02/13/2014 03:00 PM House HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HB269 | |
| HB281 | |
| Presentation: Fairbanks Resource Agency | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 269 | TELECONFERENCED | |
| *+ | HB 281 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
February 13, 2014
3:05 p.m.
MEMBERS PRESENT
Representative Pete Higgins, Chair
Representative Wes Keller, Vice Chair
Representative Benjamin Nageak
Representative Lance Pruitt
Representative Paul Seaton
Representative Geran Tarr
MEMBERS ABSENT
Representative Lora Reinbold
COMMITTEE CALENDAR
HOUSE BILL NO. 269
"An Act providing immunity for certain licensed temporary health
care providers who provide free health care services."
- MOVED CSHB 269(HSS) OUT OF COMMITTEE
HOUSE BILL NO. 281
"An Act relating to prescription of drugs by a physician without
a physical examination."
- HEARD & HELD
PRESENTATION: FAIRBANKS RESOURCE AGENCY
- HEARD
PREVIOUS COMMITTEE ACTION
BILL: HB 269
SHORT TITLE: IMMUNITY FOR TEMP. HEALTH CARE PROVIDER
SPONSOR(s): REPRESENTATIVE(s) THOMPSON
01/21/14 (H) READ THE FIRST TIME - REFERRALS
01/21/14 (H) HSS, JUD
02/13/14 (H) HSS AT 3:00 PM CAPITOL 106
BILL: HB 281
SHORT TITLE: PRESCRIPTION WITHOUT PHYSICAL EXAMINATION
SPONSOR(s): REPRESENTATIVE(s) GATTIS
01/27/14 (H) READ THE FIRST TIME - REFERRALS
01/27/14 (H) HSS, L&C
02/13/14 (H) HSS AT 3:00 PM CAPITOL 106
WITNESS REGISTER
REPRESENTATIVE STEVE THOMPSON
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Introduced HB 269 as the sponsor of the
bill.
DAVID LOGAN
Legislative Committee and DAPAC Chair
Alaska Dental Society
Juneau, Alaska
POSITION STATEMENT: Testified during discussion of HB 269.
JULIE ROBINSON
Alaska Dental Society
Alaska Mission of Mercy
Anchorage, Alaska
POSITION STATEMENT: Testified in support of the bill during
discussion of HB 269.
RANDI SWEET, Director
Health Impact
United Way of Anchorage
Anchorage, Alaska
POSITION STATEMENT: Testified in support of the bill during
discussion of HB 269.
REPRESENTATIVE LYNN GATTIS
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Introduced HB 281 as the sponsor of the
bill.
REID HARRIS, Staff
Representative Lynn Gattis
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Answered questions for the bill sponsor,
Representative Lynn Gattis, during the introduction of HB 281.
HENRY DEPHILLIPS, Corporate Chief Medical Officer
Teladoc
Greenwich, Connecticut
POSITION STATEMENT: Testified during discussion of HB 281.
EMILY ENNIS, Executive Director
Fairbanks Resource Agency
Fairbanks, Alaska
POSITION STATEMENT: Presented a PowerPoint titled "The Link to
Aging Successfully: Fairbanks Resource Agency Has a Solution."
ACTION NARRATIVE
3:05:25 PM
CHAIR PETE HIGGINS called the House Health and Social Services
Standing Committee meeting to order at 3:05 p.m.
Representatives Higgins, Keller, Tarr, Seaton, and Pruitt were
present at the call to order. Representative Nageak arrived as
the meeting was in progress.
HB 269-IMMUNITY FOR TEMP. HEALTH CARE PROVIDER
3:06:40 PM
CHAIR HIGGINS announced that the first order of business would
be HOUSE BILL NO. 269, "An Act providing immunity for certain
licensed temporary health care providers who provide free health
care services."
REPRESENTATIVE KELLER moved to adopt the proposed committee
substitute (CS) for HB 269, labeled 28-LS1251\U, Martin\Wallace,
2/4/14, as the working draft. There being no objection, it was
so ordered.
REPRESENTATIVE STEVE THOMPSON, Alaska State Legislature, reading
from a prepared statement:
An act providing immunity for certain licensed
temporary health care providers who provide free
health care services. HB 269 was drafted due to
liability concerns surrounding an inaugural Alaska
Mission of Mercy (AKMOM) event organized by the Alaska
Dental Society, and scheduled in Anchorage this coming
April. The Mission of Mercy program was started by a
group of dentists thirteen years ago in Virginia. The
MOM programs provide free dental care to local
residents who would not otherwise have access to
affordable dental care. To date, the Mission of Mercy
Program in Alaska has 187 dentist volunteers, 7 are
from out of state. The AKMOM program will provide
extractions, fillings and cleanings as well as other
procedures that can be appropriately performed in a
mission setting. Out-of-State dental professionals
will be licensed to provide pro bono service under
courtesy licenses issued by the Alaska Board of Dental
Examiners. A courtesy license is a medical
professional license issued by the Board for the
purposes of providing free services and enforcing
state disciplinary provisions.
The issue is that there is no clear answer as to
whether an out-of-state dentist professional issued a
courtesy license is covered under Alaska Statute
09.65.300. AS 09.65.300 provides statutory immunity
against civil damages resulting from an act or
omission of a health care provider who provides free
health care service, within the scope of their
license. Under AS 09.65.300 a patient must receive
written notice of this immunity as well as give
informed consent before any medical service is
provided. Under AS 09.65.300 patients still have the
right to sue the medical provider for civil damages
resulting from the provider's gross negligence, or
reckless or intentional misconduct. Unfortunately, an
attorney general's opinion indicated that it would
take a court case to definitively decide if courtesy
licenses have protections.
The original intent of the statute was to allow
retired Alaska physicians to volunteer their services.
The Department of Law opines that the meaning of the
law as to out of state providers will ultimately have
to be interpreted by the court.
HB 269 will clarify AS 09.65.300, ensuring that civil
immunity is extended to these out-of-state medical
professionals who are licensed to provide dental
services in Alaska during the Mission of Mercy Event,
without having the issue come before a lengthy
proceeding before the Court.
REPRESENTATIVE THOMPSON urged the support of the committee.
3:10:18 PM
CHAIR HIGGINS asked whether military dentists, when volunteering
their time, had immunity coverage. He shared that the legal
opinion from the Department of Law was for immunity status,
unless the courts stated otherwise. He noted that he was a
dentist.
3:11:54 PM
DAVID LOGAN, Legislative Committee and DAPAC Chair, Alaska
Dental Society, in response to Chair Higgins, explained that, as
a general rule, military dentists did not carry malpractice
insurance policies, unless they worked away from the military
base.
CHAIR HIGGINS relayed a concern from Timothy M. Lynch [Included
in members' packets] whether a temporary courtesy provider
license would be in conjunction with the requirements for a
temporary permit under AS 08.64.270. Mr. Lynch asked, if the
proposed bill removed the requirement for state licensing, would
someone other than a State Medical Board have the authority to
license physicians under this approach, which, he opined, would
create an ambiguous situation regarding licensing. He
questioned whether this would prompt a conflict between the
State Medical Board and the Alaska State Medical Association.
3:14:27 PM
DR. LOGAN replied that the proposed bill would extend AS
09.65.300, which defined that a health care provider could hold
a temporary courtesy license under AS 08.01.62. He pointed out
that courtesy licenses were very different from temporary
licenses, which were issued under AS 08.064.270, and allowed
work and remuneration in any capacity. He noted that courtesy
licenses were reserved for unique situations, and specified
under various professions. He shared that a courtesy license
was issued for short term pro bono work. He pointed out that
there could not be any earnings with a courtesy license, other
than reimbursement for travel.
REPRESENTATIVE TARR asked for information about any necessary
follow-up procedures for patients after the AKMOM event.
DR. LOGAN deferred the question to Dr. Julie Robinson, as she
could speak more specifically to the procedures and any follow
up care. He surmised that many of the procedures would be
limited, as this was not the setting for more complicated needs.
3:18:08 PM
REPRESENTATIVE SEATON asked why the proposed bill did not cover
military courtesy licensing for these voluntary services.
DR. LOGAN explained that the Alaska Board of Dental Examiners
allowed military dental courtesy licenses. He opined that most
of the other medical boards had provisions in place for military
courtesy licensing.
3:19:56 PM
CHAIR HIGGINS opened public testimony.
JULIE ROBINSON, Alaska Dental Society, Alaska Mission of Mercy,
in response to Chair Higgins, explained that the Alaska Mission
of Mercy program had 1058 volunteers, and 202 dentists. She
declared that Alaska was the 27th state to offer this program,
and that there was a follow up care protocol. She pointed out
that, in this type of setting, the scope of practice was
limited. She stated that the main goal was to eliminate pain
and infection, and to restore smiles. She relayed that patients
were informed that the dentists may be from out-of-town or out-
of-state. The registration, which must be signed, has an
immunity clause printed on the back of the form. After
treatment, there was post-operative care during which the
treatment was reviewed and written instructions for care were
provided, which included an emergency phone number that was
monitored by a dentist for the following two weeks. She
reported that the Anchorage Neighborhood Health Center had also
agreed to see ten people for no charge, following the Alaska
Mission of Mercy program. Other dentists had also offered to
see post-operative patients. She reported that these programs
in other states with similar numbers of participants would
usually have fewer than six post-operative calls.
DR. ROBINSON explained that dentists not able to see post-
operative patients had so indicated on their registration. She
reported that of the 202 participating dentists, 8 were military
or federal service dentists, and 9 were previous volunteers,
with dental licenses from many other states. She expressed the
goal to serve 2000 Alaskans in two days, and that the long term
goal was for this to be an annual event throughout Alaska. She
noted the greater challenges for a program in Alaska than for
the contiguous states. She asked that immunity protection for
the courtesy license be extended.
3:26:31 PM
DR. ROBINSON, in response to Chair Higgins, said that the
treatment dates were April 11 and 12, with service beginning at
4:30 a.m.
CHAIR HIGGINS declared his desire for the program to focus on
the working class who could not afford to go to the dentist and
did not have insurance, stating that people covered by Medicaid
already had coverage. He offered his services if he was granted
time off from the legislative session. He declared his support
for the program.
REPRESENTATIVE TARR asked how to promote the event in the
future.
3:29:06 PM
RANDI SWEET, Director, Health Impact, United Way of Anchorage,
reported that the United Way was a partner in the event. She
spoke in support of HB 269, declaring that the current volunteer
health care provider immunity act provided protection to Alaska
health care providers who volunteered their time to help
Alaskans. She reported that Alaskans were among the least
insured in the nation, with a recent study showing that 20.6
percent of the state did not have insurance. She noted that
only five other states had a higher percentage of un-insured.
She read appreciative comments from individuals participating in
the earlier free clinics offered by University of Alaska
Anchorage and the Anchorage Project Access. She asked for
support for proposed HB 269.
3:33:05 PM
REPRESENTATIVE KELLER moved to report CSHB 269, Version 28-
LS1251\U, Martin\Wallace, 2/4/14, out of committee with
individual recommendations and the accompanying fiscal notes.
There being no objections, CSHB 269(HSS) was moved from the
House Health and Social Services Standing Committee.
3:33:41 PM
The committee took an at-ease from 3:33 p.m. to 3:39 p.m.
HB 281-PRESCRIPTION WITHOUT PHYSICAL EXAMINATION
3:39:13 PM
CHAIR HIGGINS announced that the next order of business would be
HOUSE BILL NO. 281, "An Act relating to prescription of drugs by
a physician without a physical examination."
3:39:32 PM
REPRESENTATIVE LYNN GATTIS, Alaska State Legislature, declaring
"I think it's a relatively simple bill," read from a prepared
statement. She explained that proposed HB 281 would clarify in
statute that physicians would not be sanctioned for dispensing
or administering prescription medications without a physical
examination of the patient. She stated that this practice was
"called telemedicine. Telemedicine based medical care would be
delivered by primary care physicians within the State of Alaska.
Anyone needing medical care would be a candidate for this
system." She noted the benefits for a working mother with a
sick child, a rural homesteader, or an employee not able to take
the time from work. She stated that the proposed bill would
allow patients to obtain, through over the phone and on-line
consultations when physicians were able to diagnose an ailment,
any necessary prescription. She pointed out that the proposed
bill would not allow physicians to prescribe controlled
substances. She listed the benefits to include convenience to
patients, lower cost, immediate access, and higher productivity
for a healthier workforce. She noted that this would lead to
quicker access for primary care for rural residents. She
declared that telemedicine did not replace a relationship with a
primary care provider, although a telemedicine provider could be
designated as the primary care provider. This telemedicine
consultation would be considered a doctor-patient relationship.
She acknowledged the concerns for updates to patient background
information, stating that these would also be required prior to
telemedicine conferences.
3:43:34 PM
REPRESENTATIVE GATTIS, in response to Representative Tarr, said
that there would be testimony by individuals from other
participating states.
CHAIR HIGGINS pointed out that a requirement for health history
and informed consent was not included in the proposed bill. He
asked if there was an assumption for this to be conducted by the
physician.
REPRESENTATIVE GATTIS expressed her assumption that the doctor
would take the relevant information necessary for "good service
to me and back up their license."
CHAIR HIGGINS expressed his agreement that the medical
profession would ensure the proper documentation, although he
surmised that it would be prudent to include this in the
proposed bill.
3:46:09 PM
REID HARRIS, Staff, Representative Lynn Gattis, Alaska State
Legislature, shared that, as the medical community in Alaska was
tight knit, any questionable performance would be quickly
reviewed. Referencing paragraph (3), page 1, lines 12-14, of
the proposed bill, "the person consents to sending a copy of all
records of the encounter to the person's primary care provider,"
he offered his belief that a telemedicine provider would become
the primary care physician if the patient did not have a
physician, and the telemedicine provider would "take all your
information." He pointed out that this information would be
sent to an already existing primary care physician.
3:47:16 PM
REPRESENTATIVE SEATON pointed out that the proposed bill
required the physician to be in the State of Alaska. He asked
whether treatment by outside physicians would allow
prescriptions to be altered.
REPRESENTATIVE GATTIS replied that the proposed bill did not
address specialists or specialty care. She explained that
telemedicine offered consultation for relatively common issues,
such as respiratory illness, skin problems, and abdominal,
joint, and back pain.
REPRESENTATIVE SEATON, asking for clarification that Version 28-
LS1234\A of the bill was in front of the committee, questioned
where the aforementioned limitation to prescriptions was
mentioned in the proposed bill.
REPRESENTATIVE GATTIS explained that, although not mentioned
specifically in the proposed bill, telemedicine only allowed the
aforementioned care.
3:49:43 PM
CHAIR HIGGINS, referencing paragraph (3), page 1, lines 12-14,
of the proposed bill, asked who was required to send the forms,
and how would they know who to send the forms.
MR. HARRIS replied that, although the telemedicine provider
would be required to send the forms to the designated primary
care physician, the bill did not address a timeline for
transmission.
CHAIR HIGGINS noted that Teladoc was available to testify, and
he lauded its program. He asked about the procedures and
requirements for transfer of information with a program other
than Teladoc, as the proposed bill would allow consultation with
any telemedicine group.
REPRESENTATIVE GATTIS offered her belief that, as this was the
same situation with Instant Care, "we have that situation
already in place with our doctors."
CHAIR HIGGINS pointed out that the forms were filled out when a
patient attended Instant Care and Urgent Care.
REPRESENTATIVE GATTIS expressed her agreement, noting that this
was the same as filling out forms on-line. She stated "that's
really all this bill does, is it allows us to do it on-line, or
have it done over the phone. It's the same process that we go
to when we walk into a doctor's office, and tell them our health
history."
3:52:36 PM
REPRESENTATIVE TARR referenced the Alaska Federal Health Care
Access Network (AFHCAN), the telemedicine program for the Alaska
Native Tribal Health Consortium (ANTHC). She asked to better
understand what was already happening with telemedicine in
Alaska, and how the proposed bill would complement this program.
MR. HARRIS explained that AFHCAN was "a little bit different
than telemedicine." He explained that AFHCAN supplied a
provider and a medical cart to assist the patient while the
physician was on the other end of the phone. He said that the
proposed bill only specified the patient with the physician at
the other end. He relayed some complaints from rural areas that
the intermediate connection with the provider and the medical
cart, between the physician and the patient, was possibly not as
helpful as a direct connection with the physician.
REPRESENTATIVE GATTIS stated that "this relatively simple bill"
clarified in statute that physicians may not be sanctioned for
dispensing or administering prescription medications without a
physical examination of the patient, and "quite frankly, that
already happens right now." She offered her belief that many
people already called their physician with their problems and
symptoms, and requested prescriptions. She stated that the
proposed bill "clarifies and keeps them out of hot water."
3:54:46 PM
REPRESENTATIVE SEATON asked if the proposed bill restricted
doctors from out of state, specifically Veterans' Administration
or Indian Health Service physicians.
MR. HARRIS replied that, as military and ANTHC doctors had a
federal exemption which allowed them to operate, the proposed
bill would clarify this for an in-state doctor.
3:56:14 PM
CHAIR HIGGINS opened public testimony.
HENRY DEPHILLIPS, Corporate Chief Medical Officer, Teladoc,
described Teladoc as the oldest and largest telehealth company
in the United States. Describing the telemedicine industry, he
stated that he would clarify if there was something specific to
Teladoc which did not apply to the rest of the industry. He
said that the concept of telemedicine was comparable to a doctor
reference, if your primary care physician was not available. He
reported that Teladoc was the oldest in the telemedicine
industry, operating for 12 years, and that about 15 million
Americans were covered in a telemedicine program through their
employer or their health insurance company. He shared that more
than 500,000 consultations had taken place throughout the United
States, and to date, there had not been any liability issues.
He noted the telemedicine programs features which were different
than traditional cross coverage, and included: no DEA
controlled substances were allowed; a limited number of
diagnosis were treated, primarily common, uncomplicated medical
problems that were usually recurrent for the patient; the
treatments were straightforward; and, the majority of
prescriptions were generic, falling into three classes,
antibiotics, anti-allergy medications, and inhalers. He offered
his observations for the telemedicine industry, noting that
there had been internet scam offerings in the late 1990s, which
had allowed for prescriptions to DEA controlled substances. He
reported that many state medical boards had then implemented a
"prior in-person visit requirement," which entailed a physical
examination. He opined that this requirement had stopped the
scams. He explained that there was then a realization for the
similarity of cross coverage consultations with telephonic
encounters, both without the prior in-person visit. Therefore,
as regulations for exceptions became necessary, emergency
situations and cross coverage were exempted. At this point,
attorneys for the industry ascertained that telemedicine was a
cross coverage service, and was subject to that exemption. He
reported that the Alaska State Medical Board had disagreed with
this interpretation which leads to the current proposed
legislative solution. He offered his belief that the Alaska
State Medical Board had concerns that the care of Alaskans would
move to doctors outside of Alaska. He shared that the Teladoc
business model called for Alaskan care to be performed by
physicians licensed and living in Alaska. He spoke about the
perception that, if there was not a prior in-person physical
exam, the quality of care would be compromised. He declared
that the data argued against this perception, as the common,
uncomplicated medical problems had not had any liability issues.
He reported that telemedicine providers usually covered the
liability insurance for the consulting doctors, and the premiums
were at the lowest levels, Class I. He reminded the committee
that telephonic diagnosis and treatment had occurred for many
years in the cross coverage situation. He pointed to the three
take home points in the Rand Corporation telemedicine study
which was recently published in Health Affairs. The first point
reported was that people without the option for telemedicine
made emergency room visits for a non-emergency problem about 25
percent of the time. The second conclusion of the study was
that telemedicine was especially valuable for people without an
established relationship with a primary care physician. The
third conclusion was that the cost for medical care was reduced
with telemedicine. He noted that improved access and cost were
two important issues in Alaska. He explained that the proposed
bill would curtail intervention by the Alaska State Medical
Board with telemedicine. In response to an earlier question, he
noted that the telemedicine industry had worked in conjunction
with the Alaska State Medical Association to arrive at the
language in the proposed bill. He responded to a question
regarding medical history, and expressed his agreement that
although the telemedicine industry needed oversight and
structure, this should be a similar standard to that applied to
the in-person setting. He offered his belief that there was not
a legal or regulatory requirement for a copy of the record to be
sent to the primary care physician, but he emphasized that it
was good medical practice. He questioned whether it was
necessary to legislate the requirement in the telemedicine
environment.
4:05:29 PM
CHAIR HIGGINS mentioned that there was a standard of care to
which physicians were held responsible, which included an intake
form, a consent form, and a health history. He pointed out
that, although this was not written, obeying the standard of
care was necessary.
DR. DEPHILLIPS expressed his agreement, and stated that the
standard of care should be applied in all settings.
CHAIR HIGGINS suggested that the use of telemedicine needed to
be further reviewed, as the savings to Medicaid could be
substantial. He pointed out that the Alaskan Native
Corporations had offered telemedicine for many years, and that
it was working. He stated that the public sector "should be
able to do the same thing." He expressed his appreciation for
the proposed bill to further the conversation.
4:06:51 PM
REPRESENTATIVE TARR, reflecting on the use of emergency rooms
for non-emergency visits by patients who did not have a primary
care provider, asked how people could learn about the option for
the use of telemedicine.
DR. DEPHILLIPS opined that there would soon be "direct to
consumer telemedicine, there are some start-up companies that
are starting to go there." However, the majority of
telemedicine programs were sponsored by health care plans and
employers. He reported that Teladoc had about 1,750,000
Medicaid recipients, as well.
4:08:36 PM
REPRESENTATIVE TARR asked if the proposed bill would allow
Medicaid recipients to enroll.
DR. DEPHILLIPS offered his understanding that the proposed bill
would allow physicians in Alaska to enroll in a telemedicine
program, and be compensated by Alaskans not already enrolled in
a federal program. He clarified that telemedicine was already
allowed in the federal programs, and could not be regulated by
the Alaska State Medical Board. The proposed bill would allow
patients not in a federal program to have these same
opportunities. He shared that there was discussion for adding
telemedicine to the Alaska Medicaid program, allowing for
increased access and cost savings. He pointed out that it was
necessary for passage of the proposed bill, as it would offer
regulatory cover for Alaska physician licenses.
4:10:11 PM
REPRESENTATIVE SEATON asked for an explanation for the operation
of the telemedicine program.
DR. DEPHILLIPS explained that, for the sponsored primary care
model, a person would pick up the telephone and talk with a
customer service intake representative, who would collect the
appropriate information and medical history. The same process
could be conducted on line. He shared that, during the request
process, it was important to know the age of the patient and
where you were calling from, so the appropriate licensed
physician could respond. He pointed out that it could be
required for the patient to fill out the medical history and for
the doctor to review this before contact with the patient. He
explained that the physician would receive and review the
consultation request, and would contact the patient, by
telephone audio video, which had to be a Health Insurance
Portability and Accountability Act (HIPAA) compliant, secure
platform. The physician would communicate in real time with the
patient for as long as necessary to conclude with either a
treatment plan or a reference for an in-person consultation,
which resulted about 4 percent of the time. He pointed out that
there was not any financial incentive for a referral. He stated
that Teladoc hired highly trained, highly qualified physicians,
and then empowered them to make the best decisions for each
patient.
4:12:32 PM
REPRESENTATIVE SEATON asked if a patient would get the same
physician on a follow up call.
DR. DEPHILLIPS replied that, as the Teladoc program did not want
to interfere with any existing relationships with primary care
physicians, Teladoc did not allow any choice for physician,
similar to an emergency room or Urgent Care visit. He noted
that, however, some telemedicine programs did allow selection of
a physician.
REPRESENTATIVE SEATON directed attention to page 1, line 10 of
the proposed bill, and read: "the physician is located in this
state and available to provide follow-up care." He asked how
this was satisfied if the initial physician was not available
for the follow up care.
DR. DEPHILLIPS replied that there was a 72 hour window after the
initial telemedicine consultation for direct contact between the
patient and the same physician. He offered his belief that,
with a physician in Alaska, the patient could directly contact
the physician. The telemedicine industry was designed to get
patients over the acute problem, and then back in touch with
their primary care physician. He offered his belief that the
proposed bill allowed this continued "safety valve" contact in
Alaska, as these licensed telemedicine physicians resided in
Alaska.
REPRESENTATIVE SEATON expressed concern for the aforementioned
wording, and suggested a change to read: "follow-up care is
provided through the telemedicine group." He compared the
telemedicine program to his neighborhood clinic, where he was
served by whichever doctor was available. He opined that, even
though the telemedicine model would not allow for the same
physician, that physician would often become the primary care
physician, hence the wording on page 1, line 10 of the proposed
bill needed to change.
4:18:23 PM
DR. DEPHILLIPS suggested viewing the telemedicine service
industry as a physician cross coverage service. He recommended
not to put any additional burden on the telemedicine industry
that was not put on an in-person doctor. He reminded the
committee that each telemedicine doctor had access to the
medical records from the patient's previous visit.
REPRESENTATIVE SEATON noted that the state did not have a
statute requiring the prescribing doctor to be available for
follow-up, whereas the proposed bill did state this.
CHAIR HIGGINS, directing attention to page 1, line 10, of the
proposed bill, suggested to delete "and available to provide
follow up care;" which would maintain the current state standard
for all the physicians.
REPRESENTATIVE SEATON offered his belief that this specified
something that could not always be accomplished.
4:21:04 PM
REPRESENTATIVE PRUITT asked to research the intent of the bill
drafter, and the intended definition of "available."
DR. DEPHILLIPS shared that the language for paragraphs (1), (2),
and (3) was drafted collaboratively with the Alaska State
Medical Association, and he suggested discussion with the
drafter.
4:22:31 PM
The committee took an at-ease from 4:22 p.m. to 4:25 p.m.
4:25:27 PM
CHAIR HIGGINS announced that the committee intended to hold the
proposed bill.
DR. DEPHILLIPS explained that the intent of the follow up care
provision in the proposed bill, page 1, line 11, was to allow
the opportunity to obtain medical attention if there was a
problem. He shared that this could either be re-contact with
the telemedicine provider or the primary care physician.
CHAIR HIGGINS stated the desire of the committee to hear from
the Alaska State Medical Board, the bill drafter, and the Alaska
State Medical Association.
REPRESENTATIVE SEATON asked whether anyone with prescriptive
ability, including a physician's assistant, would also be
included.
4:28:22 PM
CHAIR HIGGINS left public testimony open, and stated that
proposed HB 281 would be held over.
^Presentation: Fairbanks Resource Agency
Presentation: Fairbanks Resource Agency
4:28:45 PM
CHAIR HIGGINS announced that the final order of business would
be a presentation from the Fairbanks Resource Agency.
EMILY ENNIS, Executive Director, Fairbanks Resource Agency,
stated that she would speak about assisted living services for
seniors throughout the State of Alaska, as well as a proposed
assisted living project in Fairbanks. Directing attention to
slide 1, "FRA History," she stated that Fairbanks Resource
Agency (FRA) had been offering services to seniors since the
late 1980s, and currently served more than 250 seniors in the
Fairbanks area. She reported that many discussions during the
past ten years for assisted living options outside the family
home had met roadblocks.
4:31:09 PM
MS. ENNIS moved on to slide 2, "FRA Senior Services," which
listed an array of service options to be expanded, along with
assisted living. She mentioned care coordination for help to
families with finding necessary services, and respite care to
give caregivers a break, as, 75 percent of the elder care came
from the family. She pointed out that most seniors wanted to
stay with family, and this was a much more cost effective
option. She reported that adult day centers for out of home
respite care, chore services for in-home services, and family
caregiver services for support to the caregiver were all offered
to sustain care in the family home. She mentioned Senior
Outreach [Assessment and Referral (SOAR)] which was "a really
novel program" offering training to the employees of local
businesses to help identify, and refer, when care was needed for
seniors. She addressed assisted living, where seniors could
live when it was no longer possible to live in the family home.
She referenced a report from Fairbanks Memorial Hospital which
stated that many seniors, when leaving the hospital after care
for an acute condition, were determined by staff to not be safe
for discharge. This often resulted in an out of the area search
for assisted living, as space was so limited in Fairbanks, and
could necessitate that the senior wait in an acute care bed for
days or weeks until assisted living space was located. She
pointed out that, as those days in the hospital were not covered
by insurance, it could be difficult for the hospital to collect
payment.
4:35:36 PM
MS. ENNIS introduced slide 3, "Residential Options for Seniors."
She stated that there was independent senior housing throughout
Alaska. In Fairbanks, there was Raven Landing and South Hall
Manor; however, if the senior started to decline, there were no
services at these residences. She reminded that nursing homes
provided for those with a need of skilled nursing care. Most
seniors with dementia and Alzheimer's did not need this level of
care, but instead needed, and qualified for, assisted living
care, which provided support for the activities of daily living
for a quality of life. She offered the Pioneer Home as the
primary example of assisted living in Alaska, noting that it was
a high quality model.
CHAIR HIGGINS interjected that there was a six year waiting list
to get into the Pioneer Home.
MS. ENNIS shared that the average age of entrants into the
Pioneer Home in Fairbanks was 85 years.
4:37:38 PM
MS. ENNIS discussed the key points of slide 4, "Assisted Living
Services." She said that these residences were most commonly in
an adult home-like setting, not a large institutional setting,
with full-time support and assistance with ADL (activities of
daily living) and physical activities. There was an opportunity
to socialize and recreate within the facility, and, most
importantly, the "chance to age in place." She declared that
this was often seen as the last place of residence. Seniors
were no longer living independently, as there was a need for
help, with the average time in assisted living being 18 months.
She emphasized the need to ensure the avoidance of helplessness,
boredom, and loneliness for seniors. She declared a need for
novelty in seniors' lives, when developing assisted living
projects. She stated that the Pioneer Home had an excellent
philosophy, and was an example of the Eden Alternative, which
encouraged continued growth, development, and participation in
activities. She reported that the aforementioned assisted
living project being proposed by the FRA was based on the Eden
Alternative, and the similar Greenhouse model. The physical
design allowed for home-like modules with six to ten beds in
each home. This allowed for a sense of home and identity within
the facility.
4:40:38 PM
REPRESENTATIVE TARR asked if there were any updates to an
earlier hearing which had discussed proposed regulations for the
lowering of the reimbursement rate to assisted living homes.
MS. ENNIS replied that the proposed reduction to the Medicaid
waiver rate had been put on hold for further study. She
expressed concern for this rate, as it was "far too low to
sustain positive operating budgets."
MS. ENNIS addressed slide 5, "Senior Population Facts," which
she also called "the grim facts." She stated that the senior
population facts in Alaska were startling, with four times the
rate of growth compared to the rest of the United States. She
stated that the odds for dementia and Alzheimer Disease were 1
in 2 after 75 years of age.
4:42:42 PM
MS. ENNIS pointed to slide 6, "Alaska Regional Data" reflecting
the tremendous growth of the senior population, which she
declared to be compelling.
MS. ENNIS, in response to Chair Higgins, explained that the
projection from Department of Labor & Workforce Development for
the Gulf Coast Region suggested a levelling out with some future
decline. She pointed to improved health care, expanded
specialized medicine, an increase in rural health care, and the
importing of seniors as reasons for an increase of the senior
population in the state.
4:44:30 PM
MS. ENNIS projected slide 8, "Fairbanks Area Picture," and
directed attention to a handout titled, "Fact Sheet." [Included
in members' packets] She offered her belief that the project
was replicable throughout Alaska, and that the model was
operationally sustainable. She reported that she had been
involved in a survey in December, 2012, for the number of
seniors requesting assisted living. She shared that the survey
total of 1100 seniors had included the Pioneer Home waiting
list, as well as the responses from the surveys in the
community. She projected that this number would nearly double
in six years.
4:46:26 PM
MS. ENNIS moved to slide 9, "Fairbanks Assisted Living
Residences," which listed the number of assisted living beds
available in Fairbanks. She compared the need for 1100 beds
with the current capacity for 182 beds in Fairbanks. She noted
that this gap existed everywhere in Alaska. She reported that
two new facilities had recently opened in Fairbanks, noting that
they were, however, exclusively private pay. She pointed out
the significant difference between the cost of private pay,
$7,000 per month, and the Medicaid waiver reimbursable rate of
less than $4,000 per month. She stated that small businesses
needed the higher rate to succeed.
4:47:57 PM
MS. ENNIS presented slide 10, "Challenges to Assisted Living
Development," and noted that there had not been the commercial
development for assisted living which had occurred in the Lower
48. She explained that developers in Alaska were most
discouraged by the economic risks, including the high cost of
building and the high cost of land, as there was a need to be
centrally located near hospitals. She noted the concerns for
the health care work force shortages, and that the reimbursement
rates were considered inadequate for operation. She opined that
a mix of full pay seniors with Medicaid waiver seniors would be
essential for financial success.
4:49:27 PM
MS. ENNIS directed attention to slide 11, "The Solution," and
stated that the FRA had developed a pilot project which was
sustainable, with help from investment by the State of Alaska
for some of the start-up costs. She declared that the biggest
concern was for the debt service on land and construction, as
"there was no way to keep the doors open" if the seniors served
would only use Medicaid waivers and state reimbursement. She
emphasized the essential need was assistance with the
development costs, if these assisted living options were to be
offered. She proposed that this initial assistance in up front
funding was an answer to the state interest for a public-private
partnership. She opined that other communities had non-profit
organizations "to step up" if a model could be replicated.
4:50:56 PM
MS. ENNIS explained slide 12, "Added Community Benefit," and
listed the benefits that assisted living brought to a community,
which included new jobs, an economic boost from increased
purchasing power, and that seniors could remain in town with
families.
MS. ENNIS looked at slide 13, "Next Steps," and referenced the
aforementioned Fact Sheet [Included in members' packets]. She
said that these questions were the ones most often posed in
discussion over the past six months.
MS. ENNIS expressed thanks to Rosalynn Carter for the quote on
slide 14, "There are only four kinds of people in this world."
She stressed that Alaska was approaching a crisis for senior
care, as "the numbers were staggering, the waiting lists are
exceptionally high, the length of time to find this care in our
community is unforgiveable ... if we don't start today, I'm not
sure how we're going to be able to address it."
MS. ENNIS pointed to item 1 on the Fact Sheet, which compared
the cost per bed with the Fairbanks Pioneer Home. She stated
that the proposed project would cost about $63,000 per bed each
year, compared to $119,000 per bed each year for the Pioneer
Home. She shared that the investment for the 30 bed home, $13.9
million, would be paid back in about 8 years.
CHAIR HIGGINS expressed his agreement that this was an important
issue and needed to be done for the senior citizens.
4:54:28 PM
REPRESENTATIVE TARR asked if the proposed project was similar to
the Providence facility.
MS. ENNIS replied that this was the Horizon House; however, it
was a private pay facility which asked patients for a subsidy to
the cost remainder after payment with the Medicaid waiver.
REPRESENTATIVE PRUITT, reflecting on a projected need for 2000
beds and the proposed cost of $15 million to provide 30 beds,
asked what other options were available "to fill the gap." He
asked if this was sustainable.
MS. ENNIS, expressing her agreement that this was a tiny
fraction of the iceberg, stated that the 30 bed project her
organization had proposed was a start toward fulfilling the need
in the Fairbanks area and would, hopefully, lead to three such
facilities. First, however, FRA wanted to ensure this was a
viable project for a non-profit organization. She stated that
FRA was offering $1.7 million toward the project. She offered
her belief that the program would need a bed mix of "60 percent
private pay, 40 percent Medicaid." She admitted that it was not
possible to ensure that the next patron for an open bed would
have the necessary payment type. She declared that she had not
heard of much development around Alaska, as there was great
concern for the cost of operations and development. She
reminded the committee that those services kept in-home was
another answer to the projected expenses for senior care.
4:58:24 PM
REPRESENTATIVE KELLER asked for clarification to the difference
in comparative costs with Pioneer Homes.
MS. ENNIS relayed that there were several factors, which
included union wages and benefits, and annual maintenance. She
said that a new facility, designed for energy efficiency, would
also save money.
REPRESENTATIVE KELLER asked for her input to any state
regulations that would help minimize the cost.
MS. ENNIS explained that FRA had used the lower reimbursement
rate for the Medicaid waiver in their budget, although they
would prefer that it be increased. She remarked that the small
"mom and pop" assisted living home care operations were in homes
that were already paid for.
CHAIR HIGGINS declared that it would be necessary to bring the
stakeholders together to address the many layers.
5:01:38 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 5:01 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 269 - Bill version A.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/25/2014 1:30:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB 269 - Sponsor Statement.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB281A.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Sponsor Statement.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Support DOLWD Census Data.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Support SB80 Teladoc.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 SB 80 |
| HB281 Telemed Defined.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281-DCCED-CBPL-02-06-2014.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Support Teladoc.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB 269 - Letter of Support, Alaska Native Medical Ctr..pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB 269 ASMA Letter .pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB269 Fiscal Note DCCED-CBPL-02-06-2014.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB269 Fiscal Note Law-Civ-02-07-14.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB281Fiscal Note-DCCED-CBPL-02-06-2014.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB 269 - Letter of support - United Way, 2.11.14.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB 269 - Legal Opinion, DOL 8.19.13.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB 269 - Legal Opinion, Legislative Legal Services 1.13.14.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB 269 - Support AK Mission of Mercy information.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB269 - Dental Society bullet points.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| ASL Presentation 2132014.pdf |
HHSS 2/13/2014 3:00:00 PM |
|
| HB281 Support Rand Press Release.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 Support Rand Study.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| CS HB 269 - Bill version U.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| CS HB 269 - Differences version A to U.pdf |
HHSS 2/13/2014 3:00:00 PM SL&C 3/27/2014 1:30:00 PM |
HB 269 |
| HB 269 - Sectional Summary.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB 269 - Leg Legal Opinion 2 13 14.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 269 |
| HB 281 Letter of Support.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |
| HB281 ASMB Opposition.pdf |
HHSS 2/13/2014 3:00:00 PM |
HB 281 |