Legislature(1997 - 1998)

03/27/1997 03:11 PM HES

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
 HB 152 - REGULATION OF HOSPICE CARE                                         
 Number 0135                                                                   
 CHAIRMAN BUNDE announced the next item on the agenda as HB 152, "An           
 Act regulating hospice care."                                                 
 Number 0167                                                                   
 REPRESENTATIVE AL VEZEY made a motion to move the committee                   
 substitute for HB 152, Lauterbach, dated March 26, 1997.  Hearing             
 no objections CSHB 152(HES) was now before the committee.                     
 Number 0203                                                                   
 REPRESENTATIVE JOE RYAN, Sponsor of HB 152, said CSHB 152(HES)                
 addresses some of the problems that were voiced by people employed            
 by volunteer hospices.  Those people were afraid that the fees                
 might be such that they couldn't comply with the regulations and              
 they would go out of business.  Commissioner Perdue indicated that            
 the Department of Health and Social Services (DHSS) had no                    
 intention of issuing burdensome regulations and\or fees that would            
 cause volunteer hospices any problems.  He referred to page 7, line           
 6, Article 2, which creates a different set of licensing                      
 requirements for volunteer hospice programs.                                  
 REPRESENTATIVE RYAN said CSHB 152(HES) tries to ensure a level of             
 competence, based on national standards, so that people who are               
 entering the hospice program, either volunteer and\or for profit,             
 receive the kind of treatment they desire.  This level of service             
 is critical for people with a terminal illness and prevents                   
 mistreatment or abuse.  The concept of hospice care is that someone           
 has a terminal illness and receives services to end their life as             
 peaceably as possible, surrounded by family and friends.                      
 Number 0343                                                                   
 REPRESENTATIVE VEZEY questioned why we want to or need to license             
 Number 0356                                                                   
 REPRESENTATIVE RYAN answered that there have been instances where             
 people have found inadequate conditions, people were not receiving            
 the level of care for which they were paying.  This bill would                
 ensure compliance within a national standard so that people receive           
 proper care, retain their dignity and are not taken advantage of in           
 this situation.  There are people who would abuse the system.  With           
 the increase in hospice services and the increase in the older                
 adult population, we want to make sure there is a standard of care            
 and treatment for these people.                                               
 Number 0423                                                                   
 REPRESENTATIVE VEZEY asked how a hospice could take advantage of              
 people.  He assumed people could discontinue hospice services.  He            
 was aware of fraud against senior citizens, but wondered how it               
 entered into this issue.                                                      
 Number 0467                                                                   
 REPRESENTATIVE RYAN explained that a person entering a hospice                
 program is entering with a terminal illness, they might not                   
 necessarily be able to get up and discontinue the service.  The               
 family support might not be as available, especially in Alaska,               
 because the person lacks an extended family.  People might have               
 some monies to pay for services and yet not receive basic services.           
 There have been instances where a person who was incontinent was              
 left for periods of time.  This bill ensures that there is someone            
 to provide oversight to inspect the hospice from time to time,                
 check the records, to make sure services are provided as promised,            
 the level of care is at the acceptable national standard and that             
 people are not being abused.  Some older people with serious                  
 terminal illnesses are not in a position to take care of                      
 Number 0646                                                                   
 SHELBY LARSEN, Administrator, Health Facilities Licensing and                 
 Certification, Division of Medical Assistance, Department of Health           
 and Social Services, testified next via teleconference from an                
 offnet site in Anchorage.  It would be his agency's responsibility            
 to develop regulations and (Indisc--paper shuffling) and to provide           
 the oversight to the hospice organizations.  His division has been            
 trying to work with hospice organizations since they were notified            
 about CSHB 152(HES).  They believed the bill, the way it is                   
 currently written, is readable to both the certified and volunteer            
 organizations.  They do support the bill.                                     
 MR. LARSEN explained that some of the problems which occurred are             
 that certain organizations have offered hospice services, but many            
 times they were not providing all the services which are considered           
 essential hospice services or they were offering some services                
 somewhat related to what a hospice organization provides.  His                
 division is expecting that HMOs (Health Maintenance Organizations)            
 will begin entering Alaska.   The HMOs and other managed care                 
 organizations are set up in a way that services are often                     
 fragmented.  This bill would protect the public.  Any entity which            
 claims to provide hospice services would in fact have to adhere to            
 certain standards.                                                            
 MR. LARSEN commented that this bill also provides for oversight,              
 not currently available.  In the certified facilities, Medicare               
 requires 10 percent of the hospice organizations be evaluated each            
 year.  Currently there are three certified hospice organizations              
 which are only being looked at once every three years.  Hospice is            
 a growing provider and there is the expectation that there will be            
 more hospice organizations in the future.  If this was to happen,             
 the length of time between certification reviews would grow.  The             
 division sees this as a problem.                                              
 Number 0862                                                                   
 PAULA McCARON, Hospice of Anchorage, testified next via                       
 teleconference from Anchorage.  She was pleased to see that CSHB
 152(HES) included the provisions requested by the volunteer                   
 hospices.   Specifically, the delineation of requirements for                 
 volunteer hospices regarding administration and the assurance that            
 licensing fees would not be assessed.  In talking to some of those            
 programs around the state, they indicated that they are much more             
 comfortable with those new provisions.                                        
 MS. McCARON commented that, basically, hospice provides volunteer             
 and bereavement support to families after the death of a loved one,           
 spiritual care and focus on supporting families and patients.                 
 Other health care systems only work with patients and do not                  
 provide the other services because they are not within the scope or           
 mission of that particular health care program.  There have been              
 situations where people are being offered nursing care, while it              
 may be high quality nursing care, it is being promoted as hospice             
 care.  People are not receiving the full range of services that               
 entail the hospice philosophy.  This was the reason for promoting             
 legislation.  When people are in a vulnerable and stressful place             
 in their lives and are relying on the words of others and referrals           
 by health care providers, not knowing fully what to expect, that              
 they could be ensured that they would receive the full level of               
 hospice services.                                                             
 Number 0965                                                                   
 CHAIRMAN BUNDE said that, typically, he imagined that hospice care            
 was arranged by a family member.  He asked if individuals checked             
 themselves into a hospice program without family involvement.                 
 Number 0981                                                                   
 MS. McCARON answered that, in her Anchorage program, most often the           
 referrals are a result of a family member.  The family member has             
 initiated a phone call and typically knows very little about the              
 services that a hospice provides.  The topic of dealing with a                
 loved one's impending death is so emotionally charged that often              
 people are doing all they can do to pick up the phone and make that           
 first call.  These people tend not to ask a lot of questions, in              
 terms of making sure they receive quality services.  They do                  
 express concern about the cost of care.  Referrals are usually done           
 by a family member, not the individual themselves.                            
 Number 1044                                                                   
 REPRESENTATIVE JOE GREEN said the definition of a hospice covers              
 physical, emotional, theological and other areas of service.  He              
 expressed concern that if there were rigid guidelines, would it               
 have an adverse affect on the volunteers, spiritually and                     
 emotionally.  He also asked if volunteers receive training.                   
 Number 1089                                                                   
 REPRESENTATIVE RYAN said CSHB 152(HES) would require that a                   
 volunteer receive 18 hours of training.  He felt that the people              
 who run volunteer hospice organizations, especially the volunteer             
 programs who adhere to the national standards, would request a                
 volunteer to receive training on the philosophy of a hospice and              
 what it is that a volunteer is expected to do.                                
 REPRESENTATIVE RYAN commented on the concept of hospice.  Kegler              
 Ross (Ph.) was the person who came up with the idea of death with             
 dignity, that you shouldn't be stuck alone in a hospital bed                  
 someplace with family visiting once in awhile.  He said we are just           
 going back to what used to happen, his grandmother died at home.              
 He explained that hospice aids the family.                                    
 Number 1171                                                                   
 CHAIRMAN BUNDE explained that there was initial testimony from                
 volunteer hospice organizations where people were concerned about             
 being subjected to regulations.  The committee has adopted CSHB
 152(HES) which alleviates some of those concerns.                             
 Number 1246                                                                   
 REPRESENTATIVE VEZEY felt this was an important area.  Although               
 CSHB 152(HES) talks about protecting terminally ill people from               
 fraud, he did not feel it was being addressed in this bill.  He did           
 not feel that CSHB 152(HES) addressed the issue of fraud as there             
 are not any gates in which do that.  He asked how fraud was                   
 perpetrated on a senior citizen or a terminally ill person.  He               
 felt that normally a family would request the service.  If there              
 isn't a family, he did not feel that a terminally ill person would            
 typically check themselves into a hospice.  He said a medical                 
 facility would go through some sort of process to transfer a person           
 to hospice care.  He asked what mechanisms would allow fraud to be            
 perpetrated and what could the legislature do to put some side-               
 boards up to make it difficult for fraud to occur.                            
 Number 1254                                                                   
 REPRESENTATIVE RYAN referred to the HMO concept on a nationwide               
 scale.  These are profit making organizations.  He discussed a                
 myriad of concerns regarding these organizations; not being able to           
 get an appointment in a timely manner and not getting services                
 outside the HMO.  This bill is a first step to ensure that                    
 everybody plays by the same rules, the national standards for                 
 hospice care.  It gives some oversight where there isn't any now.             
 In the future, there might be some other things that need to be               
 done.  He did not try to address all the possibilities which might            
 occur, it is just a basic framework to see that there is some                 
 oversight to ensure a standard level of hospice service.                      
 Number 1349                                                                   
 CONNIE J. SIPE, Director, Division of Senior Services, Department             
 of Administration, said her division provides Medicare counseling.            
 Medicare is a federal program which seniors qualify for by reason             
 of their own social security eligibility.  Hospice is a Medicare              
 benefit, something that the state of Alaska does not regulate.  As            
 a condition of receiving Medicare funding in the state, the state             
 has to agree to certify, to the federal Medicare agency, those                
 agencies which are qualified to be paid directly by Medicare.  The            
 federal government pays directly to an agency for the benefit,                
 known as the hospice benefit.  Alaska, for years, has had certified           
 hospice agencies, certified according to federal standards, which             
 qualifies them for federal payment.                                           
 MS. SIPE explained that the Division of Senior Services and the               
 DHSS are very supportive of getting this licensure in place as a              
 first step to make sure that we have some protection for the                  
 consumers of this service.  If someone holds themselves out as a              
 hospice agency, but doesn't care to receive Medicare money, then              
 the state has no ability to say that the organization should not              
 represent themselves as a hospice agency to consumers in their town           
 or area.  This is why licensure and federal Medicare payment                  
 certification allows certain standards.  The state does the                   
 licensure and the federal government has the state complete payment           
 certification, but the two are not the same.  If the state's                  
 certification agency in the state, located in the Division of                 
 Medical Assistance, said a certain hospice entity may not receive             
 Medicare payments because of a failure to meet the standards, then            
 that agency could provide services for their private pay clients.             
 The state would then not have any grounds to prevent them from                
 representing themselves as a hospice organization.                            
 MS. SIPE suggested that it is difficult, in this time when we are             
 not looking for more government regulation, to realize that if we             
 are interested in providing protection for the vulnerable elderly             
 it is important that, at the state level, we do the basic                     
 regulation of setting up licensure.  This bill would have more                
 detailed regulations.  The state's intent is to have the                      
 regulations parallel the federal certification standards.  Even if            
 some person or group held themselves out to be a hospice                      
 organization and decided not to be a federally certified Medicare             
 hospice agency, the state could enforce some basic standards.                 
 MS. SIPE said the same is true for us for home health care                    
 agencies, hospice agencies and certified nurse's aides.  The state            
 has leaned on federal certification payment standards, but the                
 state has not had their own enforcement mechanism in place.  The              
 state can go after organizations for criminal acts, but can't                 
 regulate how they enter the business, train staff, represent                  
 themselves, whether they get bonding, or other things which seem              
 necessary to have in place before an organization provides services           
 or calls themselves something to the public.  Licensure is a basic            
 beginning for the state of Alaska.  The high interest which was               
 shown last year, regarding protection for the vulnerable elderly,             
 is promoting legislation which would put in place some long overdue           
 regulations.  Alaska is one of the few states which doesn't have              
 basic licensure in place.  She referred to this bill, a certified             
 nurse's aid bill, as well as a possible home health agency                    
 licensing bill which would provide this basic licensure.                      
 MS. SIPE explained that under federal Medicare, a doctor prescribes           
 hospice.  Whether it is the family who suggests hospice to the                
 doctor, it is still the doctor who prescribes it under the federal            
 social security hospice benefit.  This benefit defines who is                 
 eligible, for how long a benefit period and what it covers.  It is            
 a valuable benefit under social security.  The majority of people,            
 who use hospice, receive it under this benefit.                               
 MS. SIPE said her father died 18 months ago in Florida under                  
 hospice care.  Once her father was signed up for Medicare hospice             
 care, by his doctor who certified in the normal course of his                 
 disease he would not be likely to live more than six months, the              
 hospice agencies and their nurses became a link.  Every time her              
 mother was worried, she did not have to take her husband to the               
 doctor.  The nurse would make an extra stop and check his vital               
 signs, check with the doctor to change his nausea medication.                 
 Medicare would have had to pay if her father had to run to the                
 doctor every time.                                                            
 MS. SIPE explained that the federal Medicare benefit includes extra           
 things such as paying for all of the prescription drugs relating to           
 pain relief and management of disease.  Normally Medicare does not            
 pay for any prescription drugs for our senior citizens.  The                  
 prescription drugs, which can be useful around death and dying, are           
 often expensive.  The other benefits include helping to pay for the           
 hospital bed, oxygen and other equipment.  Hospice is a wonderful             
 service and citizens will be using it whether or not the state                
 provides licensure.  Senior citizens, who use this benefit under              
 Medicare, will have some protection because of payment and                    
 certification linkage to the federal standards.  Younger citizens             
 who use hospice, under private pay or a private insurance, will not           
 have any way to ensure those standards.                                       
 Number 1655                                                                   
 RUPERT E. ANDREWS, Lobbyist, American Association of Retired People           
 (AARP), said his organization is in full support of CSHB 152(HES).            
 There was a concern that small communities would not be able to               
 meet the original regulations, but this has been addressed in the             
 current language of CSHB 152(HES).                                            
 Number 1678                                                                   
 REPRESENTATIVE FRED DYSON asked about the senior citizen ombudsman            
 in the state.                                                                 
 Number 1691                                                                   
 MS. SIPE answered that there was a long term care ombudsman, but              
 the official jurisdiction only has powers for long term care out of           
 home care or out of home care facilities only.  They can do                   
 intervention and health advocacy, but they don't have the same                
 powers as they have with nursing homes and assisted living homes.             
 Hospice would be an area that a long term care ombudsman is                   
 concerned about, but it wouldn't be within their strongest federal            
 jurisdiction nor are they authorized to serve people under age 60.            
 There are many users of hospice under age 60.                                 
 Number 1720                                                                   
 REPRESENTATIVE DYSON asked if AARP did not believe that most of the           
 consumers or family members, utilizing hospice care, are in the               
 position to make inspections and ensure quality services.                     
 Number 1738                                                                   
 MR. ANDREWS suggested that the main concern is that there should be           
 a standard of services.  As new units and services are added, they            
 should meet some standard for the consumer public.                            
 Number 1753                                                                   
 REPRESENTATIVE GREEN asked, under the current law, if he started a            
 hospice organization would there would be any standards under which           
 he would have to perform.  He also asked if he could receive                  
 Medicare payments for the services his organization provides.                 
 Number 1781                                                                   
 MS. SIPE explained that if his organization found families who                
 would privately pay him, he could do that and the state would not             
 have the ability to set standards for him or his employees.  If his           
 organization wished to be paid by Medicare or Medicaid for some of            
 the clients, then his organization would have to come to the state            
 and receive certification under the federal standards.  If his                
 organization operated in that area outside Medicare and Medicaid,             
 then the organization would not have to be licensed, they could               
 operate on a business license.  If the organization took people in,           
 then the state could come in and say that he was operating a                  
 nursing home without a license.  If he went into people's homes and           
 provided hospice care, then the state would not have a way to                 
 protect the consumers.  The consumers, at the very time that they             
 want the service, are dealing with the imminence of death.  Family            
 members do not have the energy to go out and investigate these                
 Number 1830                                                                   
 REPRESENTATIVE GREEN clarified that there is no control over what             
 his proposed organization might charge these bereaved people.  He             
 asked if there were standards if his organization received Medicare           
 Number 1845                                                                   
 MS. SIPE explained that if his organization wanted to bill Medicare           
 a rate is set for each visit, the benefit period and for certain              
 other services.  The same would also apply if he wanted to bill               
 Medicaid, the state would set a rate.  At this point, the licensure           
 law does not contemplate setting rates for private pay clients.               
 This would still be in the private market sector.  If his                     
 organization dealt with someone who had AETNA insurance which                 
 covered hospice care, the provider would either have to agree what            
 AETNA paid or get a deductible from the consumer.  If his                     
 organization just took private pay clients, no one could say                  
 anything about what he did until a criminal fraud was committed.              
 Number 1878                                                                   
 REPRESENTATIVE GREEN verified that CSHB 152(HES) would rectify this           
 Number 1883                                                                   
 REPRESENTATIVE VEZEY clarified that there is no evidence of any               
 unscrupulous characters in this business right now.  He has not               
 heard anything about how fraud would be perpetrated and what the              
 state could do to prevent it.  Another concern is that we are                 
 talking about an inspection every three, four or five years.                  
 Inspections are not a very good policing force.  There is some sort           
 of policing force out there now because he has not heard anything             
 ill about hospice programs in Alaska.                                         
 Number 1922                                                                   
 MS. SIPE clarified that she didn't speak for the DHSS, but she                
 would try to answer his questions.  Doctors, real estate agents,              
 nurses and other professions are licensed.  There isn't always an             
 inspection every year, but a complaint can be made about services,            
 quality, or a possible overreach of services to medical                       
 certification licensing.  This licensing agency has civil type of             
 investigators who can look into the matter.  They can use licensing           
 laws and take disciplinary action or write a letter.  It isn't just           
 those inspections which provide the oversight.  Without this                  
 licensure, a person would have to file a private lawsuit against              
 this person or organization.                                                  
 MS. SIPE explained that the lucky thing about this bill is that               
 since the federal government already pays the state for the cost of           
 certifying these agencies and investigating complaints, it                    
 shouldn't cost the state anything more.  She referred to the zero             
 fiscal note from DHSS.  It will only be an incremental amount above           
 that, it won't require a big new project to handle this licensure.            
 Number 1991                                                                   
 REPRESENTATIVE VEZEY asked how fraud was perpetrated against                  
 seniors and how it been adequately addressed in our laws.  He cited           
 the classic case where people are talked into signing over all                
 their worldly possessions in turn for being cared for the rest of             
 their life.                                                                   
 Number 2011                                                                   
 MR. ANDREWS expressed concern that the people who are administering           
 care to the public have a minimum amount of training, qualifying              
 them to do whatever duties they need to do, particularly in the               
 small, rural communities.  These communities do not always have the           
 opportunity to have registered nurses.  This bill would mandate a             
 minimum amount of training, so that no matter where a hospice unit            
 was created, there would be that standard of care available.                  
 Hospice provides follow-up counseling and work with the survivors.            
 Number 2049                                                                   
 CHAIRMAN BUNDE asked if it was fair to say that CSHB 152(HES) was             
 a consumer protection and equal protection issue, those who don't             
 pay for hospice currently have some consumer protection and those             
 who do pay out of their own pocket will be provided protection.               
 Number 2067                                                                   
 REPRESENTATIVE RYAN said this was a fair assessment.                          
 Number 2071                                                                   
 REPRESENTATIVE VEZEY made a motion to move CSHB 152(HES) out of               
 committee with individual recommendations and attached fiscal note.           
 Hearing no objection CSHB 152(HES) was moved from the Health,                 
 Education and Social Services Standing Committee.                             

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