03/26/2019 03:00 PM House HEALTH & SOCIAL SERVICES

         HB 97-TELEHEALTH: PHYSICIAN ASSISTANTS; DRUGS                                                                      
                                                                                                                                
4:34:07 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY announced  that  the final  order of  business                                                               
would be HOUSE BILL NO. 97,  "An Act relating to the prescription                                                               
of drugs by a physician assistant without physical examination."                                                                
                                                                                                                                
4:34:29 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ   moved  to  adopt  the   proposed  committee                                                               
substitute (CS) for HB 97,  labeled 31-LS0695\M, Marx, 3/21/19 as                                                               
the working draft.                                                                                                              
                                                                                                                                
CO-CHAIR ZULKOSKY objected for discussion.                                                                                      
                                                                                                                                
4:34:53 PM                                                                                                                    
                                                                                                                                
REID  HARRIS,  Staff,   Representative  Jonathan  Kreiss-Tomkins,                                                               
stated that HB  97 was "about increasing patient  access to care,                                                               
particularly  for rural  and medically  underserved  areas."   He                                                               
directed attention  to maps [Included in  members' packets] which                                                               
portrayed that  the entire  state, except  for the  Railbelt, was                                                               
considered to  be a medically  underserved area.  He  stated that                                                               
it could be  problematic for many rural communities  to find fair                                                               
and  cheap  access to  health  care.    He paraphrased  from  the                                                               
Sponsor Statement [Included in members' packets] which read:                                                                    
                                                                                                                                
     The 2016 Medicaid Reform bill  (SB 74) provided for the                                                                    
     use  of  telehealth  by  revising  Alaska  statutes  to                                                                    
     require  the   Alaska  Board   of  Medicine   to  adopt                                                                    
     regulations and  guidelines for physicians  rendering a                                                                    
     diagnosis,   providing   treatment,   or   prescribing,                                                                    
     dispensing, or  administering a prescription drug  to a                                                                    
     person without conducting  a physical examination under                                                                    
     AS 08.64.364.                                                                                                              
                                                                                                                                
     Unintentionally, SB  74 only addressed  physicians, and                                                                    
     the  Board   issued  guidelines  that   made  different                                                                    
     requirements   for  physician   assistants  (PAs)   and                                                                    
     physicians, citing  a lack  of legislative  intent that                                                                    
     the provisions of SB 74 should apply to PAs.                                                                               
                                                                                                                                
     The omission of  PAs from the Medicaid  Reform bill led                                                                    
     to  them being  subject to  limitations on  the use  of                                                                    
     telemedicine. Specifically, the  Medical Board released                                                                    
     guidelines stating that  physician assistants could not                                                                    
     treat   a  patient   via  telemedicine   without  first                                                                    
     conducting   an  in-person   examination,  or   with  a                                                                    
     collaborating  physician or  other practitioner  in the                                                                    
     same group practice.                                                                                                       
                                                                                                                                
     House Bill  97 aligns  the law with  the intent  of the                                                                    
     Medicaid Reform  bill, clarifying that PAs  can provide                                                                    
     telemedicine in  the same  manner as  physicians. Under                                                                    
     HB97, the  PA would  be subject  to the  same statutory                                                                    
     oversight  as  physicians  regarding  the  practice  of                                                                    
     telemedicine,   as  well   as  the   same  disciplinary                                                                    
     sanctions when appropriate.                                                                                                
                                                                                                                                
     Alaska,  with  its  vast  geographical  challenges  and                                                                    
     limited access  to vital healthcare, stands  to benefit                                                                    
     from  this legislation.  HB  97  will increase  patient                                                                    
     access  to care,  extending the  reach  of medicine  to                                                                    
     medically underserved areas.                                                                                               
                                                                                                                                
MR. HARRIS pointed  out that, although it  was legislative intent                                                               
to  allow physician  assistants (PAs)  to practice  telemedicine,                                                               
the "Medical Board didn't see it that way hence we have these                                                                   
two fix-it bills before both bodies."                                                                                           
                                                                                                                                
MR. HARRIS directed attention to the PA Scope of Practice                                                                       
document [Included in members' packets] and paraphrased from the                                                                
document, which read:                                                                                                           
                                                                                                                                
     A broad,  generalist medical education prepares  PAs to                                                                    
     take medical histories,  perform physical examinations,                                                                    
     order   and   interpret  laboratory   tests,   diagnose                                                                    
     illness, develop  and manage treatment plans  for their                                                                    
     patients, prescribe medications and assist in surgery.                                                                     
                                                                                                                                
MR. HARRIS stated that PAs could prescribe Schedule II - V                                                                      
medications, and he paraphrased from the "Drug Schedule"                                                                        
[Included in members' packets], which read:                                                                                     
                                                                                                                                
     Schedule I                                                                                                               
     Schedule I drugs, substances,  or chemicals are defined                                                                    
     as drugs with  no currently accepted medical  use and a                                                                    
     high potential  for abuse. Some examples  of Schedule I                                                                    
     drugs  are: heroin,  lysergic acid  diethylamide (LSD),                                                                    
     marijuana                (cannabis),               3,4-                                                                    
     methylenedioxymethamphetamine  (ecstasy), methaqualone,                                                                    
     and peyote                                                                                                                 
                                                                                                                                
     Schedule II                                                                                                              
     Schedule  II   drugs,  substances,  or   chemicals  are                                                                    
     defined as drugs with a  high potential for abuse, with                                                                    
     use  potentially  leading  to severe  psychological  or                                                                    
     physical  dependence. These  drugs are  also considered                                                                    
     dangerous.  Some examples  of  Schedule  II drugs  are:                                                                    
     Combination products  with less  than 15  milligrams of                                                                    
     hydrocodone   per  dosage   unit  (Vicodin),   cocaine,                                                                    
     methamphetamine,  methadone, hydromorphone  (Dilaudid),                                                                    
     meperidine (Demerol),  oxycodone (OxyContin), fentanyl,                                                                    
     Dexedrine, Adderall, and Ritalin                                                                                           
                                                                                                                                
     Schedule III                                                                                                             
     Schedule  III  drugs,   substances,  or  chemicals  are                                                                    
     defined as drugs  with a moderate to  low potential for                                                                    
     physical  and  psychological dependence.  Schedule  III                                                                    
     drugs  abuse  potential is  less  than  Schedule I  and                                                                    
     Schedule  II  drugs but  more  than  Schedule IV.  Some                                                                    
     examples   of   Schedule   III  drugs   are:   Products                                                                    
     containing  less  than  90 milligrams  of  codeine  per                                                                    
     dosage unit (Tylenol  with codeine), ketamine, anabolic                                                                    
     steroids, testosterone                                                                                                     
                                                                                                                                
     Schedule IV                                                                                                              
     Schedule  IV   drugs,  substances,  or   chemicals  are                                                                    
     defined as  drugs with  a low  potential for  abuse and                                                                    
     low risk  of dependence.  Some examples of  Schedule IV                                                                    
     drugs  are  Xanax,   Soma,  Darvon,  Darvocet,  Valium,                                                                    
     Ativan, Talwin, Ambien, Tramadol                                                                                           
                                                                                                                                
     Schedule V                                                                                                               
     Schedule V drugs, substances,  or chemicals are defined                                                                    
     as drugs  with lower potential for  abuse than Schedule                                                                    
     IV  and  consist  of  preparations  containing  limited                                                                    
     quantities of  certain narcotics. Schedule V  drugs are                                                                    
     generally  used  for  antidiarrheal,  antitussive,  and                                                                    
     analgesic purposes.  Some examples of Schedule  V drugs                                                                    
     are: cough  preparations with less than  200 milligrams                                                                    
     of  codeine or  per  100  milliliters (Robitussin  AC),                                                                    
     Lomotil, Motofen, Lyrica, Parepectolin                                                                                     
                                                                                                                                
MR.  HARRIS explained  that a  Physician Assistant  must have  an                                                               
active  and  collaborative  plan   that  was  maintained  with  a                                                               
supervisor  and,  under  the   guidance  of  their  collaborating                                                               
physician,  would be  authorized  to prescribe  Schedule  II -  V                                                               
drugs.   He  added that  the PA  must have  an authorization  and                                                               
license from the Drug Enforcement  Administration.  He summarized                                                               
and stated that  the proposed bill would  allow approximately 700                                                               
licensed  PAs  in Alaska  to  provide  telemedicine in  the  same                                                               
manner  as  physicians  and  extend  the  reach  of  medicine  to                                                               
patients  in underserved  areas.   He pointed  to the  supporting                                                               
letters  from  physician  assistants practicing  in  rural  areas                                                               
[Included  in members'  packets].   He  reported  that the  State                                                               
Medical Board  assumed a neutral  position on the  proposed bill,                                                               
and that the  fiscal note for $5300 was for  the first year only,                                                               
to pay for legal fees and to update the regulations.                                                                            
                                                                                                                                
4:41:29 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JACKSON asked if this  proposed bill could be part                                                               
of the telehealth bill as  it allowed for physician assistants to                                                               
prescribe drugs.                                                                                                                
                                                                                                                                
4:42:06 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  replied that  the  proposed  bill was  in  a                                                               
different section  of law,  even though  it intersected  to allow                                                               
physician assistants to participate in telehealth.                                                                              
                                                                                                                                
4:42:28 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE CLAMAN  asked why the  bill did not  include nurse                                                               
practitioners   as   they   were  also   allowed   to   prescribe                                                               
medications.                                                                                                                    
                                                                                                                                
MR.  HARRIS explained  that registered  nurse practitioners  were                                                               
not overseen by the State Medical Board.                                                                                        
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  interjected  that nurse  practitioners  were                                                               
already allowed  to practice telehealth, adding  that nurses were                                                               
overseen  by the  Board of  Nursing.   She stated  that physician                                                               
assistants  were  the  only  group of  providers  that  had  been                                                               
inadvertently omitted in earlier legislation, Senate Bill 74.                                                                   
                                                                                                                                
REPRESENTATIVE  CLAMAN  asked  if nurse  practitioners  had  been                                                               
allowed to practice telehealth in Senate Bill 74.                                                                               
                                                                                                                                
CO-CHAIR SPOHNHOLZ replied, "yes."                                                                                              
                                                                                                                                
4:43:37 PM                                                                                                                    
                                                                                                                                
MR.  HARRIS,  in  response to  Representative  Jackson,  directed                                                               
attention to  the AAPA guidelines [Included  in members' packets]                                                               
and paraphrased from the Education and Experience, which read:                                                                  
                                                                                                                                
     The intensive  PA program curriculum is  modeled on the                                                                    
     medical  school  curriculum.  The  typical  PA  program                                                                    
     extends  over  27  continuous months  and  begins  with                                                                    
     classroom instruction  in basic medical  sciences. This                                                                    
     is  followed  by  rotations  in  medical  and  surgical                                                                    
     disciplines   including   family   medicine,   internal                                                                    
     medicine, general  surgery, pediatrics,  obstetrics and                                                                    
     gynecology,  emergency  medicine   and  psychiatry.  PA                                                                    
     students complete  at least  2,000 hours  of supervised                                                                    
     clinical practice in various  settings and locations by                                                                    
     graduation. Almost  all PA programs now  award master's                                                                    
     degrees, and by 2020 all programs must do so.                                                                              
                                                                                                                                
4:45:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE PRUITT asked  if PAs would be required  to use the                                                               
drug database.                                                                                                                  
                                                                                                                                
MR. HARRIS said that was correct.                                                                                               
                                                                                                                                
REPRESENTATIVE PRUITT  asked why  the PAs  had been  omitted from                                                               
previous legislation.                                                                                                           
                                                                                                                                
MR. HARRIS offered his understanding  that the legislative intent                                                               
was for physicians to engage  in telemedicine with an assumption,                                                               
incorrect as it  was, that PAs working under  the physician would                                                               
also be  allowed.   After passage  of Senate  Bill 74,  the State                                                               
Medical Board stated that the  new language would not include PAs                                                               
because they were not directly named.                                                                                           
                                                                                                                                
4:46:54 PM                                                                                                                    
                                                                                                                                
DEBORAH  STOVERN, Executive  Administrator, State  Medical Board,                                                               
Division of  Corporations, Business, and  Professional Licensing,                                                               
Department of  Commerce, Community  & Economic  Development, said                                                               
that the State  Medical Board did not feel that  "they could make                                                               
the call  that the  legislative intent  was to  include physician                                                               
assistants because  the language  of the statute  said physicians                                                               
only."   She offered her  understanding the proposed bill  was an                                                               
attempt to correct that.                                                                                                        
                                                                                                                                
REPRESENTATIVE PRUITT asked for  clarification that, although the                                                               
intent  may  have  been  there,  she  could  not  "jump  to  that                                                               
conclusion because  the statute wasn't  clear enough."   He asked                                                               
if this was "clean-up" and if she did support this opportunity.                                                                 
                                                                                                                                
MS. STOVERN  said that was  her understanding of the  position by                                                               
the State  Medical Board  on this legislation.   She  pointed out                                                               
that the State  Medical Board had reviewed Senate  Bill 44, which                                                               
was identical legislation, and had issued a letter of support.                                                                  
                                                                                                                                
4:49:24 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE PRUITT  asked for clarification to  the changes in                                                               
the proposed committee substitute.                                                                                              
                                                                                                                                
MR. HARRIS  replied that the proposed  committee substitute added                                                               
a section  with an effective  bill date  of March 1,  2020, which                                                               
had been requested by the division.                                                                                             
                                                                                                                                
4:50:25 PM                                                                                                                    
                                                                                                                                
The committee took a brief at-ease.                                                                                             
                                                                                                                                
4:50:46 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY removed her objection.   There being no further                                                               
objection,  the proposed  committee  substitute (CS)  for HB  97,                                                               
labeled  31-LS0695\M, Marx,  3/21/19 was  adopted as  the working                                                               
draft.                                                                                                                          
                                                                                                                                
4:51:05 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR  asked  if   the  State  Medical  Board  had                                                               
concerns with  the prescription of drugs  by physician assistants                                                               
or with other interactions with the patient.                                                                                    
                                                                                                                                
4:51:56 PM                                                                                                                    
                                                                                                                                
MS. STOVERN  said that  the State Medical  Board had  issues with                                                               
both subject  to the collaborative  plan between  the supervising                                                               
physician and the physician assistant.                                                                                          
                                                                                                                                
REPRESENTATIVE  TARR  asked  if the  collaborative  practice  was                                                               
necessary for both issues.                                                                                                      
                                                                                                                                
MS.  STOVERN  replied, yes  it  was  correct that  the  physician                                                               
assistant would only have authority  for whatever the supervising                                                               
physician allowed.                                                                                                              
                                                                                                                                
4:53:35 PM                                                                                                                    
                                                                                                                                
CHRISTOPHER  DIETRICH, Orion  Behavioral  Health Network,  stated                                                               
that currently the PA could not  establish care without a face to                                                               
face  examination and  that  the proposed  bill  would now  allow                                                               
this.                                                                                                                           
                                                                                                                                
4:55:09 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  questioned whether  the requirement  for the                                                               
first face to face meeting was the snafu.                                                                                       
                                                                                                                                
MR.  DIETRICH  expressed his  agreement  that  the proposed  bill                                                               
would clarify this and expedite the necessary care.                                                                             
                                                                                                                                
4:56:09 PM                                                                                                                    
                                                                                                                                
AROM EVANS, MD,  Orion Behavioral Health, stated  his support for                                                               
proposed HB 97  and that his practice had  the collaborative plan                                                               
in place.                                                                                                                       
                                                                                                                                
[HB 97 was held over.]