Legislature(2021 - 2022)BARNES 124
04/20/2022 03:15 PM House LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| SB131 | |
| SB174 | |
| SB151 | |
| HB276 | |
| HB176 | |
| HB392 | |
| Workers' Compensation Appeals Commission | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 131 | TELECONFERENCED | |
| += | SB 151 | TELECONFERENCED | |
| += | HB 276 | TELECONFERENCED | |
| += | HB 176 | TELECONFERENCED | |
| + | HB 392 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| + | TELECONFERENCED | ||
| + | SB 174 | TELECONFERENCED | |
HB 176-DIRECT HEALTH AGREEMENT: NOT INSURANCE
3:32:45 PM
CO-CHAIR FIELDS announced that the next order of business would
be HOUSE BILL NO. 176, "An Act relating to insurance; relating
to direct health care agreements; and relating to unfair trade
practices." [The proposed committee substitute (CS), Version
32-LS0784\B, Marx, 4/7/22 ("Version B"), was adopted as the
working document on 4/11/22.]
3:33:14 PM
REPRESENTATIVE SNYDER moved to adopt Amendment 1 to Version B of
HB 176, labeled 32-LS0784\B.1, Marx, 4/13/22, which read:
Page 2, line 17:
Delete the second occurrence of "and"
Page 2, line 23, following "sex":
Insert "; and
(7) specify the number of
patients the health care provider has the
capacity to serve and the number of patients the
health care provider is currently serving"
3:33:17 PM
CO-CHAIR FIELDS objected for the purpose of discussion.
3:33:20 PM
REPRESENTATIVE SNYDER explained that Amendment 1, for purposes
of consumer protection, would require the provider to specify
the number of patients that the health care provider has the
capacity to serve and the number of patients the health care
provider is currently serving. She said this would give an
individual considering a health care agreement an understanding
of the level of care and amount of attention that might
reasonably be expected from the health care provider.
3:34:16 PM
CRYSTAL KOENEMAN, Staff, Representative Sara Rasmussen, Alaska
State Legislature, on behalf of Representative Rasmussen, prime
sponsor of HB 176, related that the prime sponsor has no
objection to Amendment 1.
3:34:39 PM
CO-CHAIR FIELDS removed his objection to Amendment 1. There
being no further objection, Amendment 1 was adopted.
3:34:49 PM
REPRESENTATIVE SNYDER moved to adopt Amendment 2 to Version B of
HB 176, labeled 32-LS0784\B.3, Marx, 4/13/22, which read:
Page 4, line 19:
Delete "and"
Page 4, following line 19:
Insert a new paragraph to read:
"(4) the percentage of the patients that
entered into or maintained a direct health care
agreement with the health care practice in the
preceding calendar year who are paying fees and
costs under a direct health care agreement
through
(A) the federal Medicare program; and
(B) medical assistance under
AS 47.07;"
Renumber the following paragraph accordingly.
3:34:52 PM
CO-CHAIR FIELDS objected for the purpose of discussion.
3:34:54 PM
REPRESENTATIVE SNYDER noted that Version B, the proposed CS,
includes a reporting requirement so it can be determined how
well this new approach is working and whether any areas need to
be improved. She explained that Amendment 2 would add to the
short list of information that would be tracked by requiring the
percentage of patients who are paying fees under a direct health
care agreement through the federal Medicare program or through
medical assistance under AS 47.07. She said this would provide
a sense of the spectrum of patients who are receiving care under
a direct health care agreement.
3:35:50 PM
REPRESENTATIVE KAUFMAN inquired about the end purpose of
gathering this information.
REPRESENTATIVE SNYDER replied that early research is showing a
trend that health care providers adopting the direct health care
agreement model are reducing the percentage of patients under
Medicare or Medicaid that they serve. There isn't a firm
understanding nationally on the extent of that trend, she said,
so if this is adopted in Alaska, it would help in understanding
what happens.
REPRESENTATIVE KAUFMAN said it sounds like the intent of the
amendment's sponsor is to have a quota system.
REPRESENTATIVE SNYDER responded not necessarily, it is for
assessing what is happening and whether this is or isn't a good
thing for Alaska, or whether other requirements are needed in
the future for direct health care agreements. She said she
isn't suggesting what the solution might be, but just getting
the information to ensure that all Alaskans regardless of
financial situation are able to access care consistently.
REPRESENTATIVE KAUFMAN reiterated that it sounds like it may be
for the purposes of a quota system.
REPRESENTATIVE SNYDER answered that someone advocating for a
quota system may be able to utilize this data to support that
argument, depending on what the data show. It may not support a
quota, she continued, and that is not something she has thought
beyond this amendment, only that the information would inform
the legislature's decisions moving forward.
3:37:58 PM
CO-CHAIR SPOHNHOLZ commented that different iterations of this
bill have been heard over the years, and an earlier version in a
previous legislature did have a required percentage of people on
Medicaid. She offered her understanding that Amendment 2 is not
a quota system but a transparency element to be able to
understand the way that this new approach intersects with other
important populations - seniors covered by Medicare and low-
income and disabled people on Medicaid. She stated that Alaska
has a crisis in access to care, particularly for people on
Medicare trying to find providers because the Medicare rates are
so low. Information is needed to understand whether this is
helping to meet the shortfall in Alaska or creating an
unintended consequence that may need to be remedied.
REPRESENTATIVE SNYDER confirmed that that's a fair description
of the intent with Amendment 2. She said the purpose of HB 176
is to improve access to care and to monitor how that is going to
ensure that improvement is happening. If other issues are
instead being opened, she continued, then information will be
had for informed decisions on how to fix that.
3:40:05 PM
CO-CHAIR FIELDS said this is an important amendment to ensure
that affordability is being maintained for diverse care groups.
MS. KOENEMAN specified that the prime sponsor is still analyzing
Amendment 2 and the impacts that it will have, and that there is
a level of concern with including those on federal programs.
One thought with having a direct primary care system, she
explained, is to potentially pull retired doctors or doctors
close to retirement because they would not be inundated; a
direct primary care system would allow more doctors to keep
providing care instead of leaving the workforce. She said the
prime sponsor will, as the bill moves forward, continue to
analyze whether it is a quota system or just reporting, given
they are distinctly different.
CO-CHAIR FIELDS invited comment from the Department of Health
and Social Services.
3:42:06 PM
HEATHER CARPENTER, Health Care Policy Advisor, Office of the
Commissioner, Department of Health and Social Services (DHSS),
answered that the department's main concern is including
Medicaid beneficiaries as individuals who can access direct
primary care agreements. She explained that that is in part
because there are limitations with Medicaid a provider must be
an enrolled Medicaid provider to serve a Medicaid beneficiary.
The department is reimbursing in a fee-for-service Medicaid
environment so the department doesn't have the same flexibility
that managed care might have. Additionally, she said, Medicaid
is the payor of last resort, which means DHSS must chase and
require any other third party in a third-party liability
situation to pay first. So, if Medicaid were allowed to access
these direct primary care agreements, there would be lots of
difficulty and bureaucracy and increased cost to the Medicaid
program. Ms. Carpenter further explained that individuals who
are on the Medicaid program have limited co-pays based on the
rules of the federal program, making it a very affordable
program for those who are enrolled. She offered to talk with
Representative Snyder offline to determine language that would
address both the representative's and the department's concerns
at the same time.
3:44:03 PM
CO-CHAIR FIELDS offered his understanding that under HB 176 a
Medicaid recipient could pay out of pocket for his or her direct
primary care.
MS. CARPENTER replied that the department also interprets the
bill that way. But, she noted, Medicaid covers a large breadth
of services, so DHSS would be concerned about what services
might be outside of that scope for which the individual would
want a direct primary care [agreement], and he or she would be
paying out of pocket for those services. Therefore, she pointed
out, the fiscal note includes indeterminate because the
department is unsure of the full implications to the Medicaid
program.
CO-CHAIR SPOHNHOLZ asked whether there is any prohibition within
federal Medicaid statute about participating in a direct health
care agreement.
MS. CARPENTER responded that she has received mixed signals on
that, so she will get back to the committee after more research.
REPRESENTATIVE SNYDER clarified that Amendment 2 does not make
any requirement for Medicare or Medicaid to be eligible for
direct care agreements, it would simply be a reporting
requirement for monitoring the success of the legislation.
3:45:54 PM
CO-CHAIR FIELDS withdrew his objection to Amendment 2. There
being no further objection, Amendment 2 was adopted.
3:46:05 PM
CO-CHAIR FIELDS moved to adopt Amendment 3 to Version B of HB
176, labeled 32-LS0784\B.4, Marx, 4/13/22, which read:
Page 1, line 1:
Delete "and"
Page 1, line 2, following "practices":
Insert "; and providing for an effective date"
Page 5, following line 29:
Insert new bill sections to read:
"* Sec. 4. The uncodified law of the State of
Alaska is amended by adding a new section to read:
TRANSITION: REGULATIONS. The director of the
division of insurance may adopt regulations necessary
to implement the changes made by this Act. The
regulations take effect under AS 44.62 (Administrative
Procedure Act), but not before the effective date of
the law implemented by the regulations.
* Sec. 5. Section 4 of this Act takes effect
immediately under AS 01.10.070(c).
* Sec. 6. Except as provided in sec. 5 of this Act,
this Act takes effect January 1, 2023."
3:46:06 PM
CO-CHAIR SPOHNHOLZ objected for the purpose of explanation.
3:46:08 PM
CO-CHAIR FIELDS explained that Amendment 3 was drafted in
consultation with the Division of Insurance and would provide
clarity that the Division of Insurance may adopt such
regulations as are necessary to implement the changes within HB
176. He said the amendment has value because a whole new type
of health care is being legalized and it must be ensured that
the appropriate department has appropriate regulatory authority.
MS. KOENEMAN, on behalf of the prime sponsor, stated that
Amendment 3 is important for the division, and the prime sponsor
considers the benefit necessary.
CO-CHAIR FIELDS invited the Division of Insurance to provide
comment.
3:47:30 PM
LORI WING-HEIER, Director, Division of Insurance, Alaska
Department of Commerce, Community, and Economic Development
(DCCED), thanked Co-Chair Fields for talking to the division and
sponsoring Amendment 3. She related that as the division
reviewed the bill, it was thought that in time the division may
need to fine tune it through regulation, such as some of the
reporting requirements and transparency at which the committee
is looking.
3:47:51 PM
CO-CHAIR SPOHNHOLZ removed her objection to Amendment 3. There
being no further objection, Amendment 3 was adopted.
CO-CHAIR FIELDS stated that this makes more sense than having to
legislate fine tuning provisions later.
3:48:23 PM
The committee took a brief at-ease.
3:48:36 PM
CO-CHAIR FIELDS stated that Amendment 4 would not be offered due
to Representative McCarty not being present.
3:48:44 PM
REPRESENTATIVE KAUFMAN moved to adopt Amendment 5 to Version B,
HB 176, labeled 32-LS0784\B.5, Marx, 4/14/22, which read:
Page 5, lines 14 - 19:
Delete "Before terminating a direct health care
agreement with an existing patient, a health care
provider shall ensure that the patient is transferred
to a health care provider who
(1) is able to provide the level or type of
care the patient requires; and
(2) agrees to provide to the patient the
level or type of care the patient requires."
3:48:46 PM
CO-CHAIR FIELDS objected for the purpose of discussion.
3:48:48 PM
REPRESENTATIVE KAUFMAN explained that Amendment 5 would delete
the language requiring a health care provider to transfer a
patient if the provider can no longer serve that patient. He
said he fears that providers who are aware of that liability may
choose to not engage in the service and therefore Amendment 5 is
a well-intentioned amendment to make this a better opportunity.
MS. KOENEMAN, on behalf of the prime sponsor, stated that the
prime sponsor understands the concern and the burden this may
put on providers and will defer to the will of the committee.
3:50:06 PM
REPRESENTATIVE SNYDER requested more context as to whether this
is typical language seen in other states or something uniquely
developed here.
MS. KOENEMAN replied that the language was included in the
original bill and is to ensure that a person is not "left out to
dry by a provider." For example, she related, her own primary
care provider ran some tests and discovered that the level of
care she needed was outside his scope of practice, so he
referred her to another provider to take on that level of care.
Had he not made that referral she would have not known what to
do and would have had to search for a provider on her own. This
language, she continued, is to ease that burden from the patient
while understanding that it may throw an additional burden on
the provider. She said she doesn't know if a referral instead
of a transfer would achieve the same thing or whether it is
better to remove the language.
3:52:00 PM
REPRESENTATIVE KAUFMAN offered his belief that there are ethical
responsibilities to refer and that that is implicit in the oath
under which providers operate. He related that that was the
case when his own provider retired. It is a well-intentioned
clause, he said, but he fears it will inhibit and that the code
of ethics under which doctors operate should be relied upon to
provide referrals.
CO-CHAIR SPOHNHOLZ said she is conflicted because it may take a
while for a handoff to occur and therefore a simple referral may
not meet the need; a handoff may be needed to meet the
Hippocratic oath. She is conflicted, she continued, because of
the importance of ensuring ongoing patient management for
certain chronic issues; for example, people with diabetes could
lose their vision or limbs.
REPRESENTATIVE KAUFMAN responded that he understands the
concern, but that if attractive legislation is not created then
doctors will not sign up for the program. He cautioned that
requiring doctors to sign up for placement rather than referral
could be a bar that may limit the number of providers willing to
engage in the program.
3:55:00 PM
REPRESENTATIVE SNYDER asked whether any providers are available
online to answer questions.
CO-CHAIR FIELDS noted that no providers are online. He asked
Ms. Wing-Heier to provide perspective.
MS. WING-HEIER responded that the division believes Amendment 5
would help the bill because it has the same concern as
Representative Kaufman. The division agrees with referral, she
said, but transfer is problematic. There will be providers who
can give a referral but cannot guarantee a transfer, she
advised, a provider may be full and unable to take a new
patient. Or it might create stumbling blocks for providers when
someone's condition gets to a point where the provider is not
qualified to treat and does not know anybody because it is a
condition for which the patient must go out of state.
3:56:23 PM
CO-CHAIR SPOHNHOLZ stated that Amendment 5 applies only to
people who are already in a current direct care agreement and is
about a "warm handoff" to another provider. She offered her
understanding that the division believes that requiring a warm
handoff could potentially be a barrier to providers entering
into direct care agreements and creating more market capacity.
MS. WING-HEIER confirmed that that is right. She said the
division looked at it as if the first direct care provider is
trying to transfer a patient, or handoff a patient, to a second
direct care provider and the other one is at capacity and cannot
take any additional new patients, then a barrier has been
created for that person to transfer on. Referrals are one
thing, she continued, but the division thinks that ensuring they
are transferred is problematic.
3:57:36 PM
CO-CHAIR FIELDS stated he is hesitant to remove his objection to
Amendment 5 when language has not been agreed to by the bill
sponsor and personally he is supportive of some consumer
protection. He asked whether Ms. Koeneman has suggestions for
how to have some degree of protection for referrals or transfers
without an unnecessary barrier.
MS. KOENEMAN responded that she understands the Hippocratic oath
and the desire that there be a referral. She suggested that on
page 5 of Version B, line 15, the word "transferred" be changed
to "referred" to provide some overarching language in the
statute that directs providers to refer. She said the prime
sponsor would defer to the committee, however.
3:58:58 PM
REPRESENTATIVE SNYDER stated she was going to offer two possible
alternatives, one being to [change "transferred" to "referred"].
Another alternative, she said, could be removing the language
here as a requirement and instead require the [direct care]
agreement itself to specify yes or no regarding whether transfer
assistance is part of the agreement.
3:59:45 PM
REPRESENTATIVE KAUFMAN stated that the issue is still with
placing that obligation of placement. He said referral is
within the control of the physician, but transfer is not;
placing an obligation on someone for something on which they
have no control creates an untenable situation. He said he
could withdraw Amendment 5 and suggest a conceptual amendment
that states "referred" or "directed" rather than "transferred",
which would achieve more of a consensus agreement around what is
being looking for.
4:00:34 PM
CO-CHAIR FIELDS agreed with withdrawal of the amendment.
4:00:37 PM
REPRESENTATIVE KAUFMAN withdrew Amendment 5.
4:00:45 PM
The committee took a brief at-ease.
4:01:34 PM
CO-CHAIR SPOHNHOLZ moved to adopt Conceptual Amendment 1 to
Version B of HB 176.
4:01:52 PM
CO-CHAIR FIELDS objected for the purpose of discussion.
4:01:53 PM
CO-CHAIR SPOHNHOLZ described Conceptual Amendment 1 as follows:
Page 5, line 15:
Delete "transferred"
Replace with "referred"
4:02:13 PM
REPRESENTATIVE KAUFMAN agreed with Conceptual Amendment 1.
4:02:20 PM
CO-CHAIR FIELDS removed his objection to Conceptual Amendment 1.
There being no further objection, Conceptual Amendment 1 was
adopted.
4:02:31 PM
REPRESENTATIVE KAUFMAN moved to adopt Amendment 6 to Version B
of HB 176, labeled 32-LS0784\B.7, Marx, 4/14/22, which read:
Page 1, line 8:
Delete "an annual"
Insert "a periodic"
Page 1, line 10:
Delete "annual"
Insert "periodic"
Page 1, line 11:
Delete "annual" in both places
Insert "periodic" in both places
Page 2, line 1:
Delete "annual"
Insert "periodic"
Page 2, line 9:
Delete "annual"
Insert "periodic"
Page 2, line 10:
Delete "annual"
Insert "periodic"
Page 2, line 18:
Delete "annual"
Insert "periodic"
Page 2, line 19:
Delete "annual"
Insert "periodic"
Page 3, line 11:
Delete "annual"
Insert "periodic"
Page 3, line 13:
Delete "annual"
Insert "periodic"
Page 4, line 17:
Delete "annual"
Insert "periodic"
4:02:36 PM
CO-CHAIR FIELDS objected for the purpose of discussion.
4:02:38 PM
REPRESENTATIVE KAUFMAN said Amendment 6 would create greater
flexibility in the time period to allow agreements that are not
necessarily annual. He explained that by striking "annual" and
allowing "periodic" there could be six-month, monthly, or other
agreements to provide a structure that is most beneficial for
both a provider and the patient.
4:03:11 PM
MS. KOENEMAN, on behalf of the prime sponsor, stated that this
is the language which was contained in the original version of
the bill, so the prime sponsor is supportive of this language.
MS. WING-HEIER related that the division had asked for
"periodic" to be changed to "annual" simply because insurance
policies are annual. She posed a scenario of someone choosing
to buy a health care policy with a high deductible of $20,000
and buying a direct health care agreement at $100 a month. If
that changed in three months, she pointed out, then the person's
decision for the $20,000 deductible health care policy might not
have been the best one. That is the only reason the division
had asked for annual, she stated, but it is not a huge deal.
CO-CHAIR SPOHNHOLZ said she appreciates the intent to be more
flexible but since insurance is done on an annual basis, direct
care agreements should also be made on an annual basis.
Periodic is an undefined term whereas annual is clear, she
stated, and passage of this bill is to ensure access to this
kind of care as well as provide clarity, transparency, and
protection. She said she cannot support Amendment 6 as drafted.
4:05:37 PM
CO-CHAIR FIELDS maintained his objection.
4:05:42 PM
A roll call vote was taken. Representative Kaufman voted in
favor of Amendment 6 to HB 176, Version B. Representatives
Schrage, Snyder, Nelson, Fields, and Spohnholz voted against it.
Therefore, Amendment 6 to HB 176 failed to be adopted by a vote
of 1-5.
4:06:25 PM
The committee took a brief at-ease.
4:06:30 PM
CO-CHAIR SPOHNHOLZ moved to report the proposed CS to HB 176,
version 32-LS0784\B, Marx, 4/7/22, as amended, out of committee
with individual recommendations and the accompanying fiscal
notes. There being no objection, CSHB 176(L&C) was moved out of
the House Labor and Commerce Standing Committee.
4:06:58 PM
CO-CHAIR FIELDS stated that he gives the Legislative Legal
Services the ability to make any necessary and conforming
changes.