02/26/2016 01:30 PM Senate LABOR & COMMERCE
| Audio | Topic |
|---|---|
| Start | |
| SB98 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| + | SB 98 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
SENATE LABOR AND COMMERCE STANDING COMMITTEE
February 26, 2016
1:31 p.m.
MEMBERS PRESENT
Senator Mia Costello, Chair
Senator Cathy Giessel, Vice Chair
Senator Kevin Meyer
Senator Gary Stevens
MEMBERS ABSENT
Senator Johnny Ellis
COMMITTEE CALENDAR
SENATE BILL NO. 98
"An Act relating to diagnosis, treatment, and prescription of
drugs without a physical examination."
- HEARD & HELD
PREVIOUS COMMITTEE ACTION
BILL: SB 98
SHORT TITLE: PRESCRIPTION WITHOUT PHYS. EXAM.
SPONSOR(s): SENATOR(s) MICCICHE
04/07/15 (S) READ THE FIRST TIME - REFERRALS
04/07/15 (S) HSS, L&C
04/13/15 (S) HSS AT 1:30 PM BUTROVICH 205
04/13/15 (S) Heard & Held
04/13/15 (S) MINUTE (HSS)
01/25/16 (S) HSS AT 1:30 PM BUTROVICH 205
01/25/16 (S) Scheduled but Not Heard
01/27/16 (S) HSS AT 1:30 PM BUTROVICH 205
01/27/16 (S) Heard & Held
01/27/16 (S) MINUTE (HSS)
02/01/16 (S) HSS AT 1:30 PM BUTROVICH 205
02/01/16 (S) Moved CSSB 98(HSS) Out of Committee
02/01/16 (S) MINUTE (HSS)
02/03/16 (S) HSS RPT CS 1DP 3NR NEW TITLE
02/03/16 (S) DP: GIESSEL
02/03/16 (S) NR: STEDMAN, ELLIS, STOLTZE
02/03/16 (S) FIN REFERRAL ADDED AFTER L&C
02/24/16 (S) L&C WAIVED PUBLIC HEARING NOTICE, RULE
23
WITNESS REGISTER
SENATOR PETER MICCICHE
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Sponsor of SB 98.
CHUCK KOPP, Staff
Senator Peter Micciche
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented the sectional analysis for SB 98.
JANEY HOVENDEN, Director
Division of Corporations, Business and Professional Licensing
Department of Commerce, Community and Economic Development
Juneau, Alaska
POSITION STATEMENT: Answered questions related to SB 98.
SARAH CHAMBERS, Operations Manager
Division of Corporations, Business and Professional Licensing
Department of Commerce, Community and Economic Development
Juneau, Alaska
POSITION STATEMENT: Answered questions related to SB 98.
MARGARET BRODIE, Director
Division of Health care Services
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Answered questions related to SB 98.
DR. DAVID POWERS, member
State Medical Board and practicing physician
Dillingham, Alaska
POSITION STATEMENT: Raised questions about SB 98.
CLAUDIA TUCKER
Vice President of Government Affairs for Teladoc
Virginia
POSITION STATEMENT: Testified in support of SB 98.
JOHN JESSER, Vice President
Provider Engagement Strategy
Anthem Inc.
Indianapolis, Indiana
POSITION STATEMENT: Testified in support of SB 98.
ROBIN MINARD, Director of Public Affairs
Mat-Su Health Foundation
Wasilla, Alaska
POSITION STATEMENT: Testified in support of SB 98.
ACTION NARRATIVE
1:31:17 PM
CHAIR MIA COSTELLO called the Senate Labor and Commerce Standing
Committee meeting to order at 1:31 p.m. Present at the call to
order were Senators Stevens, Giessel, and Chair Costello.
SB 98-PRESCRIPTION WITHOUT PHYS. EXAM.
1:31:39 PM
CHAIR COSTELLO announced the consideration of SB 98. She noted
that this is the first hearing. [CSSB 98(HSS) is before the
committee.]
1:32:06 PM
SENATOR MEYER joined the committee.
1:32:16 PM
SENATOR PETER MICCICHE, Alaska State Legislature, sponsor of SB
98, stated that the bill was amended in the previous committee
to include the use of telehealth technologies by behavioral
health licensing boards. He explained that the bill tries to
drive down the cost of health care in Alaska, and is an
important piece of Medicaid reform. It will improve health care
access for rural residents and prohibit unprofessional conduct
claims against a physician who is licensed in Alaska, but out of
state at the time of prescribing a prescription drug to a person
in Alaska.
He reminded members that in 2014 the legislature passed HB 281
by a near-unanimous vote to allow physicians to prescribe a
prescription drug to a person without conducting a physical
examination, within certain parameters. A controlled substance
could not be prescribed unless the health care provider was
present with the patient to assist the physician with
examination, diagnosis, and treatment.
That bill requires the telehealth physician to be located in the
state. For example, a physician in Ketchikan could conduct a
remote diagnosis and prescribe a drug in any community in
Alaska. It does not allow physicians who reside outside the
state to practice telemedicine across state lines, so the pool
of physicians that can provide telehealth services is greatly
diminished.
SENATOR MICCICHE stated that SB 98 addresses the lack of
physicians available to do remote consults by removing the
"physical, in-state presence" requirement. The physicians would
still require an Alaska medical license. He pointed out that
telemedicine services average less than one-third of the cost of
an in-person office visit and less than one-tenth the cost of an
ER visit.
What some physicians are concerned about is already allowed in
Alaska, he said. There is remote prescription of medication
occurring now with no in-person visits required as per HB 281.
The only difference this year is that a physician who resides
outside of Alaska may write the prescription. From the patient's
perspective there is zero difference. The Alaska State Medical
Board has been issuing Alaska medical license privileges to
stateside physicians for decades. The Department of Health and
Social Services (DHSS) has been using stateside physicians for
years to deliver health care via telemedicine to Alaskans at a
far more reasonable rate and it has worked out very well, he
said. The sky is not falling. Data shows patient safety is as
good if not better and over prescribing occurs less often as
compared to in-office visits.
He noted a report by the Federation of State Medical Boards of
the United States, a national non-profit organization that
represents 70 state medical and osteopathic boards on model
policy for the appropriate use of telemedicine technologies in
the practice of medicine. The report concludes that the
physician-patient relationship is clearly established when a
physician agrees to undertake diagnosis and treatment of the
patient and the patient agrees to be treated, whether or not
there has been a personal encounter between the physician and
the patient.
SENATOR MICCICHE summarized that SB 98 does six things: it
clarifies that the legislature's intent is to support
telemedicine in Alaska, prevents the Alaska Medical Board from
blocking telemedicine to private sector insurance programs,
ensures the patient controls their medical records - including
their psychiatric records, removes the requirement that the
physician must be physically located in Alaska, maintains the
requirement that the physician is licensed in Alaska, and it
provides substantive cost savings to individuals in public
programs.
SENATOR MICCICHE said both AETNA and Premera Blue Cross Blue
Shield of America support the bill. State employees currently
have this benefit.
1:37:30 PM
CHAIR COSTELLO asked Mr. Kopp to slowly walk through the
sectional analysis.
1:37:46 PM
CHUCK KOPP, Staff, Senator Peter Micciche, Alaska State
Legislature, presented the following sectional analysis for SB
98:
Section 1
Prohibits the Board of Professional Counselors from
imposing disciplinary sanctions on a licensee for
using telehealth technologies in the evaluation,
diagnosis or treatment of a person when physically
separated from the person if the licensee or another
licensed health care provider is available to provide
follow-up care, and the licensee follows patient
consent protocols for sending medical records of the
encounter to the person's primary care provider.
Section 2
Prohibits the Board of Marital and Family Therapy from
imposing disciplinary sanctions on a licensee for
using telehealth technologies in the evaluation,
diagnosis or treatment of a person when physically
separated from the person if the licensee or another
licensed health care provider is available to provide
follow-up care, and the licensee follows patient
consent protocols for sending medical records of the
encounter to the person's primary care provider;
requiring licensees meet the requirements established
by the board in regulation, and requiring the board to
adopt regulations governing the practice of telehealth
and establish standards for training, confidentiality,
supervision, and other practice related issues.
Section 3
Prohibits the State Medical Board from imposing
disciplinary sanctions on a physician for using the
full continuum of telehealth care, including rendering
a diagnosis, providing treatment, or prescribing,
dispensing, or administering a prescription drug that
is not a controlled substance without an in-person
encounter if the physician or another licensed health
care provider, or physician in the physician's group
practice is available for follow-up care, and the
physician follows patient consent protocols for
sending medical records of the encounter to the
person's primary care provider; and removes the
requirement that the physician is located in the
state.
Section 4
Prohibits the State Medical Board from imposing
disciplinary sanctions on a physician for prescribing,
dispensing, or administering a prescription drug that
is a controlled substance if the requirements of
Section 3 are met, and the physician prescribes,
dispenses, or administers the controlled substance
when an appropriate licensed health care provider is
present with the patient to assist the physician with
examination, diagnosis, and treatment.
Section 5
Prohibits the Board of Psychologist and Psychological
Associate Examiners from imposing disciplinary
sanctions on a licensee for using telehealth
technologies in the evaluation, diagnosis or treatment
of a person when physically separated from the person
if the licensee or another licensed health care
provider is available to provide follow-up care, and
the licensee follows patient consent protocols for
sending medical records of the encounter to the
person's primary care provider.
Section 6
Prohibits the Board of Social Work Examiners from
imposing disciplinary sanctions on a licensee for
using telehealth technologies in the evaluation,
diagnosis or treatment of a person when physically
separated from the person if the licensee or another
licensed health care provider is available to provide
follow-up care, and the licensee follows patient
consent protocols for sending medical records of the
encounter to the person's primary care provider.
1:42:16 PM
MR. KOPP noted that this bill is supported by two state-funded
studies; the Legislative Budget and Audit Menges Report that
highlights the need to expand telemedicine to drive down the
cost of health care, and the Menges Group Report that is an
assessment of Medicaid expansion reform that highlights
telemedicine as an ideal way to contain state-attributable
expenditures to Medicaid. The Public Works Report for the
Department of Health and Social Services also recommends
expanding telemedicine to drive down the cost of health care. He
listed the groups that support the bill and noted those letters
have been submitted to the committee.
CHAIR COSTELLO summarized that the bill scrubs state statutes to
remove the impediments to telemedicine.
MR. KOPP agreed the various boards may not impose a disciplinary
action on a licensee for using the technology while providing
health care.
CHAIR COSTELLO asked what telemedicine looks like for Alaskans.
MR. KOPP replied the standard of care for telemedicine has been
established in Alaska for at least two decades, starting with
the Alaska Native Tribal Health care Center and the Alaska
Federal Health care Network. The standard of care a physician
uses is the same as an in-person visit.
1:45:24 PM
CHAIR COSTELLO asked what prevents someone from using
telemedicine to the exclusion of in-person visits.
MR. KOPP said telemedicine isn't appropriate for every situation
and part of the health care professional's responsibility is to
let a patient know when telemedicine is not appropriate.
CHAIR COSTELLO encouraged the members to carefully review the
model policy on telemedicine in the packets that's from the
Federation of State Medical Boards of the United States. She
asked what guidelines in the legislation set out the framework
to ensure that patients continue to see a doctor in person.
1:47:38 PM
MR. KOPP said the guidelines don't need to be in statute because
the Federation of State Medical Boards Model Policy for the
Appropriate use of Telemedicine Technologies in the Practice of
Medicine addresses the question of establishing the physician-
patient relationship on page 4. He read excerpts from the policy
that clearly says how the relationship is established.
1:49:10 PM
CHAIR COSTELLO asked if he supports that group's model policy or
if there are areas that cause him concern.
MR. KOPP said the sponsor does support it; it's a policy that is
followed by nearly every state.
SENATOR MICCICHE added that the bill doesn't change the
establishment of the physician-patient relationship. The only
difference now is that it extends to a physician outside the
state of Alaska.
SENATOR GIESSEL said she wanted to clarify some potential
misunderstandings. The bill changes the requirement for a
physician to have boots on the ground in Alaska when they
provide health care through electronic means. She agreed with
Mr. Kopp that telemedicine has been going on in Alaska for a
number of years and noted that the Board of Nursing has never
restricted the use of telehealth. However, they do require the
nurse clinician to have boots on the ground in Alaska.
She highlighted that she offered an amendment to the bill in the
previous committee to include mental health practitioners. She
clarified that none of those amendments provide that these
mental health providers would be in the Lower 48. The provisions
in the bill would simply authorize those regulatory boards to
make the decision about whether or not the psychologist or
social worker needs to be a resident of Alaska. The only part in
the bill that changes the boots on the ground requirement is for
the physician licensed under the State Medical Board.
SENATOR GIESSEL described the O'Malley case explaining that a
doctor was sued by a patient who had a negative outcome after
failing to follow the doctor's recommendation to go to the
emergency room. Health care professionals address liability
through such recommendations. She asked what liability coverage
is provided for physicians operating from outside the state and
what recourse a patient would have should the physician's advice
be inappropriate.
MR. KOPP said the sponsor didn't specifically take the O'Malley
case into account, but all professional practices need to take
liability into consideration. He discussed the use of the 800
number on the Alaska Care employee health plan to seek advice
about a health concern and agreed there is liability exposure
whenever advice is given over the phone. However, seeking health
care advice over the phone is a well-established practice in
most states, he said.
1:54:19 PM
SENATOR GIESSEL pointed out that you don't get a prescription
when you call a nurse line, whereas the bill is addressing
calling a physician for health care advice and the patient could
potentially receive a prescription.
MR. KOPP recapped that physicians residing outside the state
must be licensed in Alaska in order to practice in Alaska.
1:55:05 PM
SENATOR STEVENS asked if the bill authorizes a physician who is
practicing from outside the state to prescribe a controlled
substance. His interest is in keeping these drugs out of the
hands of people who shouldn't be using them.
MR. KOPP read from Section 4 that says when a physician
prescribes a prescription drug that is a controlled substance,
an appropriate licensed health care provider must be present
with the patient.
SENATOR STEVENS questioned why the licensed health care provider
doesn't prescribe instead of the doctor who is on line.
MR. KOPP explained that not every health care provider has
prescriptive authority.
SENATOR STEVENS expressed a preference for having a licensed
health care provider who has full prescriptive authority with
the patient when a controlled substance is prescribed. He asked
why that isn't a requirement.
MR. KOPP answered that telemedicine wouldn't be needed if that
were a requirement.
SENATOR STEVENS asked if he doesn't see a danger.
MR. KOPP pointed out that Alaska has a long history of having
health aides overseeing and administering prescription drugs
that were prescribed by a physician who is on the phone.
SENATOR STEVENS expressed concern with the concept in light of
the abuse of prescribed controlled substances.
MR. KOPP said recent reports show fewer telehealth prescriptions
are written than are prescribed in the traditional doctor-
patient in-person visit.
SENATOR MICCICHE suggested the committee is missing the concept
that telemedicine generally addresses lower-level medical
issues. The dataset that shows that telehealth under prescribes
is likely because a patient would move to a higher level of care
if they had a condition that required a prescription,
particularly of a controlled substance.
SENATOR STEVENS said he'd be more comfortable if a patient had
to see a physician in person if a controlled substance is
prescribed.
2:00:53 PM
SENATOR MEYER said he, too, is concerned about physicians
outside the state making medical decisions about Alaskans,
particularly those in rural areas. He asked if the impetus for
the bill is a lack of physicians in Alaska to do remote
consults.
MR. KOPP confirmed there aren't enough telehealth physicians in
the state, in part because it's not a significant money-making
proposition.
2:02:39 PM
SENATOR MEYER asked if Medicaid pays for telemedicine.
MR. KOPP answered yes and noted the packets contain a report
that lists how Alaska reimburses Medicaid for telemedicine
services. The cost is generally one-third less than in-person
visits.
SENATOR MEYER asked if the state gets reimbursed at Alaska rates
or the rate from the state where the telemedicine doctor is
located.
MR. KOPP deferred the question to the Department of Health and
Social Services.
SENATOR MEYER asked how telemedicine providers are regulated.
MR. KOPP replied telemedicine doctors need an Alaska license to
practice and therefore are regulated by the State Medical Board.
SENATOR MICCICHE pointed out that a significant cost to the
state associated with Medicaid care is travel. A dramatic
reduction in travel is expected if this bill passes.
CHAIR COSTELLO asked if he expects this will increase the scope
of work for the licensing boards that are overseeing these
professions.
SENATOR MICCICHE said his expectation is that the State Medical
Board would not travel to an outside state for the licensing
process.
CHAIR COSTELLO clarified that she is referring to disciplinary
actions.
SENATOR MICCICHE said his expectation is that disciplinary
actions would take place in Alaska.
CHAIR COSTELLO asked if his expectation is that nobody from
Alaska would go to Florida, for example, to investigate a matter
relating to a physician living and practicing in Florida who
also is licensed in Alaska and provides telemedicine services.
SENATOR MICCICHE said the Department of Health and Social
Services is better equipped to answer the question, but his
understanding is the processes would take place in Alaska.
SENATOR GIESSEL asked for clarification on the procedure the
State Medical Board uses to license physicians. She suggested
the Division of Corporations, Business, and Professional
Licensing could probably answer both questions.
She asked Mr. Kopp if he is suggesting that the Alaska Native
Tribal Health Consortium (ANTHC) may have prescribing primary
care physicians or nurse practitioners who are located out of
state.
MR. KOPP confirmed that ANTHC partners with multiple out-of-
state physicians.
2:08:45 PM
SENATOR STEVENS said he looks forward to hearing the process for
non-Alaskans to get an Alaska license to practice medicine.
MR. KOPP referenced the 1/22/16 memo from DHSS that identifies a
severe shortage of available providers of psychiatric care and
high quality behavioral health that is exacerbated by the
instate requirement. Their perspective is that the instate
requirement must be removed. The sponsor feels that another
purpose of the bill is to facilitate what is already being done
to save millions of dollars.
CHAIR COSTELLO shared the story of a constituent whose son
refused to go to the doctor's office so he didn't get the
medication he needed. Medicaid wouldn't reimburse without an
office visit and the doctor was unwilling to make a house call
because Medicaid doesn't reimburse for travel. She asked if the
bill would address that situation.
MR. KOPP said that's outside the scope of the bill but it
highlights an issue with reimbursement for telemedicine
services.
2:12:44 PM
SENATOR GIESSEL commented on the barriers to behavioral health
care in this state related to the requirement to have a
psychiatrist on site 30 percent of the time.
SENATOR MICCICHE clarified that the bill expands the existing
telemedicine services provided in Alaska to physicians who are
located outside the state.
CHAIR COSTELLO asked Ms. Hovenden to respond to the previous
questions.
2:15:04 PM
JANEY HOVENDEN, Director, Division of Corporations, Business and
Professional Licensing, Department of Commerce, Community and
Economic Development (DCCED), said the State Medical Board does
in person interviews at the time of complete licensure.
CHAIR COSTELLO asked if that would change if the bill were to
pass.
SARAH CHAMBERS, Operations Manager, Division of Corporations,
Business and Professional Licensing, Department of Commerce,
Community and Economic Development (DCCED), said the bill
doesn't change the procedures of licensure. The expectation is
that the applicant would come to Alaska at their discretion to
attend a board meeting for the interview.
CHAIR COSTELLO asked how many individuals are in the que for
licensure in Alaska.
MS. CHAMBERS said she didn't know but without additional
resources the division wouldn't be able to maintain service
levels. That is what happened when the last telemedicine bill
passed and applications doubled. The bill would open the door to
allow doctors across the nation and other parts of the world to
practice in Alaska.
SENATOR STEVENS asked about the composition of the State Medical
Board, how often it meets, and if this wouldn't be an enormous
addition to its responsibilities.
MS. CHAMBERS estimated there are 7-9 members, primarily
different physicians with different specialties and 1 or 2
public members. The physicians are all licensed in Alaska and
she believes all the members are Alaska residents.
The board typically meets quarterly. To maintain efficient and
expedited services for Alaskans, the expectation is that the
board would need to extend its meetings to accommodate the in-
person interviews to obtain permanent licensure. The process to
obtain a temporary license is shorter, but could not be granted
again if permanent licensure isn't pursued. The expectation is
that there would be a dramatic increase in volume and complexity
as a result of working with doctors nationwide.
MS. CHAMBERS told the committee that a number of out-of-state
physicians visit Alaska to work in rural areas for limited
amounts of time, but wouldn't be able to find fulltime work. She
mentioned psychiatrists and cardiologists as examples. She
offered her belief that a large number of professionals are
anticipating this bill.
CHAIR COSTELLO asked Ms. Chambers to review the department's
fiscal note.
MS. CHAMBERS said the fiscal note anticipates $343 thousand in
personal services for two full-time licensing examiners and two
full-time investigators. Specific travel needs were not factored
in, but there is $148.6 thousand for legal services related to
investigations in the second and subsequent years. The setup
support for the new staff members is $52.5 thousand with an
additional $20 thousand in commodities for computers and office
furniture. In FY2017 the fiscal note totals $415.5 thousand and
$491.6 in subsequent years.
CHAIR COSTELLO asked how extensive she expects regulation
drafting will be if the bill were to pass.
2:24:08 PM
MS. CHAMBERS replied the expectation is that all five boards
would need to draft regulations for a cost of approximately
$10,000. That is worked into the fiscal note.
SENATOR STEVENS asked if disciplinary actions in other states
would impact the individual's ability to work in Alaska.
MS. CHAMBERS explained that there is a national database of
disciplinary actions so an Alaska board would immediately know
if a disciplinary board in another state had a finding or took
action on a license. Responding to a further question, she said
Alaska investigators would pursue any complaint filed by an
Alaskan through the telemedicine company, the state of
licensure, or private practice in another state.
CHAIR COSTELLO asked which of the boards affected by the bill
are operating in the red and which in the black.
MS. CHAMBERS offered to follow up with the information.
CHAIR COSTELLO listed the individuals available to answer
questions.
SENATOR GIESSEL asked if Medicaid reimburses for services from a
telehealth provider and how that's done if the provider is
outside the state.
2:28:39 PM
MARGARET BRODIE, Director, Division of Health care Services,
Department of Health and Social Services (DHSS), confirmed that
Medicaid reimburses for telehealth services. She reported that
telehealth services increased 400 percent between FY2010 and
FY2014. The telehealth provider bills the same as for an office
visit, but using other codes.
SENATOR GIESSEL asked the mechanism for reimbursing out-of-state
telehealth providers.
MS. BRODIE replied it is the same mechanism. She added that the
majority of providers of telehealth services to Medicaid
recipients are the regional tribal health corporations.
SENATOR GIESSEL summarized her understanding that the federal
government would pay 100 percent of the reimbursement for that
Medicaid service and the telehealth provider probably is part of
the Indian Health Service.
MS. BRODIE agreed that's the case the majority of the time.
However, it is sometimes necessary to go outside the system to
find providers.
SENATOR GIESSEL asked if Alaska receives the money because the
client is an Alaskan living in Alaska.
MS. BRODIE said the majority of telehealth services are
conducted through video, so there are two charges: a facility
fee within Alaska and also payment for the actual telehealth
service outside Alaska.
CHAIR COSTELLO asked if the department would bill the Indian
Health Service for the relevant Alaska portion.
MS. BRODIE explained that Alaska Natives and American Indians
participating in tribal health also could use tribal health
systems in other states.
SENATOR MEYER asked if Medicaid reimburses at the Alaska rate or
Arizona rate for a non-Native using telehealth services from a
provider from Arizona.
MS. BRODIE replied the payment would be based on the lowest
rate.
2:32:41 PM
CHAIR COSTELLO asked if there is ever an instance where the
outside rate is lower than the Alaska rate.
MS. BRODIE answered yes, for certain services.
2:33:20 PM
At ease
2:33:24 PM
CHAIR COSTELLO reconvened the meeting and invited Dr. Powers to
provide testimony.
DR. DAVID POWERS, member State Medical Board and practicing
physician in Dillingham said he is just finishing his second and
final term on the board. He reviewed his professional career in
Alaska and said he doesn't expect the bill will make much
difference in rural areas because telemedicine technology has
been used there since it became available. Access is equally
available for Natives and non-Natives.
He said the philosophical disagreement the State Medical Board
has with this legislation is that it does away with the
requirement that the provider is either with the patient or
there is a preexisting relationship between the provider and the
patient. Doing away with the physical exam places an additional
burden on the provider because there's a greater chance of
making a mistake. He said the first best is the doctor and
patient in the room, the second best is a doctor treating a
patient remotely with a health provider also present, and the
third best is a doctor talking to a patient without the benefit
of a physical exam or another provider with the patient. The
board perceives this legislation to fall below the standard that
has been present in the state for many years.
DR. POWERS also commented on the drafting style and questioned
why it was written in the negative.
2:38:54 PM
SENATOR STEVENS asked if this legislation would significantly
add to the responsibilities of the board and how they'd handle
that.
DR. POWERS answered yes and there already aren't enough license
examiners to process applications. The board used to interview
every applicant but that's no longer possible. They do, however,
interview license applicants if there are questions about their
education or license or there's a red flag for some reason.
SENATOR STEVENS asked how the board would treat a non-resident
applicant who was under investigation or threat of disciplinary
action. Would the applicant be denied a license to practice in
Alaska and is the board able to follow through on such
disciplinary actions?
DR. POWERS said the board would want to be party to an
investigation in another state because it would directly affect
the individual's ability to deliver health care in Alaska.
SENATOR STEVENS asked how much time he devotes to medical board
business.
DR. POWERS estimated he spends 10 hours per week and also
attends quarterly meetings that generally last two days.
SENATOR STEVENS thanks Dr. Powers for his testimony and years of
service to Alaska.
2:42:35 PM
SENATOR GIESSEL asked for clarification of a previous statement
that the State Medical Board accepted the concept of not having
boots on the ground in Alaska.
DR. POWERS said that's correct and pointed out that a lot of
people in rural Alaska lost access to psychiatric health care
overnight when the previous telemedicine bill passed. It
probably wasn't the drafter's intent, but providers outside
Alaska interpreted the language to prohibit someone outside the
state from providing telemedicine.
SENATOR GIESSEL asked if the State Medical Board has any
concerns about a physician in Florida prescribing antibiotics to
a client in Nome for sinusitis, for example.
DR. POWERS replied that's probably the board's biggest concern.
The reason is that it's impossible to diagnose some things over
the phone, a computer screen, or even video teleconference. He
listed sinusitis, strep throat, and ear infection as impossible
to diagnose without an in-person examination. It leads to
antibiotic abuse and resistant germs.
SENATOR GIESSEL said that is her concern yet the Teladoc medical
director told her the three main things they treat is
bronchitis, sinusitis, and urinary tract infections (UTIs).
2:45:00 PM
CHAIR COSTELLO asked him to highlight the nature and character
of his testimony. She listed the negative drafting approach;
concern about moving away from the in-person relationship
between the doctor and patient. She asked if he believes
something could be written into the bill to prioritize that
relationship.
DR. POWERS said he'd have to think about that, because it seems
to be at odds with the idea of getting away from a physical
interaction between a doctor and patient.
2:46:56 PM
CLAUDIA TUCKER, Vice President of Government Affairs Teladoc,
Virginia testified in support of SB 98. She related that this is
the nation's first and largest telehealth platform. Enrollees
are connected to a network of over 2,800 board-certified
physicians and mental health providers who have an average of 20
years of physician experience. They treat a wide range of
conditions including upper respiratory infections, urinary tract
infections, influenza, and sinusitis. The physicians are ER
doctors, primary care doctors, pediatricians, and internists
that have active practices. Teladoc has established more than
100 proprietary, evidence-based clinical guidelines specifically
designed for telehealth. The highest credentialing requirements
have been implemented to ensure quality interactions and
reliable resolutions.
She reported that after 10 years of service and over 1 million
telehealth visits, Teladoc has not been subject to a single
malpractice claim. They have over 28,000 members in Alaska from
over 200 companies.
MS. TUCKER described SB 98 as well thought out legislation that
considers patient safety and access to less expensive, quality
health care for simple non-emergency illnesses. She highlighted
that Alaska and Louisiana are the only states that require
telemedicine physicians to be a resident of the state in which
they practice, and Louisiana is reconsidering that policy this
legislative session. She questioned why a physician licensed in
Alaska who moves to Washington state should no longer be
permitted to practice medicine in Alaska. She pointed out that
the State Medical Board would still have jurisdiction and
oversight over the licensee.
Referencing the concern that allowing out of state physicians to
use telemedicine in Alaska would take business away from
physicians in Alaska, she said there currently aren't enough
physicians to meet the demand. The shortage of psychiatrists and
mental health providers is even more dramatic. The federal
government has designated much of Alaska as medically
th
underserved. It ranks 48 in the nation in the ratio of doctors
to residents, and 55 percent of the physicians practice in
Anchorage. Requiring physicians licensed in Alaska to reside in
Alaska in order to practice does nothing to address the shortage
or increase access to quality health care in rural Alaska. In
fact, the requirement is in conflict with the Federation of
State Medical Boards licensure compact policy. She confirmed
previous testimony that Alaskans covered through federal
programs already have access to physicians outside the state.
Removing the in-state requirement would allow all Alaskans to
enjoy this benefit.
2:52:18 PM
Addressing questions that were previously asked, Ms. Tuck said
Teladoc does not prescribe any controlled substance or lifestyle
drug. The Ryan Haight Act prohibits any prescription drug from
being issued without at least one in-person assessment. She
agreed with previous testimony that any disciplinary actions
filed in Alaska would be under the jurisdiction of the State
Medical Board. She expressed hope that Alaska would pass SB 98
joining the other 36 states that have enacted good telemedicine
policies.
SENATOR STEVENS asked for examples of lifestyle drugs.
MS. TUCKER said Viagra and birth control pills both fall in that
category.
SENATOR GIESSEL questioned how a provider in the Teladoc network
who lives in Florida would know the resistant strain that might
exist in a remote, rural community in Alaska.
MS. TUCKER said it goes back to the standard of care and a
physician's discretion. If, after the patient presents and the
medical history is before him, the physician believes the
patient has sinusitis he has the ability to write the
prescription. She noted that Teladoc has a 94 percent
satisfaction rate and the reason 6 percent of patients expressed
dissatisfaction is because the physician didn't write the
prescription the patient wanted.
SENATOR GIESSEL pointed out that sinusitis can't be diagnosed
without imaging and antibiotics are over-prescribed in that
scenario. She questioned how a provider in the Teladoc network
who lives in Florida would know what the susceptibility patterns
are for UTIs in Alaska.
MS. TUCKER described an example to illustrate that there are
parameters for prescribing antibiotics for UTIs. The Teladoc
physician looks at the patient's history, her age, history of
UTIs and previous diagnosis during an in-person doctor-patient
visit. Protocol says it would be perfectly fine for a physician
to diagnose that patient without an in-person visit. She offered
to share the data and research that supports this.
Addressing a previous question, she explained that Teladoc
encourages patients to use a primary care provider. They don't
want to serve in that capacity and to ensure they don't, they
limit access to Teladoc to three times in five months and eight
times a year. About 40 percent of patients that approach Teladoc
don't have a primary care physician and Teladoc encourages them
to find one and explains why it's important.
3:00:20 PM
SENATOR GIESSEL asked if Teladoc limits the types of treatment.
MS. TUCKER replied they treat simple non-emergency illnesses.
SENATOR GIESSEL asked if Teladoc treats migraines over the
phone.
MS. TUCKER said it would depend on a previous in-person
diagnosis and the medication that was prescribed.
SENATOR GIESSEL asked if Teladoc provides behavioral health
services.
MS. TUDKER answered yes and reiterated that they do not
prescribe controlled substances.
SENATOR GIESSEL asked how Teladoc keeps patient records secure.
MS. TUCKER explained that patients upload their medical history
to Teladoc's HIPPA compliant, secure platform. This is the
patient's record and they have 24/7 access. Teladoc asks
patients for permission to send the record of the consultation
to their primary care provider (PCP). With the patient's
permission, the PCP also has access to those records.
3:03:50 PM
JOHN JESSER, Vice President of Provider Engagement Strategy,
Anthem Inc., Indianapolis, Indiana, explained that Anthem is a
large health insurance company that markets Blue Cross plans in
14 states and Medicaid plans in about 19 states through
Amerigroup. He leads the telehealth part of the business called
LiveHealth Online. He described the technology platform they use
that provides everything that happens in a doctor's office other
than the physical hands on the patient. There's a permanent
record of the visit and electronic prescription and the claim is
submitted to the health plan. The doctor has live, high
definition video on their computer or tablet and the patient and
doctor can see each other. The physicians are board certified in
the states where the patients reside. He noted the handout that
was provided to the committee that shows Anthem is live in 47
states, but not Alaska. He said Anthem got involved in
telemedicine for three reasons: access to care, affordability of
health care, and consumer convenience.
MR. JESSER listed the employers that use LiveHealth Online and
noted that those that do business in Alaska are continually
asked when it will be available in Alaska. He appreciates Dr.
Powers' comments but he works with a number of physicians that
feel differently. He described a study they conducted that shows
an average savings of $201 per telehealth visit, which is of
great interest to employers that pay health care costs.
LiveHealth Online meets 100 percent of the Federation of Medical
Board guidelines for safe and effective telehealth. Patients are
matched with a doctor that is licensed in the patient's state,
the patient has a choice of physician, and controlled substances
and lifestyle drugs may not be prescribed. The concerns of
medical boards in many states have been alleviated sufficiently
to comfortably say a live video visit is adequate to establish a
patient-physician relationship and for the doctor to use their
judgement to prescribe.
By the end of 2016 LiveHealth Online will offer telehealth
services to close to 20 million covered lives, but not in
Alaska. They also offer these services to Medicare Advantage
members in 12 states.
3:12:20 PM
SENATOR GIESSEL asked how LiveHealth Online provides the visual
to remote areas in the states they cover.
MS. JESSER said it works with 4G wireless and often with 3G but
the video is more apt to drop. They support work going on to
expand WIFI in rural areas and in some states they're working to
make this available in a library or public school where there is
WIFI. He noted that there is also a need in urban areas. They
are also offering this to primary care doctors to use this for
their patients. This is the ideal but those doctors aren't going
to be available 24/7 and this keeps the patient from running to
the emergency room for something that's simple, he said.
3:15:16 PM
ROBIN MINARD Director of Public Affairs, Mat-Su Health
Foundation, Wasilla, Alaska, testified in support of SB 98. She
described a community health needs assessment that the
foundation conducted in 2013. The top five goals were related to
access to behavioral health care. The data collected in a
subsequent behavioral health environmental scan indicated that
residents do not have adequate access to vital behavioral health
care. This is a statewide problem. Telemedicine is a proven
method to increase access to health care and reduce costly
visits to emergency rooms. SB 98 reflects successful evidence-
based practices that can ease the access issues facing Mat-Su
and the rest of Alaska.
3:17:20 PM
CHAIR COSTELLO said she would hold public testimony open.
3:17:46 PM
SENATOR MICCICHE said his goal is to bring down the cost of
health care without compromising the quality of care. As with
most aspects of Medicaid reform, there is some resistance, he
said. Some is based on real concerns that need to be evaluated.
He pointed out that the licensing fees are receipt supported. He
would like a preference for in-state physicians to be licensed
first, but he didn't know if it would be constitutional. He
noted that Dr. Powers made a statement about changing the
doctor-patient relationship, but telehealth is already in law.
This bill simply expands that law to physicians residing outside
Alaska.
He acknowledged that the bill was drafted in the negative and
said he was in favor of changing that if there is a way. He
concluded saying the bill is designed for a positive outcome in
providing additional health care in Alaska and reducing the cost
while doing so.
CHAIR COSTELLO held SB 98 in committee with public testimony
open.
3:20:57 PM
There being no further business to come before the committee,
Chair Costello adjourned the Senate Labor and Commerce Standing
Committee meeting at 3:20 p.m.