Legislature(2019 - 2020)BUTROVICH 205

02/14/2020 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:32:07 PM Start
01:32:37 PM HB29
02:52:51 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
*+ HB 29 INSURANCE COVERAGE FOR TELEHEALTH TELECONFERENCED
Heard & Held
-Invited Testimony Followed by Public Testimony-
+ Bills Previously Heard/Scheduled TELECONFERENCED
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                       February 14, 2020                                                                                        
                           1:32 p.m.                                                                                            
                                                                                                                                
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Senator David Wilson, Chair                                                                                                     
Senator Cathy Giessel                                                                                                           
Senator Mike Shower                                                                                                             
Senator Tom Begich                                                                                                              
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Senator Natasha von Imhof, Vice Chair                                                                                           
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
HOUSE BILL NO. 29                                                                                                               
"An Act relating to insurance coverage for benefits provided                                                                    
through telehealth; and providing for an effective date."                                                                       
                                                                                                                                
     - HEARD & HELD                                                                                                             
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 29                                                                                                                   
SHORT TITLE: INSURANCE COVERAGE FOR TELEHEALTH                                                                                  
SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ                                                                                         
                                                                                                                                
02/20/19       (H)       PREFILE RELEASED 1/11/19                                                                               
02/20/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
02/20/19       (H)       HSS, L&C                                                                                               
03/26/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
03/26/19       (H)       Heard & Held                                                                                           
03/26/19       (H)       MINUTE(HSS)                                                                                            
03/28/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
03/28/19       (H)       Moved HB 29 Out of Committee                                                                           
03/28/19       (H)       MINUTE(HSS)                                                                                            
03/29/19       (H)       HSS RPT 3DP 1NR                                                                                        
03/29/19       (H)       DP: CLAMAN, DRUMMOND, SPOHNHOLZ                                                                        
03/29/19       (H)       NR: PRUITT                                                                                             
04/12/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/12/19       (H)       -- MEETING CANCELED --                                                                                 
04/15/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/15/19       (H)       Scheduled but Not Heard                                                                                
04/24/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/24/19       (H)       Heard & Held                                                                                           
04/24/19       (H)       MINUTE(L&C)                                                                                            
04/26/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/26/19       (H)       <Bill Hearing Canceled>                                                                                
04/29/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/29/19       (H)       Moved HB 29 Out of Committee                                                                           
04/29/19       (H)       MINUTE(L&C)                                                                                            
04/30/19       (H)       L&C RPT 5DP 2NR                                                                                        
04/30/19       (H)       DP: HANNAN, STUTES, FIELDS, WOOL,                                                                      
                         LEDOUX                                                                                                 
04/30/19       (H)       NR: REVAK, TALERICO                                                                                    
05/07/19       (H)       TRANSMITTED TO (S)                                                                                     
05/07/19       (H)       VERSION: HB 29                                                                                         
05/08/19       (S)       READ THE FIRST TIME - REFERRALS                                                                        
05/08/19       (S)       HSS                                                                                                    
02/14/20       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
REPRESENTATIVE IVY SPOHNHOLZ                                                                                                    
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: HB 29 Sponsor.                                                                                            
                                                                                                                                
KASEY CASORT, Intern                                                                                                            
Representative Ivy Spohnholz                                                                                                    
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: Provided an overview of HB 29.                                                                            
                                                                                                                                
SARAH BAILEY, Supervisor                                                                                                        
Life and Health Section                                                                                                         
Division of Insurance                                                                                                           
Department of Commerce, Community and Economic Development                                                                      
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: Answered questions about HB 29.                                                                           
                                                                                                                                
VICTORIA KNAPP, Chief Operations Officer                                                                                        
Mat-Su Health Services                                                                                                          
Wasilla, Alaska                                                                                                                 
POSITION STATEMENT: Testified in support of HB 29.                                                                            
                                                                                                                                
STEWART FERGUSON, Ph.D., Chief Information Officer                                                                              
Alaska Native Tribal Health Consortium                                                                                          
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Testified in support of HB 29.                                                                            
                                                                                                                                
ANITA HALTERMAN, President                                                                                                      
Alaska Collaborative for Telehealth and Telemedicine (AKCTT)                                                                    
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Testified in support of HB 29.                                                                            
                                                                                                                                
CLAUDIA TUCKER, Vice President                                                                                                  
Government Affairs                                                                                                              
Teladoc Health                                                                                                                  
Greenwich, Connecticut                                                                                                          
POSITION STATEMENT: Testified in support of HB 29.                                                                            
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
1:32:07 PM                                                                                                                    
CHAIR DAVID WILSON  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  Giessel, Begich, and  Chair Wilson.                                                               
Senator Shower arrived shortly thereafter.                                                                                      
                                                                                                                                
            HB 29-INSURANCE COVERAGE FOR TELEHEALTH                                                                         
                                                                                                                                
1:32:37 PM                                                                                                                    
CHAIR WILSON  announced the consideration  of HOUSE BILL  NO. 29,                                                               
"An  Act relating  to insurance  coverage  for benefits  provided                                                               
through telehealth; and providing for an effective date."                                                                       
                                                                                                                                
He stated  his intent  to hear an  initial overview,  a sectional                                                               
analysis,   and  invited   and   public   testimony.  He   called                                                               
Representative Spohnholz and her staff to the table.                                                                            
                                                                                                                                
1:33:18 PM                                                                                                                    
REPRESENTATIVE IVY  SPOHNHOLZ, Alaska State  Legislature, Juneau,                                                               
Alaska, HB 29 sponsor, said  this bill is about increasing access                                                               
to care  and reducing  the cost  of health  care for  Alaskans by                                                               
requiring insurers  to cover telehealth  in the state  of Alaska.                                                               
Access to telehealth  with Medicaid was one of  the core elements                                                               
of Senate Bill 74, the Medicaid  reform bill that passed in 2016,                                                               
and is provided by and  covered by Alaska's tribal health system.                                                               
It  has been  so effective  in those  markets that  it should  be                                                               
expanded to the private insurance market also.                                                                                  
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ  explained that telehealth  services are                                                               
important to increase  access to health care in  rural Alaska, to                                                               
address  behavioral   health  issues,  to  support   health  care                                                               
transformation in the state of  Alaska, and to reduce unnecessary                                                               
travel. That means Alaskans will  have access to health care even                                                               
if there is  no provider of that health care  in their community.                                                               
This  is  particularly important  in  rural  Alaska and  for  the                                                               
substance abuse  and behavioral health  crisis. HB 29  supports a                                                               
hub  and spoke  model of  health care  delivery in  which primary                                                               
care can  be provided in a  community and other providers  can be                                                               
consulted   via   telehealth.   Improving   access   can   reduce                                                               
unnecessary emergency  room (ER)  visits. New  technologies allow                                                               
providers  to   take  temperatures   and  do  other   things  via                                                               
telehealth. A telehealth  provider could look at a  wound to help                                                               
decide if  it is serious  enough to go  to the emergency  room or                                                               
whether a butterfly bandage could  be used on the wound overnight                                                               
until getting stitches the next day.                                                                                            
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ said  the Alaska  Native Tribal  Health                                                               
Consortium quantified the cost savings  for its use of telehealth                                                               
at $12.4  million in FY  2019. In  over eight years,  $70 million                                                               
has been  saved in unnecessary  travel and unnecessary  care with                                                               
telehealth. She  wants to  bring that  innovation to  the private                                                               
market.  Expanding access  to telehealth  is  also important  for                                                               
transforming the  health care  system. Lori  Wing-Heier, Director                                                               
of  Division  of Insurance,  calls  the  future of  the  hospital                                                               
virtual. Some  health care providers,  even in urban  Alaska, are                                                               
encouraging people  with communicable  diseases to stay  home and                                                               
get  their health  care  via telehealth.  A  telehealth visit  is                                                               
easier and better for people who have the flu, for example.                                                                     
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ shared  that for  all the  reasons that                                                               
she described,  there is a broad  range of support for  HB 29. HB                                                               
29 is supported by health  care providers including Orion Health,                                                               
Mat-Su Health  Services, Teladoc, Dr. Jill  Gaskill, Medical Park                                                               
Family  Practice; insurers  like Moda  Health; and  organizations                                                               
like the Alaska State Hospital  and Nursing Home Association, the                                                               
Alaska  Native Health  Board, Mind  Matters Research,  the Alaska                                                               
Commission on Aging, the Mat-Su Health Foundation, and AARP.                                                                    
                                                                                                                                
1:38:07 PM                                                                                                                    
KASEY CASORT, Intern, Representative  Ivy Spohnholz, Alaska State                                                               
Legislature, Juneau, Alaska, said  Alaska faces unique challenges                                                               
with  accessing  health  care, including  geography  and  limited                                                               
transportation  infrastructure. Alaska  has some  of the  highest                                                               
health care costs  in the country because patients  often have to                                                               
travel  to   access  care,  especially  because   Alaska's  small                                                               
population  means  there  are  fewer  providers  and  even  fewer                                                               
specialists in its communities.                                                                                                 
                                                                                                                                
MS. CASORT reviewed slide 2, How Does Telehealth Work:                                                                          
                                                                                                                                
     Interactive: a  patient and provider connect  through a                                                                    
     secure  video or  audio call.  This is  often used  for                                                                    
     behavioral  health services  and is  especially helpful                                                                    
     for patients  with limited  mobility, like  the elderly                                                                    
     or Alaskans living with disabilities.                                                                                      
                                                                                                                                
     Store-and-forward: the  provider sends  images, sounds,                                                                    
     or pre-recorded  video to a  patient or  other provider                                                                    
     for analysis. This can be used to get expert opinions.                                                                     
                                                                                                                                
     Self-monitoring:  patients  record their  symptoms  for                                                                    
     remote  monitoring. This  is  particularly helpful  for                                                                    
     high-risk  patients,  such  as someone  who  no  longer                                                                    
     needs hospitalization but needs monitoring.                                                                                
                                                                                                                                
MS. CASORT  said that according  to the Department of  Health and                                                               
Social  Services (DHSS)  FY 2019  annual Medicaid  reform report,                                                               
the  top diagnoses  and conditions  treated  via telehealth  last                                                               
year  were behavioral  health followed  by injuries,  poisonings,                                                               
and ear infections.                                                                                                             
                                                                                                                                
MS.  CASORT said  telehealth is  being used  all over  the state,                                                               
especially  within the  tribal  health  system. Nontribal  health                                                               
systems have  also been adopting  telehealth. Over a  decade ago,                                                               
Providence  became Alaska's  base  hospital offering  telehealth-                                                               
based  stroke assessments  statewide.  Its  web-based system  can                                                               
connect  neurologists with  distant  stroke patients  24 hours  a                                                               
day.  Providence has  submitted a  letter of  support for  HB 29.                                                               
Telehealth is  on the rise  because it works  and is a  huge cost                                                               
saver.  Although  most  providers, unfortunately,  do  not  track                                                               
their cost  savings associated  with telehealth,  a study  by the                                                               
Alaska  Native Tribal  Health  Consortium  found that  telehealth                                                               
averted  the need  for travel  in 40  percent of  cases and  that                                                               
number  increases   to  75  percent  when   patients  are  seeing                                                               
specialists. She reviewed slide 3,  and said the same study found                                                               
that 65  percent of patients were  seen the same day  and half of                                                               
patients are seen within an hour.                                                                                               
                                                                                                                                
MS. CASORT reviewed slide 5, Benefits of Telehealth:                                                                            
                                                                                                                                
   • Saves on health care travel costs                                                                                          
   • Faster access to critical provider and specialists                                                                         
   • Better access to health care in rural, remote, and                                                                         
     urban areas                                                                                                                
   • Allow contagious patients to stay home and still get                                                                       
     care                                                                                                                       
   • Better, faster access means a potential reduction in                                                                       
     suicides, domestic violence, and other serious events                                                                      
   • Improves training and support for home caregivers                                                                          
   • Zero impact on the state budget                                                                                            
                                                                                                                                
1:41:42 PM                                                                                                                    
MS.  CASORT  said  some  providers are  reluctant  to  invest  in                                                               
telehealth  technology because  not  all  insurers reimburse  for                                                               
telehealth health  services. There is a  disparity between public                                                               
and  private access  to telehealth  because  Medicaid does  cover                                                               
telehealth  services, but  private insurers  do not  consistently                                                               
cover these services. That is where HB 29 comes in.                                                                             
                                                                                                                                
She reviewed  slide 6, Purpose of  HB 29. She said  the bill will                                                               
increase  access to  health  care, allow  patients  to see  their                                                               
primary  care physicians,  and decrease  the cost  of travel  for                                                               
health care.                                                                                                                    
                                                                                                                                
MS. CASORT gave the following sectional analysis on slides 6-9:                                                                 
                                                                                                                                
     Section 1:                                                                                                                 
     An insurer  in the state  of Alaska that  offers health                                                                    
     care insurance plans in the  group or individual market                                                                    
     will  provide  coverage   for  benefits  delivered  via                                                                    
     telehealth   by  a   licensed   provider  without   the                                                                    
     requirement of an initial in-person meeting                                                                                
                                                                                                                                
     Section 2:                                                                                                                 
     Health  care insurer  and telehealth  are  added to  AS                                                                    
     21.42.422.                                                                                                                 
     Telehealth has the same definition in AS 47.05.270(e).                                                                     
     "The  practice  of  health care  delivery,  evaluation,                                                                    
     diagnosis,  consultation,   or  treatment,   using  the                                                                    
     transfer of health care data  through audio, visual, or                                                                    
     data  communications,   performed  over  two   or  more                                                                    
     locations."                                                                                                                
                                                                                                                                
     Sections 3 and 4:                                                                                                          
     Effective July 1, 2020.                                                                                                    
                                                                                                                                
MS.  CASORT shared  that she  has received  no verbal  or written                                                               
opposition for HB  29. She has spoken to the  largest insurers in                                                               
Alaska and none  have expressed opposition. In  fact, Moda Health                                                               
has submitted  a letter of  support. As  Representative Spohnholz                                                               
mentioned,  this   bill  has  broad  support   from  health  care                                                               
providers, insurers, and health care organizations.                                                                             
                                                                                                                                
1:44:11 PM                                                                                                                    
SENATOR  BEGICH asked  how the  bill accounts  for meeting  HIPAA                                                               
(Health   Insurance    Portability   and    Accountability   Act)                                                               
requirements.                                                                                                                   
                                                                                                                                
MS. CASORT explained  that all providers of  telehealth in Alaska                                                               
must  be licensed  in  Alaska  and must  be  registered with  the                                                               
telehealth  business registry.  In  order to  do that,  providers                                                               
must use  HIPAA-approved telemedicine technology,  which includes                                                               
video conferencing  or instant messaging or  email-type services.                                                               
Providers encrypt  their data  and monitor  for data  breaches to                                                               
receive a certification for  being HIPAA-compliant. Services that                                                               
are not HIPAA-compliant are not legally allowed.                                                                                
                                                                                                                                
SENATOR  BEGICH  pointed  out that  people  may  find  telehealth                                                               
technologies difficult  to access or utilize,  perhaps because of                                                               
education  or  skillset.  There  are areas  in  Alaska  with  low                                                               
bandwidth.  He  asked  if  the bill  takes  that  disparity  into                                                               
account.  He  is not  in  opposition  to  the  bill. He  is  just                                                               
wondering if the bill looks at that issue.                                                                                      
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ  replied  the  bill  does  not  address                                                               
access  in terms  of  the underlying  technology.  It allows  for                                                               
reimbursement for  services provided via telehealth.  There are a                                                               
variety of  efforts now to  improve access to broadband  in rural                                                               
Alaska.  The technologies  are evolving  quickly.  The number  of                                                               
HIPAA-compliant software  has expanded significantly in  the last                                                               
few   years.    Many   of   the   companies    that   have   done                                                               
videoconferencing for businesses  are expanding into telemedicine                                                               
because it  is such  a significant  market. Every  American needs                                                               
health  care. Telemedicine  is  the future,  so  the market  will                                                               
provide  some of  those solutions.  There  are also  governmental                                                               
efforts to deal with the issues he raised.                                                                                      
                                                                                                                                
SENATOR BEGICH asked if the  insurance industry would support the                                                               
bill.                                                                                                                           
                                                                                                                                
MS.  CASORT  responded  that  industry  representatives  she  has                                                               
spoken to expressed either neutrality or support.                                                                               
                                                                                                                                
SENATOR BEGICH said he hopes that  telehealth will be part of the                                                               
developing  coronavirus plan.  It  ought to  be, considering  the                                                               
issue of quarantine and an invasive virus.                                                                                      
                                                                                                                                
1:47:59 PM                                                                                                                    
SENATOR SHOWER  spoke about  the problems  of identity  theft and                                                               
how that applies to health care  data. He asked about the process                                                               
to prove who is at the other end of the line.                                                                                   
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ responded  that all providers delivering                                                               
health  care  through telemedicine  are  required  to use  HIPAA-                                                               
compliant  software,  which  is  designed  to  protect  someone's                                                               
identity  and  any  information.  There is  always  the  risk  of                                                               
breech.  The technology  is evolving  constantly and  so are  the                                                               
hackers.  It is  a  valid  concern, but  the  ability to  protect                                                               
people's privacy  with technology  is growing. The  tribal health                                                               
system  has been  providing health  care  through telehealth  for                                                               
many years,  as have  other providers. The  whole impetus  of the                                                               
bill originated  after she  was elected  to the  legislature. She                                                               
called  her  health care  provider  in  Anchorage to  schedule  a                                                               
telehealth visit  and her  provider said that  could not  be done                                                               
because it  was not  covered by her  insurance. She  learned that                                                               
not only was it not covered  by her insurance, which is no longer                                                               
the  case,  but she  also  learned  a  lot about  the  technology                                                               
required  to ensure  privacy. Her  health care  provider did  not                                                               
have that software to deliver that  service, so it was a two-part                                                               
problem.                                                                                                                        
                                                                                                                                
SENATOR SHOWER  said he wondered  how the identity of  the person                                                               
who  calls the  health  provider would  be  verified. He  assumes                                                               
there are protocols to identify someone's identity.                                                                             
                                                                                                                                
1:51:57 PM                                                                                                                    
CHAIR WILSON  said the  presentation referred  to three  types of                                                               
telehealth  services.  He  knows  that tribal  health,  and  some                                                               
behavioral  health,  visits are  interactive.  Patients  go to  a                                                               
provider for a consult and  the provider verifies the identity of                                                               
someone in person.  The state has a service  through Teladoc with                                                               
a two-step  identification process  for due  diligence. Companies                                                               
do take  steps to  try to  avoid someone  falsely claiming  to be                                                               
someone else.  He said he knows  a company that does  a biometric                                                               
scan   through   a   phone   for   telemedicine.   Someone   with                                                               
identification  data  for  another  person  could  pose  as  that                                                               
person, which is alarming. It is  hard to get companies to invest                                                               
in things like biometric scans for validation purposes.                                                                         
                                                                                                                                
SENATOR  SHOWER stated  that  he is  cautious  about forcing  the                                                               
private market  to do things  that are not appropriate.  He noted                                                               
that Representative  Spohnholz made  a comment that  not everyone                                                               
wants to do this. He asked if  there are any companies who do not                                                               
want to  do this but  are being forced to.  He said HB  29 sounds                                                               
good in  terms of saving  money and access,  but he is  trying to                                                               
think  of  a  potential  catch and  whether  the  legislature  is                                                               
overstepping its bounds.                                                                                                        
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ answered  that insurance  companies are                                                               
beginning to provide the service,  but there is unequal coverage.                                                               
Health care  providers are  reticent to  make investments  in the                                                               
necessary   infrastructure,   particularly  the   HIPAA-compliant                                                               
software  or any  other electronic  equipment,  if the  companies                                                               
can't  be  sure  that  they can  recoup  their  investments  when                                                               
providing  these  services.  This  bill  is  about  creating  the                                                               
clarity  for the  insurance providers  that the  state does  want                                                               
them  to cover  this service  in Alaska.  This is  an access  and                                                               
equity issue. People  in the private market should  have the same                                                               
access  to  low-cost, quality  health  care  services that  those                                                               
covered by  Medicaid. The  other piece  is predictability  in the                                                               
market for  health care  providers. Providers  need to  know what                                                               
will be  covered and  what will not  be covered.  The legislature                                                               
made a huge  policy call when it allowed  coverage for telehealth                                                               
for behavioral  health. Then that  coverage was expanded  for all                                                               
health care services. That was  largely within Medicaid. The bill                                                               
says the  legislature now wants  to expand that to  everyone else                                                               
so  health care  providers in  the  private market  can make  the                                                               
investments  in  the  kinds   of  equipment  and  HIPAA-compliant                                                               
software needed  to provide telehealth, since  the investment can                                                               
be recouped.                                                                                                                    
                                                                                                                                
1:57:06 PM                                                                                                                    
CHAIR  WILSON   said  his  interpretation  of   Senator  Shower's                                                               
question   was   whether   asking    providers   to   make   this                                                               
infrastructure investment could increase costs for consumers.                                                                   
                                                                                                                                
SENATOR SHOWER agreed;  there is a cost attached even  if it does                                                               
not cost the state.                                                                                                             
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ  replied that health care  providers are                                                               
being  asked  to  make  investments   but  need  certainty  about                                                               
compensation to  recoup the capital  cost. The cost  that Senator                                                               
Showers  is referring  to  is for  insurance  companies. She  has                                                               
tried  to  illustrate  the   significant  savings  from  reducing                                                               
unnecessary travel.  The Alaska  Native Tribal  Health Consortium                                                               
estimates it saved  the state of Alaska $12.4 million  in FY 2019                                                               
as a  result of using  telehealth and  $70 million over  the last                                                               
eight  years. For  people in  Senator  Shower's district,  people                                                               
could use  their phones  and HIPAA-compliant  software to  have a                                                               
wound looked at  when considering whether a long  drive to Mat-Su                                                               
Regional from Talkeetna  is necessary at 10 p.m. She  has been in                                                               
that situation. She was in  Talkeetna with her husband, wondering                                                               
whether he  needed to go  to a hospital.  Alaska spends a  lot of                                                               
money on  travel expenses  for health care.  The state  of Alaska                                                               
has saved  a lot of money  with telehealth in the  public sector.                                                               
That should be extended to those in the private market as well.                                                                 
                                                                                                                                
1:59:39 PM                                                                                                                    
SENATOR BEGICH pointed  out that that could be a  savings for the                                                               
insurance industry  because the  costs of covered  services would                                                               
be  less.  That lowers  the  burden  on insurance  companies  and                                                               
should increase profit  margins, which might lead  to lower costs                                                               
in  the  long  run  for  the  consumer.  Legislators  are  always                                                               
concerned that if the legislature  mandate something it could end                                                               
up costing  more. In  this case,  legislators could  be mandating                                                               
something that  will profit the insurance  industry, the patient,                                                               
and the state.                                                                                                                  
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ  added  that Moda  Health  submitted  a                                                               
letter of support. The cost  of medical travel is expensive. Just                                                               
to eliminate  a couple of  medevacs a year will  save significant                                                               
money. One medevac can cost  $100,000 in Alaska. Just eliminating                                                               
a few  of those would  pay for the  bottom line for  an insurance                                                               
company and individual Alaskans.                                                                                                
                                                                                                                                
CHAIR WILSON  shared that when he  was getting his MBA  in health                                                               
services  administration,  the Medicaid  cost  of  travel to  the                                                               
state was just  above $50 million. When he graduated,  it was $56                                                               
million. Now, the state is  approaching almost $70 million a year                                                               
for Medicaid travel.                                                                                                            
                                                                                                                                
2:01:42 PM                                                                                                                    
SENATOR GIESSEL  said she  views this from  the perspective  of a                                                               
private  health  care provider  and  an  advocate for  the  state                                                               
budget. Her  questions are only  to highlight challenges,  not to                                                               
disparage  the good  the  sponsor is  trying  to accomplish.  She                                                               
agreed  that  the  points  on  slide  5  about  the  benefits  of                                                               
telehealth  are spot  on, except  she would  argue that  the last                                                               
point,  the zero  impact  on the  state budget,  may  not be  100                                                               
percent true.                                                                                                                   
                                                                                                                                
SENATOR  GIESSEL said  that questions  have  revolved around  the                                                               
infrastructure   that   providers  will   need,   HIPAA-compliant                                                               
communications tools.  There are  providers who are  reluctant to                                                               
even invest in  electronic medical records. This is  much like an                                                               
investment  in the  North Slope  with  drilling a  well and  cash                                                               
flow. Digging  a well takes  money and  then it takes  of several                                                               
years to make  a profit. The same applies for  investment in this                                                               
kind of infrastructure. While it may  not be a direct cost to the                                                               
state, it  is a  cost to the  private provider.  When legislators                                                               
initially talked  about authorizing telehealth in  Alaska, one of                                                               
the  caveats was  that the  provider providing  that health  care                                                               
without being in contact with  the patient must transmit a record                                                               
of that  visit to the primary  health care provider, who  may not                                                               
be the person  providing the telehealth visit. She  wants to make                                                               
sure that is not being eroded.                                                                                                  
                                                                                                                                
SENATOR  GIESSEL said  she interprets  Representative Spohnholz's                                                               
reference to Teladoc  as Alaska hire. That was  a discussion when                                                               
legislators  talked  about  telehealth.  Teladoc is  a  Lower  48                                                               
organization with  Lower 48 providers of  various certifications.                                                               
She asked if these providers  were eroding Alaska hire and access                                                               
to Alaska physicians and other  health care providers. She agreed                                                               
with  Representative Spohnholz  about  the  Alaska Native  Tribal                                                               
Health Consortium.  It has done  phenomenal work  with telehealth                                                               
for  many years.  Although  she acknowledged  the  ANTHC has  had                                                               
those  savings, it  is also  a  closed system  that is  federally                                                               
funded. About  eight years  ago she took  a health  care provider                                                               
from  Greenland  to  various   facilities  around  Anchorage.  He                                                               
observed that  Alaska has  three health  care systems,  each with                                                               
different rules:  the private health  care system,  Medicaid, and                                                               
Native health.  She is not  sure the ANTHC system  will translate                                                               
to the state.                                                                                                                   
                                                                                                                                
SENATOR GIESSEL  then referred to  the 80th percentile  rule. She                                                               
related that she  introduced a bill to change  that rule, working                                                               
with  the Division  of Insurance.  Her question  is how  the 80th                                                               
percentile  rule  will  impact reimbursement  if  the  telehealth                                                               
provider  is outside  of the  network and  will that  help costs.                                                               
Also,   Alaska  Retirement   and  Benefits   pays  at   the  90th                                                               
percentile.  That  is a  little  known  fact  that is  not  fully                                                               
appreciated, so the state of Alaska pays a little more.                                                                         
                                                                                                                                
SENATOR GIESSEL  said it  is hard to  diagnosis an  ear infection                                                               
over the phone  for an infant without doing a  urine analysis for                                                               
infection. Telehealth  won't necessarily alleviate  the necessity                                                               
of contacting a physical health  care provider in a clinic. "That                                                               
is not to  say I don't support this. There  are caveats here that                                                               
we  have  to  appreciate  and   perhaps  find  answers  to,  like                                                               
reimbursement rates," she said.                                                                                                 
                                                                                                                                
2:07:59 PM                                                                                                                    
REPRESENTATIVE SPOHNHOLZ  said telehealth does not  eliminate the                                                               
need for  every emergency  room visit or  every clinic  visit. It                                                               
never  will. Telehealth  increases  access to  care,  and it  can                                                               
reduce travel and unnecessary emergency  room visits a lot of the                                                               
time.  Sometimes telehealth  can  encourage people  to  go to  an                                                               
emergency  room  or  get  the  level  of  care  needed,  such  as                                                               
Nurseline. Telehealth is the next  level of Nurseline. People who                                                               
call the  AlaskaCare [Employee Health  Plan] Nurseline  get high-                                                               
quality  advice from  health care  providers who  are experts  in                                                               
their  field about  the level  of care  the patient  needs and  a                                                               
high-quality telehealth  visit is the next  step. She underscored                                                               
how important telehealth is for  access to behavioral health care                                                               
because Alaska has  a shortage of providers.  A psychiatrist will                                                               
never be  in Healy,  but someone could  call a  psychiatrist from                                                               
Healy  in  a  HIPAA-compliant   software  environment.  She  said                                                               
telehealth will increase access to care.                                                                                        
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ, in  response to  the 80th  percentile,                                                               
said the bill does not  change the underlying fundamentals of the                                                               
health care economic system, but  provides a very specific, small                                                               
fix. Two  of the three systems  of health care in  Alaska already                                                               
have  access  to  telehealth. However,  parties  in  the  private                                                               
market do not  have access to it. She said  her own experience of                                                               
not  being  able  to  access  health care  via  distance  from  a                                                               
provider  she has  seen  for 20  years nudged  her  to push  this                                                               
conversation along.                                                                                                             
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ  reframed  Senator  Giessel's  question                                                               
about Alaska  hire by asking whether  Alaska could end up  with a                                                               
system of health  care providers from the Lower 48  who nudge out                                                               
providers in the  state of Alaska. She also would  like Alaska to                                                               
have  experienced  professionals  in all  ranges  of  specialties                                                               
available. However, she also wants  to make sure that health care                                                               
providers  who are  functionally small  businesses have  a stable                                                               
marketplace.  She noted  of  the 369  providers  licensed in  the                                                               
telemedicine business  registry, 254 are Alaskans.  That means 69                                                               
percent  of the  telehealth providers  are Alaskan-based.  Alaska                                                               
still has  a shortage  of some  health care  providers, including                                                               
psychiatrists.   The  Anchorage   Community  and   Mental  Health                                                               
Services (ACMHS) provide mental  health services in Fairbanks but                                                               
struggles  to  recruit  enough  psychiatrists,  so  ACMHS  has  a                                                               
psychiatrist  on contract  in Arizona.  Although the  ACMHS would                                                               
prefer to  use an Alaskan  psychiatrist, Alaska's  residents need                                                               
access to specialists.                                                                                                          
                                                                                                                                
2:12:45 PM                                                                                                                    
REPRESENTATIVE  SPOHNHOLZ  said HB  29  would  only require  that                                                               
insurers for the private market  cover telehealth, which is about                                                               
17  percent of  the  market. It  is not  undermining  any of  the                                                               
safeguards to ensure that people are getting good care.                                                                         
                                                                                                                                
REPRESENTATIVE    SPOHNHOLZ    acknowledged   that    information                                                               
technology systems  and the  electronic equipment  are expensive,                                                               
but the  health care market  wants to  do this. Dr.  Jill Gaskill                                                               
previously testified  that she likes providing  telehealth health                                                               
care.  It is  part  of the  delivery model  at  her Medical  Park                                                               
Family Practice in  Anchorage. She tells people who  have the flu                                                               
to stay  home and  use telemedicine.  Health care  providers need                                                               
assurance that  insurance will cover telehealth  for all patients                                                               
and  not  just  some.  When  that  happens,  providers  can  make                                                               
decisions  based on  what  is best  for the  patient  and not  on                                                               
insurance coverage. The health care  providers and small business                                                               
owners must make decisions, not the insurance companies.                                                                        
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ  explained that there is  zero impact to                                                               
the  state  budget because  this  does  not require  any  capital                                                               
equipment. The state's health plan  already covers telehealth, as                                                               
does Medicaid, which  is the bulk of health care  services in the                                                               
state. She  was unsure if  the retirees' plan  covers telehealth,                                                               
but  the  bill does  not  require  the  state  to build  any  new                                                               
infrastructure. The bill simply  says that insurance companies in                                                               
Alaska  should  cover  telehealth   services.  She  said  she  is                                                               
considering a committee substitute  that would require telehealth                                                               
pay parity within the private market.                                                                                           
                                                                                                                                
2:16:08 PM                                                                                                                    
MS.  CASORT explained  that telehealth  pay  parity would  ensure                                                               
that insurance companies reimburse providers  at the same rate as                                                               
in-person.                                                                                                                      
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ  agreed that several providers  asked to                                                               
be compensated at the same rate as an in-person consultation.                                                                   
                                                                                                                                
SENATOR GIESSEL shared  that she is pondering pay  parity with an                                                               
in-person  visit since  the overhead  costs are  quite different.                                                               
For example,  medical assistants do  not bring patients  into the                                                               
room since rooms are not being used.                                                                                            
                                                                                                                                
SENATOR  BEGICH asked  for confirmation  that the  bill does  not                                                               
mandate that a company provide telehealth.                                                                                      
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ answered that is correct.                                                                              
                                                                                                                                
SENATOR BEGICH  said medical costs  are quite high in  Alaska. He                                                               
assumed that  telehealth out  of state  would be  less expensive,                                                               
but telehealth could become more  attractive to providers who are                                                               
reimbursed  for  those services.  He  said  he would  rather  use                                                               
telehealth services  from a  provider in Alaska  than one  in the                                                               
Lower  48, just  in case  further care  was needed.  He expressed                                                               
interest in the overlap between  providers who are in network and                                                               
those who are not.                                                                                                              
                                                                                                                                
2:19:41 PM                                                                                                                    
REPRESENTATIVE SPOHNHOLZ  replied that  the committee  would have                                                               
an  opportunity to  talk with  individual providers  at the  next                                                               
hearing. Although  she cannot speak  for them,  several providers                                                               
told her that the ability to  decide which kinds of technology to                                                               
invest in will provide fiscal certainty.                                                                                        
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ, in  reference to  pay parity,  said an                                                               
in-person visit  may include a medical  assistant, but telehealth                                                               
providers  still will  incur costs  to  maintain their  software.                                                               
Telehealth is  often provided  from a  clinic, such  as community                                                               
mental  health  centers.  These  providers  indicate  that  their                                                               
offices must  pay to have  someone at  both ends of  a telehealth                                                               
visit. For example,  if a patient comes to a  clinic in Talkeetna                                                               
for  a   telehealth  consultation  at  the   Heart  Institute  in                                                               
Anchorage, someone  is onsite in  Talkeetna and in  Anchorage. It                                                               
is difficult  to anticipate all  the costs associated due  to the                                                               
wide-ranging  telehealth  services.  She   asked  Ms.  Casort  to                                                               
mention the most frequently offered telehealth services.                                                                        
                                                                                                                                
MS. CASORT added  that the most frequent  telehealth services are                                                               
for  behavioral health,  injuries, such  as broken  bones in  the                                                               
hands and arms, poisonings, and ear infections.                                                                                 
                                                                                                                                
SENATOR  GIESSEL  said that  for  several  decades, the  Girdwood                                                               
Clinic has taken an X-rays  and transmitted them to a radiologist                                                               
in  Anchorage.  In  addition,  the   nurse  practitioner  had  an                                                               
otoscope that can transmit a picture  to an ear, nose, and throat                                                               
specialist in Anchorage to diagnose ear infections.                                                                             
                                                                                                                                
SENATOR  GIESSEL  elaborated on  the  network  costs. If  someone                                                               
calls a  hospital with a  telemedicine question, even  though the                                                               
hospital  may be  in  the caller's  network,  the emergency  room                                                               
doctor may  be in a separate  group not in the  caller's network.                                                               
She explained  that is how  patients get surprise  bills, usually                                                               
paid at a  very high rate. However, that is  a different subject,                                                               
she said.                                                                                                                       
                                                                                                                                
CHAIR  WILSON said  members  have raised  questions  that can  be                                                               
answered  in  future hearings.  He  said  he understood  the  pay                                                               
parity issue. He worked for  an entity that had behavioral health                                                               
consultations  with  Alaska  Psychiatric  Institute.  The  entity                                                               
always  took  a  loss  on  those  visits  because  it  was  never                                                               
reimbursed at the appropriate rates.                                                                                            
                                                                                                                                
2:25:07 PM                                                                                                                    
SARAH BAILEY,  Supervisor, Life and  Health Section,  Division of                                                               
Insurance,  Department   of  Commerce,  Community   and  Economic                                                               
Development (DCCED), Juneau, Alaska, introduced herself.                                                                        
                                                                                                                                
CHAIR WILSON  said certain telehealth providers  will only handle                                                               
patients  in  the  state.  He  asked  if  there  were  any  state                                                               
regulations  barring providers  from seeing  Alaskans when  these                                                               
patients are not  in the state or  preventing insurance companies                                                               
from paying for those visits.                                                                                                   
                                                                                                                                
MS.  BAILEY   replied  she   was  not   aware  of   the  provider                                                               
requirements. The insurance contract  for insurers would indicate                                                               
which providers are  in network, out of network,  or not covered.                                                               
It would depend on the circumstances and the contract language.                                                                 
                                                                                                                                
2:26:50 PM                                                                                                                    
VICTORIA   KNAPP,  Chief   Operations   Officer,  Mat-Su   Health                                                               
Services,  Wasilla,  Alaska,  said  she works  for  a  federally-                                                               
qualified health  center in  Wasilla with  a satellite  clinic in                                                               
Big   Lake.  The   center  uses   telemedicine  for   psychiatric                                                               
evaluations  and psychiatric  medication  management. The  center                                                               
went to  a telemedicine model  about four years ago  because they                                                               
were  unable  to  find  psychiatric  providers  in  Alaska.  Some                                                               
providers use telepsychiatry, both in  Alaska and out of state. A                                                               
person comes  into the  office, is seen  by a  medical assistant,                                                               
and  then sent  to a  room to  connect via  computer to  either a                                                               
psychiatrist or  psychiatric nurse  practitioner. The  center has                                                               
been  very  successful using  this  model.  She said  staying  on                                                               
psychiatric  medications  is the  key  for  patients to  function                                                               
normally,   including   maintaining   employment   and   managing                                                               
symptoms. If  insurance carriers do not  cover telepsychiatry but                                                               
cover  in-person psychiatric  services, it  often means  patients                                                               
are unable  to receive  psychiatric care  when needed  because of                                                               
the shortage  of providers. The  wait list in the  Mat-Su Borough                                                               
is very long, she said.                                                                                                         
                                                                                                                                
2:29:02 PM                                                                                                                    
STEWART  FERGUSON,  Ph.D.,   Chief  Information  Officer,  Alaska                                                               
Native Tribal  Health Consortium, Anchorage, Alaska,  said he has                                                               
been a member, vice-president, and  president of the Board of the                                                               
American Telemedicine.  Much of what  he is going to  share comes                                                               
from 20 years  of experience in operating  a statewide telehealth                                                               
program to serve the Alaska  Tribal Health System, which has been                                                               
using  telehealth  since  2001.  The system  has  served  135,000                                                               
patients  at over  200 locations.  Questions with  telehealth are                                                               
often  is the  cost of  telehealth worth  it and  why are  people                                                               
doing  it.  When  tribal  health built  the  system,  they  asked                                                               
doctors how they would know  if telehealth gave value. The answer                                                               
was  that if  they are  still using  it, then  it provides  value                                                               
because doctors  are not  interested in  wasting time  and money.                                                               
After 20  years, over five-and-half thousand  providers have used                                                               
the system with over 400,000  patient encounters. Annually, there                                                               
are about 38,000 telehealth encounters.                                                                                         
                                                                                                                                
DR.  FERGUSON said  the tribal  health  consortium has  developed                                                               
some efficient processes. The committee  heard some data earlier,                                                               
but  it has  actually gotten  better. The  Alaska Native  Medical                                                               
Center turns around 50 percent of  the consults in 60 minutes and                                                               
80 percent within  the same day. That level of  care exceeds that                                                               
of an in-person  visit. No one can get a  specialty consult in 60                                                               
minutes  in Anchorage  or Seattle,  but  someone can  in a  rural                                                               
location. They  have embraced  the store-and-forward  model where                                                               
they  capture  information  and  send  it.  That  has  been  very                                                               
effective. They  started doing  that in  rural Alaska  because of                                                               
bandwidth  challenges,  but  they   have  done  more  live  video                                                               
conferencing lately  as bandwidth  improves. They do  about 2,400                                                               
follow up visits  each year with patients from  the Alaska Native                                                               
Medical Center, and it is  used extensively for primary care. The                                                               
Alaska Native Medical Center provides  over 40 pediatric surgical                                                               
and adult  medical services and  accepts specialty  consults over                                                               
video  conferencing.  They,  as   a  tribal  health  system,  are                                                               
investing in expansion this year  and are deploying over 120 more                                                               
video  conferencing  units  specifically to  address  opioid  and                                                               
substance  use treatment,  as well  as  education and  broadening                                                               
mental health offerings.                                                                                                        
                                                                                                                                
DR. FERGUSON said the ability of  telehealth to save on travel is                                                               
extremely important,  but not all  telehealth saves  travel. They                                                               
find that  about 15  to 20 percent  of telehealth  causes travel,                                                               
but  that's  good  travel because  they  are  catching  something                                                               
earlier in the disease state  and oftentimes avoiding unnecessary                                                               
complications or expenses of medevacs.  When they try to estimate                                                               
travel  savings, they  ask  providers on  every  encounter if  it                                                               
impacted  patient travel,  so they  can  precisely estimate  what                                                               
cases prevented  travel, where  the patient was,  the age  of the                                                               
patient,  and  the  provider  location  to  get  fairly  accurate                                                               
estimates  on  travel  savings.  When they  look  at  the  Alaska                                                               
Medicaid population that they serve  in the tribal health system,                                                               
they estimate a total travel savings  in FY 2019 of $12.4 million                                                               
through all of  their telehealth efforts and a  total savings for                                                               
the past  eight years of  $70 million, and that's  just Medicaid.                                                               
If  they look  at all  the patients  they serve  in Alaska,  they                                                               
estimate a total  travel savings in FY 2019 of  about $27 million                                                               
and  a  total of  $156  million  in the  past  years.  That is  a                                                               
pessimistic view because  they only count travel  when a provider                                                               
says it  saves travel. If they  counted all their cases,  as many                                                               
in  the lower  48 do,  they could  roughly double  those figures.                                                               
When patients  travel, they run  the risk of accidents,  but they                                                               
also lose workdays and children miss school.                                                                                    
                                                                                                                                
2:33:44 PM                                                                                                                    
DR.  FERGUSON  shared  that  an   analysis  of  5,925  telehealth                                                               
specialty  consults billed  to Alaska  Medicaid  showed that  for                                                               
every  five  telehealth  encounters,  they  prevented  four  lost                                                               
workdays and  one lost school  day. So, looking at  an eight-year                                                               
history of  all the  patients in the  tribal health  system, they                                                               
have  saved about  245,000 workdays  and 61,000  school days  for                                                               
patients using telehealth.                                                                                                      
                                                                                                                                
DR.  FERGUSON  said they  applaud  the  language  in HB  29  that                                                               
removes the need for an  in-person exam prior to telehealth. They                                                               
have  some evidence  to  support this.  Dr.  Phil Hofstetter,  an                                                               
audiologist  at  the  Norton  Sound   Regional  Hospital,  led  a                                                               
groundbreaking 20-year  retrospective study  which looked  at the                                                               
waiting time for new referrals to  see a specialist in person. He                                                               
looked  at  the   changes  in  wait  time   when  he  implemented                                                               
telehealth to  do that initial  exam. Prior to telehealth,  for a                                                               
10-year period, 47  percent of new patient  referrals waited five                                                               
months  or  longer  to  see a  specialist.  Once  telehealth  was                                                               
implemented, that  dropped to  8 percent.  Three years  later, as                                                               
they improve processes, it is now  3 percent. So, moving from the                                                               
requirement for  in-person exam  to a  virtual visit  saves time,                                                               
improves outcomes, and allows more patients to be treated.                                                                      
                                                                                                                                
DR.  FERGUSON said  they  have done  similar  studies looking  at                                                               
diabetic retinal  exams, village-based hearing exams,  and triage                                                               
models using virtual visits with  a specialist to access care and                                                               
treatment  without an  in-person visit.  Every single  study that                                                               
has  been done  demonstrates faster  treatment path,  lower cost,                                                               
greater access, and  improved outcomes. None of  this is possible                                                               
without connectivity. The Alaska  tribal health organizations, in                                                               
fact all  rural organizations, depend  on a subsidy  program that                                                               
is regulated  by the FCC (Federal  Communications Commission) and                                                               
funded  through  the  Universal  Service  Administrative  Company                                                               
(USAC).  The cost  for  connectivity in  rural  Alaska is  50-100                                                               
times  higher than  the Anchorage  rates  for connectivity.  USAC                                                               
subsidizes  that additional  cost beyond  the Anchorage  rate for                                                               
health care organizations, schools,  and libraries, but homes are                                                               
not subsidized.  That is the  great digital divide. In  the lower                                                               
48, people are talking about 5g  and 6g. In Alaska, 50 percent of                                                               
villages do not even have 3g  and when they do have connectivity,                                                               
it is expensive and restricted to monthly allotments.                                                                           
                                                                                                                                
DR.  FERGUSON   said  they  have   demonstrated  they   can  move                                                               
telehealth  into   homes.  They  take  care   of  end-of-life  or                                                               
palliative  care patients  in that  way. An  extremely vulnerable                                                               
population is  newborns. Those  with congenital  abnormalities or                                                               
respiratory issues account  for 70 percent of  all Medicaid costs                                                               
for children  in their first  year of life.  Bringing specialists                                                               
and subspecialists into  the home is a strong  step toward taking                                                               
care  of  that vulnerable  population.  The  Norton Sound  School                                                               
District  is trying  to treat  ear disease  in a  place with  the                                                               
highest rates  in the  world by bringing  the health  care system                                                               
into the schools.                                                                                                               
                                                                                                                                
2:37:01 PM                                                                                                                    
DR. FERGUSON said his staff is  working on the next generation of                                                               
tools and apps to do all this.  They intend in the coming year to                                                               
empower their patients  to participate in their  health care from                                                               
their  homes.  The  FCC  for  the first  time  is  offering  free                                                               
licenses  to tribes  and tribal  organizations  to license  radio                                                               
spectrums in their  villages. That allows the  health care system                                                               
to get  into their homes,  the last  mile issue. Low  earth orbit                                                               
satellites may  offer solutions to  connect villages to  the rest                                                               
of the  world. Together,  these technologies  could revolutionize                                                               
connectivity for  all of  Alaska with  low-cost, high-performance                                                               
bandwidth.                                                                                                                      
                                                                                                                                
DR. FERGUSON said:                                                                                                              
                                                                                                                                
     Why am I  saying this? We invest, in  the tribal health                                                                    
     system, and I know  that Providence and other providers                                                                    
     do the  same, we invest  millions of dollars  each year                                                                    
     in connectivity and  telehealth technologies because we                                                                    
     know  it  works.  But,   unfortunately,  in  the  past,                                                                    
     federal,  and state  policies have  greatly lagged  the                                                                    
     advances  in investment  in  telehealth technology  and                                                                    
     program  design. For  example, the  department recently                                                                    
     proposed  telemedicine  regulations  that,  thankfully,                                                                    
     have   been  withdrawn   that  would   have  eliminated                                                                    
     reimbursement    for    store-and-forward    processes,                                                                    
     something  that   accounts  for   90  percent   of  our                                                                    
     telehealth. This is troubling  and we should instead be                                                                    
     protecting and  supporting our telehealth  progress and                                                                    
     infrastructure. We truly are  a state of innovators and                                                                    
     we've built  successful telehealth programs  because we                                                                    
     work together,  all of us,  to meet the common  goal of                                                                    
     better health closer  to home. I'll finish  by saying I                                                                    
     applaud this committee for considering  a bill that can                                                                    
     expand the users of telehealth.  I would ask all of you                                                                    
     on this  committee and all  of our legislators  to stay                                                                    
     connected  to  the  advances  in  what's  happening  in                                                                    
     technology and health care. I  believe together we will                                                                    
     build and provide better health care.                                                                                      
                                                                                                                                
SENATOR GIESSEL asked who reimburses  for the telehealth provided                                                               
by the Alaska Native Tribal Health Consortium.                                                                                  
                                                                                                                                
DR.  FERGUSON answered  that they  do seek  reimbursement through                                                               
all payers. They have been  thankful that Medicaid has reimbursed                                                               
for telehealth since 2001 as have  many other payers. He knows of                                                               
at least  one payer that  does not  reimburse. The power  of this                                                               
bill is that all payers would reimburse.                                                                                        
                                                                                                                                
2:39:12 PM                                                                                                                    
CHAIR  WILSON  asked  if  he   knew  of  beneficiaries  who  seek                                                               
telehealth  services  when  out  of the  Indian  Health  Services                                                               
coverage area. He  gave the example of someone who  might get ill                                                               
or injured while on a trip to Florida and want a health consult.                                                                
                                                                                                                                
DR. FERGUSON answered  that he is not aware of  patients who seek                                                               
care through telehealth when outside of the state.                                                                              
                                                                                                                                
CHAIR WILSON said  the Alaska Native Medical Center saw  a lot of                                                               
nonbeneficiaries through the Anchorage service  unit. He asked if                                                               
that service is still available  for nonbeneficiaries who receive                                                               
that through dual IHS and CHC facilities.                                                                                       
                                                                                                                                
DR.  FERGUSON replied  he thought  the issue  Senator Wilson  was                                                               
addressing was whether a nonbeneficiary  who is seen at a primary                                                               
care site  can be referred  to the Alaska Native  Medical Center.                                                               
The center does take nonbeneficiaries.  That change happened some                                                               
years ago.                                                                                                                      
                                                                                                                                
2:41:40 PM                                                                                                                    
CHAIR WILSON opened public testimony on HB 29.                                                                                  
                                                                                                                                
2:42:39 PM                                                                                                                    
ANITA HALTERMAN,  President, Alaska Collaborative  for Telehealth                                                               
and  Telemedicine (AKCTT),  Anchorage, Alaska,  said telemedicine                                                               
is a  mode of  delivery. Standards of  practice don't  change, or                                                               
shouldn't,   based  on   that  mode   of  delivery.   The  Alaska                                                               
Collaborative   for  Telehealth   and   Telemedicine  is   highly                                                               
supportive  of  HB  29.  The collaborative  asks  that  there  be                                                               
consideration of  licensing issues  moving forward  so as  not to                                                               
limit access  to providers who may  not be subject to  an Alaskan                                                               
license.  AKCTT   also  asks  that   payment  parity   issues  be                                                               
addressed.  It  is  critical for  the  success  of  telemedicine.                                                               
Payment parity  will ensure that  practices in the lower  48 will                                                               
not undermine  the infrastructure  available here in  Alaska. She                                                               
would like the  state to maintain the providers in  the state and                                                               
payment  parity will  ensure  that those  practices  will not  be                                                               
eroded. New modes of delivery  do save insurance companies money.                                                               
Kaiser  Permanente,  a self-insured  provider  in  the lower  48,                                                               
expanded the use  of telemedicine because it  drives cost savings                                                               
for  insurance  companies  and  drives  better  health  outcomes.                                                               
Alaska could  benefit in the  same way  if it moves  forward with                                                               
this type of legislation.                                                                                                       
                                                                                                                                
MS.  HALTERMAN said  the American  Medical  Association has  been                                                               
pleading for  medical boards to remove  barriers to telemedicine.                                                               
Boards are  slowly responding but  not fast enough for  Alaska. A                                                               
fee-for-service  environment  does   not  motivate  change.  When                                                               
insurance  companies   don't  pay  for  telemedicine   for  their                                                               
patients,  patients  may  be  dumped  on  Medicaid  programs  for                                                               
services  that  insurance   companies  would  typically  provide.                                                               
Medicaid bears the  brunt of funding care  through cost avoidance                                                               
for telemedicine because that scope  of delivery is not available                                                               
through an  insurance company  and insurers  often don't  pay for                                                               
travel.  Patients  who  are  unable  to  receive  their  services                                                               
through insurance  companies often  fall on  hard times.  If they                                                               
are  sick, they  may lose  their insurance  and Medicaid  ends up                                                               
footing the bill.  AKCTT will be writing a letter  of support for                                                               
HB 29. Hospitals are starting  to explore relationships with out-                                                               
of-state  contractors  and  are   providing  these  services  and                                                               
piloting programs. Those  should be expanded to  the entire state                                                               
and that will create cost savings for Medicaid.                                                                                 
                                                                                                                                
SENATOR BEGICH asked her to elaborate on her first point.                                                                       
                                                                                                                                
MS.  HALTERMAN   asked  if  he  meant   her  statement  regarding                                                               
consideration of  licensing issues  moving forward  so as  not to                                                               
limit access  to providers who may  not be subject to  an Alaskan                                                               
license. She continued to say:                                                                                                  
                                                                                                                                
     We  are  facing a  changed  environment  and right  now                                                                    
     there's  the possibility  that  with  the expansion  of                                                                    
     telemedicine,  there  will   be  new  delivery  methods                                                                    
     available using new provider  types. For instance, with                                                                    
     remote patient  monitoring, many of the  providers that                                                                    
     may  be subject  to  those kinds  of  services are  not                                                                    
     subject  to  licensure.  They're  an  atypical  service                                                                    
     provider  under the  Social Security  Act. So,  I would                                                                    
     just caution to be  careful about being too restrictive                                                                    
     with   licensing   requirements  in   this   particular                                                                    
     statute.                                                                                                                   
                                                                                                                                
SENATOR  BEGICH said  he  would  talk to  the  sponsor after  the                                                               
meeting to get more clarity about the issue.                                                                                    
                                                                                                                                
SENATOR GIESSEL said she had the same question.                                                                                 
                                                                                                                                
2:48:50 PM                                                                                                                    
CLAUDIA  TUCKER,  Vice  President,  Government  Affairs,  Teladoc                                                               
Health, Greenwich,  Connecticut, said she  was also the  chair of                                                               
the  American  Telemedicine  Association  policy  board.  Teladoc                                                               
operates in  all 50 states  and 120 countries,  so it has  a good                                                               
perspective on  telemedicine. In reference to  security measures,                                                               
employees  can  only  access the  Teladoc  portal  through  their                                                               
health plan,  so Teladoc verifies  that. Teladoc also  makes sure                                                               
that  their  physicians  provide patients  with  their  licensure                                                               
number  and credentials.  While  Teladoc is  in  health care,  it                                                               
really is a technology company that is focused on health care.                                                                  
                                                                                                                                
MS. TUCKER said  Teladoc has resident physicians  in Alaska. When                                                               
a call  comes in  from an  Alaska resident,  the first  chance to                                                               
pick  up  that  call  goes  to a  physician  who  is  an  Alaskan                                                               
resident.  If  that  physician  does  not  pick  it  up,  another                                                               
physician  who is  licensed  in  Alaska will  pick  up the  call.                                                               
Teladoc gives preference to  Alaskan physicians. Teladoc strongly                                                               
supports HB 29. It believes  that if providers provide a service,                                                               
they should  be reimbursed. However, Teladoc  realizes that there                                                               
are  savings in  telemedicine.  While  a bricks-and-mortar  visit                                                               
might be $145,  an average visit with Teladoc  or its competitors                                                               
is about $49. Teladoc cautions  that the committee should not set                                                               
the floor. If  telehealth physicians are willing  to accept less,                                                               
they shouldn't be forced to take  more. The savings will be taken                                                               
from the patient and the health plan.                                                                                           
                                                                                                                                
2:51:27 PM                                                                                                                    
CHAIR  WILSON  closed   public  testimony  and  held   HB  29  in                                                               
committee.                                                                                                                      
                                                                                                                                
CHAIR WILSON made upcoming committee announcements.                                                                             
                                                                                                                                
2:52:51 PM                                                                                                                    
There being no further business to come before the committee,                                                                   
Chair Wilson adjourned the Senate Health and Social Services                                                                    
Standing Committee at 2:52 p.m.                                                                                                 
                                                                                                                                

Document Name Date/Time Subjects
HB029 Sectional Analysis ver A 2.25.19.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
HB 29
HB029 Sponsor Statement 2.25.19.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB029 Supporting Document-Letter of Support 2.25.19.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB029 Fiscal Note DCCED-DOI 3.22.2019.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB029 Letter of Support Moda Health 03.25.2019.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB029 Presentation 03.25.2019.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
HB 29
HB029 Letter of Support ACoA 03.25.2019.pdf HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup ADN Article.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup Letters of Support.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Bill Version A.PDF HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Fiscal Note.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Presentation.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sectional.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sponsor.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup Letters of Support.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup ADN Article.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Bill Version A.PDF HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Fiscal Note.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Presentation.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sectional.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup Letter of Support AARP.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup ADN Article.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup Letters of Support.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Bill Version A.PDF HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Fiscal Note.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sectional.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
HB 29
HB 29.Sponsor.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29 PowerPoint 2.13.20.pptx SHSS 2/14/2020 1:30:00 PM
HB 29
HB 29 Handout 2.12.2020.pdf SHSS 2/14/2020 1:30:00 PM
HB 29
HB 29 Dr Jill Gaskill Letter of Support.pdf SHSS 2/14/2020 1:30:00 PM
HB 29
HB 29 Moda Letter of Support.pdf SHSS 2/14/2020 1:30:00 PM
HB 29
HB 29 MMR Letter of Support.pdf SHSS 2/14/2020 1:30:00 PM
HB 29
HB 29 ANHB Letter of Support.pdf SHSS 2/14/2020 1:30:00 PM
HB 29
HB29 ASHNHA Letter of Support.pdf SHSS 2/14/2020 1:30:00 PM
HB 29
HB 29 ACOA Letter of Support.pdf SHSS 2/14/2020 1:30:00 PM
HB 29
HB 29 MSHF Letter of Support.pdf SHSS 2/14/2020 1:30:00 PM
HB 29
FN HB 29 DCCED 1.15.20.pdf SHSS 2/14/2020 1:30:00 PM
HB 29