Legislature(2017 - 2018)BARNES 124
02/01/2017 03:15 PM House LABOR & COMMERCE
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| Audio | Topic |
|---|---|
| Start | |
| HB49 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 49 | TELECONFERENCED | |
HB 49-EXTEND BOARD OF DIRECT-ENTRY MIDWIVES
3:17:31 PM
CHAIR KITO announced that the only order of business would be
HOUSE BILL NO. 49, "An Act extending the termination date of the
Board of Certified Direct-Entry Midwives; and providing for an
effective date."
3:18:12 PM
CRYSTAL KOENEMAN, Staff, Representative Sam Kito, Alaska State
Legislature, on behalf of Representative Kito, prime sponsor,
presented HB 49, which extends the Board of Direct-Entry
Midwives for four years. She mentioned that the Division of
Legislative Audit determined that extending the board is in the
best interest of the state and is important to the safety of
Alaska's women and children. The board currently licenses 52
licensees and consists of two certified direct-entry midwives,
one physician, one certified nurse, and one public member. She
explained that midwives assist in about 500 births outside of a
hospital setting each year in Alaska and many more births in a
hospital setting. She asked for the committee's support of the
proposed legislation.
3:19:40 PM
REPRESENTATIVE KNOPP asked why the board is not permanent.
3:20:08 PM
CHAIR KITO stated that Kris Curtis could better address board
term limits.
3:20:23 PM
REPRESENTATIVE STUTES asked why the board has such a large
deficit and whether there have been approaches to bring it out
of the hole.
MS. KOENEMAN stated that the board and the Department of
Commerce, Community & Economic Development (DCCED) have been
working diligently to reduce the deficit. She stated that the
investigative costs associated with the board have been a large
contributor to the deficit.
REPRESENTATIVE STUTES asked whether the board has increased its
fees.
CHAIR KITO responded that either the department or legislative
audit would be better suited to answer that question.
3:21:45 PM
REPRESENTATIVE BIRCH stated that three of his four grandchildren
were delivered by a midwife. He stated his concern for the
sunset date and asked for clarification on what the distinction
"direct-entry midwife" means.
MS. KOENEMAN answered that direct-entry midwife is a
classification by the state, but other testifiers could better
clarify that.
3:23:37 PM
KRIS CURTIS, Legislative Auditor, Legislative Audit Division,
Legislative Agencies and Offices, testified on HB 49 and
presented the sunset audit conducted on the Board of Direct-
Entry Midwives. She mentioned that a sunset audit determines
whether a board is serving the public's interest and should be
extended. She informed the committee that the sunset process
started in the 1970s, and the concept of sunset is used in many
states. The idea behind sunsetting is that when a government
entity is created, there should be an analysis of whether it
should continue in perpetuity. Occupational boards, other
boards, and commissions all have sunset dates. She stated that
last year three audits were conducted for entities terminating
this year, and this year 11 sunset audits will happen for
entities set to terminate in 2018.
3:25:16 PM
REPRESENTATIVE WOOL asked about boards that were not extended.
MS. CURTIS stated that the sunset process has been in place for
a long time, and it is unusual for an audit to recommend
termination. Audits have determined that there is no need for
continuing some entities such as the Alaska Health Care
Commission and the Board of Barbers and Hairdressers. She said
that recommendations for sunset are unusual; more often a term
is set for the next review. She related that boards cannot be
extended for more than 8 years.
3:26:26 PM
REPRESENTATIVE JOSEPHSON recalled that prior legislation
eliminated statutory oversight of midwives and instead left
regulation to the board. He asked "what was so onerous or
improper, and why did we make that change?"
MS. CURTIS stated that the reason for the change was that it is
easier for the board to change practice through regulation
without legislation and to take practice requirements out of
statue and into regulation. She offered her understanding that
the board finalized the regulations in February 2016.
3:27:59 PM
REPRESENTATIVE BIRCH restated his interest in knowing what
"direct-entry midwives" means.
MS. CURTIS offered her opinion that it is a term based on
requirements to become a direct-entry midwife, but there are
also nurse midwives who are certified nurses.
REPRESENTATIVE BIRCH asked whether there is a potential for
using the Legislative Information Office (LIO) for board
meetings to mitigate travel expenses.
MS. CURTIS stated that the audit looks at meetings and
operations and determines if the costs are reasonable. The
personal services reflect regulatory and investigative costs,
which are the biggest cost fluctuations for the board.
3:30:09 PM
MS. CURTIS began her presentation of the audit [included in the
committee packet]. In the 2014 audit, there were concerns that
investigations that posed a public safety risk were not being
actively processed. Therefore, the board was only extended two
years. She expressed that this year's audit found that the
board is serving the public's interest by monitoring licensees,
licensing appropriately, and issuing regulations that benefit
the industry.
MS. CURTIS noted that the audit recommended three changes. The
first is a recommendation to the director of the Division of
Corporations Business and Professional Licensing (DCBPL), in
consultation with the board, to increase fees to reduce the
deficit. Between the 2014 and 2016 audits, fees were increased,
but not enough to cover operations of the board. The second
recommendation is to the director to take steps in ensure
accurate record keeping of licenses, which reflects that the
audit found simple errors by the DCBPL staff. The final
recommendation is to the state legislature to consider alternate
forms of regulating the midwifery profession in light of the
large deficit and the small number of licensees who bear the
cost of the deficit. She noted that in order to address the
deficit, DCBPL was planning on raising fees by 50 percent every
two years. By 2020, the licensing fee would be around $4,000,
which would pose a barrier to entry into the profession,
limiting the number of practicing midwives.
3:33:19 PM
REPRESENTATIVE BIRCH asked how frequently a critical review of a
licensee occurs, and whether licenses have been rescinded.
MS. CURTIS stated that an investigative section within DCBPL
fields complaints to determine basis and purview before
conducting an investigation. She noted that the 2014 audit
found that some investigations had stalled, but the 2016 audit
found that they had been addressed. Licenses are rescinded
periodically on this board, like with other boards.
3:35:18 PM
REPRESENTATIVE JOSEPHSON said that "these boards" are generally
supposed to pay for themselves and questioned if that is always
good policy. He referred to the recommendation on page 11 of
the audit and asked whether it is reasonable to offer the
licensees independence if they pay the $4,000 fee or find
another mechanism if they decline.
MS. CURTIS asked for clarification whether Representative
Josephson proposes that some midwives would be regulated by a
board and some would not. She mentioned that even without the
board, licensing and oversight would be handled by DCCED.
REPRESENTATIVE JOSEPHSON stated that at some point the
institution may refuse to pay such high fees. He asked what [a
licensee] gets out of being in the commission.
MS. CURTIS stated that benefits include being close enough to
the industry to self-regulate through peer review, having rules
set in place for quality control, and having education
requirements to ensure competency. She urged the committee to
ask the testifiers why they see a benefit in being regulated.
3:39:01 PM
REPRESENTATIVE SULLIVAN-LEONARD asked whether there has been
discussion with the nursing or medical boards to assist the
Board of Certified Direct-Entry Midwives to stay active. She
asked if the board would merge with another board if disbanded
and if that has been discussed with the other boards.
MS. CURTIS stated that the other individual boards have not been
spoken to. They were mentioned due to the similarity of
occupations.
3:40:28 PM
REPRESENTATIVE WOOL stated his understanding that if the board
was not extended, then it would fall under the Division of
Corporations, Business, and Professional Licensing (DCBPL),
which doesn't have midwifery expertise. He noted that a main
point of the audit recommendations is the financial loss the
board has incurred, largely due to investigations. He asked if
the deficit would exist under a different department without the
board. He asked if the investigations are common in other
occupations, and if boards are always responsible to cover the
cost of investigations.
MS. CURTIS answered yes; there is a statute stating that all
boards must set fees to cover the cost of regulation. The
decision goes back to the 1990s. She noted that many boards
have deficits stemming from the fee setting process; deficits
are not unique to this board or the medical area. She expressed
that a deficit is often a reflection of the number of licensees
who bear the cost of investigations. Boards with a smaller
number of licensees tend to have larger deficits. She reported
that many investigations and big regulation projects drive high
costs for boards.
3:43:13 PM
REPRESENTATIVE STUTES told of her personal experience with the
Big Game Commercial Services Board, which had a huge debt, even
though its 2014 statement showed it was in the black. The next
year the budget showed the board back in the red. She pointed
out that this was clearly the result of inadequacies in
bookkeeping. She stated her concern that a deficit could be
skewed as a result of bookkeeping.
3:45:12 PM
CHAIR KITO stated that the board investigation fee issue would
be discussed by the House Labor and Commerce Standing Committee
later this session.
REPRESENTATIVE STUTES commented that increasing fees may not be
the appropriate action to address the deficit. The money is
still owed whether or not the board sunsets.
3:46:07 PM
MS. CURTIS noted that there have been problems at the department
with improper accounting of indirect individual cost allocation.
The department received a supplemental appropriation to make the
boards whole and not to hold them accountable for the improper
accounting. She noted that a more recent review of the new
accounting procedures showed that the problems with financial
reporting to the boards were corrected, and improvements have
been made in the department.
3:47:18 PM
REPRESENTATIVE KNOPP asked whether investigative costs are
associated with licensing someone or are more of a follow up
cost. He suggested that if the high costs are associated with
qualifying a candidate for licensing, then the regulations might
be excessive.
MS. CURTIS responded that some investigative costs could be
associated with licensing, but most of the more material cost of
investigations comes from complaints. The audit tests licenses
to ensure they comply with statutes and regulations, but the
department does not determine if the regulations are excessive -
regulations are passed by the legislature. She noted that if
the Legislative Audit Division heard problems and concerns about
the quality of licensing regulations, then it would pursue them,
but that has not been the case with this board.
MS. CURTIS stated, in response to a follow-up question, that the
costs largely come from the investigative section not having to
do with licensing and from working with the department of law to
get support through reimbursable service agreements.
3:49:34 PM
REPRESENTATIVE STUTES asked who determines who does the
investigation - the board or the department - as investigations
create a huge expense. She referenced her previous experience
when a board didn't want to investigate because investigating
would cost much more than the fine.
MS. CURTIS stated that the board itself must stay out of the
investigative process, because the board's opinion is rendered
on the results. The investigators can consult a board member
for expertise. She continued as follows:
They come into the division. The division is ... the
entity by statute that has the authority to do the
investigation. They come to the board, provide them
status updates. Ultimately when they have a result
from their investigation, they will provide their
suggestion or consent agreements, and the board itself
has to approve them.
3:51:27 PM
REPRESENTATIVE WOOL asked for an example of an investigation and
what would be investigated.
MS. CURTIS stated that one area investigated is unlicensed
activity. She questioned whether it is fair for the board to
bear the cost of investigating people that aren't licensed or if
it is more of a criminal offense. Another area often
investigated is malpractice, which is a public safety issue.
3:52:53 PM
CHAIR KITO stated that testifiers from other organizations are
present. He stated that the cost issue will be covered in a
later meeting, and he urged the committee to focus on "the
midwives side of things."
3:53:29 PM
REPRESENTATIVE JOSEPHSON added that the legislature has looked
at the issue, at length many times, and the committee might
benefit from some of that experience.
3:54:06 PM
DEBORAH SCHNEIDER, Chair, Board of Certified Direct-Entry
Midwives, asked for support to extend the board through HB 49.
She stated that she has been part of the profession since its
establishment in the 1990s. Midwives are hoping to see the
industry grow in Alaska, and the safest way for that to happen
is under the direction of a board that understands the
industry's specific difficulties. She offered that healthcare
dollars in Alaska are being stretched to cover Alaskan mothers
and babies, and midwives provide valuable service with an
incredible cost savings.
MS. SCHNEIDER noted that the board has been working hard to
reduce its deficit. The investigation costs are partially due
to prolonged investigations of five or six years or more. She
stated that the board could not do anything to reduce the money
spent on those prolonged investigations until changes were made
in the investigative division that brought those investigations
to a conclusion.
MS. SCHNEIDER summarized that other measures will eventually
bring the deficit under control. She remarked that by providing
midwifery with a board, Alaskans will have the best midwifery
practice in the United States. Since first becoming a board,
other states have looked to Alaska's board and regulation
process for help. She urged the committee's support of HB 49.
3:56:43 PM
REPRESENTATIVE SULLIVAN-LEONARD referred to Ms. Schneider's
letter, on page 24 of the audit, and asked for confirmation that
Ms. Schneider was in favor of an increase in fees in order to
help pay off the deficit for the board.
MS. SCHNEIDER answered yes. She noted that the board raised the
fees last year to $3,800 and she expects midwives will be paying
that for the foreseeable future. She stated that the board is
working to reduce the other areas of the deficit and work with
the investigative groups to make sure there are not extended and
protracted cases.
REPRESENTATIVE SULLIVAN-LEONARD referred to her experience in
healthcare. She stated that when the board is "ahead of the
game ... financially," she hopes fees would be adjusted
accordingly.
3:58:12 PM
REPRESENTATIVE BIRCH reiterated his question about the meaning
of "direct-entry."
MS. SCHNEIDER responded that direct-entry midwives are non-nurse
midwives. There are two categories: those who have received a
nursing degree and those with a different route of entry [to the
industry]. She noted that direct-entry midwives do not practice
in the hospital, they practice in a home or birth center and
specialize in helping low-risk mothers.
3:58:54 PM
REPRESENTATIVE BIRCH asked if there is another group of midwives
out there who went through a different path and are also
delivering children.
MS. SCHNEIDER responded that in Alaska, midwifery is practiced
by certified nurse midwives or certified direct-entry midwives.
3:59:46 PM
SUSAN TERWILLIGER, President, Midwives Association of Alaska,
expressed her support of HB 49 for herself and on behalf of the
membership of the association. She stated that she has been a
licensed midwife in Alaska since 2005 and has 29 total years of
practice. She offered that the profession is best governed by a
board that understands the industry's place in the health care
system. The profession provides comprehensive care during
pregnancy, birth, and postpartum to healthy, low-risk mothers
and babies and serves all socio-economic walks of life. The
board protects public safety by developing and updating clear
regulations, keeping with national standards, and using a
detailed system of accountability. She stated that midwives
have a close professional working relationship with the board;
there is a mutual desire to have the best laws in the nation
governing direct-entry midwives. Alaska needs midwives to be
governed by their own board. She added that some direct-entry
midwives are also nurses, but have chosen not to be certified
nurse midwives but to be direct-entry midwives. She mentioned
that there are basically two parallel routes to midwifery: nurse
midwifery or going directly into midwifery without necessarily
going through nursing school first.
4:03:08 PM
JANEY HOVENDEN, Director, Division of Corporations, Business,
and Professional Licensing (DCBPL), Department of Commerce,
Community & Economic Development (DCCED), stated that the costs
associated with licensing the profession would continue without
the board - with the exception of board-specific costs like
travel and meeting costs - but would fall under the department
or an alternative form of regulation such as another board.
4:04:02 PM
REPRESENTATIVE WOOL noted that a lot of the costs are due to
investigations of non-licensed persons, but the board is
responsible for paying for the investigations. He asked if
paying for the investigation of someone not licensed or
affiliated with the board is common to other boards.
MS. HOVENDEN stated that is correct; it is statutorily required
for boards and programs that oversee [professions].
4:05:27 PM
REPRESENTATIVE STUTES asked how many department staff members
attend the board's meetings.
MS. HOVENDEN answered typically one. She noted that the
department has undergone strict travel policy changes, which
have restricted meetings to the least costs associated.
Typically one person from the department would fly or attend the
meetings, and the department has tried to have the examiner
attend telephonically.
REPRESENTATIVE STUTES asked if this is a recent policy change.
MS. HOVENDEN answered that it has been about a year.
4:06:42 PM
CHAIR KITO opened public testimony on HB 49.
4:07:05 PM
MADISON NOLAN GRIMES, Director, Juneau Family Health and Birth
Center, testified in support of HB 49. She stated that she has
been a licensed direct-entry midwife for three years. She said
HB 49 would support midwives to maintain safe practice
guidelines and to provide safe, up-to-date care. The board
provides regulatory support to ensure that midwives are meeting
standards of care and doing the best they can for Alaskan women
and families. Maintaining the board is the best way to make
sure licensees are practicing in the safest way possible and
maintaining national standards.
4:08:06 PM
REPRESENTATIVE SULLIVAN-LEONARD asked Ms. Nolan Grimes how many
births happen per year in her practice and if physicians or
nurses assist or oversee the midwives in her practice.
MS. NOLAN GRIMES stated that her practice has three direct-entry
midwifes licensed on staff, and the practice does between 55-60
births a year. She noted that there are complications in the
course of care that require consultation due to regulations or
common sense. In such cases, there are collaborating
physicians, but they are not required to have a signed
collaboration agreement. She stated that her practice works
with physicians and advanced nurse practitioners as necessary.
4:09:15 PM
REPRESENTATIVE JOSEPHSON asked if there is a code to bill an
insurance company.
MS. NOLAN GRIMES answered yes.
4:09:36 PM
REPRESENTATIVE KNOPP asked whether there is a continuing
education component to the profession.
MS. NOLAN GRIMES answered yes. She added that within every
licensing cycle each midwife is required to meet a certain
number of continuing education units and annually have a peer
review to ensure regulations are being followed.
REPRESENTATIVE KNOPP asked who put in the requirements - the
board or the state.
MS. NOLAN GRIMES offered her understanding that there was
licensure before a board existed, so the requirements were
initially in statute. A few years ago requirements were pulled
from statute into regulation for better adaptation, which the
board now handles. She stated that the continuing education
requirements and peer reviews have not changed since they were
put in place by the legislature.
REPRESENTATIVE KNOPP asked if the potential for midwives to
practice "under the radar" was discussed with the recent fee
raise.
MS. NOLAN GRIMES stated that there were extensive conversations
within the midwifery association about that potential situation.
She mentioned that she is lucky because her practice pays the
licensing fees. She stated that there is a lot of concern that
apprentices may not join the field due to the expense - the
licensing fees might equate to a midwife's income in a month.
4:12:57 PM
JOHANNA CROSSETT, Direct-Entry Midwife, testified in support of
HB 49. She stated that she loves helping babies and mothers.
She noted that midwives save the state money in Medicaid
dollars. The unique profession requires having a direct-entry
midwifery board for proper regulation. She stated that the
board understands its unique niche in the medical community and
within the state's healthcare system. The board expertise
allows the profession to continue to adopt and uphold standards
of safe practice in Alaska.
4:14:26 PM
DEBORAH GILLESPIE, Direct-Entry Midwife, testified in support of
HB 49. She stated that she is a licensed naturopath and a
direct-entry midwife.
4:14:56 PM
REPRESENTATIVE JOSEPHSON asked whether it is legal to deliver a
baby without being licensed. He stated that it seems unfair the
licensed midwives should be "watching the rest of the Alaskans"
to see who is practicing midwifery.
MS. GILLESPIE responded that she agrees with Representative
Josephson's statements. She offered her understanding that is
not legal to practice without a license. She stated that people
helping to deliver babies in the Interior represents a portion
of investigative fees, but she is not sure how many of the
investigations involved unlicensed individuals.
4:16:54 PM
CHAIR KITO speculated that if an individual helps deliver a baby
without expectation of trade or payment, then it might not be
under a licensing investigation. If someone solicits payment or
trade for such services, then it is commerce and would engage
the licensing board.
4:17:16 PM
REPRESENTATIVE BIRCH asked who would oppose the extension of the
board, as it seems like a reasonable and necessary extension.
4:18:00 PM
MS. GILLESPIE stated that she cannot think of a reason someone
would oppose the extension. She stated that as a naturopath,
she has experience in a profession without a specific board, and
her fees tripled this year; she had $3,800 in fees as a midwife
and nearly $2,000 as a naturopath.
4:18:56 PM
REPRESENTATIVE WOOL asked if midwifery is an exclusively female
profession and what a male midwife is called.
MS. GILLESPIE stated that there are male midwives who are called
midwives.
4:19:37 PM
REPRESENTATIVE KNOPP asked if an individual would continue
practicing if it got to the point where a person couldn't afford
licensing. He stated his belief that a person would operate
underneath the radar if he/she had been priced out of the market
but knows himself/herself to be qualified.
MS. GILLESPIE offered that she thinks the state stands to lose
more midwifes than to have midwifes practice illegally.
4:20:43 PM
CHAIR KITO announced that HB 49 was held over.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB049 Fiscal Note DCCED CBPL 1.27.17.pdf |
HL&C 2/1/2017 3:15:00 PM HL&C 2/3/2017 3:15:00 PM |
HB 49 |
| HB049 Sponsor Statement 01.30.17.pdf |
HL&C 2/1/2017 3:15:00 PM HL&C 2/3/2017 3:15:00 PM |
HB 49 |
| HB049 Supporting Documents-Full Sunset Audit 01.30.17.pdf |
HL&C 2/1/2017 3:15:00 PM HL&C 2/3/2017 3:15:00 PM |
HB 49 |