Legislature(2013 - 2014)BARNES 124
03/17/2014 03:15 PM House LABOR & COMMERCE
| Audio | Topic |
|---|---|
| Adjourn | |
| Start | |
| HB316 | |
| HB282 | |
| SB159 | |
| HB288 | |
| HB281 |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | SB 159 | TELECONFERENCED | |
| += | HB 288 | TELECONFERENCED | |
| + | HB 281 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| += | HB 316 | TELECONFERENCED | |
| += | HB 282 | TELECONFERENCED | |
HB 281-PRESCRIPTION WITHOUT PHYSICAL EXAMINATION
4:46:25 PM
CHAIR OLSON announced that the next order of business would be
HOUSE BILL NO. 281, "An Act relating to prescription of drugs by
a physician without a physical examination." [Before the
committee was CSHB 281(HSS).]
4:46:32 PM
REPRESENTATIVE LYNN GATTIS, as sponsor, stated that HB 281 would
clarify in statute that physicians may not be sanctioned for
dispensing or administering prescription medications without a
physical exam of the patient. This practice is called
"telemedicine" and is medical care delivered by primary care
physicians, licensed within Alaska. Anyone needing medical care
would be a candidate for this system. She highlighted some
benefits of telemedicine for working mothers with sick kids,
rural homesteaders, or employees who cannot afford to take time
off from work. Under HB 281, patients could obtain over the
phone or online consultations in which physicians can diagnose
their ailments and provide prescriptions but stipulates that
physicians cannot prescribe controlled substances. Some
benefits of telemedicine include convenience for the patient and
affordability, with an average cost of $40 for a consultation
fee rather than an emergency room visit that could cost $1,000
or more. In fact, 25 percent of the emergency room visits are
for non-emergency care, she said.
4:48:05 PM
REPRESENTATIVE GATTIS related a scenario in which she personally
waited at the emergency room for hours to obtain after hour
care. She said her physician shared his knowledge of electronic
applications for use on a smart phone and was excited to hear
about her telemedicine bill. She offered her belief that it is
time for telemedicine. She summarized that this bill comes down
to cost and access. This bill does not replace the primary care
provider (PCP) relationship; however, in requesting consultation
a patient enters into a doctor/patient relationship. If a
patient does not have a PCP, he/she may designate a telemedicine
provider as such. She highlighted some issues previously
discussed in other committees including patient privacy.
4:49:06 PM
REPRESENTATIVE GATTIS said the health insurance portability and
accountability act (HIPPA) privacy laws apply to telemedicine
providers the same as with "brick and mortar" offices.
Telemedicine already exists and is being conducted in the state
by the Alaska Native Tribal Health Consortium (ANTHC) and the
Veterans Administration. Additionally, companies such as Home
Depot and Costco use telemedicine as part of their employee
plans. This reinforces that telemedicine is needed and is being
used. Typically, the usual conditions treated include acute
respiratory illness, skin problems, abdominal pain, back, and
joint problems. These practices can favorably impact access to
care in both rural and urban settings. In fact, with 20 percent
of Alaska's population residing in rural areas, it is imperative
that access to routine care be as quick and economical as
possible. She has held conversations in her district and many
of her constituents already support telemedicine.
4:51:07 PM
REPRESENTATIVE SADDLER said he did not see telemedicine
specifically listed in the bill.
REPRESENTATIVE GATTIS suggested that telemedicine will
specifically be clarified in an amendment.
REPRESENTATIVE SADDLER said that his wife works in public health
and has been working in telemedicine for 12 years or longer.
REPRESENTATIVE HERRON appreciated the sponsor bringing this up.
He offered a belated thank you to the late U.S. Senator Ted
Stevens, Alaska, who had raved about telemedicine in the tribal
setting, including the benefits to mental health, dental health,
and therapists. Furthermore, a pilot program in a different
bill will try telemedicine between the medical examiner and
regional hubs. He touted telemedicine by video as a means to
provide services less expensively. He said a telemedicine
connection between patient and doctor is much less expensive
than using the emergency room.
CHAIR OLSON answered that the Kotzebue program has been a
national model and has been on the cutting edge for years.
4:53:51 PM
REPRESENTATIVE MILLETT asked whether nurse practitioners will be
able to use telemedicine.
REPRESENTATIVE GATTIS answered no; that she followed the same
guidelines as if patients walked into their doctor's offices.
She explained that if a nurse practitioner works under a doctor,
it would work the same way under the telemedicine model. She
characterized it as being a connection between the patient and
his/her provider.
REPRESENTATIVE MILLETT questioned this since she is recipient of
ANTHC and understands that nurse practitioners work under
physicians and can prescribe antibiotics.
REPRESENTATIVE GATTIS answered that the federal exemption is a
little different than this model.
4:54:51 PM
REPRESENTATIVE JOSEPHSON asked for clarification on how this
would work. He envisioned someone picks up the telephone to
obtain care. He asked whether telemedicine is a business.
REPRESENTATIVE GATTIS agreed telemedicine is a business, noting
that doctor's offices are also businesses. She related a
scenario to illustrate that mothers would not need to take kids
to the doctor's office and wait, but would simply phone the
doctor and provide specific details, such as the temperature and
any allergies. The doctor would assess the information provided,
perhaps including reviewing a telephonically submitted photo and
make a diagnosis or ask the patient to come in if the doctor
believes the patient may need specialist.
4:56:49 PM
REPRESENTATIVE JOSEPHSON asked whether this would be an
enterprise in which a brick and mortar practitioner breaks away
or if this is a "doc in the box" by phone only.
4:57:11 PM
REID HARRIS, Staff, Representative Lynn Gattis, Alaska State
Legislature, in response to Representative Josephson, explained
that the bill will allow doctors already licensed in Alaska with
a "brick and mortar" business to engage in telemedicine.
However, there are some large national corporations that employ
doctors within the state, without any outsourcing. Thus, the
bill would allow these corporations to operate in the same way
other doctors do. For example, a primary care physician could
set up telemedicine with per charge fees or a doctor could
contact "Teladoc" or some other telemedicine corporation and ask
the it to run the doctor's telemedicine portion of the business.
4:58:12 PM
REPRESENTATIVE JOSEPHSON recalled previous testimony before
another committee that some medicine could be prescribed for
back pain. He asked for clarification on how to avoid
prescription abuse with telemedicine, noting in his law practice
he encountered such cases. He suggested perhaps prescription
contracts were necessary. He asked how to avoid patients
calling five telemedicine practices in a day to fraudulently
obtain drugs.
REPRESENTATIVE GATTIS answered that this bill does not address
chronic back pain, and telemedicine is limited to minor issues.
She deferred to Dr. DePhillips, Teladoc, to answer more fully.
CHAIR OLSON listed testifiers who have signed up for questions,
including telemedicine doctors and department staff from the
Department of Commerce, Community & Economic Development.
REPRESENTATIVE GATTIS related that a number of people have shown
an interest in the bill. She offered her belief that the
practice of telemedicine needs to be clarified.
5:00:32 PM
HENRY DePHILLIPS, Physician, Teladoc, answered that no Drug
Enforcement Administration (DEA) controlled substances are
allowed to be prescribed under the bill. Most telemedicine
companies that provide services in all 50 states, including
Teladoc, prohibit prescribing any DEA controlled substances
including narcotics and benzodiazepines. In fact, most
telemedicine drugs prescribed for primary care health tend to be
for sinusitis, bronchitis, and urinary tract infections and are
medicines that tend to be generic such as amoxicillin or cough
suppressants, which are not prone to abuse. Although Teladoc
occasionally receives requests for narcotics, once these people
find they are not successful in obtaining the drugs, Teladoc
typically will not hear from these people again
5:02:00 PM
REPRESENTATIVE JOSEPHSON referred to a memo he saw two months
ago with respect to an earlier version in the Senate for SB 80,
in which the state medical board opposed the bill since it tends
to redefine the practice of medicine, which has at its core the
physical examination of patients.
DR. DePHILLIPS provided history that he thought would best
answer this. In the 1990s, Internet scams occurred and people
could obtain prescriptions online without any doctors being
involved. The result was that all the state medical boards
enacted a "prior in-person requirement" which drove most of the
Internet businesses out of business. However, 15 years later,
patients can be safely connected with a physician, which is what
telemedicine is all about. Several medical boards have been
resistent to telemedicine for two reasons. First, the medical
boards, including the Alaska State Medical Board, have been
concerned about patient care going to physicians who reside
outside of their state. He understood that concern; however, he
advised that his company's business model calls for physicians
to be located in Alaska. These doctors are residents, who are
licensed in Alaska to provide care for Alaskans. That has been
Teladoc's business model, thus, the bill addresses that concern.
DR. DEPHILLIPS related the second concern, which is that the
medical boards have expressed concern about patient safety since
the boards believe that not seeing the patient in person
represents an unsafe encounter. He also understood this
concern. However, he said he is a board-certified family
physician who has practiced medicine for ten years prior to
moving to the telemedicine industry. The data does not support
the concern. He said, "At least in our company's experience.
We're now coming up this quarter on one-half of one million
telehealth consults around the 50 states." Furthermore, Teladoc
covers the liability insurance for all 50 states of network
physicians and has never had a liability claim. He concluded
that if you put good guard rails around the program, it will
work. He outlined the elements needed for telemedicine,
including using safe prescribing habits, using established
clinical practice guidelines, having a strong quality assurance
program, and treating common uncomplicated medical problems. He
related that his company has all of this, which he suspected
other telemedicine companies also have, too.
5:05:02 PM
DR. DEPHILLIPS said he is testifying today because the Alaska
State Medical Board has been reaching out and censuring doctors
who work for telemedicine companies who prescribe medications
without a prior in-person visit. He stated that Teladoc
initially attempted to work with the Alaska State Medical Board,
but the board would not "budge" on that issue; hence, Teladoc
has turned to a legislative solution. Both Representative
Gattis and Senator Dyson, as sponsors, strongly believe that
telehealth will benefit Alaskans. He noted clear documentation
that telemedicine will increase access, especially to those who
do not currently have a primary-care physician relationship.
The RAND Corporation, a non-profit organization, conducted a
study independent of Teladoc that has helped to demonstrate that
aspect. Certainly, it is very clear that medical costs are
reduced by telemedicine since one of the frequent alternatives
to a telemedicine consult is a visit to the emergency room. He
offered that as telehealth consults go up for employees,
emergency room costs for inappropriate emergency room visits
actually are reduced over time.
5:06:12 PM
REPRESENTATIVE REINBOLD asked where Teladoc is located.
DR. DEPHILLIPS said that he works out of Nashville, Tennessee,
and his company operates nationwide, with more than half the
company serving remote areas. In response to a question, he
answered that he was aware that telemedicine occurs in Alaska
through the Indian Health Service, [an agency within the U.S.
Department of Health and Human Services, responsible for
providing federal health services to American Indians and Alaska
Natives] and the U.S. Department of Veterans Affairs (VA).
5:06:44 PM
REPRESENTATIVE REINBOLD said it is hard to argue with
telemedicine due to the benefits and some significant cost
savings and people can see the benefits. However, she has
worked in the health care industry for nearly two decades. She
said, "This is really alarming to me - this bill. Telemedicine
cannot replace a patient/doctor interaction."
REPRESENTATIVE REINBOLD noted that she did not see anything in
members' packets from the [Alaska State] Medical Association,
the Dental Association, or the Board of Pharmacy. The State
Medical Board opposes the bill. She emphasized a need to hear
from insurance companies. She expressed concern about the
risks, about malpractice aspects since so much care occurs in
telemedicine without any physical assessment of patients.
5:08:17 PM
DR. DEPHILLIPS said the Alaska [State] Medical Association
discussed telemedicine with his organization. He related his
understanding that ASMA is in agreement with the terms of the
bill. His company markets telemedicine as an option only when
it isn't possible for patients to reach their own primary care
physician timely. He emphasized this as being a very important
part of the Teladoc's business model. He assured members that
his company isn't interested in being the primary care physician
(PCP). In addition, Teladoc has many health insurance company
clients, including Aetna, who offers telemedicine coverage in
many other states that have clear regulatory language to allow
it. In terms of patient safety experience, the data is clear.
Teladoc provides the liability insurance for several hundred
doctors that provide telemedicine and his company falls in the
lowest-tier of their premium profile. In the 12-year history of
Teladoc, the company has not had any liability claims.
Secondly, while the industry has perhaps had more consults, his
company has provided nearly 500,000 consults to date. Teladoc
uses evidence-based clinical practice guidelines and provides a
copy of the consult to the patient's own primary care physician
or to the patient's health insurance company so the insurance
company care managers can reach out and "hook them up" with a
primary care physician. The data is pretty compelling that
telemedicine seems to be safe when it is deployed with good
"boundaries and guardrails." Thus, it seems to really be
additive to the medical system, he said.
5:10:45 PM
REPRESENTATIVE GATTIS said that this clarifies in some ways what
is already happening. In fact, some doctors want legislative
sanction to clarify some existing practices. She related that
she worked with the Alaska State Medical Board in crafting this
bill. She pointed out HB 281 considered language suggested by
the State Medical Board and employs current technology,
including cell phone and application uses; however, HB 281 does
not include dentistry. She felt Dr. DePhillips did a good job
explaining telemedicine. The bill will clarify what some
practices currently provide, relating the federal government
already exempts telemedicine for the VA and [IHS]. This bill
will bring that type of service to rest of Alaska.
5:12:11 PM
REPRESENTATIVE MILLETT offered to explain how telemedicine has
worked in Alaska for Alaska Natives. For example, a person can
go to the clinic in King Cove and see a health aide who can
provide a prescription that saves lives. She said the
telemedicine program within the Alaska Native Tribal Health
Consortium (ANTHC) has a broader scope in terms of telemedicine,
including using streaming video and electronically sending
information back and forth. These practices help keep sick kids
healthy since a disincentive exists for those without insurance
due to cost of doctor visits. One advantage of telemedicine is
that [Alaskans] don't end up paying health care costs for minor
issues treated in the emergency room. Instead, these Alaskans
can call a telemedicine doctor to treat ailments, such as strep
throat. Of course, telemedicine can't be used to treat patients
with broken legs, broken ribs, or heart attacks, but it will
treat many types of minor medical complaints. She asked whether
this bill is modeled after IHS and VA, which provide medicine in
an established way.
CHAIR OLSON asked whether that was Dr. DePhillip's health model
for Teladoc.
DR. DEPHILLIPS answered that Representative Millett is exactly
correct. Currently, physicians are residents and licensed in
Alaska, taking care of Alaskans under the two aforementioned
federal programs. The State Medical Board in Alaska does not
want to allow this practice so some doctors are seeking a
legislative solution. He stated that the reality is that HB 281
allows the same Alaska resident licensed physicians to take care
of the rest of the citizens in Alaska, who are not in a federal
health program in the same way that the federal health programs
provide service. This bill represents "a little bit of a catch
up" so all Alaskans can benefit, he said. He has been working
in the health care industry for over 30 years and in his
experience, if a problem arises, "heads roll" in the health care
industry since medicine is high profile, high visibility, and
medical liability is a huge issue. No doctor or company wants
to be involved with [malpractice], patient safety must come
first, and there is pretty good data to demonstrate that
[telemedicine] can be done safely.
5:15:39 PM
DON HABEGER, Director, Division of Corporations, Business, and
Professional Licensing (DCBPL), Department of Commerce,
Community, & Economic Development, stated that he is the
director of DCBPL until March 29, 2014. He introduced Sara
Chambers, the Operations Manager for DCBPL.
5:16:32 PM
CHAIR OLSON referred to page 1, line 10, of HB 281 to "physician
is located in this state" and asked whether it needs to be
"licensed" physician.
MR. HABEGER answered that the aforementioned language is
inserted in the medical chapter surrounded by a large body of
qualification licensing language. In further response to a
question, agreed that at first glance he believes that a
licensed physician is covered.
5:17:32 PM
REPRESENTATIVE SADDLER said he did not see "telemedicine"
explicitly mentioned. He did not see how making a little change
in the sanction's section of law does all the things that have
been represented for telemedicine. He asked whether this is the
only thing in the way of widespread practice of telemedicine.
MR. HABEGER offered to put it in context of what the [Alaska
State Medical] board currently does and the approach it takes.
He said the board would argue it currently offers telemedicine;
however, the board also strongly believes that the patient-to-
patient contact is very important. Within the IHS model, a
physician is on one end of the line and a health aide is at the
other. The difference is that the health aide is knowledgeable
about medicine and can observe the patient from a medical
perspective. Under the bill if a health aide is not present,
the board cannot sanction a licensee to prescribe drugs.
5:19:07 PM
REPRESENTATIVE SADDLER asked whether other large sections of law
envision telemedicine. He reiterated that he is surprised the
"one little fix" would make such a big change in the practice of
medicine in Alaska.
MR. HABEGER explained that within the context of licensure, the
qualifications and the medical examination process for licensure
is quite extensive. He said that the [Alaska] State Medical
board oversees licensure and the agency just does the
processing. He said HB 281 provides a prohibition against
bringing sanction [against a doctor] for a telemedicine contact.
He reiterated that telemedicine contacts already exist and this
change in law simply means that a health aide isn't required to
be present at one end. He did not envision a huge expansion
under the bill.
REPRESENTATIVE SADDLER commented that it might just be that he
is missing something.
5:20:33 PM
REPRESENTATIVE JOSEPHSON said he is curious that this practice
already exists. He related a scenario in which a physician in
Anchorage prescribes drugs, in which the process would be that
the patient calls and describes the symptoms and obtains a
prescription. He related that in his own experience, as a
patient, that he has never called a doctor unknown to him to
obtain a prescription. He asked whether that type of activity
is currently occurring in Alaska.
MR. HABEGER said he would withdraw the term "already existing"
although telephonic diagnosis does exist. He emphasized that
the key is that the board allows a health aid or other
practitioner [to prescribe medicine without the patient or
physician being present]. In response to a question, he agreed
that currently, any health care professional, such as a
certified nurse aide (CNA), who has some training [consults with
the physician telephonically about the patient and prescribes
medicine to treat the patient.]
5:22:05 PM
REPRESENTATIVE JOSEPHSON asked what he thinks of the State
Medical Board's position that "we don't like this" when the
Alaska State Medical Association says it is okay.
MR. HABEGER referred to earlier comments on the State Medical
Board's objection to SB 80. He said the original version of
that bill included licensure of out-of-state doctors. When the
board met they were soundly against that version. He recalled
that the companion bill [SB 80] was later amended. He was not
sure [of the board's position on the amended version of SB 80.]
5:23:07 PM
REPRESENTATIVE JOSEPHSON referred to an email of January 28,
2014, from Deborah Stovern, Executive Director, State Medical
Board, that also indicates that the board was concerned about
the lack of contact [by the physician]. He recalled
Representative Millett's reference to strep throat, noting that
it would require a culture to diagnose strep throat. He further
recalled when he lived in Kalskag that he had met with a [health
care] aide in a cabin who performed a strep culture, presumably
calling a doctor in Bethel [to consult]. He characterized it as
being "bookends" or a "virtual" contact. He asked how this bill
would allow for a culture.
MR. HABEGER said he can't answer that.
REPRESENTATIVE MILLETT offered her belief that it could happen
via an application for an iPhone.
5:24:55 PM
ROBERT LAWRENCE, Physician, Chief Medical Officer, Inmate Health
Care, Department of Corrections (DOC), stated that prior to his
state work he served the Norton Sound Health Corporation as a
family physician and subsequently became the owner and cofounder
of a small medical company that used and tested the technology
that is before the committee today.
LAURA BROOKS, M.S., Health Care Administrator, Department of
Corrections, thanked the committee and the sponsor for working
with the DOC. She indicated some wording [in the bill] could
potentially impact the way the DOC practices every day.
5:25:27 PM
MS. BROOKS explained that the DOC was one of the first agencies
to start using telemedicine in order to provide improved medical
services to inmates in rural areas. She explained that in 1998
the DOC's psychiatrists began using telemedicine. This practice
has allowed the DOC to reduce costs since the psychiatrists had
previously been traveling to remote areas several times per
month. Now these doctors can provide medical care to inmates
via telemedicine, which is more efficient and cost effective.
MS. BROOKS expressed concern on the wording related to
controlled substances, which may adversely impact the department
in two areas. First, currently a psychiatrist might prescribe a
controlled substance for new arrests, who currently take
medication, or experience a mental health crisis. Currently,
this is done via the telemedicine system, which allows the
department to provide safe and immediate interventions for
mental health crises. Secondly, the DOC is a 24-hour provider.
In addition to telepsychiatry, the department has physicians,
nurse practitioners, and physician's assistants who are on call
telephonically for all DOC medical clinics and facilities,
including half-way houses and community jails. Prescribing
controlled substances is common for DOC providers, in
particular, for those who experience withdrawal symptoms. She
indicated that some intoxicated people are arrested after hours
and the department doesn't have any providers on site. She
estimated 3,000 prescriptions per year for detox protocols for
controlled substances are made by telephone by these providers.
Since telemedicine has improved the department's ability to
provide services to the DOC's clientele, the department has
concerns about how that section of HB 281 would impact them.
5:28:10 PM
DR. LAWRENCE outlined two different forms of telemedicine.
Telemedicine has long been offered in Alaska, initially as a
provider-to-provider communication. For example, if a physician
needed a consultant, the physician might use a telemedicine
consult to obtain an answer. This bill seems to relate to the
second form of telemedicine, which is a direct patient-to-
provider consultation. He clarified that the department engages
in the first type of telemedicine. He related a scenario to
illustrate how telephonic communications have been used in rural
areas, such as in Nome to treat someone who was arrested but
began experiencing alcohol withdrawal, which could lead to a
deadly condition of delirium tremens (DTs). In those instances
the treatment is to prescribe a benzodiazepine that can prevent
seizures or else the inmate must be taken to the emergency room.
Thus, an unintentional consequence of HB 281 will prevent him
from prescribing a controlled substance using telemedicine since
he could be sanctioned by the board. He said the language needs
to be clarified to address the current practices.
CHAIR OLSON indicated Dr. Lawrence is working with the sponsor
and his office to address those issues.
5:30:06 PM
REPRESENTATIVE MILLETT asked whether the DOC could be exempted
from the bill.
DR. LAWRENCE answered that would be one viable option.
5:30:23 PM
REPRESENTATIVE MILLETT asked whether any other state agencies
perform similar functions.
DR. LAWRENCE answered that in Alaska other organizations have
the same model, for example, ANTHC is the other group that uses
the same model and often experiences the same scenarios although
the patient population may be different.
CHAIR OLSON offered to keep the public testimony open.
[HB 281 was held over.]