Legislature(2001 - 2002)
03/20/2002 03:20 PM House L&C
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
HB 411-PHYSICIAN ASSISTANTS CHAIR MURKOWSKI announced that the first matter before the committee would be HOUSE BILL NO. 411, "An Act relating to physician assistants; providing that a physician assistant is a health care provider covered by certain laws relating to medical malpractice actions; adding physician assistants to the list of providers against whom unfair discrimination relating to health care insurance is prohibited and to the list of providers who can provide proof of disablement or handicap for the purpose of motor vehicle registration or for the purpose of obtaining a special license plate or a special parking permit; and providing for an effective date." Number 0090 REPRESENTATIVE HUGH FATE, Alaska State Legislature, sponsor of HB 411, testified before the committee. He said HB 411 was written at the request of the [American] Academy of Physician Assistants. The academy submitted three resolutions to accompany the bill and to be included in state law. He said the resolutions were drafted in order to update existing state laws to include physician assistants (PAs) as recognized providers of medical care. He said that it is believed that when the laws were drafted and passed physician assistants were not as prevalent as healthcare providers in Alaska. Over the ensuing years physician assistants have become integral to providing healthcare to rural and urban areas in the state - in rural areas, they are the primary healthcare providers and without them, many areas of the state would be without "true medical aid." Number 0197 REPRESENTATIVE FATE said the three resolutions attempt to rectify problematic areas of the statutes, since physician assistants aren't listed as recognized healthcare providers. This has hindered medical follow-up for the patients of physician assistants. He said the statutory changes will prevent discriminatory action against PAs without the opportunity for them to be assessed by their peers. REPRESENTATIVE FATE said [HB 411] gives PAs equal footing under insurance programs for both payment and liability purposes. He reported that HB 411 allows PAs the ability to authorize handicapped and other special medical-problem license plates. Representative Fate stated that the Division of Insurance, Department of Community and Economic Development, "is neutral" on HB 411. He noted that in the House Health, Education and Social Services Standing Committee hearing [on HB 411] the division made a point about direct payment to the office in which the PA worked. He explained the receipt location of payment is determined by either the officer under which the PA works, or by regulation under the Division of Insurance. Number 313 REPRESENTATIVE FATE said HB 411 attempts to bring PAs parity "with other healing professions in their ability to authorize those types of things that they can authorize under the physician's office that they work." REPRESENTATIVE CRAWFORD asked how a malpractice suit brought against a PA would be handled if the PA was working under a doctor somewhere. REPRESENTATIVE FATE characterized the physician - PA relationship as a "master-slave relationship." If a PA is hired by a physician's office, that physician is ultimately responsible for the actions of that PA. He pointed out that all members of the medical profession have malpractice insurance. However, Representative Fate said it would be a good idea for a PA in rural Alaska, doing primary care work, to carry additional malpractice insurance. Number 0462 CHAIR MURKOWSKI asked if the medical association had looked at the issue and weighed in one way or the other. REPRESENTATIVE FATE said the Alaska Medical Association was neutral when the PAs got a position on the Board Of Medical Examiners. He said he believed that they were neutral on this particular issue. CHAIR MURKOWSKI asked if anyone opposes HB 411. REPRESENTATIVE FATE replied no. He deferred any further technical questions to Ed Hall. REPRESENTATIVE MEYER inquired as to the educational requirements for a PA. REPRESENTATIVE FATE said that PAs have certain, "very specific limitations" and a "standardized curriculum" that enable them to be PAs, however, he was not aware of the specific requirements. Number 0649 ED HALL, Liaison, Alaska Academy of Physician Assistants, testified via teleconference. He said his organization believes [HB 411] is very important to allow PAs the ability to practice without the unnecessary encumbrances [the profession] has been suffering, especially in comparison with other mid-level caregivers, such as nurse practitioners. He specified that PAs did not help to initiate [HB 411] as a ploy to be independent practitioners. He emphasized that PAs must, by definition, collaborate with, and ultimately answer to a physician. MR. HALL said it was in the PA's best interest to carry liability insurance, as is the common practice. He said most PA education programs are Bachelor's programs, but that there are also Master's programs. Certification is required in Alaska, and is acquired by passing a national certifying exam, 100 hours of continuing medical education every 2 years, and re- certification every 6 years. MR. HALL offered that the medical board gave the academy their blessing and encouragement and he did not know of anyone who stood against the legislation. Number 0930 REPRESENTATIVE ROKEBERG asked if a PA must be practicing under a licensed physician. MR. HALL replied in the positive. He pointed out that occasionally insurance companies choose not to reimburse because care was provided by a PA. Therefore, [HB 411] will be an answer to those insurance companies, he said. Number 0985 REPRESENTATIVE ROKEBERG characterized AS 09.55.560 as the "golden key to the kingdom" statute. He said a profession defined under that statute can require a health care insurance company to reimburse them for service. He asked if there were any testifiers from the insurance industry. CHAIR MURKOWSKI reported that there are no more people scheduled to testify. REPRESENTATIVE ROKEBERG viewed that as troubling, and asked if any representatives of the insurance industry testified at the House Health, Education and Social Services Standing Committee meeting. Number 1042 REPRESENTATIVE FATE responded in the negative. REPRESENTATIVE ROKEBERG asked if it was possible for a PA to practice without a physician being in the same location at the same time. Number 1068 MR. HALL answered that it was possible for a PA to practice out of the direct supervision of a physician, but the law requires a face-to-face meeting of the physician and PA twice a quarter. Once a month there must be an electronic correspondence between the [physician and the PA]. REPRESENTATIVE ROKEBERG asked for an example of healthcare services denied reimbursement by an insurance company. MR. HALL gave an example of a patient who came into his office with a work-related injury. He also had an abscess on his elbow that was treated and billed under [workers' compensation]. He said the insurance company declined reimbursement of services because they were provided by a PA. He explained that at the time he was working with his collaborative physician in the same office. Number 1202 REPRESENTATIVE ROKEBERG asked if the charge for a procedure would be different because it was performed by a PA rather than a physician. MR. HALL answered that the charge isn't cheaper in regard to what is charged by the healthcare provider, but insurance companies reimburse differently [depending upon who performed the procedure]. He stated that HB 411 is not concerned with that issue, but rather the bill establishes that a PA can bill for a service in the first place. He voiced that [HB 411] brings the statute in line with the existing practice in the state. Number 1279 REPRESENTATIVE ROKEBERG asked if a PA could be the only medical care provider in a very rural community. MR. HALL replied in the affirmative. He explained that if a supervising doctor finds that an insurance company will not reimburse, services might be denied in the remote areas. He noted that nurse practitioners have no trouble being reimbursed and they charge the same as PAs for the same services. Number 1300 REPRESENTATIVE ROKEBERG asked if there is any "potentiality for abuse" of the provision in Section 3 that allows a PA to issue a "disabled parking pass." MR. HALL stated he saw no more potential for abuse than is the case for a doctor or nurse practitioner. He explained that nurse practitioners are able to issue special parking permits and that PAs are equivalent providers of service to nurse practitioners, although PAs have more supervision from a physician. He said he merely wants to see parity amongst mid- level providers. Number 1485 JOHN RILEY, Physician Assistant (PA); Board Chair, Alaska Primary Care Association, testified via teleconference. He informed the committee that his association's mission is to support clinics who serve patients, regardless of one's ability to pay. Physician assistants provide a large share of the health care provided in rural Alaska, and many rural clinics are staffed exclusively by PAs. MR. RILEY said there have been several instances of insurance companies refusing to reimburse services provided by PAs. He gave an example that happened in Talkeetna. He urged passage of [HB 411]. CHAIR MURKOWSKI asked Mr. Riley if the 250 PAs [in Alaska] he had specified in the resolution were primarily in rural Alaska. MR. RILEY related his belief that at least half of them were in rural areas of the state. Number 1599 SUSAN MASON-BOUTERSE, Executive Director, Sunshine Community Health Center, testified via teleconference. She said hers is a mid-level clinic with four PAs who provide the primary care. She said the providers are critical to the community's ongoing healthcare. Because state statutes do not include PAs in the listing of healthcare providers, her clinic periodically has its billing denied by third-party payers. She said it represents a significant barrier to healthcare for individuals with health insurance as well as a barrier to potential revenues for clinics. She reported that in the current financial situation, her clinic needs to be able to maximize whatever revenue it can. She urged the committee to pass [HB 411]. Number 1692 CHAIR MURKOWSKI asked if someone needing a temporary disabled permit would have to go to Wasilla. MS. MASON-BOUTERSE said that was not necessarily the case because there is a private physician in the Talkeetna area. But, if the doctor is not around or the person is a patient at the Sunshine Clinic, they would be required to leave town for that service. CHAIR MURKOWSKI noted that it would probably be easier to get needed healthcare services in a place like Talkeetna than a place like Unalaska because Talkeetna has a road out and Unalaska is exclusively served by PAs. Number 1751 REPRESENTATIVE HAYES said he believes [HB 411] to be a very good bill and thanked Representative Fate for bringing it forward. REPRESENTATIVE ROKEBERG directed the committee's attention to page 2, lines 6-7, which reads, "an employee of a healthcare provider operating within the course and scope of employment". Section 1 defines what a healthcare provider is. He said he felt the language authorizes a PA as it stands, however, being specific would be an improvement. Number 1835 CHAIR MURKOWSKI asked if there exists an employee-employer relationship between PAs and their "collaborating physician." REPRESENTATIVE FATE said that [as a dentist] he had experience with similar circumstances with [dental] hygienists. He recalled a question of private contracting versus the employee- employer relationship, and for tax purposes it was deemed that they were employees. Number 1880 REPRESENTATIVE HALCRO asked why Medicare and Medicaid reimbursed PAs less than they do regular physicians. REPRESENTATIVE FATE deferred to Mr. Hall. MR. HALL said, "Because they can" [reimburse PAs less]. He said the argument about a lower education level is used, although the standard of care is exactly the same. He explained that the same double standard exists for an assistant physician to a surgeon where the assistant physician is reimbursed at a lower rate than the surgeon. It makes sense to add PAs to the list of caregivers because the true role of PAs is not apparent to all insurance companies, he remarked. Number 1981 REPRESENTATIVE HALCRO asked, with regards to Section 2, if this would protect PAs from discriminatory [lower] reimbursements. MR. HALL replied in the positive. REPRESENTATIVE HALCRO asked Representative Fate if the state's match for the resulting higher Medicare and Medicaid reimbursements would not be higher as well. MR. RILEY said the same regulations for Medicare with the 85 percent reimbursement applies to nurse practitioners. He said [HB 411] did not set any floor on fees. "It just states that if you reimburse one provider for providing a service, you reimburse all other providers on this list for providing that service. It doesn't specify anything about the reimbursement level," he explained. CHAIR MURKOWSKI offered that there exists the ability to discriminate amongst providers. MR. RILEY said Medicaid does not have a differential reimbursement for providers. REPRESENTATIVE FATE explained that insurance companies do not know who does the treatment. In matching the funds, the amount wouldn't change, "and it's already taking into account, the single experience that that charge is being made for." Number 2094 REPRESENTATIVE HALCRO said he did not quite understand Representative Fate's response but he expressed his fear that the requirement that PAs be paid on the same level as a physician will raise the level paid by Medicare or Medicaid, and in turn raise the cost to the state. REPRESENTATIVE FATE said: I misconstrued your first statement there. Now it becomes a differential of pricing rather than a differential of treating, and that I really can't answer and to how much. I'm not really sure whether there's really been anything that will indicate what that would be.... you know, if there could even be a fiscal note to it because at the present time you don't know how much is going to be transferred. You don't know how much more work or less work or the same work, the amount of work the PA will do to make that differential in pricing cogent as far as the insurance payments are concerned. So you might have a future fiscal note, but at the present time it would be nearly impossible to even ascertain what that would be. Number 2160 REPRESENTATIVE ROKEBERG said he believed it would be the legislature's policy to allow a differential in pricing based on the scope of a provider's occupational license as in AS 21.36.090(d). He said like many of the statutes, it could be read different ways. He said, "Whether or not by underwriting differently, and paying and reimbursing differently by the license, you're providing unfair discrimination based the service." He said he would feel a lot more comfortable if there were someone at the meeting "from the Division of Insurance who could interpret this." Number 2208 STAN RIDGEWAY, Deputy Director, Division of Insurance, Department of Community and Economic Development, testified before the committee. He related his understanding that a physician would be paid at a certain level, a nurse practitioner at another, and so on. He said he isn't an expert and thus he offered to have Katie Campbell look into it more deeply. Number 2248 REPRESENTATIVE FATE reported that there is a "differential in pricing and charging" and not a differential in payment. He explained that a differential in payment is what would affect [the state's funding] match. He stated that there is a "set standard of amount to pay for certain services, regardless of what the physician or PA charged." He said, "There is a stability between the max that we already have, based on the experience of services." MR. RIDGEWAY gave an example of a reimbursement form with a charge of $8,000. He said an insurance company might say, based on contract, that it will pay $2,500. There is a big difference between what is charged and what is actually paid. He voiced that he doesn't think [HB 411] would interfere with that arrangement, whereby Medicare, Medicaid, and insurance companies set their fees at a certain level. Number 2300 REPRESENTATIVE HALCRO asked: If I am a PA, and you come to see me, and for the same procedure I bill $100 and Medicare says, "Andrew, you're a PA so normally if you were a doctor we would reimburse $80, but we are going to reimburse you $65 because you are a PA." So therefore, I get less than a physician would get. Now, we pass this bill, there's no more discrimination; the first time they send me a check for less than they'd send a physician I go, "You can't discriminate against me, we just passed a law, you need to pay me the $90."' Therefore they have to pay $15 more, or however much more, and then we would have to come up with an commensurate match. REPRESENTATIVE HALCRO asked if he was missing something. MR. RIDGEWAY said that he did not have an answer to that question, "mainly because you can charge anything, but what the insurance company pays is totally different from what you charge." He said that physicians can't come back and ask for more money in some cases with Medicaid and Medicare because that is an agreed amount. Number 2358 CHAIR MURKOWSKI asked if it would be the insurance that would cover a certain amount for a service, regardless of who performs it. MR. RIDGEWAY replied "yes." TAPE 02-39, SIDE B REPRESENTATIVE HAYES said he thought it more of a HESS [Department of Health & Social Services] issue than an [Division of] Insurance issue. He said, "If HESS thought it was a dollar issue here, we would have a fiscal note from them" that would probably be indeterminate. REPRESENTATIVE ROKEBERG disagreed with Representative Hayes and said, "This is an insurance question." Number 2327 CHAIR MURKOWSKI offered her understanding that the division had taken a neutral position on the matter, and that the division determined that there should be a zero fiscal note. MR. RIDGEWAY said Representative Murkowski was correct and that the division just regulates insurance. [House Bill 411] would add no cost to the division, and therefore no fiscal note. Number 2302 REPRESENTATIVE ROKEBERG said his interpretation of the "relatively ambiguous language" was that the status quo is preserved by [HB 411], "therefore, if there is an ability of an underwriter to make a distinction between the service provided by a PA or a physician, that this doesn't change that." He added that he didn't care for the language, and that it needs to be clarified. REPRESENTATIVE ROKEBERG asked Representative Fate if he could verify with the Division of Insurance what the impact of the language in Section 2 is as far as allowing health insurance companies to reimburse a PA at a different rate than that of a physician. He asked if "that's allowable or this maintains the status quo ... or as Mr. Ridgeway and we've discussed here, is it based on the service, not the type of provider?" Number 2199 REPRESENTATIVE KOTT moved to report HB 411 out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, HB 411 was moved out of House Labor and Commerce Standing Committee.
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