Legislature(2023 - 2024)BUTROVICH 205
03/21/2023 03:30 PM Senate HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| SB91 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | SB 91 | TELECONFERENCED | |
| + | TELECONFERENCED |
SB 91-TELEHEALTH: MULTIDISCIPLINARY CARE TEAM
3:31:18 PM
CHAIR WILSON announced the consideration of SENATE BILL NO. 91
"An Act relating to telehealth; relating to multidisciplinary
care teams; and relating to the practice of medicine."
3:31:53 PM
SENATOR MATT CLAMAN, District H, Alaska State Legislator,
Juneau, Alaska, sponsor of SB 91, introduced the legislation by
paraphrasing the sponsor statement.
Senate Bill 91 expands telehealth providers and
services available to Alaskans.
Last year, the legislature passed House Bill 265,
which created a framework in statute for telehealth
and ensured Alaskans' access to critical health care.
In the summer of 2022, Senator Claman was contacted by
a constituent who was recently diagnosed with
Amyotrophic Lateral Sclerosis (ALS). Upon receiving
her diagnosis, Sheila Swanson flew to Seattle to
receive specialty treatment. Sheila was told that she
could continue to receive care from the physician via
telehealth, but would need to fly to Seattle to
receive in-person care from the other seven members of
her multidisciplinary ALS care team, including a
respiratory therapist, speech language pathologist,
and physical therapist.
Senate Bill 91 would allow out-of-state
multidisciplinary care team members to provide
telehealth services. The bill applies to two different
situations, the first situation being on-going
treatment or follow-up care from an out-of-state
physician or member of their disciplinary care team
related to health care services previously provided by
the physician to the patient. Senate Bill 91 requires
that the physician and patient have an established
physician-patient relationship and the physician has
had a previous in-person visit with the patient.
The second situation outlined in the bill is when a
patient receives care for a suspected or diagnosed
life-threatening condition. To receive treatment from
a non-physician member of the multidisciplinary care
team, Senate Bill 91 requires a documented referral to
the member of the multidisciplinary care team by
either a physician licensed in Alaska or through a
physician licensed out-of-state with whom the patient
has a previously-established relationship.
Senate Bill 91 amends the statute passed by House Bill
265 by adding "multidisciplinary care teams" as an
option for telehealth. Alaskans deserve to receive the
appropriate care in their local support network when
possible, and Senate Bill 91 will expand these
options.
3:35:08 PM
EMMA POTTER, Staff, Senator Matt Claman, Alaska State
Legislature, Juneau, Alaska, presented the sectional analysis
for SB 91.
Section 1
AS 08.02.130. Telehealth
Amends subsection (b) to expand who may provide health
care services through telehealth. An out of state
member of the physician's multidisciplinary care team
may provide telehealth services under the following
conditions: (1) for on-going treatment or follow-up
care by the member of the physician's
multidisciplinary care team if the physician and
patient have an established physician-patient
relationship and the physician has previously
conducted an in-person visit; or (2) for a visit
regarding a suspected or diagnosed life-threatening
condition for which the patient has been referred to
the physician licensed in another state or a member of
the physician's multidisciplinary care team and the
visit involves communication with the patient
regarding diagnostic or treatment plan options or
analysis of test results for the life-threatening
condition.
Section 2
AS 08.02.130. Telehealth
Amends the definition of "health care provider" in
this section to include a member of a
multidisciplinary care team that includes a physician
licensed in another state who meets the requirements
of (b)(1) of this section.
Section 3
AS 08.02. Miscellaneous Provisions
Adds new sections AS 08.02.135: Grounds for imposition
of disciplinary sanctions of out-of-state
multidisciplinary care team members and AS 08.02.140:
Disciplinary sanctions for out-of-state
multidisciplinary care team member.
3:36:43 PM
SENATOR TOBIN asked for the definition of "multidisciplinary
care team" and whether it was established in statute.
3:37:06 PM
SENATOR CLAMAN said the term is not specifically defined, but
the practical meaning is anybody in the care team that the
primary physician relies on to provide care and treatment for
the patient.
SENATOR TOBIN opined that it would be helpful if it was more
prescriptive.
3:37:48 PM
SENATOR CLAMAN responded that his concern is that side rails to
direct who could be part of a treatment team runs the risk of
excluding somebody that a primary care physician might deem very
beneficial.
CHAIR WILSON asked whether the language in Section 2 would allow
people who are located both in-state and out-of-state to be part
of the multiple disciplinary care team and, if so, what that
might mean for licensing.
3:40:09 PM
SENATOR CLAMAN replied those are good thoughts but the purpose
is to make sure that people who are facing conditions like his
constituent are able to have the care team that works for them.
3:40:50 PM
SENATOR GIESSEL noted that the fiscal note includes the cost for
a full-time investigator 3 which seems to mean that licenses
will be examined. She asked if the bill would waive licensure
for members of the multidisciplinary care team if the primary
physician held licenses in Alaska and Washington state, for
example.
SENATOR CLAMAN mentioned the telehealth law that authorizes
physicians not licensed in Alaska to provide care via telehealth
in certain circumstances. His constituent receives highly
specialized care from her primary physician in Seattle who is
not licensed in Alaska. That physician has put together a team
of people in other practices who specialize in treating ALS. SB
91 would allow the physician licensed in Washington and the
other seven Washington-licensed specialists to provide care to
his constituent via telehealth. Those individuals would be
subject to investigation by the investigator 3 which the fiscal
note describes.
3:43:32 PM
SENATOR GIESSEL expressed skepticism and concern about waiving
licensure for an unknown roster of health care providers and
that somebody in Alaska would be paying for the licensing
investigator.
SENATOR CLAMAN relayed that his constituent's private health
insurance carrier said it would pay for the physician, but not
the other seven providers on her care team unless she flies to
Seattle. She's been making the trip, but at some point her
condition may prevent travel. He clarified that this had nothing
to do with the state Medicaid program. He acknowledged his
answer did not address Senator Giessel's concern about the cost
to add an investigator 3 position.
CHAIR WILSON noted that the bill describes "life-threatening
condition" a little differently than the language in House Bill
265 which is the existing telehealth law.
3:46:09 PM
MS. POTTER clarified that SB 91 does not change the definition
of "life threatening condition" that was used in House Bill 265.
The reference in paragraph (2) of Section 1 describes the
situation by which a patient may receive telehealth care. It
does not reference the life threatening condition that was
defined in House Bill 265.
3:46:43 PM
CHAIR WILSON referenced Section 3 and questioned how sanctions
imposed on out-of-state providers could be enforced.
3:47:39 PM
MS. POTTER replied that the telehealth law authorizes the State
Medical Board to impose disciplinary sanctions on out-of-state
physicians. SB 91 addresses a broader range of providers that
would be overseen by more than a single board, so the bill
identifies the department as the entity that provides oversight
and is authorized to impose sanctions.
3:48:32 PM
CHAIR WILSON turned to invited testimony on SB 91.
3:49:01 PM
BROOK LAVENDER, Care Services Coordinator, North Puget Sound &
Alaska, ALS Association, Girdwood, Alaska, related her
experience working with Alaskans who suffer from ALS and are
forced to make daily decisions that affect their overall
wellbeing and quality of life. Many Alaskans with ALS have had
to move to another state to receive care from a
multidisciplinary care team. The complex treatments they require
often are not available where they live or there is a
significant wait to receive the care. SB 91 seeks to improve
access to care by expanding the use of telehealth and
telemedicine. This would allow Alaskans to receive care from
specialists in other states without having to travel. She noted
that the Veterans Administration currently authorizes care from
a multidisciplinary team for veterans living in Alaska. She
emphasized that increasing access to care for people with
terminal illnesses and rare diseases is a matter of equity; all
Alaskans should have access to the type of care they need to
manage their disease and improve their quality of life. The data
shows that investing in telehealth and telemedicine improves
health outcomes and helps reduce health care costs. Passing SB
91 would send a message that Alaska is committed to supporting
its citizens by making it easier to access the care they need.
She urged the committee to pass SB 91.
3:51:58 PM
BEVERLY WOOLEY, representing self, Big Lake, Alaska, stated that
before retirement she worked in public health for more than 30
years. As such, she was testifying to voice support for SB 91 to
expand telehealth for providers and Alaskans. She related that
her goal was always to ensure all Alaskans have access to health
care services that they need in the most cost-effective way
possible. SB 91 facilitates that goal. She described her
personal need to access care from her out-of-state
multidisciplinary care team due to complications from breast
cancer treatment. There are only a few of these specialists in
the US. She flew to Ohio to establish care with a physician who
pioneered the surgical procedure she needs. The surgery is
scheduled this fall but she also needs additional pre- as well
as post-surgery care, some of which will be provided by members
of her multidisciplinary care team. If SB 91 passes, she could
receive care from these providers via telehealth. If it doesn't
pass, she will have to spend the time and considerable money to
travel to Ohio for each service. If she were to convince the
doctor to provide the services himself, it would take away the
time he has to provide the services that he alone is able to
provide. She opined that in light of the physician shortages, it
was sensible to allow members of the physician's
multidisciplinary team to provide the services via telehealth
that they routinely provide during in-person appointments. She
urged the committee to support SB 91 which will help ensure that
Alaskans receive the medical care they need for serious and
life-threatening conditions without incurring needless travel
expenses and time away from home and work.
3:57:16 PM
EMILY NENON, Alaska Government Relations Director, American
Cancer Society Cancer Action Network, Anchorage, Alaska, stated
that she worked on the telehealth legislation that passed last
year, and she was able to report that people with life-
threatening conditions were using the narrow provision to
receive the care they need. An issue that has come up since that
bill passed is that it's often somebody other than the physician
who is providing much of the care. She cited examples to
illustrate the need for the narrow expansion of the provision.
She also expressed appreciation for the provisions in SB 91 that
provide additional patient protections to ensure that the care
that's provided is up to professional standards. She thanked the
committee for considering the bill.
3:59:25 PM
CHAIR WILSON opened public testimony on SB 91.
3:59:44 PM
ERICK CORDERO, Vice President of Operations, Alaska Policy Forum
(APF), Palmer, Alaska, stated that APF urges this committee to
adopt policies that reduce health care costs and increase access
to care for all Alaskans. He said people learned a lot about
telehealth and remote health care services during the COVID-19
pandemic. This led policymakers to pass legislation in 2022 to
temporarily allow some use of telehealth, but more needs to be
done. Alaskans living in rural areas who are homebound and
immunocompromised should have access to health care providers of
their choosing and on a timely basis. Currently most Alaskans
are only able to access specialists, second opinions, or team-
based care via telehealth by traveling out of the state. This is
costly, time-consuming, and not beneficial to the person's
health. Expanding the telehealth law to include a
multidisciplinary care team will give Alaskans access to more
care professionals at a lower cost. He thanked the committee for
considering SB 91.
4:01:30 PM
CHAIR WILSON closed public testimony on SB 91.
CHAIR WILSON asked Sylvan Robb if she agreed that the bill would
allow anyone to say they were part of a multidisciplinary care
team as long as they had an established relationship. Once
that's established, the professional licensing division would
allow that individual to offer their services within Alaska via
telehealth.
4:02:22 PM
SYLVAN ROBB, Director, Division of Corporations Business and
Professional Licensing, Department of Commerce Community and
Economic Development, Juneau, Alaska, responded that she
interpreted the language in the bill to say that. She added that
Alaska statutes require anybody who practices via telehealth
within the state to register with the telehealth registry so the
division has a record of those individuals.
4:02:55 PM
CHAIR WILSON asked how many out-of-state physicians had signed
up with the telehealth registry.
MS. ROBB replied that she did not know how many people were on
that registry. She also clarified that the registry existed
prior to the passage of the telehealth bill.
CHAIR WILSON asked what impact SB 91 would have on the
department in terms of additional costs since the department
would be tasked with investigations and enforcement as opposed
to the separate boards and commissions.
4:03:59 PM
MS. ROBB confirmed that in the FY24 budget, investigations shift
from being paid by the licensees of the particular profession to
being paid with general funds. The DCCED fiscal note represents
the department's best estimate of what the cost might be for
investigations of out-of-state providers.
4:04:32 PM
SENATOR GIESSEL asked if there was a fee to sign up for the
telehealth registry.
MS. ROBB replied it's a $50 fee.
4:04:46 PM
SENATOR GIESSEL asked what the application form for the registry
looks like.
MS. ROBB replied that it's not very involved but the applicant
is required to have an Alaska business license which can be
obtained online.
4:05:37 PM
SENATOR GIESSEL asked what kind of questions the application
asks about criminal background and negligent practice.
MS. ROBB clarified that the telemedicine business registry
application is a business registry, not individuals. If a
practice covers a number of different providers, they are not to
apply individually. A sole provider must apply under their
business. The requirements are to have an Alaska business
license and to identify the primary health care code that the
business will provide. She said she'd follow up if she learns
there is other information the applicant has to provide for the
registration.
4:07:00 PM
SENATOR GIESSEL stated that as a former member of the Board of
Nursing she was dumb founded. She is a fan of telehealth but
based on what she's heard, there is no assurance that the
undefined clinicians would be qualified. She said it's
understandable that the VA provides this for veterans living in
Alaska because it has a national licensure. Alaska has a state
licensure so a licensee's credentials can be checked. She
commented that Ms. Robb's answers heightened her concern.
CHAIR WILSON asked whether the department or a board or
commission could verify the out-of-state credentials for
somebody who applies to provide telehealth services in Alaska.
4:08:59 PM
MS. ROBB paraphrased the statutory requirements for the
telehealth registry:
Sec. 44.33.381. Telemedicine business registry.
(a) The department shall adopt regulations for
establishing and maintaining a registry of businesses
performing telemedicine services in the state.
(b) The department shall maintain the registry of
businesses performing telemedicine services in the
state. The registry must include the name, address,
and contact information of businesses performing
telemedicine services in the state.
She said she didn't believe the department would have the
authority to request additional information about an applicant's
credentials without additional authorization.
4:09:36 PM
CHAIR WILSON asked about the possibility of the department
developing another registry of out-of-state telehealth providers
and members of their multidisciplinary care teams that would
address Senator Giessel's concerns about safety and the licensee
paying the cost of investigations and background checks.
4:10:17 PM
MS. ROBB confirmed that the department could develop such a
registry if it had the statutory authority and funding for the
personnel. She added that registering with the existing registry
is required for both in-state and out-of-state providers of
telehealth services in Alaska.
CHAIR WILSON stated that the concern is about due diligence to
ensure the safety of Alaskans who are receiving telehealth care
services from out-of-state providers.
CHAIR WILSON asked the sponsor if he had any closing comments.
SENATOR CLAMAN offered to answer questions.
4:11:55 PM
SENATOR DUNBAR mentioned Senator Giessel's safety concerns and
asked how much he envisions tort or medical malpractice law to
be a factor if the bill were to pass and somebody on the
multidisciplinary care team provided inadequate care and a
patient in Alaska was hurt. He commented, "It seems like they
would have pretty good cause to, frankly, sue the shirt off of
that doctor."
SENATOR CLAMAN said he didn't believe the bill would change the
analysis of whether a physician is liable for malpractice.
Should the bill pass, the more likely question would be whether
somebody like a physical therapist in Seattle who is providing
telehealth services would be subject to a medical malpractice
action in Alaska. He opined that they probably would be subject
to jurisdiction in Alaska because they registered with the
telehealth provider network and they gained a benefit from
providing that service. He opined that a secondary question was
in which jurisdiction to file the lawsuit.
4:14:42 PM
SENATOR DUNBAR asked if it was fair to say that a physician
would be at the center of the multidisciplinary care team.
4:14:57 PM
SENATOR CLAMAN agreed.
4:15:02 PM
SENATOR DUNBAR asked if it was fair to say that the original
telehealth bill relied on the fact that the specialty physicians
would be of high quality compared to similar specialists in any
other state.
SENATOR CLAMAN suggested that Chair Wilson was better able to
answer the question.
CHAIR WILSON responded that he carried the companion bill and
that was the intent.
SENATOR DUNBAR opined that it would be the physician and the
state that licensed that physician who would be held
responsible, so SB 91 seems to expand on what the legislature
deemed was okay last year. He summarized his colleague's concern
that this bill opens the net so wide that it risks including
care providers who might not provide care that is safe for
Alaskans.
4:16:28 PM
SENATOR CLAMAN said he wasn't sure there would ever be a
complete answer to the question but he believes that both the
physician at the core of the multidisciplinary care team and the
physical therapist in the example would be subject to civil
malpractice. The policy question is whether to allow somebody
with cancer, for example, to be served by members of an out-of-
state multidisciplinary care team who have expertise in the
area. This recognizes there is some regulatory authority over
the person who joined the telehealth network to provide
specialty care that isn't available in Alaska.
4:18:21 PM
SENATOR GIESSEL said she understands that telehealth solves the
problem of limited access to specialty care providers in Alaska,
but the state licenses health care professionals for the sole
purpose of protecting the public. Noting the discussion about
civil liability, she said her interest is to prevent malpractice
and fraud. She mentioned diploma mills and the highly skilled
specialty physicians that she knows who willfully committed
malpractice. She opined that the public relies on the state to
examine credentials and ensure that the licensed professionals
who practice in Alaska provide safe care. The system does not
rely on a single investigator. She said she supports the intent
of SB 91, but pieces of it need to be fixed to ensure public
safety.
4:20:05 PM
SENATOR CLAMAN said he and Senator Giessel probably agree that
the legislature's role is not to monitor malpractice litigation.
He believes that the bill strikes the right balance between
providing reasonable access to care for critically ill Alaskans
who need specialty care that an out-of-state multidisciplinary
care team can provide via telehealth and providing as much
supervision as possible for the cost. He described SB 91 as a
rational approach, but that didn't mean he wasn't open to
discussion about trying to strike a balance that's more
satisfactory to the members of the committee.
4:22:13 PM
SENATOR GIESSEL commented that during the COVID-19 pandemic
there was a definite increase in the instances of health care
providers misrepresenting their credentials.
4:22:47 PM
SENATOR TOBIN asked whether the Prescription Drug Monitoring
Program (PDMP) in Alaska communicates with the PDMP in other
states so medical providers have all the information they may
need about their patients.
MS. ROBB answered that the Alaska PDMP communicates with the
PDMPs in other states that use the same vendor and the same
software, but she didn't know what that number was. She offered
to follow up with the information.
SENATOR TOBIN said she'd appreciate the information because the
PDMP is another mechanism to ensure the safety of Alaskans.
CHAIR WILSON asked which database would have the information
about a prescription that is written by an out-of-state
telehealth provider for a patient in Alaska.
4:25:09 PM
MS. ROBB explained that physicians who are licensed in Alaska
are required to register with the Alaska PDMP.
CHAIR WILSON observed that under the telehealth bill and SB 91,
if it passes, multiple care providers who are not licensed in
Alaska but may have prescribing authority would not have to
register with the Alaska PDMP.
4:25:44 PM
MS. ROBB replied that those physicians covered by the telehealth
bill that are allowed to treat patients without being licensed
in Alaska are not required to register with the Alaska PDMP.
MS. ROBB followed up on an earlier question, reporting that at
the end of FY2022, 1,525 entities were registered with the
telemedicine registry.
CHAIR WILSON asked whether the businesses have to renew the
registration periodically.
MS. ROBB replied that the registration is perpetual.
4:26:53 PM
SENATOR CLAMAN asked how many of the 1,525 registrants were from
out-of-state versus in-state.
MS. ROBB said she didn't know but she would follow up with the
information.
4:27:20 PM
CHAIR WILSON held SB 91 in committee.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 91 v A.PDF |
SHSS 3/21/2023 3:30:00 PM |
SB 91 |
| SB 91 Sponsor Statement version A 3.15.23.pdf |
SHSS 3/21/2023 3:30:00 PM |
SB 91 |
| SB 91 Sectional Analysis version A 3.15.23.pdf |
SHSS 3/21/2023 3:30:00 PM |
SB 91 |
| SB 91 FN DCCED.pdf |
SHSS 3/21/2023 3:30:00 PM |
SB 91 |
| SB 91 Research ALS Association Multidisciplinary Care Team.pdf |
SHSS 3/21/2023 3:30:00 PM |
SB 91 |