Legislature(2015 - 2016)CAPITOL 106
02/16/2016 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| HB227 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 227 | TELECONFERENCED | |
| + | TELECONFERENCED |
HB 227-MEDICAL ASSISTANCE REFORM
3:04:14 PM
CHAIR SEATON announced that the only order of business would be
a presentation by Becky Hultberg on the landscape for hospitals
and some of the demonstration projects in the proposed bill,
HOUSE BILL NO. 227, "An Act relating to medical assistance
reform measures; relating to administrative appeals of civil
penalties for medical assistance providers; relating to the
duties of the Department of Health and Social Services; relating
to audits and civil penalties for medical assistance providers;
relating to medical assistance cost containment measures by the
Department of Health and Social Services; relating to medical
assistance coverage of clinic and rehabilitative services; and
providing for an effective date."
3:05:53 PM
BECKY HULTBERG, President/CEO, Alaska State Hospital and Nursing
Home Association, stated that she would discuss the broader
concept of payment reform and the various models discussed in
proposed HB 227, and other proposed bills. She stated that
hospitals felt that payment reform was inevitable and had
already started, both at the state and national levels. She
declared that the Alaska State Hospital and Nursing Home
Association (ASHNHA) represented all but one of the hospitals
and nursing homes in Alaska, employing more than 10,000
Alaskans. She noted that hospitals were often the largest
private sector employer in the community, as well as the largest
health care providers.
MS. HULTBERG introduced a PowerPoint, titled "Hospitals and
payment reform," and directed attention to slide 3,
"Definitions: concepts." She shared that one concept, managed
care, was a confusing term as it was used in various context to
mean many things, but it was really just a method of health care
delivery that focused on collaboration and coordination to avoid
unnecessary and duplicative care, and delays. There was an
emphasis on timeliness and effectiveness of treatment. She
declared that it was a system for actively managing health care
to reach a desired outcome for quality, and possibly lower
costs. She stated that the payment in this environment was not
fee for service. She explained that fee for service, the
current system in Alaska, was payment based on volume and the
services were not bundled, but paid for separately. Each visit
to a provider resulted in separate charges for each part of the
visit.
3:08:39 PM
REPRESENTATIVE WOOL asked about the designation for payment of a
flat rate for service.
MS. HULTBERG expressed her agreement that there were different
iterations of managed care, and this was one type. She moved
on to slide 4, "Types of payment: risk continuum," and explained
that this risk continuum depicted the scale from a provider
having no financial risk for outcomes, fee for service as the
transaction was based on volume; to the other end of the
spectrum wherein the provider was bearing full risk for
outcomes, known as a partial or full capitation or global
budget. She reported that providers would bear different levels
of risk along this continuum. She reiterated that fee for
service was defined as payment per unit, with the provider
bearing no risk, whereas with pay for performance, although the
payment may remain per unit perhaps the provider is incentivized
based on quality outcomes. There could be a holdback of payment
until certain quality objectives are met, or a bonus type
structure based on outcomes. This would still be a fee for
service although with built in incentives for different
behavior. She explained that an example of a bundled payment
would be for a knee replacement, as rather than pay for each
individual service, there would be one bundled payment for that
person for that procedure, even as the provider was at a risk
for whether the case cost more or less. She relayed that
bundling was often used for discreet events that were easy to
measure and providers typically know what the cost would be,
even though the provider was at risk for the outcome and the
cost of the procedure. She defined episode or case-based
payment as a broader type of bundling for a service. The final
payment listed on the continuum, slide 4, was for partial or
full capitation, which she defined as a per member per month
type of fee, based on the number of patients and the average
patient cost. She pointed out that the provider was at risk for
the health care cost of that population.
3:12:30 PM
MS. HULTBERG moved on to slide 6, "Definitions: types of
payment," and paraphrased from the definition for capitation,
which read: "a payment arrangement that pays a provider or
group of providers a set amount for each enrolled person
assigned to them, per period of time, whether or not that person
seeks care." She pointed out that the person receiving care
under the capitation model could either receive no care or cost
a lot more than the payment on any given month. Essentially,
this was a mechanism by which the provider was taking risk for
the population. She directed attention to the definition for
global budget, which she defined as similar to capitation. She
relayed that there were often very defined quality and outcome
metrics built into the global budget contract environments. She
offered as an example the Oregon Coordinated Care Organizations
(CCOs) in which the State of Oregon had decided that it would
manage its Medicaid population in a regional structure so, as
these CCOs would get a set amount of money to take care of a
defined Medicaid population, they would be at risk for the
health cost of this population. This would create very
incentivized care delivery at the lowest cost and highest
quality. She reported that quality metrics were built into the
contracts, as sometimes a lot of money could be spent without
getting great quality. She offered an example for the purchase
of an air conditioner for a patient with a heart condition
living in a hot climate, in order to reduce repeated emergency
room visits. She pointed out that heath conditions could be
exacerbated by the physical environment or psychological or
social needs. With the global budget or capitated environment,
the providers were incentivized to do some things that could
seem strange from a health care perspective, but actually
impacted health care needs. She stated that capitation or
global budget environments allow the health care providers to
address the underlying causes of health care spending whether
they are health care or related to some other factors.
3:16:32 PM
REPRESENTATIVE TALERICO asked in which of the six categories of
payment Alaska currently stood.
MS. HULTBERG replied that Alaska had fee for service. She
offered her belief that there were some small projects beginning
to be discussed or initiated that would move Alaska further
along on the continuum. She listed a CCO pilot on the Kenai
Peninsula, and a care coordination program in Ketchikan as "baby
steps." She offered Ketchikan as an example of a hospital doing
a great job managing care and keeping people out of the hospital
even as it resulted in a loss of revenue through their fee for
service system. She declared that there was not any incentive;
even though it was a good outcome to not have someone in the
hospital, the payment structure did not reward that, it rewarded
volume and sickness.
REPRESENTATIVE WOOL mused about the quality and value
differences, and whether the fee was disproportionate to the
service provider.
MS. HULTBERG opined that the key to the organizations involved
in global budget models was that providers were at the table as
part of the risk sharing. She shared that an out of line
physician fee brought a strong incentive to the hospital to
negotiate that fee; whereas, a fee for service environment did
not have the same pressure from providers to manage costs.
CHAIR SEATON asked what was the general driver for the
assumption of risk.
MS. HULTBERG replied the short answer was that Medicare was
driving the shift from volume to value right now. She noted
that this complete shift in the business model to move from fee
for service was really hard and that it required sophisticated
data analytics to understand the health of your population and
what could be impacted. She opined that it was important to
keep in mind that this was a journey, and that, as providers
needed to start down the path, it would take time and experience
in learning how to do it well. She stated that this was a big
shift to taking a financial risk.
3:21:15 PM
MS. HULTBERG moved on to slide 7, "Definitions: types of
organizations," and stated that these were all organizations
that managed care, even though the names were different. She
reported that accountable care organizations (ACOs) were
Medicare driven which tied provider reimbursements to quality
metrics and reductions in the total cost of care, even as there
could be different levels of risk bearing in the ACO. She
referenced the aforementioned CCO models in Oregon, pointing out
that there was a pilot program in the proposed bill. She
relayed that managed care organizations (MCOs) were an umbrella
term for health plans that provided health care for a
predetermined monthly fee, and coordinated care through a
network of physicians and providers. MCOs were a health plan
that was bearing the risk, contracting with providers for the
delivery of care and was not the model that ASHNHA would select
as it did not necessarily change the payment structure between
the insurer and the provider. She stated that the biggest thing
to remember was that all these models were for active managed
care, and for the organization to take some level of risk, so
the interests of the provider and the payer were aligned.
MS. HULTBERG addressed slide 8, "Volume to value," and described
the fee for service movement toward value, whereby payment was
tied to cost and quality. She said that Alaska could remain a
fee for service environment for a while, as part of the market
could always be fee for service. However, nationally, she
stated that "the train really has left station" and that Alaska
will be forced to move to these models from a hospital
standpoint, which would help drive the market.
3:24:37 PM
MS. HULTBERG pointed to slide 9, "Hospital trends: lower
inpatient use." She stated that hospitals were seeing a lot
fewer inpatients than previously; although, when revenue was
related to volume and inpatient use, that was a significant
trend over the 20 years depicted on the graph.
MS. HULTBERG moved to slide 10, "Reduced readmission rates."
She reported that, as CMS was now penalizing hospitals for
readmissions, thereby changing them from revenue to penalties,
these rates were declining.
REPRESENTATIVE TALERICO asked if the hospital was able to
participate in the evaluation of the readmission penalty as some
patients participated in activities that required readmission at
no fault to the health care provider.
MS. HULTBERG replied that she would respond later with
specifics, noting that these were typically for certain types of
events and for certain defined time frames. She agreed that
there was a concern among hospitals that they were not always
responsible for what happened outside the hospital. CMS was
saying that the hospital didn't quite take care of the patient,
hence the readmission, although it could be related to something
different. She reported that these were the pressures that
hospitals were under, and these pressures would most likely
increase.
REPRESENTATIVE WOOL pointed out that people sometimes became
sicker in hospitals.
MS. HULTBERG acknowledged that these were called hospital
acquired conditions, and the hospital was penalized. She
declared that payments were now changing due to this. She
offered that this was an example of tying payment to quality.
CHAIR SEATON asked if these were measured in a 30 day - 90 day
admission rate for the same condition.
MS. HULTBERG stated her agreement.
3:28:12 PM
MS. HULTBERG shared slide 11, "Employer health insurance," and
read that this was the cumulative increase in health insurance
premiums compared to wage increases and inflation over 15 years.
She shared that the take away from the chart was, as health
insurance costs have gone up, employers were shifting more costs
to the employee. She opined that it would become difficult to
continue that cost shift. She stated that real wages were
affected by this shift to employees paying more for their health
insurance premium.
3:29:23 PM
MS. HULTBERG turned to slide 12, "Growth in high deductible
plans." She pointed to the considerable growth in high
deductible health plans since 2006, noting that there were two
implications: one was that it really did provide employees with
skin in the game and awareness of cost when shopping for health
care so that patients were acting more like consumers; the
second was for bad debt, as the new amount of money was now cost
shifted to consumers for payment. She reiterated that this was
cheaper for employers. In Alaska, as the public sector had not
moved in a meaningful way to high deductible plans, there was a
disconnect between private and public health care plans.
REPRESENTATIVE TARR asked if there were high deductible plans
within the Affordable Care and Patient Protection Act and
whether these were higher risk.
MS. HULTBERG replied that the aforementioned would be within the
parameters set by the Affordable Care and Patient Protection
Act. She stated that some of the plans on the current health
exchange were considered high deductible, and that self-insured
employers would still need to meet the general parameters.
REPRESENTATIVE TARR asked if the currently required preventative
health care changes were included in the high deductible plans,
and if the high deductible was then applied for surgery and long
term stay.
MS. HULTBERG replied that preventive care was still available
with no out-of-pocket cost. She explained that the real
difference with a high deductible plan was the size of the
deductible compared to the traditional plan. She explained that
often there was an employer contribution to a health savings
account with a high deductible in a large self-insured employer
plan, and that employees were often then more sensitive to
spending as it was spent out of their account.
REPRESENTATIVE WOOL asked whether the growth in high deductible
plans was connected to the price of health costs going through
the roof, noting that a company would save money by offering a
cheaper plan which had a higher deductible.
MS. HULTBERG expressed her agreement that one way to address
more expensive plans was to buy a cheaper plan, which typically
had a higher deductible, but that even larger employers were
finding that their healthcare spending was growing at a lower
rate under this aforementioned model structure because employees
had more incentive to act like consumers.
REPRESENTATIVE WOOL observed that, with a high deductible plan,
as soon as people reach their deductible, they "start consuming
a lot more."
MS. HULTBERG expressed agreement that this "tends to be the case
no matter the structure of the plan." She opined that the key
takeaway for the provider, based on slide 12, was that it was
becoming increasingly difficult for providers to cost shift to
commercial pay, as employees could only take so much of the cost
shifting and employers could only pay so much more.
3:34:55 PM
MS. HULTBERG moved on to slide 13, "Projected Medicare Spending,
2013-2023." She referenced a report which stated that the
Medicare trust fund would be exhausted in 2026, which was
driving a lot of activity on the federal level.
REPRESENTATIVE TALERICO asked about a graph showing Medicaid
spending versus Medicare spending.
MS. HULTBERG replied that she did not have anything that
compared the two.
3:35:46 PM
MS. HULTBERG returned to slide 13 and stated that, as the baby
boomers aged into Medicare, there was a significant recognition
that, absent some changes, the program would be very difficult
to maintain.
3:35:57 PM
MS. HULTBERG referenced slide 14, "Medicare payment policies,"
which depicted Medicare cuts to nine of Alaska's larger
hospitals, which would result in $591 million of reductions in
payment over 15 years. She reported that an additional $400
billion reduction had been proposed in the recent budget by
President Obama, although she stated that she did not know if
this would be enacted. She declared that Congress had figured
out that hospitals were piggy banks, and consequently there were
cuts extended into the future to pay for current spending. She
emphasized that this environment created a lot of stress on
hospitals from Medicare payments.
REPRESENTATIVE TALERICO asked if Medicaid reimbursement was
similar to Medicare.
MS. HULTBERG relayed that Medicaid reimbursement was structured
completely differently than Medicare reimbursement. She said
that Medicare pays more on an encounter basis whereas Medicaid
pays a daily rate based on cost, a completely different payment
methodology.
3:37:34 PM
MS. HULTBERG addressed slide 15, "Medicare delivery system
changes," a copy of a press release from January, 2015, which
stated that Medicare was moving from volume to value. She
paraphrased the article, stating that "the first goal is for 30
percent of all Medicare provider payments to be in alternative
payment models that are tied to how well providers care for
their patients instead of how much care they provide, and to do
it by 2016." She went on to share that the goal was to get to
50 percent by 2018, and that the second goal was for virtually
all Medicare fee for service payments to be tied to quality and
value, at least 85 percent in 2016 and 90 percent in 2018. She
reiterated that this was a move away from fee for service to
value based payments, while recognizing that, although there
would still be some fee for service, this would be tied to
quality or other metrics.
3:38:36 PM
MS. HULTBERG pointed to slide 16, "Shrinking of Traditional
Payment," which graphically depicted payment movement under
Medicare fee for service, and the volume to value shift. She
stated that this was important to hospitals as Medicare was a
"huge part of a hospital payer mix" so hospitals did not really
have any choice for whether to accept Medicare. Consequently,
when Medicare stated that it was changing, the hospitals had to
figure out how to manage this.
3:39:07 PM
MS. HULTBERG shared slide 17, "Move to Population-based
Payment," which was another way of looking at the risk
continuum, specifically for Medicare. This moved from fee for
service to population based payment, similar to a capitated
payment.
MS. HULTBERG explained slide 18, "Accountable Care
Organizations," which showed the location of the ACOs, noting
that there were not any in Alaska. She reported that more than
70 percent of the U.S. population lived in locations currently
served by ACOs with almost 44 percent of the population living
in areas served by two or more ACOs. The movement toward an ACO
model had accelerated in the last few years, from 154 ACOs in
2012 to 426 ACOs in 2015.
CHAIR SEATON asked if the majority were plans with seniors as
the primary clients.
MS. HULTBERG clarified that these depicted were entirely the
Medicare population, and that hospitals had to move with this
shift.
REPRESENTATIVE WOOL asked for clarification that these were
Accountable Care Organizations and entirely Medicare, and he
questioned whether hospitals were treating non-Medicare patients
in the accountable care format.
MS. HULTBERG explained that the slide represented Medicare ACOs,
although there were others, noting that ACOs were a model, and
were not restricted to Medicare as a payer.
CHAIR SEATON asked if ACOs could have two separate billing or
payment systems, one for Medicare and one for other patients.
MS. HULTBERG asked for a specific organization.
CHAIR SEATON asked if the depicted ACOs existed parallel but
independent from the other billings into that facility.
MS. HULTBERG opined that it depended on the organization and
whether it was a Medicare ACO, while also seeing commercial
patients as fee for service, then there would be different
financial arrangements. She stated that with Medicaid billings,
the ACO would not necessarily need to have different systems.
CHAIR SEATON asked specifically about Alaska, questioning
whether an institution which had three payees, Medicare,
Medicaid, and commercial patients, would have three separate
payment systems.
MS. HULTBERG replied that, as many of the organizations already
had different rules and system, she was not sure whether this
would necessarily recreate a lot of different infrastructure, as
many of the organizations were already billing Medicare,
Medicaid, and commercial insurance. She opined that having to
live within all the current payment systems would not
necessarily be changed by reconfiguring the billing for any one
of them. She declared that health care billing was already
incredibly complex.
REPRESENTATIVE WOOL asked whether a Medicare mandate to
providers for a certain percentage of patients under a managed
care model would drive hospital physicians out, so it was not
necessary to work under the mandate.
3:46:52 PM
MS. HULTBERG directed attention to slide 19, "Joint replacement
comprehensive pay model," which clarified that Medicare was
doing bundled payments as well as ACOs. She stated that this
demonstration model required that all the payment in 75
geographic areas be 100 percent bundled payment for joint
replacement. She allowed that Anchorage was not included, and
that it was not ready for this bundled payment model, noting
that it was necessary to first coordinate who got what part of
the payment, among the hospital, physicians, and post-acute
care. She pointed out that this model was a five year pilot
that could become mandatory if it was successful.
MS. HULTBERG replied to Representative Wool, and considered
slide 20, "SGR out, MACRA in." She explained that physicians
were paid by Medicare under the Sustainable Growth Rate (SGR)
formula, a formula which resulted in annual cuts, forcing
Congress to pass a bill to restore payment so physicians did not
take large payment cuts. She stated that there had been
alignment to do away with SGR, and utilize a new payment system,
Medicare Access and Chip Reauthorization Act (MACRA). She said
that this would move the volume to value to physician practices,
incentivizing them to participate in alternative payment models.
If they chose to remain in a fee for service payment system,
there would be bonuses or penalties based on outcomes. She
declared that this would be a big issue in Alaska starting in
2018, as it would be difficult to operate under because there
was already a problem with Medicare access.
MS. HULTBERG shared slide 21, "Volume to value: implications for
the market." She relayed that volume to value was inevitable
once Medicare had stated that it was moving. The goal was
better health care, with the triple aim for improving the
individual experience of care, reducing the per capita cost of
care, and improving the health of the population. She stated
that the volume to value transition was driving toward this
triple aim goal. She offered an anecdote of moving from volume
to value, as it was important for the state to consider the
implications for this transition and how it would be navigated.
She offered a recommendation to continue to review pilot
projects similar to those in proposed HB 227, in order to test
some demonstration models for payment reform with hospital and
physician providers willing to assume some risk. She pointed
out that the Alaska population was not highly concentrated, so
it could necessitate "some tweaks to any model we would want to
adopt based on our unique geography and our unique provider
community." She acknowledged that parts of the Alaska system
could retain fee for service for some time; although the high
likelihood was movement toward a new model, it was necessary to
immediately start the deliberative process to determine which
one was right for Alaska.
CHAIR SEATON asked if there were additional models which would
be good to incorporate into the proposed bill.
MS. HULTBERG suggested a primary care model in Colorado and a
similar Alabama model. She opined that the key was to create an
environment for innovative projects from providers, possibly a
CCO, and maybe a few others. She relayed that, as these could
be regional, a strength of the pilot approach was for letting
the regions come forward with suggested projects tailored to
their unique needs.
CHAIR SEATON opined that there should not be limitation for any
provider groups in the proposed bill.
3:55:29 PM
REPRESENTATIVE TARR asked about a hospital perspective, noting
that the patient would be accessing Medicare services for
chronic health conditions, otherwise they would be accessing
their primary care provider. She asked about the relationship
between Medicare cuts for those people who would now have
Medicaid to access services to which Medicare had previously
covered.
MS. HULTBERG shared that there had been a concern under Medicaid
expansion about Medicaid patients crowding out Medicare patients
and whether providers would take the Medicare patients. She
reported that Anchorage used to have a Medicare access problem,
and, in response, there were now two hospital based clinics
seeing Medicare patients. She declared that private pay was
following what Medicare was doing, as were states. She relayed
that with the volume of Medicare, it was expected to see the
commercial payers follow Medicare in the payment reform market.
She declared that, as the goal was to keep people out of the
hospital, when the providers became part of the risk bearing
entity, there became a financial incentive to keep people out of
the hospital.
3:58:17 PM
REPRESENTATIVE TARR returned attention to slide 14, and asked if
it was known whether a growing senior population with the
accompanying increase in Medicare, and the cost shifting cuts
from Medicaid expansion, would be represented by increased
spending in Medicaid.
MS. HULTBERG replied that these were really cuts that were cuts
and were not related to quality payment. She said that some
cuts were related to the Affordable Care and Patient Protection
Act, and some were a result of sequestration, a combined series
of cuts that showed the increasing financial pressures on
hospitals since 2010. She declared that there were increased
efforts to improve processes and be more efficient, as Medicare
was cutting reimbursement. She stated that this had a huge
impact on the hospital business model. She noted that the first
impacts would be on small community hospitals. She relayed that
there had been a lot of response nationwide, focusing on rural
hospital sustainability. She suggested that there was a need
for payment policies to allow community hospitals to stay
viable.
REPRESENTATIVE WOOL acknowledged the upcoming Medicare mandates,
and he asked if fewer physicians would accept Medicare. He
questioned whether other insurance payers also had these
mandates, which would lead to physicians having a harder time
for opting out.
MS. HULTBERG replied that the changes on the payment side to
physicians should be watched, as there would be a significant
administrative burden on them. If physicians remained in a fee
for service environment, it would be necessary to collect and
report the metrics on four different variables, including
satisfaction, resource utilization, and quality. She opined
that there was concern for this huge administrative burden, as
some physicians would opt out from Medicare patients.
4:03:25 PM
CHAIR SEATON asked whether there were now more dual
eligibilities with the expansion of Medicaid.
MS. HULTBERG replied that she did not have the data.
CHAIR SEATON asked if this had been rising to the surface
regarding payment or reimbursement for dual eligibles system-
wide.
MS. HULTBERG replied that she had not heard anything specific.
CHAIR SEATON declared that it was interesting to try to address
this without trying to design it, and he expressed appreciation
for the global perspective. He asked that any models be
submitted for investigation.
REPRESENTATIVE WOOL expressed his agreement that this
presentation had been very informative, and he suggested that
this information would have been good to know prior to the last
presentation.
REPRESENTATIVE TARR asked about the health care partnerships
between hospitals and primary care providers. She surmised that
a move from volume to value based would be of more interest for
a hospital to become a primary care provider, and that a
challenge would be that many hospital based primary care
providers did not offer behavioral health services. She
declared that this could be a shortcoming for that model,
whereas a more traditional private practice doctor may be able
to take that on.
MS. HULTBERG replied that she had not heard of any controversy
between hospital based and non-hospital based physicians. She
declared that hospitals were very aware of the need to integrate
behavioral health services into primary care. She stated that
acute behavioral health problems showed up in the emergency
room, and that was not the place to deal with these issues. She
emphasized that the organization was very supportive of models
that would support and integrate behavioral health. She relayed
that many hospital CEOs had very high concerns for behavioral
health. She pointed out that when people did not have adequate
community support and adequate follow up care for behavioral
health issues, they ended up in the emergency rooms or in-
patient hospitalization, which was not necessarily the best
equipped environment for behavioral health care. She relayed
that Alaska State Hospital and Nursing Home Association (ASHNHA)
has gotten more involved in communication with Department of
Health and Social Services for behavioral health issues, and
expressed agreement with the need to integrate behavioral
health. She opined that recognizing the importance of
behavioral health in the overall system of care was endorsed by
ASHNHA, which supported this ongoing conversation.
4:09:22 PM
MS. HULTBERG reflected on her earlier comments, and clarified
her earlier definition of "30 day readmissions" to be for all
causes, that it did not matter for what, the hospital was still
penalized.
REPRESENTATIVE WOOL mused that as hospitals and medical care
improved and there was less need for medical care, the people in
the hospital business suffered. He suggested that a balance
needed to be met, as the incentive should be to keep people away
from hospitals and doctors, but not to punish hospitals and
doctors.
MS. HULTBERG opined that this was a core reason for the
acceleration of payment reform, as currently there were not the
right incentives. She suggested that the best scenario would be
when the provider, the patient, and the payer all had the same
incentives for a quality outcome at a reasonable cost.
4:11:00 PM
CHAIR SEATON recognized that this discussion was for better
understanding to parts of proposed HB 227. He opened public
testimony, and noted that it would also be open in the future.
[HB 227 was held over.]
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB 227 Fiscal Note_DHSS-SDMS_update_02-02-16.pdf |
HHSS 2/16/2016 3:00:00 PM |
HB 227 |
| HB 227 Fiscal Note_DHSS-BHMS_updated_02.02.16.pdf |
HHSS 2/16/2016 3:00:00 PM |
HB 227 |
| Presentation_ASHNHA_House HSS Committee Feb. 16.pdf |
HHSS 2/16/2016 3:00:00 PM |
HB 227 |