Legislature(2015 - 2016)HOUSE FINANCE 519
03/30/2016 01:30 PM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| SB74 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 74 | TELECONFERENCED | |
| + | TELECONFERENCED |
CS FOR SENATE BILL NO. 74(FIN) am
"An Act relating to diagnosis, treatment, and
prescription of drugs without a physical examination
by a physician; relating to the delivery of services
by a licensed professional counselor, marriage and
family therapist, psychologist, psychological
associate, and social worker by audio, video, or data
communications; relating to the duties of the State
Medical Board; relating to limitations of actions;
establishing the Alaska Medical Assistance False Claim
and Reporting Act; relating to medical assistance
programs administered by the Department of Health and
Social Services; relating to the controlled substance
prescription database; relating to the duties of the
Board of Pharmacy; relating to the duties of the
Department of Commerce, Community, and Economic
Development; relating to accounting for program
receipts; relating to public record status of records
related to the Alaska Medical Assistance False Claim
and Reporting Act; establishing a telemedicine
business registry; relating to competitive bidding for
medical assistance products and services; relating to
verification of eligibility for public assistance
programs administered by the Department of Health and
Social Services; relating to annual audits of state
medical assistance providers; relating to reporting
overpayments of medical assistance payments;
establishing authority to assess civil penalties for
violations of medical assistance program requirements;
relating to seizure and forfeiture of property for
medical assistance fraud; relating to the duties of
the Department of Health and Social Services;
establishing medical assistance demonstration
projects; relating to Alaska Pioneers' Homes and
Alaska Veterans' Homes; relating to the duties of the
Department of Administration; relating to the Alaska
Mental Health Trust Authority; relating to feasibility
studies for the provision of specified state services;
amending Rules 4, 5, 7, 12, 24, 26, 27, 41, 77, 79,
82, and 89, Alaska Rules of Civil Procedure, and Rule
37, Alaska Rules of Criminal Procedure; and providing
for an effective date."
1:33:07 PM
Co-Chair Thompson relayed that the committee would begin
with the telemedicine portion of the legislation.
STEWART FERGUSON, CHIEF TECHNOLOGY OFFICER, ALASKA NATIVE
TRIBAL HEALTH CONSORTIUM (ANTHC), addressed a PowerPoint
presentation titled "Better Care. Lower Costs. Impacts and
Outcomes of Telehealth in Alaska" (copy on file). He
communicated that ANTHC had been operating a telehealth
system in Alaska for almost two decades. He planned to
speak to outcomes from about 250,000 telehealth cases. He
clarified that ANTHC used the terms telehealth and
telemedicine interchangeably (slide 2). The American
Telemedicine Association (the largest body in the world
dedicated to telemedicine) treated the words as synonymous;
the terms referred to the use of telecommunications to
exchange information that could be done through medical
records, audio, video, or a combination of the two in order
to care for patients.
Mr. Ferguson highlighted the different types of
telemedicine. The most common type of telemedicine in the
Lower 48 was video-teleconferencing or synchronous
telemedicine where the patient and provider were both
participating at the same time from different locations.
When ANTHC began building telemedicine in the late 1990s it
did not have the bandwidth to support live
videoconferencing so it had begun building its system based
on store-and-forward technology, which involved capturing
data and sending it. The system captured images, heart and
lung sounds, pressure-wave forms of the ear, and other. He
believed ANTHC was currently one of the world's leading
authorities on the specific technology; it used the system
for about 40,000 to 50,000 cases per year. Home telehealth
was the third type of telemedicine. The system was not
commonly used in Alaska, but he believed it should be
considered. The system tried to care for chronically ill
patients in their home setting by monitoring weight,
glucose, blood pressure, and other. He turned to slide 4
and discussed that telemedicine was extremely prevalent
throughout the U.S. and worldwide. The side included a
chart showing that in 2011 there had been over 200 networks
throughout the U.S. - of which the Alaska Federal Health
Care Access Network (AFHCAN) was one - with almost 4,000
service sites; at that time over half the U.S. hospitals
used telemedicine, which was currently a standard of care
delivery throughout North America.
1:36:00 PM
Mr. Ferguson relayed that his presentation would address
the evidence gained, primarily in the Alaska Tribal Health
System (slide 5). He shared that he worked for ANTHC, which
co-managed the Alaska Native Medical Center (the largest
Native hospital in the U.S.) with Southcentral Foundation
to provide primary care services. The tribal health system
also had six regional hospitals (including Mount Edgecumbe
Hospital in Sitka); multi-physician health centers; sub-
regional centers staffed by nurses, physician assistants,
and in some cases doctors; and the "bread and butter" of
providing care was the use of village clinics in very
remote settings where community health aides delivered
care. Alaska's tribal health system had been designed to
serve all of the facilities, to work in remote settings,
and to meet primary care needs. He turned to slide 6 and
shared that in FY 15 the system had about 43,000 cases,
1,500 providers, and 26,000 patients. He highlighted that
26,000 patients represented about 18 percent of the Alaska
Native population. He did not believe another system
existed anywhere in the world where 18 percent of its
patients were involved in telehealth on an annual basis.
The 43,000 cases represented about 3 percent of all
outpatient encounters in the tribal health system. He
believed a person would be hard pressed to find any other
healthcare system with that level of penetration. He
relayed that growth could increase significantly, but the
current system was well utilized throughout the entire
tribal health system. Slide 6 included the system's store-
and-forward data representing how often the system captured
and sent data.
Mr. Ferguson turned to slide 7 and spoke to specialty
healthcare clinics available by video teleconference. He
shared that the system had a growing use of video-
teleconferencing, primarily because it now had the
necessary bandwidth out to most village clinics through the
expansion efforts of a number of telecommunication
carriers. The slide provided a list of various specialty
clinics offered by the Alaska Native Medical Center. He
pointed out that telemedicine offered by the center was not
strictly contained within Alaska's borders. He detailed
there were many areas where specialists were not available
in Alaska. For example, in adolescent medicine many
pediatric specialists were located in the Lower 48 (some at
Seattle Children's Hospital). The center tried to screen
women at a high risk of developing breast cancer and
conducted regular telehealth consultations between the
patients and the Mayo Clinic in Rochester, Minnesota. One
of the beauties of telehealth was the ability to bring
providers and patients together independent of distance.
1:38:54 PM
Mr. Ferguson shared that one of the benefits of having
developed the system in Alaska was a built-in evaluation
component. He detailed that every time someone did a
telemedicine case in Alaska, the center asked questions
about whether the service improved the quality of care,
educated the patient, made the provider's job more fun,
etcetera. Slide 8 included two questions community health
aides were asked in the village: whether telemedicine
improved the quality of care and whether it improved
patient satisfaction. He relayed that three-quarters of the
almost 12,000 responses showed that telemedicine had
improved the quality of care and about two-thirds of the
time they believed it improved patient satisfaction. He
drew the committee's attention to two images on the slide:
the lower left image showed a cochlear implant. He
specified that a higher percentage of babies were born deaf
in the tribal health system compared to the general
population. He elaborated that traditionally the patients
could either remain deaf or travel to the Lower 48 for a
cochlear implant and remain in the Lower 48 for about 12
months of intensive speech therapy. However, telehealth had
enabled the cochlear implants to be done in Anchorage, the
patient could return to their home, and all of the speech
therapy was conducted by telehealth. He stressed that the
system could now do things that had never been possible
before.
Mr. Ferguson pointed to the image of a diabetic retina
shown on the lower right of slide 8. He detailed that
diabetic patients could start to have problems with the
microvasculature of the blood vessels in the retina; when
those vessels started to bleed or clog it caused blindness.
However, the affliction was easily treatable if diagnosed.
Several years back the center had done a pilot study where
it sent the equipment out to the villages and screened all
the diabetics it could find. The three-month effort had
reversed a seven-year decline in the percent of annual eye
exams for diabetics. Additionally, 100 of the 300 patients
screened had needed follow up and care - they had been on a
path to blindness. Telehealth allowed ANTHC to take care
out to the patients and enabled patients to remain in their
homes. He addressed that telehealth saved money, primarily
in patient travel (slide 9). They estimated that most of
the time if travel was saved it was only saved to the
nearest regional hospital (not necessarily to Anchorage)
and that not all cases prevented travel; however, ANTHC
estimated that annually about $10 million was saved per
year in patient travel. He underscored that for every $1.00
reimbursed for Medicaid about $10 to $11 was saved in
patient travel.
1:41:43 PM
Mr. Ferguson addressed improving patient access to care on
slide 10. He explained that it was very difficult to
measure access and improvements to access in a healthcare
system. He relayed that Dr. Phil Hofstetter based out of
Nome had looked at the number of new referrals to
specialists between 1991 and 2007; he had discovered that
prior to telemedicine for a span of about 11 years, 47
percent of the patients waited 5 months or more to see a
doctor in person. Once telemedicine began to be utilized to
screen the patients to decide who needed to be flown to
Anchorage and who could wait, the number had dropped to 8
percent and 3 years later it dropped to 3 percent. The
takeaways were that telemedicine enabled patient screening
to make decisions and get patients to care faster and that
the impact of telehealth did not happen immediately. He
elaborated that it had taken 3 years for the number to drop
from 8 percent to 3 percent; some of the things required
process change. He moved to slide 11 titled "ANMC
Turnaround Time" and shared that telehealth also helped
improve how long it took for a patient to get a specialty
consult. He detailed that the medical center currently
turned around 25 percent of the health consults in 60
minutes or less. He explained a parent living in a remote
village there was a 1 in 4 chance of having a specialty
consult and treatment plan before leaving the village
clinic. He explained it was a better level of care and
higher turnaround than a person could get if they lived in
Anchorage and went to their family physician or
pediatrician. Additionally, about two-thirds of the cases
were turned around in one day.
Mr. Ferguson addressed the bigger picture of telehealth and
how it related to the changing world of healthcare (slide
12). The healthcare world was moving away from fees based
on procedures to a performance and quality based payment
structure; therefore, it was necessary to think about how
to change the delivery of care. He detailed that the vast
majority of the center's patients were low risk (care could
be provided when a person was sick and then they left the
system). High risk patients were at the other end of the
pyramid (patients with complex diseases and comorbidities)
and constituted 5 percent of the center's patients; the
group accounted for a low percentage of the center's
patients, but consumed a significant percentage of its
costs. He continued that the center had known for years
that one of the ways to treat the patients was to shift to
care management models to care for the patients. He
guaranteed increased care management was necessary if the
desire was to manage the expense of patients and to keep
them healthier.
Mr. Ferguson detailed that the center had conducted a pilot
study several months back where it tried to bring all of
the people involved in caring for its patients in two of
the most remote villages into a video session to determine
whether good care management could be done over telehealth
(slide 13). He elaborated that the center worked with
patients in Gambell and Savoonga out on St. Lawrence
Island; the locations had been selected because Norton
Sound Health Corporation based out of Nome was heavily
focused on a patient-centered medical home model with the
goal of keeping patients in the village. The trouble was
the case managers were typically in Nome and not in the
villages and the case managers for the specialists were in
Anchorage. The only way to implement the model was through
the use of telecommunications. He expounded that the center
had conducted a three-way virtual field clinic with a case
manager in Nome and Anchorage, a specialist in Anchorage,
and the patients in Gambell and Savoonga. The center
believed it was one of the ways it could help to manage the
more expensive patients.
1:45:31 PM
Mr. Ferguson stated the bottom line was the fact
telemedicine enabled the center to deliver care to the
patients in their homes. Additionally, the center could
start trying to predict the trajectory of its patients and
to use telehealth to manage them before they necessarily
enter the system. The center had done a study several years
back where it had looked at infants who were the most
expensive and vulnerable Medicaid population (slide 14). He
elaborated that they were typically infants who had entered
a neonatal intensive care unit (NICU). He pointed to a
chart on slide 14 and relayed that most of these children
would cost between $40,000 and $80,000 in the first year of
their lives. He continued that the infants would be
returned to a village clinic with no specialists, doctors,
and potentially no nurses. He furthered that if an infant
went into a NICU with a diagnosis of respiratory disease,
congenital anomalies, or both, they were almost guaranteed
to be an expensive patient for several years to come. The
center proposed wrapping a "whole umbrella of telehealth
services around these children." The minute the infants
were discharged from the NICU there were pediatric
specialists willing to be involved and case managers to
support them. He explained that parents suddenly had access
to resources throughout Alaska and the Lower 48. The center
estimated the model could save about 37 percent of the
overall patient cost through fewer emergency department
visits, fewer hospitalizations, and other. He explained
that telehealth could provide day-to-day care for the
center's patients and it could be part of a much more
complex, solution focused way to take care of patients
through proper analytics.
1:47:26 PM
Vice-Chair Saddler asked for the terminology for an in-
person consultation. Mr. Ferguson replied that it was "in
person."
Vice-Chair Saddler had heard from providers that while
telemedicine allowed improved access, there were challenges
with the non-standard charting. He explained providers
received chart notes and could not interpret them. He asked
if there were chart note standards.
Mr. Ferguson replied that one of the challenges in
telehealth had always been to make sure to have a complete
patient record in front of the remote site. The center was
addressing the issue in a couple of ways. He explained that
the tribal health system was moving to a shared electronic
health record, which did help. He elaborated that when the
center utilized telehealth, especially store-and-forward,
it trained the providers to put the relevant information
into the telehealth consult to send to the provider. The
center was currently in the process of integrating
telehealth back into the electronic health records so
things were appropriately logged and charted within the
patient's chart.
Vice-Chair Saddler asked if the level of care was
qualitatively the same for telehealth versus in person. Mr.
Ferguson believed center clinicians would say the level of
care was as good or better [via telehealth]. The trick was
to avoid doing things that were not possible through
telehealth. He elaborated that the center's providers were
trained to immediately suggest a patient be seen in person
if the provider could not treat the patient, recognize what
they were looking at, or could not care for the patient.
Vice-Chair Saddler asked what could not be done by
telemedicine.
Mr. Ferguson answered that services provided via telehealth
were broad. He explained that procedures requiring skills
to touch a patient could not be done via telehealth. There
were certain things where perhaps the appropriate data
could not be captured. For example, if a provider was
testing heart and lung sounds and could not hear exactly
what they needed, it would require an in person visit. He
relayed that ANTHC had done a study for the Indian Health
Service (IHS) about five years earlier where it had
addressed the percentage of healthcare that could be done
through telehealth and what percentage could not. As part
of the study ANTHC had interviewed about 10 different
specialists including dermatologists and cardiologists. The
general answer had been that it varied from about 10 to 80
percent depending on the specialty. He elaborated that a
high percentage of dermatology could be done through
imagery, whereas things like behavioral and mental health
required live video.
Vice-Chair Saddler asked if the practice of telemedicine
had been hindered by technological limitations (i.e. end-
user equipment or broadband access between the provider and
telehealth consult) in Alaska.
Mr. Ferguson answered that about 12 to 15 years ago
bandwidth had not been sufficient, but it was no longer a
challenge. He detailed that although about half the sites
were on satellite, which introduced a delay, it was not
really a hindrance to telehealth at present.
1:51:02 PM
Representative Guttenberg quoted from a speech given by the
Federal Communications Commission (FCC) Commissioner
Jessica Rosenworcel to the American Telephone Association
several years earlier "In Alaska, under the leadership of
Dr. Stewart Ferguson, I saw how village clinics well beyond
the last road mile, so remote that they can only be
assessed by telephone, can nevertheless provide first-class
care using a mix of broadband and store forward
technology." He thanked Dr. Ferguson for his work at the
forefront of delivering telehealth services. He was
involved in broadband issues because he lived in Fairbanks
and did not have the service; everything was buffered. He
referred to healthcare pilot program charts done a few
years earlier by the FCC and a presentation provided by FCC
Chairman Kevin Martin. He referenced dots on the
presentation representing villages across Alaska. He was
astounded all of the places across Alaska had broadband
capabilities for telemedicine. He added that he was
delighted, but astounded. He had been in villages where all
of the kids and the village council were huddled around the
library taking broadband off the routers because the
service was not available elsewhere or it was very
expensive. He asked if the clinics had dedicated broadband
accessibilities that was only available to rural health
clinics as part of the pilot program. He asked about costs
that were exorbitant many places in Alaska. He noted that
costs were driven down by e-rate in some places. He stated
that for medicine, regardless of the costs, may be
efficiencies. He asked if they were factors or whether the
program was so far along they were integrated into a
success.
Mr. Ferguson answered that the clinics depended heavily on
the Universal Services Fund (USF) for access to bandwidth.
He explained that the fund was a federally subsidized
program (paid for with funds brought in from telephone bill
tax), which enabled rural healthcare facilities (village
clinics and sub-regional hospitals in Alaska) to buy
bandwidth at no more than the cost in the nearest
municipality or city of 50,000 (i.e. Anchorage). For
example, connectivity could be bought from Savoonga into
Anchorage or Nome for the same cost he would personally pay
to get from his hospital across to Providence in Anchorage.
He relayed that a T1 satellite link of 1.5 megabits per
second ran about $8,000 per month; in Anchorage the cost
was $180 per month. He explained that it meant the clinic
in Savoonga would pay $180 per month and USF would cover
the remaining cost of the $8,000. He elaborated that
because of the high cost of satellite in Alaska, the state
consumed about 60 percent of the entire national subsidy
for USF. Most of the tribal system's village clinics had
between two and four T1s, which gave them enough bandwidth
to do multiple videoconferencing sessions, electronic
health records, store-and-forward, phone and fax, and
other. He continued that the electronic capability was due
to USF. He added that he met with the FCC whenever it came
to Alaska due to the critical importance of continuing the
program; without the program the tribal health system could
not afford the connectivity.
1:56:16 PM
Representative Guttenberg believed he had part of a plan in
place [related to bandwidth], but he noted it was a subject
for a different time. He stated that the bill included very
little dialogue about doing reports on broadband
availability. He asked if the bill needed to include
language specifying that telemedicine programs were
eligible for USF. Alternatively, he asked if the programs
were already eligible for the funds under the rural
healthcare programs.
Mr. Ferguson answered that almost all rural healthcare
facilities (e.g. doctor offices, public health, and other)
were eligible to apply for USF. He did not believe it was
necessary for the state to take any action.
Representative Edgmon remarked that SB 74 was an omnibus
reform bill for healthcare, which devoted a number of
sections to telehealth and attempted to facilitate
increased telehealth opportunities in primary care,
behavioral health, and urgent care. He asked whether one of
the areas may be a priority in terms of expanded
opportunities.
Mr. Ferguson replied that he could not prioritize the
areas, which were all huge for Alaska. The state did not do
anywhere near the amount of behavioral and mental health
services it could be providing to patients in Alaska. He
stressed the tremendous need and relayed that the services
were one of the easiest to provide via telehealth. He
detailed that most telehealth programs in the Lower 48
started with tele-mental health and tele-behavioral health;
therefore it was easily done - the infrastructure and
bandwidth were available. He believed looking for
opportunities to expand the area was great. He specified
that the death by trauma rate had been 5 times the national
average in Alaska. He continued that the state had
incredible emergent emergency department needs throughout;
therefore, the ability to connect with someone via
telehealth to determine whether a patient needed to be
flown to a hospital or stabilized was potentially huge for
the state. He noted that ANTHC had started some pilot
programs, which had been very successful. He remarked that
the system did a significant amount of primary care
telehealth, but he did not believe it was utilized at the
level it could be. Additionally, he believed care
management was the secret to helping manage costs going
forward and telehealth was a substantial part of that.
Representative Edgmon relayed that he had spoken with
Robert Clark at the Bristol Bay Area Health Corporation
(BBAHC) who had communicated that the Bristol Bay Hospital
did a significant amount of behavioral health services [via
telehealth]. He asked if Mr. Ferguson believed the bill
went far enough to aid what ANTHC and other regional
providers were attempting to do with telehealth.
Mr. Ferguson believed from a telehealth perspective the
bill was pretty much right on. One of the challenges was
determining what the system wanted to do with telehealth;
the service did not merely happen on its own. He believed
the state and tribal health system needed to determine
where to put the focus and how to do it. He understood that
part of the legislation was to work on that level of
planning. He believed the bill focused on the areas of need
and the obvious areas of opportunity. He did not believe
ANTHC or he personally, would be asking for anything in
addition to the current bill language.
2:01:44 PM
Representative Edgmon asked if the bill would open up
opportunities for accessing providers residing out of
state. He wondered if the opportunities would be hugely
significant or a good compliment to current services
offered to patients. He referred to Mr. Ferguson's earlier
testimony that the majority of the tribal health system's
patients fell into the lower risk category.
Mr. Ferguson replied that there were different kinds of
telehealth. Telehealth provided by some other companies was
a direct to consumer service, which he believed had value.
He believed the committee would hear from the company
Teladoc later in the meeting. He elaborated that there were
plenty of consumers who would like to have the ability to
talk to a doctor at night. The telehealth offered by the
tribal health system was primarily provider to provider or
care management and often times involved complex cases. The
system made every effort to ensure it was fully integrated
into the electronic health record, which was an important
piece of what the system did. There was room for all of the
various types of telehealth services, which were not all
the same. He relayed that no matter what kind of telehealth
an entity used, there was a growing need to reach outside
the state's borders. He detailed that many pediatric
specialists simply did not exist in Alaska - many had moved
out of Alaska based on changes that occurred at Providence
Hospital and other places. Efforts were always underway to
make it work; therefore, anything to help with the effort
was beneficial.
2:03:35 PM
Representative Gara expressed appreciation Mr. Ferguson's
work. He understood what the bill did in terms of making it
more permissive to do telehealth for behavioral health
treatment, but he was unsure how the bill expanded the
ability for more telehealth services. He observed that the
tribal health system was already offering a substantial
amount of services. Apart from the behavioral health area,
he wondered what else the bill was doing to expand
telehealth outside of the behavioral health services.
Mr. Ferguson answered that the bill included some
provisions to support new models working directly with IHS
and tribal facilities to expand telehealth. One of the
challenges was in aligning the payment model with the cost
of providing telehealth. He detailed that sometimes
telehealth cost more than traditional healthcare, but it
became beneficial when factoring in money saved on travel
and identifying disease earlier. Part of what the bill
offered was the conversation with the state to consider
what else could be done and how to model the associated
costs.
Vice-Chair Saddler asked if other states had the same
requirement as Alaska that telehealth providers must be
licensed in the same state as the patients resided.
Mr. Ferguson replied that it varied across the U.S. For
example, Minnesota specified that a licensed provider with
good standing in any state could provide care to
Minnesotans, whereas New Mexico required a $10 separate
license to provide telehealth, which was easily attainable.
The American Telemedicine Association identified the issue
as one of the greatest barriers to telemedicine because it
made it hard for physicians to know what they needed in
different states.
Vice-Chair Saddler asked if there was any place
telemedicine had expanded too far and it had been necessary
to pull back from something not working as anticipated. Mr.
Ferguson was not aware of any. He stated that in his
experience of running and building a couple of different
programs, he had observed the opposite problem. He
elaborated that it took significant effort to build the
programs and many times it was necessary to continue work
on the program to keep it going; therefore, programs did
not typically get to a point where they ran amok. He added
that he was not aware of any other programs that had.
2:07:17 PM
Representative Guttenberg highlighted that several years
earlier a broadband taskforce had determined the standard
for the state should be 100 megabits, which was clearly not
the case. He noted the standard speed had been lowered to
10 megabits. He was concerned about chasing the technology
and reasoned it would not be possible to run a program on a
10-year-old computer. He asked if the telemedicine
community was planning for future capabilities. He reasoned
that a program in the development phase may not run on a
computer in a rural area. He detailed that programs would
be pushing technology due to increasing capabilities. He
wondered if there was a planning group observing the
situation. He asked how the interconnectivity worked with
someone in a rural community interacting with a doctor in
Anchorage who needed a specialist in another state. He
asked if the capability existed.
Mr. Ferguson agreed that the technology was changing at a
rapid rate, which impacted telemedicine in a number of
ways. There were a number of lower cost, high performing
devices, which made it necessary for the tribal health
system to do the appropriate level of testing to determine
whether they were good enough for clinicians to use. Some
of the devices available were not diagnostic quality - the
items may be sufficient for a quick image, but not
something a specialist could use. He relayed that Alaska
had the world's only National Telehealth Technology
Assessment Center, which had been federally funded and in
operation for about six years. He elaborated that the
center assessed about six different technologies on an
annual basis (e.g. stethoscopes, other scopes, and
etcetera). The challenge was to locate funding or work with
organizations to pay to put the technologies out into the
field, but it was done with the ANTHC's tribal partners.
Additionally, they were looking at some mobile devices
available. He detailed that the system's telehealth
platform had gone from computer-based to IPad, IPhone, and
Android - providers used the tools when doing consults. He
elaborated that the system did videoconferencing on IPhones
out to village sites. He shared that in the past the system
had used an otoscope to take a still image, but it could
now beam the image live to the doctor. The system mixed
store-and-forward and live telehealth capabilities. He
spoke to involving other providers and relayed that the
system had gone to a desktop videoconferencing solution
called Vidyo. He detailed that the system liked the
service, which enabled people to join a secure room; other
clinicians could be invited and it enabled the sharing of
images and live feeds from medical devices.
2:11:08 PM
Representative Edgmon asked about fiber optic cable. He
referred to an article about the company Quintillion
breaking ground in Nome. He believed there was future
prospect of fiber optic cable paralleling the outer coast
of Alaska to get services out to the Aleutians, the North
Slope, and higher services to Kodiak. He remarked on the
significant difference between fiber optic cable service
and the traditional TERRA Southwest service provided in
Southwest Alaska. He noted Southwest Alaska was very
grateful for the TERRA Southwest service provided through
GCI. He asked about ways the services could be further
expanded once the fiber optic cable was more fully in
place.
Mr. Ferguson answered that fiber allowed a transition from
satellite to terrestrial, which significantly decreased
delays. Additionally it provided much bigger bandwidth,
which was the biggest issue. The most significant impact of
the Quintillion fiber would be to bring terrestrial
connectivity to the villages along the North Slope
(especially to Barrow where the tribal health center had a
regional hospital). Once Barrow was off of satellite the
hospital would have the ability to access an electronic
health record shared in Kansas City, which was not possible
over satellite (he noted it was possible at a clinic, but
not at a hospital). The increased service would enable the
tribal health facilities to all be on one medical record
and higher bandwidth videoconferencing would be possible.
He remarked that the upgrade would change everything for
the remote villages. He believed once TERRA reached Nome,
Dillingham, and Kotzebue it huge impact on healthcare. When
TERRA had reached the villages the tribal health system had
put Nome on the same electronic health record and the
system had increased tribal health in the areas.
2:13:23 PM
Co-Chair Neuman believed the most recent cost estimates of
expanding fiber optics statewide was over $2 billion. He
asked if the amount was accurate. Mr. Ferguson answered
that he did not know the cost, but it would be huge.
Co-Chair Neuman remarked on Mr. Ferguson's testimony about
many of the wonderful capabilities of telemedicine. He had
not received information specifying opportunities available
for Southwestern Alaska with specific internet services or
the connectivity that could be used regionally. He
understood that technology changed daily. He wondered if
there was a way to get a better idea of what could be used
and what could not be used throughout the state. He asked
about technology available in Alaska.
Mr. Ferguson replied that the tribal health system tracked
what the current connectivity was to its 200-plus sites. As
a general rule, the system did not find that the delays
introduced by satellite prohibited it sufficiently from
utilizing telemedicine. The largest issue was how much
bandwidth the villages had (even over a satellite link).
Most of the system's sites had sufficient bandwidth; the
system was not limited to providing the services it wanted
to provide related to store-and-forward, live
videoconferencing, electronic health records, and
integrating the villages into its other services provided.
He added that the tribal health system even utilized tele-
pharmacy to dispense medications at remote sites. The
tribal health system was almost past the point of being
limited by bandwidth or satellite. He relayed that
terrestrial connectivity did help for large facilities like
hospitals. He concluded that at present there was not a
kind of telehealth the system could not do because a place
was on satellite or lower bandwidth.
2:16:08 PM
Co-Chair Thompson thanked Mr. Ferguson for the tremendous
work he did. He remarked how surprising the technology
capabilities were at present.
REBECCA MADISON, EXECUTIVE DIRECTOR, ALASKA E-HEALTH
NETWORK AND BOARD MEMBER, NORTHWEST TELEHEALTH (via
teleconference), spoke from prepared remarks:
Thank you for inviting me to address your committee.
My name is Rebecca Madison. I am the Executive
Director of the Alaska eHealth Network and am on the
Executive board of the Alaska Telemedicine and
Telehealth Collaborative. Both are non-profit
organizations dedicated to decreasing healthcare costs
through effective use of technologies. I also served
as chairman of the Alaska Federal Healthcare Access
Network for 9 years as that group developed
telemedicine technology for the Alaska Native health
system.
I would like to speak to the strong need for
telemedicine, prescription drug monitoring, and health
information exchange as they apply to Medicaid Reform
starting with some real world examples from other
states.
· Mississippi implemented a home based telemedicine
program directed at diabetes and other chronic
conditions. The program saved Mississippi
Medicaid $189 million in its first year and was
so successful that Texas has begun implementation
of the same program in Austin.
· Maine showed a cost savings of $2 million dollars
in one 60 day period for 162 patients by using
telemedicine for patient follow up, thus reducing
hospital re-admissions.
· New Mexico implemented a hospital-level care
program in patient homes. Patients showed
comparable or better clinical outcomes and the
program achieved savings of 19 percent over costs
for similar in-patients. Cost savings came
through less time in the hospital and fewer tests
performed.
· A study in Michigan showed a 59 percent and 67
percent reduction in CT scans and chest x-rays
respectively, when providers used health
information exchange services to review radiology
results.
2:18:38 PM
Ms. Madison continued to read from prepared remarks:
And savings aren't just to Medicaid. Departments of
Justice and Corrections also have shown significant
savings:
· The University of Texas Medical Branch conducted
over 250,000 telemedicine consultations with
prison inmates at a net savings to taxpayers of
$780 million dollars.
· The Colorado Department of Corrections reported
savings of $450 per telemedicine intervention,
about $100,000 per year through transportation
and security cost reductions.
In our own state of Alaska, Providence Health and
Services provides eICU services to Critical Access
Hospitals statewide keeping patients and families in
their communities.
You also heard from Stewart Ferguson on the Tribal
Health system travel savings and the impact on wait
times.
SCL Health, a private corporation with services in
Montana, Colorado and Kansas saw a combined savings
across all payors of $226.7 million by implementing
clinician to clinician specialty consults, clinician
to patient virtual visits and consumer mobile self-
tracking services.
Telemedicine, opioid monitoring and health information
exchange without a doubt are definitely becoming
mainstream and are no longer specialized projects.
One major issue is that much of this data was siloe'd
in the past and required providers to sign into many
different systems to get the information they needed.
This silo'ing of data systems means that many
providers don't use the systems because they don't
have time or knowledge to search through multiple
databases for all the patient data they need.
In Alaska, we can now leverage the health information
exchange infrastructure to provide a single point of
entry into health data from many systems - from
electronic health records, to telemedicine systems, to
drug databases and a host of other services. This
single point of entry can further streamline and
produce savings to both Medicaid and providers
statewide.
2:20:58 PM
Ms. Madison continued to address a written statement:
Cost savings are accomplished through healthier
patients. By putting data in the hands of providers
and, yes, also in the hands of patients, we can ensure
a healthier population. It takes a team of payers,
providers and patients to lower healthcare costs.
Of course, there is also a significant impact on
patients and patient care, particularly those patients
with chronic conditions, which we could also discuss
at length. But in light of our current fiscal
situation, I felt it is important today to stress the
financial impact which coordinated access to
telehealth and other healthcare data has on the
healthcare system in general and Medicaid, in
particular. We must stem the rising cost of
healthcare. We have the systems and the will to do so.
Medicaid reform can leverage these systems, in place
today, to give all Alaskans an opportunity to receive
better care at a lower cost.
2:22:12 PM
Co-Chair Neuman referred to Ms. Madison's testimony about
the abilities of other states to use telemedicine, much of
which he believed sounded wonderful. He asked how much of
the technology was available in Alaska.
Ms. Madison replied that all of the technology could be
made available, there was no reason Alaska could not use
the same technologies as other states. Some may be cost
prohibitive because of the size and number of patients, but
a business case could be done for those things.
Co-Chair Neuman asked if Ms. Madison believed Alaska was
doing everything possible in the telemedicine industry to
support and utilize its current programs. Ms. Madison
replied that she believed the state was doing all it could
to use its current programs. However, she did not believe
everything possible was being done to reach the patients.
She believed it was important to include the patients in
the healthcare through their care managers.
Co-Chair Neuman believed Ms. Madison had testified that
Alaska had the ability to purchase the technology to
acquire some of the things other states were doing. He
asked for verification that Alaska currently did not have
the necessary technology. Ms. Madison answered that there
was sufficient technology in Alaska to do much of the work,
but there were some things that could not be done (e.g. the
state was not currently set up for some of the home
telehealth programs). She concluded that the state had
significant technology to provide many of the telehealth
services.
Co-Chair Neuman requested an update from the Department of
Health and Social Services (DHSS) on telemedicine services
currently provided. Additionally, he was interested in
services the state did not provide and whether they could
be offered.
Co-Chair Thompson noted his office would try to get the
information from DHSS.
2:24:52 PM
Vice-Chair Saddler referred to page 20 of Ms. Madison's
presentation on Live Health Online (LHO), which made the
notation that the patient's copay was the same for an LHO
visit as it would be for an in person visit [note: the
presentation referred to was provided by a presenter later
in the meeting]. He understood that the access was easier
timewise. He asked if there was a disincentive to using
telemedicine if the cost was the same. He asked if there
was any advantage to the patient if the cost was the same.
Ms. Madison replied that she had provided several
references and was uncertain which document Vice-Chair
Saddler was referring to. She stated that the bill began
the process to use the items to determine how to best
contain costs; it started the discussion for things like
parity and what the cost of a telemedicine visit should be
versus the cost of an office visit. She believed the topic
was another discussion that needed to be looked at by
Medicaid and the current administration.
Representative Guttenberg referred to Ms. Madison's
testimony that Alaska was not doing enough to reach out to
the patients. He asked if she differentiated between rural
and urban on the issue. He believed the state had taken on
rural healthcare first because it included the largest
savings. He remarked that in other communities the savings
may not be much, but they may be considerable relatively
speaking. He asked her to be more specific on her
statement.
Ms. Madison clarified that she had not meant the state did
not reach out. She explained that as providers there was
still not the direct patient in-the-home connectivity that
would benefit the patients. For example, Mississippi had
done a home-based telemedicine program that had involved
screening every patient discharged from the hospital to
determine whether the patient should use telehealth from
home. Subsequently, the patients on telehealth had been
monitored in their homes (e.g. if a person were at risk of
falling they would be monitored by video and if a patient
was diabetic they would be monitored with equipment
measuring glucose and other various tests). She detailed
that monitoring the individuals at home had eliminated the
need for readmission and had brought many of the chronic
conditions under control because the patients had not
previously had sufficient interaction with providers. She
elaborated that much medical follow up could be done with
nurses at a much lower cost.
Co-Chair Thompson clarified that the presentation currently
shown on a projector screen in the committee room was for a
later presenter.
2:29:09 PM
DOCTOR HENRY DEPHILLIPS, CHIEF MEDICAL OFFICER, TELADOC,
NASHVILLE, TENNESSEE (via teleconference), relayed he had
been pleased to hear Dr. Ferguson's testimony. He lauded
Dr. Ferguson for doing a phenomenal job with a phenomenal
program. He remarked that legislation the prior year (HB
281) had moved the State of Alaska forward significantly in
the world of telemedicine. He discussed that Teladoc had
worked with the Alaska State Medical Association (ASMA) on
HB 281 and in deference to ASMA, bill sponsors had
incorporated a provision requiring a physician rendering
telemedicine care be licensed in Alaska and an Alaska
resident. He referred Dr. Ferguson's response to an earlier
question that licensing requirements varied in the U.S. He
did not want to speak for Dr. Ferguson, but he believed the
doctor had probably been referencing the federal
telemedicine programs, which he believed the tribal health
system was a part of (the Veterans Administration system
and many others were also a part of the federal system). At
the state level (i.e. private companies and people under
state government programs) where the state legislation and
regulations apply there was actually substantial
uniformity. To do a telemedicine consultation in any state
a provider was required to have a license in that state. He
elaborated that only Alaska-licensed physicians in the
private sector and state government were allowed to do
telemedicine consultations for the citizens of Alaska.
2:31:41 PM
Mr. DePhillips returned to discussing HB 281 (from the
prior year) and the ASMA. He relayed that after the bill
had passed and Teladoc went to recruit positions to offer
telemedicine services in Alaska, it had quickly discovered
that the supply and demand challenge was much more acute
than it had thought. He continued it was very difficult to
ask doctors in Alaska to do additional work via telehealth
or other because they were already stressed to or beyond
capacity. Subsequently, a group (including Teladoc) had
come together in the current year to discuss removing the
residency requirement. He detailed that for decades the
Alaska State Medical Board responsible for credentialing
and licensing physicians to render services to Alaskans had
been issuing licenses to physicians resident in Alaska as
well as physicians outside the state (primarily in the
State of Washington, but other states as well) to render
services to Alaskans. He highlighted his intent to speak to
the provision in SB 74 that removed the in-state residency
requirement to allow Alaska licensed physicians (certified
by the state's medical board) to render telemedicine and
other services to Alaskans. He communicated that Alaska was
the only state with a residency requirement encapsulated in
legislation.
2:33:12 PM
Mr. DePhillips relayed that telemedicine had existed for a
bit and Teladoc had built its program around primary care
telemedicine for common uncomplicated medical issues.
Teladoc had been established in 2002 and was coming up on
1.5 million e-visits across all 50 states. From a patient
safety standpoint, across the country for in person care
for about every 1 million visits there were 17 medical
malpractice cases filed and carried through to completion
where an award was made (the average award was $248,000).
Teladoc was approaching 1.5 million visits and had never
had a medical malpractice go through to completion and
awarded, filed with its carrier, or litigated. He believed
the record was a reasonably good marker for patient safety.
From an oversight perspective, a comprehensive electronic
health record embedded in a technology platform provided
the ability to do very intense quality oversight, which was
not available in a private practice brick and mortar
setting. Teladoc looked at the data including prescribing
patterns, appropriate prescribing, and other. He relayed
that the company did not allow any Drug Enforcement Agency
(DEA) controlled substances or lifestyle drugs in the
program. The company's overall prescribing rate was
currently running at 77 percent of all consult requests;
the brick and mortar average as reported on the Center for
Disease Control (CDC) website was currently 82 percent. He
detailed that based on the company's volume, its overall
prescribing was statistically significantly below the
national average.
Mr. DePhillips discussed the comprehensive electronic
health record shared between the patient and physician
prior to the visit, completed during the visit, and shared
with the patient's primary care physician after the visit.
He referred to a committee member's earlier comment about
concern related to the quality of medical records. He
believed that because of the platform approach and quality
oversight that the quality of the clinical record was quite
strong compared to charts in the in person setting where
there was less oversight. The company wanted care to be
local; Teladoc had built a five minute lead time into the
platform that gave a licensed and resident physician the
opportunity to respond to the consult before a non-resident
physician could respond. The company actually preferred for
care to be given by licensed and resident physicians (they
had to be licensed by law), but the capacity was not
sufficient to service the clients.
2:36:41 PM
Mr. DePhillips addressed cost savings and referenced well-
done third-party studies. He shared that a Harvard Medical
School researcher had studied claims in the population of a
national home improvement retailer - He noted the company
did not want its name used in the study, but he added that
its logo was orange. He shared that for every consult done
by one of the company's 150,000 employees (including those
in Alaska), for the self-insured employer responsible for
the cost of medical care across the individuals who used
the service and their independents who did not use the
service there was a savings per consult of $1,157. He
stressed that the savings was much higher than he had
expected. He believed it indicated the shortage of the
provision of primary care services. Before the individuals
in the study had the telemedicine benefit they had used the
emergency room for non-emergency common, uncomplicated
medical issues. He relayed that Teladoc had worked with
ASMA on SB 74 and he believed the entity's concerns were
understandable. He referred to the credible nature of
Teladoc's program. The association had vocalized concern
about other companies that may come up if things were
legislated. The company recommended that the standard of
care for any medical issue needed to be met regardless of
the modality of treatment (i.e. whether in person or
remote) and the standard must be the same. Additionally,
Teladoc recommended a technology neutral approach. He
referred to the two prior testifiers who had specified
technology was moving extremely quickly. He did not believe
any legislature in the country should be in the business of
assessing and determining what technology was appropriate
in healthcare. He believed the issue should be left up to
practicing physicians to decide how they collect
information and what information they need to meet the
standard of care.
Mr. DePhillips addressed three modalities offered by
Teladoc including audio-videoconferencing; uploading of
high definition photographs, which were probably superior
to video (smart phone still cameras had about seven to nine
times the resolution of the video camera) for things like
skin lesions, pink eye, and other; and a subset of medical
issues could be handled by telephone. He elaborated that
the ability to diagnose issues (e.g. bronchitis, sinusitis,
urinary tract infections, and other) over the phone helped
with the bandwidth issue and the diagnosis could be safely
done after the medical record was shared via store-and-
forward. He relayed that no data indicated any of the
modalities were either superior or inferior to any of the
others, which was the reason Teladoc continued to offer all
three options. He added that if data emerged showing one of
the modalities was superior, the company would go with that
option. He communicated that Teladoc was currently
servicing GCI, Alaska Airlines, Fred Meyer, and Aetna,
Premera, Lowes, Costco, BP, Shell, and other. He noted
Aetna would love to bring the program to state employees.
The company would love to have the ability to allow Alaska
licensed physicians residing in other states to render
services in Alaska to the employees of the entities he had
listed.
2:40:47 PM
Representative Munoz asked if Teladoc's fees were the same
across state lines. Mr. DePhillips answered in the
affirmative. For example, for a company doing business in
all 50 states, Teladoc charged the company the same price
to offer the service in each state. There was also a
uniform fee schedule for reimbursement going out to the
board certified physicians rendering care. There were a
couple of minor, few and far between exceptions, but the
company tried hard to have a uniform fee schedule.
Representative Munoz asked if the fees were published and
whether the patient knew the fees prior to services being
rendered. Mr. DePhillips answered that the cost of the
visit was $45.00. He detailed that the sponsor (i.e. the
employer or health plan) would pick up a portion of the
amount (some sponsors covered the entire amount). He
referred to an earlier question by a committee member about
why the service would be utilized if an in person visit
cost the same. The data was clear that unlike most medical
benefits it was a benefit a company should want employees
to use more and not less because it provided a safe access
to care option for patients to use rather than being faced
with going to the emergency room or utilizing more
expensive options. The companies paying the entire $45 had
four times the utilization of the companies pitching in
nothing. He furthered that the ROI [return on investment]
for the company responsible for the cost of care went from
5 to 1 on the $45 patient copay to 20 to 1 on the zero
patient copay.
2:42:51 PM
Vice-Chair Saddler asked if there was any area of
telehealth that was not providing the results he hoped to
see. He asked if there were areas in which Mr. DePhillips
would advise against using telehealth.
Mr. DePhillips answered that behavioral health was an
"absolute slam dunk" for telehealth. He pointed to short
supply of behavioral health services, especially in the
pediatric population. He mentioned dermatology as another
area where telemedicine provided a good option. He stressed
the conservative nature of the industry and relayed that
when interviewed for his position at Teladoc he had
interviewed all board members and senior management and had
asked what they would choose if they had to decide between
patient safety and profit. He would not have taken the job
if the answer had not been patient safety every step of the
way. The bottom line was no one in the industry could
afford an article on the front page of the Wall Street
Journal saying that the industry had done too much, gone
too far, and had a bad result; the situation would be bad
for the specific company and for the industry as a whole.
He reiterated that the industry had been very conservative
and had good clinical guardrails in place around the
programs. He believed all of its direct competitors also
had a clean medical liability history. He stressed that the
industry had not gone too far. He believed it had
intentionally been very conservative in the rollout of
services because they all wanted to ensure clinical quality
was the first priority.
Vice-Chair Saddler referred to testimony about the
malpractice rate. He asked about the liability and
insurance implications for a physician offering services
via telemedicine.
Mr. DePhillips replied that the problem had been solved by
using an insurance carrier that insured all of the
physicians who worked in the Teladoc and other programs.
Teladoc provided the medical malpractice insurance for all
of the doctors. Second, Teladoc's agreements with the
physicians included a hold harmless clause specifying if an
issue occurred, Teladoc would take responsibility on behalf
of the physician.
2:45:20 PM
WALLACE ADAMSON, VICE PRESIDENT, ANTHEM, INC., COLUMBUS,
OHIO (via teleconference), spoke in support of SB 74. He
shared that he was a family physician and had worked in
various business capacities over the past 16 years for
Anthem. Anthem was a health insurance company with
approximately 36 million members operating Blue Cross and
Blue Shield plans in 14 states and Medicaid plans in 20
states through its Amerigroup subsidiary. He currently led
the physician strategy for Anthem's telehealth solution
LiveHealth Online. He addressed a PowerPoint presentation
titled "Introducing LiveHealth Online" (copy on file). He
explained that LiveHealth Online allowed consumers to have
live face-to-face real time visits with the physician of
their choice. In addition to the consumer option, the
system also offered LiveHealth Online to physicians for use
in their practices, which enabled them to offer telehealth
opportunities to their own patient populations. He relayed
that the wait time for a visit on LiveHealth Online
averaged 10 minutes or less. The program targeted minor
health problems of a somewhat urgent nature (i.e. sinus
infections, ear aches, and other). Visits were available 24
hours per day, 7 days a week, and 365 days per year.
Mr. Adamson moved to slide 3 that included a map of the
United States. He detailed that the program was currently
offered to 16 million Anthem members in 47 states and the
District of Columbia (shown in green). The company did not
operate in Alaska, Texas, and Arkansas due to the local
regulatory and legislative environments (shown in gray).
California was shown in a darker green because its program
included a Spanish language offering of LiveHealth Online
called Cuidado Medico. Indiana was shown in light green to
indicate that the state recently had a statute change that
would allow prescribing via telehealth effective July 1
[2016].
Mr. Adamson relayed that Anthem offered a real time video
visit giving patients access to the board certified
physician of their choice. The company had also rolled out
a LiveHealth Online psychology. He noted that behavioral
health was a natural fit for telehealth and worked very
well. He spoke to the importance of telehealth from the
employer prospective. He detailed the company had national
employers including Wells Fargo, FedEx, Safeway that
offered LiveHealth Online to their employees (excluding
Alaska).
2:49:39 PM
Mr. Adamson relayed that Anthem's primary reason for
providing the service was related to access and cost of
care. The company preferred for individuals to see their
own physician and believed patients could get the highest
quality care from the ongoing relationship with the doctor
they had chosen. Unfortunately, many individuals did not
have the benefit of that type of relationship; the majority
of Anthem members did not have an ongoing relationship with
a primary care physician. He addressed the busy schedules
doctors held and referred to earlier testimony about the
demands on Alaska physicians. He detailed that the company
liked to be available as the backup (e.g. at 10:00 p.m. on
a Friday night or Sunday morning at 7:00 a.m.) if someone
was in need of care. He turned to slide 5 titled
"HealthCore study results are promising" and spoke to cost-
savings. The company had conducted an extensive study of
Anthem results from its claims data on people using the
program. The study had compared LiveHealth Online users
living in the same state with the same health problem. For
example, the study had looked compared Anthem members
living in Ohio who received treatment for a sinus infection
through LiveHealth Online, urgent care, a clinic, the
emergency room, and a primary care visit. The study had
looked at a three-week period, which included costs for
follow up, imaging, pharmacy, and other; it had concluded
there was a savings of approximately $201 to $202 per visit
with LiveHealth Online. The study had also determined that
the patterns of care were very comparable to the other
locations. For example, follow up visits and prescribing
were very closely aligned between the different treatment
settings. He communicated that the program was valued by
consumers; 90 percent of individuals who used the program
specified they would use it again and 85 percent reported
that their medical problem was completely resolved.
Mr. Adamson addressed an earlier question about the
benefits of telemedicine even if the cost differential was
the same. Anthem had heard loud and clear from consumers
about the time savings telemedicine provided. He believed
the time savings would only be amplified in Alaska given
its landscape and geography. He detailed that most people
in the Lower 48 reported they saved two to three hours of
time using telemedicine versus an in person doctor visit.
He noted the value to employers when they were able to keep
people in the workplace.
2:53:29 PM
Vice-Chair Saddler referred to language on slide 20 of the
presentation specifying that the copay for each
consultation was a flat $49, which was the same as a
doctor's visit. He asked if it was a disincentive to use
telehealth if the cost was the same as an in person visit.
Mr. Adamson answered that the total cost of a visit was
$49, which included the health plan's contribution and the
individual's copay (some people had copay and others had
coinsurance). When Anthem had implemented the program in
2013 there had been a "spirited" discussion on what to do
with copays compared to primary care. The company had
decided the least disruptive strategy at the time was to be
equal with the primary care component. The company wanted
the program to be neutral and did not want to stimulate
excess demand or create a disincentive for its use. With a
couple of years under its belt, the company heard from
consumers that the price was very fair, especially for
individuals with a health savings account and a high
deductible plan ($49 for a visit was much better than the
rate at a local urgent care or an emergency room). Anthem
spoke to many different companies that set the benefits and
different companies did different things. He detailed that
some companies wanted to offer low copays to individuals to
encourage them to use the service, whereas other companies
had higher copays because they believed the service would
be over-utilized.
Vice-Chair Saddler asked if Anthem experienced any problem
with the over-prescription of opioids via telehealth. Mr.
Adamson answered that opioids and lifestyle drugs were
blocked on LiveHealth Online; therefore, it was not a
problem for the company. He believed the same was true for
most of the major telehealth companies.
2:56:34 PM
Representative Gattis relayed that she had offered a bill
related to telehealth in the past; she was a big proponent
of technology and telehealth. She spoke to the significant
amount of time it took parents to take a sick child to the
doctor, which included driving and wait time. Additionally,
she believed waiting in a waiting room with other sick
children had to factor in to the convenience factor of
using telemedicine. She remarked on the advances of
technology over time. She believed telemedicine added to
convenience, cost-savings, and provided another option for
parents.
Co-Chair Thompson thanked Mr. Adamson for his testimony. He
spoke to advances in technology and reasoned the
legislature would eventually have teleconferencing to see
the testifiers.
2:58:21 PM
HEATHER SHADDUCK, STAFF, SENATOR PETE KELLY, relayed that
Sections 13 through 19 of the legislation dealt with the
Prescription Drug Monitoring Program (PDMP), beginning on
page 15, line 23. Section 13 was amended by only requiring
data collection for the database or dispensing for federal
Schedule II, III or IV controlled substances. Section 14,
page 16, line 1 amends by only requiring data collection
for prescribing, administering, or dispensing federal
Schedule II, III, or IV drugs. The section updated data
collection to a minimum of once a week (line 11). Currently
the PDMP was updated on a monthly basis.
Ms. Shadduck addressed changes in Section 15, which added
additional access to the database (page 16, line 27 through
page 18, line 16). The first change was in number 3 on page
17, line 9 where the bill amended law to authorize a
licensed practitioner to delegate database access to a
supervised employee or clinical staff. The second change
started on line 14 and would authorize a registered
pharmacist to delegate database access to supervised
employees or clinical staff. The third change was in number
7 on line 29; a new section was added to authorize database
access to the State of Alaska Medicaid pharmacy program.
The fourth change appeared in number 8 on page 18, line 3;
a new section was added to authorize database access to the
State of Alaska Medicaid Drug Utilization Review Committee
for utilization review of prescription drugs provided to
Medicaid recipients. Number 9 on line 8 added a new section
to authorize database access to the State of Alaska medical
examiner. Number 10 added a new section to authorized de-
identified data access to the State of Alaska DHSS Division
of Public Health. The division would not need access to
identifiable data to fulfill public health objectives
regarding controlled substances.
Ms. Shadduck addressed the change in Section 16 beginning
on page 18, line 17. The change removed optional use and
maintained immunity for individuals using PDMP. Section 18
on page 19 related to board regulations and review of PDMP.
Number 3 was added to the section to set a procedure and
timeframe for registration for the PDMP. Number 4 required
prescribers and pharmacists to review the controlled
substance prescription database before prescribing,
administering, or dispensing a federal Schedule II, III, or
IV controlled substance to a patient. Some exemptions had
been added in based on some public testimony in the Senate
including: a) for those in an inpatient setting; b) at the
scene of an emergency or in an ambulance; c) in an
emergency room; d) immediately before, during, or within
the first 24 hours after surgery. Section 19 included new
subsections: o) required prescribers and pharmacists to
review the PDMP database when prescribing or dispensing a
federal Schedule II, III, or IV controlled substance to a
patient; p) required notifications to boards when a
practitioner registered with the database; q) authorized
the Board of Pharmacy to forward unsolicited notifications
to prescribers and dispensers of database information about
patients who may be obtaining controlled substances
inconsistent with generally recognized standards of care;
and r) collect dispensing data and update the PDMP database
on at least a weekly basis. She relayed that most of the
items were conforming to clean up changes in the other
sections. She reminded the committee that the
recommendations had come from the Controlled Substance
Advisory Committee, which had been reported to the governor
prior to the start of the current session.
3:03:59 PM
Representative Guttenberg stated that the pharmacists had a
concern about the redundancy of the requirement mandating
them to check the database before filling a prescription
because a doctor was also required to check the database
when writing a prescription. He asked for Ms. Shadduck's
feedback on the issue.
Ms. Shadduck replied that the sponsor had worked with
others in the Senate and with DHSS on the issue. She
explained that the pharmacists were responsible for
populating the database. She believed it made sense not to
require pharmacists to check the database before
dispensing, but they had to populate it. The requirement
for physicians to check the database prior to writing a
prescription would remain. She explained the change would
alleviate some of the problems where the pharmacists feel
they had to enforce the issue, when it should really be the
doctor's responsibility to know whether it was wise to
prescribe a controlled substance. She furthered that
doctors would be the most equipped to consider whether an
addiction problem was present.
Representative Guttenberg remarked that the discussion was
only about individuals the system had problems with. He
surmised that most of the population was fine. He spoke
about individuals shopping for doctors to receive
prescriptions. He asked for verification that doctors would
have the ability to see what other doctors had prescribed
to a patient.
Ms. Shadduck replied that it was what the sponsor wanted.
Part of the information came from the white paper she had
provided from the Controlled Substances Advisory Committee
[State of Alaska Controlled Substances Advisory Committee
"White Paper: Increasing the Effectiveness of Alaska's
Prescription Drug Monitoring Program (Alaska's PDMP)" dated
January 29, 2016 (copy on file)]; currently only 13.5
percent of prescribers and 40 percent of dispensers were
using the database as an optional database. She furthered
that by making use of the database mandatory would give
doctors access to the information. She knew DHSS had worked
hard to improve the database; the intent of requiring
database updates at least once a week that it would be
updated more frequently. The goal was to provide
flexibility for pharmacies that were ready to update the
database on a daily basis (some small pharmacies were not
ready for that). The intent was for doctors to have the
ability to see if a person was doctor shopping. She noted
that Doctors Inc. had given great testimony about the
emergency room project - once they had the data they could
identify individuals who were doctor shopping.
3:07:58 PM
Co-Chair Thompson noted that Senator Pete Kelly and
Representative Liz Vasquez were present in the room.
MELINDA RATHKOPF, PRESIDENT, ALASKA STATE MEDICAL
ASSOCIATION, WASILLA (via teleconference), spoke to ASMA's
position on the PDMP. The association's goal was care for
patients in Alaska and determining the best way to provide
the care. The association was supportive of the PDMP (it
had been working with the legislature and administration
and recognized the national and global problem with opioid
abuse) and of looking at ways to improve the problem of
opioid abuse in Alaska. The association appreciated some of
the language included in the bill about ways to utilize the
database to its fullest potential without being overly
burdensome to the provider. She relayed that ASMA had
requested that Schedule IV be dropped from the mandatory
pre-lookup. She detailed that ASMA saw the need to include
Schedule II and III (opioids and drugs more likely to have
a higher abuse potential), but it felt that Schedule IV
(that by nature had a lower abuse potential) was
potentially very burdensome on providers on a day-to-day
basis. She referred to the exception made for instances
within the first 24 hours after surgery and requested to
add "or procedure" to the exemption. She explained that
often it was not necessarily a surgery, but a procedure
where a doctor may be prescribing a short-term substance
pre-procedure. She relayed that ASMA wanted to work with
the legislature and strongly supported the idea of the
database, but wanted to look at ways to make the system
more usable for the provider and to determine the best way
to deal with the overall problem.
3:11:20 PM
Representative Gara asked about the current prescription
drugs doctors were required to look up. Dr. Rathkopf
answered that there was currently no requirement for a pre-
lookup. At present providers were using the database when
they had concerns about over-prescribing or about a patient
who may be doctor shopping and getting prescriptions
elsewhere.
Vice-Chair Saddler asked if Dr. Rathkopf had any
information about breeches of privacy in the current PDMP.
Dr. Rathkopf answered that she had not heard of any. She
elaborated that the ASMA had not discussed or had as many
issues with the privacy concerns. She explained that as
providers they were looking at the utilization of the
database on a patient level; at that level providers
already assumed patients were sharing personal information
and providing access to their prior medications. She
believed the biggest concern was giving doctors a way to
look up patients' prescriptions in case they were not
forthcoming about medications they were taking. She
detailed that when patients saw doctors on a one-on-one
basis they had already waived their rights for some of
those issues. She concluded that the privacy issue had not
come out of the provider side and it had not been brought
up by physicians that she was aware of.
Vice-Chair Saddler asked how long it took to check the
database. Dr. Rathkopf answered that she was a pediatric
allergist/immunologist and prescribed very little opioids
and narcotics; therefore, she did not utilize the database
in her own day-to-day patient care. Other providers in the
emergency room and pain specialists had told her the check
could take up to 10 minutes. She had registered for the
database to see how difficult the registration process was.
Representative Gara looked at the emergency room treatment
exception in the bill where pre-lookup in the database was
not required. He did not want to provide prescription
access to a person seeking extra narcotics. He assumed that
unless a person was suffering a real injury a person would
not have the ability to walk into the emergency room to
obtain a prescription. He asked whether Dr. Rathkopf saw
any room for abuse in the area.
Dr. Rathkopf replied that the purpose of the exemption was
that ASMA did not want to delay response to a person in
critical condition. She believed the database was utilized
most frequently by pain specialists and emergency room
doctors; they already saw the utility of the database. She
was not saying that an emergency room doctor would not
consult the database if someone was being discharged in
stable condition with a prescription for Schedule II or III
drugs. The primary concern was about having to halt patient
care until the mandatory pre-lookup was done.
3:15:50 PM
Representative Gara understood the reason for the
exception. He could not envision a circumstance where the
emergency room exemption would make it possible for a
person to get extra prescriptions they did not need. He
asked if there was any danger he was missing.
Dr. Rathkopf answered that she did not believe so. She
expounded that the idea was to ensure that patient care was
not hindered. The emergency room providers were already
using the database and individuals who were seen as a high
risk of seeking multiple prescriptions would be looked up
in the system.
Co-Chair Neuman asked what it took to get on and enter into
the database. Dr. Rathkopf answered that she had registered
the prior day. She detailed that the database was a
separate site not tied to licensing or anything else. The
initial registration took about five minutes, but then it
required the registrant to download a form requiring a
notary. She relayed that fortunately she had a notary in
her office, but most providers did not. The process
included finding a notary, scanning the document,
resubmitting it. Once all of the information was submitted,
it took overnight to get approval.
Co-Chair Neuman relayed that he had spoken to other doctors
about the topic. He had asked DHSS for information about
the topic, but had not yet received it. He asked for
verification that the registrant was required to read and
sign 7 pages of regulations.
Ms. Rathkopf answered that there were some documents she
had read, which required the registrant to agree to the
terms. Subsequently, the registrant was sent the additional
paperwork. The registrant was required to have a DEA
number, provider number, and state license number. The
reason for the notary requirement was to show proof the
person registering for the database was who they claimed to
be. She had not found the initial registration particularly
cumbersome other than the notary requirement. She
reiterated that after completing the registration it had
taken overnight to get the approval. She had not had the
need to look up a patient for an opioid narcotic so she
could not personally attest to how long that part took. She
had heard reports that the process took an average of 10
minutes.
Co-Chair Neuman had heard concerns from other doctors that
they were hesitant to sign that they had read and fully
understood all of the regulations. He referred to the
confusing nature of federal documents. The doctors were
concerned they could lose their DEA license because it was
essentially perjury if a doctor did not fully understand
what they read. He asked Dr. Rathkopf if she would feel
comfortable signing the documents.
3:19:46 PM
Ms. Rathkopf answered that she had read many of the
documents in her role on ASMA and surmised that perhaps she
was more comfortable reading through the documents. She was
much more familiar with the system than she had been a year
ago before she had become president of ASMA. The
requirements did not stand out as bothersome or concerning,
but it may be because she was more prepared going into it
based on her experience on ASMA.
Co-Chair Neuman asked Dr. Rathkopf believed general
practitioners (the bulk of the state's family doctors)
would feel comfortable signing each of the federal
documents. He remarked that individuals who signed the
agreement, but did not understand it could potentially lose
their DEA license.
Ms. Rathkopf responded that it was difficult to generalize
across a spectrum of providers. She specified that some
individuals could be more concerned and read things in more
detail and there were others who did not and were more
comfortable.
Co-Chair Neuman had spoken to several doctors, one of whom
was from a pain clinic, who had refused to sign the
documents because of the concern. He remarked that the bill
also allowed assistants or people who worked for a doctor
to access the database. He asked if Dr. Rathkopf would
allow her employees to access the database.
Ms. Rathkopf replied that she believed the provision, which
enabled a doctor to have a designee, was very favorable.
She could see there could be concerns about giving an
unlicensed person the ability to do something on the
doctor's behalf, however, doctors would be selective in who
they chose. She furthered that most likely the doctor would
select a medical assistant or nurse who had some medical
training. The board supported the addition of the delegate
account. She relayed that it had been identified nationally
as a best practice of prescription drug management
programs.
3:22:55 PM
Co-Chair Neuman stated he had spoken with doctors who
relayed that doctors tended to know, particularly in
smaller communities like Juneau and Mat-Su, which doctors
tended to over-write prescriptions. He asked if Dr.
Rathkopf felt the same.
Ms. Rathkopf believed it was one of the things doctors
thought they knew. She stated it was like the proverbial
"you think your neighbor has a problem, but you don't have
a problem." She furthered that it was hard to say because
it was not possible to be in the other person's shoes or to
know their patients. She elaborated that a person may see a
lot of prescriptions were coming from a certain provider,
but she did not know of any doctors over prescribing. She
knew both pain specialists and emergency room doctors, who
by volume probably prescribed more than doctors not in
those specific fields. She concluded it was very difficult
to make that generalization without being in the room with
the individual patients, knew the indications, and how many
prescriptions the doctor was prescribing. She believed it
was a hard generalization to make.
Co-Chair Neuman referred to Dr. Rathkopf's remarks. He
surmised doctors and pharmacists had a moral or ethical
oath to notify the state medical or doctor's boards if they
felt one of their peers was possibly writing too many
prescriptions.
Dr. Rathkopf believed if a provider witnessed provider care
that was harmful to a patient they had some responsibility
to address the provider personally or through other means.
She had not had to take that action at a provider level
[note: due to a poor phone connection some testimony was
inaudible], but at a pharmacy level she had reported to the
pharmacy board when she thought inappropriate care was
given. She replied that if she witnessed an instance [of
inappropriate care] she would put it under the same type of
moral obligation or ethical category.
3:26:29 PM
Co-Chair Neuman asked Dr. Rathkopf if she or a pharmacist
suspected a person of over writing prescriptions that there
was a moral obligation to report the person.
Ms. Rathkopf replied that her answer reflected her personal
belief, but she could not answer for every provider because
the question pertained to what a person believed was moral
and ethical. She explained what was normal for a pain
specialist to prescribe was a much higher threshold than
what was normal for her to prescribe.
Co-Chair Neuman believed there were already systems in
place. He surmised that if there was more than one doctor
in a community they generally knew who tended to over
prescribe. He opined they would have a moral duty to report
the issue to the Alaska State Medical Board. He continued
that the board would question why the reporting doctor
believed another doctor was over-prescribing. Subsequently,
the board would take action if they believed the doctor was
over-prescribing. He believed there were already systems in
place to stop the over prescribing of opioids. He believed
the system was already managed by doctors and the medical
board. He asked if the state needed more intrusive laws
into people's lives.
Ms. Rathkopf answered that the country was still facing a
national problem [with opioid use]. She detailed that other
states with prescription drug database programs had shown
decreases in opioid prescriptions. There were best practice
models in certain states, which had shown decreases in
prescriptions for opioid narcotics with the use of a
prescription database.
3:29:02 PM
Representative Gara asked Ms. Shadduck if the bill included
a requirement for a physician to submit a list of the drugs
they prescribed to the board and the database.
Ms. Shadduck answered in the negative. The bill required
the prescriber to check the database prior to dispensing a
prescription. The population of the database was done by
the pharmacist.
Representative Gara asked for verification the bill
required a weekly report to be sent to the state medical
board. Ms. Shadduck replied in the affirmative. She pointed
to Section 14, page 16, line 11, which required the
database to be updated a minimum of once a week.
Representative Gara referenced Ms. Shadduck's statement
that only pharmacists would enter data into the PDMP. He
provided a personal example where he had received a
prescription medication at the emergency room after
breaking some ribs the previous year. He assumed his doctor
had prescribed the medication, which was provided at the
hospital. He wondered if emergency room prescriptions did
not get entered into the database.
Ms. Shadduck answered in the negative. She clarified that
the pharmacist filling the prescription entered the
information into the PDMP. She explained that every written
prescription should not be entered into the database. For
example, a doctor could prescribe a narcotic to a patient,
but the patient could decide not to get the prescription
filled. The point was to prevent including prescriptions in
the PDMP that had never been filled. Under the current
system, if the pharmacist who filled Representative Gara's
prescription was one of the 40 percent who used the
database, they would have entered the information into the
system.
Representative Gara asked if pharmacists always filled
prescriptions. He wondered if a prescription could be
filled in an emergency room by a physician. Ms. Shadduck
deferred the question to DHSS.
3:32:42 PM
AT EASE
3:43:35 PM
RECONVENED
Co-Chair Thompson introduced the following testifiers who
would continue to address the PDMP.
DOCTOR JAY BUTLER, CHIEF MEDICAL OFFICER, DEPARTMENT OF
HEALTH AND SOCIAL SERVICES, expressed his intent to provide
context on the PDMP portion of the bill. He shared that in
2015 more than 80 Alaskans had died following an opioid
overdose. He remarked that while heroin use had dominated
the news headlines, it was important to remember that
almost twice as many deaths occurred due to overdose of
prescription opioids. Of the 36 individuals who had died of
a heroin overdose, more than half had also been taking
prescription opioids at the time of death. He considered
how to stop the situation from continuing. He asked the
committee to think about the opportunities for prevention
surrounding an Alaskan who had died of an overdose. He
shared that after an overdose was taken and a person's
breathing stopped, Naloxone could have been administered to
reverse the depressive respiratory effects and a life could
have been saved. One of the barriers to that opportunity
had been removed with the passage of SB 23 [legislation
passed in 2016 related to the prescribing of opioids]. When
considering the individual's life it would most likely be
discovered that opioid dependency had led to the overdose.
At that stage, prevention included screening and diagnosis
of dependency as a chronic health issue in order for the
problem to be destigmatized and treated. Traveling further
back in time in the person's life may reveal a tendency to
self-medicate. He elaborated that self-medication often
started with an otherwise healthy person living with a
combination and an addictive substance (the demand and
supply side of the equation).
Dr. Butler continued to discuss the scenario. He explained
that increasing resiliency and wellness early in life by
decreasing the impact of adverse childhood experiences and
improving emotional wellness later in life were important
measures for preventing traumatic stress and mitigating the
impact in reducing demand. To address the role of the
addictive substance in the case of opioids, it was
necessary to address the supply by reducing the flood of
opioids into the state's communities through more rational
pain management strategies and prevention of diversion. The
effort could in part be addressed by utilization of the
PDMP. He stressed that the PDMP was not a Panacea, but it
was an important part of the overall strategy when
considering the entire flow of events leading to an
overdose death. He relayed that deaths were just the tip of
the iceberg; it was estimated that for every person who
died of an opioid overdose, 12 more were hospitalized and
25 were admitted in the emergency department. The number of
opioid prescriptions in the U.S. quadrupled between 1990
and 2010; the number of opioid deaths had also quadrupled
during the same period.
Dr. Butler discussed that a number of drivers had
contributed to the substantial increase in opioid use. He
explained there was really no evidence that the prevalence
of pain increased four-fold during 1990 and 2010. He
emphasized that Americans consumed roughly 80 percent of
the world's supply of opioids. He questioned whether the
U.S. really had that much more pain than the rest of the
world. He detailed that 19,000 Americans had died in 2014
of prescription opioid overdose and 10,000 more had died of
heroin overdose. He furthered that the two epidemics were
closely related; 80 percent of heroin users started by
using opioid pain killers. Additionally, many heroin users
also supplemented with opioid pain killers. Two major risk
factors for opioid overdose are: higher doses, which can be
common when opioids were used for long periods to control
chronic pain (dosages could become very high when
medications were obtained from multiple providers); and co-
administration with benzodiazepines (e.g. Valium and
Xanax). The PDMP helped providers to monitor total dosages
dispensed from all sources and to identify potentially
dangerous combinations. He believed the vast majority of
prescriptions were well intentioned, but too often led to
misuse, particularly when the opioids were dispensed in
larger-than-needed quantities.
3:50:02 PM
Doctor Butler discussed that benzodiazepines were Schedule
IV drugs. Under best practices, often Schedule IV drugs
were included in the required PDMP lookup. He had spoken
with providers who utilize the PDMP - one provider who had
seen a patient for the first time, accessed the PDMP and
had been surprised to find the person had been prescribed
1,200 opioids in the past year and 1,000 benzodiazepines.
He furthered that about half of the prescriptions were from
one provider. He remarked that the question about what to
do about that was very pertinent. He continued that
Provider A had contacted Provider B, who had responded that
they had no idea they had prescribed that much. He stated
that the database not only helped providers know what other
people were doing; it was also a reminder to individual
providers about what they prescribed. The Alaska PDMP was
underutilized that needed to be used more if it was going
to be used.
Dr. Butler addressed that recommendations incorporated into
SB 74 included components of the nine broad recommendations
from the Controlled Substances Advisory Committee. A number
of the recommendations were controversial to various
people. The two recommendations that had given him the
greatest pause were the required registration and lookup.
He shared that it had taken him 15 minutes to register,
which had involved locating his DEA number and other
information. He only remembered having to get a single page
notarized. He acknowledged that finding a notary could be
burdensome to some people. He would prefer to remove
barriers to make the right choice the easy choice, instead
of putting mandates in place. He believed there were
opportunities to make registration easier. He reasoned that
if registration was tied to license renewal the
notarization requirement could potentially be eliminated.
He deferred to the Department of Commerce, Community and
Economic Development (DCCED) to address the feasibility of
the idea. He was initially opposed to the mandatory lookup.
He detailed that more than 20 states required a mandatory
lookup in some form. He elaborated that the bill sponsor
had worked to determine how to implement the requirement
while striking the appropriate balance between access to
care, patient and provider autonomy, patient privacy,
quality of care, and addressing the opioid epidemic.
3:53:38 PM
Dr. Butler communicated that he rarely used the term
epidemic, but he was comfortable calling the four-fold rise
in the rate of death from one specific cause over a less
than one decade an epidemic. He pointed out that young
people accounted for many of the deaths. Thus, when
considering the years of potential life lost or work lost
to the state, the impact in Alaska was fairly large.
Co-Chair Neuman remarked it had been wonderful working with
Dr. Butler on reform packages over the past four years. He
added he had first met Valerie Davidson, Commissioner,
Department of Health and Social Services during work on
recidivism reduction. He asked how many of the 80 opioid
overdose deaths in Alaska [in 2015] had been prescribed by
a doctor.
Dr. Butler replied that providing access to the PDMP for
the state medical examiner as well as de-identified data
for epidemiological analysis would help answer those types
of questions. He added that those were the critical types
of questions to be able to address the challenge.
Co-Chair Neuman surmised that it was highly likely that the
drugs had been over-prescribed by the person's doctor. He
surmised that a person may have depression issues due to
excess chronic pain and overdosed because they did not want
to live any longer. He asked about the likelihood of the
scenario.
Dr. Butler answered that roughly 1 in 10 deaths had some
evidence of suicidal intent. There was some overlap as a
cause of death, but it was important to recognize that the
vast majority of the evidence was that the overdoses were
accidental. He addressed national studies on where people
obtained prescription opioids without a prescription. The
broad majority obtained the drugs from a friend or
relative. He guessed that most people at the table had at
some point had opioids in their medicine cabinet at home
because the prescription sizes had increased over the past
10 years. He explained that there really was a ready
available supply. He reiterated his earlier statement that
the PDMP was not a cure-all, but it was a way to track
prescriptions so individual providers could know what was
going on with an individual patient. Additionally,
providers would have the ability to look have visibility
into where medications were coming from for a patient or
potentially to a family. In terms of other sources, it was
interesting that theft and purchasing only accounted for
about 5 percent. Nationally, about 5 percent of all
prescriptions came through emergency departments, whereas
about 50 percent came from primary care providers (i.e.
internal medicine physicians, family practice, and advanced
practice nurse practitioners). He noted there was no
visibility into the issue for Alaska on its own. He
explained that the statistic did not mean primary care
providers were writing a large percentage of opioid
prescriptions; the number reflected that the group of
providers saw a high number of patients and did often did
prescribe opioids for chronic pain.
3:58:33 PM
Dr. Butler continued to answer the question. He relayed
that proposed changes in the bill aligned with a number of
the national best practices and with the recently published
national guideline co-published by the American Medical
Association (AMA) Journal and the CDC on March 15 [2016].
The best practices recommended a provider to check the PDMP
prior to writing a new prescription for an opioid and to
recheck the PDMP at regular intervals if the provider was
prescribing opioids for chronic long-term pain management.
Co-Chair Neuman discussed that his family doctor knew
everything about him because he wanted to live a long life.
He elaborated that he did not eat right and his cholesterol
was slightly high. He surmised all doctors should talk with
their patients about the cause and effect prior to
prescribing medications. He surmised doctors considered how
multiple medications worked together and what the cause
would be of taking or not taking them, which was the reason
doctors told patients to take their prescriptions as
specified. He reasoned that prescriptions were not to give
to a person's friend, neighbor, or loved one. He followed
the directions of his doctor when receiving prescriptions.
He thought all doctors should have that relationship with
their patients.
Dr. Butler agreed that the scenario described by Co-Chair
Neuman should happen. He shared that he had experienced a
medical issue and a provider had insisted on subscribing
some Percocet even though he did not personally feel he
needed them. He heard from a number of people that they
were raised to take their medicine as instructed - if a
person was prescribed 50 Percocet they may feel the need to
take them - the problem was especially prevalent for older
people who just added it to the list of medications they
took. What Co-Chair Neuman was describing was the ideal and
the PDMP should help to facilitate the relationship. He
stressed that the situation did not just involve bad people
- people were all just human. He referred to a new
medication his father had started, which he noticed was
contradictory to a medication his father was already
taking. His father communicated that the doctor had not
asked about other medications. Subsequently his father told
the doctor about the other prescriptions and the doctor
immediately canceled the new medication. He explained that
often the ideal of everyone communicating did not happen.
Part of the goal of the PDMP was for all providers to
understand what was being prescribed.
Co-Chair Neuman discussed that it was the job of the
pharmacy to interpret one drug's interaction with another.
He believed when the pharmacy filled the prescription they
would have noted the new medication was not compatible with
others being taken by Dr. Butler's father. He thought there
were already things in place to catch the issue.
Dr. Butler answered that it would be great if the person
went to the same pharmacy for all of the medications, but
it was not what happened.
Co-Chair Neuman thought Medicaid or Medicare billing would
catch the issue at the end of a billing period.
Doctor Butler replied that Medicaid was an important
example. He detailed that currently the Medicaid pharmacist
did not have any visibility on medications without a
Medicaid claim. He furthered that a very robust business
model was to get some opioids through the Medicaid program,
sell them for cash, use the cash to visit another provider,
get more opioids, and so on. He explained that the practice
had been documented in other states. He did not know
whether it was happening in Alaska, but there was no way of
currently knowing because the Medicaid pharmacist did not
have access to the PDMP.
Co-Chair Neuman stated that he had asked the pharmacist
about the issue. He relayed that generally when
prescriptions were paid for in cash the pharmacist called
the prescribing doctor to let them know. He believed the
pharmacies were pretty aware of what was going on. He
opined that pharmacies and doctors had a tight relationship
in Alaska.
Vice-Chair Saddler referred to Dr. Butler's testimony that
the PDMP was a part of the solution. He asked for the other
elements of the solution.
4:05:31 PM
Dr. Butler replied that he thought in terms of infectious
diseases, trains of transmission, and the opportunities to
interrupt transmission. He thought about how a person who
ultimately died of an overdose had started as healthy as
anyone in the room at one point in time. He specified that
often when people became addicted to opioids it started
with a prescription for an acute injury. He continued that
the situation resulted in no problem for most people. He
added that most people using opioids recreationally did not
go on to heroin, but a significant portion did. When
tracing how a person became addicted, receiving a
prescription for an injury was one of the contributing risk
factors. He believed that apart from intervening on the
supply of opioids in the community through the PDMP, better
pain management, limiting the number of pills dispensed,
and looking for other modalities of management in the case
of chronic pain were all important. Additionally, he
believed addressing behavioral health was critically
important as understanding of how early childhood trauma
increased the risk of self-medication later in life. He
referred to a study in England suggesting nearly 60 percent
of heroin and crack/cocaine use was attributable to adverse
childhood experiences. Also important was being able to
recognize addiction and to intervene with treatment;
treatment opportunities included medication assisted
therapy (e.g. Buprenorphine). He believed there was
currently a big inequality in the 900,000 American
providers that could write prescriptions for Schedule II
opioids with only 34,000 qualified to write prescriptions
for Buprenorphine. Methadone was another option and
Naltrexone was a very promising approach for individuals
who had gotten through withdrawal and were off opioids and
who wanted to take extra steps to ensure they could remain
clean.
4:08:11 PM
Vice-Chair Saddler asked if the opioid epidemic could be
controlled without increased use of the PDMP. Dr. Butler
answered that if he was convinced it made no difference at
all he would not be sitting before the committee. The seven
states recognized as doing the largest portion of the
nationally recognized best practices (Tennessee, Kentucky,
Ohio, Wisconsin, New York, Connecticut, and Massachusetts)
had seen declines in the total number of prescriptions for
opioids, a decline in the number of high dose opioids, a
very significant decline in the amount of doctor shopping,
and increases in the number of Buprenorphine prescriptions.
He submitted it was a sign there were more people seeking
treatment once they were recognized as opioid dependent.
Vice-Chair Saddler asked for clarification. Dr. Butler
replied that they were not discussing something like a flu
vaccine that he could specify was 60 percent effective.
Evidence had shown the PDMP had helped in other states. He
believed it was more probable the system would help in
Alaska than not.
Vice-Chair Saddler asked for the reason behind the high
prescription of opioids. He asked if there was a profit to
the pharmacist or pharmaceutical companies. Alternatively,
he asked if it was defensive medicine or patient
satisfaction.
Dr. Butler answered that during the early part of the 20th
Century as everyone responded to the first opioid epidemics
occurring in the late 19th Century, there had been a
tendency to avoid opioids and there had not been a
multitude of other options. As a result, he believed pain
had probably been under managed. By the time he had started
his training there had been good progression - he recalled
specifically being told if he had a patient dying of
cancer, to make them comfortable and not worry about that
patient being addicted to morphine. In the 1990s
particularly with the Federal Drug Administration (FDA)
approval of Oxycodone, things had changed. He specified
that there had been a perfect storm of an aggressively
marketed opioid combined with a flawed philosophy (i.e.
pain was the fifth vital sign). The philosophy was still
part of the way Center for Medicaid and Medicare Services
(CMS) did reimbursements based on patient satisfaction. He
was included in a number of people working to push the
federal government to change the practice, which he
believed created an unreasonable impetus to make sure
people answer the question that everything was done to
manage their pain. There had been some very large fines,
particularly against one manufacturer, for marketing that
did not address the emerging risk of addiction and overdose
with their product. He believed the country was finally
beginning to get away from the concept of the fifth vital
sign. He detailed that pain was very subjective, it was not
like blood pressure, temperature, pulse, or respiratory
rate that was easy to measure.
4:12:32 PM
Representative Gara spoke from his perspective as a spouse
of a health professional and believed there were physicians
who over prescribed opioids. He referred to a growing pain
medicine practice he found troubling, which the bill would
not impact. He wanted to ensure that all of the required
prescriptions were entered into the database. He referenced
his earlier question about whether pharmacists always
filled prescriptions in the emergency room. He asked for
verification that a pharmacist entered the information into
the PDMP.
Dr. Butler answered most likely. He specified that the
program was currently voluntary; therefore, whether the
data was entered into the PDMP depended on whether the
pharmacist participated in the program. The participation
was much higher among pharmacists than by providers. In the
ideal situation the prescriber assessed a person's
controlled substance history using the PDMP, wrote and
filled a prescription if there were no issues; the
information was then recorded in the database. He explained
that in terms of the scenario described by Representative
Gara, it depended on where a patient went for treatment. He
reiterated that the program was currently voluntary.
Representative Gara wanted to ensure that all of the
prescriptions were entered into the database. He remarked
that the legislation currently required pharmacists to
enter the data into the PDMP. He asked if there was always
a pharmacist in the emergency room or whether it was
necessary to add specific language to the bill related to
the emergency room setting.
Doctor Butler answered that it depended on where a patient
went. In general a patient would receive a prescription
from the emergency room to take to a pharmacy, which may be
in the hospital. He had not experienced a situation where a
doctor brought the filled prescription directly to a
patient in the emergency room.
Representative Gara stated that he did not know the
difference between Schedule II, III, IV, or V drugs. He
asked for verification that the bill currently applied to
Schedule II and III drugs.
Doctor Butler answered that the bill also included Schedule
IV drugs. He explained that Schedule I included illegal
substances the FDA specified had no recognized medical
value. Schedule II tended to be opioids as well as some
stimulants such as Attention Deficit and Hyperactivity
Disorder (ADHD) drugs. Schedule III included things like
anabolic steroids. Schedule IV included benzodiazepines -
he remarked it was a bit of a conundrum because the
medications were much more frequently prescribed, but based
on an analysis of Veterans Administration data, really
potentiated the risk of death when an opioid was co-
prescribed. He did not have an easy answer to make the
requirements easy, while also reducing the risk of an
adverse event. Schedule V drugs included Codeine containing
cough syrups; there was a risk of abuse, but probably not
as high. Schedule IV also included drugs like Tramadol,
which was an analgesic. He reported he was receiving
increased calls asking about abuse of Tramadol or
diversion. He currently did not know. He explained it was
where the de-identified access for public health was useful
in order to further understand prescribing patterns. It was
not currently known whether something was coming in from
another country and if it was being prescribed in Alaska.
He explained that the office of the medical examiner was
primarily to give healthcare providers statewide a heads up
when a substance started to be seen more in the state (e.g.
such as synthetic cannabinoids the past year). He remarked
that a Tramadol overdose was particularly nasty and tended
to include seizures and low blood sugars. He believed being
able to recognize the symptoms was important for providers.
4:18:25 PM
Representative Gara surmised there may be an amendment to
remove Schedule IV drugs from the bill. He asked if there
was an easily identifiable small group of Schedule IV drugs
that should be left in the bill.
Dr. Butler answered that if the list had to be whittled
down he would include drugs that were currently a problem
such as benzodiazepines and Tramadol. The problem was the
situation was always dynamic. For example, he questioned
how to handle a situation when new drugs arose in the
future - he asked if it would be changed through regulation
or whether it would require a statute change. He noted the
State Controlled Substances list currently required a
statutory change; there was currently a bill before the
legislature that would add Tramadol to the list, which he
believed had not been scheduled for a hearing.
Representative Gara repeated drugs mentioned by Dr. Butler
including benzodiazepines, Tramadol, and some definition
that would describe other drugs by regulation the state did
not currently know how to write. He reasoned it was the
legislature's job to figure out. He had looked into writing
a bill to limit the amount of some of the more dangerous
opioids that could be prescribed, but he had been told as a
matter of federal law that the limits on the number of
opioid pills that could be prescribed were stringent. He
asked if a person could get addicted to opioids on a few
pills or whether it took a multitude of pills.
Additionally, he asked if existing law prevented doctors
from prescribing an addictive amount of opioids.
Doctor Butler answered that he was not aware of what the
limits were. He had heard from a number of people over the
past several months talking about receiving 100 pills at
one time. He had personally received a prescription for 50
pills after oral surgery, which he believed was a high
amount - particularly when the drugs were dispensed as a
"just in case" precaution. He had never run into a problem
with a patient with terminal pain requiring continual
refilling because you could dispense a fairly large amount
if needed. He was not familiar with that being an issue.
Representative Gara stated if there was something
meaningful that could be done to limit the number of
opioids that could be prescribed he would not mind
considering it.
4:21:56 PM
Representative Pruitt surmised that the database started to
resemble medical reform as opposed to Medicaid reform.
There was some concern about the privacy of having the
information exist on a database. He thought there was a
timeframe from which the information was removed from the
database, which he believed made sense. He asked if it was
the case.
Doctor Butler responded that the timeframe was two years.
Representative Pruitt remarked that the bill focused on
Medicaid reform; however, he believed the database fell
into the medical reform category. He referred to some
concern about the privacy related to people's information
in the database in perpetuity. He believed the information
was only on the database for a certain period of time. He
used the Division of Motor Vehicles as an example and
explained that at a certain point some old offences dropped
off a person's record. He believed it made sense for the
information to be removed from the database after a certain
period of time. He reasoned that people who had not used an
opioid for two or three years were not the people the bill
was aiming to address. He asked for verification of the
accuracy of his statements. He wanted to put some of the
privacy concerns about maintaining a database with a long-
term record of a person's usage of prescription drugs.
Dr. Butler commented on the critical importance of the
question. He believed the information was maintained on the
PDMP for two years before being deleted.
Representative Pruitt saw the database and conversations
related to behavioral health as chasing the problem in many
cases. He opined that the root cause had yet to be focused
on. He referred to Dr. Butler's testimony about the root
cause going back into the 1990s and making sure cancer
patients did not have pain. He noted certain committee
members had faced that challenge. He relayed that he had
spoken with Dr. Rathkopf who had highlighted that the CDC
had recently come out with new recommendations that he
believed may assist in the current discussion. He
referenced that the CDC's 6th recommendation highlighted
that long-term opioid use began with treatment of acute
pain ["CDC Guideline for Prescribing Opioids for Chronic
Pain - United States, 2016" (copy on file)]. The
recommendation noted that in most cases [medication for]
three days or less would often be sufficient and more than
seven days would rarely be needed. He asked whether there
was a current opportunity to facilitate a conversation with
the state medical board or other mechanism about utilizing
the CDC recommendations to put them into regular use. He
spoke to beginning to address the root cause of the problem
in some capacity by utilizing the CDC recommendations. He
asked if the bill needed to contain language giving the
state the mechanisms to take action by working with
providers to limit the amount prescribed (to prevent a
person from receiving 30 to 50 days' worth of medication).
4:26:20 PM
Dr. Butler answered that a number of things came to mind.
He relayed numerous provider surveys and individuals he had
spoken to (including medical students) reported they had
not had significant training in pain management or
addiction medicine. He believed it was the point
historically where physical health had not been integrated
with behavioral health as it should be. He believed
promulgating the guidelines would be very helpful because
he heard from providers who were not sure what to do. The
common situation the recommendations did not address
thoroughly was the patient who had already been on opioids
for several months and the need to get them off the drugs.
He concluded that the recommendations were not a complete
educational package yet, but they represented a huge step
forward. The recommendations also used data he had
referenced earlier highlighting the risks when a person got
above a certain dose and associating doses often times
connected with more prolonged periods of therapy as well as
the co-administration with benzodiazepines. He specified
that every state had a requirement for a certain amount of
continuing medical education credits. A number of states
required the education to be in pain management and/or
addiction medicine. He had met with the state medical board
once, which had been loath to have any kind of requirement
for training; however, it was an option pursued in other
states. He added that it was now required for the federal
healthcare workforce. He relayed there were a number of
approaches, which could be used.
Representative Pruitt remarked on earlier testimony that
doctors sometimes believed other doctors were over-
prescribing medication. He detailed that sometimes it
sounded like doctors were not aware of the amount they were
prescribing. He hoped over-prescribing was limited in terms
of negligence. He remarked that training was one component.
He asked if there was still a need for something firmer
than guidelines.
Dr. Butler answered that sometimes it required "a stick as
well as a carrot" to make that happen, which was where
things like requiring a PDMP lookup before writing a
prescription could help. He suggested an amendment which
could be considered would be an exemption to the lookup for
quantities less than three-day supply (the number in the
CDC guidelines).
4:30:05 PM
Representative Pruitt asked if there was an opportunity to
engage some of the providers with the State Medical Board
to facilitate the conversation within the provider
community with the ultimate goal of providing
recommendations (taking the CDC guidelines into account) to
the legislature. He remarked that the legislature could
decide whether it thought the recommendations should be put
in statute or Dr. Butler could decide whether a regulatory
change was needed. He stated that some great providers had
provided feedback; however, they were not talking to all of
the providers. He wondered if there was an opportunity to
get providers more engaged. He noted that currently the AMA
and the state had not specified the CDC recommendations
should go forward. He wanted to make sure the guidelines
were addressed. He referred back to working to address the
root cause of the [opioid] problem. He asked if there was
something the legislature could do at present or whether
Dr. Butler and DHSS could do to help facilitate the
conversation.
Dr. Butler answered that he did not believe any of the work
should be done without engaging providers. One of the best
opportunities to engage providers was through the various
professional societies. He detailed there was significant
interest in the topic; he had personally been asked to
speak to the Academy of Family Practice, ASMA, and the
Alaska Nurse Practitioner Association. He stressed that the
groups provided marvelous input. He agreed with Dr.
Rathkopf's testimony that the perspective of the primary
care provider was desperately needed. He added that Dr.
Rathkopf was a pediatric allergist had a different
perspective; he personally was an infectious disease
provider and opioids were the last thing his patients
needed because opioids led to the reason they were seeing
him. He elaborated that providers all had different points
of view; therefore, input from as many people as possible
and through the organizations was important. He explained
that the way the CDC and AMA worked was fairly collegial;
the entities operated to put out guidelines and
information. He believed the AMA had recently published the
guidelines the same day as the CDC to get the information
out to their providers. He noted that all of the guidelines
related back to an assumption there was a functioning PDMP.
He agreed it was a part of healthcare reform, although the
bill included a very specific piece related to the Medicaid
program in terms of access for the Medicaid pharmacist to
the PDMP.
4:33:57 PM
Representative Gattis had received emails from a couple of
providers who had a problem with the PDMP. The providers
stated that the PDMP excluded the emergency room and
surgeons who dispense 90 percent of the narcotics by
volume. Alternatively, she thought Dr. Butler had specified
the number was about 5 percent. She asked Dr. Butler to
comment on the figures and discrepancy.
Dr. Butler would be happy to provide the background
publications where the numbers had been derived; it was an
issue of the total number of prescriptions. He explained
that when looking at surgeons or ER physicians as a
proportion of all the prescriptions they write, the higher
percentage was for opioids, but the total number was
actually smaller. The primary care providers, which made up
a larger group, wrote a larger number of prescriptions.
Representative Munoz had a concern about opioids in the
hands of young people below the age of 20 or 21. She asked
if there was any evidence that addiction was greater in a
younger person than in a much older person.
Dr. Butler answered that it was a good question, but he was
not sure he was the best person to answer. He referred to
an emerging science in neurodevelopment suggesting the
adolescent brain was susceptible to addiction to a wide
variety of substances (more so than the brain of someone 25
years of age or older). He added that a person's youth was
definitely a time of high risk in terms of experimentation.
He believed people struggled with a perception that opioids
were merely "granny's pills" and they were perfectly safe.
He believed everyone in the room had heard some of the
heartbreaking stories in Juneau about how pills had led to
worse things and ultimately to overdose.
Representative Munoz asked if other states were able to
limit the availability of pain narcotics to a younger
population with a prescription limit of three days, seven
days, or other.
Dr. Butler answered that he was not aware of any states
that had implemented age limits related to the number of
pills prescribed. The pediatric component was one of the
gaps in the recommendations; it was not addressed in the
CDC guideline and had been a criticism from the American
Academy of Pediatrics. He knew the pediatric community
recognized the issue of one that needed to be addressed.
Representative Munoz asked if Dr. Butler believed the
participation of all prescribers in the database would
prevent or deter over prescriptive tendencies. Dr. Butler
answered that all he could do was look at the other states
to see that the number of prescriptions had declined when
participation in the PDMP was required. The data was in
fairly early stages, but there was no evidence there had
been worse pain control because of fewer number of
prescriptions.
Representative Munoz asked how much Medicaid was spending
on pain narcotics in Alaska. Dr. Butler did not personally
know, but he believed a colleague would know (Erin Narus,
Lead State Pharmacist, State Medicaid Pharmacist Healthcare
Services, Department of Health and Social Services).
Co-Chair Thompson noted that Dr. Narus would testify next.
4:39:01 PM
Co-Chair Neuman believed he had spent more time on the
issue than anyone in the building. He added that he went
back several years with Dr. Butler and others on the topic.
He expressed concerns about the topic. He relayed that his
wife was a pharmacy technician, and there was currently no
enforcement except by pharmacy technicians and pharmacists.
He believed when prescriptions were altered to increase the
amount on a prescription it was done in the time between a
doctor office and the pharmacy. He noted that his wife had
been faced with telling an individual the pharmacy believed
the written prescription was illegal it would be destroyed.
He was scared that his wife had to tell a drug addict or
distributor she would not fill a prescription. He stressed
that retribution could be high and extreme. He recalled
that several years back a senior couple had been murdered
in Big Lake within a half mile from his house; the offender
had stolen the couple's prescription drugs. He had concerns
about who was responsible for telling drug addicts their
prescription may be illegal. He emphasized that the issue
had to be addressed. He remarked on calling the troopers
who emailed a report - he added that the troopers did not
respond to the issue. He detailed there were fewer troopers
in Alaska at present than at any time in the past.
4:42:05 PM
Co-Chair Neuman continued to discuss his concerns, citing
pharmacy theft, which was prevalent. He specified that
pharmacies were very concerned about the issue and most had
security cameras. He reasoned that people who work in
pharmacies or have access to drugs were human and stole the
drugs - some to take care of their own habits and others
sold the drugs. He believed the bill was creating an
opportunity to increase access to information in the
database. He surmised that the database would show who had
received prescriptions, the amounts, and the address of the
individual. He stated that most people he had spoken with
about the issue were very concerned. He relayed that people
were surprised to find out about the PDMP that contained
information about a person and their prescriptions. He
understood the database helped emergency room doctors, but
he believed emergency room doctors were triage and there to
get a person to a primary care provider as soon as possible
- generally within one or two days. He was greatly bothered
the government was keeping track of all the prescription
drugs people took. He reiterated his opposition to giving
others access to the database.
Co-Chair Neuman relayed an anecdotal story about a pharmacy
technician who was addicted to drugs and who gave out
information about people in the database. He surmised the
people who received the information could potentially rob a
person's house. He was extremely bothered that when the
Medicaid bill had been before the legislature and the state
had not spoken to Medicaid patients. He emphasized people
dealing with the issues were faced with real problems.
4:45:09 PM
Co-Chair Neuman discussed information he had heard from his
family doctor, who was losing patients. He detailed that
his doctor had insurance out of California or Washington
and those two states had implemented new insurance
regulations requiring patients to go to a pain clinic when
receiving medication for long-term pain management. He
stated the costs were $550 per visit compared to $125. He
reasoned that a person would be faced with leaving their
family doctor to see someone different who did not know
their medical history. He added that more and more people
were signing up for Medicaid; he wondered what it did to
the cost of the Medicaid program. He asked what the change
did to the cost of prescriptions for Medicaid. He referred
to his past chairmanship of the DHSS budget subcommittee.
He recalled that DHSS had been getting about $40 million
from the federal government and the Department of
Administration had been receiving $20 million in rebates
from pharmaceutical companies. He stated that the companies
were charging more for prescriptions than their actual
cost.
Co-Chair Neuman continued that Alaska's 700,000 residents
were currently spending over $60 million plus
administrative fees, which he thought easily accounted for
another $10 million to pharmaceutical companies. He stated
that Alaskans were spending more for the cost of drugs so
companies could get the money back under the guise of
covering the cost of prescription drugs for Medicaid, which
was about $1 million per week. He questioned whether more
government in people's lives made it right. He did not
believe so. He remarked that a state board produced a
preferred drug list. He believed it was plausible that the
drugs on the list were from companies who provided higher
rebates. He had huge concerns about the issue. He opined
that if the scenario was possible, the state should be
taking a hard look. He spoke to the concerns about the
invasion of privacy. He remarked that the database could be
accessed by the federal government. He continued that the
federal government was taking long strides to take away
guns from honest people. He thought the federal government
could use the database to identify people it believed
should not have guns. He did not support taking guns away
from individuals. He could live with the current PDMP,
which pharmacists, primary care and ER doctors could access
if they needed.
4:50:07 PM
Co-Chair Neuman could not believe the legislature was
considering making it mandatory for doctors to use the
database. He reasoned a person could be long-term patient,
but would still be included in the database. He believed
not all doctors would want to delegate authority to someone
in their office to write scripts. He spoke to cost drivers
and did not know how much it would cost to update the
database weekly. He emphasized that the database was
currently updated on a monthly basis. He believed it was
essentially worthless. He had been told weekly updates
would be expensive by the director of boards and
commissions. He understood the problem of opioid abuse and
overdoses, which was the reason he had worked hard to
address the issue. He mentioned an earlier question about
addressing the problem. He stressed the legislature had
included $30 million ($10 million per year for three years)
to start treating the problem - to treat Alaskans with
addiction problems without current access to treatment. He
remarked it had been specified in a gap analysis he had
worked on with Dr. Butler. He believed the best thing the
state could do was to try to treat the problem and the
addicts in the state. He opined it was the cheapest and
least intrusive method. He continued it would keep people
from trying to break into homes to steal prescription
drugs. The people he talked to wanted less government in
their lives. He stressed that the PDMP requirement was not
less government. He emphasized the personal nature of the
information.
Co-Chair Neuman continued to address his concerns about
expanding access to the database. He asked people to
imagine what a drug gang would do with the information. He
did not know anyone who felt comfortable with the issue. He
stressed that other databases got hacked and so could state
databases. He wondered what an insurance company would do
with the information if they got the data. He added that
every doctor who had called in during public testimony had
specified various points that needed to be amended.
4:54:50 PM
Co-Chair Neuman continued to speak to his concern about the
issue. He referred to discussion during the meeting about
limiting the amount of pills a doctor could prescribe. He
asked if that was really where people wanted government to
go. He understood it saved lives. He stated that there had
been over 1 million prescriptions in the PDMP the previous
year. He questioned whether the committee was asking to
erode the personal rights of more Alaskans. He understood
that people overdosed on drugs. He referred to his earlier
question about whether the 80 Alaskans who had overdosed
had been getting prescription drugs by their doctor who had
not been prescribing correctly. He recalled that Dr. Butler
had agreed for the majority of the cases it was probable.
He reiterated that he could live with the current system.
He believed the topic needed much more discussion before
leaving the committee. He was upset at the idea of more
intrusion into people's rights, which he believed was not
the government's role. He remarked that the requirement
would increase the cost of government; he thought the bill
would require an increase of 5 or 6 new state positions for
enforcement. He reiterated his other concerns. He had
spoken with a doctor at a pain clinic who had specified he
would not access the database. He restated earlier
testimony. The doctor had specified that if he saw the name
of one of his patients on the list he may not be able to
treat the person. He wondered how many other doctors in
Alaska would feel the same way. He mentioned the shortage
of doctors in Alaska.
4:58:19 PM
Representative Guttenberg remarked that SB 74 was a
Medicaid reform bill, which he believed was about the
process of medicine. He surmised the conversation seemed to
be "walking back and forth" over the practice of medicine.
He furthered that one of the goals was to create
efficiencies and to reduce the escalating costs of
medicine, which were out of control. He added that the
costs were out of control in Alaska even with the expansion
of Medicare. He reasoned the bill was about taking control
of those costs. He continued that the state had more
control over the Medicare environment than it did over
anyone else. He did not want to get into the practice and
reasoned that the state had almost no control over the
area. He elaborated that it was not possible to tell a
physician what to do. He stressed that the state did not
want government in the room telling a physician how to
practice medicine. He believed the PDMP would enable the
discovery of things as a "side version of what that is,"
whether it was about prescribing things that should not be
prescribed in certain amounts to certain people. He
mentioned efficiencies in telemedicine and other areas. He
addressed the issue of privacy. He discussed when he walked
into a clinic he saw schedulers, people filling out
insurance forms, and filing. He reasoned there were
national HIPAA [Health Insurance Portability and
Accountability Act] laws dealing with the issues. He asked
if there was a history of abuse, prosecutions, or behavior
that was out of the norm that the committee should be
concerned about. He referenced expanding for individuals in
a pharmacy or doctor's office to access the database
(outside of the pharmacist or doctor). He always questioned
who had access to what in a doctor's office. He asked if
the issue had been a problem.
Dr. Butler answered that the security issue was critically
important. He had spoken with DCCED and state troopers
about whether or not there had been breeches in the Alaska
PDMP. He was particularly concerned about linking the PDMP
to homicides and releases of data because the troopers were
not aware of this. He stressed that if people were aware of
crimes of that nature they needed to report them to law
enforcement. The national experience had been that
disclosures occasionally occurred - he was aware of two
occurrences. The first involved a law enforcement official
in a state with open access to law enforcement, which was
not listed among the best practices and was not a good
idea. The second occurrence involved a healthcare provider
with access to the medical record who had tried to get
information on an ex-spouse in Ohio. He was not aware of
any similar issues occurring in Alaska based on the
conversations he had with DCCED and the state troopers. He
encouraged other department officials available to testify
to weigh in on the issue if they had something to add.
Dr. Butler continued that the concern about hacking into
private information was valid (the same went for financial
institutions), but no national experts were aware of any
occurrences where data from the PDMP had been used to
target people for robberies. He stated that "it gets to
that question of just how prevalent opioids are in the
community because you don't really need to do that." He
detailed that a number of the larger national relators had
issued advisories to their agents to make them aware that
people often times showed up at open houses and asked to
use the restroom because it was a chance to pilfer the
medicine cabinet. He stressed that the PDMP was not needed
to find those opportunities. He continued that a person
could monitor the obituaries to look for someone who died
at home after a long illness and could break in during the
person's memorial service. There were all kinds of ways for
crimes to be committed that did not involve the PDMP. He
had not been able to find documentation of crimes that had
been proposed involving the PDMP. He stressed that security
was critical and he deferred to DCCED or other for further
detail into security precautions against hacking into the
PDMP. He was curious how the precautions compared to those
for the Alaska Permanent Fund Corporation and other. He
provided a scenario about online hacking to steal money. He
reasoned those hacking interests would not care about the
PDMP.
5:05:35 PM
Representative Guttenberg asked if troopers had access to
the database. Dr. Butler clarified that troopers did not
have access to the database without a subpoena or search
warrant. He had asked state troopers whether they had ever
investigated a crime related to release of information from
the PDMP.
Representative Edgmon asked about the genesis of the bill
section. Dr. Butler believed the section had been added in
a Medicaid Reform Subcommittee in Senate Finance. He noted
confirmation from the sponsor.
Representative Edgmon remarked on the compelling viewpoints
from both sides of the issue. He asked if the discussion
was at the nascent stage. He wondered if the issue had not
been thought through about cost to the provider and issues
of privacy infringements versus the greater good of not
having a centralized database.
5:07:38 PM
Dr. Butler replied that if part of the question was about
why he was speaking to the issue, the answer was he was not
actually sure. He reasoned the program was not in his
department. He answered that the process was ongoing and
the state's PDMP was not new. He continued that it had been
one of the topics of discussion in looking at healthcare
reform as a quality of care issue by the healthcare
commission before it had been disbanded. Some of the
discussion had been fulfilling the will of the House
Finance Committee to implement the recommendations of the
healthcare commission. He explained the discussion was not
new.
Representative Edgmon referred to Dr. Butler's testimony
that the state did not have the ability to compile numbers
or meaningful statistics on opioid addictions or possible
overdoses. He asked for verification that Dr. Butler
believed the state was hindered because it did not have a
centralized drug database.
Dr. Butler responded that the state was able to monitor
overdose deaths and to some degree hospitalizations for
overdose. He noted those issues did not relate to the PDMP.
The discussion was about considering how to do more than
the testing and count the numbers. For example, addressing
questions like treatment. The discussion was also about how
to reduce the number of people requiring treatment. He
considered whether it would be sustainable to continue to
pour funding into treatment if there was an opportunity to
address the problem at its root cause, which was often
related to the combination of stress and the availability
of an addictive substance. In terms of the utility of data
in the PDMP it was primarily as a communication tool among
providers. He speculated that part of the reason the
subject had been added to SB 74 was its involvement in the
Medicaid program - the access for the Medicaid pharmacist
was part of stewardship for public funding that went to
Medicaid beneficiaries - in order to reduce fraud and
provide improved care. Access to the database was
concerning because privacy was critically important;
however, he believed the limited expansions and access were
on a need-to-know basis (similar to a national security
issue) in terms of who was currently unable to make
important decisions that would improve the health of
Alaskans absent the data in the PDMP.
5:11:18 PM
Representative Edgmon believed the vastness of the issue
was engendered more discussion. He vocalized his interest
in hearing from the bill sponsor on the benefits of the
provision, which seemed to be apparent. He added there were
also costs and implications that may not be fully
understood. He was trying to weigh both sides of the issue.
Co-Chair Thompson thanked Dr. Butler for his testimony.
5:12:26 PM
ERIN NARUS, LEAD STATE PHARMACIST, STATE MEDICAID
PHARMACIST HEALTHCARE SERVICES, DEPARTMENT OF HEALTH AND
SOCIAL SERVICES (via teleconference), relayed that most of
the points she had planned to address had been covered by
Dr. Butler. She provided a brief overview of the one the
role of the Alaska Medicaid drug utilization review
process. Currently under federal law the nation's Medicaid
programs were required to provide for a drug utilization
review program for covered outpatient drugs. The
requirement was primarily to ensure that prescriptions were
appropriate, medically necessary, and not likely to result
in adverse medical results. The federally mandated drug use
review program had two broad components. The first
component was a prospective drug utilization review
program, which looked at the point of sale of
prescriptions. She detailed that when an individual filled
a prescription at the pharmacy there were rules within the
claims adjudication system to help the pharmacy to be aware
of other medications the patient may currently be taking.
After being entered into the point of sale the claim was
sent to the Medicaid claims processing system. The second
component was a retrospective drug utilization review. She
specified her office worked with the drug utilization
review committee - an interdisciplinary committee of
practitioners throughout Alaska (e.g. physicians, mid-level
practitioners, and pharmacists) - and reviewed trends of
medications and looked for ways to reduce fraud and abuse
and to guide clinical prescribing utilizing evidence-based
medicine tenets.
Representative Pruitt asked if Dr. Narus saw the database
as a key part in helping the state to save money on
pharmaceuticals in the Medicaid program. Dr. Narus answered
that access to the PDMP by licensed pharmacists within the
Alaska Medicaid program was critical in order to prevent
hospitalizations and to ensure the appropriate utilization
of funds.
5:16:12 PM
Representative Pruitt believed the answer was "yes." He
thanked Dr. Narus for her response.
Representative Munoz asked about the cost spent on
narcotics in the Medicaid program. Dr. Narus replied that
she did not have the specific number, but she could provide
it. She added that in December [2015], narcotic analgesics
had been the top number of claims in the Alaska Medicaid
system.
Representative Munoz asked for the total cost of all
Medicaid pharmaceuticals had been during that month. Dr.
Narus replied that she would follow up with the
information.
Co-Chair Thompson thanked Dr. Narus for her testimony.
5:18:25 PM
AT EASE
5:30:16 PM
RECONVENED
Co-Chair Thompson asked DCCED to address the committee.
JANEY HOVENDEN, DIRECTOR, DIVISION OF CORPORATIONS,
BUSINESS AND PROFESSIONAL LICENSING, DEPARTMENT OF
COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT, introduced
herself and other department staff available to testify.
She clarified that the department's fiscal note included
the cost for telemedicine and the PDMP expansion; the PDMP
only accounted for one-fifth of the fiscal note, which
would fund a program coordinator and a small amount of
travel for the coordinator to attend Board of Pharmacy
meetings. She relayed that the cost to update the PDMP
weekly or daily (instead of monthly) would be $2,175 per
year.
Co-Chair Thompson asked for clarification.
Ms. Hovenden replied that for the division to update the
PDMP weekly or daily with information received from
pharmacists it would cost $2,175 annually. Currently the
database was updated monthly.
Co-Chair Thompson asked for verification the cost was
associated with updating the database weekly versus
monthly. Ms. Hovenden answered in the affirmative and
explained it was a software issue.
SARA CHAMBERS, ADMINISTRATIVE OPERATIONS MANAGER, DIVISION
OF CORPORATIONS, BUSINESS AND PROFESSIONAL LICENSING,
DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT,
spoke to questions and concerns that had been raised
earlier. She clarified that the PDMP had been in existence
for several years; a list of people receiving opioid
prescriptions currently existed and was purged every two
years. She detailed that the information was accessible by
a very limited number of licensed prescribers and providers
in the state and the authority could not currently be
delegated to anyone (e.g. a pharmacy technician, or other
office personnel). She stated that the ability to delegate
the authority was included in the current bill. She
furthered that what the provision would look like and what
side rails may be included to achieve some of the
protections concerns was certainly open for discussion.
Federal government access to the PDMP was restricted to
licensed medical providers with a right to access specific
patient data (their own patients). She noted that the
Veterans Administration (VA) and IHS would have a different
definition than in the State of Alaska, but it would boil
down to what the federal and state licensing requirements
were for qualified doctors and pharmacists. She referenced
the seven-page signature form [mentioned earlier by Co-
Chair Neuman] and relayed the division was working with Co-
Chair Neuman to determine what the form may be. She
detailed that it did not appear to be a PDMP form; it was
perhaps a DEA form. The division was dedicated to increased
efficiencies - all of its licensing programs had moved to
online renewal capability in the current year. She noted
the division had received significant positive feedback
from licensees.
5:36:02 PM
Ms. Chambers relayed that the division had worked with
Doctor Butler; she thanked him profusely for his assistance
and education on the subject. Additionally, the division
had worked with the bill sponsor to continue its commitment
to making the processes as efficient as possible for
providers.
Co-Chair Thompson referred to an earlier question that he
did not believe had been answered. He asked if the PDMP
data on patients with opioid prescriptions shared with the
federal government.
Ms. Chambers answered that access to the PDMP was currently
available to the federal government only when an agent of
the federal government was a qualified licensed medical
provider; those individuals had the ability to the data
regarding their own patients just like any other non-
government private doctor. Additionally, the information
was available to law enforcement through a subpoena or
warrant issued in a court order process. She was not aware
of any other current or proposed federal government access.
Vice-Chair Saddler spoke to a letter from the Board of
Pharmacy [dated February 11, 2016 (copy on file)]
indicating the federal funding for the PDMP ended August
31, 2013. He continued that currently there was another
grant DHSS was receiving. He asked what the funding source
would be past 2021. He asked Ms. Hovenden for details on
the current cost of the PDMP and what the cost would be
after the expansion.
Ms. Hovenden replied that the cost was approximately
$100,000 for the PDMP expansion. The cost included one
personnel and some travel costs.
Vice-Chair Saddler asked for the current cost. Ms. Hovenden
replied that the cost was currently $85,000.
Vice-Chair Saddler surmised that the total cost would be
$185,000. Ms. Hovenden affirmed.
Vice-Chair Saddler asked if the funding was available
through a federal grant up to 2021. Ms. Hovenden replied in
the affirmative.
Ms. Chambers clarified that currently the division received
$120,000 annually through federal funding. The funds paid
for the database at approximately $80,000 to $85,000 [per
year]. The additional funding was set aside to pay support
staff assisting with the PDMP. She explained the division
did not receive the grant money if it was not utilized. The
division received adequate funding for the PDMP at present.
She detailed that the division had applied in a partnership
with DHSS for another grant, but it had not quite made the
cut. Subsequently, the division had been working with Dr.
Butler and his team on enhancing the grant. She detailed
that if received, the grants would cover the additional
expenses anticipated in the fiscal note; therefore, the
cost would be fully funded by a grant, which she understood
was the original legislative intent for the PDMP. The
funding would prevent the division from being in the
quandary of having to go to its licensees or registered
users to charge a licensing fee. The division had been very
active in partnership with DHSS to continue to seek grant
opportunities; the grant opportunities moved the PDMP from
a list of numbers and data - which was critically
important, especially to grant access to Medicaid - into a
robust statewide opioid control program.
5:41:27 PM
Vice-Chair Saddler pointed to the letter mentioning
legislative intent put in by former Senator Lyda Green
specifying it was not the intent of the legislature for
professional users of the database to absorb the cost; it
was the intent that the PDMP would be funded by federal
grants and state appropriations. He asked if it was the
legislation that had created the database.
Ms. Chambers answered in the affirmative.
Representative Pruitt returned to the discussion about
federal government access to the database. He spoke to
concern about people who were not doctors accessing the
database. He asked if a federal law required the state to
give the federal government access to the PDMP through a
subpoena. Alternatively, he asked if the state felt it
needed to provide the data in those circumstances.
Ms. Chambers answered that the law was currently in state
statute.
Representative Pruitt surmised that the state's own statute
could be changed in order to appease some concerns about
giving the federal government access to information. He
suggested prohibiting the transfer or cooperation with the
federal government on access to the database.
Ms. Chambers answered she would need to review the statute
to determine exactly how law enforcement was clarified. She
tended to agree with the tone mentioned by Dr. Butler that
the state's own Department of Public Safety and troopers
would have that level of access. She could not say without
researching the statute, whether it allowed or prohibited
federal law enforcement to have access to the information.
She would look into the issue.
Representative Gara understood the purpose of the database,
which would enable one physician to see if an individual
was shopping around and seeking large amounts of
prescription drugs. He referred to page 16 of the bill and
wondered why the pharmacist had to send a list of
individuals they prescribed drugs to the board. He wondered
about the purpose.
Ms. Hovenden replied that the board administered the PDMP.
The information was not literally sent directly to the
board; it went to the PDMP, which was managed by the board.
Representative Gara asked for verification that the
language requiring pharmacists to submit information to the
board meant the pharmacists were to submit the information
into the database. Ms. Hovenden replied in the affirmative.
Representative Gara referred to the provision requiring
pharmacists to submit the information a minimum of once a
week. He thought there had been a provision requiring a
pharmacist to enter the information quicker. He asked for
verification that the submittal of information was required
on a weekly basis. Ms. Hovenden replied in the affirmative.
5:46:18 PM
Representative Munoz referred to testimony from the prior
evening by a pharmacist who was concerned about having to
recheck the database after the initial prescribing doctor
had checked the database. She wondered if it would be
appropriate to have the Board of Pharmacy overseeing the
program if the state only required the prescribing doctor
to check the database. She wondered if it would be more
appropriately housed in the State Medical Board.
Ms. Chambers answered that the division oversaw all
professional licensing boards including the Board of
Pharmacy and the State Medical Board. She detailed that it
was "six of one, half dozen of another" - any particular
board may be given the statutory authority by the
legislature to govern the process, but the division
administered the program from a day-to-day standpoint.
Representative Munoz asked if the PDMP was managed
currently by the Board of Pharmacy. Ms. Chambers answered
in the affirmative.
Representative Edgmon asked if the concept flowed through
the Board of Pharmacy and State Medical Board. Ms. Chambers
answered that the idea of expanding the PDMP had been
generated outside of the division; the proposed expansion
had not initiated by the Board of Pharmacy or State Medical
Board. She furthered that the division had become involved
in answering technical and impact types of questions when
the legislation had been drafted.
5:48:28 PM
Representative Edgmon asked discussing the issue as a
policy measure would be in the normal course of business
for the board.
Ms. Chambers answered in the affirmative. She detailed the
Board of Pharmacy discussed the PDMP regularly and was an
engaged partner in its governance and administration. She
specified that because the State Medical Board was not
responsible for governance of the PDMP, it had not to her
knowledge had such a robust discussion; however, it had
thoroughly discussed the telemedicine aspect of the bill.
Vice-Chair Saddler asked if there had ever been a breach of
the integrity of the PDMP. Ms. Hovenden replied in the
negative.
Vice-Chair Saddler asked what the practical effect would be
if the pharmacist was removed from the redundant task of
doing a pre-check of the database. He asked if it would
tend to diminish the effectiveness of the database. Ms.
Chambers answered that the conversation was a result of
testimony the heard by the committee. She detailed the
conversation was being held with the bill sponsor, Dr.
Butler, and other engaged personnel.
Co-Chair Neuman asked if there had never been a breach of
information that was obtained from the PDMP. Ms. Hovenden
deferred the question to the database manager.
Co-Chair Neuman believed there was no way to know if
someone with access to the database told someone else about
the information.
5:52:01 PM
Co-Chair Thompson asked the database manager to address the
question related to system security.
BRIAN HOWES, PROGRAM MANAGER, PRESCRIPTION DRUG MONITORING
PROGRAM, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (via
teleconference), relayed that there had been no breach of
the database; the data had not been shared to his
knowledge. He relayed there had never been a complaint
regarding a breach. He explained that someone would have to
make a complaint that the data had been obtained illegally.
He furthered that through different complaint processes the
division could have the ability to determine who had
accessed the information and whether or not it was used
inappropriately.
Co-Chair Thompson surmised that if there was a breach it
would have been by someone with legal access to the PDMP
involving printing off the data and passing it on to
someone illegally. Mr. Howes answered in the affirmative.
Vice-Chair Saddler stated that there may not have been a
breach of the database there may have been a non-technical
human breach. Mr. Howes answered in the affirmative.
5:54:00 PM
Representative Guttenberg surmised the state would not know
if there was or was not a breach. He wondered how the state
would know either way. Mr. Howes replied that it would
require a complaint that data had been shared with someone
else. He furthered at that point the division would
determine which provider had looked up the patient. There
was an audit trail within the program, which would enable a
lookup of the information. From that point, they would go
through an interview process to determine what had happened
and what the person had done with the data.
Representative Guttenberg asked how many complaints there
had been. Mr. Howes replied there had been no complaints.
Representative Guttenberg asked if that was throughout the
history of the database. Mr. Howes answered in the
affirmative.
Representative Edgmon asked referred to testimony there had
been no breaches or sharing of the data from the PDMP. He
referred to the human intelligence factor. He remarked on
federal access by qualified medical agents and law
enforcement. He asked who had state access to the PDMP
outside the division.
Mr. Howes answered that any access was by a licensed
prescriber or dispenser regarding a patient or a patient
they anticipated seeing. The statute specified that
federal, state, and local law enforcement may receive
printouts from the database based on a court order or
search warrant demonstrating probable cause for the action.
Representative Edgmon asked if currently every provider had
to participate. Mr. Howes answered that there was currently
no requirement for providers to look at the database.
Representative Edgmon asked how many practitioners used the
database. Mr. Howes answered the percentage was low.
Approximately 700 to 800 out of the 6,400 prescribers used
the database. He detailed that whether a prescriber needed
to access the system depended on their type of practice.
5:57:23 PM
Representative Edgmon surmised that the characterization
that the database was centralized was not accurate. He
believed the bill sponsor wanted the database to fully
encapsulate the providers and dispensers.
Co-Chair Thompson surmised that 10 percent of the providers
were registered and utilizing the database.
Ms. Hovenden answered that currently a low percentage of
the users would be correct.
Ms. Chambers clarified that the bill would make the shift
from what could arguably be termed a pilot program into a
centralized repository of data to connect providers and
prescribers across the state and to shift into a robust
opioid control program. The connection to Medicaid was to
provide DHSS and Medicaid personnel the opportunity to save
Medicaid costs and better manage those elements through a
small sliver of a wider Medicaid reform bill. She believed
the intent was to move from a voluntary, not widely used
program, to a more official program that would provide more
reliable data to accomplish the variety of goals.
6:00:00 PM
Representative Gara remarked that he did not particularly
have a concern about the security of the database; however,
he surmised there was no signal to specify if a breach did
occur. He referred to testimony the division would not know
if there was a breach unless someone knew their information
had been breached and they complained to the division. He
believed that would not happen. He opined that the fact the
division would not know if a breach occurred would have
been a fairer response to Co-Chair Neuman's earlier
question. He reasoned it mattered how good the system's
security was.
Vice-Chair Saddler asked if having a mandatory database was
likely to be a condition of any existing or future federal
benefit or funding. He remarked there had been a number of
provisions from the Affordable Care Act with delayed
implementation. He could imagine the federal government may
want the data.
Ms. Chambers deferred the question to DHSS and was not
aware of anything of that nature coming down the pike.
6:02:20 PM
Ms. Shadduck spoke to the question asked by Vice-Chair
Saddler. She discussed that on March 10, 2016 the U.S.
Senate had passed the comprehensive Addiction and Recovery
Act (SB 524). She detailed that Alaska's two senators had
voted in support of the act. She furthered that Section 601
of the bill included language requiring states to use a
PDMP in order for states to access the federal grants to
combat opioid and other addiction problems; it would also
be required for prescribers to look up federal Schedule II,
III, and IV drugs before prescribing and dispensers would
be required to input the same data. Some of the
recommendations had been reinforced by the passage of U.S.
Senate Bill 524.
Co-Chair Thompson asked if the required the state to share
access to the information with the federal government. Ms.
Shadduck did not believe so, but she would follow up.
Ms. Shadduck relayed that based on the testimony, the bill
sponsor was very willing to work with the committee on
final tweaks to the sections under discussion. The sponsor
realized there were concerns and was open to some of them.
Representative Gara referred to the concept of sharing
state savings with emergency rooms. He spoke to concerns
about people going to an emergency room for care when they
did not need an emergency room. He addressed the expensive
nature of the care. He continued that part of SB 74 helped
solve the problem, which would result in fewer people going
to the emergency room for inappropriate care. He wondered
why the state would pay hospitals money for the reduced
number of patients, especially when the state had a $4.4
billion deficit.
VALERIE DAVIDSON, COMMISSIONER, DEPARTMENT OF HEALTH AND
SOCIAL SERVICES, replied that the program included in the
bill was modelled after a Washington State program. During
the last and current budget processes, DHSS had heard from
the Ketchikan hospital that it had applied for an
innovation grant from CMS. She believed the hospital had
spent $700,000 to decrease its ER overutilization, but it
had cost $1.5 million in lost revenue if those same
patients had come to the ER. The hospital had communicated
there was not much financial incentive for providers to
look at the ER overutilization when it ended up costing
them money. The program in Washington State had been a
public private partnership between several parties; SB 74
included the same concept making sure all parties worked as
hard as possible to be able to achieve the savings. She
reiterated that the Ketchikan hospital had reported it
spent $700,000 to lose $1.5 million, which was not much
incentive for facilities to change the way they did
business. She surmised if there was a way to change the way
healthcare was delivered in a more appropriate way and to
have the opportunity to share the savings, perhaps the
savings shared could be applied more appropriately in other
settings (e.g. developing better partnerships with primary
care providers, utilizing support services, and other).
6:08:58 PM
Representative Gara stated that the loss was based on
hospitals not receiving very large charges in the ER for
non-emergency care. He surmised the hospitals were not
getting the higher amount of money because they were not
able to charge non-ER patients with ER rates. He was not
convinced by the argument. He continued that hospitals
would benefit in the ER setting by having Medicaid reform
cover people who they had not previously been receiving
compensation for (people without children and the expanded
Medicaid population). He asked for verification the
hospitals were receiving much more money for ER care
through Medicaid expansion.
Commissioner Davidson answered in the affirmative. The goal
was to make sure people were using the ER appropriately -
for ER care. The challenge was that under the current
federal EMTALA [Emergency Medical Treatment and Labor Act]
emergency rooms did not have a choice when it came to
letting a person in the door; emergency rooms were required
to provide a certain level of care prior to sending
individuals on their way.
Representative Gara reasoned that individuals would either
receive coverage through private insurance or Medicaid
expansion. He spoke to the concept of no incentive for
hospitals to reduce ER care. He stated that a significant
part of the bill was about creating a managed care plan and
establishing people with a primary physician in order to
avoid using the ER [for inappropriate reasons]. He believed
that even without incentives to the hospital, the bill was
intended to steer people away from the ER. He did not buy
the lack of incentive as a justification to ask the state
to compensate emergency rooms for no longer treating people
who should not be in an ER.
Vice-Chair Saddler asked if Commissioner Davidson saw any
other situations in which the federal government would
require the state to have mandatory PDMP reporting as a
condition of a federal payment, grant, benefit, or
participation.
Commissioner Davidson answered that she was not aware of
any additional requirements.
6:12:09 PM
Representative Edgmon asked if there was an existing model
that could help the state reform Medicaid that did not
involve a public private sector relationship.
Commissioner Davidson asked if the question was specific to
ER overutilization or broader.
Representative Edgmon discussed whether the state went
through a managed care and/or accountable care
organizations. He surmised that it appeared necessary to
have the private sector involved in terms of being able to
make Medicaid more efficient and cutting down on ER super-
utilizers that cost the program more. He reasoned that the
ER was a business entity; therefore, if they were given
some incentive they would comply accordingly. Likewise, if
the incentive was removed, the need to comply dissipated.
Commissioner Davidson answered that the department
appreciated the bill's broad flexibility and the options
available for DHSS to work with providers and stakeholders
on ways to test certain theories. She pointed to the broad
demonstration authority described in the bill as an
example, such as a public private partnership for the ER
overutilization project. The department could opt to do
some of the things on its own, but she did not believe it
achieved the right result. She wanted to ensure providers
giving good and appropriate care to patients could continue
to do so. She did not have all of the answers, but she
believed the bill provided more tools to work with people
in Alaska to design a healthcare system that worked for
everyone. She continued that there were lessons the state
could learn from other states, but some may not necessarily
work in Alaska. The state could elect to use a model from
another state, but the challenge was selecting a model that
worked for Alaska, for as many people as possible, and that
met the state's unique challenges. She pointed issues such
as access to care (travel would always be a concern). She
continued that during certain times of the year in certain
regions, infants and children were impacted by respiratory
syncytial virus, which would result in increased ER
utilization and Medivacs. She noted her daughter had fallen
into the category when she was an infant. She spoke to
improving the delivery of healthcare, while recognizing
efficiencies were necessary to continue to provide
healthcare into the future. She believed everyone
recognized that Medicaid was not sustainable in its current
form. She stressed the need to reform Medicaid and believed
the state's best opportunity to implement reform was with
its partners.
6:16:56 PM
Representative Guttenberg asked about the ER-shared
reimbursement. He understood the issue in the short-term
and that hospitals would change their business models. He
asked if it would be appropriate to put a five-year
timeline on the shared reimbursement. He reasoned that
after five years the hospitals would have changed their
business model. He detailed that reform to the system
included efficiencies the hospitals recognized were needed
as well. He spoke to providing incentives for several years
for hospitals to remodel, retooling, changing processes,
and other. He wondered if a timeline was appropriate to
allow hospitals time to transition.
Ms. Shadduck replied that one of the parts of Section 31
required the Alaska State Hospital and Nursing Home
Association (ASHNHA) to report back on the successes and
challenges. She did not want to put an arbitrary end to the
shared savings, but she surmised that ASHNHA could also be
asked to report on the processes and shared savings.
Section 28 on Medicaid reform asked the department to
report on savings based on reforms implemented by the bill.
She detailed there were a couple of reporting mechanisms
throughout the bill. She did not want to speak on behalf of
emergency rooms and their doctors because she did not know
their business practices inside and out.
Co-Chair Thompson relayed that amendments to the bill
should be submitted to his office by April 1, 2016 at 5:00
p.m.
CSSB 74(FIN) am was HEARD and HELD in committee for further
consideration.
Co-Chair Thompson discussed the schedule for the following
day.