Legislature(2021 - 2022)DAVIS 106
03/03/2022 03:00 PM House HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| HB265 | |
| HB292 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HSCR 2 | TELECONFERENCED | |
| += | HB 265 | TELECONFERENCED | |
| *+ | HB 292 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| + | TELECONFERENCED |
HB 265-HEALTH CARE SERVICES BY TELEHEALTH
3:06:46 PM
CO-CHAIR ZULKOSKY announced that the first order of business
would be HOUSE BILL NO. 265, "An Act relating to telehealth;
relating to the practice of medicine; relating to medical
assistance coverage for services provided by telehealth; and
providing for an effective date."
3:06:55 PM
CO-CHAIR SNYDER moved to adopt the proposed committee substitute
(CS) for HB 265, Version 32-LS0754\N, Foote, 3/1/22, as a
working document.
CO-CHAIR ZULKOSKY objected for the purpose of discussion.
3:07:18 PM
REPRESENTATIVE SPOHNHOLZ, as prime sponsor, presented the
proposed CS for HB 265, Version N. She stated that HB 265,
Version N, is designed to create a framework for access to
telehealth while ensuring patients' safety and choice in the
state.
3:07:41 PM
The committee took a brief at-ease at 3:07 p.m.
3:07:57 PM
REPRESENTATIVE SPOHNHOLZ continued that the intention of the
proposed legislation would be to remove barriers to telehealth
and allow the state to make regulations based on quality-of-care
metrics with individual practitioners. She stated that the
three changes the CS would make are at the request of several
stakeholders. The first proposed change would allow physicians
licensed outside of Alaska to provide health care to Alaskans
who have an established relationship with the physician through
an in-person exam. She explained that follow-up exams could
take place via telehealth, allowing for continuity of care. The
second proposed change would remove the in-person requirement
for advanced nurse practitioners to prescribe controlled
substances. She said one of the major objectives would be to
allow flexibility for prescribing behavioral health medications
in rural Alaska. The third proposed change would add facilities
authorized by the Department of Health and Social Services
(DHSS) to telehealth provisions so they could deliver behavioral
health services.
3:11:20 PM
GENEVIEVE MINA, Staff, Representative Ivy Spohnholz, Alaska
State Legislature, on behalf of Representative Spohnholz, prime
sponsor, paraphrased the explanation of changes of the proposed
CS for HB 265, Version N, [included in the committee packet],
which read as follows [original punctuation provided]:
Section 1 Replaces any reference to "examination" with
"visit," and updates corresponding language throughout
the bill, except for providers licensed in another
state. Removes language in subsection (a) of version W
related to the telehealth authority of providers
licensed in another state. This language is replaced
with subsection (b), which creates an exemption for
physicians licensed in another state to deliver health
care services within their scope of practice if there
is an established physician-patient relationship, the
non-resident physician has given the patient an in-
person physical exam, and the services are related to
ongoing treatment or follow-up care related to past
treatment. Cleans up the provisions regarding
medication assisted treatment by removing subsection
(d) in version W, which pertained to services
addressing opioid use disorder. This language was
deemed unnecessary to ensure the telehealth delivery
of medication assisted treatment to treat opioid use
disorder (i.e., medication, counseling, and behavioral
health therapies). Revises the prescribing authority
provisions by separating physicians, podiatrists,
osteopaths, and physician assistants in subsection (e)
from advanced practice registered nurses (APRNs) in
subsection (f). Amends the APRN language in subsection
(f) to remove the in-person requirement for
prescribing controlled substances (including
buprenorphine) via telehealth. This does not change
the prescribing scope for these providers. Creates
subsection (h) to remove requirements to document all
attempts for an in-person visit and prevents the
department or board from limiting the physical setting
of a health care provider delivering telehealth.
Clarifying language is inserted under subsection
(j)(2) defining all providers in this section as
licensed in good standing. 2 Section 3 Creates
subsection (h) under Title 18 to remove requirements
to document all attempts for an inperson visit. This
section replicates the same provisions on
documentation and physical setting for emergency
medical services as Section 1. Section 4 Amends
telehealth services included in Alaska Medicaid by
explicitly including home and community-based waiver
services in subsection (a)(2) and adding services
provided under a state plan option (e.g., 1915(k)
services) in subsection (a)(3). Adds language in
subsection (b), line 13 to ensure the department must
revise regulatory language to include telehealth in
the definition of a "visit." Section 5-6 These are new
sections adding telehealth provisions to entities in
Title 47, which are grantees that deliver community
mental health services, or facilities approved by the
department to deliver substance use disorder
treatment. Their authority to deliver telehealth was
previously unaddressed in version W because they are
not applicable to the provisions in Title 8, or the
Alaska Medicaid provisions in Title 47. Both sections
replicate the same telehealth provisions on cost,
scope of services, patient protections, documentation,
and physical setting as Section 1. Section 5 creates
AS 47.30.585 to include entities designated under AS
47.30.520 AS 47.30.620, which are approved to
receive grant funding by the Department of Health and
Social Services to deliver community mental health
services. Section 6 creates AS 47.37.145 to include
public or private treatment facilities approved by the
Department of Health and Social Services in AS
47.37.140 to deliver services designated under AS
47.37.40 AS 47.37.270 addressing substance use
disorders.
3:16:13 PM
REPRESENTATIVE MCCARTY shared his personal involvement with
telehealth and telemedicine. He questioned whether the medical-
assisted treatment (MAT) service would be in the induction
process or part of the continued medication service.
3:17:10 PM
REPRESENTATIVE SPOHNHOLZ responded that the intention of the
proposed legislation would be to let the boards determine the
adoption of individual regulatory packages. She expressed the
assumption that clinicians would want initial assessment and
treatment plans to be developed in person. She stated that
defining this in [the legislation] was avoided so the governing
boards, which are committed to the best practices, could
determine the appropriate modality. She explained that some of
the language focuses on quality of care, but quality should not
be "the enemy of access," because in many parts of Alaska there
is no access to care. She pointed out that Sara Chambers could
answer questions concerning the adoption of regulations and
oversite, and Director Gennifer Moreau-Johnson could address
behavioral health.
REPRESENTATIVE MCCARTY, with a follow-up question, referenced a
situation when a patient was not given "great care" while under
distance medication services. He argued that when a client is
physically present, abreactions can be detected. He expressed
the concern that in the induction process of MAT, when a client
is transitioning to medication from [addictive] substances,
nuances cannot be detected using telemedicine. He requested
additional information concerning this.
3:20:25 PM
REPRESENTATIVE SPOHNHOLZ responded that boards would adopt
regulations based on the appropriate standards of practice and
scope of training. She added that there is nothing in the
legislation which would require a provider to deliver a certain
type of care via telehealth, or for a patient to receive care
via telehealth. Both the patient and the provider would have to
consent to telehealth delivery within the proposed framework.
She argued that boards should make the appropriate telehealth
regulations, not legislators.
3:22:10 PM
GENNIFER MOREAU-JOHNSON, Director, Division of Behavioral
Health, Department of Health and Social Services, in response to
Representative McCarty, stated that induction via telehealth had
been allowed during the COVID-19 pandemic. She expressed the
belief that there are federal requirements for face-to-face
induction, and the state would refer to the federal
requirements.
3:22:44 PM
SARA CHAMBERS, Director, Division of Corporations, Business, and
Professional Licensing, Department of Commerce, Community &
Economic Development, in response to Representative McCarty,
stated that the division has been working closely with the
sponsor to ensure the intent would be clear. She said, "The
regulations would be the appropriate place for any siderails or
narrowing to happen on a case-by-case basis." She added that
this is also the understanding of the medical and nursing
boards. She stated that the [proposed legislation] would lift
the requirement for in-person care, but it would also give the
boards the ability to further restrict [the care] under certain
circumstances.
3:23:39 PM
REPRESENTATIVE PRAX questioned the language in Section 1 of the
[proposed CS] which would restrict providers residing in other
states. He argued, "Once you get on the telephone, Seattle is
sort of the same as Anchorage."
3:24:16 PM
REPRESENTATIVE SPOHNHOLZ responded that the original draft of
the legislation allowed providers not licensed in Alaska to have
more access to deliver services to Alaskans via telehealth. She
explained that there is an enforcement issue because Alaska does
not have licensure compacting, and there is no enforcement
mechanism to hold a provider accountable.
3:26:17 PM
REPRESENTATIVE PRAX, with a follow-up comment, stated that an
alternative would be to address the compacting issue, which
would be an entirely different subject.
REPRESENTATIVE SPOHNHOLZ responded in the affirmative,
explaining that an assortment of licensing standards would have
to be changed. She expressed the opinion that compacts can be
controversial, and this would not be the responsible thing to do
for the state.
3:26:54 PM
REPRESENTATIVE FIELDS, in response to Representative Prax's
question, stated that another reason for [restricting outside
providers] would be to limit the incentive for large, multi-
state providers, as their services could push patients to
primary care outside of Alaska, undermining the provider
workforce in the state. He acknowledged that some people would
need to access specialists outside the state, and this should be
"the balance."
REPRESENTATIVE SPOHNHOLZ explained that outside providers can
still get licensed in Alaska, and if a provider wants to
practice in the state, but not live here, he/she can still
obtain a license.
3:28:19 PM
REPRESENTATIVE MCCARTY commented that many providers consider
Alaska a place to make a good amount of money while living in
another state. Concerning "usual and customary" reimbursement
rates, he questioned [which state] would be considered [the
rate] origin. In example, he said a provider may be licensed in
a state with a "usual and customary" reimbursement three-times
less than the [standard charge] in Alaska.
3:30:00 PM
REPRESENTATIVE SPOHNHOLZ responded that Alaska's rates are
higher, and nonresident providers licensed in Alaska already can
charge Alaska's rates. The proposed legislation would make no
changes to this. She explained that compensating a provider at
a lower rate would be a disincentive to provide telehealth care
and not support the business model. She indicated that
different rates cannot be set for non-Alaska providers. She
expressed the understanding that Alaska providers support the
payment parity provision because it supports expanding
telehealth in the state. In reference to the point made by
Representative Fields, she stated that the marketplace needs to
be built for Alaska providers, especially in rural Alaska, where
there are few providers.
3:32:11 PM
REPRESENTATIVE KURKA questioned the process to become licensed
in Alaska for a physician who lives outside of Alaska. He
expressed the understanding that obtaining the initial license
in Alaska would require residency at a hospital. He questioned
the process and practicality of someone living outside of the
state while practicing in Alaska.
REPRESENTATIVE SPOHNHOLZ responded that there are many
nonresident providers practicing in Alaska. She deferred to Ms.
Chambers.
3:33:20 PM
MS. CHAMBERS explained that there is no residency requirement to
be licensed in Alaska. The term "residency" refers to a phase
of professional progression in becoming a physician and not a
physical home. She stated that there are many providers in the
state who have never "set foot" in the state. She gave a quick
overview of the process for providers to become licensed in
Alaska, adding that it is the same for nonresidents and
residents.
3:34:52 PM
REPRESENTATIVE KURKA, with a follow up, questioned whether the
residency requirement would be a part of attending medical
school in any state.
MS. CHAMBERS responded in the affirmative.
3:35:33 PM
CO-CHAIR ZULKOSKY removed her objection.
REPRESENTATIVE MCCARTY objected for the purpose of an additional
question. He stated that insurance companies make payments
according to the point of service billing code. He questioned
whether the location [of a telehealth visit] has an impact on
the payment.
3:36:32 PM
CO-CHAIR ZULKOSKY, referring to time constraints, suggested that
the question be addressed at a later time.
REPRESENTATIVE MCCARTY removed his objection. There being no
further objection, Version N was before the committee.
3:37:08 PM
RENEE GAYHART, Director, Division of Health Care Services,
Department of Health and Social Services, responding to
Representative McCarty's question, explained that currently
telehealth is considered the same as an in-office service. She
continued that "usual and customary" rates are paid in
[accordance with where the provider's office] is located.
3:38:50 PM
CO-CHAIR ZULKOSKY re-opened public testimony on HB 265, Version
N.
3:39:14 PM
JULIA LUEY, Vice President and interim CEO, Integrated and
Residential Services, Volunteers of America (VOA) Alaska,
explained that VOA Alaska is a nonprofit, behavioral health
organization specializing in therapeutic services for youth,
young adults, and families. She offered VOA's support for the
proposed legislation, as it would maintain and expand Alaskan's
access to vital behavioral health services. She explained that
telehealth platforms had been significantly broadened during the
pandemic through temporary allowances and emergency declarations
at the state and federal levels, and more Alaskans had been able
to be reached. Prior to the pandemic, telehealth for behavioral
health services had been restricted to master's level
clinicians. During those services one party had to be within
four walls of a clinic. This created barriers in meeting
individuals in their recovery and healing process. She
expressed the opinion that telehealth, phone, and text are
avenues for helping individuals across Alaska's unique
landscape. She thanked the committee for the legislation, as it
would be a great enhancement to the behavioral health system of
care.
3:41:27 PM
SARAH ELIASSEN, representing self, voiced support for the bill.
She stated that at 96 years old, telehealth is important because
she could visit with her physician and get the attention needed
without having to obtain transportation to Anchorage from Eagle
River, and back. She emphasized that telehealth is important to
seniors. She shared that it had never occurred to her as a
young person that one day she would not be able to drive. She
said, "I want to impress upon you that it is important all over
the state, where people do not have transportation to get to a
doctor." She said it is impossible for her to get to Anchorage
without imposing on friends or family, adding that these people
are not responsible for taking her to the doctor. She said this
method of health care is a "blessing."
3:45:08 PM
SUZANNE ISHII-REGAN, representing self, thanked the state and
its disability services for quickly pivoting and being flexible
during the pandemic. She stated that she has a family member
who uses a ventilator and is immunocompromised, and telehealth
during the pandemic helped her family stay connected with their
physician while reducing contact with the public. The ability
to access telehealth reduced barriers concerning mobility issues
and weather.
3:48:08 PM
PAMELA SAMASH, representing self, explained that she supports
the proposed legislation because telehealth is a "great" option
for rural Alaskans, seniors, and doctors. She commented that
during telehealth meetings physicians often would see only a
patient's face. She stated that physicians may be missing other
issues without seeing the entire body, as "body language is 99
percent of communication." She said that with a "little TLC
this could be just perfect."
3:51:21 PM
KYLE ZEBLEY, Executive Director, American Telemedicine
Association (ATA) Action, stated that ATA Action is the ATA
affiliated trade association focused on advocacy. He stated
that ATA Action supports the legislature's effort to expand
access to high-quality care by allowing Alaska's licensed
providers to treat patients via telehealth without a prior in-
person examination. He stated that ATA Action approves of the
legislature's effort to allow physicians, osteopaths,
[podiatrists], and physician assistants to prescribe controlled
substances, when appropriate, via telehealth without an in-
person exam. He said ATA Action maintains that a care plan,
including telehealth, should be the choice between a patient and
his/her provider. He stated that patients should be able to use
telehealth to receive prescriptions for substances that fall
under Schedule III and Schedule IV categories, and certain
patients with substance abuse disorders should receive
prescriptions via telehealth for stimulants in the Schedule II
category. He stated that, [in addition to providers already
mentioned], ATA Action "strongly" encourages the legislature to
allow advanced practice registered nurses the permission to
prescribe controlled substances without an in-person exam. He
acknowledged the effort to permit out-of-state providers not
licensed in Alaska to render telehealth services to patients
referred by an Alaska-licensed provider, but he urged the
committee to remove barriers and allow out-of-state providers
licensed and in good standing within their home states to
practice without having to navigate the current licensure
requirements. He commented that there are aspects of the
proposed legislation to support.
3:54:06 PM
JACKI CHURCHILL, representing self, shared that she has an
immune compromised family member. She voiced support for HB
265. She stated that she is a nurse and expressed the opinion
that the options for telehealth should be available to all
Alaskans, whether or not they are established with an out-of-
state provider. She said, "Many times an opinion is needed more
than an exam when it comes to life-saving decisions," and an
important benefit of telehealth is that, before travel, a
patient and a provider can ensure they are a "good fit." She
explained in detail the benefits of telehealth with a physician
in Seattle during her spouse's cancer treatment, referencing an
appointment over the phone which turned out to be "lifesaving."
She summarized the benefits of telehealth as minimizing health
risks, mitigating inconveniences, and reducing out-of-pocket
costs.
3:58:00 PM
TIFFANY HALL, Executive Director, Recover Alaska, voiced support
for [Version N]. She stated that Recover Alaska works across
the state to reduce the harms of excessive alcohol use. She
cited that before the pandemic at least 44,000 Alaskans
experienced an alcohol-use disorder, but only 15 percent of
those who qualified received treatment. She related that the
location of services and stigma are barriers for people not
receiving treatment. She cited that during the pandemic roughly
one-third of Alaskans increased their alcohol use in order to
cope with stress. She expressed the opinion that there has been
a long need for treatment. She argued that the legislation
would help close the gap. One critical equity aspect is the
inclusion of multiple modalities, such as video, audio only, and
text options. She shared that she is in long-term recovery and
had relied heavily on telehealth opportunities during the
pandemic. She stated that mental health disorders often trick
people into thinking they do not need help, and any initial
barriers [to ask for help] "feel too big." She stated that
expanding telehealth is a great step forward for the state, and
a great step forward in terms of equity and reducing health
disparities across the state.
4:00:43 PM
LIZETTE STIEHR, Executive Director, Alaska Association on
Developmental Disabilities (AADD), voiced support for [Version
N]. She stated that AADD is a trade association of
organizations across the state which provides services to people
with developmental disabilities. She stated that the
utilization of remote services moved forward during the
pandemic, and many service providers for the developmentally
disabled were able to reach isolated clients. She stated that
the Alaska Mental Health Trust Authority had provided a grant
which supported training, provided handbooks, and facilitated
on-going meetings between providers. She added that these
providers continue to deliver robust services today. She stated
that AADD strongly supports the financial parity in the
[proposed] legislation.
4:03:36 PM
JESSICA ESTES, member, Alaska APRN Alliance, voiced support for
[Version N]. She stated that the legislation is important to
the clients that she serves, as they can be offered telehealth
regardless of their location, which ensures continuity of care.
She stated that continuing established relationships with
providers is also important for patients receiving end-of-life
care. She thanked the bill sponsor for the opportunity to
continue the services created during the pandemic.
4:05:06 PM
LANCE JOHNSON, Administrative Director, Behavior Health
Services, Norton Sound Health Corporation, spoke in support of
[Version N]. He voiced the preference for audio-only health
services. He explained that using audio-only services allows
people to be in an environment of their choosing, where they
feel safe. For example, he said, using telehealth in a village
office leaves a client feeling "exposed." He referenced a
housebound client who effectively completed an intensive
substance abuse program. He argued that without the ability to
receive treatment through audio-only services, the individual
would not be here today. He expressed the opinion that
telephone services allow people to be more vulnerable;
therefore, their progress is consistent. He added that audio-
only health services are also important because of the internet
issues which "plague" rural Alaska. He said having limited
internet does not make telehealth the best option, while audio
services allow people a greater choice in getting the needed
support. He thanked the committee, especially the bill sponsor.
4:07:20 PM
LARRY JOHANSEN, representing self, voiced support for the
legislation. He stated that as a lifelong Alaskan he has
experienced difficulties being reached in the remote places in
the state, and the pandemic taught people to be comfortable
using video as a form of communication. He shared that he has
had Parkinson's disease for 14 years, and, because of [his
disability] and the necessity to take ferries and flights, it
has taken him up to 10 days to travel to Seattle to see his
physician. He noted the expense of this travel. He said the
proposed legislation would benefit not only people like himself,
who stand to lose a great deal by not having medical services,
but it would increase all Alaskan's ability to receive medical
attention. He shared that in-person visits often allow only one
hour for a patient to cover everything that has happened to
him/her in the last six months. Personally, he does not know
how a medication will work until he is "in the real world," and
issues can be addressed much quicker using telehealth. He
concluded that the [proposed] legislation is important for a
large state.
4:12:13 PM
ANN RINGSTAD, Executive Director, National Alliance on Mental
Illness (NAMI) Alaska, stated that NAMI Alaska advocates for
access to mental health services, treatment, support, and
research and is steadfast in its commitment to raising awareness
and building a community of hope for all of those in need
throughout Alaska. She stated that in some cases telehealth
access is the only support available in the community. She
cited statistics on Alaskans with mental health issues and
argued that the proposed legislation would help many who do not
have access to mental health care. She stated that telehealth
has been a pivotal development in creating the ability to access
care in Alaska where resources are limited. She said that it
has been "a silver lining" from the pandemic and possibilities
continue to grow. She stated that NAMI Alaska supports the
legislation. She thanked the bill sponsor.
4:14:35 PM
CO-CHAIR ZULKOSKY, after ascertaining that there was no one else
who wished to testify, closed public testimony on HB 265.
CO-CHAIR ZULKOSKY announced HB 265 was held over.
| Document Name | Date/Time | Subjects |
|---|---|---|
| CS HB 265 v N 03.01.22.pdf |
HHSS 3/3/2022 3:00:00 PM |
HB 265 |
| CS HB 265 v N Summary of Changes 03.02.22.pdf |
HHSS 3/3/2022 3:00:00 PM |
HB 265 |
| HB 265 Testimony - Received as of 03.02.22 - 1.pdf |
HHSS 3/3/2022 3:00:00 PM |
HB 265 |
| HB 265 Testimony - Received as of 03.02.22 - 2.pdf |
HHSS 3/3/2022 3:00:00 PM |
HB 265 |
| HB 265 Testimony - Received as of 03.02.22 - 3.pdf |
HHSS 3/3/2022 3:00:00 PM |
HB 265 |
| HB 265 Presentation 02.16.22.pdf |
HHSS 3/3/2022 3:00:00 PM |
HB 265 |
| HB 292, Sponsor Statement, Ver. A.pdf |
HHSS 3/3/2022 3:00:00 PM |
HB 292 |
| HB 292, Sectional Analysis.pdf |
HHSS 3/3/2022 3:00:00 PM |
HB 292 |
| HB0292A.PDF |
HHSS 3/3/2022 3:00:00 PM |
HB 292 |
| Kevin Fimon Resume 2021 AMHTA_Redacted.pdf |
HHSS 3/3/2022 3:00:00 PM |
Gov Appointee to Mental Health Trust Authority |