Legislature(2021 - 2022)DAVIS 106
04/20/2021 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| HB133 | |
| HB145 | |
| HB58 | |
| HB153 | |
| HB58 | |
| HB153 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | HB 133 | TELECONFERENCED | |
| + | HB 145 | TELECONFERENCED | |
| += | HB 58 | TELECONFERENCED | |
| *+ | HB 153 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
HB 145-EXPAND PHARMACIST AUTHORITY
3:25:42 PM
CO-CHAIR ZULKOSKY announced that the next order of business
would be HOUSE BILL NO. 145, "An Act relating to the Board of
Pharmacy; relating to health care services provided by
pharmacists and pharmacy technicians; and relating to the
practice of pharmacy."
3:25:54 PM
CO-CHAIR SNYDER presented HB 145, as prime sponsor. She
explained that the intent of HB 145 is to increase access to
care and to protect pharmacists and ensure that pharmacists can
be reimbursed for providing services that they are permitted to
provide. She went on to read from the Sponsor Statement [hard
copies included in committee packets], which read as follows
[original punctuation provided]:
Passage of House Bill 145, "The Pharmacist
Mobilization Act," increases access to care and
ensures Alaska's pharmacists are reimbursed when
providing services.
I am introducing it at the request of the Alaska
Pharmacists Association in partnership with the Alaska
Board of Pharmacy and the University of Alaska/Idaho
State Doctor of Pharmacy Program.
The coronavirus pandemic has shown that pharmacists
can engage at an elevated level to help deliver
necessary healthcare to all Alaskans. Pharmacists have
provided COVID-19 testing, vaccinations, and
telehealth visits, and have helped patients manage
chronic health conditions. This bill will update
outdated statute so pharmacists can continue providing
these services.
HB 145 defines the patient care services that
pharmacists and pharmacy support staff can
independently provide, allows pharmacist technicians
to administer vaccines when under the direct
supervision of a licensed pharmacists, and empowers
the Board of Pharmacy to regulate pharmacists, student
pharmacists, and pharmacy support staff who provide
these services.
Furthermore, the bill updates the current provider
anti-discrimination statute to support insurance
coverage of these patient care services when provided
by a pharmacist. Currently, pharmacists are one of the
only healthcare professionals not listed in this
statute.
HB 145 largely updates outdated statutes to align with
current practices. Its passage benefits Alaskans by
increasing healthcare access during and after the
pandemic. Please support this common sense,
housekeeping bill that will help your local, patient-
oriented pharmacies continue to provide essential
services.
3:29:12 PM
ALLIANA SALANGUIT, Staff, Representative Liz Snyder, Alaska
State Legislature, provided the sectional analysis of HB 145 on
behalf of Representative Snyder, prime sponsor. She summarized
the Sectional Analysis [hard copies provided in committee
packets], which read as follows [original punctuation provided]:
Sec. 1: Adds language to AS 08.80.030(b) Powers and
Duties of the Board, statute that outlines the Board
of Pharmacy's powers, that allows the Board of
Pharmacy to adopt rules to regulate the independent
monitoring of drug therapy and independent pharmacist
prescribing of vaccines and naloxone.
Sec. 2: Adds a new subsection to AS 08.80.045
Nonprescription Drugs that aligns statute with the
current practice of pharmacists recommending non-
prescription medications and devices for treating
minor and self-limited conditions.
Sec. 3: Amends AS 08.80.155 Emergency Permit to
increase the Board of Pharmacy's flexibility to grant
emergency licenses for all relevant licenses used in
pharmacies.
Sec. 4: Amends AS 08.80.168(a) Administration of
Vaccines and Related Emergency Medications by adding
"prescribe" to existing vaccine administration
statute.
Sec. 5: Amends AS 08.80.168(b) by replacing "dispense"
with "prescribe and administer" in regards to
administering an opioid overdose drug.
Sec. 6: Adds a new subsection to AS 08.80.168 that
allows a pharmacy technician to administer a vaccine
or related emergency medication but only if they have
been authorized by the Board of Pharmacy to do so AND
if they are under the direct supervision of a licensed
pharmacist who meets the requirements in AS 08.80.168
(a).
Sec. 7: Adds language to AS 08.80.297(a) Prescription
Prices Available to Consumer that allows personnel who
are not licensed pharmacists to disclose the cost of
filling a prescription when directed by a pharmacist
working at the same institution.
Sec. 8: Amends AS 08.080 Pharmacists and Pharmacies by
adding a new section, AS 08.80.337 Other Patient Care
Services, that: ? Allows a pharmacist to provide
patient care services for a disease or condition with
an existing diagnosis under an agreement made with and
approved by a practitioner ? Limits patient care
services that pharmacists can provide to those that
are minor, selflimiting, and have a CLIA-waived
laboratory test which guides clinical decision making.
? Provides language that allows pharmacists to be
reimbursed for providing these services 04/07/21 Sec.
9: Amends AS 08.80.480 Definitions by removing "dosage
form" as a definition of "equivalent drug product".
This allows pharmacists to make minor, non-therapeutic
changes to prescriptions using clinical judgement and
expertise without contacting the prescriber for verbal
or written approval. This does not allow a pharmacist
to substitute a dosage form that would negatively
impact patient outcomes, safety, or cost
effectiveness. Examples of appropriate substitutions
under this section include changing from a tablet form
of medication to a capsule form of the same medication
and strength.
Sec. 10: Amends AS 08.80.480(30) by adding
"dispensing" and "independent prescribing" to the
definition of the "Practice of Pharmacy" to align with
the changes made in Section 4 & 5 (AS 08.80.168) of
this bill. These additions better represent actual
provision of naloxone and vaccine by pharmacists.
Sec. 11: Amends AS 21.36.090(d) Unfair Discrimination
to include "pharmacists" as protected health care
providers in the provider anti-discrimination statute.
This aligns the state statute with federal statute
(CFR 438.12) and afford pharmacists the same
protection as all other healthcare providers when
engaging health plans for covered services such as
ordering laboratory tests, point-of-care testing,
vaccine prescribing and administration, preventative
health services, managing minor self-limiting
conditions, and participating in collaborative disease
state management.
3:33:30 PM
GRETCHEN GLASPY, Pharm.D., President, Alaska Pharmacists
Association, testified in support of HB 145. She explained that
the Alaska Pharmacists Association (APA) represents over 200
pharmacists, pharmacy technicians, and student pharmacists
statewide. She said that she earned her Doctor of Pharmacy in
2007 and has been a practicing pharmacist in Alaska since 2014.
Currently, she works as the Clinical Informatics Pharmacist at
Bartlett Regional Hospital in Juneau, Alaska, which requires her
to merge information technology with clinical pharmacy practice.
She continued that HB 145 came about through collaboration
between the APA, the Board of Pharmacy, and the University of
Alaska Anchorage/Idaho State Doctor of Pharmacy Program. The
Board of Pharmacy began reviewing statutes at the request of
State of Alaska Governor Mike Dunleavy; however, the COVID-19
pandemic highlighted the ways in which the statutes are out of
date in regard to pharmacy practice. She continued that it also
seeks to add pharmacists to the Provider Antidiscrimination
Statute, as pharmacists are one of the only providers not
currently listed. She concluded that HB 145 would allow
pharmacists to engage at a much higher level, both during and
after COVID-19.
3:35:33 PM
JUSTIN RUFFRIDGE, Pharm.D., Board Member, State Board of
Pharmacy, testified in support of HB 145. He explained that he
is a pharmacist in Alaska and owner of a few pharmacies around
the state. He shared that, from the perspective of the State
Board of Pharmacy, HB 145 is an imperative piece of legislation
in order to properly regulate the pharmacy profession. The
expanded authority of the board that the bill proposes is not
currently represented well by the current statute, he opined,
and said that the board was told that statutory adjustments must
be made in order to regulate certain professions. He added that
the board considers the proposed bill to be a "housekeeping"
bill and that there is enough support for it to pass.
3:37:39 PM
TOM WADSWORTH testified in support of HB 145 and added that,
although he is an educator at the University of Alaska Anchorage
(UAA), the views are his own and do not reflect UAA. He said
that he is a practicing pharmacist of 19 years and an educator
of pharmacy students. He explained that the first class of
pharmacy students in the UAA system were graduated in 2020, and
another class will graduate in a few weeks [in 2021]. He
explained that pharmacists receive professional graduate
training of 4 years, with at least 2,000 hours of experiential
training, and most go on to begin post-graduate residency
programs, which offer additional training. Beyond that, he
continued, pharmacists can become board certified in various
fields, such as primary care and pediatrics. Over half of all
practicing pharmacists now practice outside of the pharmacy
community, he said, and the statutes do not reflect this
reality. Many pharmacists work in primary care in tribal or
veteran health care in capacities that have nothing to do with
dispensing medications, but instead focus on general health,
wellness, and medication management. He expressed that these
pharmacists are filling a vital need in Alaska, and pharmacists
can be a solution to healthcare shortages.
3:40:52 PM
AMY PAUL, Pharm.D., Faculty Clinical Pharmacist, Providence
Family Medicine Center, testified in support of HB 145. She
shared that Providence Family Medicine Center (PFMC) is a
patient-centered medical home and the only family medicine
residency in the state of Alaska. She said that her practice
includes 36 resident positions and about 30 faculty and staff
positions, and the center services over 10,000 Alaskans in the
Anchorage, Alaska area. The number one resource to treat
patients is medications, she opined, however most medical school
graduates receive only about a semester of pharmacology, yet
these graduates are expected to appropriately choose and utilize
the most optimal medication therapy for patients. Due to her
position, she is able to work alongside physicians in Alaska and
help determine the most appropriate medication for patients.
She noted that primary care physicians, partially due to the
time restraints at play, have to address the "what" when
diagnosing a patient, but are not able to address the "why."
She shared that she is able to fill this void and meet with
patients, educate patients about their diseases, and offer ideas
for lifestyle changes, so that patients can receive the most
benefit with the least side effects.
MS. PAUL offered an example of this in which she met with a
patient who had been diagnosed with diabetes for over 20 years
and had never been taught to use an insulin pen at mealtimes.
She helped this patient learn how to use the device and she was
also able to help this patient obtain a glucose monitor so that
the patient could have more data on appropriate doses. She also
spoke to this patient about quitting smoking, and together
developed a plan to help the patient quit. Later, she
continued, this patient sent her a message expressing how she
wished every clinic had "a pharmacist like you." She concluded
with the hope that it is obvious that utilizing clinical
pharmacists to optimize patient care like this allows for
providers to meet with patients about acute needs, and allows
for patient and provider satisfaction. Unfortunately, many of
these services are not reimbursed by insurance due to current
regulations, despite the fact that the same services are
reimbursed when provided by a different type of clinician. This
makes these kinds of services unsustainable in primary care
facilities, she expressed, but the patients who have experienced
services provided by a pharmacist in the private sector
understand the benefits.
3:46:54 PM
REPRESENTATIVE MCCARTY asked Mr. Wadsworth about a letter from
Sara Chambers, Division Director of Department of Commerce,
Community, & Economic Development (DCCED) [hard copy included in
the committee packet]. He quoted line 3, paragraph 3 of the
letter, which read as follows [original punctuation provided]:
Since this statute specifically calls out vaccinations
and related emergency medications, it effectively
prohibits pharmacists from independently rendering
other patient care services.
REPRESENTATIVE MCCARTY asked whether Mr. Wadsworth could address
this statement about the concern of professional licensing.
MR. WADSWORTH answered that that opinion came about as a result
of an inquiry by the Board of Pharmacy from the Department of
Law as the board attempted to promulgate some regulations. What
the letter effectively states and the reason for including it,
he continued, is that HB 145 would not expand pharmacist
prescriptive authority. The three items listed for prescriptive
authority stand at vaccines, Naloxone, and situations that exist
under the pharmacist collaborative agreement. He explained that
the collaborative agreement allows for pharmacists to enter into
a practice in collaboration with a primary provider, which
allows the pharmacists to write prescriptions for treatment,
like the example Dr. Paul shared earlier in the committee
meeting. He said that model of interpreting statute or
regulation essentially says that, if those items are
specifically stated, then every other prescriptive authority is
excluded from the statute.
CO-CHAIR SNYDER offered clarification that the letter from Sara
Chambers was received by the committee in response to some
questions that arose in a House Labor and Commerce Standing
Committee meeting on April 12, 2021. She shared that
Representative Kaufman had expressed concern that HB 145 would
"open the barn door," and the letter was intended to assuage his
fears.
3:51:19 PM
SARA CHAMBERS, Director, Commercial Business Professional
Licensing (CBPL), Department of Commerce, Community & Economic
Development, explained that the question refers to current law
and the proposed legislation and reiterated that it was in
response to the earlier House Labor and Commerce Standing
Committee meeting. She asked for further clarification on the
type of additional information Representative McCarty was
seeking.
REPRESENTATIVE MCCARTY responded that he is curious about the
proposition in the bill that would expand the services that
pharmacists would be able to administer, which he said he
understands was crafted with legal counsel. Alternatively, he
said that Ms. Chambers' letter says that according to legal
counsel, pharmacists cannot practice beyond the three criteria
mentioned previously.
CO-CHAIR SNYDER responded that there is specific language about
Naloxone and vaccinations in HB 145. The remaining services
mentioned in the bill, she continued, are consistent with the
practice of pharmacy as it is in its current state. The bill
works to provide some clarification and details around the
practice of pharmacy so that the board is then empowered to
regulate the field, she added.
MS. CHAMBERS offered clarification that, because this question
was raised in a different committee, the letter address the
state of the current law and does not address HB 145. The
current law states that there are restrictions to what
pharmacists can do because vaccinations and emergency
medications are specifically stated. The question was not an
interpretation of the bill, and she presumed that this is where
the confusion lies.
3:54:51 PM
REPRESENTATIVE PRAX offered his understanding that the
assumption is that pharmacists can't "do anything" until given
permission and told that the proper regulations are in place.
He asked whether it's true that pharmacists need to be given
permission to do something beyond the normal scope of practice.
MR. WADSWORTH responded that when one reads the Pharmacy Act,
which is what HB 145 seeks to amend, it's clear that there is
already a definition about pharmaceutical care and patient care
services. There needs to be a differentiation between
medication and prescriptive authority, he continued, as there
are many providers that offer patient care services that do not
prescribe medicine, such as social workers. Similarly, he said,
pharmacists provide patient care services but do not necessarily
prescribe medication. He explained that Dr. Paul is already
performing the actions that are proposed in HB 145, but the
intended consequence of the bill is to expand the definition of
pharmaceutical care and bring clarity to the definition of
"patient care services," which are the services that pharmacists
can do independently that do not result in a prescription, such
as smoking cessation or diabetes education. He said that these
services are already in statute, but are not delineated with
enough clarity, which is what brings about the "Negative-
Implication Canon" indicated in Ms. Chambers' letter. He
explained that clarity is sought after so that the board can
promulgate and regulate these issues.
MR. RUFFRIDGE added that the board speaks the easiest on this
issue since that is where the "Negative-Implication Canon" term
first originated. The request for the letter to be included in
the packet of information is to ensure that there are no
questions as to what pharmacists can and should be able to do,
he said. Pharmacists are not seeking to expand the authority to
prescribe medications; there is already a means by which to do
this. He noted that in other meetings across the state, there
have been similar questions raised on whether expanding
pharmacists' authority is what is being proposed. Consequently,
the board sought a legal opinion on whether there would be any
way that a pharmacist would obtain expanded prescriptive
authority, and it is a definitive "no." The answer, he relayed,
is that pharmacists may prescribe only under a collaborative
practice agreement, for vaccines, or for Naloxone. He continued
that HB 145 is regarding the other area of pharmacists' duties
[patient-care services] that many pharmacists are already
actively engaged in across the state. He said that the board
has attempted to regulate what those services look like, who is
engaged in the services, and what requirements exist in order to
engage in the services, but since it is not well-defined in
statue, the board cannot regulate it.
4:00:05 PM
REPRESENTATIVE SPOHNHOLZ asked Mr. Ruffridge and Mr. Wadsworth
what the most common services are that are not being reimbursed,
and whether reimbursement is being denied by both private and
public payors.
MR. RUFFRIDGE replied that there were a wide variety of issues
that arose during the COVID-19 pandemic through his professional
capacity as a pharmacist. For example, COVID-19 testing was the
most prominent issue, and as pharmacists are not able to
credential or contract for Clearwave [a patient engagement
platform] COVID-19 tests due to the current statutory
limitations, many insurance companies chose to not cover a
pharmacist who was asking for a Clearwave test. He expressed
that the pharmacist community was restricted in this way until
federal action was taken, and that federal action is limited.
He shared his understanding that in order to engage pharmacists
in the future and to ensure that this problem does not happen
again in the future, action is needed. In addition to the
"worrisome" case of COVID-19 testing, he added that there is a
large number of other areas in which pharmacists are engaged in,
such as the diabetes testing mentioned earlier in the meeting by
Dr. Paul, but pharmacists continue to be engaged in these
avenues at a lower level due to the inability to contract or
credential with health plans such as Clearwave because
pharmacists are not recognized.
MR. WADSWORTH added that there is an active program inside the
tribal programs and the VA where pharmacists have been operating
as clinical pharmacists and already providing the services that
Dr. Paul mentioned earlier in the meeting. These pharmacists
work alongside the nurses, physician's assistants (PA), and
physicians, and have been operating in this capacity for at
least three decades. He noted that this uptick has not been
seen in the private sector, and that Dr. Paul is one of three
primary care pharmacists in a private practice setting in all of
Alaska. He said that the reason for this is due to the
difficulty experienced by pharmacists attempting to enroll with
the health plan on their medical benefit in the same way that a
PA or a nurse practitioner or physician would enroll. Many
states, he continued, have addressed this issue, and in the
state of Washington, for example, insurance companies are
allowing pharmacists to enroll with commercial insurances. For
this reason, these pharmacists are able to submit the same
claims that a physician would, because these services are now
recognized as in the scope of practice as it falls under the
collaborative practice agreement. He explained that this is how
Dr. Paul operates. The difficulty comes when some commercial
payors and some state payors are either not able to enroll, or
those services are being deemed as not eligible due to a "so-
called" scope of practice issue. He noted that HB 145 would
allow pharmacists to offer more services at which they excel,
but cannot currently offer due to restrictions.
4:05:47 PM
CO-CHAIR ZULKOSKY opened public testimony on HB 145.
4:06:10 PM
CHARLES MCKEE, testified on HB 145. He spoke about a personal
legal case that he said came about because Governor Dunleavy
"veto-ed Medicaid/Medicare." He explained that he went to the
hospital in an emergency situation and there were no funds
available for his medical bills.
4:08:35 PM
KYLE POHL, MD, had his testimony in support of HB 145 presented
by Kylie Goff. Ms. Goff said that Dr. Pohl works for the Alaska
Native Tribal Health Consortium, but his comments being relayed
by Ms. Goff are his own. Ms. Goff said Dr. Pohl has provided a
full spectrum of pediatric care throughout the state of Alaska
for the past five years, practicing in Anchorage, Alaska, Nome,
and the surrounding villages. He has noticed that, at all of
these locations, he could not be as effective as he is without
the help of an "outstanding group of pharmacists." His work in
rural Alaska has relied heavily on the support of skilled
pharmacists, and the pediatric well-child immunization campaign
has been the result of a combined effort of physicians and
pharmacists. Through this campaign, the number of children who
are up to date on immunizations has drastically increased, as
well as the number of children who have been provided a well-
child check, which offers screening on critical birth and
development and routine lab studies in the region. A program
has also been created to help care for the complex adult
population, which includes strategies to manage chronic diseases
such as diabetes, heart disease, hypertension, and chronic
kidney disease. Pharmacists have been critical in helping to
create pathways to improve screening for cervical cancer, colon
cancer, breast cancers, and many other diseases, and have been
critical in each stage of the process.
4:11:04 PM
NATALIE MCCAY, Pharm.D., testified in support of HB 145. She
shared that she is a pharmacy technician at Petersburg Rexall
Drug (PRD) in Petersburg, Alaska. She noted that PRD is locally
owned by two sisters, and said that she has noticed that the
owners are often the first people that patients come to with
questions or to ask for advice. She opined that HB 145 is
especially important for rural communities such as Petersburg,
and that allowing pharmacists to provide additional healthcare
services will provide increased access for patients where it can
otherwise be limited. She added that allowing technicians to
administer vaccines while supervised would allow more of the
community to get vaccinated, which is especially important
during the COVID-19 pandemic.
4:12:16 PM
SUSAN WHEELER, Pharm.D., testified in support of HB 145. She
said that she is a pharmacist working at the Yukon Kuskokwim
Corporation (YKC). She shared that the pharmacists at YKC are
already providing many of the services that would be impacted by
changes proposed in HB 145. The pharmacists are fully
integrated with the other providers, nurses, and healthcare
professionals in the corporation; however, due to an inability
to enroll pharmacists as billing providers, YKC is unable to
receive compensation for the services provided by its
pharmacists. She shared her understanding that pharmacists are
the most readily available healthcare professionals, yet at this
time in Alaska, pharmacists are the only healthcare
professionals that are not listed in the provider
antidiscrimination statutes. This means that the most readily
available healthcare professionals are compensated minimally, if
at all, for providing the same services that would be otherwise
covered if provided by other healthcare professionals, she said.
She explained that the lack of compensation makes it difficult
to provide the uncompensated services that pharmacists are well-
prepared and eager to provide. She noted that this makes these
services less readily available, which may prevent some patients
from receiving some of the services that pharmacists could
quickly, easily, and competently provide.
4:14:18 PM
DIRK WHITE, Pharm.D., testified in support of HB 145. He shared
that he and his wife have been practicing in a community
pharmacy in Sitka, Alaska, over 30 years. He expressed that the
field has changed immensely throughout his lifetime, and
predicted that more changes are to come. He commented that
regulations need to be updates to reflect those changes, and to
anticipate future changes. He noted that, in addiction to
testing for COVID-19, pharmacists would like to also be able to
test for streptococcus ("strep"), for the flu, testing for
diabetics, lipid panels, and more. He opined that HB 145 would
allow for these changes to happen.
4:16:02 PM
DOUG BARTKO, Pharm.D., testified in support of HB 145. He
stated that he had a small pharmacy in Wasilla, Alaska from the
1990s through the year 2008, and one of the largest problems he
had was receiving rejection of claims when billing insurance
companies. He said that HB 145 would give student pharmacists
status as a provider, and reiterated that pharmacists are the
only healthcare professionals without provider status.
4:17:22 PM
BARRY CHRISTENSEN, Pharm.D., testified in support of HB 145. He
said that he is a community pharmacist in Ketchikan, Alaska, and
he and his family have practiced as pharmacists since Ketchikan
was founded over 47 years ago. He is a second-generation
pharmacist, and two of his daughters have also become
pharmacists. He disclosed that he is also co-chair of the
legislative committee for the Alaska Pharmacist Association. He
said pharmacy has changed significantly since his father began
practicing in 1974, and that HB 145 recognizes the changes and
that modern pharmacists are in a better position to help
patients meet pharmaceutical needs. He opined that pharmacists
need the statutory language in HB 145 in order to best serve
patients.
4:18:38 PM
RENEE ROBINSON, testified in support of HB 145. She said that
she is an associate professor at the University of Alaska/Idaho
State University College of Pharmacy. She also serves as
president-elect of the Alaska Pharmacists Association, as well
as the co-principal investigator on a CDC and Department of
Health and Social Services funded seven-month demonstration
project that supports reimbursement of pharmacists providing
health services to ensure an increased access to rural and
underserved Alaskans. Her career has also included the training
of future pharmacists. She opined that HB 145 would resolve
long-standing regulatory issues that impede continued progress.
4:20:36 PM
CO-CHAIR ZULKOSKY, after ascertaining that there was no one else
who wished to testify, closed public testimony on HB 145.
CO-CHAIR ZULKOSKY announced that HB 145 was held over.