Legislature(2019 - 2020)BUTROVICH 205
02/28/2020 01:30 PM HEALTH & SOCIAL SERVICES
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ALASKA STATE LEGISLATURE SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE February 28, 2020 1:30 p.m. MEMBERS PRESENT Senator David Wilson, Chair Senator Natasha von Imhof, Vice Chair Senator Cathy Giessel Senator Tom Begich MEMBERS ABSENT Senator Mike Shower COMMITTEE CALENDAR SENATE BILL NO. 120 "An Act relating to administration of psychotropic medication to a patient without the patient's informed consent; and providing for an effective date." - HEARD & HELD SENATE BILL NO. 179 "An Act relating to the licensure of nursing professionals; relating to a multistate nurse licensure compact; and providing for an effective date." - HEARD & HELD PREVIOUS COMMITTEE ACTION BILL: SB 120 SHORT TITLE: ADMINISTRATION OF PSYCHOTROPIC MEDICATION SPONSOR(s): SENATOR(s) GIESSEL BY REQUEST 05/06/19 (S) READ THE FIRST TIME - REFERRALS 05/06/19 (S) HSS 02/28/20 (S) HSS AT 1:30 PM BUTROVICH 205 BILL: SB 179 SHORT TITLE: NURSING: LICENSURE; MULTISTATE COMPACT SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR 02/05/20 (S) READ THE FIRST TIME - REFERRALS 02/05/20 (S) HSS, L&C, FIN 02/24/20 (S) HSS AT 1:30 PM BUTROVICH 205 02/24/20 (S) -- MEETING CANCELED -- 02/28/20 (S) HSS AT 1:30 PM BUTROVICH 205 WITNESS REGISTER JANE CONWAY, Staff Senator Cathy Giessel Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented the sectional analysis for SB 120. ALBERT WALL, Deputy Commissioner Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 120. CYNTHIA MONTGOMERY, Psychiatric Nurse Practitioner Alaska Psychiatric Institute Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 120. MICHAEL ALEXANDER, M.D., Chief Psychiatrist Alaska Psychiatric Institute Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 120. MARIEKE HEATWOLE, representing self Anchorage, Alaska POSITION STATEMENT: Testified in support of SB 120. SARA CHAMBERS, Division Director Division of Corporations, Business and Professional Licensing Department of Commerce, Community and Economic Development Juneau, Alaska POSITION STATEMENT: Presented an overview of SB 179. JULIE ANDERSON, Commissioner Department of Commerce, Community, and Economic Development Anchorage, Alaska POSITION STATEMENT: Presented an overview of SB 179. DANETTE SCHLOEDER, Chair Alaska Board of Nursing Anchorage, Alaska POSITION STATEMENT: Presented an overview of SB 179. MARIANNE MURRAY, D.N.P., Executive Administrator Alaska Board of Nursing Anchorage, Alaska POSITION STATEMENT: Presented an overview of SB 179. ACTION NARRATIVE 1:30:26 PM CHAIR DAVID WILSON called the Senate Health and Social Services Standing Committee meeting to order at 1:30 p.m. Present at the call to order were Senators Giessel, von Imhof, Begich, and Chair Wilson. SB 120-ADMINISTRATION OF PSYCHOTROPIC MEDICATION 1:30:45 PM CHAIR WILSON announced the consideration of SENATE BILL NO. 120, "An Act relating to administration of psychotropic medication to a patient without the patient's informed consent; and providing for an effective date." He noted that the committee would hear an overview of the bill and take invited and public testimony. 1:31:35 PM SENATOR GIESSEL, speaking as sponsor of SB 120, said the bill addresses the administration of psychotropic drugs. She said Alaska Psychiatric Institute (API) has gone through some recent challenges and the bill addresses one of those challenges, the ongoing psychiatrist shortage in Alaska. Currently, API has one fulltime year round psychiatrist. Under current statute, a psychiatrist is the only person who can conduct an initial assessment of a patient in a behavioral health crisis and decide whether to prescribe a psychotropic medication. SENATOR GIESSEL explained that psychotropic medications help calm patients down to make them safe and to ensure the safety of the staff and other patients. A psychiatric crisis or emergency situation is an acute disturbance in a person's behavior, thought, or mood. If left untreated, it may lead to harm to the individual or to others. A psychotropic drug includes olanzapine, chlorpromazine, and haloperidol to treat psychosis, bipolar disorder, and severe behavioral health disorders and lorazepam, a valium-type medication used to treat anxiety reactions. SENATOR GIESSEL said API's mission is to provide the best possible care for its patients and the state needs to help so they can better meet those needs. An Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) is present when the psychiatrist is not available, observing any patient crisis, breakdown, or the buildup that leads to that crisis situation. These professionals can make an educated judgment about the use of one of these psychotropic drugs, but currently must call the psychiatrist if he is not at the institute. SB 120 would allow the APRN or PA observing the patient with escalating behavior to make the assessment, diagnosis, and decision about whether to prescribe and administer the medication without any delay. It would remove an obsolete statute that requires that only a psychiatrist can order the use of psychotropic medication. The use of de-escalation techniques and the medications will help keep patients in a safe hospital setting where these patients can be cared for appropriately rather than being sent to a jail when their out of control behavior leads to assault. SENATOR GIESSEL said these medications are already approved for APRNs and PA. 1:37:36 PM JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State Legislature, Juneau, Alaska, gave the sectional analysis for SB 120. She noted that Amendment 1, in members' packets, would address an oversight in the drafting of the bill. It adds physician assistant in Section 1, line 12. Allowing a physician assistant to assess and prescribe psychotropic medications is a crucial part of the bill, she said. 1:38:36 PM At ease 1:38:57 PM CHAIR WILSON reconvened the meeting. MS. CONWAY said that after an assessment is made, the patient's behavior must be documented to explain why other remedies were not successful and the necessity to prescribe the drug. Subsection 2 removes the word "licensed" since physicians are already licensed. It adds Advanced Practice Registered Nurses and Physician Assistants to the list of those who can prescribe psychotropic medication and outlines how that must be done. MS. CONWAY said subsection (c) on page 2, line 15, would outline the time period, 72 hours, the medication can be prescribed. AS 47.30.839 requires a court order to go beyond prescribing three days, which is not addressed in this bill. Section 2 also adds transition language and an immediate effective date. 1:41:08 PM ALBERT WALL, Deputy Commissioner, Department of Health and Social Services, Anchorage, Alaska, said SB 120 arose from discussions with Senator Giessel on ways to improve care and reduce stress on API's psychiatrists, who are on call 24/7, 365 days a year. 1:42:17 PM CYNTHIA MONTGOMERY, Psychiatric Nurse Practitioner, Alaska Psychiatric Institute, Anchorage, Alaska, said SB 120 is in the best interest of patients. Alaska has many psychiatric providers, but API is required to use contractors and locum tenens providers to provide care to the most seriously mentally ill patients in Alaska. These temporary psychiatrists are often from the Lower 48 and are not familiar with Alaska's unique laws surrounding mental health. Even when the patient's primary care provider is present, if the provider is an APRN or PA, the registered nurses on duty must call API's psychiatrist to prescribe any psychotropic medications. MS. MONTGOMERY said that because the psychiatrist may not be immediately available, the medication cannot be given to patients in a timely manner. The psychiatrist may not be familiar with the patient and may be unwilling to prescribe crisis medication. She has observed registered nurses call a locum tenens psychiatrist and the psychiatrist does not understand the statutory necessity. Often, patients are out of control and refuse to take the offered medications. Allowing the patient's own provider to prescribe the medication is in the best interest of the patients and the facility. Besides preventing potential harm to themselves or others, the medication can mitigate damage to the brain during psychotic agitation and aggression. The Joint Commission Standards require that a licensed, independent practitioner who is most familiar with the patient be responsible for that patient's care. 1:45:52 PM MICHAEL ALEXANDER, M.D., Chief Psychiatrist, Alaska Psychiatric Institute, Anchorage, Alaska, said SB 120, the crisis medication bill, is imperative. He is the only psychiatrist at API and is on call for 20 to 25 days per month. When API began to provide services, there were only psychiatrists on staff and not psychiatric nurse practitioners or physician assistants. In the last 10 years, nurse practitioners and physician assistants were added to the medical staff. These professionals previously prescribed psychotropic medications, but about a year ago it was discovered that only psychiatrists could do so. He said these professionals are capable of prescribing and administering psychotropic drugs and should be given the opportunity to care for their patients. 1:47:49 PM CHAIR WILSON opened public testimony on SB 120. 1:48:01 PM MARIEKE HEATWOLE, representing self, Anchorage, Alaska, said she previously worked as a nurse at Anchorage Psychiatric Institute, but is currently pursuing a degree as a psychiatrist nurse practitioner. She echoed the previous testimony in support of SB 120. It resolves a statutory discrepancy and ensures patient- centered care. 1:49:04 PM CHAIR WILSON closed public testimony on SB 120 and solicited a motion. 1:49:17 PM SENATOR VON IMHOF moved to adopt Amendment 1: 31-LS0866\S.1 Marx 2/25/20 AMENDMENT 1 OFFERED IN THE SENATE TO: SB 120 Page 1, line 12: Delete "or a registered" Insert ", physician assistant, [OR A REGISTERED]" 1:49:25 PM There being no objection, Amendment 1 was adopted. CHAIR WILSON held SB 120 in committee. SB 179-NURSING: LICENSURE; MULTISTATE COMPACT 1:49:54 PM CHAIR WILSON announced the consideration of SENATE BILL NO. 179, "An Act relating to the licensure of nursing professionals; relating to a multistate nurse licensure compact; and providing for an effective date." He said Senate Rules Committee introduced SB 179 at the request of the governor. He stated his intention to have an overview of the bill, take invited testimony and public testimony. 1:50:53 PM SARA CHAMBERS, Division Director, Division of Corporations, Business and Professional Licensing, Department of Commerce, Community and Economic Development (DCCED), Juneau, Alaska, introduced herself. 1:51:27 PM JULIE ANDERSON, Commissioner, Department of Commerce, Community, and Economic Development, Anchorage, Alaska, said SB 179 allows Alaska to join the Nurse Licensure Compact (NLC). This is a multistate compact that allows nurses to practice in all participating states. The Nurse Licensing Compact would help address the registered nurse shortage across the state with increased flexibility of health care emergency preparedness and still allow the state to maintain its autonomy. Currently, 34 states have joined the NLC and 11 states have pending legislation to join. The NLC is supported in Alaska. In a recent survey of Alaska licensees, 87 percent of Alaska resident nurses indicated their support for Alaska joining the compact. The Alaska Board of Nursing voted to support joining the NLC last year. 1:52:44 PM DANETTE SCHLOEDER, Chair, Alaska Board of Nursing, Anchorage, Alaska, began a PowerPoint "Nurse Licensure Compact, SB 179." She reviewed slide 2: Mission: Actively promote and protect the health of the citizens of Alaska through the safe and effective practice of nursing as defined by law. License Numbers for FY2019 *Registered Nurses: 14,697 *Licensed Practical Nurses: 805 Advanced Practice Registered Nurses: 1,388 Certified Nurse Aides: 3,416 Total licensees: 20,306 MS. SCHLOEDER reviewed slide 3, What is Licensure? Minimum qualifications to practice. Age and experience are not a factor of licensure. Licensure requirements for NLC are more comprehensive than Alaska. MS. SCHLOEDER said all nurses graduate from accredited programs and sit for the same licensing examination. Licensing and competency are not synonymous. The Alaska Board of Nursing voted to support the compact after listening to nurses and employers. The board examined the evidence-based literature and nursing practice trends in Alaska and throughout the nation. The board also considered the experiences of the other 34 state nursing boards that have joined the compact. The Alaska Board of Nursing recognizes that while the original version of the NLC may not have been a good fit for Alaska, the enhanced NLC with its rigorous requirements for multistate licensure is a good fit. She offered the Board of Nursing's support for SB 179. 1:56:31 PM MARIANNE MURRAY, D.N.P., Executive Administrator, Alaska Board of Nursing, Anchorage, Alaska, asked what problem the board is trying to fix. DR. MURRY reviewed slide 4, Nursing Facts in Alaska That Impact Healthcare: • The average time for nursing licensure. • Nurse licensure application completion rate. • Loss of income for the nurse. • Loss of patient contact hours. • Amount of nursing graduates She said it currently takes 12 to 16 weeks for a nurse to obtain initial licensure, primarily because the application requires primary source documents. These documents include college transcripts and employment verification. Further, background checks must be completed. Once the application is complete, the board's licensing examiners can start the approval process. She said that 97 percent of applications submitted are initially incomplete, so licensing examiners work with the applicants to identify the needed documentation. Since source documents are verified or provided by other states or colleges, it can take weeks or sometimes months to arrive. She said staff is currently working on applications submitted in early November 2019. CHAIR WILSON asked if there is a process for nurses to obtain temporary licensure. DR. MURRAY answered yes, but licensees must complete an application. With the four-month delay in getting licensure, there is a loss of income for a nurse coming to Alaska. The average wage for Alaskan nurses is $85,000 per year, so nurses could potentially lose about $20,000 while awaiting their licenses. Most important is the loss of patient contact hours. DR. MURRAY said Alaska has two nursing schools. As the previous director of the University of Alaska Anchorage (UAA) School of Nursing, she offered her view that Alaska has great schools, but not enough nursing graduates. UAA graduates about 250 nurses each year and Charter College graduates about 75. Ninety-five percent of those graduates have jobs within six months. She pointed to the chart on the bottom of slide 4 from the U.S. Health Resources and Services Administration (HRSA) from January 2020 showing that by 2030, the expected need is 5,400. Alaska ranks as number one in the nation for needing registered nurses. 2:00:11 PM SENATOR BEGICH asked what the unmet needs are today in order to compare that to the projection for 2030. DR. MURRAY replied she had the HRSA information for 2030. SENATOR BEGICH explained that the largest growth area in Alaska has been the health care industry, which is driven by the rapid increase in Medicaid expansion. He asked if the projections took into account that the need may level off. DR. MURRAY replied it might, but the average age of nurses is 50 or 55, so in ten years many nurses will retire. The Alaska population over age 65 is anticipated to double in the next 20 years, so Alaska will still have a significant need. SENATOR BEGICH asked how UAA's budget cuts have impacted nurse recruitment and graduation. He asked if there is a shortage because people are not interested or that resources have diminished. DR. MURRAY responded that one key issue at UAA was hiring faculty to teach nursing. She opined that a number of people in Alaska want to go to nursing school, but it makes people nervous to think about becoming faculty at a university that is financially unstable. 2:03:18 PM SENATOR GIESSEL highlighted that nursing applications went online in July 2019, but it is still taking 12 to 16 weeks to process. She asked her to identify the issues. DR. MURRAY replied the application volume of up to 350 per month is one issue. There is also a backlog because applications are incomplete due to a lack of primary source documentation. Source documents must be submitted and verified by the universities or employers. Thus, the applicants and agency staff must wait for other people to submit information. She acknowledged that some of the inefficiencies are related to the process. SENATOR GIESSEL asked how many temporary licenses are issued. MS. CHAMBERS offered to follow up with the information. SENATOR GIESSEL recalled that these figures were in the most recent sunset audit. She asked how long it takes to process and issue temporary licenses. DR. MURRAY answered that temporary licenses can take time because an application must be completed and the applicant must meet certain criteria for a temporary license. SENATOR GIESSEL asked why someone would apply for a temporary license. DR. MURRAY cited the example of a recent graduate who applied for a temporary license while waiting to take the NCLEX (National Council Licensure Exam). 2:05:47 PM SENATOR GIESSEL summarized that there is an opportunity to become licensed while waiting for results and then go through a fuller licensing process. She asked if the board would be able to issue temporary licenses in an emergency, such as an outbreak of coronavirus. MS. CHAMBERS cited the 2018 earthquake as an example. Some Lower 48 states wanted to send nurses to Alaska to help and it took over a week to issue temporary licenses for each of about a dozen nurses. The board had to mobilize people to prioritize and expedite those applications. In an emergency situation that might require several hundred nurses in rural areas, the process of obtaining a temporary license could take time because applicants must still make an application and go through the vetting process. MS CHAMBERS said this bill will help diminish or eliminate the impact of waiting weeks for documents to trickle in. The compact eliminates that for applicants who want multiple licenses in compact states because the home state completes the primary source verification. Her staff can usually issue a completed application within 10 days. SENATOR GIESSEL expressed concern that the process has deteriorated. In the past, Alaska has had outbreaks of RSV (respiratory syncytial virus) affecting newborns, primarily in rural Alaska. Thus, Alaska has had a need for specialized neonatal nurses. The board expeditiously executed those temporary licenses and worked hard to put that process in place. She recalled that the board had a very efficient process. She noted that the board has gone to online applications. MS. CHAMBERS replied that the division has worked on the inefficiencies it can control. However, it cannot control the time it takes for documentation to arrive. During the 2018 earthquake, the board waited for the health care manger at the facility to gather the documentation for its nurses. Once the board receives the documentation, temporary licenses can be processed quickly. She acknowledged that processing temporary licenses for a dozen nurses took up to a week. In a situation where more nurses were needed, it would have taken longer because the board must follow current laws. 2:11:14 PM SENATOR VON IMHOF related her understanding that nurses go through the rigorous process of qualifying for a license in their home state. If Alaska is part of the compact or modified compact, nurses would have 60 days to provide documentation during the licensure process. She understood Ms. Chambers identified bottlenecks out of the division's control. She related her understanding that the bill suspends an application after 60 days if the documentation is not received and it remains suspended until it is completed. MS. CHAMBERS said the compact is a uniform agreement among participating states that agree to all of the terms and requirements. This particular compact cannot be modified or altered. She pointed out that SB 157, a professional licensing reform bill, would give the division and boards the tools to offer modified or increased temporary licensure similar to what Senator von Imhof described. SB 157 would provide the solution since it would apply to all professions, including nurses. SENATOR VON IMHOF asked whether it makes sense to pull nursing out of the reform bill or think about how to enhance SB 179 due to the nursing shortage, the aging population, and the geographic location of Alaska. She said any number of illnesses or pandemics could come to the state at any given time. SENATOR GIESSEL asked for the duration of a temporary license. DR. MURRAY answered six months. SENATOR GIESSEL noted that temporary licenses are covered under AS 08.68.210. She asked Dr. Murray to describe what licensure by endorsement means. DR. MURRAY responded that licensure by endorsement involves licensing an applicant in Alaska who holds a license in another jurisdiction. 2:15:30 PM SENATOR GIESSEL said licensure by endorsement is covered under AS 08.68.200, which seems like an expeditious process for someone who is licensed in another state. DR. MURRAY replied that applicants seeking licensure by endorsement still must apply for licensure and be vetted, which takes time. 2:16:21 PM DR. MURRAY reviewed slide 6, What is the Nurse Licensure Compact?: It is an agreement among states to offer an optional multistate license to nurses who have met eleven high standards of education, training, and discipline-free practice. AS 28.37.010. Compact Enacted. The Driver License Compact is enacted into law and entered into with all other jurisdictions legally joining in it in the form substantially contained in AS 28.37.110 - 28.37.190. Alaska joined the Driver License Compact in 1986. She reported that Alaska participates in over 25 different compacts. DR. MURRAY reviewed slide 7, What is the Nurse License Compact? The Alaska Board of Nursing retains full authority to: • Ensure all nurses practicing in Alaska follow its standards, laws, and rules • Offer multistate licensure or single state licensure as an option • Remove the ability of a nurse with a multistate license to practice in our state. The Interstate Compact Commission agreement is in statute and can only be changed when all participating states agree to new laws. DR. MURRAY reviewed slide 8, Benefits to Alaska: Reduces cost/burden on nurses. Reduces cost/burden on employers. Expedites disaster relief. Adds options to keep Alaska-trained nurses in state. She said the board held townhall stakeholder meetings in Juneau, Anchorage, and Fairbanks. The board met many nurses who hold licenses in many other states. DR. MURRAY reviewed slide 9, Benefits to Alaska: Increases access to care. Increases telehealth solutions for Alaskans. Eases burden on military families. Expands employment opportunities for Alaska nurses: • Facilities online education. • Telehealth work. • Seasonal employment flexibility. 2:19:05 PM DR. MURRAY reviewed slide 10, NLC Requirements vs Alaska Requirements. She said that Alaska licensees do not have to pass an English language proficiency exam. Alaska licensees are not required to be free of a felony or misdemeanor convictions related to the practice of nursing nor do applicants in Alaska need to have a social security number. DR. MURRAY reviewed slide 11, Nurse Licensure Compact in 34 states. The slide depicted a map of the 34 states in the NLC. She noted that Indiana and New Jersey were joining and 10 states have pending legislation. DR. MURRAY reviewed slide 12, Nurse Licensure Survey Results. She noted that when she joined the board in September, it had just voted to move forward with the compact. The board conducted a survey about the Nurse Licensure Compact in December 2019 and over 3,527 licensees responded, the majority of which reside in Alaska. CHAIR WILSON asked what type of nurses were included in that number. DR. MURRAY said the survey was sent to anyone who had an RN or LPN [licensed practice nurse] license. Advanced Practice Registered Nurses hold an APRN and an RN license, so APRNs would have received the survey. SENATOR VON IMHOF asked if traveling nurses are paid the same as Alaska nurses and if using traveling nurses is less expensive for hospitals. MS. CHAMBERS replied those are questions to ask employers; nurse salaries are not regulated by licensure. She noted that the Alaska State Hospital and Nursing Home Association (ASHNA) supports the bill. 2:22:44 PM DR. MURRAY reviewed slide 13, Survey Results, which read: 3,573 nurse completed the 2019 Alaska Compact Survey! 92 [percent] of all respondents are in favor of joining the Nurse Licensure Compact 89 [percent] of Alaskan resident nurses are in favor of joining the compact 87 [percent] of the nurses would apply for a compact nurse license if available. DR. MURRAY reviewed slide 14, Nurse Licensure Compact SB 179. The table in this slide shows overwhelming support by residents, union and nonunion members, and respondents who hold a license solely in Alaska as well as other jurisdictions. SENATOR GIESSEL related her understanding that about 40 percent of nurses with an Alaska license have their primary residence outside of the state, so nurses living in Oregon were asked whether Alaska should be a compact state. DR. MURRAY confirmed that the board polled all of the Alaskan nurse licensees. SENATOR GIESSEL pointed out that an estimated 40 percent of those are out-of-state residents. SENATOR VON IMHOF asked how much the licensing fee for nurses is. DR. MURRAY replied a new application costs $375. SENATOR VON IMHOF asked if fees will change with the compact. DR. MURRAY said the board believes fees for compact licensure would probably be more since the nurse will not pay extra fees in other states. SENATOR VON IMHOF asked if nurses coming to Alaska will pay $375 to get an Alaskan endorsement, if Alaska is in the compact. 2:26:17 PM MS. CHAMBERS said that under the compact, nurses could select either a single state license or a multistate license, which would allow them to work in any of the other 34 compact states. Nurses with a multistate license would not have to apply for or pay for licensure because they already have the multistate privilege. The multistate compact is tied to the home state, so anytime a nurse moves from Alaska to another compact state or from a compact state to Alaska, they would need to transfer their home state status within the compact. Everyone renews their license in their home state, which is the way licenses are currently renewed. She said the division anticipates being able to charge more for the multistate licenses and the board will continue to adjust fees annually. The board has committed that the multistate license will not cost single-state licensees additional fees. The board wants to make sure that Alaskan nurses who do not want to enter the compact will not pay for compact activities. SENATOR VON IMHOF said $375 is not a large fee but multiplied by 500 people it is substantial. She asked what out of state nurses are paid and said she wants to make sure that this bill will not displace Alaskan nurses. CHAIR WILSON added that licensure fees go to investigations of bad actors and complaints. He does not want to short fund investigative services that provide safety of residents. He asked if there would be a way to add an additional fee, if necessary, for nurses who come to Alaska under the compact. MS. CHAMBERS replied the division is considering setting the multistate compact fee higher. The compact does not allow states to assess an additional fee for visiting nurses since it will circumvent the purpose of the compact. However, every state has its own fee-setting process. She pointed out that Alaska nurses currently absorb the investigative costs. The division wants to make sure that when investigating multistate nurses, the costs are allocated to those nurses who are in the compact. The 34 states in the compact have not seen an overwhelming increase in investigative activity. Currently, 650 nursing jobs are available in the state. There is quite a difference between the available nurses and the available jobs. SENATOR BEGICH said residents want jobs in Alaska, but the state cannot provide the training and recruit for faculty. He related his understanding that Alaskan residents would pay more, but out-of-state residents would not pay any fees to work in Alaska. MS. CHAMBERS confirmed that is how the compact works. If a flight nurse works in the Lower 48, the nurse must have a license to care for that patient once the flight lands. There are plenty of opportunities for Alaskan residents to benefit from not having to pay when these residents want to utilize additional economic opportunities, for example, in telehealth. SENATOR BEGICH said that sounds almost like a disincentive to keep people in the state. The state does not want to trap people in Alaska, but if the state has a shortage of 670 nurses and adds an additional incentive to leave the state, this could be a potential disincentive to fill the nursing gap, not an incentive. Twenty-one percent of the workforce today are not in- state residents. These non-residents get services and pay nothing for them. This seems to be an example of increasing that. He asked for some reassurance. CHAIR WILSON suggested that some employers could speak to that. 2:35:31 PM MS. SCHLOEDER said she has always had a primary Alaskan license. Three years ago she answered the call to help train new nurses through online education. She has to have licenses in Washington and Montana in order to teach online. She is lucky that she only needs three licenses. She met a nurse educator who has 37. She has to have a license for every state where she has a student because teaching nursing is practicing nursing. There are highly trained nurses in Alaska who would like to teach online, and online education is very popular in advanced practice, in doctorate programs, and others, but these nurses do not want to get a license in every state where they have students. CHAIR WILSON noted the interest in the bill and reminded people that they could send written testimony to firstname.lastname@example.org. SENATOR BEGICH said Ms. Schloeder indicated that it is a disadvantage to APRNs, but according to slide 2, these nurses are not eligible to enter the compact. MS. SCHLOEDER said an online instructor who is teaching Advanced Practice Registered Nurses would still need to hold licenses in those states. SENATOR BEGICH asked what government regulates the nurse licensure compact. MS. CHAMBERS said the Alaska Board of Nursing has full control and sovereignty over nursing practice in Alaska. 2:38:32 PM SENATOR BEGICH said he was asking a slightly different question. The NLC has structures and processes that can be changed and the state would be under those processes if it signs the compact. He asked which government is in charge of that. MS. CHAMBERS said that like the other 27 compacts, including the driving, mining, and children placement compacts, there is a body made up of member states who facilitate the conversation. That is the Interstate Commission. If Alaska joins, there will be 35 board chairs who represent each state. Each state has an equal voice. The terms of what the commission can and cannot do is in the bill. All legislatures adopting the compact say that state boards retain sovereignty over practice and set the priorities for licensure. The commission has nothing to do with the day-to-day evaluation of nurses. It is about how to facilitate the conversation about how the compact is going to operate. CHAIR WILSON asked if the Department of Law reviewed this compact. MS. CHAMBERS replied it is the governor's bill, so the Department of Law wrote it. The division worked with the Department of Law many months in drafting the bill. SENATOR GIESSEL recapped that nurses with a multistate license who come to Alaska will not be charged anything. She expressed concern about the potential loss of revenue for the Board of Nursing under the compact. MS. CHAMBERS responded that not all those licensees are in compact states. There is a percentage of licensees outside of Alaska who would still be required to obtain an Alaskan license because these licensees are not part of a compact. The board anticipates that there may be a loss of revenue for the board from up to 4,000 nurses. Conversely, the workload on the board will decrease because it will not be processing all those licenses. The division held conversations internally and with the staff to answer questions about whether the expenses of the board will decrease. If the board does not need as much staff to process applications, it will lose staff through attrition or the division will assign staff members to other programs. The division is not only keen on tracking those expenses to have transparent conversations with the board and stakeholders but also so that the board and licensees know that the costs of multistate licenses might go up. SENATOR GIESSEL questioned whether that makes sense. She said there are currently 6,000 licensed nurses and it takes about 10 minutes to renew a license, so there should not be staff costs to process. She acknowledged that renewal fees allow the board to stay solvent. DR. MURRAY said the board loses 3,000 licensees each biennial renewal. The board has a steady rate of nurse licensees along with considerable fluctuation in the number of other licensees. CHAIR WILSON invited Ms. Chambers to present the sectional analysis for the bill. 2:44:45 PM MS. CHAMBERS noted that much of the bill is adding the compact license where nursing licenses already exists. She presented the following sectional analysis for SB 179: Section 1: Amends AS 08.02.010 (Professional Designation Requirements) to add AS 08.69 (the Multistate Nurse Licensure Compact chapter, created by Section 23 of this Act) as a qualification designation requirement for registered nurses. Section 2: Adds AS 08.69 (created by Section 23 of this Act) to AS 08.11.120 (Audiology Exemptions), to allow a nurse that holds a multistate license to perform hearing sensitivity evaluations. Section 3: Extends the Board of Nursing's existing authority to govern AS 08.69 (created by Section 23 of this Act), and identifies the executive director of the board as the interstate commission licensure compact administrator Section 4: Exempts AS 08.69 (created by Section 23 of this Act) from the Administrative Procedures Act, as nurses licensed under this chapter are subject to the due process provided in the Nurse Licensure Compact. Section 5: Requires the Registered Nurse (RN) or Licensed Practical Nurse (LPN) offering to practice in this state to submit evidence of qualification to practice and to be licensed under this chapter (AS 08.68) or AS 08.69 (created by Section 23 of this Act). 2:47:04 PM Section 6: Extends the existing required qualifications in AS 08.68.170 (Qualifications of Registered or Practical Nurse Applicants) to nurse applicants under AS 08.69 (created by Section 23 of this Act). Section 7: Clarifies that AS 08.68.190(b) (under License by Examination) pertains only to Alaska state nursing licensure. Section 8: Creates a new subsection (c) under AS 08.68.190 (under License by Examination), which explains that if the qualifications are met for both AS 08.69 (created by Section 23 of this Act) and AS 08.68.170, the Board of Nursing shall issue a multistate license. Section 9: Amends AS 08.68.200 (Licensure by Endorsement) to pertain only to single state licensure in Alaska. Section 10: Amends AS 08.68.220 (Fees) to authorize the Department of Commerce Community and Economic Development to set fees for multistate licenses issued by the board. Section 11: Amends AS 08.68.230(a) (under Use of Title and Abbreviation) to authorize a multistate license holder under AS 08.69 (created by Section 23 of this Act) to use the title Registered Nurse and the abbreviation R.N. Section 12: Amends AS 08.68.230(b) (under Use of Title and Abbreviation) to authorize a multistate license holder under AS 08.69 (created by Section 23 of this Act) to use the title Licensed Practical Nurse and the abbreviation L.P.N. Section 13: Amends AS 08.68.230(d) (under Use of Title and Abbreviation) to add single state language to temporary permits and to note that an LPN that holds a temporary permit in the state can use the title Temporary Licensed Practical Nurse and the abbreviation TLPN. Section 14: Clarifies in AS 08.68.251 (Lapsed Licenses) that single state or multistate nursing licenses may be reinstated if lapsed for fewer than five years. Sections 15-19: Amend AS 08.68.270 (Grounds for Denial, Suspension, or Revocation) and 08.68.275 (Disciplinary Sanctions) to add the multistate license to the existing types of licenses that may be disciplined by the board. 2:49:59 PM SENATOR BEGICH asked, if the board invalidates someone with a multistate license, is that person affected in every state. MS. CHAMBERS answered yes. If someone is in violation of a statute or regulation in a state where these licensees are authorized to practice, that Board of Nursing can determine that someone is guilty under the state's administrative procedure and not welcome to practice in the state any longer. That is reported through the nursing database, which the state currently uses. The other states are notified and can take action on that license. No nurse with active discipline can hold a multistate license. A state would have to convert the license to a single state license for the nurse to practice. Section 20: Maintains exemptions in AS 08.68.800 (Exceptions to Application of Chapter) for nurses who are working in limited circumstances under a license issued in another state. Section 21: Amends AS 08.68.805 (Delegation of Nursing Functions) to include nurses who hold a multistate license under 08.69 (created by Section 23 of this Act). Section 22: Amends AS 08.68.850(1) (Definition of "advanced practice registered nurse) to include registered nurses licensed under AS 08.69 (created by Section 23 of this Act). Section 23: Creates AS 08.69, Multistate Nurse Licensure Compact. It includes the purpose, definitions, provisions, jurisdiction, licensing provisions, authority of state boards, information- sharing, governance and rulemaking authority, due process, enforcement, dispute resolution, withdrawal, severability, and amendment. These articles are uniform to all 34 other states within the compact and are mandatory for participation. Sections 24-36: Amend statutes to add AS 08.69 (created by Section 23 of this Act) to the definitions of nursing as found throughout state law: Section 37: Allows the department to adopt regulations necessary to implement the changes made by this Act, to take effect under AS 44.62 on the effective date as noted in Section 38. Section 38: Makes Section 37 (Transition Regulations) effective immediately once the bill is signed. Section 39: Makes Sections 1-36 of this Act effective as of July 1, 2021. 2:52:48 PM SENATOR VON IMHOF offered her belief that each state has unique statutes. She asked if a nurse comes to Alaska as part of the compact and violates a unique statute that is different from the other states, would they lose the privilege to practice in other states for violating one unique thing in Alaska. DR. MURRAY replied the board would investigate and if necessary, would work with the licensee's home state to have his/her license revoked so that nurse would not be eligible for a multistate license. SENATOR VON IMHOF noted that Dr. Murray spoke about 11 things that were similar or standard between Alaska and the NLC. She asked if each traveling nurse who works in Alaska is responsible for identifying the unique laws in Alaska. 2:54:30 PM MS. SCHLOEDER answered that nurses are responsible for knowing the Nurse Practice Act in their home state. Nurses holding a multistate license must be familiar with the Nurse Practice Act in each state in which the nurses practices. MS. CHAMBERS said employers have a fiduciary responsibility to make sure visiting nurses are knowledgeable to limit their own liability, but the state does work with traveling nurses to make sure they are familiar with Alaska's laws. This bill will not change the state's current practice. SENATOR GIESSEL asked how the board will know if nurses from other states are in Alaska. MS. CHAMBERS said Alaska currently licenses nurses who reside in other states, but the board does not know when these licensees are practicing in Alaska. The board also does not know when nurses are practicing at military bases or for Alaska Native organizations since these organizations are exempt from Alaska licensure. The Board of Nursing and the division do not currently keep tabs on those nurses. SENATOR GIESSEL pointed out one difference. If a person violates the Nurse Practices Act, the division will have collected a licensing fee to help offset the cost of adjudication of the violation. Under this compact, the division would not have that same financial availability. 2:57:10 PM SENATOR BEGICH said the board knows that a total of 20,306 licenses were issued to nurses in various categories. Under the compact, the state would no longer know the number of licensed nurses in Alaska. He said he didn't know if that was an issue. MS. CHAMBERS said the division has access to the nursing database so it would have information if someone filed a complaint against a nurse. The division would use the same disciplinary process it currently uses. She said knowing how many licensed nurses are practicing in the state is important for certain data collection points and to estimate fees. Employers are responsible for day-to-day management of their nurses, whether it is in a private clinic under a doctor or in a large facility under a chief nursing officer. 3:00:08 PM CHAIR WILSON asked the division to provide more information about the fees, noting that he does not want to shortchange the investigative practice of the board. CHAIR WILSON held SB 179 in committee. 3:01:51 PM There being no further business to come before the committee, Chair Wilson adjourned the Senate Health and Social Services Standing Committee at 3:01 p.m.