Legislature(1993 - 1994)

03/17/1994 03:00 PM House HES

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= 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                                                   
  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                                                                
  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                                                                
  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                       
  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                 
  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                         
  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                        
  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                    
  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                     
  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                        
  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                        
  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                           
  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                     
  Number 300                                                                   
  CHAIR TOOHEY asked the witnesses to be brief in their                        
  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                  
  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
  CHAIR TOOHEY asked if Seward was a certified rural                           
  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                           
  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                  
  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                         
  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                           
  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                       
  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                   
  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                   
  Number 170                                                                   
  REP. KOTT associated with Rep. Olberg's comment, and said                    
  the fiscal note was out of proportion and possibly wildly                    
  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.                                    

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