04/14/2014 01:30 PM Senate HEALTH & SOCIAL SERVICES

        HB 281-PRESCRIPTION WITHOUT PHYSICAL EXAMINATION                                                                    
                                                                                                                                
2:05:19 PM                                                                                                                    
CHAIR  STEVENS  announced  the consideration  of  HB  281.  [CSHB
(L&C)  was before  the committee.]  He said  it was  the first                                                               
hearing on the bill. The intent  is to have the sponsor introduce                                                               
the bill,  take public  testimony, and  look to  the will  of the                                                               
committee.                                                                                                                      
                                                                                                                                
2:05:35 PM                                                                                                                    
REPRESENTATIVE  LYNN GATTIS,  Alaska  State Legislature,  Juneau,                                                               
Alaska, sponsor of HB 281. She  said HB 281 is the companion bill                                                               
to SB 80  and is, essentially, Section 2 of  that bill. She noted                                                               
that she  has provided a  comparison table of  HB 281 and  SB 80.                                                               
She related that  HB 281 clarifies in statue  that physicians may                                                               
not be  sanctioned for  dispensing or  administering prescription                                                               
medications without  a physical examination of  the patient. This                                                               
practice is called telemedicine.                                                                                                
                                                                                                                                
She  explained  that  telemedicine-based medical  care  would  be                                                               
delivered by  primary care physicians  located in  Alaska. Anyone                                                               
needing medical  care would be  a candidate for this  system. She                                                               
gave examples  of who might benefit  and be able to  attain over-                                                               
the-phone or  online consultations where physicians  can diagnose                                                               
an ailment and,  if necessary, provide a  prescription. This bill                                                               
stipulates  that  physicians  would  not  be  able  to  prescribe                                                               
controlled substances.                                                                                                          
                                                                                                                                
She  listed the  benefits  of telemedicine:  convenience for  the                                                               
patient, affordability, rapid access,  higher productivity from a                                                               
healthy workforce,  and primary care access  for rural residents.                                                               
The efficient quality comes down  to cost and access. She pointed                                                               
out that  telemedicine does not  replace the relationship  with a                                                               
primary care  provider. By requesting a  consultation and filling                                                               
out an intake  form, consent and medical history  forms, a person                                                               
is  entering into  a doctor/patient  relationship.  If a  patient                                                               
does  not have  a primary  care  provider, they  may designate  a                                                               
telemedicine  provider  as  such.  Patient  privacy,  the  Health                                                               
Insurance Portability and Accountability  act (HIPA), and privacy                                                               
laws apply to telemedicine.                                                                                                     
                                                                                                                                
She  noted that  telemedicine already  exists and  is working  in                                                               
Alaska. Alaska has been one  of the pioneers of telemedicine. The                                                               
Alaska   Native   Tribal    Health   Consortium,   the   Veterans                                                               
Administration, and  the military,  use telemedicine.  Outside of                                                               
the  state,  major  employees  like Home  Depot  and  Costco  use                                                               
telemedicine.                                                                                                                   
                                                                                                                                
She  gave  examples of  medical  conditions  of people  who  seek                                                               
telemedicine:   acute   respiratory    illness,   uterine   track                                                               
infections,  skin problems,  abdominal pain,  and back  and joint                                                               
problems. She  said 20  percent of  Alaska's population  lives in                                                               
rural areas and needs quick and economical medical care.                                                                        
                                                                                                                                
2:09:56 PM                                                                                                                    
CHAIR  STEDMAN noted  that  the committee  is  familiar with  the                                                               
concept of telemedicine.                                                                                                        
                                                                                                                                
REPRESENTATIVE GATTIS  said the  bill has not  been heard  in the                                                               
Senate Health and Social Services  Committee. She emphasized that                                                               
there is a  difference between the two bills.  She explained that                                                               
HB  281 requires  physicians  to be  located  in Alaska.  Another                                                               
difference  is  SB 80  required  that  physicians bill  insurance                                                               
companies, a provision not included in HB 281.                                                                                  
                                                                                                                                
CHAIR  STEDMAN noted  one  zero fiscal  note  from Department  of                                                               
Commerce, Community and Economic Development (DCCED).                                                                           
                                                                                                                                
2:11:56 PM                                                                                                                    
SENATOR MICCICHE asked why out-of-state doctors cannot be used.                                                                 
                                                                                                                                
REPRESENTATIVE  GATTIS replied  that  the bill  has gone  through                                                               
various House committees  and Alaska doctors said  they wanted to                                                               
protect Alaskan doctors.                                                                                                        
                                                                                                                                
SENATOR  MICCICHE  reported  that  currently  there  are  several                                                               
thousand people using  doctors who would no longer  be allowed to                                                               
use them.                                                                                                                       
                                                                                                                                
REPRESENTATIVE  GATTIS said  the Native  Health Consortium  has a                                                               
federal  exemption  that allows  them  to  go  out of  state  for                                                               
telemedicine.                                                                                                                   
                                                                                                                                
SENATOR  MICCICHE said  several companies  also use  out-of-state                                                               
physicians.                                                                                                                     
                                                                                                                                
REPRESENTATIVE  GATTIS  deferred  to Dr.  DePhillips  to  discuss                                                               
Costco and Home Depot.                                                                                                          
                                                                                                                                
SENATOR MICCICHE said they were not the only companies.                                                                         
                                                                                                                                
2:13:56 PM                                                                                                                    
DR. HENRY  DEPHILLIPS, Corporate Chief Medical  Officer, Teladoc,                                                               
Nashville, Tennessee,  answered questions related to  HB 281. Dr.                                                               
DePhillips   responded   to   Senator  Micciche's   question   by                                                               
explaining that  there a three  large telemedicine  companies and                                                               
two  of those  three  have  put together  a  national network  of                                                               
physicians.  He said  Teladoc has  several Alaska  physicians. He                                                               
noted Teladoc  has a difference  in interpretation of  the Alaska                                                               
Medical Board rules  than the Board does, which  is what prompted                                                               
the bill.  He said  Teladoc has  been operating  in Alaska  for a                                                               
while under the  "cross coverage exemption." He  said Teladoc and                                                               
other companies  are looking for regulatory  coverage through the                                                               
bill,   which  would   include  Alaska   licensed  and   resident                                                               
physicians.  He reported  that Teladoc  worked  closely with  the                                                               
Alaska Medical Association  and agreed that the  care of Alaskans                                                               
should be rendered by Alaska physicians.                                                                                        
                                                                                                                                
2:15:52 PM                                                                                                                    
SENATOR   MICCICHE  asked   why   telemedicine   is  limited   to                                                               
physicians, especially in rural areas.                                                                                          
                                                                                                                                
DR.  DEPHILLIPS said  nurse  practitioners, physician  assistants                                                               
and others,  are not  included because  Teladoc made  a conscious                                                               
business  decision to  keep  the standard  of  patient care  very                                                               
high. He  said they  knew they  would be a  target and  they have                                                               
been  a target  over  the  last 12  years.  Toledo's  model is  a                                                               
physician-only  model, as  are the  other two  companies. Another                                                               
reason  is because  the Medical  Board censured  physicians doing                                                               
telemedicine,  which  is  the  reason behind  the  need  for  the                                                               
legislation. He  thought lower level providers  were regulated by                                                               
a different board.                                                                                                              
                                                                                                                                
SENATOR MICCICHE inquired  about dispensing controlled substances                                                               
via telemedicine. He brought up  a concern regarding post-op care                                                               
medications.                                                                                                                    
                                                                                                                                
DR. DEPHILLIPS said that is a  topic that has been discussed with                                                               
the Department of Corrections and  others during the evolution of                                                               
the bill. He  stated it is a balancing act.  The concern was with                                                               
past history  of internet  prescribing controlled  substances. He                                                               
said  it  was  Toledo's  decision not  to  allow  DEA  controlled                                                               
substances. He  believed the other  two companies also  have that                                                               
policy. It  keeps the abuse  issue at  bay and makes  the Medical                                                               
Boards happy. He  noted the Department of  Corrections allows DEA                                                               
controlled substances  to be prescribed via  telemedicine because                                                               
there is a  clinically trained person on site.  The bill provides                                                               
for that exception.                                                                                                             
                                                                                                                                
2:19:38 PM                                                                                                                    
SENATOR MICCICHE  used an example  of a post-op patient  in rural                                                               
Alaska who requires  medication back in the village.  He asked if                                                               
there is a way for controlled substances to be prescribed.                                                                      
                                                                                                                                
DR. DEPHILLIPS said  there is currently not a  way for controlled                                                               
substances to be prescribed using  telemedicine. He observed that                                                               
if someone post-op  in a village requires  pain control requiring                                                               
a  controlled  substance,  they  would  also  need  an  in-person                                                               
assessment. He  concluded that there  is currently not  a vehicle                                                               
to dispense a controlled substance.                                                                                             
                                                                                                                                
2:21:30 PM                                                                                                                    
JENNIFER  MEYHOFF,  Alaska  Association of  Health  Underwriters,                                                               
Anchorage, Alaska,  testified in  support of  HB 281.  She opined                                                               
that telemedicine has  the potential to help  contain high health                                                               
care costs.                                                                                                                     
                                                                                                                                
SARA CHAMBERS,  Director, Division of Corporation,  Business, and                                                               
Professional  Licensing, Department  of  Commerce, Community  and                                                               
Economic Development (DCCED),  Juneau, Alaska, answered questions                                                               
related to HB 281.                                                                                                              
                                                                                                                                
CHAIR STEDMAN asked if the  department has any concerns about the                                                               
bill.                                                                                                                           
                                                                                                                                
MS. CHAMBER said the department  does not have concerns. She said                                                               
she  believes the  State Medical  Board has  gone on  record with                                                               
their concerns.                                                                                                                 
                                                                                                                                
CHAIR STEDMAN closed public testimony.                                                                                          
                                                                                                                                
REPRESENTATIVE GATTIS  concluded that HB  281 is not  a catch-all                                                               
and not a  hospital, but brings Alaska into the  21st Century and                                                               
will provide access to low-level health care. She shared a story                                                                
about her experience with telemedicine.                                                                                         
                                                                                                                                
2:25:20 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
2:28:03 PM                                                                                                                    
SENATOR MICCICHE moved to report CS for HB 281 from committee                                                                   
with individual recommendations and attached zero fiscal note.                                                                  
                                                                                                                                
CHAIR STEDMAN announced that without objection, CSHB 281(L&C) is                                                                
reported from the Senate Health and Social Services Standing                                                                    
Committee.