HB 117-EXTEND BOARD OF DIRECT-ENTRY MIDWIVES  4:02:18 PM CO-CHAIR FIELDS announced that the first order of business would be HOUSE BILL NO. 117, "An Act extending the termination date of the Board of Certified Direct-Entry Midwives; and providing for an effective date." 4:02:28 PM REPRESENTATIVE DAN ORTIZ, Alaska State Legislature, introduced HB 117 as prime sponsor. He explained that the bill would extend the termination date for the Board of Certified Direct- Entry Midwives to June 30, 2023, as recommended by the Division of Legislative Audit (DLA). He said that the board is composed of five members: two direct-entry midwives, one physician, one certified nurse midwife, and one public member. Statute dictates the responsibilities of the board, he said, which include examining and issuing certificates and permits, establishing regulations for certification and practice requirements, ordering disciplinary actions, and approving curricula and standards for education and training. He noted that the bill has a nearly $22,000 fiscal note, which would be paid for by the revenue from license fees. 4:04:33 PM KRIS CURTIS, Legislative Auditor, Legislative Audit Division, presented the legislative audit [included in the committee packet] on the Board of Direct-Entry Midwives, titled "A Sunset Review of the Department of Commerce, Community, and Economic Development, Board of Certified Direct-Entry Midwives (board)." She explained that the purpose of the audit is to discover whether the board is serving the interests of the public and whether it should be extended. She read the report conclusions on page i of the audit, which read as follows [original punctuation provided]: Overall, the audit concluded that the board served the public's interest by conducting meetings in accordance with state laws and effectively certifying midwives. The board adopted regulatory changes to improve the profession, but failed to pursue statutory changes due to concerns over related costs. Additionally, the audit found the peer review process was not effectively monitored by the board and improvements were needed over the Division of Corporations, Business and Professional Licensing's (DCBPL) investigative process. In accordance with AS 08.03.010(c)(8), the board is scheduled to terminate on June 30, 2021. We recommend the legislature extend the board's termination date two years, to June 30, 2023, which is significantly less than the eight-year maximum allowed in statute. The reduced extension is due to an issue identified during the audit that may impact the board's ability to protect the public and the board's reluctance to recommend statutory changes in the public's best interest. The details of the issue are not included in this report to preserve the confidentiality of an ongoing investigation. The reduced extension reflects the need for continued oversight. MS. CUTRIS then directed attention to page 7 of the audit, which shows a scheduling of licensing statistics. She noted that there were 51 certified midwives and apprentices as of January 31, 2020. MS. CURTIS turned to page 8, which depicted the schedule of fees. She said that the fees were raised in fiscal year 2017 (FY 17) to address a deficit, and as a result, the board has one of the highest occupational fees of any occupation. MS. CURTIS turned to page 9, which included a schedule of revenues and expenditures showing that the board had a deficit of just over $19,000 as of January 2020. She explained that at the time of the audit, the management of the Division of Corporations, Business and Professional Licensing (DCBPL) was of the opinion that the deficit would be fully resolved by the end of FY 21. MS. CURTIS read excerpts of the recommendations on pages 11 and 12, which read as follows [original punctuation provided]: Recommendation 1 The board should recommend statutory changes that benefit the public. The board identified a need to change certification statutes to align Alaska's midwifery laws with national standards. However, due to the legal costs involved with the project, the board did not recommend statutory changes. Recommendation 2 DCBPL's chief investigator should ensure investigations are completed timely. Three cases open over 180 days from July 2016 through January 2020 were evaluated by auditors. All three were found to have unjustified periods of inactivity ranging between 54 and 114 days. It was also noted that supervisory review of two of the three cases was not documented as required by DCBPL procedures, indicating review did not occur or did occur and was not documented. According to DCBPL staff, the inactivity was the result of turnover and competing priorities. Recommendation 3 The board should improve oversight of the peer review process. The board delegated peer reviews to the Midwives Association of Alaska's Action and Accountability Committee. However, the board did not establish procedures to provide assurance that reviews were adequately completed. The board did not consider the need for or importance of monitoring the peer review process. According to AS 08.65.030(b), the board may, by regulation, require a CDM undergo a uniform or random period of peer review to ensure quality of care. Inadequate monitoring of the peer review process increases the risk that the reviews will be deficient, which increases the risk to public safety. MS. CURTIS directed attention to page 23, which discussed responses to the audit. She noted that the commissioner of the Department of Commerce, Community and Economic Development (DCCED) did not respond to Recommendations 1 and three because these recommendations were directed only to the board. In response to Recommendation 2, regarding improving the timeliness of investigation, the commissioner shared that the department was adding an additional supervisory position to assist with the caseload. MS. CURTIS directed attention to page 27, which included the board chair's response to the audit. She explained that the chair expressed disappointment with the "short, two-year extension recommendation." Regarding Recommendation 1, to pursue statutory changes when needed, she said that the chair characterized the board's inaction as "justified" because it was a way to reduce costs, and further noted that the board chair expressed that the board should not be penalized for practicing what was characterized as "fiscal responsibility." In response to Recommendation 2, regarding the timeliness of the investigative process, Ms. Curtis said the board chair concurred with the recommendation but was not of the opinion that it should impact the extension recommendation. She said that the board chair concurred with Recommendation 3. 4:10:00 PM BETHEL BELISLE, Chair, Board of Certified Direct-Entry Midwives, said that the audit caused several concerns and discussed the peer review process as addressed in Recommendation 3, which the board delegates to the Midwives Association of Alaska's Action and Accountability Committee (AAC), composed of members of the Board of Certified Direct-Entry Midwives who have been voted in by other members. She explained that when a chart includes certain circumstances, which could include emergency transport, care in the Neonatal Intensive Care Unit (NICU), or the death of a mother and baby, the chart is then submitted to AAC. The committee reviews the chart to determine whether the midwife broke any statutes or regulations; if so, AAC sends the charges to the full board for review. At the time of the audit, she said, there were no charts being sent to the board. In response to the determination by the audit that AAC was not "doing its proper job," the board initiated an audit that called for a complete review of all charts submitted since 2014. She shared that, while the review committee has found nothing to indicate that AAC has failed to do its job, the board has begun the process of revamping the peer review committee, giving midwives the ability to have confidential peer review but giving the board complete oversight over any outcome that requires emergency services in NICU stay or death. MS. BELISLE then addressed the Recommendation 1 from the audit, identified as a need to change certification statutes to align Alaska's midwifery laws with national standards. She characterized this change as "difficult" and expressed that Alaska has always been a leader in the standard of midwifery care, and that all current statutes meet or exceed the Certified Professional Midwife (CPM) model. The licensure fee is $3,800 every two years, she said, and the fiscal responsibility of the board is to pay off debt. She concluded that she would like the board's sunset audit be changed to four years rather than two years, due to the progress that the board has already made. 4:13:42 PM CO-CHAIR FIELDS asked Ms. Belisle to explain the difference between a certified nurse midwife and a certified direct-entry midwife. He then asked whether the legislature's action on HB 117 would have any impact on Alaskans who receive care from certified nurse midwives. MS. BELISLE responded that certified nurse midwives are nurses who have gone through higher education and have a larger scope of practice than certified direct-entry midwives. She said that CDE midwives go through the process of doing an apprenticeship followed by a national exam and have a much narrower scope of practice than certified nurse midwives. She explained that the standard she referenced earlier is called "certified professional midwife," which is a national certification that acknowledges a nurse midwife has met or exceeded a minimal level of practice standards. She stated that a change in the sunset date would not impact certified nurse midwives in any way. 4:15:06 PM CO-CHAIR SPOHNHOLZ asked Ms. Belisle to describe the alignment of educational standards in Alaska to national standards, and what would be involved in the changes. MS. BELISLE explained that certified nurse midwives, until recently, were required to have taken a course of study approved by the Board of Certified Direct-Entry Midwives, which was generally sourced from an online school and did not involve college credit. In 2020, she said, the standards were changed to require that, in order to become a midwife, courses be taken through a school accredited by the Midwife Education Accreditation Council (MEAC). She expressed that MEAC- accredited schools limit the ability of practitioners to become midwives because they're online schools that include components requiring students to travel for different skills workshops. She said that the cost of a MEAC-accredited school has limited the number of apprentices applying for licensure. She said that the national standard referenced in the audit states "any method to midwifery," which could mean that the board could return to what was originally used as an approved course of study. CO-CHAIR SPOHNHOLZ asked Ms. Belisle whether she is suggesting that aligning Alaska's standards with MEAC accreditation standards would be rolling back standards in the state. MS. BELISLE responded that it would be widening the standards. She said that every midwife has to take part in the apprenticeship model and then the national test. She explained that currently, it is limited to the MEAC schooling in the form of a "college type" degree, but if expanded to the national CPM standard, it would allow for either option. She noted that she recently resumed her training to take the MEAC courses and is of the opinion that widening the standards would be preferable, because passing the national test is what really matters. CO-CHAIR SPOHNHOLZ asked Ms. Belisle to describe the time commitment by midwives during apprenticeship training in Alaska. MS. BELISLE responded that the board requires a minimum of 100 prenatal visits, a minimum of 65 births including observing, assisting, and primary care, and a minimum of 100 post-partum visits and newborn exams. 4:18:40 PM REPRESENTATIVE MCCARTY recalled Ms. Belisle's earlier comments about the fiscal responsibility to pay down debt. He asked what the debt is and the reason for it. MS. BELISLE replied that she only recently joined the board and said that a subsequent testifier could likely answer that question better. She stated that the debt was incurred about eight years ago and was "several hundred thousand" dollars in investigations that were applied to the board. 4:19:39 PM SARA CHAMBERS, Director, Division of Corporation, Business, and Professional Licensing, Department of Commerce, Community and Economic Development, responded to Representative McCarty's question. She said that the board has approximately 50 licensees, which she said is a "small number," but has the same resources for investigative activity as any other board. She explained that the reason for this is that AS 08.01.065 requires all licensing programs to be self-funded. She said that there is a greater chance of serious investigations in the medical industry, and licensees will often challenge and appeal board decisions. There have been significant investigations and appeals for which the board has incurred legal costs, she said, and expressed that a board regulating a large number of licensees would not have incurred that level of debt because there would be a sufficient number of licensees to pay these fees. 4:21:52 PM REPRESENTATIVE MCCARTY asked how many licensees are needed to make the board self-sustaining. MS. CHAMBERS replied that the licensee fees were increased several years ago. She said that the number of licensees required to make the board self-sustaining isn't known because there are too many factors that can't be enumerated. She recalled that there was discussion during a different legislative audit that it might make sense to merge this board with another, but the board and the industry shared that it would strongly prefer to remain autonomous. She concluded that for the second quarter ending December 31, 2020, the board posted its first surplus for the year to date. REPRESENTATIVE MCCARTY expressed his understanding that the board has enough licensees to exist, but investigations have caused the debt. He said that his experience lends him the understanding that investigations have a "cap" in order to ensure that any individual board is not overburdened by investigative costs. MS. CHAMBERS replied that capping investigative costs is an idea that the department has tried to bring to the attention of the legislature for years. She alluded to an unsuccessful bill that would have created a cost equalization model. 4:26:06 PM REPRESENTATIVE SNYDER asked Ms. Chambers whether she could speak about the magnitude of the anticipated legal costs associated with aligning Alaska's midwifery standards with national standards. MS. CHAMBERS expressed her belief that there was a misunderstanding on the part of the previous board about the cost, and that there would not have been a great legal cost. She said the claim by the board doesn't make sense to her because seeking a legislative sponsor would not come with a cost. She noted that Ms. Belisle, the board chair, was not on the board at the time of the confusion. 4:27:45 PM REPRESENTATIVE KAUFMAN asked Ms. Belisle whether there would be hardship imposed by the two-year extension period proposed under HB 117, and whether it would have a tangible impact on the board's ability to operate. MS. BELISLE replied that it feels very "heavy" to know that certain actions could potentially change the entire way certified direct-entry midwives operate. She expressed that while extending the sunset date by only two years wouldn't have a tangible impact on the board's ability to operate, she said that "we'll be right back where we are today." 4:28:55 PM CO-CHAIR SPOHNHOLZ asked Ms. Belisle whether it's possible that approving a two-year extension at this time might give the board the opportunity to document some of the changes being made. She shared her understanding that the board is in the process of implementing changes, and she suggested that a two-year extension could possibly give the board the opportunity to complete and document those efforts and later seek an eight-year extension from the committee. MS. BELISLE replied that it would motivate the board to complete the changes. She said that the peer review process will be completed in April 2021, which is also when the statutory changes will be completed. 4:30:00 PM REPRESENTATIVE KAUFMAN asked Co-Chair Fields whether there would be a benefit to hearing HB 117 in the House Health and Social Services Standing Committee as well. CO-CHAIR FIELDS responded that board renewals typically go through the House Labor and Commerce Standing Committee, notwithstanding the subject matter.