Legislature(2015 - 2016)BELTZ 105 (TSBldg)
03/01/2016 01:30 PM Senate LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| SB98 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 98 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
SB 98-PRESCRIPTION WITHOUT PHYS. EXAM.
1:32:51 PM
CHAIR COSTELLO announced the consideration of SB 98. She noted
that this is the second hearing, public testimony is open, and a
committee substitute (CS) is anticipated.
1:33:48 PM
At ease from 1:33 p.m. to 1:38 p.m.
1:39:00 PM
DR. MELINDA RATHKOMPF MD, President, Alaska State Medical
Association (ASMA), thanked the sponsor and her staff for
working with ASMA to address its concerns with SB 98. She
assured the committee that the primary concern is the care of
patients and that is driving her comments today. She said ASMA
supports the use of telemedicine, but wants to ensure there is
appropriate oversight and regulation as it expands in Alaska.
ASMA supports the model where a provider gives care over a video
feed while another health care provider is with the patient to
help facilitate the visit. Typically, there is a preexisting
doctor-patient relationship or there's a relationship between
the doctor giving care and the health care provider on the other
end. There is also the ability for follow up care either in-
person or a future telemedicine visit with the same provider.
She said this model has great potential to expand access to care
and reduce costs. The Alaska State Medical Association supports
this model.
However, ASMA is concerned with telehealth models of care when
there is no prior established doctor-patient relationship, the
patient doesn't get to select the provider, and they don't have
easy follow-up with the same provider. ASMA is concerned about
providers outside Alaska that may not understand the challenges
some patients in Alaska face. She described a personal example
early in her career in Alaska. A physician from Stanford
contacted her about transferring care of an Alaska Native infant
who had a rare immune deficiency and required ventilator support
to breath. Her family lived in a remote village outside of
Barrow and the Stanford physician hadn't checked to see if the
family had electricity or running water in the home. She also
didn't understand why the family wouldn't have mentioned these
impediments to care.
She questioned how it would be possible to ensure the best care
for patients if this new model is adopted, and stressed the need
for the State Medical Board to have the authority to regulate
this new model. She said ASMA appreciates the new draft that
gives the medical board oversight at the individual physician
level, but what's needed is more oversight at the company level.
If a telemedicine company as a whole doesn't meet the standards
of care that others deliver, the state needs the ability to stop
that delivery of care. She concluded that this isn't about
stopping the use of telemedicine, but about ensuring it's done
well and protects the health of Alaskans.
1:44:29 PM
DR. HENRY DEPHILLIPS M.D., Chief Medical Officer for Teladoc,
said he wanted to start his testimony by responding to the last
question about guaranteeing to protect the health of Alaskans.
He explained that clinicians always look at evidence-based data
to make treatment decisions. For example, decades ago the
standard of care for a heart attack was bed rest for two weeks.
Today the standard of care for a heart attack is to get the
patient up and out of bed within the first 24 hours. Outcome
studies comparing the two treatment modalities demonstrate that
the latter results in much better patient outcomes.
DR. DEPHILLIPS recommended the committee look at the data. He
first pointed out that for every 1 million visits to private
practice physicians, approximately 17 liability claims go to
completion. The average payout for each claim is $248,000. By
comparison, telemedicine nationwide has done 2 million e-visits
and not one medical liability claim has been filed.
DR. DEPHILLIPS talked about the cost savings associated with
telemedicine. A Harvard Medical School researcher independently
did a pre and post look at the telemedicine benefit a Fortune
500 employer decided to implement among its employee base. After
18 months the analysis of 150,000 employees and their families
showed that every consult done through the telemedicine program
resulted in an average medical cost savings of $673.
Extrapolating that to the 575,000 visits that Teladoc did in
calendar year 2015, indicates that Teladoc has been able to save
all clients combined, $387 million in medical cost savings. A
majority of those are savings in the emergency room for the
treatment on non-emergency conditions.
He shared the data point that Teladoc currently operates in 49
states, including Alaska, and covers approximately 15 million
Americans. Clients in Alaska include GCI, Alaska Airlines, Home
Depot, Lowes, Premera, Aetna, and Costco. He noted that Aetna is
contemplating extending the telemedicine benefit to all state
employees. These companies buy the benefit so Teladoc has been
well vetted.
DR. DEPHILLIPS explained that Teladoc's quality oversight
program looks at prescribing patterns across its prescriber
network. An interesting outlier popped up this month in that
program and he wonders how long it would take the private
practice world to pick up a similar outlier.
DR. DEPHILLIPS concluded his remarks saying SB 98 is focused on
allowing physicians that are licensed by the State Medical Board
to practice the medicine they were trained to practice and
decide for themselves what modality to use to diagnose and treat
patients. With all the safeguards currently in place, patient
safety appears to be doing extremely well under the current
model.
1:51:54 PM
SENATOR GIESSEL asked if there is a limit to the number of times
that a person can call a Teladoc provider before they're
referred to a primary care doctor.
DR. DEPHILLIPS said any person who uses Teladoc services 3 times
in 90 days or 8 times in a 12 month period is immediately
flagged and Teladoc reaches out and tells the patient they need
to get a primary care physician. The patient is excluded from
the program until they demonstrate they have established that
relationship.
SENATOR GIESSEL asked what instructions are given to a patient
in the event they don't get better.
DR. DEPHILLIPS explained that there are discharge instructions
after every e-visit, including what to do if the patient doesn't
improve. For 72 hours after the e-visit there is a secure email
communication between the patient and the clinical staff,
including the physician. Second, Teladoc can identify the
patients that don't have a primary care physician and reach out
to the health plan partner to help the patient find a physician.
Third, their physicians tell patients if the telemedicine
platform is not appropriate for the illness or problem. They are
directed them to their primary care physician or to call 911.
This happens 4 percent of the time.
1:57:14 PM
DR. DAVID POWERS M.D., family physician in practice in
Dillingham, mentioned his previous testimony and emphasized that
the current telemedicine model is open to all comers. He
highlighted the potential misperception about what it's like in
rural Alaska and opined that SB 98 won't help a lot of these
people get medicines if they're prescribed. The medicine would
have to be mailed from a pharmacy in Anchorage or the person
could go to the village health aide. The latter is how medicine
is dispensed in the existing telemedicine model. He opined that
SB 98 will mostly impact Alaskans that live in larger cities
where pharmacies are available.
DR. POWERS gave the bill high marks for convenience and cost
savings, but said it will never meet the standard of an in-
person visit. He assured the committee that the State Medical
Board has no financial irons in this fire. The board simply
wants the best health care for Alaskans.
CHAIR COSTELLO noted the individuals available to answer
questions.
2:00:35 PM
BILL ALTLAND, member, Board of Pharmacy, said he's a registered
pharmacist who has worked in rural Alaska. He mentioned a new
regulation and attorney general opinion related to non-public
health service providers in rural Alaska not needing to be
licensed if they work for the Native health system. He believes
this will become the rule for pharmacy, dental and nursing and
wonders how professional boards in the state will address that.
CHAIR COSTELLO asked Ms. Hovenden to respond to Mr. Altland's
questions.
2:04:36 PM
JANEY HOVENDEN, Director, Division of Corporations, Business and
Professional Licensing, Department of Commerce, Community and
Economic Development (DCCED), said Mr. Altland is referring to
the federal law that exempts medical professionals working for
tribal corporations or the federal government from the
requirement to be licensed in Alaska.
SENATOR GIESSEL advised that Indian Health Service employees are
federal and they must be licensed in a state, but not
necessarily the state where they're practicing. She recalled
that has been the case for about 20 years, but it's new that
employees of Native corporations would be exempt. She emphasized
the importance of clarifying the issue.
MS. HOVENDEN agreed to provide follow-up information.
2:06:31 PM
CHAIR COSTELLO closed public testimony on SB 98. She advised
that the committee received a draft committee substitute and
would recess until 2:30 to give staff time to review it.
2:35:59 PM
CHAIR COSTELLO reconvened the meeting and asked for a motion to
adopt the committee substitute (CS).
2:36:16 PM
SENATOR GIESSEL moved to adopt the work draft CS for SB 98,
labeled 29-LS0838\E, as the working document.
CHAIR COSTELLO objected for discussion purposes and invited Mr.
Eiler to explain the changes.
2:36:40 PM
WESTON EILER, Staff, Senate Labor and Commerce Committee and
Senator Mia Costello, explained the changes that appear in
version E of SB 98.
Page 2, lines 16-19, primarily adds the words "standards of
care" and other drafting conventions. Section 3 amends the
duties of the board to include text provided by some of the
stakeholders. He read the language on page 3, paragraph (6),
about adopting regulations establishing standards of care under
AS 08.64.364. Page 3, line 9, starts the renumbering of the
sections. Page 4, lines 5-10, subsection (d), clarifies that a
physician may not prescribe an abortion-inducing drug or
prescribe a controlled substance without a prior physician-
patient relationship.
MR. EILER advised that these changes were made in consultation
with stakeholders to provide additional safeguards for
telemedicine. He noted that Legislative Legal Services opined
that changing the preambulatory language in each section from
prohibitions to the positive could be inferred by the courts as
the legislature specifically limiting authorizations to what is
listed.
He noted a memorandum from the Department of Commerce, Community
and Economic Development (DCCED) that responds to previous
questions about the financial impact of the boards affected by
SB 98. The packets also contain an April 17, 2012 opinion from
the Department of Law that gives context to the question raised
about licensing requirements for pharmacists working for Alaska
Native tribal health programs.
2:40:37 PM
CHAIR COSTELLO removed her objection.
2:40:46 PM
SENATOR GIESSEL moved a conceptual amendment to rewrite the
language on page 4, lines 7-10, paragraph (2). It would read as
follows:
CONCEPTUAL AMENDMENT 1
(2) prescribe, dispense, or administer a
prescription drug in response to an Internet
questionnaire or electronic mail message with whom the
physician does not have a prior physician-patient
relationship.
CHAIR COSTELLO found no objection and Conceptual Amendment 1 was
adopted. She asked if there was further objection to the amended
committee substitute.
2:42:26 PM
SENATOR ELLIS asked Mr. Eiler to reference the five concerns
expressed by the Alaska State Medical Association, and the
extent to which the CS addresses those concerns. "That would
determine if I maintain further objection to the adoption of the
committee substitute," he said.
2:43:03 PM
MR. EILER said the committee worked closely with ASMA and the
sponsor to implement provisions of the letter dated 2/25/2016,
most of which relate to providing safeguards and sideboards. He
listed the concerns on page 1: 1) the prescription not be a
controlled substance, 2) the physician be located in Alaska, 3)
the physician or another physician in group practice is
available to provide follow-up care, 4) the patient consent to
sending a copy of the records to the patient's primary care
provider. He offered his belief that the CS addresses those
concerns.
SENATOR ELLIS again asked if all the concerns articulated by the
Alaska State Medical Association are fully addressed in the
committee substitute.
MR. EILER replied: "I think we have achieved the provision they
would like to see amended in advancing or moving forward the
legislation."
2:45:08 PM
SENATOR GIESSEL directed attention to Section 3 that addresses
the duties of the board. She said she suspects the language
regarding standards of care comes from the model policy of the
Federation of State Medical Boards organization. She opined that
it would provide the board the latitude to be specific about
telehealth services.
CHAIR COSTELLO said she'd like someone from the Alaska State
Medical Association to answer Senator Ellis's question.
2:46:34 PM
At ease
2:48:03 PM
CHAIR COSTELLO reconvened the meeting and asked Senator Ellis to
restate his question for Dr. Rathkompf.
SENATOR ELLIS asked the extent to which the proposed committee
substitute addresses the five concerns outlined in the Alaska
State Medical Association letter.
2:49:43 PM
DR. MELINDA RATHKOMPF MD, President, Alaska State Medical
Association, said ASMA is appreciative that the CS addresses
many of the concerns, but the issue that is not addressed is the
suggestion to create a registry for businesses that are
conducting telemedicine in order to provide oversight at a
business level. ASMA feels it's important to have some
capability to regulate or provide business oversight, since it
is a different model of telemedicine that is strictly company-
run.
CHAIR COSTELLO asked if the provisions in the bill allowing the
board to adopt regulations provides the authority for business
oversight. If not, would she like that to be added.
DR. RATHKOMPF answered yes, that needs to be added. There is
oversight at the individual physician level, but there is no
assurance that telemedicine businesses coming into the state
will adopt that same standard. She questioned what the oversight
would be if a business didn't adopt the same standard.
CHAIR COSTELLO asked Senator Ellis if he maintained his
objection.
2:51:43 PM
SENATOR ELLIS answered yes. He added that he appreciates the
work that's been done to address four of the five concerns but
it seems that the Labor and Commerce Committee is the place to
address the issue of business oversight.
CHAIR COSTELLO said it's the intent of the chair to deliver the
best work product possible to the next committee.
She asked Ms. Hovenden if she had language to suggest for a new
paragraph (7) in Section 3 that allows the board to adopt
regulations to provide appropriate business oversight.
SENATOR GIESSEL said she appreciates what ASMA is proposing, but
she believes that authority belongs to the Division of
Corporations, Business and Professional Licensing, not the State
Medical Board.
2:53:32 PM
JANEY HOVENDEN, Director, Division of Corporations, Business and
Professional Licensing, Department of Commerce, Community and
Economic Development, said she believes this can be fleshed out
in regulations. Her belief is that it would be under the
jurisdiction of the State Medical Board but she would have to
research that further. She deferred further comment to Sara
Chambers.
2:54:22 PM
SARAH CHAMBERS, Operations Manager, Division of Corporations,
Business and Professional Licensing, Department of Commerce,
Community and Economic Development (DCCED), said her
understanding is the statutory authority to develop a mandatory
registry would need to be housed in the State Medical Board
under AS 08.64.101, or an appropriate subsection. The division
would need to be granted the authority to support the board's
development of such a registry.
SENATOR GIESSEL recapped the answer and said that seems outside
the expertise of the State Medical Board.
MS. CHAMBERS replied her understanding is that any sort of
license or registry that would fall under the purview of the
State Medical Board would need to reside under that board. The
division could regulate the registry but then it would fall
outside the State Medical Board's jurisdiction. They would be
unable to pass judgement on whether a telemedicine company had
the protocols to ensure their employees are acting according to
the standards of the Federation of State Medical Boards and
American Medical Association for telemedicine that are already
in place.
2:57:15 PM
CHAIR COSTELLO stated that the amended committee substitute for
SB 98 has not been adopted, and she would hold the bill awaiting
a new committee substitute.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Director Hovenden's Letter to Sen Costello SB 98 3-1-16.pdf |
SL&C 3/1/2016 1:30:00 PM |
SB 98 |
| CS SB 98 (L&C) - Ver. E.pdf |
SL&C 3/1/2016 1:30:00 PM |
SB 98 |
| AK-PA Letter concerning SB 98 - 02-25-2016.pdf |
SL&C 3/1/2016 1:30:00 PM |
SB 98 |