 PM
REPRESENTATIVE GARDNER moved to adopt Amendment 1, as follows:
Page 1, line 11, following "senior services provider"
Insert "regardless of age"
There being no objection, it was so ordered.
REPRESENTATIVE KOHRING moved to report CSHB 156, as amended, out
of committee with individual recommendations and the
accompanying fiscal notes. There being no objection, CSHB
156(HES) was reported from the House Health, Education and
Social Services Standing Committee.
HB 151-RESPONSIBILITY FOR CARE AFTER EYE SURGERY
CHAIR WILSON announced that the next order of business would be
HOUSE BILL NO. 151 "An Act relating to provider responsibility
for ocular postoperative care; and providing for an effective
date."
4:21:38 PM
WAYNE HAGERMAN, O.D., explained that he has been practicing as
a private optometrist in Sitka, Alaska since 1984. He stated
his opposition to HB 151 and that it will have a detrimental
effect to the community of Sitka. In Sitka, he described, there
is a community hospital and a visiting ophthalmologist that has
provided service since 1997 and provides cataract surgery to the
community members. He said that the ophthalmologist, Dr. Tim
Gard, is from the Hillsboro Eye clinic in Oregon. He pointed
out that [Dr. Gard] has provided these services to the community
hospital as a benefit to the community, especially the senior
citizens who are unable to travel elsewhere to have these
surgical procedures attended to. He emphasized that he has
worked closely with Dr. Gard for seven years and co-managed
these patients without difficulty. He opined that it would
cause undue hardship for Dr. Gard to have to remain in Sitka for
five days following eye surgery and wishes the committee would
reconsider the passing of HB 151.
4:23:31 PM
REPRESENTATIVE ANDERSON inquired as to Dr. Hagerman's position
if the bill were amended to require a two-day stay following
post-operative surgery, as opposed to the original five-day
stay.
DR. HAGERMAN stated that there is not a resident ophthalmologist
in Sitka so there is no possibility to refer patients to another
surgeon. He said that the 48-hour change is amenable.
REPRESENTATIVE ANDERSON asked if Dr. Hagerman preferred the two
day amendment as opposed to the 5 day stay [following eye
surgery].
DR. HAGERMAN said that he preferred a two-day requirement but
that a 24-hour requirement would be more than adequate [for an
ophthalmologist to stay in the area following eye surgery].
REPRESENTATIVE GARDNER inquired as to patients in Sitka needing
the services of an ophthalmologist when one was not available.
DR. HAGERMAN said that there is an understanding between himself
and the ophthalmologist that when there is some complication
that goes beyond the level of expertise [of the optometrist],
the visiting ophthalmologist would stay and deal with it.
REPRESENTATIVE GARDNER asked what would happen if the
complication arose after the ophthalmologist left [Sitka].
DR. HAGERMAN stated that he and the ophthalmologist are in
constant communication about the follow-up care of these
patients and the situation described has not yet arisen.
REPRESENTATIVE SEATON inquired as to the practicality of setting
the two-day [ophthalmologist] stay requirement after eye
surgery. He asked Dr. Hagerman what his opinion was concerning
this stay requirement.
DR. HAGERMAN said that generally, it is within a day or two days
after the surgery.
4:26:17 PM
CHAIR WILSON stated that HB 151 has been difficult [for her] and
that she has been indecisive. She explained that she called Dr.
Gard [the ophthalmologist serving Sitka] and learned that many
of his patients are residents of the pioneer home and would be
unable to leave [Sitka] for surgical procedures. She related
that Dr. Gard informs his patients that they will have to fly to
Seattle if there are complications after he leaves Sitka. She
reported that Dr. Gard said that he could deal with the two-day
stay requirement after surgery, and that he would still serve
Sitka's needs. She stated that Dr. Gard had a question
concerning the stay requirement and it extending to the patient.
She said that he asked if the legislation would require the
patient to stay two extra days after surgery, because many times
they do not.
REPRESENTATIVE ANDERSON interjected that there are no
requirements related to the patient staying in the area where
the surgery occurred.
CHAIR WILSON explained that Dr. Gard had said that many times he
has stayed to make sure that every patient was taken care of.
She said that she had asked if there was any time when someone
had to fly to Seattle [for emergency care] and [Dr. Gard] had
said, "No, that has never happened." She opined that the 5-day
requirement [for the ophthalmologist to stay in the area where
surgery occurred] is too much. She mentioned a letter from the
Medical Association which promoted the 5-day stay requirement
for ophthalmologists, but acquiesced to the 2-day amendment.
REPRESENTATIVE ANDERSON stated that in the packet, the Alaska
State Medical Association sent a letter on March 4, 2005 which
stated that they represent physicians across the state and they
support HB 151. He said that they didn't reference the 2 versus
5 days [stay requirement] and there may be a discrepancy about
which association is being discussed.
The committee took an at-ease from 4:30:32 PM to 4:30:55 PM.
4:30:59 PM
REPRESENTATIVE ANDERSON clarified that a letter from the
American Academy of Ophthalmology, dated March 15, 2005 stated
support of HB 151. He explained that this letter was an attempt
to indicate the areas of concern regarding common surgical
complications and they reference that within the first 48 hours
certain complications can occur.
CHAIR responded that Dr. Gard teaches future ophthalmologists
and optometrists and he said that his concerns [for post-
operative care] included increased pressure or infection.
REPRESENTATIVE SEATON stated that in the letter from the
American Academy of Ophthalmology, the listed complications are
those that can occur in the first 48 hours [after surgery] but
it is not clear that they support the 48-hour stay requirement
as opposed to the original 5-day stay requirement.
4:33:15 PM
CARL ROSEN, M.D., clarified that 48 hours will cover common
complications and 5 days is preferred as it will cover all
aspects of possible patient complications after cataract or
interocular surgery. He stated that, "two days, if that's what
it takes to get improved patient quality of care, then we can
accept that."
CHAIR WILSON stated that if there is no amendment there could be
the risk of ophthalmologists refraining from serving remote
areas within Alaska.
REPRESENTATIVE ANDERSON noted that the letter from the American
Academy of Ophthalmology states, "The enactment of HB 151 ...
will insure that patients have access to a surgeon within the 48
hour window in which the complications from eye surgery could
occur."
REPRESENTATIVE SEATON said that as he reads the letter, it does
not say that they are revising their recommendation from 5 days
to 48 hours. He pointed out that the letter is saying that
certain complications can occur within 48 hours.
4:35:39 PM
REPRESENTATIVE ANDERSON stated that the American Academy of
Ophthalmology encompasses all of the medical physicians who
practice ophthalmology and they recommend [the ophthalmologist
to remain after surgery] 5 days. He said that the House Health,
Education and Social Services Standing Committee prefers the
amended 2 day stay requirement.
CHAIR WILSON said that it is obvious that American Academy of
Ophthalmology is aware of the amendment and that they endorse HB
151 with the 2-day amendment.
4:36:32 PM
ERIC CHRISTIANSON, O.D., said that he has been an optometrist in
Ketchikan since 1990, and there is not a full time
ophthalmologist. He explained that there is an ophthalmology
group that rotates through Ketchikan one week a month and they
perform surgeries. He mentioned that since 1990, he has been
involved with 3 or 4 eye care emergencies and most occurred
within a few days after surgery. He said that in Ketchikan,
older surgical techniques are used and the results aren't as
good. He said that he refers his patients to Seattle. He said:
When I refer to a surgeon, I am counting on the skill
of the surgeon and the ability of his particular team
that he has put together to take care of the patient
... the outcomes of surgery are much better when you
have a team and that includes the surgeon, but it also
includes the other staff members in the office,
including optometrists to manage the patient and
return them at an appropriate time. The opposition
that I have to this bill is ... the legislature
shouldn't be regulating comanagement. It should be
regulated by the boards. I was a board member ... for
eight years ... I have never heard one peep from the
Medical Board regarding any problems with comanagement
with optometrists ...
4:39:54 PM
CHAIR WILSON stated that she called the Medical Board and they
don't meet until next month. She said that she considered
holding this bill until next month to give the Medical Board a
chance to respond to the issues related to HB 151.
DR. CHRISTIANSON stated that his concern is that passing HB 151
is opening a "huge can of worms." He said that passing this
legislation would affect comanagement decisions of health care
professionals in rural communities. He emphasized that when
referring for surgery, health care providers are counting on the
clinical judgment of the surgeon that is being referred to.
REPRESENTATIVE GARDNER asked how long patients stay in Seattle
after their surgery is complete.
DR. CHRISTIANSON said that, typically, a patient will see the
surgeon, have the surgery completed, and see the surgeon the
following day. Depending on the procedure, if a patient is
stable enough there is no reason for them to stay longer. He
related that he then sees the patient for a follow up 7 days
after the surgery. He pointed out that his responsibility for
the patient occurs as soon as they are released from the
surgical facility.
REPRESENTATIVE GARDNER asked if it was accurate to say, assuming
there are no problems, that after a patient has surgery they are
seen by the surgeon the following day and then can return home.
DR. CHRISTIANSON replied that is correct.
4:42:42 PM
REPRESENTATIVE SEATON stated that he has had a problem with HB
151 in that there is a "board process." He said that with [Dr.
Christianson's] testimony, as the Chair of the State Medical
Board, it is clear that this issue has not been addressed by
ophthalmologists.
DR. CHRISTIANSON clarified that he is a part of the "Optometry
Board."
REPRESENTATIVE SEATON said that the HESS committee is trying to
get information from the State Medical Board because the issues
surrounding HB 151 are within the Board's jurisdiction to
regulate. He pointed out that there is no information on
ophthalmologists appealing to the State Medical Board and asking
for assistance with this issue. He added that he has real
concern about legislating particular medical procedures in place
of the State Medical Board.
4:44:39 PM
REPRESENTATIVE MCGUIRE referred to HB 151 and said:
on page 2, line 13 ... my understanding is that if the
distance the patient would have to travel to the
regular office of the operating surgeon would result
in an unreasonable hardship of the patient ... it is
an exception.
DR. CHRISTIANSON pointed out that HB 151 states that co
management agreements may occur only when the patient must
endure an unreasonable hardship to travel to the operating
surgeon.
REPRESENTATIVE MCGUIRE said that in many places in Alaska, the
situation of "unreasonable hardship" would apply. She inquired
as to medical malpractice insurance requirements.
DR. CHRISTIANSON replied that he carries $3 million in
malpractice insurance.
REPRESENTATIVE MCGUIRE inquired as to the amount of malpractice
insurance that the ophthalmologist that Dr. Christianson works
with carries.
DR. CHRISTIANSON clarified that he does not work with the
ophthalmologist; he refers patients to an ophthalmologist. He
said that there is no financial connection.
4:47:04 PM
REPRESENTATIVE MCGUIRE said:
please understand that the sponsor's intentions are
not to be disrespectful to you, nor are mine ... I got
a couple of emails that said ... I was saying that I
didn't think optometrists were valuable, or important,
or professionals and that's just the absolute opposite
of how I feel. I think that ... your profession is
extremely important, valuable, that the patient care
is great - I have an optometrist, I need them, I have
terrible eyes - so, I just want to get that on record,
but back to the medical malpractice insurance, when
you enter into these comanagement agreements, is there
a direct shift in liability that occurs ... one of the
things ... I have a concern about is, when things go
well they go well, and then when they don't, with the
eyes, it's a disaster ... the surgeon comes in, does
the surgery, gets on a plane, leaves, and now you're
there and you are dealing with ... a problem on your
hands. In the co-management agreement ... is the
liability for medical malpractice then shifted to you
for the primary act of the surgeon ...
4:48:44 PM
DR. CHRISTIANSON stated that he is not well versed in medical
malpractice.
DR. ROSEN said that malpractice is shared, but the primary
responsibility ultimately falls on the surgeon's hands.
4:49:34 PM
CHAIR WILSON inquired as to when co management occurs.
DR. CHRISTIANSON said that he refers patients to a specific
surgeon after he has diagnosed them. He said that patients like
to get back within a reasonable time frame to avoid high travel
costs. He emphasized that he trusts the surgeon to return the
patient at a time when they feel it is appropriate.
CHAIR WILSON clarified that patients usually return home, from
Seattle, by the second day after surgery.
DR. CHRISTIANSON said that is correct except if they have other
plans in Seattle, as well.
REPRESENTATIVE ANDERSON stated his belief that this bill isn't
about comanagement as much as it is about the surgeon staying
for two days after surgery is performed. He reiterated
Representative McGuire's comment that the distance an Alaskan
patient would have to travel for surgery would constitute
"hardship" and asked for a comment regarding this.
DR. CHRISTIANSON stated that decisions related to patient care
are for the surgeon to decide. He emphasized that the Alaska
State Medical Board should decide if regulations are needed for
specific situations regarding patient care and management. He
opined that regulating patient care is not up to the legislature
to mandate. He said that attempting to pass HB 151 is
"precedent setting" legislation.
4:53:02 PM
DR. WILLY SHIELDS, ophthalmologist, informed that he has
specialty training in retina care. He said that he has patients
referred to him from optometrists and from ophthalmologists and
that though the bulk of his patients are referred from the state
of Washington, there are some patients who come from Alaska. He
said that, as a result, he is affected by the co-management
relationship. He continued:
I certainly have my opinions about how co management
can work ... when I think about the state of Alaska
and how things are spread out ... I, personally, think
that it's going to be very difficult to take care of
patients in the larger sense without having a co-
management system. The problem that I see that
surfaces when there is an attempt to have rules or
regulations about co management, obviously you want to
make sure that there is a certain level of quality
that is adhered to, and I think that that is
fundamentally our responsibility whether
ophthalmologists or optometrists, but the major
problem ... is ... it is difficult to set up co
management ... rules that forgive ... co management
relationships between rural settings ... and ... co
management in a kind of urban ... setting. The
challenge is , how do you say that it is okay to have
co management in one setting and not the other. As
Dr. Christianson has said ... if there is a good
relationship and I know that kind of care that the
optometrist can provide in their community then I am
perfectly okay with the patient going back.
CHAIR WILSON inquired as to Dr. Shields' opinion on the two-day
stay requirement issue related to HB 151.
DR. SHIELDS related that there are times when a patient will
undergo surgery, and return home the following day. He said
that, depending on the patient and the situation, the time
frames change. He added that there are instances where patients
would be advised to abstain from travel because of complications
with healing process.
REPRESENTATIVE MCGUIRE reminded Dr. Shields that HB 151 pertains
to surgeons performing eye surgery in Alaska. She explained
that it is not uncommon for the legislature to make different
rules pertaining to rural parts of the state than for urban
[areas in Alaska].
DR. SHIELDS thanked the committee and all participants for the
efforts involved in understanding HB 151. He responded to line
14, within HB 151, and inquired as to the definition of
"hardship."
CHAIR WILSON stated that "hardship" can simply be that an
individual would not be able to afford airfare [required for
travel related to eye surgery].
REPRESENTATIVE GARDNER confirmed that Dr. Shields advocated for
the practice of sending a patient home 24 hours after surgery.
DR. SHIELDS said that is appropriate in many circumstances. He
emphasized that follow-up care would be involved after surgery.
REPRESENTATIVE ANDERSON asked Dr. Shields if he understood
Representative McGuire's earlier clarification regarding HB 151
being applicable only within the state of Alaska; he asked if
Dr. Shields had performed surgery in Alaska; he asked how Dr.
Shields was contacted to testify before the committee.
DR. SHIELDS said that he understood the clarification regarding
HB 151; he replied that he had never performed surgery within
Alaska; he said that he was contacted by Paul Barney, an
optometrist who works for the Pacific Cataract Group in
Anchorage and has received phone calls from Dr. Michael Bennett.
REPRESENTATIVE GARDNER said, "Representative Seaton talked about
a letter of support [for HB 151] from the "medical board" and
... in my packet I have a letter of support from the Alaska
State Medical Association, which is an association of
practitioners, not the board; am I missing something?" She said
that she is hoping to clarify as there is a big distinction
between the "medical board" and the "medical association."
REPRESENTATIVE ANDERSON stated that Representative Gardner is
correct and the Alaska State Medical Association endorses HB
151, not the Alaska Medical Board.
5:05:41 PM
BOB FORD, M.D., ophthalmologist, said that he lives in
Washington state but that he established an office [Pacific
Cataract and Laser Institute] in Anchorage, seven years ago. He
stated:
I believe ... all of the ophthalmologists and the
optometrists agree that the surgeon is the captain of
the ship for post-operative care, and the surgeon
feels that responsibility and he is going to be sure
that it is done and there are two ways to do that: he
can do it himself ... and that is good ... but it is
also very legitimate to delegate things and if you
have quality people that you trust, you can delegate.
I come up typically on Monday and I'll typically
operate for three days - Tuesday, Wednesday and
Thursday and then I go home ... the only reason I'm
comfortable doing that is because I have a very
skillful optometrist that's the full-time doctor there
... my office is open 5 days a week ... for post-
operative care. I've cared for, literally, thousands
of patients with Dr. Barney and I know he's very quick
... to recognize ... [post-operative complications]
... I've done approximately 8,000 surgeries in the
last 7 years, in Anchorage ... I have had three cases
that have needed my attention post-operatively, none
of them within the first 48 hours, interestingly
enough, and those 3 cases I took care of, one of them
three weeks after surgery ... so this bill wouldn't
have addressed that ... my thoughts and feelings on
this are very colored by my experience with my father.
My father was a family doctor and I watched him work
with surgeons and I could tell that my dad's patients
trusted my dad ... and the surgeons trusted my dad
too, and they'd get the patients right back to my dad
for post-operative care ... it was good for the
patients because my dad knew them better than anybody
else did ... I believe that patients nowadays want the
same thing for their eye surgery. If their doctor is
a surgeon, they'll want their doctor to do the surgery
and care for them afterward, if their doctor isn't a
surgeon, which is the case of 80 percent of the
patients in Alaska because 80 percent of the eye
doctors are not surgeons in Alaska ... they're going
to ask their doctor ... who should do my surgery and
their doctor will set that up and then they're going
to want to be right back in the care of their doctor
as soon as possible. I don't see that you can set a
specific time that works ... I haven't had a single
case, not one case, where the fact that I went home
Thursday night caused any harm to any patients ... if
you pass this legislation, then I will certainly
cooperate with it, and I'll spend another two days up
here at the end ... I don't think the legislation is
needed and it would hamper the way I practice, which a
lot of patients like and a lot of doctors like ... but
... I trust your judgment and ... I'll cooperate to
the best of my ability.
5:11:01 PM
CHAIR WILSON inquired as to the costs associated [for patients]
if HB 151 passes and Dr. Ford would be required to stay in
Anchorage for an additional day; she asked if the passing of HB
151 would make Dr. Ford hesitate about coming to Alaska to
perform surgery.
DR. FORD replied that if he were required to stay an additional
day after surgery, he would not charge patients extra. He
clarified that he does not pay optometrists for comanagement,
and that they bill separately. In response to Chair Wilson's
second question, Dr. Ford stated that he might hesitate but that
he feels a strong commitment to serve with his colleagues at
their practice.
REPRESENTATIVE GARDNER said that a surgeon that performs eye
surgery in this state can delegate the responsibility of post-
operative care to another ophthalmologist, according to HB 151.
She pointed out that Dr. Ford could easily delegate and one of
his partners could provide post-operative care, and that his
practice would, in essence, not be affected by HB 151.
5:13:00 PM
DR. FORD stated:
my partner, the one that sees all of my patients,
"post-op" up here, Dr. Barney, he is an optometrist,
not an ophthalmologist. And I feel that this bill ...
is anti-optometry, it really is, because the spirit
behind this bill is optometrist's are not capable of
doing first quality, post-operative care ... I believe
the way I do it is first rate ... I believe Dr. Barney
is just as able to screen for problems, as anybody
else. In fact, he's probably seen more cataract
surgeries, "post-op" than the average ophthalmologist
has.
5:13:39 PM
REPRESENTATIVE ANDERSON inquired as to Dr. Ford's opinion
regarding the Academy of Ophthalmology's guidelines on post-
operative surgical care.
DR. FORD said that the typical ophthalmologist is opposed to
comanagement. He explained that there is a conflict between
optometrists and ophthalmologists because optometry is a group
of forward looking, ambitious people and they've moved forward
in their ability to diagnose and treat disease, which is
threatening to ophthalmologists. The American Academy of
Ophthalmology is fundamentally not very supportive of
comanagement, he related, and there's hard feelings between
ophthalmology and optometry at the leadership levels because of
the struggle of the expansion of practice. He added that he is
more pro-comanagement than the leadership of the American
Academy of Ophthalmology is and respectfully disagrees with the
Academy on this subject of comanagement.
REPRESENTATIVE MCGUIRE inquired as to whether Dr. Ford takes
"call."
DR. FORD replied that he does not take "call" [ability to be
available for of-hours medical emergency calls] and it has
created negative feelings between him and some of the other
ophthalmologists. He explained that he has recently decided
that it would be fair to take "call" and is in the process of
setting the situation up so that he can rotate call with other
ophthalmologists in his office.
REPRESENTATIVE MCGUIRE said:
at the root of this bill I think there are some of us
that are supportive of it for the reason that we want
to attract ... retain ... more medical doctors,
ophthalmologists, to our community that are going to
live in our community and be here to service the needs
of the people that live in our state ... I suspect ...
that if I said "Would you be willing to fly your plane
up here, on a moment's notice, to take care of
somebody that had a very serious eye emergency that
had not paid you for an eye treatment" ... you would
probably say no and that's kind of the point I am
getting at ... it's an opportunity to come in, I
understand ... but that being said, you don't stick
around and I appreciate what you said on the record
today about the "call."
CHAIR WILSON interrupted and stated that Representative
McGuire's comments are not related to HB 151.
REPRESENTATIVE MCGUIRE said:
the point of this is that if we allow certain
procedures to create a market, then we deter some
people from entering the market ... the only other
final analogy I have is, paralegals, ... I have met
some paralegals that are some of the most competent
people ... I have met paralegals that are smarter than
a lot of the lawyers that I have met and so life
experience, and working on the job can make you
extremely competent. So, this is not about
optometrists not being competent ... the choice that's
made at the outset is your own, about whether you
choose to get a medical degree or whether you choose
to get an optometry degree ...
5:20:23 PM
REPRESENTATIVE SEATON inquired as to Dr. Ford participating in
comanagement arrangements.
DR. FORD said that for the last 20 years, almost all of his
patients have been comanaged.
SAM TRIVETTE said that he had eye surgery in Seattle and could
have instead [had eye surgery] in Anchorage, and if he had, this
bill would have had impact. He explained that he was referred
[for surgery] to an ophthalmologist by his optometrist in Juneau
and after the surgery, was seen by his local optometrist for
follow-up post-operative care. He said that if the follow-up
care had to have been done by an ophthalmologist, he would have
had real difficulty as there is only one ophthalmology group in
Juneau and he has had negative past experiences with them. He
explained, "if I had to stay for 48 hours because an
ophthalmologist would not do a comanagement, I would have to eat
that money and that's expensive, hotels are not cheap anymore,
and meals are not either. I feel this bill is unnecessary and I
don't think the legislature should be forcing this on the
medical system." He emphasized that this is an issue that is
between him and his physician and he does not understand why
statute is necessary.
5:24:58 PM
FRANK BICKFORD said that Dr. Ford spoke of a potential war
between optometry and ophthalmology in his testimony and there
is a need to clarify this. He informed that optometrists do a
good job at what they do and what they are trained to do and
that optometrists and ophthalmologists get along in Alaska. He
said:
The frustrating point that I heard today, was Dr. Ford
stating, if he can't come back to Anchorage, he'll
have his optometrist come from Outside. There are
ophthalmologists in Anchorage, why not add those
ophthalmologists as part of the comanagement
agreement. It's very simple, there is no reason why
the ophthalmologists in Anchorage can't be part of
this ... after 48 hours the optometrists are back in
the system under this bill, so they're not taking
optometrists out of the whole picture, they are part
of the picture but those first 48 hours are critical
in eye care and that's why the American Academy of
Ophthalmology endorses this bill with that change.
CHAIR WILSON inquired as to the insurance paying all involved,
if in fact there were situations where two ophthalmologists and
an optometrist treated one patient.
CARL ROSEN replied yes, and that there is a fee split that
Medicare and the "OIG" (Office of the Inspector General) has
deemed appropriate for appropriate comanagement that is in place
and it is usually "80/20" for the typical relationship.
5:27:48 PM
CHAIR WILSON said that what she is hearing over and over is the
fact that the patient is going to feel comfortable most with the
person the patient knows the best. She questioned whether it
really makes a difference in terms of who does the follow-up
care after eye surgery.
DR. ROSEN argued that the patient usually does not understand
what the comanagement relationship is and that's what the "OIG"
and Medicare expect. He said:
I would just say the litmus test for you people who
are making these decisions ... would you prefer to
have your physician take care of you, and to make
decisions or would you prefer to have someone who does
not do the cutting, someone who does not do the
sewing, who does not make the difference in your
visual system in the operating room ... I am not anti-
optometrists. I think that we're going to improve eye
care, we're going to set a precedent, we're going to
say look, you operate, you need to take care of that
patient, and after that , we can go about our business
as usual.
REPRESENTATIVE ANDERSON added, "isn't it true that a patient
after back surgery might feel more comfortable ... with their
massage therapist, that doesn't mean that they're healthier with
a massage therapist."
DR. ROSEN reiterated that the average person is unaware of the
difference between optometrists and ophthalmologists. He opined
that it is the job of the pathologists to make the best
decisions because ophthalmologists know more [about eye care]
than constituents and patients.
5:31:58 PM
DR. MICHAEL BENNETT, stated that throughout the course of the
committee meeting, optometrists have been compared to
paralegals, massage therapists, and other ancillary medical
personnel. He emphasized that optometrists are not ancillary
medical personnel. He explained that optometrists are doctorate
level physicians and are trained in optometry school to do post-
operative care. He said, "the whole gist seems to be ... are we
willing to settle for this ... second standard of care in post-
surgical care, as opposed to having the "real" doctor look at
the patient, and ... I don't know that it's gotten across very
well, it's the whole notion of that, that is offensive. I have
spent a long time doing post-operative care; I feel equally
qualified to recognize the problems that are being talked about
here, through the general ophthalmologists. And, obviously the
surgeons that I have referred patients to ... feel likewise, or
they would not be sending the patients back to me."
REPRESENTATIVE MCGUIRE said that a medical degree, which takes
about eight years to complete, is different than a degree in
optometry.
DR. BENNETT clarified that an optometry degree takes eight years
before it is completed.
REPRESENTATIVE MCGUIRE inquired as to the difference between
optometrists and ophthalmologists. She said, "Why not just
become a medical doctor?"
DR. BENNETT replied that he didn't want to become a medical
doctor.
REPRESENTATIVE MCGUIRE opined that people make a choice about a
degree they want, and then they come [to the legislature] and
demand additional powers to be granted in their profession.
5:36:19 PM
DR. BENNETT informed that optometry has grown and changed
considerably in the past few decades. He said that
practitioners are continually expanding their capabilities and
their level of knowledge. He explained that medical doctors can
obtain training and determine their competency to utilize new
techniques with patients, while optometrists cannot.
REPRESENTATIVE MCGUIRE said that people make a choice about a
profession and that the legislature cannot grant additional
"powers" to suit changing needs.
DR. BENNETT said that comanagement with optometry has been
regulated by the federal government since 1980 and optometrists
made the choice to have the capability to comanage [and have
been comanaging] for 25 years. He clarified that [optometrists]
are not asking for an expansion of authority in comanagement,
but that [the legislature] does not rescind [optometrist's]
authority in comanagement. He continued:
to become the only state in the country, where
optometrists, after 25 years of successful
comanagement, are now prohibited from doing so, for
whatever time period. This is not something new,
you're actually trying to turn the tables back 25
years ... I'm not here asking you to give me something
I don't already have, I'm asking you not to take
something away I've been doing successfully for a long
time. There have been a number of studies, two of the
major ones, authored by ophthalmologists, looking at
comanagement, looking at thousands and thousands of
retrospective cases and looking for outcome
differentials between optometry comanaged patients and
patients who are followed by the surgeon, they can't
find the problem, there's no difference in outcome.
5:40:52 PM
CHAIR WILSON asked Dr. Rosen if there is any other state has
passed legislation similar to HB 151.
DR. ROSEN said that four states have looked at similar
legislation. He opined that HB 151 will benefit people and
optometrists will get a chance to participate [in eye care].
5:42:47 PM
REPRESENTATIVE ANDERSON moved to adopt a Conceptual Amendment,
as follows:
I move amendment number 1 which would change on page
1, line 12, 120 hours to 48 hours, and then on page 2,
line 1, 120 hours to 48 hours. And have the legal
services make it a conceptual amendment so it's
conforming in case I've missed any applicable language
that doesn't reference 48 hours that needs to be
changed.
5:43:10 PM
REPRESENTATIVE SEATON objects. He stated his concern that the
48-hour amendment is arbitrary and that the testimony has shown
that most complications [after eye surgery] do not occur within
the 48-hour timeframe. He opined that, "we are just changing to
48 hours because maybe we can pass the bill with 48 hours and we
can't pass it with what the ophthalmologists themselves
recommend ... and so, I'll withdraw my objection for that, but I
have a problem with doing ...".
REPRESENTATIVE ANDERSON said that the American Academy of
Ophthalmology is stating that 48 hours is acceptable and the
idea of the bill is that doctors stay an extra day after
surgery.
CHAIR WILSON noted that Representative Seaton's objection was
withdrawn. There being no further objection, [Conceptual]
Amendment 1 was adopted.
5:45:03 PM
REPRESENTATIVE KOHRING offered that the committee hold this
legislation over until the next meeting because there seems to
be real hesitation among members and concerns from the
community.
REPRESENTATIVE ANDERSON opined that HB 151 can move. He said:
We've waited nine days ... we've had about 5 hours of
testimony duplicative for the optometrists,
duplicative of Dr. Rosen, and have another committee
of referral. And, we also have the ability for people
to allow it to pass, but vote do not pass or "no rec"
on the file and report if they're worried about the
record.
The committee took an at-ease from 5:46:21 PM to 5:47:02 PM.
5:47:08 PM
REPRESENTATIVE ANDERSON moved to report HB 151 out of committee
with individual recommendations and the accompanying fiscal
notes.
REPRESENTATIVE SEATON made an objection and stated:
I think that we've had a lot of testimony here, and I
think the testimony has come down to ... surgeons
should use their medical expertise and should
determine when, within their medical expertise, a
person should be able to leave and what we are trying
to do is insert ourselves between the medical doctors
and their decisions and say that the medical doctor
that says that his patient is free to go in 24 hours
is making a bad decision, an incorrect decision, and
we are going to insert the legislature into a medical
decision and say ... that we know better ... I think
that that is a very big mistake. I also think that on
page 2, line 12 where we say "this doesn't apply to
rural Alaska", [we are saying] it doesn't matter about
the care there, it only applies to Anchorage and
Fairbanks, basically ... I have a real problem with
aspects if the bill but, especially, that we're
inserting ourselves ... in the state medical board's
place.
5:48:49 PM
REPRESENTATIVE KOHRING said that he has concerns about the
legislation but that he will not object to move the bill to the
next committee. He explained that the bill will have more
opportunities for those that oppose this legislation to convince
members of other committees to prevent the bill from going
forth. He shared that his concerns are similar to
Representative Seaton's and he will vote to move the bill but
mark a "do not pass" recommendation on the "sheet."
5:50:04 PM
REPRESENTATIVE GARDNER she said that it is clear that this bill
addresses a problem that doesn't exist. She mentioned that she
agreed with Representative Seaton's comments.
CHAIR WILSON noted that she agreed with Representatives Seaton
and Gardner. She highlighted that this is not normal
[legislation] for Alaska. She said, "We try to make sure that
what we do doesn't have any ramifications in other areas and I
... am concerned that this is setting a precedent and the wishes
of the committee is that we move this bill and so we have an
objection, so I will go ahead and call the role."
5: 51:03 PM
A roll call vote was taken. Representatives Kohring, McGuire,
Anderson, and Cissna voted in favor of HB 151. Representatives
Seaton, Gardner, and Wilson voted against it. Therefore, CSHB
151(HES) passed and was reported out of the House Health,
Education and Social Services Standing Committee by a vote of 4-
3.
ADJOURNMENT
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned around 5:51:42 PM.
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