Legislature(2019 - 2020)DAVIS 106

02/27/2020 03:00 PM HEALTH & SOCIAL SERVICES

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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ HB 242 PRESCRIPTION OF OPIOIDS; DATABASE TELECONFERENCED
Heard & Held
-- Testimony <Invitation Only> --
*+ HB 189 CHILD IN NEED OF AID; NOTICE OF PLACEMENT TELECONFERENCED
Heard & Held
-- Testimony <Invitation Only> --
*+ HB 184 CONTROLLED SUB. DATA: EXEMPT VETERINARIAN TELECONFERENCED
Heard & Held
-- Testimony <Invitation Only> --
                     ALASKA STATE LEGISLATURE                                                                                 
       HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                        February 27, 2020                                                                                       
                            3:06 p.m.                                                                                           
                                                                                                                                
                             DRAFT                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Tiffany Zulkosky, Chair                                                                                          
Representative Ivy Spohnholz, Vice Chair                                                                                        
Representative Matt Claman                                                                                                      
Representative Harriet Drummond                                                                                                 
Representative Geran Tarr                                                                                                       
Representative Lance Pruitt                                                                                                     
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Sharon Jackson                                                                                                   
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
HOUSE BILL NO. 189                                                                                                              
"An   Act  relating   to   the   identification,  location,   and                                                               
notification of  specified family  members of a  child who  is in                                                               
state custody."                                                                                                                 
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
HOUSE BILL NO. 242                                                                                                              
"An Act relating to the  prescription of opioids; relating to the                                                               
practice  of dentistry;  relating  to the  practice of  medicine;                                                               
relating to  the practice of  podiatry; relating to  the practice                                                               
of osteopathy; relating  to the practice of  nursing; relating to                                                               
the practice of optometry; relating  to the practice of pharmacy;                                                               
relating to the practice of  veterinary medicine; relating to the                                                               
state  medical examiner;  relating  to  the controlled  substance                                                               
prescription database;  relating to  the duties  of the  Board of                                                               
Pharmacy; and providing for an effective date."                                                                                 
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
HOUSE BILL NO. 184                                                                                                              
"An  Act exempting  veterinarians  from the  requirements of  the                                                               
controlled substance prescription database."                                                                                    
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 189                                                                                                                  
SHORT TITLE: CHILD IN NEED OF AID; NOTICE OF PLACEMENT                                                                          
SPONSOR(s): REPRESENTATIVE(s) TALERICO                                                                                          
                                                                                                                                
01/21/20       (H)       PREFILE RELEASED 1/10/20                                                                               

01/21/20 (H) READ THE FIRST TIME - REFERRALS

01/21/20 (H) HSS, JUD 02/27/20 (H) HSS AT 3:00 PM DAVIS 106 BILL: HB 242 SHORT TITLE: PRESCRIPTION OF OPIOIDS; DATABASE SPONSOR(s): REPRESENTATIVE(s) JOSEPHSON 02/07/20 (H) READ THE FIRST TIME - REFERRALS 02/07/20 (H) HSS, L&C 02/27/20 (H) HSS AT 3:00 PM DAVIS 106 BILL: HB 184 SHORT TITLE: CONTROLLED SUB. DATA: EXEMPT VETERINARIAN SPONSOR(s): REPRESENTATIVE(s) TALERICO

01/21/20 (H) PREFILE RELEASED 1/10/20

01/21/20 (H) READ THE FIRST TIME - REFERRALS

01/21/20 (H) HSS, FIN

01/29/20 (H) BILL REPRINTED 02/27/20 (H) HSS AT 3:00 PM DAVIS 106 WITNESS REGISTER REPRESENTATIVE DAVE TALERICO Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented HB 189 as the sponsor of the bill. CHRISSY VOGELEY, Manager Community Relations Office of Children's Services Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Testified and answered questions during discussion of HB 189. REPRESENTATIVE ANDY JOSEPHSON Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented HB 242 as the sponsor of the bill. CATHERINE REARDON, Staff Representative Andy Josephson Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented the Sectional Analysis of HB 242 on behalf of the bill sponsor, Representative Josephson. SARA CHAMBERS, Director Division of Corporations, Business, and Professional Licensing Department of Commerce, Community & Economic Development Juneau, Alaska POSITION STATEMENT: Testified and answered questions during discussion of HB 242. LAURA CARRILLO, Executive Administrator Board of Pharmacy Juneau, Alaska POSITION STATEMENT: Testified during discussion of HB 242. REPRESENTATIVE DAVE TALERICO Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Introduced HB 184 as the sponsor of the bill. DR. SARAH COBURN, President Alaska State Veterinary Medical Association (AKVMA) Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 184. DR. JIM DELKER Alaska State Veterinary Medical Association Soldotna, Alaska POSITION STATEMENT: Answered questions during discussion of HB 184. DR. SCOTT FLAMME Board of Veterinary Examiners Fairbanks, Alaska POSITION STATEMENT: Testified in support of HB 184. ACTION NARRATIVE 3:06:53 PM CHAIR TIFFANY ZULKOSKY called the House Health and Social Services Standing Committee meeting to order at 3:06 p.m. Representatives Zulkosky, Drummond, Spohnholz, and Tarr were present at the call to order. Representatives Claman and Pruitt arrived as the meeting was in progress. HB 189-CHILD IN NEED OF AID; NOTICE OF PLACEMENT 3:07:33 PM CHAIR ZULKOSKY announced that the first order of business would be HOUSE BILL NO. 189, "An Act relating to the identification, location, and notification of specified family members of a child who is in state custody." 3:08:14 PM REPRESENTATIVE DAVE TALERICO, Alaska State Legislature, paraphrased from a prepared statement [Included in members' packets], which read: Ensuring Extended Family Members Are Contacted As Potential Foster Parents Under Alaska law a youth who faces the unfortunate circumstance of being placed in foster care is entitled to a placement that is in his or her "best interests". Federal law and rules internal to the Office of Children's Services (OCS) note that a search of family members and friends who are akin to family members should be completed in a timely manner, within 30 days. The main provision of HB 189 makes sure a supervisor signs off that the requirement of a diligent search for family members has occurred. If it has not, the social worker is directed to complete that search to the supervisor's satisfaction in as timely a manner as possible. HB 189 puts into statute this additional protection, which is not currently addressed by OCS statutes or policy but is warranted due to the continuous high social worker turnover rate. Some social workers are very new, and many don't make it as social workers beyond one year or two years. Having a supervisor sign off that a family search has been thoroughly conducted will ensure children are protected, and in the best foster home possible. This provision is expected to be cost- neutral. It is recognized in the area of foster care that, where a good family placement is available, keeping a child in their family is often the placement that is the child's best interests. 3:10:23 PM REPRESENTATIVE TALERICO explained Proposed Amendment 1, which he read: Page 1, lines 9 - 11 Delete "If circumstances prevent the department from completing this due diligence search in 30 days, the department shall complete the search as soon as possible." Insert "in this subsection, an adult family member means a person who is 18 years of age or older and who is related to the child as the child's grandparent, aunt, uncle, or sibling." REPRESENTATIVE TALERICO offered to deliver this to the committee. CHAIR ZULKOSKY asked about the existing Office of Children's Services (OCS) relative search process. 3:11:46 PM CHRISSY VOGELEY, Manager, Community Relations, Office of Children's Services, Department of Health and Social Services, pointed out that, as there was already a federal statutory requirement that all adult family members need to be notified regarding the removal of a child within 30 days, the proposed bill without the amendment would just codify in state statute what was already a federal requirement. She added that OCS already had the policies and procedures in place to ensure that this happened. She noted that there was an ongoing relative search, with social media as an excellent source for finding relatives. Any findings were then put into the data base under the case file and all those relatives were automatically notified. As this was ongoing, there was a question for when a supervisor would sign off on this. She reminded the committee that a requirement to sign off would become another administrative task for the supervisor. 3:13:57 PM REPRESENTATIVE SPOHNHOLZ asked whether there was the capacity for this to be done in practice on a regular basis. MS. VOGELEY acknowledged that, while OCS did have struggles, the division had a 52 percent relative placement rate versus the national average of 32 percent. She declared that, even though this placement rate was one of the highest placement rates in the United States, there was still room for improvement. She offered her belief that OCS did have the capacity. She pointed out that there was a difference for children that were defined by the Indian Child Welfare Act (ICWA), as OCS had compacted with the tribal co-signers for a much more extensive relative search. She added that the tribal partners were capable of finding "an incredible number of relatives." She noted that, for children not defined under ICWA, OCS did "as much as we can with what we have because it is a federal mandate, but it is unfunded." REPRESENTATIVE SPOHNHOLZ asked if the children placed with family members were more stable and there was less turnover. MS. VOGELEY replied, "yes." REPRESENTATIVE SPOHNHOLZ asked if it was already in the best interest of OCS to be doing this work. MS. VOGELEY replied, "yes." REPRESENTATIVE SPOHNHOLZ expressed her agreement and shared an anecdote for her adoption of a foster child who had initially been placed with biological relatives who did not have the capacity to care give for her. REPRESENTATIVE TARR asked if this was the same or similar to an earlier bill by former Representative Les Gara. MS. VOGELEY asked if this was a reference to House Bill 151. REPRESENTATIVE TARR offered her belief that it was another bill. REPRESENTATIVE SPOHNHOLZ stated that House Bill 151 required that a supervisor sign off that a comprehensive relative and family friend search had taken place within 30 days each time there was a placement change, and then House Bill 27, in 2017, required the court to confirm this at the status hearings. CHAIR ZULKOSKY asked about the costs anticipated in the attached fiscal note, noting that a portion of the proposed bill appeared to codify what was already federally required. 3:18:28 PM MS. VOGELEY reiterated that the federal mandate to contact all adult family members within 30 days was an unfunded requirement and that OCS did this to its best ability. She reported that, in compacting with the tribes, OCS knew how long a relative search would take and how much it would cost. She relayed that, if the intent of the proposed bill was to contact all adult family members, this would be an extensive relative search similar to the tribal searches. She reported that this took about 10 hours at a cost of $56.11 per hour. The fiscal note took into account the total cost considering the number of children removed, minus the costs passed along to the tribes to conduct these relative searches, and the remainder was the cost to do extensive relative searches for children not defined by ICWA. She offered her belief that the proposed amendment which specified a much smaller search would eliminate the fiscal note. CHAIR ZULKOSKY opined that the [Alaska] Tribal Child Welfare Compact was beneficial to the State of Alaska in understanding costs for OCS to do these extensive family searches. REPRESENTATIVE DRUMMOND asked about the OCS responsibility if family members were not in Alaska. MS. VOGELEY replied that this could be an entire presentation. She explained that OCS was still required to notify out of state relatives and should a relative request placement of the child with them, the Interstate Compact Replacement of Children would dictate that Alaska work with that state. She emphasized that it was a long process with many documents. There was the possibility that a case worker would escort the child to their relative in another state or OCS would pay for the relative to come to Alaska to escort the child. She added that this was not uncommon. CHAIR ZULKOSKY referred to the fiscal note and asked about the percentage of children covered by ICWA. MS. VOGELEY said that she would research that information. REPRESENTATIVE TARR reported that the proposed bill had "a little bit of an overlap in terms of the language" to the earlier bill referenced, and she read from that bill regarding the department transfers of a child from one out of home placement to another. She shared an anecdote of her work with OCS and a constituent and asked whether being prescriptive was more important than the child's safety. 3:24:25 PM REPRESENTATIVE SPOHNHOLZ asked for the OCS definition of "adult family members of the child." MS. VOGELEY replied that there was not a federal definition for the notification of adult family members; however, there was a definition in Alaska statute. She stated that she would follow up. CHAIR ZULKOSKY asked about any overlap with earlier legislation and requirements by the federal government. She asked which component of the proposed bill was necessary for statutory language versus the need for funding and a standardized internal OCS policy and process. She asked if OCS promulgated its own rules and regulations to guide this work and could be used for a budget request. She opined that it appeared there was a lot of policy overlap and asked if a gap existed in the policy. MS. VOGELEY offered her belief that OCS currently had enough in policy so there was not any gap. She reported that the concern raised by family members who were not notified was mainly due to the parents not sharing that information with OCS. She acknowledged that, although it was not a perfect system, OCS did "try our best." She added that in these situations there were clearly family dynamics that prevented timely notifications. CHAIR ZULKOSKY opined that currently there was "enough policy cover," although there was a large unfunded mandate. 3:28:01 PM REPRESENTATIVE TALERICO offered his belief that it was important to put in Alaska statute what was already in federal statute. He offered to provide the proposed amendment which added the definition for adult family member, and would include a child's grandparent, aunt, uncle, or sibling. He shared an anecdote for constituents who did not have that contact, and another anecdote about a friend who was successfully raised by his sibling. In response to Representative Spohnholz, he said that the definition for adult family member was included in the proposed amendment. REPRESENTATIVE SPOHNHOLZ referenced the issue regarding a relative not being notified and asked if there was a gap between the law and practice. REPRESENTATIVE TALERICO shared that the relative was ultimately contacted, was approved by OCS, and the children were moved. He expressed his concern that due process was "skipped over in favor of an accusation." REPRESENTATIVE SPOHNHOLZ asked about the timing for this episode in question, as there had been legislation passed in 2017 and 2018 which addressed this topic. REPRESENTATIVE TALERICO replied that most of this occurred in August and September 2019. 3:33:12 PM HB 189 was held over. HB 242-PRESCRIPTION OF OPIOIDS; DATABASE 3:33:18 PM CHAIR ZULKOSKY announced that the next order of business would be HOUSE BILL NO. 242, "An Act relating to the prescription of opioids; relating to the practice of dentistry; relating to the practice of medicine; relating to the practice of podiatry; relating to the practice of osteopathy; relating to the practice of nursing; relating to the practice of optometry; relating to the practice of pharmacy; relating to the practice of veterinary medicine; relating to the state medical examiner; relating to the controlled substance prescription database; relating to the duties of the Board of Pharmacy; and providing for an effective date." 3:33:30 PM The committee took a brief at-ease. 3:34:36 PM REPRESENTATIVE ANDY JOSEPHSON, Alaska State Legislature, stated that there was a problem which needed to be addressed, and, although the proposed bill presented some ideas, he was open to solutions. He paraphrased from a prepared statement [Included in members' packets], which read: The purpose of this bill is to reduce addiction and overdose death from opioids prescribed by health care professionals, by improving the effectiveness of the State's controlled substance prescription database by requiring healthcare licensing boards to set prescription standards for their professions. Alaska's controlled substance prescription database was created and placed under the responsibility of the Board of Pharmacy in 2008. The database was designed as a tool to help healthcare providers identify patients who were "doctor shopping" or deliberately obtaining prescriptions from multiple unknowing providers to feed addictions. As opioid addition has increased in Alaska and the nation so has our understanding of links between legal prescription, addiction and illegal use of controlled substances. Healthcare providers and policy makers are looking for ways to turn the tide of addiction and death. Strengthening the prescription database system is one positive step we can take. HB 242 will improve the prescription practice of Alaska's many great healthcare providers and help identify and remove the small minority of prescribers who deliberately or negligently over prescribe controlled substances. I encourage you to support this legislation and to reach out to my office with any questions and suggestions. REPRESENTATIVE JOSEPHSON paraphrased a KTUU news story [Included in members' packets], which addressed "a doctor from Soldotna and a nurse practitioner from Eagle River are accused of illegally overprescribing opiates for years, raising questions how the state tracks prescription drug abuse." He reported that the news story ended by noting "the state has no prescription limit flags that automatically alert licensing boards when someone appears to be overprescribing." He reported that his office had done exhaustive research, acknowledging there was a problem and that he wanted to discuss a solution. He said that making changes to prescription of controlled substances and the use of the data base required reviewing the statutes of each of the five professions that were able to prescribe controlled substances: physicians, advanced practice nurses, dentists, optometrists, and veterinarians. He added that it was also necessary to review the pharmacy statutes. REPRESENTATIVE JOSEPHSON stated that the basis of the proposed bill: (1) gave each of the five licensing boards explicit responsibility to adopt regulations establishing opiate prescription standards for their respective professions, referred to as MMEs; standards would enable the Department of Commerce, Community & Economic Development employees who staff the licensing boards to proactively identify prescribers who deviated from standards, and then share that information with the practitioners and the boards, and investigate when appropriate; (2) addressed the problem of prescribers who failed to register with the database or failed to review the patient information before prescribing. He opined that the boards did not enforce registration by the prescribing physicians. The proposed bill (3) upgraded the database software to record when a prescriber enters the database and reviews the patient records, and (4) required licensing boards to take disciplinary action against licensee who fail to register a review; To require pharmacists to check the data base before filling a prescription to confirm that the prescriber reviewed the patient's record in the data base as was required by law. He suggested that, as two pharmacy organizations had submitted concerns regarding this, there may be a database solution. He went on to state that the proposed bill required the state medical examiner to inform the Board of Pharmacy when a death was caused by an overdose, as that board was responsible for managing the database. The Board, in turn, would inform healthcare providers and their licensing boards if a provider prescribed a controlled substance during the three months preceding death; this provision was intended to educate prescribers who may not be aware that a patient had addictions and to bring investigators attention to events. He reiterated that he was receptive to suggestions on this proposed legislation. He acknowledged that there were important medical practices such as pain clinics which prescribed more controlled substances, and that he wanted to develop a system as seamless as possible. He pointed out that not only was there patient addiction, but that there also existed "pill mills." 3:42:12 PM CATHERINE REARDON, Staff, Representative Andy Josephson, Alaska State Legislature, presented the Sectional Analysis [Included in members' packets], which read: Section 1: Amends the powers and responsibilities of the Dental Board to require the board to adopt regulations establishing opioid prescription dosage standards for practitioners licensed by the board. Section 2: Amends the powers and responsibilities of the State Medical Board to require the board to adopt regulations establishing opioid prescription dosage standards for practitioners licensed by the board. Section 3: Amends the powers and responsibilities of the Board of Nursing to require the board to adopt regulations establishing opioid prescription dosage standards for practitioners licensed by the board. Section 4: Amends the powers and responsibilities of the Board of Optometry to require the board to adopt regulations establishing opioid prescription dosage standards for practitioners licensed by the board. Section 5: Adds a new subsection to the Board of Pharmacy statutes requiring pharmacists to confirm, before filling a prescription for a Schedule II-IV controlled substance, that the prescriber reviewed the patient's prescription records in the controlled substance prescription database before prescribing. Section 6: Amends the powers and responsibilities of the Board of Veterinary Examiners to require the board to adopt regulations establishing opioid prescription dosage standards for practitioners licensed by the board. Section 7: Adds a new subsection to the statutes governing investigation of death by the State Medical Examiner, directing the Medical Examiner to report to the Board of Pharmacy when a person's death was caused by an overdose of a schedule II-IV controlled substance. The Medical Examiner shall report the deceased person's name, address and date of birth to the Board of Pharmacy which shall take action as directed in Section 15 of the bill. Section 8: Amends the statutes governing the Controlled Substance Prescription Database to specify that the database will identify healthcare practitioners who fail to review patient information in the database as required by law and that the database will identify each occurrence of failure to review. Section 9: Clarifies that security and confidentiality of the database is a requirement rather than an aspiration by deleting the words "undertake to" on page 8 line 11. Section 10: Requires licensing boards to take disciplinary action against practitioners who fail to register with the database or review patient information as required by law. Section 11: Removes protection from civil liability for healthcare practitioners who fail to access information in the database. Section 12: Deletes the requirement that prescription information in the database be purged after two years and removes the requirement that the Board of Pharmacy establish a "time frame" for healthcare practitioners to register with the database. Section 13: Makes mandatory rather than optional, the notification by the Board of Pharmacy, to the relevant practitioner, licensing board and pharmacist when a patient receives a prescription for controlled substances in quantities or frequency inconsistent with generally recognized standards of safe practice. Section 14: Makes mandatory rather than optional, the issuance of annual reports that compare individual healthcare practitioner's opioid prescribing practice with other practitioners of the same occupation and similar specialty. Section 14 also requires copies of the reports to be sent to the practitioner's licensing board and to the medical director of a group practice. Those copies will exclude information that identifies patients. Recipients of reports may only disclose information to other individuals who have access to the database. Section 15: Directs the actions of the Board of Pharmacy when the board receives notice from the Medical Examiner as required by Section 7 of the bill, that a person's death was caused by an overdose of a schedule II-IV controlled substance. The board shall review the database to identify healthcare practitioner who prescribed a schedule II-IV controlled substance to the person during the three months preceding death and notify the practitioner and relevant licensing board. Section 16: Requires the six licensing covered by this bill boards and the Department of Commerce, Community and Economic Development to adopt necessary regulations within one year of the January 1, 2021 effective date of Sections 1-15. Section 17: Establishes an immediate effective date for the regulation adoption authority required to implement Section 16. Section 18: States the bill takes effect on January 1, 2021 with the exception of the authority to adopt regulations contained in Sections 16 and 17 of the bill. 3:55:56 PM REPRESENTATIVE TARR directed attention to the fiscal note for business and professional licensing and asked about the request for two investigators and a paralegal for enforcement. MS. REARDON replied that she had not heard anything about the fiscal note, but that she was not surprised that it could take those resources for effective enforcement. 3:58:15 PM SARA CHAMBERS, Director, Division of Corporations, Business, and Professional Licensing, Department of Commerce, Community & Economic Development, reported that the proposed fiscal note was extremely conservative, and it leaned toward a best-case scenario. She stated that the worst-case scenario would necessitate a doubling of the investigative team in order to close the gap and fulfill the proposed bill. REPRESENTATIVE TARR asked about the increase to the participant fee in order to pay for the proposed cost. MS. CHAMBERS replied that the current fee was $25, although the intent language for the database had declared that it not be funded by user fees. She stated, "we're in a pickle right now. There isn't grant funding for enforcement." She stated that there was a policy call for the Legislature on whether to change the fee or use another model for payment, as there was less than 100 percent compliance with registration. REPRESENTATIVE SPOHNHOLZ asked about the delta for the number of registrants and the number of licensees. MS. CHAMBERS said that she would supply that specific data but pointed out that there were many medical professionals who did not have the authority to prescribe controlled substances. REPRESENTATIVE PRUITT reflected on the passage of the bill, and relayed that the intent of the bill had been to make the database mandatory. He asked what had been done to ensure compliance, and would the proposed bill be fulfilling any gaps. He then asked about the security and confidentiality. 4:05:18 PM LAURA CARRILLO, Executive Administrator, Board of Pharmacy, explained that the rationale for removing the two years was in consideration of Senate Bill 74 to allow the assessment of prescription data over time. She reported that removal of the requirement to purge the data would not allow Department of Health and Social Services to analyze the data. MS. CHAMBERS stated that this database was complex and only two people were authorized to view it. She declared that it was used as a research tool to attack the opioid crisis as a whole, and that the spirit of Senate Bill 74 was for this to be an educational tool to allow prescribers to make better decisions, and not to be used as an enforcement tool. She stated that there was another delta between expectations and reality for the database. She pointed out that to maintain security and confidentiality, it had to be determined how many state employees would have access to certain levels of data. She declared that the biggest expense was for the technology behind this. CHAIR ZULKOSKY asked how many states had this Prescription Drug Monitoring Program (PDMP) database. MS. CARRILLO said there were 43 states using this same platform connected through [indisc] health. CHAIR ZULKOSKY asked for more context to how a more mature PDMP was using that information. MS. CARRILLO said that she would research the evolution of the PDMP in other states. CHAIR ZULKOSKY expressed her agreement that there was a policy call for how to use this collected data and added that more data would allow for better understanding for risks in the community. She asked for more information as to how other states utilized this data within their systems. 4:09:54 PM REPRESENTATIVE PRUITT offered his belief that there had been a positional shift from, in 2008, "if you want to and no one did" to "you're going to." He opined that there was an insistence on wanting this to be mandatory, but there was not any enforcement. He asked why this position had changed and what was an appropriate balance of pressure. MS. CHAMBERS replied that Boards, as this was put into Title 17 and into Title 8 as a requirement for each separate board, could determine within the scope of their existing authority what the penalty might be. She shared some examples for the allowable civil authority. She reported that the Alaska State Legislature was interested in "taking the temperature" of the position to the opioid crisis. She pointed out that data had not been mandatory, and that during a presentation by the then Chief Medical Officer, Dr. Butler, it had been noted "that we don't even know what we're looking at right now with prescribing." She reported that current review of the data indicated there was inadvertent misuse of the PDMP as well as over prescription. She pointed out that, as there was not even a definition for over prescription, it was difficult to set a threshold for any red flags. She noted that only the State Medical Board had set in regulation a threshold, which could be "squishy" dependent on the type of practice. She declared the need for determining what Alaska wanted from the PDMP, and that each Board had existing authority to determine discipline. She added that the Alaska State Legislature could set penalties in statute. REPRESENTATIVE PRUITT asked if there was a need for the legislature to make a larger statement to the Boards for a certain level of enforcement. 4:17:03 PM MS. CHAMBERS explained that the MME requirement in the proposed bill had not been asked of the Boards, although it made sense if a definition for over prescription was a concern. She pointed out that the State Medical Board had taken a leadership role, even though the other boards had not been asked to determine a definition. She reported that some of the Boards had set extremely long time periods for allowance of non-registration as they did not want to be "heavy handed." She pointed to some of the problems for registration. She reiterated that, if this was the expectation of the Legislature, this proposed bill was a good vehicle to offer more tools. REPRESENTATIVE DRUMMOND referenced a report [Included in members' packets] which stated that 49 states, as well as Guam and the District of Columbia, had fully operational PDMPs. She asked if the DEA (Drug Enforcement Administration) authorized the prescribers of Schedule II to IV controlled substances and questioned whether this information could be included in the PDMP. She asked whether the pharmacies were aware of prescribers who were DEA authorized for controlled substances. MS. CHAMBERS expressed her agreement that there was this list and that they did work with the DEA. She pointed out that one state, Missouri, had the PDMP as the municipal, not the state, level. In response to Representative Drummond, she said that Missouri used a different software. REPRESENTATIVE SPOHNHOLZ offered her belief that the PDMP history was good for context but did not matter for her current decisions. She shared a list of topics she would like to hear addressed in a future hearing. 4:22:41 PM REPRESENTATIVE SPOHNHOLZ referenced a section of the bill which asked pharmacists to review whether the original prescriber had checked the database and asked whether this policy would turn pharmacists into monitors of other providers. REPRESENTATIVE JOSEPHSON reported that this concern was shared by the sponsor, as he wanted that both the providers and the pharmacists treat the patients, prescribe medication, and focus on the job. He shared an anecdote for a pharmacist being rebuked for refusing to fill a prescription. He pointed out that, although the Board of Pharmacy was the ultimate decider, the Board did not want to be involved in calling other Boards regarding other providers. He suggested that a system should contact the Boards when a provider had not registered or had not checked that a patient had recently received a prescription from another provider. He reiterated that he was "wedded to solving the problem not to any particular solution." He pointed out that these burdens were placed on the pharmacist because they were "in the catbird seat, they're the ones who are entering the data." He questioned the timing for when the data was entered into the data base. 4:27:07 PM HB 242 was held over. HB 184-CONTROLLED SUB. DATA: EXEMPT VETERINARIAN 4:27:34 PM CHAIR ZULKOSKY announced that the final order of business would be HOUSE BILL NO. 184, "An Act exempting veterinarians from the requirements of the controlled substance prescription database." 4:27:59 PM REPRESENTATIVE DAVE TALERICO, Alaska State Legislature, introduced HB 184 and paraphrased from the Sponsor Statement [Included in members' packets], which read: HB 184 is proposed to exempt Veterinarians from Prescription Drug Monitoring Programs (PDMPS). Prescription Drug Monitoring Programs (PDMPs) were designed for use in human medicine to identify doctor shopping by human patients and monitor trends in prescribing practices by health care providers. Veterinarians want to be part of the solution of the opioid crisis, but PDMPs have not been an effective mechanism to do this. By mandating that veterinarians query and report the owner's name and date of birth, there are significant concerns about potential violations of privacy of human medical information. Veterinarians are not trained in privacy regulations concerning human medical data, nor are they trained in appropriate medications, doses, or prescribing practices for human medicine. As we have talked informally with pet owners and others in the general public, they are not aware that their veterinarian would have access to any part of their medical information and are dismayed to learn this. Animal patients themselves cannot be effectively tracked through PDMPs. Animals do not have a unique identifier such as a social security number or even date of birth. The animal's name may be changed over time, the date of birth is often not known, and the owner may change over time. One national survey found that fewer than 10 cases of veterinary shopping occur annually in the United States and concluded that "veterinarians are a de minimus source of controlled substances." Even those few cases of veterinary shopping are typically identified by the veterinarians themselves, not through PDMPs. In 2017 veterinarians prescribed 0.34% of all the opioids dispensed by retail pharmacies in the country (source IQVIA National Prescription Audit). Exempting veterinarians from the PDMP will not diminish the judicious use of controlled substances that is already practiced by veterinarians and regulated by the Drug Enforcement Agency and the state licensing board. Exempting veterinarians from the PDMP will allow veterinarians to provide timely and appropriate medical management for each individual patient. It may actually save state funds and increase the efficiency of the PDMP for its intended purpose by allowing for more accurate interpretation of prescription data and prescribing trends in human medicine. Over 30 states currently exempt veterinarians from PDMP requirements. Several of those states originally required veterinarians to report to the PDMP but have since exempted veterinarians for many of the same reasons described above. 4:31:04 PM CHAIR ZULKOSKY asked about the percentage rate in commercial pharmacies. REPRESENTATIVE TALERICO stated that, in 2017, veterinarians prescribed 0.34 percent of all the opioids dispensed by retail pharmacies in the country. In response to Chair Zulkosky, he said that he did not have the hard number for this percentage. 4:32:00 PM REPRESENTATIVE SPOHNHOLZ asked what percentage veterinarians were of the total prescribers in the country. REPRESENTATIVE TALERICO deferred to later testifiers. REPRESENTATIVE CLAMAN asked about the percentage of prescription dispensing veterinarians in Alaska relative to the rest of the country. REPRESENTATIVE TALERICO replied that he did not know. REPRESENTATIVE CLAMAN asked whether the veterinarians were also the dispensers. REPRESENTATIVE TALERICO offered his belief that it was necessary to be a licensed pharmacy to dispense an opioid. 4:34:52 PM DR. SARAH COBURN, President, Alaska State Veterinary Medical Association (AKVMA), stated that the Alaska State Veterinary Medical Association (AKVMA) was "a professional association dedicated to promoting the excellence and professionalism of Alaska veterinarians in advancing the health and well being of animals in the public." She declared support of the proposed bill, as it would exempt veterinarians from participating in the state Prescription Drug Monitoring Program (PDMP). She stated that the veterinary community wanted to contribute to solutions to the opioid crisis, but participation in a program designed for use by humans was not appropriate. She reported that more than 30 states exempted veterinarians from the PDMP requirements, and some states have now enacted legislation which removed veterinarians from participation because their inclusion has not proven to be helpful in addressing the human opioid epidemic. She listed numerous reasons for not requiring veterinarians to search or report information into the PDMP, including that animal patients cannot be effectively tracked, and veterinarians are not trained to evaluate human prescription information or in privacy regulations concerning human medical data. She added that most pet owners were not aware that the licensed veterinary technician was the delegated person to access the personal medical prescription history, considered an invasion of privacy by many people. She expressed concern that information entered into the PDMP for animal patients would skew the data and place a disproportionate cost and burden on veterinary clinics as small business owners. She pointed out that the information had to be submitted manually as the veterinary software did not interface with the PDMP. She pointed out that exempting veterinarians would not diminish the effectiveness of the PDMP program. She acknowledged that although opioids were used by veterinarians, these were used for surgical procedures and anesthesia. She pointed out that veterinarians still had to meet strict security, record keeping, and storage requirements of controlled substances. She added that the DEA monitored the flow of controlled substances. She concluded, offering her belief the exemption of veterinarians from using the PDMP would not weaken the success of the program or affect the judicious and highly regulated use of controlled substances by veterinarians. She reiterated that the AKVMA supported HB 184. REPRESENTATIVE CLAMAN asked if the statistics she referenced were for Alaska. DR. COBURN said that these were recent statistics from the PDMP annual report for each profession in Alaska. REPRESENTATIVE CLAMAN asked if veterinary clinics were considered retail pharmacies. DR. COBURN said, "they are not." 4:42:53 PM DR. JIM DELKER, Alaska State Veterinary Medical Association, in response to Representative Claman, he said that a prescription for a pet could be filled either by the veterinarian or a pharmacist. He declared that most veterinarians had the pharmacy fill the prescription for opiates to relieve the veterinarian of the pressures to report. In response to Representative Claman, he said that who dispensed a medication would depend on the drug. He pointed out that the drugs indicated in more drug overdoses such as oxycontin, Percocet, and Vicodin were not commonly dispensed by veterinarians. REPRESENTATIVE CLAMAN asked for clarity for the difference between prescribing and dispensing. DR. DELKER said that he would write a prescription to the pharmacy for a medication they did not carry, noting that a controlled substance had to have a written prescription, whereas an antibiotic did not. REPRESENTATIVE CLAMAN asked if veterinarians dispensed small quantities of opioid medication from their clinic. DR. DELKER replied that the majority of those were sent to a retail pharmacy. CHAIR ZULKOSKY asked if Alaska veterinarians could dispense opioids within the clinic. DR. COBURN said, "yes." CHAIR ZULKOSKY asked about the percentage of opioids dispensed from a clinic before using a commercial pharmacy. DR. COBURN said that she would follow up for the number. She stated that opioids were in limited use as take home medications, that most opioids were used in the hospital related to surgical procedures and were not to be dispensed. CHAIR ZULKOSKY pointed out that the PDMP illuminated the data for opioid prescriptions. She expressed her understanding that there were conditions for opioids dispensed in a clinic. She asked how often Alaska veterinarians used commercial pharmacies versus directly dispensing controlled substances. DR. COBURN said that she would research that. CHAIR ZULKOSKY shared an anecdote that animal owners had intentionally harmed an animal in order to drug shop for controlled substances, and she asked if there was mandatory reporting in Alaska for suspicion of animal abuse. DR. COBURN stated that there was not mandatory reporting but that it was authorized to report without any privacy concerns. She declared that animal abuse was illegal in Alaska, and that ethical conduct would lead a veterinarian to report to an appropriate authority if there was concern for intentional injury. She stated that, as it was necessary to have a veterinarian-client/patient relationship, the standard of care in veterinary medicine was for an in-person physical examination of the animal to establish that relationship. She shared that the PDMP was not designed for animal data. CHAIR ZULKOSKY asked about the training or guidance provided to veterinarians to utilize the PDMP. 4:52:23 PM MS. CHAMBERS explained that when the PDMP became mandatory for all prescribing professions and pharmacists, which included veterinarians, the Board of Veterinary Examiners had the authority and ability to work with the Board of Pharmacy to write the regulations to figure these out. She declared that it had been a struggle for the Board of Veterinary Examiners to wrestle with these issues for how to make it work. She reported that these efforts to make it work did not progress, and, since 2018, there had not been an attempt at a regulations project or a move to adapt the technology. CHAIR ZULKOSKY reiterated that there was not broad support provided to users of the PDMP by the Department to ensure they had what was necessary to access or provide information. MS. CHAMBERS pointed out that the PDMP was primarily designed for human use. When the Board of Veterinary Examiners reviewed the statutes, they realized that, with the way the law was written and the way the technology was set up, it was necessary for more work to understand how to advise their licensees. She stated that it was not possible for her department to train licensees until the Board of Veterinary Examiners worked through these problems with regulation and technology changes. 4:55:49 PM DR. SCOTT FLAMME, Board of Veterinary Examiners, reported that he had been practicing in Fairbanks for the past 17 years. He declared that 38 states had now exempted veterinarians from the PDMP. He acknowledged the difficulty for using a data base for animal data that was designed for humans, and shared that other states had this same struggle. He emphasized that it "just does not work." He declared that veterinarians cared about the opioid epidemic and wanted to do their part to help prevent addiction and to prevent any harm to Alaskans. He pointed out that veterinarians in Alaska only prescribed 0.34 percent of the controlled substances. He offered an analogy of buying a $60,000 pickup truck to plow a driveway that was 12 feet long and 5 feet wide., adding that it did not make any sense as the data was not helpful. He stated that the PDMP was costly to the public, and that the public was shocked when it learned that veterinarians who had no training in human medicine or privacy laws were mandated to access the private health data before prescribing to an animal patient. He added that the public was equally dismayed when their PDMP risk scores were altered because of an animal prescription, as the assessments included a mix of human and animal data. He stated that the cost to the public would be borne out with an increase in the shortage of veterinarians. He pointed out that the Board of Veterinary Medical Examiners was mandated to investigate and discipline veterinarians who failed to correctly use the PDMP, while paying for those investigations. He noted that Alaska had the highest licensing fees for veterinarians in the United States. He urged support for HB 184. 5:00:21 PM HB 184 was held over. 5:01:05 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 184A 02.17.2020.PDF HHSS 2/27/2020 3:00:00 PM
HB 184
HB 184 Veterinarian Medical Association PP.pdf HHSS 2/27/2020 3:00:00 PM
HB 184
HB 184 Sponsor Statement.pdf HHSS 2/27/2020 3:00:00 PM
HB 184
HB 184 Legislative Alert PDMP exemption for veterinarians 12.21.2019.pdf HHSS 2/27/2020 3:00:00 PM
HB 184
HB 184 Board of Veterinarian Examiners Letter.pdf HHSS 2/27/2020 3:00:00 PM
HB 184
HB 184 Fiscal Note DCCED.pdf HHSS 2/27/2020 3:00:00 PM
HB 184
HB 189 ver A 1.24.20.PDF HHSS 2/27/2020 3:00:00 PM
HB 189
HB 189 Sponsor Statement 1.24.20.pdf HHSS 2/27/2020 3:00:00 PM
HB 189
HB 189 Fiscal Note DHSS.pdf HHSS 2/27/2020 3:00:00 PM
HB 189
HB 242 Sectional Analysis.pdf HHSS 2/27/2020 3:00:00 PM
HB 242
HB 242 Pharmacy Board Audit 2017.pdf HHSS 2/27/2020 3:00:00 PM
HB 242
HB 242 PDMP 2019 Legislative Report.pdf HHSS 2/27/2020 3:00:00 PM
HB 242
HB 242 Sponsor Statement.pdf HHSS 2/27/2020 3:00:00 PM
HB 242
HB 242 Audit of the Medical Board 2019.pdf HHSS 2/27/2020 3:00:00 PM
HB 242
HB 242.PDF HHSS 2/27/2020 3:00:00 PM
HB 242
HB 242 Fiscal Note DCCED.pdf HHSS 2/27/2020 3:00:00 PM
HB 242
HB 242 Fiscal Note DHSS.pdf HHSS 2/27/2020 3:00:00 PM
HB 242
HB 242 Overprescription by Spayd & Davidhizar.pdf HHSS 2/27/2020 3:00:00 PM
HB 242