Legislature(2019 - 2020)BELTZ 105 (TSBldg)
03/14/2019 01:30 PM Senate LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| Confirmation Hearing(s): | |
| SB44 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| *+ | SB 44 | TELECONFERENCED | |
| + | TELECONFERENCED |
SB 44-TELEHEALTH: PHYSICIAN ASSISTANTS; DRUGS
2:13:02 PM
CHAIR REINBOLD reconvened the meeting. She announced that the
final order of business would be SENATE BILL NO. 44, "An Act
relating to the prescription of drugs by a physician assistant
without physical examination."
2:13:05 PM
SENATOR COSTELLO clarified the original version of SB 44 was
before the committee. Senator Bishop objected for discussion
purposes.
2:13:15 PM
SENATOR CATHY GIESSEL, Alaska State Legislature, Juneau, stated
that this bill relates to telehealth and physician assistants.
She said that while she is a health care professional, she is
not a physician assistant (PA) and derives no benefit from the
bill. She described this bill as a "clean up bill" that will
increase access to care throughout Alaska. She paraphrased from
her sponsor statement for SB 44, which read:
The 2016 Medicaid Reform bill (Senate Bill 74)
provided for the use of telehealth by revising Alaska
statutes to require the Alaska Board of Medicine to
adopt regulations and guidelines for physicians
rendering a diagnosis, providing treatment, or
prescribing, dispensing, or administering a
prescription drug to a person without conducting a
physical examination under AS 08.64.364.
2:14:19 PM
Consequently, the omission of PAs from the Medicaid
Reform bill has led to them being subject to
limitations on the use of telemedicine. Specifically,
the Medical Board released guidelines stating that
physician assistants could not treat a patient via
telemedicine without first conducting an in-person
examination personally, or with a collaborating
physician or other practitioner in the same group
practice.
2:14:54 PM
SENATOR GIESSEL said that physician assistants (PAs) have been
prohibited from practicing telemedicine. She explained that
physician assistants are a type of clinician that developed
during the Vietnam War. These were medics who went to Vietnam
and had to practice very high-level medical care. Actually, they
replaced doctors in the war field. They came back to the US with
these skills. Physicians realized that these medics were highly
skilled.
She referred to a document in members' packets labeled "AAPA."
The American Academy of Physician Assistants (AAPA) discusses
the education and experience of physician assistants. PAs are
required to have 27 continuous months of education, including
classroom education in medical sciences, and to perform
rotations in medical and surgical disciplines, family medicine,
internal medicine, general surgery, pediatrics, and obstetrics.
These medical professionals must have at least 2,000 hours of
clinical practice in various settings and almost all physician
assistant programs are master's degree programs. In fact, it
will be required by the year 2020. After graduation, they must
pass the physician assistant national certifying exam and be
licensed by the state. Every two years they must complete 100
hours of continuing medical education and every ten years they
must take an exam to recertify. She characterized these
physician assistants as medical professionals with substantive
education.
2:17:02 PM
SENATOR GIESSEL referred to medical board guidelines for
collaborating physicians and physician assistants in members'
packets. She said that physician assistants (PAs) must practice
under the supervision of a collaborating physician. They must
have an active collaborative plan, which describes the nature of
the relationship, the scope of practice, where they will be
practicing, and what controlled substances they can prescribe.
Physician assistants have the authority and ability to apply to
the Drug Enforcement Administration to obtain authorization to
prescribe controlled substances. They may or may not choose to
do so, but if they do, their collaborating physicians oversee
the prescribing authority.
2:18:12 PM
SENATOR GIESSEL related the controlled substances physician
assistants are authorized to prescribe, including schedule II
through schedule V drugs. She offered to provide the document,
but basically explained that schedule II includes drugs such as
oxycodone and morphine, schedule III includes drugs such as
codeine, schedule IV includes drugs such as Darvon, and Schedule
V includes drugs such as Robitussin with codeine.
2:19:01 PM
SENATOR GIESSEL explained that the bill would expand
telemedicine to physician assistants (PAs). She continued to
review her sponsor statement, as follows:
SB 44 amends the law, aligning with the intent of the
Medicaid Reform bill, to clarify that physician
assistants can provide telemedicine in the same manner
as physicians. Under SB 44, the physician assistant
would be subject to the same statutory oversight as
physicians regarding the practice of telemedicine, as
well as the same disciplinary sanctions when
appropriate
Senate Bill 44 will increase patient access to care,
particularly for rural and medically-underserved
areas. The bill will allow PAs to use telemedicine,
extending the reach of medicine to underserved areas.
This is particularly important in Alaska, with vast
geographical challenges and limited access to vital
healthcare.
She referred to HRSA document in members' packets. Alaska
is a health professional shortage area.
2:20:40 PM
SENATOR BIRCH asked for further clarification on whether this
would cover nursing and nurse practitioners.
SENATOR GIESSEL said that nurse practitioners have independent
practice in Alaska and can open their own clinics and have no
limitations on prescriptive authority. They can obtain Drug
Enforcement Administration (DEA) numbers that allow them to
prescribe controlled substances, which has been in place since
1983. They often practice with physician assistants (PA) and
often perform the same work, but PAs are under the state medical
board and require supervision.
2:21:44 PM
SENATOR COSTELLO appreciated the history of PAs. She watched a
Vietnam War documentary and can see many individuals came back
from that war with an arsenal of experience in the field. She
said "patient" is replaced with "person" However, on page 3,
line 13 of the bill relates to the term "physician-patient
relationship." She asked whether the term "patient" is defined
in statute or if it is a commonly-understood term.
SENATOR GIESSEL said that law uses the term "person" and
"patient" as medical terminology and often refers to them as
clients. She characterized it as a term of art whereas person is
a legal term. However, physician-patient relationship in used in
other places in the medical statutes.
2:23:32 PM
JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State
Legislature, Juneau, paraphrased the sectional analysis, which
read as follows:
Senate Bill 44 Sectional Analysis (vsn U)
Telehealth: Physician Assistants; Drugs
Section 1: Amends AS 08.64.101(a)(6) by requiring the
board to adopt regulations for a physician assistant
practicing telehealth under AS 08.64.364, and that the
regulations must use a recognized national model for
standards of telehealth care.
Section 2: Amends AS 08.64.364(a) by saying that
disciplinary action cannot be directed toward a
physician assistant for prescribing drugs via
telehealth if the drugs are not controlled substances,
if follow up care can be provided from its medical
group, and if consent has been given by the patient
for care and sharing of records to the primary care
provider.
Section 3: Amends AS 08.64.364(b) by saying that a
physician assistant may administer botulinum toxin
(Botox) if they meet all the requirements set out in
08.64.364 and is supervised by an appropriate licensed
health care provider
Section 4: Amends AS 08.64.364(c) by renumbering and
adds that a physician or physician assistant may not
prescribe, dispense or administer a prescription drug
via an Internet questionnaire or email message without
having a prior patient/doctor relationship.
2:25:47 PM
SENATOR COSTELLO said that it seems that the guidelines that
were written by the board just need to be updated to include
PAs. she asked whether the sponsor has considered adding an
immediate effective date.
MS. CONWAY said that this bill would become effective after the
governor signs the bill.
2:26:21 PM
SENATOR BIRCH asked whether administering Botox is a change.
SENATOR GIESSEL answered that Botox requires the presence of a
licensed health care provider who is authorized to administer
that medication. This is current law for physicians and the bill
adds PAs. Currently, physicians can prescribe, dispense, and
administer a controlled substance or botulinum toxin when an
appropriate licensed health care provider is present with the
person. This language is listed separately because these are
heavy duty medications being administered.
2:27:43 PM
CHAIR REINBOLD opened public testimony on SB 44.
2:29:38 PM
CHERISE HUG, Physician Assistant (PA), Orion Behavioral Health
Network, Eagle River, stated she is a PA in Anchorage and works
in child and adolescent psychiatry. About half of her time is
spent in person and the other half is spent providing
telemedicine to remote communities throughout the state. She
said PAs are allowed to provide telemedicine, but they cannot
prescribe medications without having a face-to-face
relationship. She said this has created a burden and difficulty
for patients in rural communities to access care. She said that
the delay can be detrimental to families. Currently, if she
provides an initial evaluation via telemedicine, she cannot
start any medication. This causes delays and hinders patient
care. It requires patients to travel and adds significant travel
costs to patient care.
2:31:33 PM
SENATOR BIRCH asked for her experience with audio or video
transmission and if it is an effective means of providing care.
MS. HUG answered that she uses an Internet-based service that
has a video connection. She said they have good cameras, but it
depends on what patients have at their end. She explained that
the quality of the video tends to be pretty good. She said that
she often works with other clinics and patients can go to a
community health office for the telehealth appointment.
SENATOR BIRCH asked how patients receive their prescriptions.
DR. HUG answered that patients use mailout pharmacy services via
Walgreens and Southcentral Foundation. The patient's provider
ships the medication directly to the patient.
2:34:19 PM
SHIGONE BEIGHLE, Physician Assistant (PA), Orion Behavioral
Health Network, Anchorage, echoed Ms. Hug's testimony. She
stated that about 50 percent of her patients are pediatric
psychiatric patients in rural communities. She was raised in a
rural community of 500 in Aniak. She said that at age 13 she
lost three peers to suicide. Her school had a population of 50
between 7th-12th grades. She said that the loss of three
students in one year was significant. She said that Alaska has
the highest rate of teen suicide and Alaska Natives and rural
communities have the highest rates.
She said that her organization provides care via telehealth to
children throughout the state, including Barrow and King Cove.
This service provides opportunities she wished had been
available to depressed teens during her high school years. She
related a patient experience, in which a child under the age of
10 had three depressive stints at North Star Behavioral Health
(North Star) with limited out-patient care and delayed access
stabilization and care. Although North Star provided the initial
care, the child will face delays for stabilized care and
maintenance if she cannot not write prescriptions until she
meets face-to-face with the child. She said that in these
situations, the parents and medical staff are already dealing
with an unstable child or a child in need. She said adding
travel is expensive and adds undue burdens for those working to
help children in crisis. She said that she got into the field of
medicine and psychiatry because of the great need in Alaska and
her desire to serve the rural population. She expressed
gratitude for the services that her organization provides and
the telehealth services it provides. She expressed concern that
medical professionals see patients and then cannot do anything,
which is detrimental to patients. She said, "Maybe not being
seen and doing nothing is almost the same."
2:37:20 PM
CHAIR REINBOLD recalled a friend's experience at a hospital
emergency room, with very high costs for services. She hoped
that telemedicine would help reduce costs. She hoped to further
discuss emergency room costs and the trauma psychiatric patients
experience in those situations.
2:38:56 PM
CHAIR REINBOLD held public testimony open on SB 44.
2:39:19 PM
SENATOR GIESSEL referred to six letters of support from
physician assistants in rural Alaska that are in members'
packets.
[SB 44 was held in committee.]