Legislature(2013 - 2014)CAPITOL 106

02/14/2013 03:00 PM House HEALTH & SOCIAL SERVICES

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03:06:49 PM Start
03:07:23 PM HB44
04:01:53 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
+ Bills Previously Heard/Scheduled TELECONFERENCED
         HB 44-ADVANCE HEALTH CARE DIRECTIVES REGISTRY                                                                      
3:07:23 PM                                                                                                                    
CHAIR HIGGINS announced that the  only order of business would be                                                               
HOUSE BILL  NO. 44, "An  Act relating  to a registry  for advance                                                               
health care directives."                                                                                                        
3:08:23 PM                                                                                                                    
REPRESENTATIVE LINDSEY HOLMES,  Alaska State Legislature, relayed                                                               
that this  was an act relating  to a registry for  advance health                                                               
care  directives.    She  shared  that a  more  common  term  for                                                               
"advance  health  care  directive"   was  "living  will."    This                                                               
directive  allowed  for  power   of  attorney,  and  described  a                                                               
person's  health   care  wishes  in   the  event  a   person  was                                                               
incapacitated  and  unable to  make  their  own decisions.    The                                                               
directive laid out what care the  person wanted and did not want,                                                               
and who was  authorized to make decisions for them.   She relayed                                                               
that advance  health care directives  already existed  in statute                                                               
and were  not a new authority.   She explained that  the proposed                                                               
bill enabled Department  of Health and Social  Services (DHSS) to                                                               
create a  voluntary registry which  would allow people  to submit                                                               
this  living will  to DHSS  for inclusion  in a  confidential and                                                               
secure data  base.   The registry would  be accessible  by health                                                               
care facilities  within Alaska.   She  shared that,  although she                                                               
had a living  will, it was locked away and  it could be difficult                                                               
to access  during an  emergency.  The  proposed bill  would allow                                                               
the advance health care directive to be accessed on-line.                                                                       
3:10:59 PM                                                                                                                    
CHAIR HIGGINS asked  if there was a fiscal note  for the proposed                                                               
bill, as the registry would require software.                                                                                   
3:11:13 PM                                                                                                                    
REPRESENTATIVE HOLMES replied that  DHSS would explain the fiscal                                                               
note.   She  shared  that  the submitted  living  wills would  be                                                               
scanned and  then put onto the  registry.  She reported  that, as                                                               
this software was already available,  it could be more economical                                                               
to buy.  She agreed that  there were some upfront costs, and that                                                               
the ongoing costs would be reduced over time.                                                                                   
3:12:09 PM                                                                                                                    
GRACE ABBOTT, Staff, Representative  Lindsey Holmes, Alaska State                                                               
Legislature, reported that  the fiscal note reflected  the set up                                                               
costs  and maintenance  of the  registry, and  salary for  a full                                                               
time  employee  to  ensure  that regulations  were  in  place  to                                                               
establish methods  for identification  and confidentiality.   She                                                               
offered her  belief that, in  time, the full time  position would                                                               
be reduced to a part time position.                                                                                             
3:13:11 PM                                                                                                                    
REPRESENTATIVE SEATON  directed attention  to the  proposed bill,                                                               
page 2, line 12, and asked for the definition of an "agent."                                                                    
3:13:48 PM                                                                                                                    
MS. ABBOTT, in  response, explained that an agent,  a guardian or                                                               
a  surrogate were  designated  by the  individual  who filed  the                                                               
directive and  were listed in  the directive.  She  compared this                                                               
to a durable power of attorney.                                                                                                 
3:14:51 PM                                                                                                                    
MS. ABBOTT  referred to  the "House  Bill 44  Sectional Analysis"                                                               
[Included  in  members'  packets]  and offered  an  analysis  for                                                               
Section 1  of the proposed  bill.   She explained that  Section 1                                                               
protected a  health care facility  from liability for  access, or                                                               
non-access, to the registry.                                                                                                    
3:15:21 PM                                                                                                                    
MS. ABBOTT moved  on to Section 2, subsection  (a) which directed                                                               
DHSS to  create and maintain the  registry.  She stated  that the                                                               
registry  would only  contain the  name  and scanned  copy of  an                                                               
advance health care directive for any registered individual.                                                                    
3:15:48 PM                                                                                                                    
MS.  ABBOTT  explained  that   subsection  (b)  established  that                                                               
participation  in the  registry  was completely  voluntary.   She                                                               
reported  that  subsection  (c) defined  that  the  registry  was                                                               
confidential  and who  had access  to the  directive.   She noted                                                               
that this subsection  also allowed DHSS to provide a  copy of the                                                               
advance health  care directive to  a hospital outside  the state,                                                               
if  requested by  the individual  or guardian.   She  stated that                                                               
subsection (d) enabled the registry  to be available on line, and                                                               
that subsection (e)  clarified that DHSS was  not responsible for                                                               
the legal validity of each directive.                                                                                           
3:17:24 PM                                                                                                                    
MS.  ABBOTT   noted  that  subsection  (f)   clarified  that  the                                                               
directive  could  be  removed  at any  time  and  was  completely                                                               
3:17:40 PM                                                                                                                    
CHAIR  HIGGINS asked  to clarify  whether  a living  will on  the                                                               
registry would supersede a family member.                                                                                       
MS.  ABBOTT  replied  that  the  advance  health  care  directive                                                               
supplied more  information for medical  issues, and  that doctors                                                               
already had  regulations for  the acceptance  of authority.   She                                                               
stated that immediacy of care was the most important.                                                                           
3:18:51 PM                                                                                                                    
REPRESENTATIVE  KELLER referred  to  the proposed  bill, page  2,                                                               
line 23, and  asked who had the authority to  access the registry                                                               
and the individual's directive.                                                                                                 
MS.  ABBOTT replied  that although  it was  anticipated that  the                                                               
doctor would  most likely  access the  registry, the  sponsor did                                                               
not want  to limit  access as the  administrative practices  at a                                                               
hospital could have a different protocol.                                                                                       
3:19:52 PM                                                                                                                    
MS. ABBOTT resumed her explanation  for subsection (h) and shared                                                               
that  DHSS  was permitted  to  charge  a  fee equivalent  to  the                                                               
administrative cost, or  not charge a fee.  She  pointed out that                                                               
DHSS  was  not  permitted  to  charge a  fee  for  removal  of  a                                                               
directive.   She reported that  subsection (i) empowered  DHSS to                                                               
make  regulations   for  cyber  access  to   a  directive,  while                                                               
subsection  (j)  empowered DHSS  to  make  regulations for  human                                                               
access.    She noted  that  the  sponsor  wanted DHSS  to  create                                                               
regulations which worked best for them.                                                                                         
3:21:43 PM                                                                                                                    
MS. ABBOTT moved  on to subsection (k), which  protected DHSS and                                                               
its  employees from  any  legal liability  for  operation of  the                                                               
registry.   She  concluded  with subsection  (l), which  provided                                                               
definitions of registry and directive.                                                                                          
3:22:15 PM                                                                                                                    
REPRESENTATIVE SEATON asked to clarify  whether the definition of                                                               
directory as  written in the  proposed bill would only  include a                                                               
written directive, and that any  advancement for directives would                                                               
require a change to the law.                                                                                                    
3:22:50 PM                                                                                                                    
MS. ABBOTT explained that the  definition for a written directive                                                               
included scanned  copies, as  these were  the only  current means                                                               
for acceptance into the registry.                                                                                               
3:23:55 PM                                                                                                                    
REPRESENTATIVE  REINBOLD asked  if the  concept for  the proposed                                                               
bill had been initiated by lawyers or physicians.                                                                               
MS. ABBOTT  replied that Representative Holmes  had initiated the                                                               
proposed  bill as  a response  to the  difficulty for  having the                                                               
actual copy of a directive in hand.                                                                                             
3:24:56 PM                                                                                                                    
REPRESENTATIVE  REINBOLD reported  that  approximately 12  states                                                               
offered this service  for no charge.  Directing  attention to the                                                               
proposed bill,  page 3, line 3,  she asked if this  referred to a                                                               
registration fee.                                                                                                               
MS. ABBOTT replied that the referenced  fee would pay for DHSS to                                                               
file the  advanced health  care directive on  the registry.   She                                                               
declared that  the assumption was to  not charge a fee,  but that                                                               
the proposed  bill allowed  DHSS to charge  a fee,  not exceeding                                                               
the actual cost, for filing the directive.                                                                                      
3:26:08 PM                                                                                                                    
REPRESENTATIVE REINBOLD,  referring to the fiscal  note [Included                                                               
in members'  packets] asked for  an explanation to  the continued                                                               
fees being so high in Alaska.                                                                                                   
MS.  ABBOTT deferred  to DHSS,  as they  had researched  the cost                                                               
differential for various contracted vendors.                                                                                    
3:26:52 PM                                                                                                                    
REPRESENTATIVE  REINBOLD  asked if  there  had  been any  polling                                                               
regarding the proposed bill among the medical community.                                                                        
MS. ABBOTT replied that there  had not been any negative comments                                                               
from the  medical community.   Noting  that advanced  health care                                                               
directives  already  existed, she  offered  her  belief that  the                                                               
proposed  bill  would provide  the  medical  community with  more                                                               
information for better treatment.                                                                                               
3:28:13 PM                                                                                                                    
REPRESENTATIVE SEATON  directed attention  to page  2, line  3 of                                                               
the  proposed  bill, and  asked  for  clarification as  to  which                                                               
individual this referred.                                                                                                       
MS. ABBOTT replied  that this was a legal way  for stating that a                                                               
person could write and file the directive for themselves.                                                                       
3:29:04 PM                                                                                                                    
REPRESENTATIVE SEATON  asked if the  agent would also be  able to                                                               
submit the directive.                                                                                                           
MS.  ABBOTT replied  that although  an  individual could  receive                                                               
assistance for  completing the directive,  the individual  had to                                                               
file with the registry, either by mail, fax, or electronic.                                                                     
3:30:23 PM                                                                                                                    
CHAIR HIGGINS  asked about the  open ended fee referenced  in the                                                               
proposed bill.                                                                                                                  
JILL LEWIS,  Deputy Director-Juneau, Central Office,  Division of                                                               
Public  Health, Department  of Health  and Social  Services, said                                                               
that  the  proposed  bill  limited  the fee  to  only  cover  the                                                               
administrative cost.   She reported that DHSS  was considering to                                                               
not charge, similar  to other states, which was  reflected in the                                                               
fiscal note.   She  offered her  belief that  a fee  would reduce                                                               
MS. LEWIS, in response to Chair  Higgins, said that a fee was not                                                               
included in the fiscal note.                                                                                                    
CHAIR HIGGINS pointed  out that, although a fee  was not included                                                               
in the fiscal  note, it was not prohibited in  the proposed bill.                                                               
He reported  that document fees could  be as high as  $300 for an                                                               
individual's records.  He stated  that technically the Department                                                               
of  Health  and Social  Services  could  charge  up to  $300  per                                                               
3:32:22 PM                                                                                                                    
MS. LEWIS read  from the narrative on page 2  of the fiscal note,                                                               
"a fee might offset administrative  costs but would likely reduce                                                               
participation."  She affirmed that  the fiscal note assumed there                                                               
would not be a fee.                                                                                                             
CHAIR  HIGGINS replied  that  he was  not  comfortable with  this                                                               
assumption,  and he  declared  that  if there  was  no intent  to                                                               
charge,  then  this  should  be written  in  the  proposed  bill.                                                               
Pointing out  that information technology (IT)  was expensive, he                                                               
asked about the recourse if  the $137,000 allocated in the fiscal                                                               
note was not sufficient.                                                                                                        
MS.  LEWIS replied  that research  by DHSS  was "pretty  certain"                                                               
that the allocation would be sufficient.   She said that DHSS had                                                               
looked into  building the  program software,  but had  found that                                                               
national  registries already  existed at  a much  more reasonable                                                               
cost.    She  clarified  that   the  fiscal  note  was  based  on                                                               
conversations  and  cost  structure estimates  with  an  existing                                                               
3:34:10 PM                                                                                                                    
CHAIR  HIGGINS asked  how  a  living will  would  be written  and                                                               
MS.  ABBOTT,  in response,  said  that  the advance  health  care                                                               
directive would  be submitted  by an individual  to DHSS,  but it                                                               
would not  be confirmed  as valid  simply by  its listing  on the                                                               
3:34:54 PM                                                                                                                    
REPRESENTATIVE KELLER  asked what  percentages of  the population                                                               
of  other  states  were participating,  and  what  percentage  of                                                               
participation was anticipated in Alaska.                                                                                        
MS. LEWIS replied that Alaska  could expect 1,000 registry users,                                                               
although   there  was   anecdotal  information   suggesting  that                                                               
Providence Alaska  Medical Center in Anchorage  already had 1,000                                                               
directives  on file.    She opined  that  a comparable  statewide                                                               
ratio could  increase the  registry use to  4,000.   She reported                                                               
that the flat rate fee  structure for the proposed registry would                                                               
include a minimum of 5,000 registrants.                                                                                         
3:36:38 PM                                                                                                                    
MS. ABBOTT  said that the  fiscal note also included  an outreach                                                               
program to the communities to  encourage and, hopefully, increase                                                               
3:37:11 PM                                                                                                                    
REPRESENTATIVE  KELLER  asked to  clarify  that  the fiscal  note                                                               
included  an outreach  program.   He asked  about private  sector                                                               
data  bases in  other states.    He questioned  whether he  could                                                               
register  in  advance to  the  Providence  Alaska Medical  Center                                                               
3:38:03 PM                                                                                                                    
REPRESENTATIVE KELLER  announced that  he had heard  rumors about                                                               
an  iPad application  to store  personal health  records, and  he                                                               
asked if there were any options other than a public registry.                                                                   
MS. ABBOTT said  that individual hospitals had  created their own                                                               
registry however,  unless a person  was a current patient  at the                                                               
hospital,  the  advanced  health  care  directive  would  not  be                                                               
accessible.   She opined that  many users of advance  health care                                                               
directives were not a target demographic for iPad.                                                                              
3:39:44 PM                                                                                                                    
MS. LEWIS said that a trend  for some states was alignment of the                                                               
advance  care  directives  with   the  state  health  information                                                               
exchange.   She offered her  belief that electronic  records were                                                               
an  optional  qualifying  condition  for  incentive  payments  to                                                               
3:40:38 PM                                                                                                                    
REPRESENTATIVE   KELLER  asked   to  clarify   that  the   health                                                               
information exchange was a data  base for sharing medical records                                                               
among providers, and  was not the same as a  health exchange.  He                                                               
noted  that the  State  of Alaska  had  financially encouraged  a                                                               
health information exchange in the state.                                                                                       
3:41:11 PM                                                                                                                    
REPRESENTATIVE  TARR,  referring  to the  attached  fiscal  note,                                                               
asked to clarify the cost  if there were only 1,000 participants.                                                               
She also asked  about the significant change to  cost of services                                                               
in FY 2015.                                                                                                                     
3:42:03 PM                                                                                                                    
MS.  LEWIS, in  response to  Representative Tarr,  said that  the                                                               
potential  maximum fee  would be  much lower  as there  were more                                                               
participants.   She  pointed out  that the  fee charged  by other                                                               
states  was  very  nominal,  and  that DHSS,  if  they  chose  to                                                               
implement a  fee, would follow  that direction.  She  opined that                                                               
DHSS would  not try to  recoup the  entire cost for  the registry                                                               
unless directed by the legislature.                                                                                             
REPRESENTATIVE TARR  suggested that  the proposed bill  should be                                                               
more  explicit for  a limit  to the  fee, in  order to  guarantee                                                               
success for the program.                                                                                                        
3:43:52 PM                                                                                                                    
REPRESENTATIVE  REINBOLD noted  that  there was  no  fee for  the                                                               
registry  in  other  states.    She  directed  attention  to  the                                                               
$112,000 for personal services and  the $11,000 for travel listed                                                               
in  the attached  fiscal note,  and  reported that  the cost  per                                                               
registrant would  be more  than $1,000 if  there were  only 1,000                                                               
participants, as projected.   She declared that  there were tough                                                               
budget decisions  currently being discussed, and  she offered her                                                               
belief that  it was necessary to  "shrink our budget, if  we want                                                               
it sustainable."   Noting that  the concept of the  proposed bill                                                               
was worthy  of discussion, she  asked why Alaska would  not model                                                               
after Virginia,  as that state  had been offering the  program at                                                               
no operational cost since 2008.                                                                                                 
MS. ABBOTT explained that participation  in Virginia had occurred                                                               
when  hospitals   had  aligned  with  a   healthcare  information                                                               
exchange  and, as  that was  not occurring  in Alaska,  there was                                                               
anticipation for creation with this registry.                                                                                   
3:45:47 PM                                                                                                                    
REPRESENTATIVE SEATON  directed attention  to page  2, line  7 of                                                               
the  proposed bill,  and noted  that there  was language  for the                                                               
release of directives, but no  mention for a means of submission.                                                               
He  asked  for  an  explanation  as  to  why  an  agent  for  the                                                               
participant could access  a copy of the directive,  but could not                                                               
file a certified copy for the participant.                                                                                      
MS.  ABBOTT, in  response,  opined that  Alaska statute  declared                                                               
that only  an individual could  fill out the advance  health care                                                               
directive, therefore  the proposed  bill extended this  intent by                                                               
stating that  only the individual  could submit the  directive to                                                               
the registry.   She pointed out that an  individual could receive                                                               
assistance with this task.                                                                                                      
3:47:32 PM                                                                                                                    
MS.  LEWIS  detailed  that  the   proposed  full  time  dedicated                                                               
position for the registry during the  first few years was to work                                                               
with people in  outreach programs, to offer a toll  free line for                                                               
technical  assistance,  and to  scan  the  paper directives  when                                                               
submitted.  She  noted that it was also necessary  to determine a                                                               
system  for  the security  of  the  paper documents  which  would                                                               
ensure  compliance  with  the Health  Insurance  Portability  and                                                               
Accountability Act (HIPAA).                                                                                                     
3:48:39 PM                                                                                                                    
REPRESENTATIVE  SEATON asked  to clarify  that it  was acceptable                                                               
for  an  agent  to  submit  the  health  care  directive  for  an                                                               
individual upon  admission to a  health care facility,  yet there                                                               
was a barrier for filing with the registry.                                                                                     
MS. ABBOTT, in response to  Representative Seaton, explained that                                                               
the intent  for requiring an  individual to register would  be to                                                               
ensure "it is not falsified."                                                                                                   
3:49:34 PM                                                                                                                    
CHAIR  HIGGINS, directing  attention to  page 2  of the  attached                                                               
fiscal note  for the  proposed bill,  asked about  the projection                                                               
for  4,000 directives.   He  questioned if  this was  a realistic                                                               
projection, and  if not,  how this  program could  become revenue                                                               
neutral.  He expressed that,  although the concept of the program                                                               
was good, he was concerned with the potential cost.                                                                             
3:51:13 PM                                                                                                                    
CHAIR HIGGINS opened public testimony.                                                                                          
3:51:37 PM                                                                                                                    
MARIE DARLIN,  Coordinator, AARP Capital City  Task Force, stated                                                               
that  AARP  had  submitted  a  letter  of  support  [Included  in                                                               
members' packets].  She reminded  the committee that it had taken                                                               
four years to get the  advance health care directives approved by                                                               
the legislature, and  AARP viewed this proposed bill  as the next                                                               
step toward  usefulness for the  directives.  She  encouraged use                                                               
of the directives, and she  declared that many of the committee's                                                               
questions were  answered on  the directive  itself.   She offered                                                               
that   AARP  would   be  "helping   to  spread   the  word"   for                                                               
participation in the registry, and  she endorsed that any fee for                                                               
registration be nominal.  She  shared that AARP had almost 95,000                                                               
members in Alaska.   She declared that the  most important aspect                                                               
of the advance  health care directive was  to initiate discussion                                                               
for what the individual wanted in  advance of any emergency.  She                                                               
declared that AARP supported the proposed bill.                                                                                 
3:55:22 PM                                                                                                                    
REPRESENTATIVE TARR  asked if  the AARP  membership was  aware of                                                               
the opportunity to file a directive.                                                                                            
MS. DARLIN, in  response, said that AARP had focused  on the need                                                               
for advance health  care directives, and she  emphasized the need                                                               
for a family discussion with regard to the directives.                                                                          
REPRESENTATIVE TARR, referencing the  number of advance directive                                                               
registrants   through  Providence   Alaska   Medical  Center   in                                                               
Anchorage, asked  if AARP  was surprised that  so few  people had                                                               
currently registered.                                                                                                           
MS.  DARLIN questioned  the number  of  individuals with  advance                                                               
health  care directives,  and noted  that a  registry would  be a                                                               
means to ascertain  this.  She declared that  the directives were                                                               
an important ongoing project.                                                                                                   
REPRESENTATIVE  TARR   asked  if  many  people   kept  their  own                                                               
MS. DARLIN offered an anecdotal  story of advance directives with                                                               
her family.                                                                                                                     
4:00:17 PM                                                                                                                    
JEFFREY  MITTMAN, Executive  Director,  American Civil  Liberties                                                               
Union of  Alaska (ACLU),  stated that the  proposed bill  "was an                                                               
excellent  balance  of  the  state   providing  a  mechanism  for                                                               
individuals in  the State of Alaska  to voluntarily be part  of a                                                               
scheme  that  improves  the  provision   of  health  care,  while                                                               
recognizing the  need for  medical decisions  to be  made between                                                               
the patient  and his  or her healthcare  provider."   He declared                                                               
that ACLU supported proposed HB 44.                                                                                             
4:00:59 PM                                                                                                                    
CHAIR HIGGINS stated that he would leave public testimony open.                                                                 
CHAIR HIGGINS held over HB 44.                                                                                                  

Document Name Date/Time Subjects
HB044 Ver A.PDF HHSS 2/14/2013 3:00:00 PM
HB 44
HB044 Sectional.pdf HHSS 2/14/2013 3:00:00 PM
HB 44
HB044 Sponsor Statement.pdf HHSS 2/14/2013 3:00:00 PM
HB 44
HB044 Fiscal Notes-DHSS-EP-2-9-13.pdf HHSS 2/14/2013 3:00:00 PM
HB 44
HB044 Background - Memo Re AHD Registry.pdf HHSS 2/14/2013 3:00:00 PM
HB 44
HB044 Supporting Documents - AK Commission on Aging.pdf HHSS 2/14/2013 3:00:00 PM
HB 44
HB044 Supporting Documents - AARP.pdf HHSS 2/14/2013 3:00:00 PM
HB 44