HOUSE FINANCE COMMITTEE March 21, 2020 9:05 a.m. 9:05:44 AM [Note: continuation of the 3/20/20 1:30 p.m. meeting, see separate minutes for detail.] CALL TO ORDER Co-Chair Johnston called the House Finance Committee meeting to order at 9:05 a.m. MEMBERS PRESENT Representative Neal Foster, Co-Chair Representative Jennifer Johnston, Co-Chair Representative Dan Ortiz, Vice-Chair Representative Ben Carpenter Representative Andy Josephson Representative Gary Knopp Representative Bart LeBon Representative Colleen Sullivan-Leonard Representative Cathy Tilton Representative Adam Wool MEMBERS ABSENT Representative Kelly Merrick ALSO PRESENT Senator Peter Micciche, Sponsor; Michael Willis, Intern, Senator Peter Micciche; Kris Curtis, Legislative Auditor, Alaska Division of Legislative Audit; Jane Conway, Staff, Senator Cathy Giessel; Representative Matt Claman, Sponsor. Cynthia Montgomery, Nurse Practitioner, Alaska Psychiatric Institute. PRESENT VIA TELECONFERENCE Andree McLeod, Self, Anchorage; Carrie Doyle, President, Alaska Advanced Practice of Registered Nurses Alliance, Anchorage; Marieke Heatwole, Self, Anchorage; Sara Kozup, Certified Psychiatric Nurse Practitioner, Alaska Advanced Practice of Registered Nurses Alliance, Anchorage; Michael Alexander, MD, Director of Psychiatry, Alaska Psychiatric Institute, Anchorage; Carrie Doyle, Alaska Advanced Practice of Registered Nurses Alliance; Tom Taube, Deputy Director, Division of Sport Fisheries, Department of Fish and Game; David Rutz, Director, Division of Sport Fisheries, Department of Fish and Game. SUMMARY HB 247 SPORT FISHING ENHANCEMENT SURCHARGE CSHB 247(FSH) was REPORTED out of committee with seven "do pass" recommendations and three "no recommendation" recommendations and with one new fiscal impact note from the Department of Fish and Game. HB 290 ALTERNATIVE TO ARREST: MENTAL HEALTH CTR. CSHB 290(JUD) was REPORTED out of committee out of committee with six "do pass" recommendations, three "no recommendation" recommendations, and one "do not pass" recommendation; and with one previously published zero impact note: FN1 (LAW); one previously published indeterminant note: FN2 (DPS); and two previously published fiscal impact notes: FN3 (DHS) and FN4 (DHS). CSSB 120(HSS) ADMINISTRATION OF PSYCHOTROPIC MEDICATION CSSB 120(HSS) was REPORTED out of committee with a "do pass" recommendation and with two previously published zero fiscal notes: FN1 (DHS) and FN 2 (DHS). SB 137 EXTEND BOARD OF PAROLE SB 137 was REPORTED out of committee with a "do pass" recommendation and with one previously published fiscal impact note: FN1 (COR). Co-Chair Johnston reviewed the meeting agenda. SENATE BILL NO. 137 "An Act extending the termination date of the Board of Parole; and providing for an effective date." 9:06:41 AM Co-Chair Johnston OPENED and CLOSED public testimony. Co-Chair Johnston asked for a brief reintroduction of the bill. SENATOR PETER MICCICHE, SPONSOR, the bill would extend the Board of Parole from 2020 to 2025. He highlighted the importance of the bill, given the need for a Board of Parole. He asked his staff to provide additional detail. MICHAEL WILLIS, INTERN, SENATOR PETER MICCICHE, shared that the bill would extend the Board of Parole from June 30, 2020 to June 30, 2025. He detailed that the board was serving the public's interest by effectively evaluating prisoners' likelihood of recidivism and whether a prisoner poses a threat to the public. He relayed that Kris Curtis with the Division of Legislative Audit was available for additional questions. 9:08:42 AM Representative Knopp asked if the fiscal note showed an increased or decreased cost from prior fiscal notes. Mr. Willis answered that he had not looked at prior fiscal notes. He deferred the question to the legislative auditor. Senator Micciche answered that he had reviewed prior fiscal notes. He highlighted that the auditor's report (copy on file) showed that the cost had increased because SB 91 [crime reform legislation passed in 2016] had added five positions. He believed there may be an opportunity to reduce the members on the board the following year once the impacts of HB 49 [crime reform legislation passed in 2019] were understood. He explained that a reduction in board members would bring the cost down somewhat. Representative Carpenter directed a question to the legislative auditor. He asked about the board's ability to effectively evaluate the likelihood of recidivism. He asked if it was something the audit was able to evaluate with statistics the Department of Corrections or board kept on hand. KRIS CURTIS, LEGISLATIVE AUDITOR, ALASKA DIVISION OF LEGISLATIVE AUDIT, replied that what the sunset audit reviewed was dictated by statute (the 11 various statutes were included in the appendix of the audit report). The audit did not look at the quality of a board's decisions in terms of whether they were making the right decisions. The background information sections of the audit explained how a board went about making decisions and the tools it used. When Legislative Audit did its testing, it made sure a board was using the tools described in regulation, but it did not reaffirm a board's decision. 9:11:04 AM Representative Wool stated that the renewal date had been pushed back due to HB 49. He thought the board extension had been reduced from eight to five years. He asked if the extension was too long considering that SB 91 and HB 49 had taken place during a short timeframe. He knew that numerous staff had been added as a result of SB 91. He thought a reduction may occur sooner than five years. Ms. Curtis answered that HB 49 had not been considered [in the audit]. She elaborated that when the audit report had been written, Legislative Audit did not know what legislation would pass; therefore, she had recommended a five-year extension. The last time the board had been extended was three years earlier. At that time, she had recommended a six-year extension, which had been cut down to three years due to uncertainty. The length of the extension was solely up to policy makers. She reported that the Board of Parole was very well run and had done an amazing job with the change they had gone through. Senator Micciche answered that there would be a parole board whether or not the extension was made. He elaborated that whether the board was extended for 3, 5, or 8 years, the things the legislature would have to adjust were independent of the board extension. He noted he was on the Department of Corrections finance subcommittee. He referenced exhibit 3 on page 2 [of the audit] and considered whether the legislature had over capitalized the board with positions now that there was no longer a requirement for a Board of Parole hearing. He believed the legislature would have to work through the issue in the budget process. He explained that the board would still need to be extended and he did not see the five years as being a factor in how the legislature adjusted the board's budget in the next five years. 9:13:30 AM Co-Chair Foster MOVED to REPORT SB 137 out of committee with individual recommendations and the accompanying fiscal note. There being NO OBJECTION, it was so ordered. SB 137 was REPORTED out of committee with a "do pass" recommendation and with one previously published fiscal impact note: FN1 (COR). CS FOR SENATE BILL NO. 120(HSS) "An Act relating to administration of psychotropic medication to a patient without the patient's informed consent; and providing for an effective date." 9:13:55 AM Co-Chair Johnston OPENED public testimony. ANDREE MCLEOD, SELF, ANCHORAGE (via teleconference), strongly opposed the legislation. She found it stunning to hear that involuntary medications had been administered without a physician's determination and authority for nearly ten years at the Alaska Psychiatric Institute (API). She was intimately aware of many aspects of the current mental health system in Alaska because of a family member. She stated that the current system was broken and needed to be fixed. She thought the legislation was ill conceived. Ms. McLeod relayed that one full-time and three part-time psychiatrists worked at API according to the Department of Health and Social Services (DHSS) Deputy Commissioner [Albert] Wall. She believed testimony the past Thursday had created more questions and raised flags. She asked why Dr. Alexander was so overworked and why more full-time psychiatrists had not been hired. She did not believe it was an acceptable answer to say that it was difficult to hire psychiatrists. She believed API had been given plenty of time and resources to hire adequate staff and ramp up bed capacity. She asked what the hold up was. Ms. McLeod shared that she had worked for the state long enough to know that if an administration was serious about fixing a problem, the red tape easily disintegrated. She highlighted that the emergency declaration that brought Wellpath to manage API came with substantial funding. She asked what had happened to the money and why more psychiatrists had not been hired to help Dr. Alexander. She asked what had caused the increase in assaults. She questioned whether there had been more reports or if assaults had actually increased. She stated there had been optimism the previous year when Kevin Huckshorn came from Wellpath to API because of her expertise in de-escalating situations. She asked whether Ms. Huckshorn's methods had been implemented thoroughly. Ms. McLeod stated that the crux of the legislation was to allow physician assistants (PAs) and advanced practitioner registered nurses (APRNs) to have parity with psychiatrists and physicians. She stressed there was a disparity for a reason. She underscored that PAs and APRNs were not of the same caliber, had not had the same training, and did not have the same depth and breadth as psychiatrists and physicians. From the perspective of a family member who often had to give up her family member's rights and liberties to the state, it was incumbent to trust who her family member was treated by and where they went at API. She emphasized that the trust had been breached when she found there had been malpractice for ten years at API where PAs had been able to authorize involuntary medication orders. Ms. McLeod hoped the committee would not move the bill forward. She wanted physicians and psychiatrists to be the ones to determine whether psychotropic medications should be administered without consent. She implored the committee to not move the bill forward. 9:19:51 AM Representative Josephson thanked Ms. McLeod for her testimony. He recognized that she had a passion and expertise and good governance on the topic. He noticed that the bill would delete a section that specified a registered nurse could make the initial determination about the administration of a psychotropic drug. He believed the world functioned because there were registered nurses (RNs) and he clarified he did not mean any disrespect to the profession. He believed it seemed inarguable that the bill would ratchet up the level of training and would no longer allow an RN to potentially administer the drugs. He noted that the bill specified the person would be an APRN, PA, or doctor. He asked if the change made the situation better in Ms. McLeod's eyes. Ms. McLeod replied in the negative. She had dealt with many APRNs and PAs inside and outside of API. She stated that they had made mistakes. She elaborated that one current member of the API management team had previously been a health provider at API and had treated her family member. She discussed that the provider had made serious mistakes and when questioned about it, Ms. McLeod found the person's response shocking. She reported that incorrect medications had been prescribed to her family member. She recalled being yelled at by the individual. She did not believe APRNs had the demeanor to make the decisions when tensions ran high. She stated that doctors and physicians had been trained. She did not believe they were the same caliber. 9:23:28 AM CARRIE DOYLE, PRESIDENT, ALASKA ADVANCED PRACTICE OF REGISTERED NURSES ALLIANCE, ANCHORAGE (via teleconference), spoke in strong support of the bill on behalf of the APRN Alliance. She shared that she had a doctorate in nursing practice and is an APRN. She read from a prepared statement: The APRN Alliance wholeheartedly supports SB 120, as passed by the Senate. We discussed the bill at a recent board meeting where all four disciplines of advanced practice nursing - certified nurse specialists, certified nurse anesthesiologists, certified nurse midwives, and certified nurse practitioners - participated in the discussion. We note that there have been some strong statements of support in favor of this bill as written. Providence Hospital supports the bill as passed by the Senate. API, who does know a few things about the subject, supports the bill as passed by the Senate. The State Medical Association supports the bill as passed by the Senate. There is a lot of knowledge and expertise there and yet, based on a few minutes of committee discussion in the final days of session, it appears there is an effort to limit an advanced practice nurse's ability to practice. We applaud Senator Giessel in trying to remove barriers to practice. In 2010, the Institute of Medicine's Future of Nursing Report and more recently, the executive order on protecting and improving Medicare for our nation's seniors, both recognize that burdensome supervision requirements and licensure requirements that limit professionals from practicing to the top of their licensure and education. We are concerned that the amendment to this bill will introduce burdensome and unnecessary restrictions to practice. APRNs are educated and trained to administer these medications and we are ready to do so if this bill is passed and signed into law. Madam Chair, nurse practitioners throughout the state are on the front lines of a global pandemic, working for you and the citizens of the State of Alaska. We ask that you do the same for us. I'd be happy to answer any questions, but I'd like to emphasize that we do support the bill as passed by the Senate. Thank you. Representative Wool believed that one of the issues at hand was not about the medical knowledge of an APRN. He highlighted that the bill pertained to an involuntary medication, which was a constitutional issue where someone was forced to do something they did not necessarily want to do. He believed it was the crux of the issue. He believed the issue went a bit beyond medical. He stated that the committee had been told that API had one psychiatrist for 50 or more patients, albeit they had heard conflicting evidence. He asked if Ms. Doyle found it cause for concern. Ms. Doyle replied that nationwide there was a shortage in psychiatrists and psychiatric APRNs and in resources for mental health needs. The bill would help alleviate some of the burdens. Representative Wool asked if there was a psychiatric APRN credential within the State of Alaska. He noted that Ms. Doyle had listed the four kinds of APRNs on the [APRN Alliance] board. He observed she had not listed a psychiatric APRN. He understood that some states had a credentialed psychiatric APRN. Ms. Doyle responded that there were four types of APRNs including nurse practitioners. Within the groups there were six population foci, which included mental health psychiatric care. She relayed that it was a certification. Representative Wool asked if all of the APRNs at API were psychiatric APRNs. Alternatively, he wondered if a different subdiscipline could work at API. He observed that the bill did not require psychiatric APRNs specifically. Ms. Doyle answered that state statutes and regulations prohibited nurses from working outside of their certification. She could not speak about API and who the facility had on staff, but she assumed they were psychiatric nurse practitioners. Co-Chair Johnston noted there were individuals from API available to answer the question after public testimony. 9:28:54 AM MARIEKE HEATWOLE, SELF, ANCHORAGE (via teleconference), shared that she is a registered nurse. She urged unanimous support and passage of SB 120. She shared that she had worked as a nurse at API in 2016 and she was currently studying to become a psychiatric mental health nurse practitioner. She stated that with all due respect to earlier testimony, her experience with the patients and medical professionals at API was top quality. She elaborated that the bill provided a necessary tool for the smooth operation of inpatient psychiatric care and mostly for the safety and comfort of patients. She was available for any questions. 9:30:12 AM Representative Josephson asked if in Ms. Heatwole's experience people at API complied with the law that required documenting the maximum frequency of administration and specific conditions under which medication would be given. Additionally, when the crisis finished there was a requirement to have and document a discussion with the patient about precursors to the crisis and ways to avoid future crises. He asked if Ms. Heatwole recalled compliance at API with other parts of the existing law. Ms. Heatwole answered that she could not stress enough the importance of documentation. She shared that documentation was one of the nurses' primary jobs. She emphasized that all staff members at API were trained in de-escalation and it had always been the first attempt. She detailed there had always been an attempt to verbally deescalate and employees were taught how to physically deescalate. She relayed that crisis medication was always a last resort. She underscored that she had never felt uncomfortable when the situation arose because she knew the attending medical provider and patient. Staff were licensed, credentialed, and qualified and there had always been full documentation. Representative Wool gathered that Ms. Heatwole had worked at API. He referenced Ms. Heatwole's testimony that she was currently studying to obtain a psychiatric mental health nurse practitioner certification. He asked if she had been an RN or APRN when she had worked at API. He asked for some history of her work experience at API. Ms. Heatwole answered that in 2016 she had worked as an RN at API. She shared that she was currently in a program pursuing psychiatric mental health nurse practitioner licensure. As Ms. Doyle had stated, she would be an APRN with specific credentialing in psychiatric mental health care across the lifespan. She appreciated the opportunity to point out the credentialing required 650 direct clinical hours, not with an employer but with a mentor licensed in the same field. She noted it was considerably more than what a physician would require in a general psychiatric residency. Representative Wool asked about her experience at API when situations required an emergency chemical intervention and the appropriate licensed people were called. He asked if the person called had typically been a psychiatrist or a PA or APRN. Ms. Heatwole replied that at the time, she believed that every unit had been open, and the units were staffed perhaps equally by APRNs maybe even more so than psychiatrists. She did not know the precise answer. She deferred to Dr. Alexander with API for further detail. Representative Wool asked if having the licensure of psychiatric mental health nurse practitioner should be a prerequisite of the type of APRN responsible for administering psychotropic intervention. Ms. Heatwole asked if Representative Wool was referring to the fact that a physician, not a psychiatrist, was referenced. Representative Wool answered in the negative. He explained that the bill referenced APRN but did not delineate psychiatric mental health nurse practitioner. Ms. Heatwole agreed and noted the bill did not use specific language for a physician either. She stated that if a change in bill language was considered she would defer to the bill sponsor. She would be surprised to learn anyone would hire someone to serve the specific population without the credentialing. She believed Ms. Doyle had addressed some state requirements in her testimony. She deferred to someone with more intimate knowledge of the issue for any additional detail. 9:36:12 AM Representative Carpenter asked if changes in the bill were bringing the law in line with current practice. Co-Chair Johnston noted the question could be answered by individuals available online after public testimony. Ms. Heatwole agreed wholeheartedly. She shared that Alaska had one of the fullest licensure and credential recognitions of APRNs. She elaborated that APRNs were already working with the medications. She added that the treatment in a crisis situation was the difference of a combination and dose of medication that nurse practitioners and PAs were already working with. Furthermore, it would fall to these professionals to manage patients with complete follow up care, which was already happening and within their scope of practice. 9:37:54 AM AT EASE 9:38:42 AM RECONVENED Representative Knopp addressed Ms. Heatwole. He noted that Ms. Heatwole had stated she had previously worked for API and that she had administered [psychotropic] drugs. Under the old statute, Ms. Heatwole had administered the drugs at the recommendation or approval of a physician after consultation. He thought the underlying question was whether, in order to administer the drugs, PAs and APRNs should be going through the same training that Ms. Heatwole was currently undertaking. Ms. Heatwole believed they did [receive the same training], and she would let others speak to that. She also believed the issue may be regulated in statute as mentioned by Ms. Doyle. 9:40:23 AM SARA KOZUP, CERTIFIED PSYCHIATRIC NURSE PRACTITIONER, ALASKA ADVANCED PRACTICE OF REGISTERED NURSES ALLIANCE, ANCHORAGE (via teleconference), spoke in support of SB 120 as passed by the Senate. She read from a prepared statement: I appreciated Senator Giessel in trying to remove barriers to practice. I understand that there have been concerns raised about the ability of psychiatric nurse practitioners to order psychotropic medications during an emergency. Mastering the few psychotropic medications used in emergency mental health and knowing what risks to monitor for is a straightforward part of our job. Advanced practice nurses order these medications and monitor for their effectiveness every day. Choosing to forcibly administer a psychotropic medication is also an ethical and a system decision. In my undergraduate nursing program, I took the same ethics course as the medical students. I then had additional ethical education in my graduate program. As a former registered nurse, I have participated in forcibly administering medications and am therefore more aware of emotional and physical risks to both patients and staff. Nurses are also the people who manage the system of the hospital. A forced medication event pulls caregivers from other units and disrupts the flow of care hospital wide. Not only am I capable of ordering emergency psychotropic medications, my education and background make me the perfect person to make this clinical decision. I would be very happy to answer any questions, but I would like to emphasize that I support the bill as passed by the Senate. Thank you. 9:42:24 AM Co-Chair Johnston thanked the testifiers for taking the time to call in. She CLOSED public testimony. Co-Chair Johnston asked for a brief reintroduction of the bill. JANE CONWAY, STAFF, SENATOR CATHY GIESSEL, relayed that the bill was designed to help treatment facilities with existing staff shortages throughout the state and to ensure safety for the patients and staff who work in the facilities. She clarified that the bill could help additional facilities beyond API, including Fairbanks Memorial, Mat-Su, Bartlett Regional Hospital, and Providence. Representative Wool noted that the bill sponsor or her staff [in a previous hearing on the bill] had stated that many of the APRNs had ten years of experience at the facility. He shared that he had worked in "these" facilities and had been involved in forcible medication situations in the past. He understood the intent of the legislation. He remarked that a previous testifier had highlighted that the practitioners knew the patients and their history - it was comforting when a practitioner knew a patient well and understood their behaviors. He asked about a situation where a temporary or new APRN did not have the ten years' experience and did not have the psychiatric mental health nurse practitioner licensure. He asked if all of the APRNs at API were licensed in psychiatric health. He recalled that the APRN designation had been changed in statute recently. He asked if all of the APRNs envisioned in the bill were psychiatric mental health nurse practitioners. MICHAEL ALEXANDER, MD, DIRECTOR OF PSYCHIATRY, ALASKA PSYCHIATRIC INSTITUTE, ANCHORAGE (via teleconference), replied in the affirmative. He relayed that at API there were a number of different nurse practitioners, including three APRNs working in psychiatry, one physician assistant, and two physician assistants who worked in family practice medicine. He stressed that the medical officer who was a family practice doctor or the other physician assistants did not have the specific training or experience and were never contacted regarding the issue [of administering psychotropic drugs]. He stated it was always the psychiatric APRN or the psychiatric PA who would be contacted regarding crisis medications. 9:47:02 AM Representative Wool asked if the PAs at API were under licensure of the psychiatrists also at the facility. Mr. Alexander replied affirmatively. He had a collaborative association with his PA who worked in psychiatry. The other two PAs were under the collaboration of the medical officer. Representative Wool referenced testimony that Dr. Alexander was the one full-time psychiatrist at API. He noted a testifier had stated there were also part-time psychiatrists. He asked if that was the case. If so, he surmised that Dr. Alexander was not the psychiatrist for all of the current API residents. Mr. Alexander answered that he was the only psychiatrist at API who worked for the State of Alaska. He elaborated that apart from his position there were three nurse practitioners and one PA. Additionally, API tried to utilize a temporary contract employee as well as utilizing locum tenens. There was currently one contract employee and one locum tenens doctor temporarily working at API. He believed there were six open psychiatrist positions at API. He had been working hard to try to fill them; however, getting psychiatrists up to Alaska was extraordinarily difficult. Representative Josephson thought there were key two issues. The first was the practice of making a decision to administer a psychotropic drug vicariously through the eyes and ears of information telephonically. He stated that the current law allowed the practice for doctors but not others. He asked for verification that a doctor was responsible for making those types of decisions over the phone based on what people told them. For example, a doctor could receive a call while they were shopping or having dinner. Mr. Alexander responded affirmatively. Representative Josephson surmised that the bill was an expansion of the current law. He remarked that the second key issue was whether there was confidence in the APRN and PA community. He noted that Dr. Alexander's testimony was that he had confidence in the ability of the APRNs and PAs because most of the institutions would only hire individuals with the appropriate training and experience. Dr. Alexander replied in the affirmative. He elaborated that the individuals were specifically trained to provide psychiatric care. 9:50:48 AM Representative Sullivan-Leonard asked if the Alaska State Medical Board had weighed in on the legislation. Ms. Conway responded that there had not been correspondence from the State Medical Board. She believed the board was currently in a state of flux, which she speculated could be the reason the bill had not received a letter of support. She did not know for sure. She relayed there was a letter from the Alaska State Medical Association. Representative Sullivan-Leonard requested a copy of any letters of support. Ms. Conway agreed. She had thought the committee had the letters. Representative Sullivan-Leonard still had concern that the bill was being considered by the House Finance Committee instead of the House Health and Social Services (HSS) Committee. She noted that the HSS Committee typically dug deeply into the potential ramifications of a change in licensure, especially with a psychotropic drug administration. She stressed the medication was very intensive and meant to be administered against a patient's will or approval. She stated that she had big concerns about the bill and thought it needed additional scrutiny. 9:52:33 AM Co-Chair Johnston asked Ms. Conway to share which committees heard the bill in the Senate. Ms. Conway responded that the bill had received an HSS referral [in the Senate]. Co-Chair Johnston asked for verification that the Senate HSS Committee had thoroughly reviewed the bill. Ms. Conway answered affirmatively. 9:53:12 AM Representative Carpenter shared that he was hesitant to pass a bill that he did not fully understand. He wondered how many types of medications had to be prescribed in an effort to alleviate a mental health crisis situation. He asked if the same medication was used across the board or if the type of medication used was specific to the individual. Mr. Alexander responded that the number of medications used varied by state and over time as more medications were developed. However, a combination of medications was often used. He elaborated that sometimes an antipsychotic drug like Olanzapine could be used alone in a liquid form. He noted that sometimes Olanzapine was not enough on its own. He shared that in his training they had used a combination of Haloperidol, Cogentin, or Benadryl along with a Benzodiazepine valium type of medication. He shared that multiple hospitals throughout the United States used the different combinations - the combinations were not unique to Alaska. The medications used on a particular person depended on whether there was an allergy list or whether something had been effective in the past. Mr. Alexander shared that API looked to the most effective and least amount of dosing possible. He explained that the nurse who would be calling for a crisis situation had the information in a patient's medical record. He summarized that API typically used Haloperidol, Chlorpromazine/Thorazine, Zyprexa/Olanzapine, Benadryl/Diphenhydramine for side effects, and a benzodiazepine such as Ativan. He stated it was a small grouping of medications; there were not numerous medications available in an immediate release liquid form, which was the reason the specific medications listed were used. 9:56:14 AM Representative Carpenter remarked on the complexity of the issue. He asked Dr. Alexander to provide more information on API's process for determining which doctors or others were authorized to administer medications. Alternatively, he asked if a specific certification was all a person needed. Mr. Alexander replied that it was a standard training as part of a medical residency. He clarified it was not something unique, it was a regular occurrence for psychiatrists that began at the start of a residency or when working in any facility. Representative Carpenter asked if Dr. Alexander was speaking about medical doctors only. Alternatively, he wondered if APRNs were included. Mr. Alexander explained that he was referring to psychiatrists. He added that often times emergency room physicians and nurse practitioners prescribed the medications. His prior answer applied to psychiatrists and psychiatric nurse practitioners at API - both received the training and had experience working in psychiatric facilities. The medicines used in a psychiatric crisis were the same medications used on a daily basis for resolution of psychotic symptoms or otherwise. 9:58:40 AM Representative Wool asked for clarity. He asked for verification that an APRN or PA could prescribe an antipsychotic medication like Thorazine on a daily basis. Dr. Alexander responded affirmatively. Representative Wool provided a hypothetical scenario where a PA, APRN, or someone in the facility determined an emergency intervention was required for a patient. He stated that current law required the medical provider to call a doctor in the situation. He asked for verification that the bill would enable a PA or APRN at the facility to decide to use the medications. Dr. Alexander replied, "Of course." Representative Wool stated his understanding that the APRN or PA could prescribe emergency medications against a patient's will and after the crisis situation was resolved the patient would take their medicine as prescribed by the same individual. He wondered about the 24-72 hour period. He referenced line 11, page 10 of the legislation related to the quantity of an authorized dose and the method of administering that dose. He asked if a doctor would be called in an emergency intervention even if a PA or APRN prescribed the medication without the doctor. Dr. Alexander responded in the negative. He explained that the PA or APRN was considered an independent practitioner and the doctor would not be called. The PA or APRN would be managing the different calls and issues throughout the 24-hour period they were on call. Representative Wool thought that after a certain point the PA or APRN would inform the doctor about an intervention that took place. Dr. Alexander agreed that if the patient was the doctor's, the PA or APRN would notify the doctor; however, if it was their own patient, the PA or APRN would be managing the medication anyway. Representative Wool thanked the doctor for highlighting the point. 10:01:53 AM Representative Carpenter MOVED to ADOPT Amendment 1, 31- LS0866\K.1 (Marx, 3/19/20) (copy on file): Page 1, lines 12-13: Delete ", physician assistant, [OR A REGISTERED] or advanced practice registered nurse" Insert "[OR A REGISTERED OR ADVANCED PRACTICE REGISTERED NURSE]" Page 2, lines 4 -5: Delete", physician assistant, or advanced practice registered nurse" Page 2, following line 21: Insert a new bill section to read: "* Sec. 2. AS 47.30.838 is amended by adding new subsections to read: (e)A physician assistant or advanced practice registered nurse may make a determination under (a)(l) of this section or order or renew medication under (a)(2) of this section only if the evaluation facility or designated treatment facility has designated the physician assistant or advanced practice registered nurse as a person who may make a determination under (a)( I) of this section or order or renew medication under (a)(2) of this section. (f)Each evaluation facility and designated treatment facility shall establish criteria for its designation of the physician assistants and advanced practice registered nurses who may make a determination under (a)( I) of this section or order or renew medication under (a}(2} of this section." Renumber the following bill sections accordingly. Page 2, line 28: Delete "Section 2" Insert "Section 3" Co-Chair Johnston OBJECTED for discussion. Representative Carpenter explained that the amendment made him more comfortable with the oversight and risk management of the bill. He expressed discomfort at the limited time the committee had spent on the bill. He believed that if PAs and APRNs were given the ability to administer [psychotropic] medication in an emergency situation, the facility should share in the risk of the decision. The amendment would require the evaluation facility to establish criteria for its own use, ensuring that people were properly trained and authorized to make decisions. 10:03:10 AM Representative Knopp spoke against the amendment. He thought the question was whether there was confidence in the ability of trained and experienced APRNs and PAs to administer a drug in a crisis intervention situation. He had complete confidence in the ability of the nursing staff to administer the drugs. He explained that medical professionals who lived and breathed the work daily were qualified to make the decisions. He believed the bill helped remove unnecessary regulation. He remarked that it was not that long ago there had not been PAs and numerous other types of healthcare providers. He believed the individuals were uniquely skilled and qualified. Co-Chair Johnston asked one of the testifiers to address the risk associated with the current bill proposal. She asked if nurse practitioners carried their own malpractice insurance. She also wanted to understand the risk or malpractice carried by API. CYNTHIA MONTGOMERY, NURSE PRACTITIONER, ALASKA PSYCHIATRIC INSTITUTE, responded that as a state entity, the facility was covered by a state provided malpractice insurance. She added that when she practiced in the community, she was either covered by a facility's malpractice insurance or her own malpractice insurance when working independently. 10:05:59 AM Co-Chair Johnston asked Ms. Doyle to respond to her question as well. CARRIE DOYLE, ALASKA ADVANCED PRACTICE OF REGISTERED NURSES ALLIANCE (via teleconference), replied that it depended on whether it was a private practice. She elaborated that occasionally APRNs were covered by a facility provided malpractice insurance. She relayed that most APRNs also carried their own malpractice insurance. 10:06:31 AM Representative Wool read from the amendment. He thought the designation or criteria sounded like an APRN could be a psychiatric mental health nurse practitioner and/or that a PA would work under a psychiatrist at the facility. He believed it was something that was already taking place. He asked if he was correct. Mr. Alexander responded that he did not understand the question. Representative Wool asked if Dr. Alexander had seen the amendment. Dr. Alexander responded affirmatively. Representative Wool clarified that Amendment 1 specified that a facility may make a determination and establish criteria. He asked if a facility could establish the criteria specifying that an APRN [working at the facility] was a psychiatric mental health nurse practitioner. Dr. Alexander believed the determination that an APRN or PA could provide the service, should be innate within their duties and not determined by individual facilities. 10:08:39 AM AT EASE 10:17:04 AM RECONVENED Representative Carpenter appreciated the discussion. He WITHDREW Amendment 1. Representative Sullivan-Leonard highlighted the bill's reference to an evaluation facility or a designated treatment facility. She asked for additional detail on the evaluation facility. She wondered, for example, if a prison could be considered an evaluation facility for patients with psychiatric issues. Ms. Conway did not believe a prison would be under the purview of the legislation. She deferred the question. 10:18:24 AM Co-Chair Johnston noted that API had a relationship with the state's correctional system. She asked Dr. Alexander if the bill would apply to a correctional facility. Dr. Alexander answered that he did not know whether the bill would apply to a correctional facility. He was not certain how correctional facilities mandated medications to be given to patients or in a crisis situation. Representative Sullivan-Leonard considered that the bill would broaden the scope for a PA or APRN to administer psychotropic medications. She reasoned that if an evaluation facility was considered within the parameter for a correctional facility, correctional facilities would have the same authority as API. She highlighted that the conversation had been around behavior health and the API facility; however, the bill may be used in different facilities. She wondered if her thoughts were accurate. Ms. Conway believed the bill implied that the terms evaluation facility or designated treatment facility pertained to psychiatry. She did not know that a prison would be considered a facility for psychiatric evaluation. She remarked that [deputy] Commissioner Wall [deputy commissioner for Medicaid & Health Care Policy, Department of Health and Social Services] could have answered the question if he had been available. 10:20:37 AM AT EASE 10:25:09 AM RECONVENED Ms. Conway relayed that AS 47.30.670 defined a designated treatment facility as a hospital, clinic, institution, center, or other healthcare facility that has been designated by the department for treatment or rehabilitation of mentally ill persons. She noted that the list did not include correctional institutions. an evaluation facility was defined as a healthcare facility that has been designated or is in operation by the department to perform the evaluations described in AS 47.30.660 or a medical facility licensed under AS 47.32 or operated by the federal government. 10:26:30 AM AT EASE 10:27:15 AM RECONVENED Co-Chair Foster MOVED to REPORT CSSB 120(HSS) out of committee with individual recommendations and the accompanying fiscal notes. Representative Carpenter OBJECTED. He found supporting documentation that did not include a letter from the State Medical Board. He believed passing the legislation without a recommendation from the board was ill advised. He did not support passing the bill. A roll call vote was taken on the motion. IN FAVOR: LeBon, Ortiz, Wool, Josephson, Knopp, Johnston, Foster OPPOSED: Sullivan-Leonard, Tilton, Carpenter The MOTION PASSED (7/3). There being NO further OBJECTION, it was so ordered. CSSB 120(HSS) was REPORTED out of committee with six "do pass" recommendations and four "no recommendation" recommendations and with two previously published zero fiscal notes: FN1 (DHS) and FN2 (DHS). HOUSE BILL NO. 290 "An Act establishing an alternative to arrest procedure for persons in acute episodes of mental illness; relating to emergency detention for mental health evaluation; and relating to licensure of crisis stabilization centers." 10:29:38 AM Co-Chair Johnston OPENED Public Testimony. ANDREE MCLEOD, SELF, ANCHORAGE (via teleconference), spoke in opposition to the bill. She stated the legislation impacted people who experience acute psychiatric emergencies and the development of organizations with staff and it had not been vetted through the Health and Social Services Committee or the Labor and Commerce Committee. She stated that "we're all aware and we're all desperate for easy fixes to our broken mental healthcare system." She believed there was a tendency to grasp for almost any fix. She thought the bill was ill conceived. She stressed the need for a comprehensive package to fix the broken system. She pointed out that the bills all had impacts on the system. She opined that bills should not move forward when they were not vetted by the right committees. She appealed to members to vote against the bill and to include it in part of a comprehensive package in the future. Ms. McLeod stated that the bill criminalized mental illness. She stressed that the arrest followed the person who had an acute psychiatric emergency, which had severe ramifications for the person going forward. She used a hypothetical scenario where a person was arrested because they lashed out and hit someone while having a heart attack or some kind of extreme emergency due to high blood pressure. She asked members to consider that the symptoms of a person's illness could create a criminal record. She mentioned HB 312 sponsored by Representative Matt Claman that had passed several years earlier. She believed it had criminalized mental illness. She stated that people in API or any medical facility who exhibit symptoms that could be deemed threatening could be arrested and taken to jail. She emphasized that the court record followed the individuals and impacted their jobs and future living situations. She reiterated her desire to see HB 290 brought back in the future as part of a comprehensive package. Co-Chair Johnston CLOSED Public Testimony. She asked Representative Claman to provide a reintroduction of the bill. 10:33:40 AM REPRESENTATIVE MATT CLAMAN, SPONSOR, highlighted that there had been questions at the last hearing about the definition of acute behavioral health crisis. He read the definition included in an email from the Department of Health and Social Services: a situation in which an individual's behavior or state of mind puts that individual at risk of hurting themselves or others or prevents them from being able to care for themselves or function safely in the community as a result of a mental health diagnosis or a substance abuse disorder. He explained that the bill did not include the definition because it was common in the law for the courts to look at what they refer to as the "plain meaning rule." He elaborated that from the perspective of the Department of Law's Civil Division, the plain meaning rule would take the definition of acute behavioral health crisis and recognize that it included both substance abuse and behavioral health issues. The division believed the bill was inclusive of the broad terms and there was not a need for a more specific definition in statute. He offered to provide a longer introduction and/or answer questions. Co-Chair Johnston asked Representative Claman to address the concerns raised in public testimony. She stated that the bill was more about keeping people out of jail as opposed to putting them in jail. Representative Claman agreed. The purpose of the bill was to divert individuals who were appropriate for treatment away from a repeat cycle where they were not getting successful treatment in jail. He detailed that many of the individuals could be stabilized in a short period of time. He shared that states that used the crisis intervention model had much better results and police officers found the method in the bill was a better way to work with repeat offenders in the community. He explained that they had actually been able to reduce criminal behavior and achieve savings in terms of psychiatric care and public safety expenses. 10:36:28 AM Co-Chair Foster MOVED to REPORT CSHB 290(JUD) out of committee with individual recommendations and the accompanying fiscal notes. Representative Carpenter OBJECTED. A roll call vote was taken on the motion. IN FAVOR: Ortiz, Wool, Josephson, Knopp, LeBon, Foster, Johnston OPPOSED: Sullivan-Leonard, Tilton, Carpenter The MOTION PASSED (7/3). There being NO further OBJECTION, it was so ordered. CSHB 290(JUD) was REPORTED out of committee with six "do pass" recommendations, three "no recommendation" recommendations, and one "do not pass" recommendation; and with one previously published zero impact note: FN1 (LAW); one previously published indeterminant note: FN2 (DPS); and two previously published fiscal impact notes: FN3 (DHS) and FN4 (DHS). HOUSE BILL NO. 247 "An Act relating to the fish and game fund; establishing the sport fishing enhancement surcharge; relating to the repeal of the sport fishing facility surcharge; providing for an effective date by amending the effective date of sec. 21, ch. 18, SLA 2016; and providing for an effective date." 10:37:25 AM Co-Chair Johnston OPENED Public Testimony. Co-Chair Johnston CLOSED Public Testimony. Co-Chair Johnston asked for a brief reintroduction to the bill. TOM TAUBE, DEPUTY DIRECTOR, DIVISION OF SPORT FISHERIES, DEPARTMENT OF FISH AND GAME (via teleconference), relayed that the bill would allow the Department of Fish and Game (DFG) to continue to collect a reduced sport fishing license surcharge beyond the date it was set to expire. The sport fishing surcharge was collected in order to pay off the bonds issued to construct the Ruth Burnett Sport Fish Hatchery in Fairbanks and the William Jack Hernandez Sport Fish Hatchery in Anchorage. The surcharge also funded Chinook and Coho salmon production in Southeast Alaska, which would be lost when the surcharge sunset. The statute authorizing the bonds and surcharge would sunset on January 1 of the calendar year following the repayment of the bond obligations (at the end of the current year). Mr. Taube elaborated that the bill would retain the statute authorizing DFG to collect the surcharge, but at a reduced rate. The revenue from the surcharge would be used for ongoing maintenance and repairs at state sport fish hatchery facilities as well as continued enhancement of sport fisheries in Southeast. 10:39:27 AM Representative Wool asked if there had been discussion about not reducing the surcharge. He understood the bond had been paid off. He noted testimony from the previous hearing on the bill that a reduced number of nonresident licenses was projected, especially in the current year. He cited Mr. Taube's testimony that the money would be used for other maintenance projects and not for the initial hatcheries that were built. He asked if there had been discussion about leaving the fee at the current rate. Mr. Taube responded that at the time the surcharge had been implemented, DFG had made commitments to discontinue it after the bonds were paid off. He relayed that when the bill had been conceived, DFG had realized there were components of the Fairbanks and Anchorage hatcheries that were not completed at the time of construction due to rising construction costs in the mid-2000s. He referenced a backup well at the Fairbanks hatchery and some effluent filtering at the Anchorage hatchery as examples. Due to the high cost of the investment of the hatcheries, the department had decided to go with a reduced amount to try to partially remain with the commitment made when the bonds were first created. Co-Chair Johnston remarked that in the past the department had been asked if any of the funds had been used for operations. Mr. Taube replied that the entire surcharge had been directed to paying off the bonds themselves. The component of the bill would be used for covering maintenance staff, replacing hatchery vehicles, and for components of the hatcheries that had not been put in place when the hatcheries were constructed. He reported that daily operations were currently being covered by [federal] Dingle Johnson funds. 10:42:25 AM Representative Carpenter asked if there had been any discussion about revenue alternatives in light of the fact that the fee was scheduled to sunset and the bill would extend the fee and use the funds for a different purpose than originally intended. He asked if there were alternatives about how to continue with maintenance and repairs at the hatcheries. Mr. Taube replied that DFG would be continuing to pay for the operations as it did via Dingle Johnson funds. He elaborated that for larger components, DFG would likely come to the legislature for capital improvement project funds to make necessary upgrades to allow the hatchery to continue functioning. Representative Carpenter opined that the conversations should continue to take place in an operational sense. He stated that the people had paid a tax via a license fee. He stated that the purpose for the fee was gone and the people's money should be returned to them. He believed that if the legislature needed to fund maintenance, the conversation should take place. 10:44:22 AM DAVID RUTZ, DIRECTOR, DIVISION OF SPORT FISHERIES, DEPARTMENT OF FISH AND GAME (via teleconference), provided a brief narrative about items that had been left out of the bill and items included in members' bill packets. He stressed that the hatcheries were stocking 270 locations throughout Alaska and they supported hundreds of thousands of angler-days, a sport fishing effort that generated over $5,000 to the Alaskan economy. He elaborated that most of the stocking areas were baren lakes that were once void of fish population - there had been no fishing opportunities in those areas previously. The vast majority of the angling efforts on stocks were Alaskan residents and most of the stocking locations were within close proximity of major population centers where anglers could access excellent fishing for minimal out of pocket cost. He noted it was a great benefit. The stocking efforts also reduced effects on wild fish populations, many of which were experiencing times of low production. He underscored it was a great driver for reducing the division's dependence on General Fund monies and would help the department with anticipated shortfalls caused by reduced non-resident license fees resulting from COVID-19. He reported that the division was fully supportive of the legislation. 10:46:02 AM Co-Chair Foster MOVED to REPORT CSHB 247 (FSH) out of committee with individual recommendations and the accompanying fiscal note. There being NO OBJECTION, it was so ordered. CSHB 247(FSH) was REPORTED out of committee with seven "do pass" recommendations and three "no recommendation" recommendations and with one new fiscal impact note from the Department of Fish and Game. 10:46:42 AM Representative Tilton MOVED to bring back HB 259 [2020 legislation proposed by the governor to pay a 2019 supplemental Permanent Fund Dividend] for additional discussion. She relayed that the bill would pay the past Permanent Fund Dividend (PFD) back to the people. 10:47:07 AM AT EASE 10:48:00 AM RECONVENED Co-Chair Johnston OBJECTED. Representative Tilton believed it would be prudent to bring HB 259 back before the committee because the legislature was looking at a long-term economic stabilization plan. She highlighted that the committee heard from businesses the previous day that talked about the need for an influx of cash into communities. She elaborated that committee members had also heard from individuals. She shared that she had received numerous emails with concerns about how they would deal with daily living expenses. Additionally, the governor had come forward with an economic stabilization plan that included HB 259. She stated it was dependent on the legislature to make decisions on the issues. She thought the bill could be used as a vehicle to consider and discuss the stabilization of the economy. 10:49:16 AM Representative Sullivan-Leonard concurred with Representative Tilton. She stated that the committee was finally not hearing something related to health and social services and was having a discussion about fiscal policy and the budget. She elaborated that legislators had heard loud and clear from across the state that many residents were looking for back PFD funds for support. She recognized there had been discussion with regard to federal funds coming through, but she believed the quickest route to get funds to the public was through the PFD. She supported Representative Tilton's motion. Co-Chair Johnston MAINTAINED her OBJECTION. 10:50:04 AM AT EASE 10:50:24 AM RECONVENED Co-Chair Johnston discussed her objection. She stated that while she appreciated the comments by Representative Tilton and Representative Sullivan-Leonard, she objected because she believed the legislature would be looking at a comprehensive relief bill that was currently being worked on. She stated that the subject in HB 259 could be part of that legislation, but she did not yet know. She did not believe a supplemental PFD was the only part of relief. She had concerns about what kind of relief the state would provide because it was not an issue of a month's time. She stated it could be an issue of 18 months to two years. She wanted to make certain the state had the funds and the tools to accommodate it. She emphasized the importance of cash for the state's daily needs. She elaborated that most of the state's retail and service organizations were currently closed. She was concerned about their economic stability going forward and she wanted to ensure that any funding provided by the state went to Alaskan businesses, and residents in the most need. Representative Josephson associated himself with Co-Chair Johnston's remarks. He understood the importance of cash; however, the numbers were still the numbers. He appreciated Co-Chair Johnston's thoughtful comments. 10:52:19 AM Representative Tilton appreciated Co-Chair Johnston's comments as well and agreed on the importance of being thoughtful in developing a comprehensive package. She highlighted that the legislature had a stabilization plan for consideration, and she had not seen something come from the legislature itself. She remarked that bringing HB 259 back was not necessarily about the dividend itself, but it could be used as a vehicle to have the discussion. She highlighted that the committee had heard testimony from the business community the previous day and had received testimony from the public indicating a strong need for cash. She reasoned that businesses would not remain stable or open even with innovative ways to alter their business style. She pointed out that if people did not have cash in their pockets, businesses would not be stabilized. Her overall concern was for the state's residents. She underscored the need to look at how the state would get money out to the economy during an unprecedented time. Co-Chair Johnston thanked Representative Tilton for her remarks. She stated that everyone on the committee was very concerned about everyone in Alaska. She MAINTAINED her OBJECTION. A roll call vote was taken on the motion to bring HB 259 before the committee. IN FAVOR: Sullivan-Leonard, Tilton, Carpenter, OPPOSED: Wool, Josephson, Knopp, LeBon, Ortiz, Johnston, Foster The MOTION FAILED (3/7). Co-Chair Johnston indicated the meeting would be Recessed to a Call of the Chair. [See separate minutes dated 3/23/20 11:33 A.M.] ^RECESSED 10:55:03 AM