02/13/2014 01:30 PM Senate LABOR & COMMERCE
| Audio | Topic |
|---|---|
| Start | |
| SB129 | |
| SB80 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| *+ | SB 80 | TELECONFERENCED | |
| *+ | SB 129 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
SENATE LABOR AND COMMERCE STANDING COMMITTEE
February 13, 2014
1:32 p.m.
MEMBERS PRESENT
Senator Mike Dunleavy, Chair
Senator Peter Micciche, Vice Chair
Senator Donald Olson
Senator Bert Stedman
MEMBERS ABSENT
Senator Johnny Ellis
COMMITTEE CALENDAR
SENATE BILL NO. 129
"An Act extending the termination date of the Board of Certified
Real Estate Appraisers; and providing for an effective date."
- HEARD & HELD
SPONSOR SUBSTITUTE FOR SENATE BILL NO. 80
"An Act relating to the practice of telemedicine; relating to
licenses for out-of-state physicians or podiatrists to practice
telemedicine in this state under certain circumstances; and
relating to insurance coverage for telemedicine."
- HEARD & HELD
PREVIOUS COMMITTEE ACTION
BILL: SB 129
SHORT TITLE: EXTEND BOARD OF REAL ESTATE APPRAISERS
SPONSOR(s): RULES BY REQUEST OF LEG BUDGET & AUDIT
01/22/14 (S) READ THE FIRST TIME - REFERRALS
01/22/14 (S) L&C
02/13/14 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
BILL: SB 80
SHORT TITLE: OUT-OF-STATE PHYSICIAN LICENSE
SPONSOR(s): DYSON
03/15/13 (S) READ THE FIRST TIME - REFERRALS
03/15/13 (S) L&C, FIN
04/03/13 (S) SPONSOR SUBSTITUTE INTRODUCED-REFERRALS
04/03/13 (S) L&C, FIN
02/13/14 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
WITNESS REGISTER
SENATOR ANNA FAIRCLAUGH
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Sponsor of SB 129.
KRIS CURTIS, Legislative Auditor
Legislative Audit Division
Legislative Affairs Agency
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Testified on SB 129 to describe the sunset
review of the Board of Certified Real Estate Appraisers.
CHUCK KOPP, Staff
Senator Fred Dyson
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Introduced SB 80 on behalf of the sponsor.
HENRY DEPHILLIPS, MD., Chief Medical Officer
Teladoc, Inc.
Greenwich, Connecticut
POSITION STATEMENT: Testified as a subject matter expert on the
telemedicine industry in support of SB 80
DON HABEGER, Director
Division of Corporations, Business, and Professional Licensing
Department of Commerce, Community and Economic Development
Juneau, Alaska
POSITION STATEMENT: Provided information relevant to SB 80
ACTION NARRATIVE
1:32:48 PM
CHAIR MIKE DUNLEAVY called the Senate Labor and Commerce
Standing Committee meeting to order at 1:32 p.m. Present at the
call to order were Senators Stedman, Micciche, and Chair
Dunleavy. Senator Olson arrived during the course of the
meeting.
SB 129-EXTEND BOARD OF REAL ESTATE APPRAISERS
1:33:28 PM
CHAIR DUNLEAVY announced the consideration of SB 129. "An Act
extending the termination date of the Board of Certified Real
Estate Appraisers; and providing for an effective date."
1:33:40 PM
SENATOR ANNA FAIRCLAUGH, sponsor of SB 129, introduced the bill
explaining that it extends the Board of Certified Real Estate
Appraisers ("Board") for four years from June 30, 2014 to June
30, 2018. The extension is for just four years to ensure that
the new federally mandated responsibilities are appropriately
instituted and that the board has the support staff to do its
duties.
1:35:25 PM
KRIS CURTIS, Legislative Auditor, Legislative Audit Division,
Legislative Affairs Agency, Alaska State Legislature, Juneau,
Alaska, explained that the agency conducted a sunset review of
the Board of Certified Real Estate Appraisers to determine
whether it was serving the public's interest and whether it
should be extended. The audit determined overall that BCREA is
protecting the public's interest by effectively licensing and
regulating real estate appraisers. The Board monitors licensees
to ensure that only qualified individuals practice and adopts
regulatory changes to improve the real estate appraisal
profession in Alaska. The Board is scheduled to terminate June
30, 2014 and Legislative Audit is recommending an extension of
only four years due to the increase in federally mandated
responsibilities.
MS. CURTIS reported that the audit included two recommendations
for operational improvements, both of which were directed to the
Division of Corporations, Business and Professional Licensing
(DCBPL) within the Department of Commerce, Community, and
Economic Development. The first recommendation was to improve
administrative support to the Board by addressing delays in
investigations. The second was for the director of the division
to improve the investigative case management system.
The audit found that the investigative case management system
does not fully support the investigative unit. It was purchased
with the expectation that it would be immediately functional as
a case management tool, but it is deficient due to software
limitations and a lack of procedures. Both DCBPL and the Board
concur with the audit recommendations.
1:36:28 PM
CHAIR DUNLEAVY recognized that Senator Olson joined the
committee.
CHAIR DUNLEAVY stated that public testimony would remain open
and he would hold SB 129 in committee for further consideration.
SB 80-OUT-OF-STATE PHYSICIAN LICENSE
1:38:08 PM
CHAIR DUNLEAVY announced the consideration of SSSB 80. "An Act
relating to the practice of telemedicine; relating to licenses
for out-of-state physicians or podiatrists to practice
telemedicine in this state under certain circumstances; and
relating to insurance coverage for telemedicine." He asked for a
motion to adopt the work draft committee substitute (CS) for
SSSB 80.
SENATOR MICCICHE moved to adopt CS for Sponsor Substitute for SB
80, labeled 28-LS0615\P, as the working document.
CHAIR DUNLEAVY objected for discussion purposes.
1:38:33 PM
CHUCK KOPP, Staff, Senator Fred Dyson, introduced CSSSSB 80 on
behalf of the sponsor. He spoke to the following sponsor
statement: [Original punctuation provided.]
CS SSSB 80 introduces into Alaska's Medical Practice
Act the practice of telemedicine, sets parameters for
prescription of controlled substances without an in-
person contact between physician and patient,
establishes a definition for telemedicine, and
provides that health care insurers may not require in-
person contact between a health care provider and a
patient before payment is made for services. With
Alaska's large rural and remote areas, the need for
telemedicine is especially acute with much of the
state designated as medically underserved by the
federal Health Resources and Services Administration.
CS SSSB 80 will provide expanded opportunity for
health care delivery for individuals and businesses
throughout Alaska. Today, the only delivery of
telehealth in Alaska is via the Alaska Federal Health
Care Access Network (AFHCAN), established in 1998 to
provide telehealth services for Federal beneficiaries
in Alaska, including Alaska Natives. The Alaska Native
Tribal Health Care Consortium (ANTHC) manages the
telehealth program and provides statewide health and
information technology services to Alaska Natives and
American Indians, in addition to supporting local
tribal health organizations. CS SSSB 80 will allow the
cost-savings and efficiencies of telehealth to be
delivered to the many other constituencies in Alaska
that do not qualify to participate in the ANTHC
telehealth program.
In Alaska and nationwide, the ongoing discussion of
how to provide greater access to health care at a
reasonable cost is becoming ever more relevant.
Telemedicine is emerging as a key element in the
delivery of health services to children, seniors and
other vulnerable populations through the integration
of technology and provider care. The Patient
Protection and Affordable Care Act is leading to
increased demand that physicians interact with more
patients. Telemedicine allows physicians to consult
with more patients, and enables patients to meet with
their physicians in a shorter time period. In terms of
economic advantages, telemedicine saves travel time
and expense for patients who otherwise have to leave
home and work to see a health care provider, provides
for more timely diagnosis of ailments, and reduces
unnecessary ER visits.
MR. KOPP highlighted the changes between the CS and the original
version of the bill.
Section 1 adds a new Sec. 08.64.245 in the Medical Practice Act
establishing the practice of telemedicine.
Section 2 establishes three rules for prescribing, dispensing or
administering prescription drugs without a physical examination
if 1) the prescription drug is not a controlled substance; 2)
the physician is located in-state and available to provide
follow-up care; and 3) the person receiving the care consents to
sending a copy of the records of the encounter to their primary
care provider if the prescribing physician is not their primary
care provider, and the physician sends the records to the
person's primary care provider.
This section no longer has the original license provision for an
out-of-state licensing option for out-of-state physicians to
practice the delivery of telemedicine within the state.
Section 3 adds a new paragraph (7) to AS 08.64.380 to define the
practice of telemedicine.
Section 4 adds a new Sec. 21.54.102 that provides that an
insurance company may not require an in-person visit between a
physician and patient before payment for services is covered.
Section 5 provides an effective date for the Act.
1:43:28 PM
MR. KOPP noted that Premera Blue Cross recommended that the bill
state that if an insurance plan provides coverage for
telemedicine, then prior in-person contact between a health care
provider and a patient is not mandated to receive coverage for
that service. The sponsor agreed.
1:44:16 PM
SENATOR OLSON asked if the Medical Board is in favor of the
bill.
MR. KOPP said that the Medical Board opposed the initial
legislation that included the out-of-state license. They have
not articulated their position since that provision was removed.
The State Medical Association is neutral on the legislation.
Responding to a further question, he said he hasn't spoken with
the Alaska Physicians & Surgeons Association.
SENATOR OLSON referenced the reporting requirements in Section 2
and asked what happens if a person doesn't have a primary care
physician.
MR. KOPP explained that if there is no primary health care
provider, the requirement that the records be forwarded would
not be necessary.
SENATOR OLSON asked how Indian Health Service (IHS) patients in
rural Alaska participate in this program.
MR. KOPP said any IHS-eligible person is eligible through the
Alaska Federal Healthcare Access Network (AFHAN) [that is
managed by the Alaska Native Tribal Health Care Consortium.] The
bill expands the law to apply to anybody who is not a federal
entity and is not otherwise in an eligible class such as Alaska
Native.
SENATOR MICCICHE stated support for the provision that prohibits
prescribing controlled substances telephonically.
1:47:26 PM
At ease
1:48:12 PM
CHAIR DUNLEAVY reconvened the hearing.
1:48:22 PM
HENRY DEPHILLIPS, MD., Chief Medical Officer, Teladoc, Inc.,
Greenwich, Connecticut, stated that he was speaking primarily as
a subject matter expert on the telemedicine industry. He would
clarify when his comments were specific to Teladoc.
SENATOR MICCICHE noted the substance abuse issues in Alaska and
asked Dr. DePhillips to discuss the reasons that the bill
prohibits prescribing controlled substances.
DR. DEPHILLIPS explained that the telemedicine industry
typically uses the standard of not allowing the prescription of
any Drug Enforcement Administration (DEA) controlled substances.
Telemedicine is relatively new to the medical field and most of
the companies in the industry understand that the bar needs to
be fairly high. Thus, the industry excludes DEA defined
controlled substances at both the federal and state level.
SENATOR MICCICHE asked Dr. DePhillips to discuss the cross
coverage exemption and how this isn't overstepping the bounds of
current practice.
DR. DEPHILLIPS explained that to combat Internet prescribing
scams that cropped up in the 1990s, most state medical boards,
including Alaska's, instituted a prior in-person visit
requirement for physicians. This was very successful, but in
about 2005 it occurred to some folks that cross covering was
technically a violation of the prior in-person visit
requirement.
To address this technical violation, many state medical boards
have said that physicians who agree to cross cover one another
may treat the patient over the phone or remotely without a prior
in-person visit. However, legislation such as SB 80 is needed
because there has been a difference of interpretation of that
segment of the rules.
DR. DEPHILLIPS explained that counsel for Teladoc did an
evaluation of the regulations on a state-by-state basis and came
to the conclusion that Teladoc and its competitors are a
physician cross coverage service, and would therefore qualify
under the cross coverage exception to the prior in-person visit
requirement. Most of the telemedicine companies have operated
this way in most states, but occasionally a medical board has
intervened with one of the physicians. That happened in Alaska
when the State Medical Board intervened with a Teladoc
physician.
Teladoc was unable to come to a mutual agreement with the State
Medical Board and decided to take a legislative approach. The
premise is that the quality of the cross coverage service in the
telemedicine industry is at least equal to traditional cross
coverage. The data supports this. Teladoc has done more than
half a million consults with 15 million Americans in a
telemedicine program without any liability issues. Patient
safety and patient care has not been compromised.
DR. DEPHILLIPS highlighted that the Rand Corporation conducted
and published an independent study in the journal Health Affairs
just last week. It talked about the fact that telemedicine
reduces emergency room use for non-emergency problems, improves
access for patients who don't have a primary care physician, and
improves access for patients who can't get to their primary care
physician timely. He encouraged the committee members to review
the summary of that study.
1:55:30 PM
SENATOR MICCICHE asked him to discuss choosing the right
treatment for a particular malady.
DR. DEPHILLIPS explained that the telemedicine industry generally
treats common, uncomplicated medical problems that are unlikely to
become complex or worrisome. The general process is that a call comes
in to a call center either telephonically or online requesting a
consultation. The person indicates their location, age and the nature
of the request. A medical history is required at the beginning of the
process and the patient does not receive access to a physician until
that medical record is complete. Then the case is sent to the
appropriate licensed physician and he/she reviews the medical record.
Teladoc, and perhaps other companies, requires the physician to
review the data in the medical record before he/she is given access
to the patient for the consultation visit. There is a real time
interaction and if the physician has any level of discomfort, he/she
is empowered to tell the patient he/she must see a physician in
person. Teladoc statistics show that this happens about four percent
of the time. He noted that the physician gets paid for rendering care
regardless of the recommendation so that doesn't enter into the
decision.
1:59:12 PM
SENATOR OLSON asked Dr. DePhillips where he went to medical
school
DR. DEPHILLIPS replied he attended Hahnemann University that is
now known as Drexel University in Philadelphia, Pennsylvania. He
is a board certified family physician, licensed in Tennessee.
SENATOR OLSON asked him to discuss the State Medical Board
objections to out-of-state physicians essentially practicing in
the state.
DR. DEPHILLIPS explained that the perceived concern is that the
care of the citizens of Alaska will start going, through
telemedicine, to physicians in other states. The legislation
addresses this concern with the requirement that the physician
taking the consultation must be licensed in Alaska and a
resident in the state of Alaska. Teladoc is comfortable with the
requirement and that is their business model.
Alaska and other medical boards have also voiced concern about
patient safety, but two data points argue against that. First is
the cross coverage situation that has existed for decades. The
second is the more than half a million consultations that have
been done through telemedicine without a bad outcome or even a
liability claim. He opined that the requirement for an in-person
visit with the primary physician was a good idea about 15 years
ago, but technology has come to a point where it's appropriate
to set that aside.
2:03:04 PM
SENATOR OLSON spoke to the difficulty of getting people from
outside Alaska to appreciate what remote living actually means.
He cited the example of an elderly person having an anaphylactic
reaction and asked about protection for that person.
DR. DEPHILLIPS said the same risk exists for a person who visits
a physician in person; they might go home, take the first dose
of a prescription medicine, and have an anaphylactic reaction.
The safeguard in telemedicine is that the consulting physician
can tell the patient they need an in-person visit.
2:05:48 PM
SENATOR OLSON pointed out that somebody in a remote location who
is complaining of chest pain might not have the option of vising
a physician in person.
DR. DEPHILLIPS maintained that having telephonic or audio visual
access to a physician is a step in the right direction if
implemented well. Responding to a further question, he
reiterated that Teladoc provides the liability insurance for its
doctors and has never had a claim.
SENATOR OLSON asked about protection when someone is on a boat
outside the bounds of state waters and subsequently enters state
waters.
DR. DEPHILLIPS said that in public safety and most professions
there is a justification defense for emergencies.
SENATOR MICCICHE asked if there isn't a waiver for emergency
treatment in most situations.
DR. DEPHILLIPS said he isn't an attorney but the Good Samaritan
rule exists in many, but not all, places.
SENATOR OLSON related a personal story of getting sued after
rendering help.
2:08:57 PM
DON HABEGER, Director, Division of Corporations, Business, and
Professional Licensing, Department of Commerce, Community and
Economic Development (DCCED), explained that the State Medical
Board promulgated a regulation that addresses emergency
situations. It says that prescribing, dispensing, and furnishing
prescription medication is excluded for use in emergency
situations.
2:09:56 PM
CHAIR DUNLEAVY removed his objection. Finding no further
objection, he stated that CSSSSB 80 was adopted.
SHEELA TALLMAN, Senior Manager of Legislative Policy, Premera
Blue Cross, offered to answer questions. There were none.
CHAIR DUNLEAVY found no public testimony.
SENATOR OLSON said he'd like to hear the State Medical Board's
opinion of the committee substitute.
MR. KOPP said the sponsor has requested that.
CHAIR DUNLEAVY announced he would keep public testimony open and
hold SB 80 in committee for further consideration.
2:11:26 PM
There being no further business to come before the committee,
Chair Dunleavy adjourned the Senate Labor and Commerce Standing
Committee meeting at 2:11 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| 4 SS SB80.pdf |
SL&C 2/13/2014 1:30:00 PM |
SB 80 |
| 2 CS SS SB80 - An Act relating to practice of telemedicine.pdf |
SL&C 2/13/2014 1:30:00 PM |
SB 80 |
| 1 CS SSSB 80 - Sponsor Statement.pdf |
SL&C 2/13/2014 1:30:00 PM |
SB 80 |
| 3 CS for SSSB80 - Section Analysis.pdf |
SL&C 2/13/2014 1:30:00 PM |
SB 80 |
| SB 129 Ver A.pdf |
SL&C 2/13/2014 1:30:00 PM |
SB 129 |
| SB 129 Sponsor Statement.pdf |
SL&C 2/13/2014 1:30:00 PM |
SB 129 |
| SB 129 Supp Doc-DCCED BCREA Audit 2013.pdf |
SL&C 2/13/2014 1:30:00 PM |
SB 129 |
| CS SSSB 80 - Letter of Support.PDF |
SL&C 2/13/2014 1:30:00 PM |
SB 80 |
| Telemedicine saves dollars and makes sense for Alaskans.pdf |
SL&C 2/13/2014 1:30:00 PM |
CS SS SB80 |
| SB080SS-DCCED-CBPL-02-07-14.pdf |
SL&C 2/13/2014 1:30:00 PM |
SB 80 |