Legislature(1993 - 1994)
03/17/1994 03:00 PM HES
* first hearing in first committee of referral
= bill was previously heard/scheduled
= bill was previously heard/scheduled
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE March 17, 1994 3:00 p.m. MEMBERS PRESENT Rep. Cynthia Toohey, Co-Chair Rep. Con Bunde, Co-Chair Rep. Gary Davis Rep. Al Vezey Rep. Pete Kott (arrived 4:25 p.m.) Rep. Harley Olberg Rep. Bettye Davis Rep. Tom Brice MEMBERS ABSENT Rep. Irene Nicholia (excused) COMMITTEE CALENDAR *HB 341: "An Act relating to physician assistants; and providing for an effective date." PASSED OUT OF COMMITTEE *HB 490: "An Act allowing a local bidder preference in certain contracts for school construction." PASSED OUT OF COMMITTEE *HB 488: "An Act relating to the scholarship loan program; and providing for an effective date." NOT HEARD (* First public hearing.) WITNESS REGISTER REP. JOE SITTON Alaska State Legislature State Capitol Juneau, Alaska 99801-1182 465-2327 Position Statement: Prime Sponsor of HB 341 JOHN RILEY, President Alaska Academy of Physician Assistants 1217 E. 10th Avenue Anchorage, Alaska 99501 Phone: (907) 257-4600 Position Statement: Testified in support of HB 341 (testified in Juneau) KIMBERLY BUSCH, Director Division of Medical Assistance Department of Health and Social Services P.O. Box 110660 Juneau, Alaska 99811 Phone: (907) 465-3355 Position Statement: Answered questions on HB 341 DAVE W. WILLIAMS Medical Assistance Administrator Division of Medical Assistance Department of Health and Social Services P.O. Box 110660 Juneau, Alaska 99811 Phone: (907) 465-3355 Position Statement: Answered questions on HB 341 JACK HEESCH, Lobbyist Alaska Academy of Physician Assistants P.O. Box 201608 Anchorage, Alaska 99520 Phone: (907) 279-0478 Position Statement: Testified in support of HB 341 (Spoke via teleconference) CLAY LANGLAND, P.A. Pelican, Alaska 99832 Phone: (907) 735-2250 Position Statement: Testified in support of HB 341 (Spoke via offnet) JOHN WINKELMAN, P.A. Healy, Alaska 99743 Phone: (907) 683-2211 Position Statement: Testified in support of HB 341 (Spoke via offnet) JEANNE CLARK, P.A. 479 Slater Drive Fairbanks, Alaska 99701 Phone: (907) 452-4117 Position Statement: Testified in support of HB 341 (Spoke via teleconference) DITA DE BOER P.O. Box 1526 Seward, Alaska 99664 Phone: (907) 224-8468 Position Statement: Testified in support of HB 341 (Spoke via teleconference) DAVID JOHNSON, P.A. P.O. Box 3465 Seward, Alaska 99664 Phone: (907) 224-5205 Position Statement: Testified in support of HB 341 (Spoke via teleconference) ROBERT WOODS 751 Old Rich Highway Fairbanks, Alaska 99701 Phone: (907) 451-6561 Position Statement: Testified in support of HB 341 (Spoke via teleconference) JESSICA STEVENS Talkeetna, Alaska 99676 Phone: (907) 733-2273 Position Statement: Testified in support of HB 341 (Spoke via offnet) BEVERLY HUGO, P.A. P.O. Box 677 Barrow, Alaska 99723 Phone: (907) 852-5333 Position Statement: Testified in support of HB 341 (Spoke via teleconference) MICHAEL JOHNSON, Legislative Aide Rep. Joe Sitton Alaska State Legislature State Capitol Juneau, Alaska 99801 Phone: (907) 465-2327 Position Statement: Provided information on HB 341 BOB WARD Associated General Contractors of Alaska 10003 Frank Maier Drive Juneau, Alaska 99801 Phone: (907) 586-1648 Position Statement: Testified in support of HB 490 PREVIOUS ACTION BILL: HB 341 SHORT TITLE: PHYSICIAN ASSISTANTS' SERVICES SPONSOR(S): REPRESENTATIVE(S) SITTON,JAMES,Nicholia JRN-DATE JRN-PG ACTION 01/03/94 2016 (H) PREFILE RELEASED 01/10/94 2016 (H) READ THE FIRST TIME/REFERRAL(S) 01/10/94 2017 (H) HES, FINANCE 03/02/94 2588 (H) COSPONSOR(S): NICHOLIA 03/17/94 (H) HES AT 03:00 PM CAPITOL 106 BILL: HB 490 SHORT TITLE: SCHOOL CONST: ALASKA BIDDER PREFERENCE SPONSOR(S): REPRESENTATIVE(S) VEZEY JRN-DATE JRN-PG ACTION 02/14/94 2379 (H) READ THE FIRST TIME/REFERRAL(S) 02/14/94 2379 (H) HES, FINANCE 03/17/94 (H) HES AT 03:00 PM CAPITOL 106 BILL: HB 488 SHORT TITLE: RESTRICT STUDENT LOANS TO ALASKA SCHOOLS SPONSOR(S): REPRESENTATIVE(S) VEZEY JRN-DATE JRN-PG ACTION 02/14/94 2379 (H) READ THE FIRST TIME/REFERRAL(S) 02/14/94 2379 (H) HES, STATE AFFAIRS 03/08/94 (H) MINUTE(HES) 03/17/94 (H) HES AT 03:00 PM CAPITOL 106 ACTION NARRATIVE TAPE 94-54, SIDE A Number 000 CHAIR TOOHEY called the meeting to order at 3:06 p.m., noted members present and announced the meeting would begin with hearing HB 341. HB 341 - PHYSICIAN ASSISTANTS' SERVICES Number 029 REP. JOE SITTON, Prime Sponsor of HB 341, read the sponsor statement. He said HB 341 would amend several of Alaska's current statutes relating to health care providers in order to give Alaskans greater access to quality health care. He added that no place is more unique than Alaska when it comes to the role of the physician assistants (PA). Number 072 CHAIR TOOHEY asked if, in the eyes of the medical profession, the nurse practitioner and PA were seen as equals and had an equal ability to give care. Number 075 JOHN RILEY, President, Alaska Academy of Physician Assistants, responded in the affirmative. He said the head of the medical board told him about a month ago that he considered both professions to be equal. Number 087 REP. BUNDE asked if Medicare pays at the physicians's rate if a Medicare patient sees a PA who is working under a physician. Number 095 MR. RILEY answered in the affirmative. Number 097 REP. BUNDE asked, "If the PA had an independent operation, as the law currently exists, why couldn't the PA charge Medicare? And wouldn't the rate probably be lower than the physician's rate?" Number 104 MR. RILEY answered this probably was true, and each office has its own fee structure. Number 105 REP. SITTON added that he believed doctors charge more than PAs in the Lower 48. Number 111 REP. BUNDE clarified that the thrust of his question was that, for the same work, if a PA worked in a physician's office, Medicare probably would be charged at a higher rate than if the PA worked alone. Number 114 MR. RILEY agreed that this was true. Number 120 CHAIR TOOHEY said KIMBERLY BUSCH and DAVE WILLIAMS would address billing and clear some of this up. Number 123 REP. GARY DAVIS asked if, under this bill, the PAs would still be working for physicians. He also wondered if they would be able to bill directly instead of going through the mark-up phase. Number 129 MR. RILEY said this bill does not really affect PAs that are working in a physician's clinic because in that situation they would continue to bill in the same manner. This bill affects PAs who would apply for their own number and be in solo practice situations. Number 135 REP. BRICE asked how many of the 194 PAs mentioned in the fiscal notes are currently billing under a physician. Number 140 MR. RILEY said about 35 percent of the PAs in the state work for Corrections, Industrial Medicine or Indian Health Services, so perhaps 65 percent work in family practice settings. He said he did not know how many of those were billing under a physician. Number 147 KIMBERLY BUSCH, Director, Division of Medical Assistance (DMA), Department of Health and Social Services, offered the correction that the division assumes it is being billed for PA services connected with Indian Health Services. Number 155 CHAIR TOOHEY asked Ms. Busch to address the fiscal note and the billing procedures. Number 160 MS. BUSCH said PA services are an important part of the state's health care delivery system. She explained that Medicaid reimburses PA services if PAs work under a physician or in a designated rural health clinic. Often PAs are the only practitioner in a rural health clinic and under that construct, the federal government sets a rate for the service, a per-encounter rate. In the physician's office, they are paid according to a fee schedule that varies from 70 to 85 percent of what the physician bills. Number 192 CHAIR TOOHEY asked if the physician was differentiated from the PA on the Medicaid bill. Number 198 MS. BUSCH said the renderer is not identified on the bill. She added that an assumption was made on the fiscal note to be friendly regarding payment to PAs. She referred to a bill brought forward by optometrists in which optometrists would be paid the same as physicians for those procedure codes which they are capable of rendering. She cautioned that this is the trend in the health field and asserted her concern for the future. Number 218 CHAIR TOOHEY asked if payment would be forthcoming "down the pike" if a specific price were set in statute. Number 221 MS. BUSCH said she presumed a price would not be set in statute because prices are raised or set in regulation. In the future she would expect to hear from providers that for the same procedure codes they should be paid "the same as". She said it is an equity issue with providers and that although she is sympathetic to this issue this is also a cost issue for the departmental budget. She said there are already two service providers, added by the legislature, for which funding has not been appropriated. She asked for careful consideration before adding yet another provider category for which there would not be an appropriation of funds. Ms. Busch emphasized that this would be an entirely different matter if funds were being appropriated and she asked that Alaskans not be promised something that would not actually be put on the books. Number 250 DAVE W. WILLIAMS, Medical Assistance Administrator, Division of Medical Assistance, Department of Health and Social Services, reiterated the department is not at odds with PAs. He said PAs provide a valuable service, especially in rural Alaska. He asserted one truth about cost in Medicaid programs is that access affects the cost of the program; if you increase access, you increase the cost. He stated his belief that he is in the middle of the road regarding the fiscal impact of this bill, but explained this is not an exact science, and in the past they have made inexact estimates. He further stated if this bill becomes law, there will immediately be 170 professionals in Alaska who will have the right to bill Medicaid. Mr. Williams said his assumption is a minimum of ten percent of the PAs would enroll during the first year. He pointed out that the bill says nothing about PAs remaining in the physician's office, so there is nothing that says you cannot bill as a PA, and then refer to the doctor. He added there is nothing in the bill that says you won't, on the other hand, take the 4.4 average visits per client per year to a physician and say that one or more of those go to the PA. He said Medicaid would probably pay less if a PA was billing directly. He concluded that he could not exactly tell if his estimations were high or low. He said the highest encounter rate Medicaid pays right now is $53.00. He said if that figure was used to estimate, the result would be around $800,000 instead of the $999,000 that is on this bill. He further stated if he assumed the PA was going to bill in addition to the physician, this would increase the fiscal note. Number 306 REP. OLBERG asked if every PA worked under the direct supervision of a physician. Number 308 MR. WILLIAMS said this is an equity issue in that PAs are not equal to advanced nurse practitioners (ANPs). He said PAs need to have a collaborative agreement while ANPs do not, and this bill does not change that situation. He explained that ANPs by federal law are paid at 80 percent of the charges, and this does not work well in Alaska because often times the charges are to a fully or partially Medicaid-eligible population. He estimated that payment to a PA would be at 70 percent. Number 328 CHAIR TOOHEY asked, if this bill passed, would PAs be number six on the list, and would there automatically not be funding available for that category? Number 335 MS. BUSCH explained if PAs were added to the list without appropriating additional funding, then another provider on the list would not receive funding. She pointed out that LCSWs, psychologists, and direct entry midwives are three provider categories above PAs on the list located in Section 47.07.035. Number 356 REP. OLBERG asked if this list represented the order in which people do not get paid. MS. BUSCH replied this was correct. REP. OLBERG commented that the list was upside down, which was pathetic. MS. BUSCH explained that this list is optional and about nine services are mandatory, by federal law, before taking this list into consideration. REP. OLBERG said the list is still upside-down. REP. BRICE commented that it was an inverse order of funding. Number 380 REP. G. DAVIS mentioned that it was ironic that PAs were not on the list. Number 391 MS. BUSCH responded that it lacks logic to add to this list if there are not sufficient appropriations. REP. BUNDE assumed a precedence was being set on this list and asked if ANPs were funded. MS. BUSCH said some ANP services are mandatory and some, like those relating to the psychiatric or geriatric specialties, are optional. The family nurse practitioner and the pediatric nurse practitioner, who are analogous to PAs, are mandated under federal law. Number 422 REP. BUNDE asked what the fiscal note was on ANPs, as compared to PAs. Number 425 MR. WILLIAMS said this was problematic, but he would answer the question. He explained that ANPs are split into two main groups. He said there are nurse midwives, and PAs don't deliver babies, but nurse midwives do. He said PAs do some of what nurse midwives do, so the comparison is not equal because PAs are not offering the same services. He said one is working next to a doctor and the other is fairly independent. He stated nurse practitioners have billed the division through January at about $231,000 and PAs have billed the division through January at about $171,000; the division will pay roughly $800,000 for the year when these are added together. He further said ANPs were not added, previously, which makes this estimation difficult and problematic. Number 456 REP. BUNDE said according to federal mandate, ANPs were funded and he wondered if ANPs were funded at approximately the same level that it would cost to fund PAs, that rough approximation being $800,000 to $1,000,000. Number 465 MR. WILLIAMS replied that he did not see them as that equal. Number 466 REP. BUNDE asked if they would cost the same. He said ANPs provide a medical service and it costs a certain amount and PAs provide a medical service and it should cost the same amount, because neither are doctors. Number 473 MR. WILLIAMS replied that it depends on how you value the development of the profession. He said it was his understanding that nurse practitioners have more on-the-job training. He related that both have been to school, but PAs work alongside of physicians. He said their services encompass different things. He said he did not know the specifics, but there is a PA school in Sitka which would have more information. He said we do need better access in rural Alaska, but the bottom line is we do not want to say we are going to pay PAs and then not have the money to do so. Number 492 REP. BRICE said in attempts to avoid over or underfunding, accurate information is needed to make good decisions. He said for the fiscal year 1993 for ANP services there should be a single number to determine what is needed. He asked how many of the 194 PAs in Alaska were currently filing their fees under a doctor or through a rural health clinic. Number 514 MR. WILLIAMS said he didn't have that number with him. He said there are 165 practicing in Alaska. REP. BRICE expressed his concern about potential "double- dipping," and said a clear delineation would need to be made within the fiscal note indicating that some of these services would be a wash. He referred to Section 47.07.035 and said we should be able to determine at the end of the fiscal year how much money has been spent in each category. TAPE 94-54, SIDE B Number 077 MR. WILLIAMS said this fiscal note does not include "double dipping" and noted the figures would be higher if this were included, and would be lower if it were assumed that the PA would split the number of visits with the physician. Number 082 REP. BRICE asked what the expenditures were for the fiscal year 1993 under the ANP category. MR. WillIAMS said he did not price ANPs because they were in a different practice, a different profession, and a different setting. Number 086 CHAIR TOOHEY acknowledged that the question was not answered. She offered Mr. Williams some potentially helpful unidentifiable written information (indiscernible). Number 090 REP. OLBERG began by saying the fiscal note did not, for the most part, represent additional spending. Number 092 MR. WILLIAMS said there are 170 or so PAs in Alaska, and he assumed approximately ten percent of them would enroll if this bill were passed. Number 098 REP. OLBERG said this did not address his question. He said in theory, if PAs get $499,000 of the total "x" amount given to the department then the amount spent on Medicaid is not going to be "x" plus 499,000; it is going to remain at "x" dollars, with PAs getting a share of that money. He continued by theorizing that a fiscal note could be set at zero, and would have a fiscal impact within the department, but not on the total general fund budget. Number 109 MS. BUSCH said that certainly if this were true there would be some wonderful solutions to the increases in medical costs, but unfortunately this was not the case. She explained that physicians in the marketplace have certain expectations of earnings, and the PAs can be a means to generate income. She said the division has experienced adding new practitioners and this has not saved them any money. She explained the physician would continue to generate the same income as before, and if the PA were functioning as an independent, this would generate a separate income. Number 130 REP. OLBERG responded that it was not his assumption that this would save money. He explained that if $300 million were given to Medicaid and ten new practitioners were added, each generating a million dollars each, Medicaid would still spend $300 million. The total cost to the state would remain the same and the money would come from some other source. Number 136 MS. BUSCH said she failed to understand because in her experience when practitioners were added the cost increased. She expressed her concern that the money would not be appropriated. Number 149 REP. OLBERG replied that his concern was not about the money being available, nor was it about people's expectations. He said he wanted to know if this fiscal note represented spending beyond a certain level. Number 153 MS. BUSCH apologized for not previously understanding the question and said, "Yes, this represented going beyond the budget and would have to be appropriated in addition to what the governor had requested." Number 158 REP. OLBERG asked, "So before we pay anybody, we automatically do not pay the first five or six or ten or fifteen people on this list?" Number 160 MS. BUSCH responded this was correct and dependent upon legislative appropriations. Number 162 REP. OLBERG asked, "If the level stays the same, would thirteen of these groups not receive money instead of twelve?" Number 164 MS. BUSCH said if the department does not get the growth they have requested for 1995, it would be possible to go down to number 25 on the list. Number 169 CHAIR TOOHEY said her concern was philosophical in that the PAs must not assume they are not qualified to be on the list; they are as qualified as ANPs and others on the list. She said not paying them was simply a matter of not having the money to do so. Number 176 MS. BUSCH said the division is purchasing services from PAs who are working with physicians or in rural settings. She agreed that it is not that PAs are not valued, but more a matter of keeping costs down by not paying PAs directly. Number 180 CHAIR TOOHEY asked, if this bill does not pass, would a PA working in a clinic in the middle of Alaska get paid? MS. BUSCH said if a clinic has been certified as a rural health clinic, has met certain conditions and has been licensed accordingly, then a PA can practice solo there. She added that the PA pays a fee to the overseeing physician. Number 192 MR. RILEY said the purpose of this bill refers to PAs who are enrolled (indiscernible). Number 205 JACK HEESCH, Lobbyist, Alaska Academy of Physician Assistants, stated they vehemently disagree with Mr. William's statement about ANP certified nurse midwives providing the same services as PAs. He said PAs provide the same services as ANPs, but not as nurse midwives. He further stated the amount of money spent on nurse midwives should not be rolled in with the money spent on ANPs, and then estimated to be part of an $800,000 fiscal note. He said PAs don't deliver babies. Number 221 CHAIR TOOHEY requested that witnesses indicate their desire to communicate in writing rather than by head shaking. Number 226 CLAY LANGLAND, Physician Assistant, testified from Pelican. In an attempt to simplify the discussion, he presented a theoretical situation in which there were three Medicaid patients in Alaska: one in Anchorage, one in Juneau and one in Pelican. He asked, "Supposing there was a rural health clinic designated in Pelican, would all three Medicaid patients be able to receive reasonable medical care?" He pointed out that the patients in Anchorage or Juneau would have more choice and ease, whereas the patient in Pelican would have limited access to reasonable care. Number 250 CHAIR TOOHEY asked Mr. Langland if he worked in the same office as a physician and asked if there was a physician in Pelican. She said, according to Ms. Busch, Pelican would qualify as a rural clinic and therefore would be paid; whereas the other practitioners would not be paid except through the physician. Number 255 MS. BUSCH clarified that the clinic would need to be licensed in order to qualify for payment. Number 257 MR. LANGLAND said there is no physician in Pelican and he confirmed that the clinic is a certified rural health clinic. He said this afternoon's discussion needs to stay focused on reasonable client services and accessibility. Number 280 MS. BUSH agreed that accessibility is important. She said the problem is really in nonrural areas because in order for a PA practicing independently in a nonrural area to receive Medicaid funding they have to bill through a physician. In the given scenario, a Medicaid patient would not have a choice between going to a PA independently or going to a physician. Number 300 CHAIR TOOHEY asked the witnesses to be brief in their testimonies. Number 307 JOHN WINKELMAN, a Physician Assistant at the Healy Clinic, testified via teleconference that the Healy clinic is located about 100 miles from Fairbanks. He explained that the clinic is now privately owned, whereas it was previously designated as a rural health clinic and received reimbursement from state Medicaid for services. He said in 1988 the state cut reimbursement dollars and the clinic dropped from the rural health setting status. He said the clinic continues to see Medicaid patients on a fee for service basis. He explained that in practical terms this means that the Medicaid patients in that area have to travel to Fairbanks, and the clinic continues to see the emergency cases. Mr. Winkelman stated his support of HB 341 because it would provide for services locally and would also promote a level playing field in the health care arena. Number 377 REP. BRICE asked for a brief at-ease from 4:08 p.m. to 4:09 p.m. Number 390 JEANNE CLARK, Physician Assistant, Fairbanks, testified via teleconference that this bill was drafted because of some undesirable barriers to patients that need to be addressed. She stated the current billing situation is advantageous to PAs, so if this bill passes, PAs would not necessarily go solo and obtain their own Medicaid numbers because reimbursement from Medicaid would be at a much lower rate. She said passage of this bill would not necessarily increase costs in the way that was previously mentioned by Mr. Williams. Ms. Clark acknowledged money as an important issue, but emphasized that the focus needs to remain on providing health care to all people. CHAIR TOOHEY, as a point of clarification, said this bill does not stop a PA from billing independently, but is for Medicaid patients (indiscernible.) Number 445 DITA DE BOER testified from Seward that PAs fulfill a very special need in the medical field and should be integrated into the medical practice. She supported the passage of HB 341. CHAIR TOOHEY asked if Seward was a certified rural caregiver. MS. DE BOER replied that it was not. Number 476 DAVID JOHNSON, Physician Assistant, testified from Seward that he works at a Native health clinic. He explained that the PAs role involves having a physician as a referral source. He stated his support of HB 341. Number 508 CHAIR TOOHEY said the purpose of this bill is to put the funding under Medicaid and has nothing to do with qualifications. She encouraged witnesses to testify on the concept of the bill. Number 527 CHAIR TOOHEY excused Rep. Bunde for another meeting. Number 530 ROBERT WOODS testified from Fairbanks in support of HB 341. He said maintaining certification as a rural health provider is an expensive proposition. He added that the majority of PAs in Alaska practice with primary private practice physicians. Mr. Woods said there is a shortage of qualified health care providers in this state and there always will be. He said if he were unable to bill Medicaid patients, he would have to deny them care in deference to patients with insurance coverage that would pay 80 percent reimbursement as opposed to a lower Medicaid rate of say 30 or 40 percent. Number 558 JESSICA STEVENS testified from Talkeetna. She said because of all the paperwork involved, the clinic in her community functioned for nine months without designation as a rural health clinic. During those nine months Medicaid patients were seen, but the clinic will never get reimbursed for that time. She described her community as a poor rural area where people do not have access to the kind of health care they need. She said the clinic provides a necessary service but has been in danger of closing precisely because it has been unable to bill Medicaid for services rendered. She said she recognizes PAs as providers equal to ANPs. She emphasized the designation process as a lengthy one and mentioned the clinic will probably be subsidizing care for another three months because their status is still undetermined. TAPE 94-55, SIDE A Number 003 CHAIR TOOHEY thanked Ms. Stevens and asked if there were any further questions on-line. Number 008 BEVERLY HUGO, Physician Assistant, testified from Barrow in support of HB 341. She said Medicaid should honor the services PAs give in rural areas or areas away from metropolitan areas. She added that they provide a vital service for people that otherwise would have no access. She said she is in school health services and she works with a physician at the Barrow health clinic. Number 022 CHAIR TOOHEY said for the record the bill would not be moved out today but amendments could be addressed. She asked Mr. Riley if he wanted to give a wrap-up. Number 030 MR. RILEY expressed the expectation that PAs be put on the optional list in Section 47.07.035. He said they want to have a precedent in order even though it is likely that there will not be funding this year. He said it does not necessarily follow that PAs should not be put on the list because of that. He said, in reference to the fiscal note discussed earlier by Mr. Williams, that there are about 200 adult ANPs, and of those, about 20 have billed Medicaid. He said that means there are 20 ANPs who are not nurse midwives but who are billing the state for $400,000 total. The cost to the state is half of that, which is $200,000. He further stated there are eight certified nurse midwives who are responsible for the other $400,000 in charges. Mr. Riley concluded that charges generated by the ANPs need to be further looked into because the work done by PAs is, essentially, identical to the work done by ANPs. Number 058 CHAIR TOOHEY asked if this bill would allow rural providers to be paid. Number 059 MR. RILEY said PAs work in 38 communities in Alaska and there are only eleven certified rural health clinics, so there are a bunch of communities that are not rural health clinics that cannot bill Medicaid. Number 063 CHAIR TOOHEY asked if they worked under a physician. Number 063 MR. RILEY said yes, they are under licensure to work under a physician, but the physician is not in the practice with them. He said they cannot legally bill Medicaid because the physician is not in the clinic. Mr. Riley specified that HB 341 is for those situations. He added that the Alaska State Medical Association, the Nurses' Association, the Alaska Nursing Home and Hospital Association, the Public Health Association, and the Health Care Coalition all support this bill. MR. RILEY addressed the issue of cost shifting. He said this process took root when insurance companies told PAs they would no longer be processing their claims. He said there were PAs in clinics who were not supposed to be billing through their physicians. He said this is no longer occurring. Mr. Riley said they hope that reimbursement will be set at the same rate as ANPs, at 80 percent, which will be a reduction from the 100 percent that is now being used. He added that this could be a cost savings. He stated HB 341 also prohibits insurance companies from discriminating against services provided by PAs, and that almost all of the health care providers in the state have this protection under law except PAs. He stated another reason to include this legislation would be because it allows PAs to provide workmen's compensation evaluations. He said PAs are already doing this, and the legislation would formalize that procedure. Number 102 CHAIR TOOHEY asked if there were any questions. Number 105 REP. BRICE made a motion to move Amendment 1. Number 110 REP. B DAVIS asked to speak before considering the amendment. Number 115 CHAIR TOOHEY called for a brief at-ease from 4:30 p.m. to 4:32 p.m. She stated she wanted to move the amendments and then continue tomorrow. Number 117 REP. KOTT objected to Amendment 1. Number 118 MR. RILEY said federal law does not allow PAs to hand out handicapped parking permits, but Section 3 of the bill establishes that PAs can hand out handicapped parking permits, therefore placing state law in conflict with federal law. Mr. Riley suggested some housecleaning, given his understanding that this was a friendly amendment offered by the sponsor. Number 129 MICHAEL JOHNSON, Legislative Aide to Rep. Sitton, said when the bill was originally drafted, PAs suggested issuing handicapped parking permits and this seemed to be a good idea. It was later learned that federal law controls this function. This amendment merely deletes that section from the bill. Number 141 REP. KOTT withdrew his objection. Number 142 CHAIR TOOHEY, hearing no objection, adopted Amendment 1. She asked for a motion on Amendment 2. Number 145 REP. G. DAVIS moved Amendment 2. Number 146 CHAIR TOOHEY asked for discussion on this amendment. She asked if the committee was assuming that PAs were going to be put on the list. She asked for the pleasure of the committee. Number 153 REP. G. DAVIS moved Amendment 2. Number 155 CHAIR TOOHEY, hearing no objection to Amendment 2, the motion carried. She asked for the pleasure of the committee on this amendment. Number 158 REP. BRICE made a motion to move HB 341 with individual recommendations. He suggested that major questions relating to the fiscal note be addressed by the Finance Committee. He said it was fine public policy to have PAs added to the list. Number 168 REP. OLBERG stated for the record that since a straight answer from the department on fiscal matters was not forthcoming, the bill might as well be sent to the Finance Committee. Number 170 REP. KOTT associated with Rep. Olberg's comment, and said the fiscal note was out of proportion and possibly wildly incorrect. Number 176 CHAIR TOOHEY asked that a roll call vote be taken. Reps. Toohey, G. Davis, Vezey, Kott, Olberg, B. Davis, Brice voted yea. HB 341 passed unanimously out of the committee with individual recommendations. HB 490 - SCHOOL CONST: ALASKA BIDDER PREFERENCE Number 189 CHAIR TOOHEY brought HB 490 to the table. Number 192 REP. OLBERG asked if the chair would entertain a motion. Number 193 REP. AL VEZEY, Prime Sponsor of HB 490, gave a sponsor statement and said HB 490 was a simple bill. He noted a regulation in Title 4 of the Alaska Administrative Code that bars school districts from giving a local bidder preference. He stated this is not in keeping with good public policy and explained that HB 490 does not mandate a local bidder preference, it merely prohibits the prohibitions on a local bidder preference. Rep. Vezey made a motion to move HB 490 from committee with the attached fiscal note. Number 209 CHAIR TOOHEY asked the sponsor if there would be a problem with this being brought to court. Number 215 REP. VEZEY said no, he did not think this would be a problem, but he did mention that the cost of filing a lawsuit is only $75.00. Number 216 REP. BRICE mentioned there are other Alaskan provider preference statutes that are in use, and this would just be added to those preferences. Number 224 BOB WARD, Associated General Contractors of Alaska (AGC), testified in support of HB 490. He said the bill does not break new ground as the concept of bidder's preference has been in existing law for years. He said it allows for municipalities in rural (indiscernible). Mr. Ward further stated this bill helps Alaska contractors support the state financially and it also helps the local people who work for the local contractors. Number 241 REP. KOTT asked what AGC policy is on hiring Alaskans. Number 247 MR. WARD replied that his understanding was that Alaskan contractors were Alaskans. Number 250 CHAIR TOOHEY asked for the pleasure of the committee. Number 255 REP. KOTT made a motion to move HB 490. Number 256 CHAIR TOOHEY, hearing no objection, passed HB 490 out of the committee with attached fiscal note. Seeing no further business before the committee, CHAIR TOOHEY adjourned the meeting at 4:42 p.m.