03/08/2005 03:00 PM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HB151 | |
| HB16 | |
| HB20 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 151 | TELECONFERENCED | |
| + | HB 16 | TELECONFERENCED | |
| + | HB 20 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
HOUSE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
March 8, 2005
3:07 p.m.
MEMBERS PRESENT
Representative Peggy Wilson, Chair
Representative Paul Seaton
Representative Tom Anderson
Representative Lesil McGuire
Representative Sharon Cissna
Representative Berta Gardner
MEMBERS ABSENT
Representative Vic Kohring
COMMITTEE CALENDAR
HOUSE BILL NO. 151
"An Act relating to provider responsibility for ocular
postoperative care; and providing for an effective date."
- HEARD AND HELD
HOUSE BILL NO. 16
"An Act relating to funding for school districts operating
secondary school boarding programs and to funding for school
districts from which boarding students come; and providing for
an effective date."
- MOVED HB 16 OUT OF COMMITTEE
SPONSOR SUBSTITUTE FOR HOUSE BILL NO. 20
"An Act relating to a separate appropriation bill for operating
expenses for primary and secondary public education and
establishing a date by which the bill must be transmitted to the
governor each year; relating to notice of nonretention for
tenured teachers; and providing for an effective date."
- MOVED CSSSHB 20(EDU) OUT OF COMMITTEE
PREVIOUS COMMITTEE ACTION
BILL: HB 151
SHORT TITLE: RESPONSIBILITY FOR CARE AFTER EYE SURGERY
SPONSOR(S): LABOR & COMMERCE BY REQUEST
02/14/05 (H) READ THE FIRST TIME - REFERRALS
02/14/05 (H) HES, L&C
03/01/05 (H) HES AT 3:00 PM CAPITOL 106
03/01/05 (H) Scheduled But Not Heard
03/08/05 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 16
SHORT TITLE: SCHOOL FUNDS RELATED TO BOARDING SCHOOLS
SPONSOR(S): REPRESENTATIVE COGHILL
01/10/05 (H) PREFILE RELEASED 12/30/04
01/10/05 (H) READ THE FIRST TIME - REFERRALS
01/10/05 (H) EDU, HES, FIN
02/24/05 (H) EDU AT 11:00 AM CAPITOL 106
02/24/05 (H) -- Meeting Canceled --
03/01/05 (H) EDU AT 11:00 AM CAPITOL 106
03/01/05 (H) Moved Out of Committee
03/01/05 (H) MINUTE(EDU)
03/03/05 (H) EDU RPT 3DP 2NR
03/03/05 (H) DP: SALMON, WILSON, NEUMAN;
03/03/05 (H) NR: GATTO, THOMAS
03/08/05 (H) HES AT 3:00 PM CAPITOL 106
BILL: HB 20
SHORT TITLE: EDUCATION FUNDING
SPONSOR(S): REPRESENTATIVE SEATON
01/10/05 (H) PREFILE RELEASED 12/30/04
01/10/05 (H) READ THE FIRST TIME - REFERRALS
01/10/05 (H) EDU, HES, FIN
01/24/05 (H) SPONSOR SUBSTITUTE INTRODUCED
01/24/05 (H) READ THE FIRST TIME - REFERRALS
01/24/05 (H) EDU, HES, FIN
01/25/05 (H) EDU AT 11:00 AM CAPITOL 106
01/25/05 (H) -- Meeting Canceled --
02/01/05 (H) EDU AT 11:00 AM CAPITOL 106
02/01/05 (H) Heard & Held
02/01/05 (H) MINUTE(EDU)
02/22/05 (H) EDU AT 11:00 AM CAPITOL 106
02/22/05 (H) -- Meeting Canceled --
03/01/05 (H) EDU AT 11:00 AM CAPITOL 106
03/01/05 (H) Moved CSHB 20(EDU) Out of Committee
03/01/05 (H) MINUTE(EDU)
03/03/05 (H) EDU RPT CS(EDU) NT 2DP 3NR
03/03/05 (H) DP: WILSON, NEUMAN;
03/03/05 (H) NR: SALMON, GATTO, THOMAS
03/08/05 (H) HES AT 3:00 PM CAPITOL 106
WITNESS REGISTER
JOHN BITTNER, Staff to Representative Anderson
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented HB 151 on behalf of the sponsor,
Representative Anderson.
CARL ROSEN, M.D., President
Alaska Academy of Ophthalmology
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 151.
CYNTHIA BRADFORD, Secretary of State Affairs
American Academy of Ophthalmology
Corvallis, Oregon
POSITION STATEMENT: Testified in support of HB 151.
BOYD WALKER, Optometrist
Homer Eye Care Center
Homer, Alaska
POSITION STATEMENT: Testified in opposition to HB 151.
MICHAEL BENNETT, President
Alaska Optometric Physicians Association
Juneau, Alaska
POSITION STATEMENT: Testified in opposition to HB 151.
MICHAEL COULTER, Ophthalmologist
Alaska Lasik Center
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 151.
REPRESENTATIVE JOHN COGHILL
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Testified as the sponsor of HB 16.
ACTION NARRATIVE
CHAIR PEGGY WILSON called the House Health, Education and Social
Services Standing Committee meeting to order at 3:07:42 PM.
Representatives Wilson, Seaton, Anderson, McGuire, Gardner, and
Cissna were present at the call to order.
HB 151-RESPONSIBILITY FOR CARE AFTER EYE SURGERY
3:09:30 PM
CHAIR WILSON announced that the first order of business would be
HOUSE BILL NO. 151 "An Act relating to provider responsibility
for ocular postoperative care; and providing for an effective
date."
3:10:10 PM
REPRESENTATIVE ANDERSON, speaking as the sponsor of HB 151,
explained that he wants HB 151 to work for both optometrists and
ophthalmologists, although at this point he said he agrees with
the ophthalmologists.
3:11:29 PM
JOHN BITTNER, Staff to Representative Anderson, Alaska State
Legislature, relayed that HB 151 outlines rules and restrictions
regarding the delegation of postoperative care for eye surgery
patients. Section 1 places limits on how and when a surgeon who
performs eye surgery in the state may delegate responsibility
for postoperative care of the patient to someone else. He
explained that some of the restrictions include defining the
provisions of the comanagement agreement, mandating that the
surgeon who performs the surgery must remain physically
available to the patient for 120 hours, and allowing the
ophthalmologist to delegate the responsibility for after care if
they arrange for another ophthalmologist to care for the patient
for those 120 hours. Furthermore, the restrictions also outline
when a comanagement agreement for postoperative care may be
entered into, maintains that any fees incurred as a result of
the agreement must reflect fair market value, and includes
provisions for the disclosure of the comanagement agreement to
the patient.
MR. BITTNER relayed that Sections 2-3 require compliance with
Section 1, thus, maintaining consistency in the statutes.
Section 4 specifies the definition of "knowingly," which is a
term used in Sections 1 and 3. Sections 5 and 7 amend the
uncodified law of the State of Alaska to add an effective date,
which allows the Alaska State Medical Board (State Medical
Board) to begin the regulations process before the rest of the
bill takes effect. Section 6 amends the uncodified law allowing
the application of the amendments made by the bill to eye
surgery occurring on or after the effective date of Sections 1-
4. Mr. Bittner clarified that the intent of HB 151 is to
provide standards of care regarding comanagement agreements for
postoperative care of eye surgery patients. He added that the
sponsor feels that there is a minimum standard of care each
Alaskan should expect after receiving eye surgery, which HB 151
ensures. He specified that this bill in no way reflects poorly
on the comanagement system. The sponsor is not against the
collaboration of ophthalmologists and optometrists when it is in
the best interest of the patient. The bill merely establishes
limits to the comanagement system to ensure that the patient's
needs come first.
3:13:54 PM
REPRESENTATIVE SEATON asked if the State Medical Board currently
has the ability to regulate postoperative care.
REPRESENTATIVE ANDERSON deferred to the ophthalmologists.
3:15:13 PM
REPRESENTATIVE GARDNER asked if there are other surgical
procedures for which the state mandates that the surgeon remain
available for a specified amount of time.
MR. BITTNER replied that he was not aware of any, but he offered
to research that and provide an answer.
3:16:04 PM
CARL ROSEN, M.D., President, Alaska Academy of Ophthalmology, in
response to Representative Seaton's question, said that the
State Medical Board has the jurisdiction to regulate
postoperative care, although the issue has yet to arise. In
response to Representative Gardner, Dr. Rosen said that the
"lion's share" of comanagement occurs between ophthalmology and
optometry.
DR. ROSEN, after relating his background in ophthalmology,
related that the Alaska Academy of Ophthalmology favors HB 151,
in order to protect patients and to avoid the abuses that have
arisen from comanagement. Comanagement originally began with
good intentions, although it has become distorted based on
financial incentives, he said. He asked the committee to join
together to raise the standard of medical care for Alaskans by
keeping the "bar high or elevated." He related his belief that
ophthalmologists, despite that optometrists would have folks
believe that ophthalmologists are nothing more than surgical
technicians who are only capable of wielding a scalpel or laser,
represent the best the American medical system has to offer. He
said:
There will be rare times when comanagement is
necessary and legitimate: in rural areas with no
other ophthalmologist or surgeon available, or when
the surgeon has no other choice but [has] to leave
shortly after an operation. However, we are asking to
shut the door on the routine use of this arrangement,
which unfortunately occurs here in our state.
Patients simply do not understand what they are
getting into until it is too late.
DR. ROSEN then provided an example of a comanagement case in
which a patient, who was operated on by an ophthalmologist who
routinely has an optometrist follow postoperative care, came to
the emergency room for a corneal surgical complication. The
optometrist, as is typical, was nowhere to be found because
optometrists have never taken call for hospitals or emergency
rooms at Providence Hospital or Alaska Regional Hospital. Since
the emergency room physician isn't going to track down or refer
to an optometrist for liability issues, an ophthalmologist is
contacted and [the aforementioned patient] becomes that
ophthalmologist's responsibility.
DR. ROSEN continued:
In summary, comanagement can be a legitimate and
useful tool for patients in rare circumstances, but
should never be employed on a routine basis whereby
the optometrist expects to be paid for every patient
[who] gets referred to a particular ophthalmologist;
this was never the intent of the Office of the
Inspector General or Medicare. .... Please, join us
in closing this loophole that will ensure that our
constituents and our patients retain the highest
quality of medical care available.
3:20:38 PM
REPRESENTATIVE GARDNER posed a situation in which a patient
needs emergency services from another surgeon because the
original surgeon is unavailable. She asked whether the services
rendered would be billed separately.
DR. ROSEN said that may be true, however, it can be a battle
with the insurance company. In further response to
Representative Gardner, Dr. Rosen explained that although the
insurance company may be responsible for the payment in certain
instances, it's more complicated if the surgery is an elective
procedure paid via cash.
3:22:08 PM
CYNTHIA BRADFORD, Secretary of State Affairs, American Academy
of Ophthalmology, speaking on behalf the body's 27,000 members,
related that HB 151 addresses a problem unique to surgical eye
care, which is an issue that affects other states. She added
that ocular care and surgery is one of the few situations in
which non-physicians are inappropriately [allowed to provide]
postoperative care on a sometimes-routine basis. Comanagement
was intended for special situations only, although it has been
abused for financial reasons. She characterized HB 151 as good
health policy, which she supports.
3:24:21 PM
BOYD WALKER, Optometrist, noted his opposition to HB 151 because
he feels it's not in the public's best interest. He related,
"Representative Anderson has been given some misleading
information, which unfortunately he is providing to [the
committee] as factual." He relayed that testimony has alluded
to "cataract mills," where optometrists refer patients to
surgeons for comanagement fees. He said that he could assure
the committee unequivocally that such an arrangement doesn't
exist in Alaska. Furthermore, such a situation is unethical for
both the surgeon and the referring optometrist. He said:
There does exist in Anchorage a surgical center, which
is the thinly veiled subject of this bill. And this
center has established a reputation for quality
patient care and surgery, and many optometrists in the
state refer to this clinic - not for a comanagement
fee as purported by the supporters of this bill - but
rather because optometrists know that their patients
will be given the best quality care available. And by
far, the most outrageous assertion in Representative
Anderson's statement is that optometrists are not
qualified by training or experience to handle any
serious complications resulting from cataract surgery.
I have been comanaging patients in this state for
close to 20 years and many of these patients were
comanaged with surgeons who apparently support this
bill, including Dr. Rosen, whom I highly respect.
They apparently had no concerns about my ability to
either manage or identify the need to return that
patient to them for surgical intervention for a
postoperative complication. Comanagement has been
effectively regulated in Alaska and all other states,
for decades, by the guidelines established by the U.S.
Department of Health and Human Services. Dr. Rosen
states that this legislation would have no fiscal
impact to consumers or to health care cost, where
obviously the cost of the patient will be
significantly greater if the patient has to travel to
receive postoperative care [from] a surgeon that he
could've received locally from an optometrist. In
summary, this bill in no way improves the quality or
safety of eye care for surgical eye patients in the
state of Alaska. In fact, this bill is an ill-
conceived attempt to limit competition and the freedom
of choice of patients seeking eye surgery in our
state.
The proponents of this bill have attempted to demean
the optometric management of post surgical patients,
citing that optometrists are non-medical. Alaska
state law does entitle properly credentialed
optometrists to diagnose and treat ocular conditions,
despite Dr. Rosen's claim to the contrary.
Practically all post surgical patients will return
home one-day postoperatively and home in Alaska may be
a long distance from the surgeon. So, being able to
access a local optometrist for diagnoses and treatment
of post surgical complications, in many cases, saves
the patient expensive and possibly unnecessary travel.
Due to the diverse geography of our state and the
location of eye surgeons in the larger population
centers, optometrists who are located in remote areas
of our state are very important in assuring that
patients have direct access to care. This bill would
restrict that access. In my opinion, it would be a
great disservice to Alaska residents. Please do not
approve this unnecessary legislation.
3:28:19 PM
CHAIR WILSON asked for an approximate time range for which
surgeons should be available for postoperative care to avoid
complications.
DR. WALKER replied that surgeons are capable of that judgment.
He said that much of this legislation seems to imply that the
optometrist is dictating to the surgeon when the patient will be
returned to the optometrist. Although the surgeon should have
every right to determine how long the patient is kept under the
surgeon's control, a law allocating the amount of time surgeons
have to keep their patients "doesn't appear to be good
medicine," he opined. In further response to Chair Wilson, Dr.
Walker said he was not advocating a specified amount of time
because that's not the optometrist's job rather the surgeon is
responsible for the patient. Furthermore, the surgeon should
have confidence in the optometrist, otherwise the surgeon
shouldn't participate in a comanagement situation with the
optometrist.
3:29:57 PM
MICHAEL BENNETT, President, Alaska Optometric Physicians
Association, spoke in opposition to HB 151. He related that the
practice of having optometrists and ophthalmologists work
together to care for surgical patients is what comanagement is
about. He offered that comanagement is not exclusive to eye
care, for instance after oral surgery a patient returns to
his/her dentist for follow-up care. He highlighted that
optometrists outnumber ophthalmologists in Alaska about 5:1 and
are accessible in most locals whereas ophthalmology isn't. He
explained that optometrists diagnose the majority of surgical
conditions, refer patients to the appropriate specialists, and
prepare the patient for the necessary procedures. Since 1980,
comanagement procedures have been codified by Medicare and have
been ruled on more than once by the federal Office of the
Inspector General. In 1999, the Office of the Inspector General
issued the following guidelines for comanagement: it is not to
be a foregone conclusion that the surgeon will return the
patient for follow-up care to the referring practitioner, but it
should be addressed on a case-by-case basis; the services should
be medically necessary to the patient; the referral back should
be a clinically appropriate amount of time as judged by the
surgeon; and the services performed should be commensurate with
the amount of fees split. Postoperative care does not result in
an additional fee to the patient because a portion of the
surgical fee is designated for the postoperative care, which is
divided by 90 days and split by the amount of days the patient
is under the surgeon's care versus the other practitioner's
care, he related. In response to Chair Wilson, Dr. Bennett
explained that when the surgeon bills for the procedures, a
modifying code at the end of the procedure code is used to
indicate that the postoperative services will be split. If the
optometrist bills for that postoperative care, he/she would also
use a postoperative modifying code. In further response to
Chair Wilson, Dr. Bennett answered that he sees postoperative
patients almost daily. He related that many people choose to
leave Juneau to have medical care so he accommodates those
patients when they return from surgery. Dr. Bennett further
related that most of [his] follow-up is for patients who opt to
have surgery in Seattle or Anchorage because there are no
surgeons who come into Juneau and leave.
3:35:57 PM
DR. BENNETT, in response to Representative Gardner, explained
that if a patient opts to receive surgery out of town, the
amount of time between the patient returning home and the
surgery depends on the medical procedure. For instance, he
related that he works with a glaucoma specialist, in Seattle,
who occasionally performs cataract surgery and allows patients
to return to Juneau one day after the procedure and thus the
[optometrist with the comanagement agreement] would be in charge
of that patient's care. However, there are certain types of
glaucoma surgeries that are more complicated and often require
adjustments and interventions by the surgeon, and thus the
surgeon will require those patients to stay in Seattle for a
longer duration of time. The notion that one timeframe is
appropriate for all eye surgeries doesn't work, he opined. The
timeframe should be left to the surgeon and isn't a judgment
that optometrists, to his knowledge, are trying to make for the
surgeons. He highlighted that the surgeon is responsible for
the patient's 90-day postoperative period, and therefore the
ophthalmologist needs to be available to the patient or vice
versa if an issue arises within that 90-day postoperative
period. The surgeons and optometrists must work together to
provide the highest quality outcomes for their patients, he
stated.
DR. BENNETT opined that postoperative optometric care is not
only convenient and efficient for patients living in urban
areas, but it's imperative for those living in rural areas. He
alluded to the idea that the legislation would make it a
misdemeanor for optometrists to treat people five days after
surgery. He reiterated that comanagement has been effectively
federally regulated and the guidelines are "spelled out." If
the policy is abused, it should be addressed by the appropriate
State Medical Board. No other state has expanded upon the
federal regulations regarding eye surgical comanagement, he
added. Therefore, this legislation would limit the normal scope
of the optometrist's practice. He noted that many studies have
been conducted on comanaged ocular surgery and no difference in
the quality of outcomes has been shown between postoperative
care provided by optometrists versus the original surgeon.
[This legislation], he opined, will certainly make this care
more difficult to access and more expensive in regard to travel
that may be required of patients. In conclusion, Dr. Bennett
expressed the hope that the committee would agree that HB 151 is
anticompetitive, unnecessary, and not in the best interest of
patients.
3:42:19 PM
DR. BENNETT, in response to Representative Seaton, relayed that
the legislation would negatively impact patients in Juneau who
leave town for surgery because they would either be forced to
stay in the community where the surgery was performed or to
return to Juneau and place the optometrist in an "awkward legal
position for rendering care." He commented that he does not
know how this legislation would affect the comanagement
relationships with those patients receiving surgery out of
state.
REPRESENTATIVE SEATON said Dr. Bennett's question needs to be
answered at some point.
3:43:59 PM
MICHAEL COULTER, Ophthalmologist, Alaska Lasik Center, began by
saying that he was in favor of HB 151. He noted his agreement
with earlier testimony regarding the fact that comanagement has
existed for a long time as a result of ophthalmologic
requirements in certain communities and is successful in many
venues. However, he also noted his agreement with earlier
testimony that comanagement has the potential for abuse, which
"reek of collusion when referrals are made for monetary or
revenue stream considerations." He opined that this legislation
is an "inter-ophthalmologic effort to set certain standards for
all surgeons practicing in the state of Alaska." Currently,
there are six surgeons whom share call duties for Providence
Alaska Medical Center and Anchorage Regional Hospital and they
receive complex referrals from all over the state. He said:
We feel that if the standard of care would require
that all surgeons that would like to be a part of the
community and on staff at the hospitals also share in
that call, and certainly that if we are unable to take
call or unable to see our own postoperative patients,
that we are able to release our patient to a peer who
is also an ophthalmologist, board certified, and able
to do surgery. It's our feeling that, as the surgeon,
the surgeon himself or herself is best prepared to
identify potential complications in the immediate
postoperative period .... I do not agree ... that
this would somehow limit [an optometrist's] ability to
care for patients, especially here in Juneau; there
are two ophthalmologists here who are board certified
and work currently in the community .... The fact is
that nothing in the bill would restrict an optometrist
from seeing their patients, especially in situations
where it is a hardship, as deemed by the patient, to
be able to see the original surgeon; so there should
be no restriction in the flow of patient from their
surgeon to the optometrist. They're not barred, for
example, from providing care to the patient
postoperatively during the first five days. Our
requirement simply is that surgeons, that are doing
... surgery, remain available or can transfer the
responsibility for postoperative care to another
surgeon. And unfortunately, in the community of
Anchorage there are situations in which some surgeons
are operating, leaving immediately, leaving all
postoperative care, in the first moments after
surgery, to non-medically licensed professionals that
with all their skill and training - in our opinion -
are less capable of identifying potential
complications in a manner that the surgeon who
performed the procedure would be.
DR. COULTER offered that data from the American Academy of
Ophthalmology states that the surgeon who provided the original
care is in the best position to identify early postoperative
complications. During the first 120 hours after surgery is when
most complications occur, and he suggested that 48 hours is when
most "catastrophic complications might occur." Therefore, he
related his belief that surgeons should be held to the ethical
standard by which the surgeon is available for the first couple
of days of postoperative care.
DR. COULTER recalled testimony from optometrists stating that
the ophthalmologist should be allowed to determine, rather than
be legislated, when a patient can be released. Although Dr.
Coulter agreed with the aforementioned, the American Academy of
Ophthalmology has made it clear that ophthalmologists should be
available for at least five days postoperative; the burden
should not be left to ophthalmologists who have no association
with the patient. Malpractice insurers require that the surgeon
remain available to the patient or that the obligation be passed
on to another surgeon of equal competence for a period of days
after surgery. He said comanagement is "good" and the bill does
not limit access to optometric care, especially for those who
have limited access to ophthalmologists in their community. He
said:
The mandates through the American Academy of
Ophthalmology and the American Society of Cataract and
Refractive Surgeons have put through a joint policy
that are essentially recommendations, but there is no
ability to enforce those recommendations. And Alaska,
being fairly far away from the Lower 48, is often seen
... as perhaps a place that in the past has not met
standards of care .... I would suggest that Anchorage
and the larger communities of Alaska have met and do
meet the standards of medical care and all
ophthalmologic specialties. We do not necessarily
need to rely on outside professionals to render
appropriate or standard of care medical procedures.
And if those individuals wish to come and practice in
the state, that's fine as long as they're willing to
be here and take their share of call and take the
burden of community care upon their shoulders ....
So, for those reasons I support HB 151; I see it as an
advantage to the patients of Alaska. I think it
ensures that a surgeon is available for them for 48
hours and I'd urge your consideration for a favorable
vote on it.
3:52:23 PM
DR. COULTER, in response to Representative Gardner, said that
the American Academy of Ophthalmology is not an entity that
enforces its policies. In further response to Representative
Gardner, Dr. Coulter estimated that in excess of 90 percent of
board-certified ophthalmologists are members of the American
Academy of Ophthalmology.
3:53:12 PM
REPRESENTATIVE GARDNER asked whether the surgeons who come to
Anchorage and have the comanagement practices that Dr. Coulter
finds "objectionable" are members of the aforementioned body.
DR. COULTER answered he does not know, but added that most
surgeons abide by the recommendations from the aforementioned
body. He opined that HB 151 is about ensuring a standard is met
in a community that perhaps used to benefit from traveling
surgeons. Dr. Coulter indicated that HB 151 is about the entire
medical profession, and therefore he didn't see how it would
impact optometrists in their comanagement relationships.
3:54:11 PM
REPRESENTATIVE SEATON asked if an Anchorage surgeon were to
receive a referral from an optometrist in Juneau, under the
[proposed] provisions, would the surgeon only be able to refer
the patient back to an ophthalmologist.
DR. COULTER replied "no," the surgeon would need to personally
be available to the patient for 48 hours. A patient can choose
whether to return to Juneau to be seen by the patient's own
optometrist, which "is fine." He added that the spirit of the
reformation is that the surgeon should be available to that
patient to take responsibility for the postoperative care,
although he noted that an ophthalmologist can't force a patient
to see him/her for postoperative care. Dr. Coulter related his
understanding that under HB 151 there should be no limit to
optometric postoperative care.
3:56:02 PM
REPRESENTATIVE SEATON surmised then that an optometrist can
provide postoperative care for free or for other fees, although
it must be unrelated to the comanagement agreement.
DR. COULTER said the optometrist can charge what he/she desires
for the postoperative care. He related that when one of his
patients return to his/her community from which it's difficult
to get in touch with him, he makes a copy of the patient's
medical records and instructs the patient that "always without
compromise [the surgeon] see them at least 24 hours after the
procedure." However, when the patient lives in a rural area
it's easier to see an optometrist, he noted. He reiterated that
the point is that if a patient should change his/her mind or
have complications, the surgeon should be available during that
postoperative period.
3:57:30 PM
REPRESENTATIVE SEATON reiterated his understanding that the
optometrist can provide the postoperative care, as long as the
optometrist doesn't have an agreement to provide postoperative
care as part of the fee distribution under a comanagement
agreement.
DR. COULTER said that as long as the [postoperative care] is
outlined, [the bill] doesn't outlaw comanagement. He reiterated
that the legislation won't limit access to care or to the
surgeon who performed the surgery.
3:58:29 PM
REPRESENTATIVE MCGUIRE pointed out that ophthalmologists, as
medical doctors, have higher costs than optometrists and it's
less costly for them to enter into a comanagement agreement for
postoperative care with an optometrist. Therefore, a
comanagement agreement [for postoperative care] allows the
ophthalmologist to build-in lower costs. However, the consumer
is often unaware of the circumstances of the agreement and the
details of the postoperative treatment, she said. Due to the
aforementioned cost shifting mechanism, the patient "loses"
because the surgeon [isn't required] to be available 48 hours
postoperative if a complication arises. This legislation, she
opined, specifies that a surgeon, through a comanagement
agreement, can't shift the responsibility of postoperative care
to someone who doesn't have the same training. However, the
patient's choices are "preserved" in this legislation and it
doesn't prohibit a medical doctor from contracting with an
optometrist to provide care at some other point besides the
immediate postoperative time.
4:00:52 PM
REPRESENTATIVE SEATON highlighted the language on page 2, lines
12-15, which restricts the comanagement agreement to only
situations when the distance to the ophthalmologist is a
hardship for the patient and when the surgeon's personal travel
or illness is a factor. He surmised then that the comanagement
agreements are not fully available to the ophthalmologist and
optometrist, and can only be entered into under those
circumstances specified in the bill.
DR. COULTER replied, "For example, if a patient feels it's a
hardship to return and would prefer to see the optometrist ...
that would be fine, by my understanding."
CHAIR WILSON added her understanding that the legislation
doesn't prevent a surgeon from releasing the patient, 48 hours
after postoperative care, to follow-up care with an optometrist.
DR. COULTER relayed that the goal of HB 151 is to provide the
best quality patient care. If there weren't abuses of this
process, this wouldn't be an issue, he opined. He clarified
that the intent is to ensure that those surgeons who operate
within the state feel obligated to remain for a portion of the
postoperative period so that a disproportionate number of
postoperative complications don't fall in the laps of the six
ophthalmologists taking call for the state. Although
optometrists are well trained, they cannot perform surgery for a
problem that they identify, he noted. He related that surgeons
have no problem with competition. Furthermore, surgeons want
people to have choices, but patients should understand what they
are getting into, he opined.
4:04:51 PM
DR. COULTER, in response to Chair Wilson, said that a surgeon
can make agreements with another surgeon to [provide] care to a
patient if the original surgeon is inaccessible. He reiterated
that the goal of the legislation is to provide the best quality
of care, which he opined is when the surgeon remains available
to the patient for a few days postoperatively.
4:07:59 PM
REPRESENTATIVE SEATON pointed out that both "120 hours" and "48
hours" have been mentioned in reference to the surgeon's
postoperative availability, although the legislation specifies
"120 hours."
DR. COULTER said that according to the American Academy of
Ophthalmology and the American Society of Cataract and
Refractive Surgeons, 120 hours postoperative is the standard
period of time during which the patient is most likely to have
postoperative complications. If 120 hours seems excessive, 48
hours would be the minimum time in which a "catastrophic"
postoperative complication might occur. Therefore, a surgeon
should remain available for that time period or transfer the
patient to a peer, he added. In further response to
Representative Seaton, Dr. Coulter related that he could make
the studies relating to the postoperative timeframe available to
the committee.
4:09:41 PM
REPRESENTATIVE GARDNER suggested that if the current procedures
are placing patients at risk, this issue should be addressed by
the State Medical Board rather than the legislature.
DR. COULTER said that he can't comment on the State Medical
Association's ability to regulate how long a surgeon stays in
state after performing an operation.
4:10:19 PM
REPRESENTATIVE GARDNER asked if the [aforementioned body] is
"charged with sort of identifying and clarifying good medical
practice."
DR. COULTER replied that, in part, the State Medical Board is
responsible because surgeons have to meet rigorous standards to
obtain a medical license for the state. Certainly, the body is
effective at removing "poor surgeons or surgeons of excess
complications, or mass public outcry." However, he reiterated
that the extent of the body's power to regulate comanagement is
another issue.
4:11:23 PM
REPRESENTATIVE ANDERSON said:
To answer Representative Gardner's question, I think
that the Alaska Medical Association is the
professional regulatory body, but ... the
ophthalmologists came to me ... because they wanted
the foundation, the codification by statute. And, so
often, we see associations and professions come to
[the legislature] first ... and kind of by
extrapolation their professional regulatory body
handles it on a second level, but ... the strategy is
important and then there would be no miscommunication
....
REPRESENTATIVE ANDERSON highlighted that the legislation
mandates that doctors are available two days postoperatively,
and if not, the doctor must make arrangements with a peer. He
related his belief that the optometrist's testimony that the
legislation would prevent competition has been refuted by
addressing the patient's rights. In regard to the postoperative
timeframe, Representative Anderson said "I plan to make an
amendment. I think five days is unreasonable, and I know [that
was taken] from the federal language, but I think two days is
fine ...."
4:14:05 PM
REPRESENTATIVE MCGUIRE said in Alaska surgeons are required to
have a medical license and there is a "board that tracks that
and makes sure that the surgeons [who] come into our state are
competent." She related her belief that licensing encompasses
not only the surgery but also the after care, the
troubleshooting, and being there in critical moments. She
alluded to the idea [that comanagement] transfers the medical
licensee's credentials and the patient's fees to an
[optometrist] who doesn't have the residency, experience in
troubleshooting, and the additional higher sciences degree.
Furthermore, in some instances, it's for monetary value. She
said that regulating this through the State Medical Board is not
enough when it effects consumers so broadly, and therefore the
legislature needs to "spell it out in the statutes." She
relayed that many patients go into the [comanagement agreement]
because of the cost, although they are often [unaware] of the
consequences, which can be severe, if something goes wrong. She
noted that doctors ought to share the responsibility of call
duty, which is a service to the community, although she
acknowledged that doctors aren't profiting from it and are
putting themselves on the line from a liability standpoint.
4:17:24 PM
CHAIR WILSON added that the House Health, Education and Social
Services Standing Committee must keep in mind the best interest
of the residents of the state. She noted that the first
responders, people who attend to emergency situations and
transfer patients to hospitals, abide by the rule that they
never transfer a patient to a "lower level of care." She opined
that the aforementioned example is similar to this legislation
before the committee today because it assures the patient is in
[competent] hands.
4:19:15 PM
REPRESENTATIVE SEATON expressed concern with legislatively
saying "48 hours is right" when the committee does not have
enough data to make that determination. Furthermore, under this
legislation there is no distinction between very acute and very
difficult eye surgeries versus the normal eye surgeries, but
rather [HB 151] assumes that every eye surgery is the same and
48 hours is an appropriate time for all those surgeries.
REPRESENTATIVE MCGUIRE inquired as to an eye surgery that isn't
acute.
REPRESENTATIVE SEATON reiterated that he didn't believe the
committee has the data to specify the timeframe, especially when
much of the testimony has related numerous situations in which
patients have went to Seattle [for surgery] and are sent back to
Juneau after 24 hours. Again, Representative Seaton expressed
discomfort with "pulling that number out of the hat" without any
[supporting] data.
DR. COULTER replied that if a patient opts to have surgery out
of state that's his/her choice, however, the bill addresses in-
state procedures. He related that a patient who leaves 24 hours
postoperative is not necessarily "a bad thing" for
himself/herself or the surgeon. He opined that the legislation
is not suggesting that the "surgeon and patient be handcuffed"
but rather that the surgeon is available to treat the patient or
reassign that responsibility to a peer. Dr. Coulter reminded
the committee that the norm for a postoperative period [during
which the surgeon should be available] recommended by the
largest national bodies of ophthalmologists is 120 hours while
the 48-hour requirement is the suggested minimum. Moreover, the
paid postoperative period can extend for three months, and
nothing in HB 151 would stop optometry from being included in
that.
4:23:51 PM
DR. COULTER, in response to Chair Wilson, specified that Dr.
Garret Sitenga is the ophthalmologist in Homer.
4:24:44 PM
CHAIR WILSON opined that [comanagement situations] are more
specific to the Anchorage area, but asked if it happens anywhere
else in the state.
4:25:07 PM
DR. WALKER related his understanding that Dr. Coulter is asking
the committee to support HB 151 in order to control surgeon's
actions, however, he questioned how the terms "optometry and
comanagement" facilitate that goal. Dr. Walker said that he
didn't support limiting a requirement for a patient to remain
under a surgeon's control for a specified amount of time.
However, this legislation does impact the access to [after
surgery] follow-up care by an optometric physician. Dr. Walker
acknowledged the issues related to call, but pointed out that
it's not an issue that involves optometry or comanagement.
Therefore, he inquired as to why HB 151 would encompass
comanagement and optometric care when [the intent] seems to be
to limit surgeons.
4:26:51 PM
REPRESENTATIVE ANDERSON, in response to Representative Seaton,
said the medical doctors testified that most complications arise
two to five days postoperative, and the five days is reflected
in the federal recommendations. Since the five days suggested
at the federal level may be difficult for the surgeon's coming
into state, two days has been suggested as the minimum.
4:28:13 PM
CHAIR WILSON announced HB 151 would be held for further
consideration.
HB 16-SCHOOL FUNDS RELATED TO BOARDING SCHOOLS
4:29:18 PM
CHAIR WILSON announced that the next order of business would be
HOUSE BILL NO. 16 "An Act relating to funding for school
districts operating secondary school boarding programs and to
funding for school districts from which boarding students come;
and providing for an effective date."
4:29:35 PM
REPRESENTATIVE JOHN COGHILL, Alaska State Legislature, sponsor,
explained that the main purpose of HB 16 is to help boarding
schools in Alaska. House Bill 16 provides that under certain
circumstances [the state] will give a stipend to some students
to attend boarding schools. He related that he has a
"sensitivity to how that might affect other schools so ...
[there are] some sideboards ...," which are as follows: the
boarding school has to be operating on a 180-day school system
calendar; if a student's absence from his/her [district school]
places the school "under the number floor," and ends funding,
then that student shall be held harmless. The five-year
timeframe in the legislation would allow the legislature to
evaluate the impacted boarding schools in Galena, Bethel, and
Nenana. He added that the aforementioned school districts use
the "student dollar count" towards schooling, similar to the
state run boarding school of Mt. Edgecumbe, however, different
cost factors are involved with Mt. Edgecumbe.
REPRESENTATIVE COGHILL relayed his personal experience regarding
the positive influence of boarding schools in Nenana. He
related that the House passed similar legislation last year, by
a vote of 38:0, but questions in the Senate arose about the
operations of one of the schools. Although he said he felt that
the questions in the Senate were addressed, the question as to
whether these boarding schools will take the "best and the
brightest" from the smaller districts remains. Representative
Coghill opined that would not be the case. He added that
boarding schools have saved the state money, although "it's
debatable how much." For example, a smaller district with a
lower ratio of students means the dollar per student is high,
but [if a student] came to the larger district, the student
dollar reimbursement is lower based on the [school district's
cost factors]. He opined that he is not "doing it for the
savings" but rather he is interested in boarding schools because
they are "one avenue where education really does excel" due to
the combined interests from the parents, children, and
community. He noted that many of the students are coming from
"tough circumstances," and they are being offered the
opportunity to change their lifestyle and excel.
REPRESENTATIVE COGHILL reiterated that the sideboards will allow
[the legislature] to evaluate if this system will work, and if
so, why it works so well. The earlier mentioned districts have
applied their own "sweat equity capital" into these schools.
For example, Galena has made creative usage out of its airbase
and uses it for "absolutely fascinating" vocational technology,
while Nenana focuses on a more college preparatory approach to
learning. He highlighted that seven out of fifteen students
from Nenana's 2004 graduating class went to universities.
REPRESENTATIVE COGHILL said the Department of Education and
Early Development (EED) would determine the monthly stipend plus
the cost of travel to and from the boarding school one time, for
each student.
4:40:12 PM
REPRESENTATIVE GARDNER said she loves HB 16 because it supports
school choice and offers rural children more opportunities. She
explained that the superintendent of Galena, Jim Smith, pointed
out that its vocational technology program meets a need in the
state, which should be expanded upon. Furthermore, the school
also provides a socially comfortable environment for children
that come from less than ideal situations. She related her
belief that perhaps, if not the "best and the brightest," [the
schools retain] the most motivated children. However, she asked
whether the [boarding schools' obtaining] motivated children
could adversely impact their home schools. Even if that's the
case, Representative Gardner said that she wouldn't want to
stand in the way of those students and would rather encourage
it, even if there's a certain cost to their home schools.
REPRESENTATIVE COGHILL replied yes, adding that a student should
be allowed to excel to the best of his/her ability. However,
the home districts and parents are also looking for the best
education for students, and the purpose of this legislation is
not to hurt local home districts.
4:43:48 PM
REPRESENTATIVE COGHILL, in response to Representative Seaton,
clarified that the school district [within which the boarding
school is located] would receive a reimbursement or a stipend
for the boarding of a student.
4:44:22 PM
REPRESENTATIVE CISSNA said she supports the concept of HB 16,
but noted her frustration that other programs in the state
desperately need the state's investment and support.
REPRESENTATIVE COGHILL highlighted that the sideboards on the
legislation evaluate how it's working. He acknowledged that the
legislation will benefit fewer students than he would like.
However, there is also debate regarding how the rural
communities are going to answer educational needs.
Representative Coghill concluded by noting that the legislature
"needs to work on all fronts."
4:46:00 PM
CHAIR WILSON inquired as to the amount of the stipend.
REPRESENTATIVE COGHILL replied that the attached fiscal notes
highlight an annual round-trip airfare cost and the yearly
costs, which amounts to a monthly stipend that ranges from $472
to $577. He pointed out that boarding school costs are much
more than $500 a month [per student].
CHAIR WILSON related her belief that the children at Mt.
Edgecumbe benefit greatly from the school. She highlighted the
preparedness and knowledge she encountered when teaching those
students a state government class.
REPRESENTATIVE MCGUIRE moved to report HB 16 out of committee
with individual recommendations and the accompanying fiscal
notes. There being no objection, HB 16 was reported out of the
House Health, Education and Social Services Standing Committee.
HB 20-EDUCATION FUNDING
CHAIR WILSON announced that the next order of business would be
SPONSOR SUBSTITUTE FOR HOUSE BILL NO. 20 "An Act relating to a
separate appropriation bill for operating expenses for primary
and secondary public education and establishing a date by which
the bill must be transmitted to the governor each year; relating
to notice of nonretention for tenured teachers; and providing
for an effective date." [Before the committee is CSSSHB
20(EDU).]
4:49:19 PM
REPRESENTATIVE SEATON, speaking as the sponsor of HB 20, stated
that the purpose of this legislation is to provide early funding
of education, and require a separate appropriation budget for
the expenses of primary and secondary schools. He highlighted
that the governor is required to submit the education budget by
the fourth day of the legislative session, thereafter, the
legislature completes and resubmits it to the governor by March
5. This legislation was amended from its previous incarnation,
HB 19, to include all appropriations including "pupil
[transportation and] special schools", but may not include
appropriations for things such as "capital projects." The
aforementioned separates the contentious issues within each
school district.
REPRESENTATIVE SEATON specified that the main purpose of HB 20
is to end the disruptive practice of districts [being forced to]
send layoff notices to many teachers on March 15 because of the
uncertainty of the budget. The aforementioned practice results
in the loss of qualified teachers and disrupts morale, he
offered. He relayed that HB 20 establishes a process [to
complete the budget to avoid the aforementioned consequences]
and has the support of numerous school boards, teachers, the
National Education Association (NEA), and the Alaska Federation
of Teachers (AFT).
4:52:06 PM
CHAIR WILSON opined that the schools have been concerned with
the aforementioned issues for some time and [hopefully] this
will make a difference.
4:52:21 PM
REPRESENTATIVE GARDNER moved to report CSSSHB 20(EDU) out of
committee with individual recommendations and the accompanying
fiscal notes.
REPRESENTATIVE MCGUIRE objected, although she said she is
willing to let the legislation move out of committee today. She
related her belief that although the concept is great, there are
also other parts of the budget that deserve equal focus. She
expressed concern that HB 20 establishes hard-and-fast rules and
dates for the legislature and the governor when it's difficult
to know what types of issues the legislature will face.
REPRESENTATIVE SEATON related that there has been testimony from
the administration stating that the submission of the education
budget by the fourth day of the session is very "doable." He
reiterated that the goal is to separate education from other
issues, such as capital projects, which generally halt progress.
He added that it won't interfere with any type of supplemental
[budget appropriation].
4:55:23 PM
REPRESENTATIVE MCGUIRE again agreed that the notion behind HB 20
is great, but pointed out that often how things play out in
reality are more complex.
4:56:12 PM
REPRESENTATIVE MCGUIRE withdrew her objection.
There being no further objection, CSSSHB 20(EDU) was reported
from the House Health, Education and Social Services Standing
Committee.
ADJOURNMENT
4:56:12 PM
There being no further business before the committee, the House
Health, Education and Social Services Standing Committee meeting
was adjourned at 4:56 p.m.
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