04/18/2017 03:00 PM House HEALTH & SOCIAL SERVICES

                HB 215-DHSS: PUBLIC HEALTH FEES                                                                             
                                                                                                                                
3:05:21 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ announced that the  first order of business would                                                               
be HOUSE BILL NO. 215, "An  Act relating to program receipts; and                                                               
relating  to fees  for  services provided  by  the Department  of                                                               
Health and Social Services."                                                                                                    
                                                                                                                                
3:06:03 PM                                                                                                                    
                                                                                                                                
TOM SPITZFADEN,  Staff, Representative Paul Seaton,  Alaska State                                                               
Legislature, paraphrased from the  Sponsor Statement [Included in                                                               
members' packets], which read:                                                                                                  
                                                                                                                                
     This  bill would  amend AS  44.29.022(a)  to grant  the                                                                    
     Alaska  Department of  Health and  Social Services  the                                                                    
     authority    to   collect    fees   to    support   the                                                                    
     administration  of  public  health programs.  The  bill                                                                    
     would  also  add public  health  fees  to the  list  of                                                                    
     designated   general  fund   program  receipts   in  AS                                                                    
     37.05.146(c),  making  clear  that the  fees  collected                                                                    
     would be used to support public health operations.                                                                         
                                                                                                                                
     Currently, the division is not  able to charge fees for                                                                    
     all  the  potential  public health  services  it  could                                                                    
     because the list of "public  health related duties" for                                                                    
     which  fees  are allowed  is  limited  to maternal  and                                                                    
     child  health,  preventive   medical  services,  public                                                                    
     health  nursing,   nutrition,  health   education,  and                                                                    
     laboratories.                                                                                                              
                                                                                                                                
     This bill will  give the Division of  Public Health the                                                                    
     opportunity  to  collect  reasonable  fees  to  support                                                                    
     essential  public health  services consistent  with its                                                                    
     duties  and authority  under state  law; services  that                                                                    
     protect Alaskans  from preventable illness,  injury and                                                                    
     death.   Examples  of   public   health  services   and                                                                    
     functions  provided by  the  Department that  currently                                                                    
     lack   fee  authority   include  data   extraction  and                                                                    
     analysis,  training,  expert consultation,  inspections                                                                    
     and     certifications,     enforcement     activities,                                                                    
     administrative functions, and professional services.                                                                       
                                                                                                                                
     HB 215 is  necessary to allow the  Department of Health                                                                    
     and  Social  Services'  Division of  Public  Health  to                                                                    
     increase and diversify  revenue opportunities, ensuring                                                                    
     the  means  to  support public  health  operations  and                                                                    
     thereby  reducing   reliance  on  general   funds.  The                                                                    
     Division  of Public  Health budget  includes nearly  $7                                                                    
     million in  revenue from  fees, primarily  for clinical                                                                    
     laboratory  and  public  health  nursing  services  and                                                                    
     certified  copies of  vital records.  The widening  gap                                                                    
     between  public health  costs and  state general  funds                                                                    
     jeopardizes  our ability  to  protect  and promote  the                                                                    
     health of  Alaskans. It is  necessary in  public health                                                                    
     that those  who can  pay, should contribute  to support                                                                    
     these essential services.                                                                                                  
                                                                                                                                
3:09:21 PM                                                                                                                    
                                                                                                                                
MR. SPITZFADEN paraphrased from the Sectional Analysis [included                                                                
in members' packets], which read as follows [original                                                                           
punctuation provided]:                                                                                                          
                                                                                                                                
     Section  1  (page  1,  line 4)     Adds  public  health                                                                  
     program fees under AS 18.05.010  to the definition list                                                                    
     of designated  general fund  program receipts  and non-                                                                    
     general fund program receipts  AS 37.05.146(c) that are                                                                    
     accounted for separately  and appropriations from these                                                                    
     program  receipts are  not made  from the  unrestricted                                                                    
     general fund.                                                                                                              
                                                                                                                                
     Section 2 (page 1, line  7)   Amends AS 44.29.022(a) to                                                                  
     allow the  Commissioner of the  Department of  Health &                                                                    
     Social  Services  to  create  a schedule  of  fees  for                                                                    
     services   for   public   health  programs   under   AS                                                                    
     18.05.010.                                                                                                                 
                                                                                                                                
3:10:16 PM                                                                                                                    
                                                                                                                                
JILL LEWIS,  Deputy Director -  Juneau, Central  Office, Division                                                               
of Public Health, Department of  Health and Social Services, said                                                               
that  the Division  of  Public Health  focused  on programs  that                                                               
addressed the health status of  every Alaskan and community.  The                                                               
Public Health Services  controlled infectious diseases, prevented                                                               
chronic  diseases  and  injuries, protected  maternal  and  child                                                               
health, and promoted healthy life  styles.  She stated that there                                                               
was a  widely held  belief that  the division  should do  more to                                                               
maximize collections  for billable services where  possible.  She                                                               
reported that  public health had traditionally  relied on federal                                                               
grants  and  state  general  funds   rather  than  fees;  whereas                                                               
national public health agencies had  now been forced to reexamine                                                               
fees  as  a  funding  stream   in  order  to  continue  providing                                                               
essential services,  and Alaska  was no  different.   She pointed                                                               
out that  the division was  not able to  charge fees for  all the                                                               
services  offered.   She said  that there  was an  opportunity to                                                               
collect  fees for  immunization,  as well  as  health and  safety                                                               
issues; for  birth and marriage certificates  and data extraction                                                               
and analysis;  for lab tests, training  and expert consultations.                                                               
She pointed out that the  proposed bill would enable the division                                                               
to  be  more  self-sufficient  and  collect  reasonable  fees  to                                                               
support these public health services.   She offered some examples                                                               
of these fees, which included:   inspection of devices such as x-                                                               
ray, CT  scan, and  MRI; reasonable  fees for  custom statistical                                                               
and epidemiological analysis  on the public health  data sets, as                                                               
the  division resources  were consumed  in simply  collecting the                                                               
data.   She reported that  other states  charged an annual  or an                                                               
hourly  fee  for analytical  work.    She  pointed out  that  the                                                               
division turned  away these requests for  analytical work because                                                               
there  were  no longer  the  staff.    She  noted that  only  the                                                               
radiologic  health would  be a  required fee,  whereas the  other                                                               
fees  would be  optional,  as communities  could  decide if  they                                                               
wanted the  service or preferred  to use  a private vendor.   She                                                               
explained that for  each new fee, the division  would establish a                                                               
separate  regulation to  allow the  public  and the  stakeholders                                                               
ample  opportunity for  input.   She pointed  out that  the rates                                                               
were limited  to the actual  cost for providing the  service, and                                                               
fees were only  charged when the cost benefit  was economical, in                                                               
the public interest and did  not undermine the mission to protect                                                               
and promote the public health of  Alaskans.  She added that there                                                               
would  be a  system of  waivers or  a sliding  scale of  fees, to                                                               
ensure that the  fees were applied equitably.   She declared that                                                               
the collected  receipts would be  applied back to  the generating                                                               
program,  instead of  the  general  fund.   She  stated that  the                                                               
"widening  gap between  our  public health  costs  and our  state                                                               
general  fund jeopardizes  our ability  to  provide the  services                                                               
that  protect  Alaskans  from preventable  illness,  injury,  and                                                               
death."  She  emphasized that the proposed bill  was necessary to                                                               
allow the  Division of Public  Health to be  more self-sufficient                                                               
and reduce the reliance on general funds.                                                                                       
                                                                                                                                
3:17:16 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JOHNSTON asked  if there  was a  benefit for  the                                                               
department to contract out the  services until it was established                                                               
what fee services were necessary.                                                                                               
                                                                                                                                
MS.  LEWIS acknowledged  that there  was uncertainty  "around the                                                               
amounts  that we  put in  the fiscal  note and  what we  think we                                                               
might be  able to collect  right off the  bat."  She  stated that                                                               
there would be  opportunities during the upcoming  fiscal year to                                                               
review this through the regulation  packages and assess the need.                                                               
She  pointed out  that the  fiscal note  began in  FY 2019.   She                                                               
suggested that  the position might  need to be spread  among many                                                               
people, and that  it would take some time to  realize the overall                                                               
potential.                                                                                                                      
                                                                                                                                
3:20:40 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SULLIVAN-LEONARD asked if  the division had spoken                                                               
with outside groups regarding assistance.                                                                                       
                                                                                                                                
MS.  LEWIS expressed  agreement  that they  did  work with  their                                                               
partners, although relying on the  kindness of these partners was                                                               
not a  good long-term strategy  for the division.   She explained                                                               
that establishing a fee would bring the cost up front.                                                                          
                                                                                                                                
3:22:51 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE   SULLIVAN-LEONARD  asked   how  to   determine  a                                                               
reasonable fee,  what mechanism  would be  used to  determine the                                                               
fee, and who would be charged.                                                                                                  
                                                                                                                                
MS. LEWIS said that this fee  would vary for each service and, as                                                               
they would  be limited to the  cost, they first needed  to figure                                                               
the  cost.   She suggested  that  review of  data, training,  and                                                               
consultation would most  likely be an hourly or annual  fee.  She                                                               
reiterated that all  these fees would be cost based,  and if they                                                               
were not  economical, the division  would not continue  to pursue                                                               
these.                                                                                                                          
                                                                                                                                
3:24:33 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SULLIVAN-LEONARD offered an  example of a chest x-                                                               
ray.                                                                                                                            
                                                                                                                                
MS.  LEWIS  explained  that  the  division  did  not  have  x-ray                                                               
machines,  although  they inspected  them.    She said  that  the                                                               
division  was  already  charging  fees  to  organizations.    She                                                               
suggested  that  there was  an  opportunity  to do  analysis  for                                                               
community  organizations and  non-profits,  and  less likely  for                                                               
individuals.                                                                                                                    
                                                                                                                                
3:26:11 PM                                                                                                                    
                                                                                                                                
CHAIR  SPOHNHOLZ   commended  the  department  for   its  review,                                                               
especially given the  new fiscal reality. She shared  that as she                                                               
had done  community health needs  assessments and  data analysis,                                                               
the  ability to  purchase  this data  analysis  "could be  really                                                               
valuable, there's been  a lot of times, I  think, when non-profit                                                               
organizations  have wanted  that  kind of  information and  being                                                               
able  to  ...  essentially buy  additional  information  analysis                                                               
could be  really useful."   She suggested that the  proposed bill                                                               
be  set  up for  more  transparency  for other  organizations  to                                                               
better understand  how this could  work.  She shared  her concern                                                               
that the  proposed bill had  brought to her attention  that there                                                               
were  not inspections  to much  of the  radiologic equipment,  as                                                               
currently  only  x-rays were  billable.    She explained  that  a                                                               
Department   of  Law   determination   stated   that  the   other                                                               
inspections  could  not  be  charged  for as  there  was  not  an                                                               
explicit authority.                                                                                                             
                                                                                                                                
MS.  LEWIS expressed  agreement, pointing  out that  although the                                                               
department  had  the broad  authority  to  inspect, certify,  and                                                               
register radiologic  devices for  humans, they  did not  have the                                                               
authority  to charge  a  fee.   As  there  was  no other  revenue                                                               
source, and  there was only  one health physicist for  the state,                                                               
it would  be necessary to  make a second  hire.  She  stated that                                                               
the proposed  fees would be  based on  the cost of  personnel and                                                               
the expected travel, with a small additional cost for supplies.                                                                 
                                                                                                                                
CHAIR SPOHNHOLZ  asked if  there was  a sense  for the  amount of                                                               
equipment that should be inspected.                                                                                             
                                                                                                                                
MS. LEWIS  replied that  there were  hundreds, if  not thousands,                                                               
mostly found in the larger clinics and hospitals.                                                                               
                                                                                                                                
CHAIR  SPOHNHOLZ  asked  whether this  inspection  would  require                                                               
special expertise.                                                                                                              
                                                                                                                                
MS. LEWIS  explained that this was  not the same person  as would                                                               
conduct the  clinical service, and it  required special equipment                                                               
to calibrate the machines and ensure they were operating safely.                                                                
                                                                                                                                
3:31:13 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE EASTMAN  asked about  the steps taken  to identify                                                               
the availability for private inspectors.                                                                                        
                                                                                                                                
MS.  LEWIS  replied  that  there   were  no  independent  private                                                               
inspectors  in  Alaska, although  there  were  inspectors out  of                                                               
state.    She  reported  that Department  of  Health  and  Social                                                               
Services did not have the funding for this.                                                                                     
                                                                                                                                
3:32:04 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  TARR asked  if the  department was  limited to  a                                                               
charge for services and was not allowed for any extra revenue.                                                                  
                                                                                                                                
MS. LEWIS replied that they were  only allowed to charge fees for                                                               
cost.                                                                                                                           
                                                                                                                                
3:32:42 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE EASTMAN  directed attention  to page 2,  [line 2],                                                               
of the proposed  bill, musing that "it sounds  rather vague," and                                                               
asked if  this should be  interpreted to  mean that a  refusal to                                                               
pay was  not economically  feasible to collect,  or was  this per                                                               
case.                                                                                                                           
                                                                                                                                
MS. LEWIS clarified that the  department would perform an overall                                                               
review to determine whether this  was an economical fee to pursue                                                               
for the  service.  She stated  that the waivers would  be granted                                                               
on  an individual  basis.    She reported  that  the process  for                                                               
application to  a waiver,  including criteria  and qualification,                                                               
was already in regulations to be applied equally to everyone.                                                                   
                                                                                                                                
3:34:47 PM                                                                                                                    
                                                                                                                                
CHAIR SPOHNHOLZ announced that HB 215 would be held over.