Legislature(2009 - 2010)BUTROVICH 205

02/10/2010 01:30 PM HEALTH & SOCIAL SERVICES


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01:32:31 PM Start
01:32:50 PM SB168
03:07:12 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ SB 168 TRAUMA CARE CENTERS/FUND TELECONFERENCED
Heard & Held
*+ SB 169 APPROP: TRAUMA CARE FUND TELECONFERENCED
Scheduled But Not Heard
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                       February 10, 2010                                                                                        
                           1:32 p.m.                                                                                            
                                                                                                                                
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Senator Bettye Davis, Chair                                                                                                     
Senator Joe Paskvan, Vice Chair                                                                                                 
Senator Johnny Ellis                                                                                                            
Senator Joe Thomas                                                                                                              
Senator Fred Dyson                                                                                                              
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
All members present                                                                                                             
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
SENATE BILL NO. 168                                                                                                             
"An  Act  relating  to  state  certification  and  designation  of                                                              
trauma centers;  creating  the uncompensated  trauma care  fund to                                                              
offset  uncompensated  trauma  care   provided  at  certified  and                                                              
designated trauma centers; and providing for an effective date."                                                                
                                                                                                                                
     - HEARD AND HELD                                                                                                           
                                                                                                                                
SENATE BILL NO. 169                                                                                                             
"An Act appropriating $5,000,000 to the uncompensated trauma                                                                    
care fund; and providing for an effective date."                                                                                
                                                                                                                                
     - SCHEDULED BUT NOT HEARD                                                                                                  
                                                                                                                                
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: SB 168                                                                                                                  
SHORT TITLE: TRAUMA CARE CENTERS/FUND                                                                                           
SPONSOR(s): HEALTH & SOCIAL SERVICES BY REQUEST                                                                                 
                                                                                                                                
03/27/09       (S)       READ THE FIRST TIME - REFERRALS                                                                        
03/27/09       (S)       HSS, FIN                                                                                               
04/08/09       (S)       HSS AT 1:30 PM BELTZ 211                                                                               
04/08/09       (S)       Heard & Held                                                                                           
04/08/09       (S)       MINUTE(HSS)                                                                                            
02/10/10       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
                                                                                                                                
BILL: SB 169                                                                                                                  
SHORT TITLE: APPROP: TRAUMA CARE  FUND                                                                                          
SPONSOR(s): HEALTH & SOCIAL SERVICES BY REQUEST                                                                                 
                                                                                                                                
03/27/09       (S)       READ THE FIRST TIME - REFERRALS                                                                        
03/27/09       (S)       HSS, FIN                                                                                               
04/08/09       (S)       HSS AT 1:30 PM BELTZ 211                                                                               
04/08/09       (S)       Heard & Held                                                                                           
04/08/09       (S)       MINUTE(HSS)                                                                                            
02/10/10       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
SENATOR COGHILL                                                                                                                 
Alaska State Legislature                                                                                                        
Juneau, AK                                                                                                                      
POSITION STATEMENT: Sponsor of SB 168.                                                                                        
                                                                                                                                
WARD HURLBURT, Chief Medical Officer                                                                                            
Department of Health and Social Services                                                                                        
Director, Division of Public Health                                                                                             
Anchorage, AK                                                                                                                   
POSITION STATEMENT: Supported SB  168.                                                                                        
                                                                                                                                
DR. FRANK SACCO, Trauma Director                                                                                                
Alaska Native Medical Center                                                                                                    
Chair, State Trauma Systems Review Committee                                                                                    
Anchorage, AK                                                                                                                   
POSITION STATEMENT: Supported SB  168.                                                                                        
                                                                                                                                
DR. REGINA CHENAULT, State Chair                                                                                                
American College of Surgeons Committee on Trauma                                                                                
Anchorage, AK                                                                                                                   
POSITION STATEMENT: Supported SB  168.                                                                                        
                                                                                                                                
DAVID HULL, Chair                                                                                                               
Governor's Alaska Council on Emergency Medical Services (ACEMS)                                                                 
Fire Chief, North Tongass Fire Department                                                                                       
Ketchikan, AK                                                                                                                   
POSITION STATEMENT: Supported SB  168.                                                                                        
                                                                                                                                
ROD BETIT, President                                                                                                            
Alaska State Hospital and Nursing Home Association                                                                              
Juneau, AK                                                                                                                      
POSITION STATEMENT: Supported SB  168.                                                                                        
                                                                                                                                
MARK JOHNSON, Chief                                                                                                             
Emergency Medical Services (EMS)                                                                                                
Juneau, AK                                                                                                                      
POSITION STATEMENT: Supported SB 168.                                                                                         
                                                                                                                                
MARTHA MOORE, representing herself                                                                                              
Juneau, AK                                                                                                                      
POSITION STATEMENT: Supported SB 168.                                                                                         
                                                                                                                                
SOREN THREADGILL, retired Chief                                                                                                 
Emergency Medical Services (EMS)                                                                                                
Anchorage Fire Department                                                                                                       
Anchorage, AK                                                                                                                   
POSITION STATEMENT: Supported SB 168.                                                                                         
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
1:32:31 PM                                                                                                                    
                                                                                                                                
CHAIR BETTYE  DAVIS called the  Senate Health and  Social Services                                                            
Standing Committee  meeting to order  at 1:32 p.m. Present  at the                                                              
call to order were Senators Ellis, Paskvan and Davis.                                                                           
                                                                                                                                
                SB 168-TRAUMA CARE CENTERS/FUND                                                                             
                                                                                                                                
1:32:50 PM                                                                                                                    
CHAIR DAVIS announced consideration of SB 168.                                                                                  
                                                                                                                                
1:34:37 PM                                                                                                                    
SENATOR DYSON and SENATOR THOMAS joined the meeting.                                                                            
                                                                                                                                
SENATOR  COGHILL, sponsor  of  SB  168, said  the  bill is  pretty                                                              
simple  in its  workings;  it creates  a fund  much  like a  piggy                                                              
bank,  the  purpose  of  which  is to  get  hospitals  to  try  to                                                              
increase  their trauma  ratings.  It came  out of  the College  of                                                              
Surgeons  report  that  he  read   almost  two  years  ago,  which                                                              
revealed  that  the  trauma  system  in  Alaska  is  not  as  well                                                              
coordinated as it could be.                                                                                                     
                                                                                                                                
He  explained  that Alaska  put  together  a voluntary  system  of                                                              
trauma care about  sixteen years ago, and it has  done many things                                                              
well, but  there are things that  could be done better.  There are                                                              
currently 24  hospitals in  Alaska. There is  one Level  II trauma                                                              
center  at  the Alaska  Native  Medical  Center in  Anchorage.  Of                                                              
those 24 hospitals,  there are four Level IV  trauma centers, none                                                              
of them  in Fairbanks or  Anchorage. This  bill creates a  fund to                                                              
incentivize  hospitals to  move up to  a trauma  Level II  or III.                                                              
There are  two hospitals in Anchorage  within reach of  a Level II                                                              
and one in  Fairbanks that could  easily reach a Level  III if the                                                              
state can  help them  get their uncompensated  care taken  care of                                                              
and provide the right incentives.                                                                                               
                                                                                                                                
1:37:46 PM                                                                                                                    
SENATOR  COGHILL  referred members  to  the November  2008  Trauma                                                              
System Consultation  report  by the American  College of  Surgeons                                                              
Committee on Trauma  (ACSCOT), which is the report  that moved him                                                              
to start  looking more  closely at  this issue.  Page 7  lists the                                                              
challenges  and vulnerabilities  of the Alaska  trauma system.  He                                                              
said the  first hearings on this  bill occurred on the  House side                                                              
last  year, and  since  that time  he has  had  two meetings  with                                                              
stakeholders  including   hospitals,  Department  of   Health  and                                                              
Social  Services  (DHSS),  and   others.  Their  discussions  have                                                              
resulted  in  some  very  positive  steps.  DHSS  has  made  it  a                                                              
priority to  improve trauma  care in Alaska.  They have  created a                                                              
position in the  department to oversee it and have  hired a person                                                              
whose  responsibilities  will  include  development  of  a  trauma                                                              
system  strategic  plan  and  creation  of  standards  for  trauma                                                              
triage.                                                                                                                         
                                                                                                                                
However,  he  pointed out,  as  the  College of  Surgeons'  report                                                              
states,  "few incentives  exist  for hospitals  to participate  in                                                              
the trauma system."  That is where SB 168 comes  in. The hospitals                                                              
have been  doing a  yeoman's job,  but they  could do  better. The                                                              
doctors do  a yeoman's  job, but they  have private  practices and                                                              
work in  the hospitals on  call. Both get  credit for  doing their                                                              
jobs very  well, but the collaboration  between them has  not been                                                              
as  good as  it  could  be. He  hopes  this  bill will  help  them                                                              
establish  a better  relationship  that will  allow  them to  work                                                              
together to improve the level of trauma care available.                                                                         
                                                                                                                                
1:41:19 PM                                                                                                                    
SENATOR COGHILL  acknowledged  that Alaska  has a large  volunteer                                                              
base and  a lot of people  who are unpaid first  responders. These                                                              
volunteers  should   be  commended   and  supported  in   any  way                                                              
possible,  he said;  they  invest their  lives  in helping  people                                                              
from the  time of  any tragedy  until they  can reach  a hospital,                                                              
but  if their  work  goes unappreciated  at  the  entrance to  the                                                              
hospital  because  there  is  not   a  good  working  relationship                                                              
between  the doctors  and  the hospitals,  the  system has  failed                                                              
them and the people of Alaska.                                                                                                  
                                                                                                                                
SENATOR COGHILL related  his own experience with  the system when,                                                              
just over  two years ago, his  grandson fell and suffered  a brain                                                              
trauma.  The boy  was  stabilized in  Fairbanks  and medevaced  to                                                              
Anchorage, but  it was almost  seven hours  from the time  he fell                                                              
until  he saw  a doctor.  His  grandson died.  He  does not  blame                                                              
anyone; everyone  was doing  the best  they could  do, but  it was                                                              
just not  good enough.  He is  very motivated  to push  this issue                                                              
forward.                                                                                                                        
                                                                                                                                
1:43:08 PM                                                                                                                    
He said  the fund is just  a piggy bank  right now, with  no money                                                              
in it, and  asked that the  committee forward a $5  million fiscal                                                              
note to  Finance to  fill the  fund. That  amount is  commensurate                                                              
with the  amounts similarly  populated states  have set  aside for                                                              
uncompensated  care. He admitted  that he does  not know  how they                                                              
are  going to  come up  with that  money and  said he  is open  to                                                              
suggestions.  One option is  to ask the  Department of  Health and                                                              
Social  Services   to  re-identify  a  portion  of   the  Medicaid                                                              
"Disproportionate   Share"   funds,   which   are   intended   for                                                              
uncompensated care.  Another, suggested  by the House, is  to take                                                              
a  portion of  the tobacco  tax  or tobacco  settlement money  for                                                              
this purpose; that is general fund money anyway.                                                                                
                                                                                                                                
SENATOR COGHILL  went on  to provide a  sectional analysis  of the                                                              
bill.                                                                                                                           
                                                                                                                                
Section 1  provides that  the commissioner  [of the Department  of                                                              
Health and Social  Services] shall establish  special designations                                                              
based  on  nationally  recognized  standards  and  procedures  for                                                              
varying levels  of trauma care.  In other  words, in order  to get                                                              
into  the  fund,  a  hospital  has   to  have  reached  nationally                                                              
recognized standards  for trauma care.  He added that he  is loath                                                              
to give  the department  any more  authority to make  regulations,                                                              
but knows of no  other way to do it. The good news  is that Levels                                                              
I through IV are  very well defined in national  standards and are                                                              
outlined in Alaska statutes.                                                                                                    
                                                                                                                                
Section 2(b) creates  the fund and states that  the fund "consists                                                              
of  money appropriated  to it  by the  legislature." Section  2(c)                                                              
designates  it as  uncompensated  trauma care  money and  provides                                                              
for a  review by those  committees that  already do  trauma system                                                              
review.                                                                                                                         
                                                                                                                                
1:46:39 PM                                                                                                                    
Section  2(d) creates  stability  in the  fund by  limiting to  25                                                              
percent per  year the amount  of total assets, including  earnings                                                              
that the commissioner can give to one trauma center.                                                                            
                                                                                                                                
SENATOR  COGHILL   said  when  his  grandson  fell,   they  didn't                                                              
question how  much it would  cost to get  the care he  needed, but                                                              
the  care  was not  available.  Alaska  can  do better.  He  would                                                              
rather accomplish  that through incentives than directives;  it is                                                              
a better  business model,  and Alaska's  health care situation  is                                                              
much more fragile than some people realize.                                                                                     
                                                                                                                                
1:49:01 PM                                                                                                                    
SENATOR  ELLIS asked  if  there will  be  any distinction  between                                                              
for-profit and non-profit health care facilities.                                                                               
                                                                                                                                
SENATOR COGHILL  said some  of that is  left to the  Department of                                                              
Health  and  Social Services,  but  he  does not  anticipate  that                                                              
there will be  any distinction. He said Providence  is most likely                                                              
to reach a Level  II designation, and the regional  hospital could                                                              
establish at least  a Level III fairly easily.  There are economic                                                              
considerations  because  they  compete  for  the  same  customers,                                                              
which is  another reason he  thinks an incentive-based  program is                                                              
best.                                                                                                                           
                                                                                                                                
1:50:14 PM                                                                                                                    
SENATOR  THOMAS  said  he  is concerned  that  there  is  so  much                                                              
lacking in Alaska's  trauma care. He asked if it is  due to a lack                                                              
of insurance coverage for trauma situations.                                                                                    
                                                                                                                                
1:50:59 PM                                                                                                                    
SENATOR COGHILL  answered  that insurance  will pay, and  Medicaid                                                              
does pay,  but a  lot of  the uncompensated  care is more  primary                                                              
care  related,  and he  thinks  the  state  should first  look  at                                                              
uncompensated  trauma care. Another  part of  the issue has  to do                                                              
with  the  different  business models.  For  example,  the  Alaska                                                              
Native  Tribal Health  Consortium  (ANTHC) is  a  Level II  trauma                                                              
center; they  keep paid doctors  on staff. Doctors working  at the                                                              
other  hospitals have  private practices  to maintain  and are  on                                                              
call  for emergency  room (ER)  work.  Their interest  is to  keep                                                              
their private  practices healthy,  so there  is a natural  tension                                                              
in the  working relationship.  He  hopes to relieve  some  of that                                                              
tension so  trauma doctors  can afford to  be on call  more often;                                                              
this  fund will  give hospitals  a  designated uncompensated  care                                                              
package they can  count on if they raise their  trauma levels, but                                                              
insurance will still be a huge factor.                                                                                          
                                                                                                                                
1:53:05 PM                                                                                                                    
SENATOR THOMAS  restated that  the problem is  more one  of having                                                              
doctors available continuously.                                                                                                 
                                                                                                                                
1:53:42 PM                                                                                                                    
SENATOR  PASKVAN   said  he  thinks  the  public   has  a  natural                                                              
expectation  that  hospitals  have   the  capacity  to  deal  with                                                              
trauma.  He  also  knows  there   is  a  contractual  relationship                                                              
between  hospitals and  emergency rooms.  He asked  how this  will                                                              
apply  to  the   separate  legal  entity  that   is  staffing  the                                                              
emergency room.                                                                                                                 
                                                                                                                                
SENATOR COGHILL said  he does not know, but he  thinks they should                                                              
draw  that out  in  the course  of discussion.  Those  contractual                                                              
relationships should not be barriers.                                                                                           
                                                                                                                                
1:54:57 PM                                                                                                                    
SENATOR ELLIS  asked if  hospitals break  out their  uncompensated                                                              
trauma care  from other types of  uncompensated care. He  said his                                                              
impression    is   that   for-profit    facilities   "eat"    less                                                              
uncompensated  care; they  tend to  pass more  of the  cost on  to                                                              
paying customers.                                                                                                               
                                                                                                                                
1:56:03 PM                                                                                                                    
SENATOR COGHILL responded  that he is not an expert  in that field                                                              
but  believes  the  uncompensated  care  through  disproportionate                                                              
share is streamed  to hospitals when they bill  Medicaid and flows                                                              
fairly  equally  whether  an institution  is  non-profit  or  for-                                                              
profit. Probably  the biggest difference  is where the  money ends                                                              
up in investment, whether in profit centers or additional care.                                                                 
                                                                                                                                
1:57:12 PM                                                                                                                    
SENATOR DYSON  said the  uncompensated costs  for both  for-profit                                                              
and non-profit hospitals  often get shifted to  third-party payers                                                              
and more  lucrative portions of  the business. Governor  Murkowski                                                              
started an  effort to fix that  by saying, if government  is going                                                              
to  force   hospitals  to  provide   uncompensated  care   in  the                                                              
emergency room,  then government should  come up with  a mechanism                                                              
to pay for that  so they don't have to  cost-shift. Unfortunately,                                                              
he didn't get very far with it.                                                                                                 
                                                                                                                                
He said he is  very proud of the hospitals in  his area, including                                                              
Providence  and Alaska  Regional, but  a lot  of money that  comes                                                              
into Providence  does not  stay in Alaska.  He was surprised  that                                                              
Alaska's hospitals  are not equipped to provide a  higher level of                                                              
treatment and,  if this bill will  provide the incentive  for them                                                              
to do that, he is really in favor of it.                                                                                        
                                                                                                                                
1:59:57 PM                                                                                                                    
SENATOR COGHILL said  he thinks the profit that  hospitals make is                                                              
due  to  them, whatever  the  business  model.  The fact  is  that                                                              
hospitals in  Alaska cannot  turn people  away from the  emergency                                                              
rooms, and the state has to find a way to pay for it.                                                                           
                                                                                                                                
2:00:54 PM                                                                                                                    
SENATOR  COGHILL  said  the  College  of  Surgeons  recommended  a                                                              
mandate, but  he doesn't want  to go there.  This is  an incentive                                                              
and, because  of this  bill, changes are  already being  made. Not                                                              
only has  DHSS hired  a coordinator,  but hospitals have  actually                                                              
begun discussions  with each  other and  with the military,  which                                                              
has trauma  doctors  who are familiar  with trauma  in war  zones.                                                              
They are looking  at how the military can work  with the hospitals                                                              
and how they will  deal with the hand-off. They  already have out-                                                              
of-state  doctors coming  in  to  work at  some  hospitals, so  he                                                              
knows it can be done.                                                                                                           
                                                                                                                                
2:02:38 PM                                                                                                                    
SENATOR ELLIS asked  Senator Coghill where he came  up with the $5                                                              
million figure and whether that will increase in future years.                                                                  
                                                                                                                                
2:03:25 PM                                                                                                                    
SENATOR  COGHILL said  the  figure  is based  on  data from  other                                                              
comparable  states  and  what  they  are  doing  in  uncompensated                                                              
trauma care. He  realizes that the department is going  to come in                                                              
with  a neutral  position because  they  don't want  to spend  any                                                              
more money;  he can appreciate that  they are under  huge downward                                                              
pressure, but if the state does less, it will get less.                                                                         
                                                                                                                                
2:04:32 PM                                                                                                                    
WARD HURLBURT,  Chief Medical  Officer, Department  of Health  and                                                              
Social Services;  Director,  Division of  Public Health,  said one                                                              
of the  first things he  learned when he  started in his  job last                                                              
summer  was  how  appreciative people  are  of  Senator  Coghill's                                                              
interest  and   hard  work  in   this  area.  One  of   the  major                                                              
responsibilities  of the division  has to  do with the  prevention                                                              
of unintentional injuries and handling those after they occur.                                                                  
                                                                                                                                
He  said  he worked  as  a  physician in  Naknek,  in  Dillingham,                                                              
Alaska in 1961,  where he saw a  lot of trauma injuries.  After he                                                              
completed his training  as a general surgeon, he  spent many years                                                              
at the Alaska  Native Medical Center  (ANMC), where a big  part of                                                              
what  he did was  deal with  trauma. Part  of the  reason for  the                                                              
high incidence of  trauma in this state is the  lifestyle; the way                                                              
many Alaskan citizens  make a living is hazardous;  transportation                                                              
is hazardous; recreation in the state can also be hazardous.                                                                    
                                                                                                                                
DR.  HURLBURT said  when  he was  with  the Alaska  Native  Health                                                              
Service  after  the  1964  earthquake, he  was  very  involved  in                                                              
planning  for the new  facility;  as part of  that planning,  they                                                              
recognized the problem  that unintentional injury  and trauma play                                                              
in the lives of  Alaska Natives and built a facility  that met the                                                              
standards needed to provide that kind of care.                                                                                  
                                                                                                                                
He stressed  that trauma  is the biggest  killer of  Alaskans from                                                              
birth  to age 44;  it is  third behind  cancer and  cardiovascular                                                              
disease as the cause  of death of all Alaskans,  regardless of age                                                              
and is the  number one killer of  Alaska Natives of all  ages. The                                                              
administration  has  learned  about  the trauma  systems  and  the                                                              
categorization  of  trauma  systems   through  the  Alaska  Trauma                                                              
System  Review  Committee  and the  Alaska  Council  on  Emergency                                                              
Medical Services  (ACEMS).  The American  College of Surgeons  has                                                              
taken  the lead;  they  are usually  the  first  specialty to  see                                                              
serious  trauma victims,  so their  professional organization  was                                                              
instrumental in developing Alaska's system.                                                                                     
                                                                                                                                
2:09:19 PM                                                                                                                    
He said this  is the kind of  system that the rest of  the country                                                              
has adopted and  accepted, and it has generated  improved results.                                                              
The  New  England   Journal  of  Medicine,  a   respected  medical                                                              
journal, compared  the mortality  outcomes for trauma  victims who                                                              
got to  certified trauma  facilities  and those  who did not,  and                                                              
found about a  25 percent difference. There was  a lower mortality                                                              
rate  for those  trauma  victims  who  were treated  in  certified                                                              
trauma facilities.                                                                                                              
                                                                                                                                
Alaska is the  only state in the  country, he said, that  does not                                                              
have  a Level  I or  a  Level II  trauma center  for  most of  the                                                              
population.  He admitted that  Alaska may  not have a  justifiable                                                              
need for a Level  I trauma center in the near future;  the Level I                                                              
trauma  center for  Alaska is  Harborview Hospital  in Seattle  at                                                              
this  time. But  this is  the only  state  that does  not have  at                                                              
least  a  Level  II  trauma  center  for  most  of  its  citizens;                                                              
Anchorage  is the largest  city  in the United  States without  at                                                              
least a Level II trauma center.                                                                                                 
                                                                                                                                
DR. HURLBURT  confirmed that,  consistent with the  recommendation                                                              
in the  American College  of Surgeons  2008 report,  they  hired a                                                              
trauma  system  coordinator  named  Julie Rabeau  last  week.  She                                                              
previously  worked with  Alaska  Native Tribal  Health  Consortium                                                              
(ANTHC)  and as  a trauma nurse  in Las  Vegas. Her  mother  was a                                                              
nurse in Kotzebue,  and her father was a doctor in  Alaska, so she                                                              
has strong Alaskan  roots and a passion for the job.  He said they                                                              
recognize that hospital  participation in meeting  the criteria is                                                              
voluntary; they also  recognize that the standards must  be met by                                                              
both  the physicians  and the  hospitals.  For a  Level II  trauma                                                              
certification,   general  surgeons  must   be  available   in  the                                                              
emergency room  within 20 minutes of  the call; for Level  III, 30                                                              
minutes  is the  standard. Level  II also  has a  higher level  of                                                              
neurosurgical  capability.  He asserted  that  it  would not  make                                                              
sense for  Fairbanks Memorial  to go  for Level  II, but  it would                                                              
make sense  and would serve the  citizens of that region  for them                                                              
to go for a Level III.                                                                                                          
                                                                                                                                
2:13:50 PM                                                                                                                    
DR.  HURLBURT  agreed  with  Senator  Coghill  that  it  would  be                                                              
reasonable for Alaska  Regional to go for a Level  II, but said it                                                              
probably would  not meet the  needs of Anchorage  because Regional                                                              
does  not have  sufficient capacity.  Providence,  because of  its                                                              
size and current  capabilities, would be better placed  as a Level                                                              
II   facility.   The   administration   encourages   health   care                                                              
facilities and  the physician community  to embrace this  and seek                                                              
certification.                                                                                                                  
                                                                                                                                
There is an  interesting example in Tacoma, Washington,  where two                                                              
large competing  hospitals, St Joseph  and Tacoma  General, agreed                                                              
to work  together to create one  trauma call system;  patients are                                                              
taken to  one or  the other depending  on a  schedule. He  said he                                                              
was very skeptical  about it when it started, but  it has lasted a                                                              
number of years  now and seems to work. Madigan  military hospital                                                              
at Fort  Lewis is also part  of that collaboration,  although they                                                              
don't take  civilian victims there  very often. Anchorage  has two                                                              
large civilian hospitals  and a military hospital; if  they can do                                                              
it  in  Tacoma, he  said,  they  ought to  be  able  to  do it  in                                                              
Anchorage.                                                                                                                      
                                                                                                                                
The  position  of  the administration  is  neutral.  The  Governor                                                              
clearly  recognizes  and agrees  with  the need,  but  there is  a                                                              
preference  to  do this  on  a voluntary  basis  and,  in a  tight                                                              
budget  year, the  $5  million associated  with  it in  SB 169  is                                                              
difficult.                                                                                                                      
                                                                                                                                
2:17:13 PM                                                                                                                    
SENATOR THOMAS  asked if  there are  additional costs  anticipated                                                              
in human capital, beyond the $5 million fund.                                                                                   
                                                                                                                                
DR. HURLBURT  said there is some  concern among hospitals  that if                                                              
they  are designated  as trauma  centers, they  will attract  more                                                              
uncompensated  care. There  may  be some  other additional  costs,                                                              
but  the  major  concern  he has  heard  articulated  is  that  of                                                              
attracting more patients who do not have coverage.                                                                              
                                                                                                                                
SENATOR THOMAS  said if that is  case, it is not only  a personnel                                                              
issue, but an  insurance issue, which brings up  questions such as                                                              
whether  the  state  should  mandate   insurance  or  move  toward                                                              
greater affordability  of  insurance for  individuals in  order to                                                              
remove some of the problem with uncompensated care.                                                                             
                                                                                                                                
2:19:08 PM                                                                                                                    
DR. HURLBURT  agreed that is  a major concern.  He said he  sees a                                                              
report each  quarter on the  level of profitability  of the  15 or                                                              
20 largest  hospitals in  the Northwest.  The number two  hospital                                                              
in terms  of profitability is generally  Sacred Heart, which  is a                                                              
Providence  hospital   in  Spokane,  Washington;   number  one  is                                                              
usually  Children's Hospital.  Alaska's  Providence  is not  large                                                              
enough to make it  into the report, but he understands  that it is                                                              
the most  profitable hospital  in the  Providence system.  He also                                                              
understands  that   Alaska  Regional  is  part  of   the  Hospital                                                              
Corporation of  America and  is profitable for  them, so  both are                                                              
solid  financially.  They  need  to  be  profitable  in  order  to                                                              
reinvest and  return profit  to their owners;  part of  managing a                                                              
business  is making  the bottom  line. The sisters  are quoted  as                                                              
saying "No  money, no  mission," and they  will naturally  tend to                                                              
protect any challenges to their level of profitability.                                                                         
                                                                                                                                
2:20:51 PM                                                                                                                    
SENATOR  DYSON asked  if  the Alaska  Native  Medical Center  will                                                              
treat non-native patients who need Level I or II trauma care.                                                                   
                                                                                                                                
DR.  HURLBURT said  they will  take some  non-native patients  but                                                              
have only 150 beds, so their ability is limited.                                                                                
                                                                                                                                
SENATOR  DYSON asked  if he is  correct, that  nothing in  federal                                                              
regulation prevents them from doing that.                                                                                       
                                                                                                                                
DR. HURLBURT confirmed that is correct.                                                                                         
                                                                                                                                
SENATOR  DYSON  asked  if  the   same  is  true  of  the  military                                                              
hospitals.                                                                                                                      
                                                                                                                                
DR.  HURLBURT said  he  does not  know that  system  as well,  but                                                              
thinks that any hospital can take a trauma victim.                                                                              
                                                                                                                                
2:23:00 PM                                                                                                                    
SENATOR PASKVAN said  the discussion of how soon  surgeons must be                                                              
available  at   Level  I  and   Level  II  facilities   assumes  a                                                              
contractual  agreement between  the hospital  and the  physicians,                                                              
and that infers  there is a transfer of care out  of the emergency                                                              
room and into the hospital. He asked if that is true.                                                                           
                                                                                                                                
DR. HURLBURT  replied that  is basically  correct. Level  I trauma                                                              
centers have  physicians in-house at  all times; Level  II centers                                                              
have  anesthesiologists  in-house,  but not  general  surgeons  or                                                              
orthopedists.  In any hospital,  the trauma  victim goes  first to                                                              
the emergency  room  to be seen  by the  emergency room  physician                                                              
who performs  triage, makes  an assessment, and  then calls  for a                                                              
surgeon as  necessary. Generally,  the on-call physician  sees the                                                              
patient   while  still   in  the   emergency   room  and   assumes                                                              
responsibility at that time.                                                                                                    
                                                                                                                                
Regarding the  point that ANMC  physicians are salaried,  yes they                                                              
are, he said,  but when he was  a surgeon there he had  a full day                                                              
operating  schedule  and clinics  to  do and  did  trauma care  at                                                              
night. It  was somewhat  easier there, in  that he had  colleagues                                                              
who could  pick up  the ball  from him if  he got  tied up  with a                                                              
trauma victim, but he did have a day job.                                                                                       
                                                                                                                                
2:25:28 PM                                                                                                                    
SENATOR PASKVAN  clarified that what  he is focusing upon  is that                                                              
it  may be  troubling  to  members of  the  public  if they  don't                                                              
understand  their emergency  room is qualified  to handle  trauma;                                                              
he wants to  be careful how they  use language in this  regard. He                                                              
restated  that what  they are  really  talking about  is that  the                                                              
emergency   room  physician   performs  triage   and,  while   the                                                              
paperwork may take  some time to catch up, there  is a transfer of                                                              
care from the emergency  room doctor to the surgeon  who is called                                                              
to  address  specific  issues.   It  is  the  timeliness  of  that                                                              
transfer of care  that reduces the mortality rate that  is seen in                                                              
the difference between designated and non-designated hospitals.                                                                 
                                                                                                                                
DR. HURLBURT  agreed it  is very important  to recognize  that the                                                              
quality  of care  is very  good  in this  state, but  it has  been                                                              
proven that when  hospitals meet the specific criteria  for trauma                                                              
centers, the survival rate is significantly better.                                                                             
                                                                                                                                
2:27:17 PM                                                                                                                    
SENATOR PASKVAN asked  what Dr. Hurlburt believes is  the best way                                                              
to  get the  money where  it is  needed  so that  surgeons can  be                                                              
there within 20 or 30 minutes.                                                                                                  
                                                                                                                                
DR. HURLBURT said  he doesn't know. The study in  Tacoma looked at                                                              
the different  specialties and how  often they get called  in, and                                                              
then tried to come  up with fair compensation based  on those call                                                              
projections.  For example,  a  urologist might  not  be called  in                                                              
very often,  so he would  be paid less  than would  an orthopedist                                                              
who  is called  in  frequently.  There is  an  expectation in  the                                                              
country today  that doctors should  be compensated if they  are on                                                              
call;  some hospitals  hire  physicians  especially  for that.  He                                                              
said that  raises the  concern that  they could  be placing  those                                                              
doctors in competition with the doctors on staff.                                                                               
                                                                                                                                
2:29:14 PM                                                                                                                    
SENATOR THOMAS  mentioned information in Representative  Coghill's                                                              
booklet about  prevention, and  asked if  there are statistics  to                                                              
support the success of public education programs.                                                                               
                                                                                                                                
DR.  HURLBURT said  yes,  they have  seen  prevention efforts  pay                                                              
off; the trauma  mortality rates are lower than they  were when he                                                              
came to  Alaska, despite  the advent  of snow  machines and  other                                                              
more dangerous  methods of  locomotion. But,  he said,  prevention                                                              
can mean a lot  of different things, like the  program "kids don't                                                              
float," which  has reduced the  number of drowning  fatalities. It                                                              
also  means  getting  other disciplines  involved;  he  cited  the                                                              
improvements  highway engineers  have made  in the  safety of  the                                                              
highway between Anchorage and Girdwood.                                                                                         
                                                                                                                                
2:31:20 PM                                                                                                                    
DR. FRANK  SACCO, Trauma Director,  Alaska Native  Medical Center;                                                              
Chair, State Trauma  Systems Review Committee,  Anchorage, Alaska,                                                              
said the  committee is  made up  of doctors, nurses,  pre-hospital                                                              
care  workers, and  hospital  administrators.  They  meet twice  a                                                              
year to  review how Alaska  is doing as  a trauma system  and find                                                              
ways  to   improve.  Trauma  systems   arose  from   the  military                                                              
experience.  In  that  model, there  is  a  pre-planned  response.                                                              
Victims go through  several levels of care from the  time they are                                                              
injured;  they receive  initial care  from pre-hospital  emergency                                                              
personnel; they get  stabilized; they get moved,  and finally they                                                              
are admitted  to the facility  where they will receive  definitive                                                              
care.  Every  person who  touches  those  patients has  the  right                                                              
training;  each  place  they  go  is prepared  to  give  them  the                                                              
optimal  care  every  step of  the  way.  That  is the  basis  for                                                              
civilian  trauma  systems;  both  federal  and  state  governments                                                              
recognize that.  Alaska was one  of many states that  started down                                                              
the road  toward developing  a state  trauma  system in the  early                                                              
1990s, when Loren  Leman introduced the first bill  and decided to                                                              
make  this  completely  voluntary.  In  the 15  years  since  that                                                              
legislation,  only  five  hospitals  out  of  the  24  acute  care                                                              
facilities  have been  designated, and  four of  those are  in the                                                              
native health system.                                                                                                           
                                                                                                                                
2:35:10 PM                                                                                                                    
DR. SACCO said  this is not a red  or a blue-state issue;  it is a                                                              
non-partisan  issue  like  fire  departments  and  ambulances.  He                                                              
admitted that there  are a lot of questions about  how this can be                                                              
done,  but  there are  270  Level  II trauma  centers  around  the                                                              
country  and almost  all  of them  are community  hospitals,  both                                                              
for-profit  and non-profit. Because  a lot  of states  are further                                                              
along  in  this  process,  Alaska  has  the  opportunity  to  take                                                              
advantage of  what they have  already done.  This is the  level of                                                              
care  people want  for themselves  and their  family members,  the                                                              
kind of  care most  people think  they already  have. Some  states                                                              
have waited  to do anything  until a high-profile  incident forced                                                              
them  to react,  but  he emphasized  that this  is  a huge  public                                                              
health problem  that affects almost  everybody. He thinks  it is a                                                              
good  idea to  provide incentives  for  hospitals to  participate,                                                              
but if that  doesn't work, then  the State needs to take  steps to                                                              
ensure that Alaska has a trauma system.                                                                                         
                                                                                                                                
2:38:27 PM                                                                                                                    
DR. REGINA  CHENAULT, State  Chair, American  College of  Surgeons                                                              
Committee  on Trauma,  Anchorage, Alaska,  said she  is a  general                                                              
surgeon,  the  physician  member   of  the  Alaska  Department  of                                                              
Administration,  Violent Crimes Compensation  Board, and  a member                                                              
of the Alaska  Trauma Systems Review  Committee. She is  in the ER                                                              
a  lot, and  the fact  that Alaska  is  the only  state without  a                                                              
designated  trauma hospital  for  the general  public  is a  great                                                              
concern for  her. It  is a  public safety  threat for everyone  in                                                              
Alaska and,  she believes,  an ethical issue.  She said  she works                                                              
at  the  Alaska  Native  hospital,  which is  a  Level  II  trauma                                                              
center; their  mission is to provide  care to the  Alaska Natives,                                                              
and their  beds are usually full.  She has had the  opportunity to                                                              
provide surgical  care in several different places  since she came                                                              
to  Alaska in  2003, including  Soldotna,  Kodiak, Ketchikan,  and                                                              
Anchorage, both in  a private setting and at  the native hospital,                                                              
and she stressed  that there are  people dying who should  not be,                                                              
because the  systems are not  in place. There  is a lot  of trauma                                                              
in  the  state  of  Alaska; there  are  high  levels  of  domestic                                                              
violence; law enforcement  officers are being shot;  Alaska has to                                                              
get this trauma  designation program in place so  Alaskans can get                                                              
the same standard  of care that the people in the  other 49 states                                                              
are  already  receiving.  An organized  approach  to  trauma  care                                                              
gives  everyone  a  25  percent  better  chance  of  surviving  an                                                              
injury, she  said, this is  the reason we  must pass this  bill as                                                              
soon as possible.                                                                                                               
                                                                                                                                
2:41:29 PM                                                                                                                    
DAVID  HULL,   Chair,  Governor's  Alaska  Council   on  Emergency                                                              
Medical  Services   (ACEMS);  Fire   Chief,  North   Tongass  Fire                                                              
Department, Ketchikan,  Alaska, said he is a  practicing paramedic                                                              
with 35 years  of responding to  all kinds of emergency  calls for                                                              
help, and  it is  from this  arena that  he approaches  the issue.                                                              
Trauma is  any bodily  injury from  an external  force; it  can be                                                              
accidental  or intentional.  Trauma  puts a  tremendous burden  on                                                              
families  and communities  all across  Alaska. An  average of  400                                                              
Alaskans  die each  year  from trauma,  and  for  every death,  11                                                              
people  are hospitalized.  Insurance  does not  cover  all of  the                                                              
costs. A  study done in  2004 showed that  for trauma  patients in                                                              
Alaska,  the  economic  cost  of   the  hospital  stay  alone  was                                                              
estimated at  over $73  million; one  in four hospital  admissions                                                              
was  uncompensated,  which  puts   an  additional  burden  on  the                                                              
state's hospitals and  health care system. The trauma  system is a                                                              
predetermined,    organized,   multi-disciplinary    response   to                                                              
managing the  care and treatment  of severely injured  people. The                                                              
statewide  trauma system  also provides a  framework for  disaster                                                              
preparedness  and response.  For  a severely  injured person,  the                                                              
time between an  injury and receiving definitive care  is the most                                                              
important  predictor of  survival. It  is commonly  known as  "the                                                              
golden hour,"  but in  some places  in Alaska, that  can be  a day                                                              
or,  depending  on  the  weather,  a  week.  The  local  Emergency                                                              
management System  (EMS) responders  across the state  have gotten                                                              
pretty good  at getting viable  trauma patients to  the hospitals;                                                              
then it  becomes the  hospitals' and  the doctors'  responsibility                                                              
to keep  up that  good work. Increased  hospital participation  is                                                              
necessary for the  statewide trauma system to  function optimally.                                                              
The goal  of a statewide  trauma system  is to see  every hospital                                                              
in Alaska become  designated as a trauma center  at an appropriate                                                              
level;  the ultimate  goal  of everyone  involved  however, is  to                                                              
save  lives. The  Alaska Council  on EMS  seeks the  legislature's                                                              
support for a  fully functioning trauma system,  including funding                                                              
for the development  of trauma centers and  legislation addressing                                                              
the  issue   of  incentives  for   trauma  care   designation  and                                                              
uncompensated care trauma patients.                                                                                             
                                                                                                                                
2:44:53 PM                                                                                                                    
MR.  HULL  closed  by  asking  the  legislators  to  consider  his                                                              
request   to  help  build   a  coordinated   approach  to   trauma                                                              
management.                                                                                                                     
                                                                                                                                
2:45:02 PM                                                                                                                    
ROD  BETIT, President,  Alaska  State  Hospital and  Nursing  Home                                                              
Association, Juneau,  Alaska, stated  that hospitals  support this                                                              
legislation.  He  said  Senator   Coghill  attended  their  annual                                                              
meeting in Soldotna  this year, and they talked about  some of the                                                              
challenges  preventing  hospitals   from  moving  forward  without                                                              
legislation   like  this   to   help  closed   the   gap  on   the                                                              
uncompensated care  burden and the availability of  physicians. To                                                              
do this,  they have  to be assured  that physicians  with specific                                                              
specialties are in  the hospital within certain  time frames. That                                                              
is  a  pretty   tall  order;  these  physicians   are  independent                                                              
practitioners. He  thinks they can  get there, but  suggested that                                                              
they amend  the language  in this  bill to  give the  commissioner                                                              
the  discretion  to  use  the  fund   to  address  other  economic                                                              
barriers in addition to uncompensated care.                                                                                     
                                                                                                                                
2:48:08 PM                                                                                                                    
SENATOR PASKVAN asked  what the position of hospitals  would be to                                                              
increasing the cost  of compensated care to help  cover the trauma                                                              
system.                                                                                                                         
                                                                                                                                
MR.  BETIT said  that is  the typical  way of  doing things.  When                                                              
costs have to be  recovered, either an arrangement  is made with a                                                              
government  entity to  help  offset those  costs,  or an  increase                                                              
does  appear on  the payer's  bill.  Senator Dyson  spoke to  that                                                              
earlier in  terms of cost  shifting. He  said he hopes  the amount                                                              
that is  not otherwise recoverable  will be minimized,  but trauma                                                              
tends to carry with  it a larger percentage of  patients who don't                                                              
have  full coverage  than regular  health care  does. These  costs                                                              
would  not show  up in  uncompensated care  however, because  they                                                              
are to  ensure the  availability of  specially trained  physicians                                                              
within  the  required  20  or  30  minute  window,  regardless  of                                                              
whether or not there is a patient.                                                                                              
                                                                                                                                
SENATOR PASKVAN  clarified that  he was  asking if hospitals  have                                                              
considered  increasing costs  for  compensated  payers across  the                                                              
board,  in  order   to  diffuse  the  cost  of   obtaining  trauma                                                              
certification.                                                                                                                  
                                                                                                                                
MR. BETIT could not speak to that.                                                                                              
                                                                                                                                
2:51:09 PM                                                                                                                    
SENATOR COGHILL  asked Mr. Betit if  he knows what is  going on in                                                              
Congress with regard to trauma payment issues.                                                                                  
                                                                                                                                
MR. BETIT said everything  is pretty much up in the  air, with all                                                              
that  has been  going on  with federal  health  reform lately.  He                                                              
said he will let  the committee know if he gets  any clarification                                                              
on that.                                                                                                                        
                                                                                                                                
2:52:53 PM                                                                                                                    
MARK  JOHNSON, Chief,  Emergency Medical  Services (EMS),  Juneau,                                                              
Alaska, said  he was involved  with Representative Lehman  when he                                                              
got the initial  legislation passed in 1992-1993.  It provides for                                                              
state certification  of trauma centers using the  American College                                                              
of  Surgeons  standards.  He added  that  a  comprehensive  trauma                                                              
system plan  as defined  by the American  College of  Surgeons and                                                              
others  includes everything  from injury  prevention through  pre-                                                              
hospital and hospital care, to rehabilitation.                                                                                  
                                                                                                                                
He  stated   that  Alaska   has  made   significant  progress   on                                                              
prevention and throughout  the EMS and trauma systems.  Alaska has                                                              
one  of the  most comprehensive  trauma registries  in the  United                                                              
States;   the  trauma   training  courses   required  for   trauma                                                              
certification, such  as trauma nurse training and  advanced trauma                                                              
life  support  have  been readily  available  to  Alaska  hospital                                                              
staff for many  years. Certification requires a  certain amount of                                                              
equipment,  which  is already  available  in  all of  the  state's                                                              
facilities;  it   requires  a   process  for  continuing   quality                                                              
improvement,  and  that is  also  happening  in many  of  Alaska's                                                              
hospitals. One obstacle  to getting Alaska's trauma  system to the                                                              
desired  standard is  that emergency  departments  are trained  to                                                              
provide  a  certain  level  of care,  but  if  there  is  internal                                                              
bleeding   or    another   situation   that    requires   surgical                                                              
intervention,  they need  to have  a surgeon  on call and  readily                                                              
available.  That is where  Alaska's system  is falling  down right                                                              
now; it is inconsistent.                                                                                                        
                                                                                                                                
2:57:30 PM                                                                                                                    
MR. JOHNSON  said this bill is a  good step because it  creates an                                                              
incentive,  which was  lacking in  the  previous legislation.  The                                                              
American  College of Surgeons  recommends  that every hospital  in                                                              
Alaska  should  be  designated at  the  appropriate  level.  Small                                                              
rural  hospitals should  be  a Level  IV, and  four  of them  have                                                              
already  achieved that  status;  mid-sized hospitals  should be  a                                                              
Level  III.  In  the  1990s,  his   office  co-sponsored  American                                                              
College of  Surgeons reviews at  eight different hospitals  in the                                                              
state,  and some  came  close to  passing  Level  II; the  biggest                                                              
hang-up  was the on-call  schedule.  He pointed  out that  some of                                                              
the  surgeons  who  have  private  practices  know  the  insurance                                                              
status of  patients before  they do surgery;  if the  surgeons are                                                              
on  call for  emergencies  and get  called  in the  middle of  the                                                              
night, they  have no way  of knowing if the  patient is or  is not                                                              
insured,  and roughly  a  quarter  of them  turn  out  not to  be.                                                              
Hopefully,  this  incentive  will   be  enough  encouragement  for                                                              
hospitals,  in cooperation  with their on-call  staff, to  provide                                                              
that  care. He  pointed out  that there  could also  be some  peer                                                              
pressure  brought to  bear as  hospitals  begin to  step up,  that                                                              
will encourage  other hospitals  to do it.  He believes  that once                                                              
they  achieve  certification,  they   will  find  it  makes  their                                                              
operation as a whole much smoother and more efficient.                                                                          
                                                                                                                                
3:00:03 PM                                                                                                                    
MARTHA  MOORE,  representing  herself, Juneau,  Alaska,  said  she                                                              
supports this  bill and would like  Bartlett to become  a Level II                                                              
trauma center. She  used to work in Mark Johnson's  office and had                                                              
many discussions  with hospital  staff about  this issue.  She has                                                              
heard nurses  say they have no idea  what to expect when  a trauma                                                              
victim comes  into the ER; they  should know and be  prepared. She                                                              
has heard  paramedics say that taking  victims to a  trauma center                                                              
has  a whole  different feel  to them,  because a  trauma team  is                                                              
there and  ready to  take over. The  hospitals that  have achieved                                                              
certification  say  that  their  staff's stress  levels  are  down                                                              
because  they have  all trained  and practiced  the protocols  and                                                              
procedures they  will use to deal  with trauma victims;  they feel                                                              
confident and prepared.  She thinks that if every  hospital in the                                                              
state puts forth  the effort to become certified,  it will improve                                                              
care for  all Alaskans,  and she  hopes this  bill will  be enough                                                              
incentive for them to do that.                                                                                                  
                                                                                                                                
3:03:11 PM                                                                                                                    
SOREN   THREADGILL,  retired   Chief   of   EMS,  Anchorage   Fire                                                              
Department, Anchorage,  Alaska, said  he is the  Chair of  the Red                                                              
Cross Disaster Consortium  and a member of ACEMS,  and he supports                                                              
this  bill.  He  thinks it  will  improve  Alaska's  trauma  care,                                                              
thereby   improving  patients'   outcomes.  It   is  one   of  the                                                              
responsibilities  of  government  to  take  care  of  its  people,                                                              
especially in this  case, when people are not  really cognizant of                                                              
the  difference between  levels of  care; they  just expect  their                                                              
hospitals to be able to take care of them.                                                                                      
                                                                                                                                
He said EMS started  in the 1960s due to the  large number highway                                                              
traumas.  There  is fair  amount  EMS can  do  at  the scene,  but                                                              
definitive  care is  provided  at the  hospitals.  The ACS  review                                                              
emphasizes  the  importance  of  collaboration  between  EMS,  the                                                              
hospitals,  law enforcement,  first  responders, dispatchers,  and                                                              
the public.  If this kind of  collaborative system is  followed as                                                              
recommended  by ACS, it  really will  do wonders toward  improving                                                              
Alaska's trauma care.                                                                                                           
                                                                                                                                
3:05:26 PM                                                                                                                    
CHAIR DAVIS  closed public  testimony for  today. She  pointed out                                                              
that  the  fiscal   notes  attached  to  SB  168   from  both  the                                                              
Department  of Revenue  (DOR)  and the  Department  of Health  and                                                              
Social   Services  are   zero,  but   SB  169,   the  $5   million                                                              
appropriation  bill, is still  alive if they  wish to  consider it                                                              
at some point.                                                                                                                  
                                                                                                                                
[SB 168 was held in committee.]                                                                                                 
                                                                                                                                
                                                                                                                                
3:07:12 PM                                                                                                                    
There being no further business to come before the committee,                                                                   
Chair Davis adjourned the meeting at 3:07 p.m.                                                                                  

Document Name Date/Time Subjects