Legislature(2013 - 2014)CAPITOL 106
03/19/2013 03:00 PM House HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HB134 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 134 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
March 19, 2013
3:03 p.m.
MEMBERS PRESENT
Representative Pete Higgins, Chair
Representative Wes Keller, Vice Chair
Representative Benjamin Nageak
Representative Lora Reinbold
Representative Paul Seaton
Representative Geran Tarr
MEMBERS ABSENT
Representative Lance Pruitt
COMMITTEE CALENDAR
HOUSE BILL NO. 134
"An Act requiring Medicaid payment for scheduled unit dose
prescription drug packaging and dispensing services for
specified recipients."
- HEARD AND HELD
PREVIOUS COMMITTEE ACTION
BILL: HB 134
SHORT TITLE: MEDICAID PAYMENT FOR MEDISET PRESCRIPTION
SPONSOR(s): REPRESENTATIVE(s) COSTELLO
02/20/13 (H) READ THE FIRST TIME - REFERRALS
02/20/13 (H) HSS, FIN
03/19/13 (H) HSS AT 3:00 PM CAPITOL 106
WITNESS REGISTER
REPRESENTATIVE MIA COSTELLO
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Introduced HB 134, as the sponsor of the
bill.
CHARLES GUINCHARD, Staff
Representative Mia Costello
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented HB 134 on behalf of the sponsor,
Representative Costello.
MATTHEW KEITH, Vice President of Pharmacy
Geneva Woods Pharmacy
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
MARY MUNDELL
Susitna Mediset Services
Wasilla, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
RUTH DUKOFF
Medical Director
North Star Hospital
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
PAUL BROTHERTON, Manager
Anchorage Medset Pharmacy, Inc. (AMP Pharmacy)
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
JON SHERWOOD, Medicaid Special Projects
Office of the Commissioner
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Testified during discussion on HB 134.
CHAD HOPE, Pharmacy Program Manager
Medical Assistance Administration
Division of Health Care Services
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion on HB 134.
CABLE STARLINGS
Anchor House
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 134.
JOANNE SULLIVAN, RN
Hope Community Resources, Inc.
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 134.
PATRICIA SENNER, Family Nurse Practitioner
Alaska Nurses Association
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 134.
AMY ONEY
Mama's Assisted Living Home
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 134.
KATIE BALDWIN-JOHNSON, Program Officer
Alaska Mental Health Trust Authority
Department of Revenue
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 134.
THERESA BRINSKY, RN
Marlow Manor Assisted Living
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 134.
REESE MCKINNEY
Palmer, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
SHERRY METTLER
Assisted Living Industry
Kenai, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
MARY JO METTLER
Northern Lighthouse
Kenai, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
CHRISTINA JOHNSON
Kenai Eye Care
Kenai, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
MARY NICHOLSON
Nicholson's Assisted Living Home
Kenai, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
ACTION NARRATIVE
3:03:36 PM
CHAIR PETE HIGGINS called the House Health and Social Services
Standing Committee meeting to order at 3:03 p.m.
Representatives Higgins, Seaton, Reinbold, Nageak, Keller, and
Tarr were present at the call to order.
HB 134-MEDICAID PAYMENT FOR MEDISET PRESCRIPTION
3:04:47 PM
CHAIR HIGGINS announced that the only order of business would be
HOUSE BILL NO. 134, "An Act requiring Medicaid payment for
scheduled unit dose prescription drug packaging and dispensing
services for specified recipients."
3:05:03 PM
REPRESENTATIVE KELLER moved to adopt the proposed committee
substitute (CS) for HB 134, labeled 28-LS0303\P, Mischel,
3/18/13, as the working draft. There being no objection, it was
so ordered.
3:05:50 PM
REPRESENTATIVE MIA COSTELLO, Alaska State Legislature, speaking
as the sponsor of HB 134, said that the proposed bill would move
an existing program into state statute. She reported that
Alaska's population of older than 65 years was the fastest
growing in any state and the group of seniors 85 years of age
and older was expected to triple in the next 20 years. She
declared that the growing cost of health care was a challenge to
the state, and would be a consistent issue moving forward. She
declared that the mediset program allowed more flexibility for
older Alaskans as they made living decisions. She reported that
some costs associated with nursing homes and emergency room
visits were astronomical. She explained that this program
allowed for an enhanced pharmacy service, by packaging
medications and delivering them weekly, which decreased the
confusion for adherence to a medication regimen. She pointed
out that the program was prescribed by a doctor, so that all the
medication management would be through a mediset pharmacy. She
indicated that it would remove much of the guesswork by home-
based caregivers, as the drugs would be packaged by specific
regimen. She pointed out that this program would dispose of
unused medications and would better allow monitoring for
adherence to medication schedules. She explained that all of
this would decrease emergency room visits and help control
costs. She declared that this should become a policy, so that
the state would continue this valued program. She explained
that the program would lead to "overall cost savings when you
look at the entire health care system," as it would support care
systems that were less expensive than nursing homes or full-time
staff to ensure adherence to a medication schedule.
3:11:27 PM
REPRESENTATIVE NAGEAK asked if mediset was an existing program
in Alaska.
REPRESENTATIVE COSTELLO replied that the state had been
reimbursing the pharmacies for dispensing this program for many
years.
3:12:07 PM
CHARLES GUINCHARD, Staff, Representative Mia Costello, Alaska
State Legislature, offered to discuss the Sectional Analysis for
the proposed CS for HB 134 [included in members' packets]. He
directed attention to Section 1 of the proposed CS which amended
AS 47.07 to establish AS 47.07.031, entitled "Scheduled unit
dose prescription drug dispensing services and transportation
services." He explained subsection (a), which gave the
Department of Health and Social Services (DHSS) the power to
reimburse a pharmacy for dispensing services and non-local
transportation costs for prescriptions requiring medication
compliance packaging. This subsection also gave DHSS the power
to adopt regulations specifying which persons qualified for
reimbursement under this program. He emphasized that non-local
transport referred to the transportation cost to any community
without a mediset pharmacy. He also highlighted that DHSS could
adopt regulations to determine eligibility for these services,
and for those providers who were currently eligible to remain
so.
3:14:05 PM
REPRESENTATIVE SEATON asked to better clarify the areas defined
as local delivery.
MR. GUINCHARD offered his belief that the cost for a local
delivery, within the same town, was already included in a
standard dispensing fee.
3:15:07 PM
REPRESENTATIVE SEATON asked where non-local delivery cost was
specified in the proposed bill.
MR. GUINCHARD directed attention to page 2, line 18, which
explained that local delivery cost was included with the mediset
fee. He pointed to page 2, line 19, for the definition of non-
local delivery. He stated the necessity to separate these in
order to allow determination of the non-local costs on a case-
by-case basis.
3:16:37 PM
CHAIR HIGGINS suggested that, although the language in the
sectional analysis for AS 47.07.031(a) referenced non-local
costs, in the proposed section [AS 47.07.031(a)] there was no
mention of non-local costs. He asked if this was to be assumed.
MR. GUINCHARD, in response, said that transportation costs were
addressed in two places in Version P, page 1, line 9, which
established a dispensing fee and a separate transportation
service fee and also on page 2, line 18. He stated that the
proposed bill would keep the non-local transportation fee, if
necessary, separate.
3:18:28 PM
MR. GUINCHARD moved on to subsection (b) of the Sectional
Analysis, which specified that the dispensing fee established
under subsection (a) must include eligible dispensing services
including the local transportation costs. He reported that
subsection (b) listed the dispensing services associated with
pharmacies which were eligible for reimbursement under
subsection (a). He clarified that it also specified that the
fee established in subsection (a) should not include any service
already paid for in another pharmacy dispensing reimbursement,
emphasizing that the proposed bill did not intend to duplicate
any costs within this additional fee, and would allow the DHSS
to take into account any payments already issued under the
standard dispensing fee.
MR. GUINCHARD pointed to subsection (c) of the Sectional
Analysis, which specified that DHSS would pay for the most
economical transportation costs if local delivery was not an
option.
3:20:16 PM
CHAIR HIGGINS asked if there was a fiscal note for the
economical transportation cost.
MR. GUINCHARD replied that there was not yet a fiscal note,
explaining that proposed HB 134 had been submitted to DHSS, and
DHSS had raised concerns, although those concerns did not alter
the intent of the bill. He said that DHSS would now provide a
fiscal note based on Version P, which had addressed many of the
department's concerns.
3:21:39 PM
REPRESENTATIVE REINBOLD requested clarification that the
transportation was only for the product, not for a person.
MR. GUINCHARD replied that this was determined on a case-by-case
basis, as local transport sometimes included a representative
from the pharmacy for delivery of the medication. He opined
that special shipping or handling for non-local transport may
include a pharmacy representative.
REPRESENTATIVE REINBOLD asked if rural delivery would include a
pharmacy representative.
MR. GUINCHARD explained that this clause had been inserted
because some communities required a float plane or a snow
machine to deliver the medications. He said that this gave DHSS
some discretion to determine the most economical transport, as
there were too many cases to spell out in statute.
3:23:32 PM
REPRESENTATIVE REINBOLD asked if a pharmacy professional,
instead of a courier, would be the delivery person. She offered
that the difference in hourly wage between a pharmacist and a
courier would be "dramatic."
MR. GUINCHARD replied that he did not have a specific answer and
suggested that DHSS might better respond.
3:24:21 PM
CHAIR HIGGINS clarified that it was not the intent to pass the
bill out of committee today.
3:25:00 PM
REPRESENTATIVE KELLER asked if private health insurance included
these transportation costs. Noting that not all pharmacists
were qualified for mediset, he asked if there was concern for
any impact to a small, local pharmacy.
MR. GUINCHARD replied that the intent of the proposed bill was
to establish reimbursement for those pharmacies that "go above
and beyond what a traditional pharmacy would do." He expressed
agreement that not all pharmacies could provide this additional
service.
MR. GUINCHARD, in response to Representative Keller, said that
he did not know if private insurance would cover this additional
cost.
3:27:17 PM
REPRESENTATIVE SEATON asked for clarification as to whether the
language on page 2, line 5, of the proposed bill referred to the
training of the courier or the packager in the pharmacy.
MR. GUINCHARD explained that this referred to a representative
of the pharmacy handling the packaging.
3:28:39 PM
MR. GUINCHARD elaborated on subsection (d), which allowed a
pharmacy to consolidate all of an individual's medications into
medication compliance packaging, as long as at least one of the
medications was designated to require this packaging service.
He said that medications not specified by a provider were not
eligible for reimbursement. He declared that currently a
physician was required to write mediset on each prescription,
and if that was not written, it was necessary for the pharmacy
to follow up with the physician to check if it could be included
in the mediset package. He said that the intent of subsection
(d) was to allow pharmacies to take the initiative to
consolidate all of a person's medications.
3:29:46 PM
REPRESENTATIVE KELLER asked if non-prescription drugs would be
included. He asked if drugs bundled in this manner were more
expensive than if purchased over the counter.
MR. GUINCHARD directed attention to Version P, page 2, line 25.
He read: "However, a dispensing fee established under (b) and
(c) of this section may be paid only for the prescription that
requires medication compliance packaging." He explained that
this would allow the medication to be included in the packaging,
but would not allow for any oversight fee to be charged.
3:31:07 PM
REPRESENTATIVE SEATON asked if a patient receiving mediset
medications could order from many different pharmacies.
MR. GUINCHARD replied that, as the fee was tied to each
prescription, the cost should remain the same.
REPRESENTATIVE SEATON asked to clarify whether the fee was only
paid once with multiple packaging, or would it be paid for each
medication listed as mediset.
MR. GUINCHARD replied that the current system allowed for a
reimbursement to the pharmacy for each prescription included in
the mediset packaging; however, the proposed bill would set a
rate for each prescription included in the packaging. If a
physician did not indicate that a medication was necessary for
mediset, it could be included in the packaging, but would not be
eligible for the additional fee.
3:34:39 PM
MR. GUINCHARD presented subsection (e), which specified that a
pharmacy would receive payment if all the specified services in
the reimbursement fee criteria were provided. He explained that
DHSS would establish one fee, based on a survey, for the
provision of these services. He declared that, as the
reimbursement would be uniform, then the services had to also be
uniform.
MR. GUINCHARD indicated that subsection (f) defined medication
compliance packaging, and unit dose. He explained that Section
2 amended uncodified law to specify that any change to Medicaid
was subject to final federal approval, and that Section 3
provided an effective date contingent on the necessary federal
approval under Section 2.
3:36:25 PM
CHAIR HIGGINS asked to clarify that, should the proposed bill
become statute, any loss of federal money would obligate that
the state pay for the program.
MR. GUINCHARD explained that the intent of Sections 2 and 3 was
that, in the event that the federal government did not approve
this as a Medicaid system eligible to receive a federal
reimbursement, the bill would not take effect.
3:37:37 PM
CHAIR HIGGINS requested clarification of the following langauge
on page 2, line 1: "the fee shall reimburse a qualified
pharmacy for the following dispensing services if the services
are not otherwise reimbursed under this chapter." He asked
whether the state would have to pay if federal funding was
eliminated.
MR. GUINCHARD deferred that question to DHSS.
3:38:16 PM
REPRESENTATIVE REINBOLD, referring to page 2, line 9, asked if
the on-call licensed clinical pharmacist billing had already
been paid.
MR. GUINCHARD replied that this was one of the criteria for the
service above and beyond that of a traditional pharmacy; hence
it would be considered when establishing the reimbursement fee.
CHAIR HIGGINS asked what brought about this proposed bill, and
whether this would have any effect on adaptation with the
Affordable Care Act.
3:40:32 PM
REPRESENTATIVE COSTELLO replied that the state would still
promulgate regulations; the proposed bill would put a policy
directive into statute and the state would continue to maintain
its flexibility. She shared that the proposed bill determined
that reimbursement to an enhanced pharmacy should be in statute
for its savings in health care for an individual. She declared
that the State of Alaska was not under any obligation if the
federal government did not approve the program.
3:42:28 PM
REPRESENTATIVE KELLER referenced a report that there were about
2 million health crises annually in the United States resulting
from medication mistakes. He asked if the state could afford to
do this.
3:43:43 PM
REPRESENTATIVE SEATON asked about the proposed changes to
regulations, and whether the physician or the pharmacist would
determine that the mediset supply would be for 7 days or 30
days. He pointed out that the longer dosage would decrease the
dispensing fee.
MR. GUINCHARD in response, pointed to Version P, page 3, line 5,
and clarified that the use of the term "mediset" could be a
brand name, and was, instead, referred to in the proposed bill
as "medication compliance packaging." He stated that the
specified period was designated by an authorized health care
provider.
3:47:14 PM
REPRESENTATIVE SEATON requested that testimony from the
pharmacies specify whether a prescription for a 30-day supply
would be dispensed as a 30-day supply, or as a 7-day supply
dispensed 4 times. He also requested an explanation as to how
the delivery charge would be determined.
3:47:53 PM
REPRESENTATIVE REINBOLD asked whether mediset was a copyright
term, or if any pharmacy could use this.
MR. GUINCHARD said that he had not encountered any copyright
issues, and that, as there were variations to the term, the
proposed legislation had included a definition.
3:48:51 PM
REPRESENTATIVE REINBOLD expressed her agreement that the
packaging was helpful and useful to patients.
3:49:14 PM
CHAIR HIGGINS opened public testimony.
3:50:44 PM
MATTHEW KEITH, Vice President of Pharmacy, Geneva Woods
Pharmacy, offered his belief that mediset services were easily
confused to be "simply a way to package medication, and that's
called compliance packaging." He declared the importance for
understanding that it included clinical services, care
coordination, and packaging of medication to optimize adherence
by patients, which helped reduced "the 125,000 deaths attributed
to poor adherence in a year, or the $300 billion in excess
hospitalizations, ER visits and lost productivity." He showed a
short video about mediset services.
3:56:43 PM
MR. KEITH, noting that other pharmacies also offered this
clinical pharmacy service with compliance packaging, stated his
belief that it allowed patients to remain at a lower level of
care, which saved considerable cost to the overall health care
system. He pointed out that drug therapy was the primary
intervention for health care, and was less than 10 percent of
the total cost of health care, whereas hospitalization and
physician visits could each be more than 30 percent of the total
health care cost. He declared drug therapy to be a cost
effective mechanism for providing care, but that it was
necessary for patients to take the drugs, in order for this to
work. He explained that short cycle dispensing, as opposed to
30-day prescriptions, was mandated for long-term care by the
Centers for Medicare and Medicaid Services (CMS), as it allowed
for medication changes, without the waste from unused
prescriptions. He shared that reports from other states
indicated that the use by Alaska of assisted living homes for
elder care and compliance packaging was "ahead of the curve."
He reported that, in Canada, 26 percent of the people received
their medicine in compliance packaging, versus less than 2
percent in the U.S.
3:59:08 PM
MR. KEITH, in response to Chair Higgins, said that the time for
pharmacy staff to coordinate with the physicians and other care
givers to ensure that all the medications were identified and
properly included, the process for the clinical review, the
packaging, and the delivery was a significantly greater cost
than the over-the-counter pharmacy service. He reported that
the proposed changes to eliminate the reimbursement for this
service would have made it impossible to maintain the service.
4:00:19 PM
REPRESENTATIVE SEATON asked for a definition of local and non-
local delivery, as listed in the proposed bill.
MR. KEITH said that local would be defined as a reasonable drive
distance, whereas non-local would be characterized as necessary
to be mailed or shipped.
REPRESENTATIVE SEATON asked what would be included as local
delivery by an Anchorage pharmacy.
MR. KEITH offered his belief that Alaska regulations defined
this as a 50-mile radius, which he confirmed was practical.
REPRESENTATIVE KELLER asked if this service posed any risk for a
pharmacy, and would it increase the insurance cost.
MR. KEITH affirmed that an increase to the level of service for
clinical care included an increased risk with liability for
failure to perform the service well.
4:02:31 PM
CHAIR HIGGINS asked whether there was a level of training for
the delivery person.
MR. KEITH, in response, said that the Geneva Woods delivery
personnel were licensed pharmacy technicians, trained for an
understanding of mediset containers.
4:03:10 PM
REPRESENTATIVE REINBOLD asked if these same licensed pharmacy
technicians would deliver to a rural address.
MR. KEITH replied that this would not be practical or cost
effective. He stated that there would be a follow up phone call
with the patient, for any additional or supplemental education.
4:03:52 PM
REPRESENTATIVE SEATON asked if the non-local delivery would be
with Fed Ex, UPS, or similar.
MR. KEITH expressed his agreement.
4:04:21 PM
MARY MUNDELL, Susitna Mediset Services, clarified that, although
there were delivery services which included Fed Ex, her
organization was a delivery service with drivers who delivered
from Sutton to Talkeetna.
4:05:23 PM
RUTH DUKOFF, Medical Director, North Star Hospital, stated that
her facility used mediset for its residential children as it
increased the safety for medication distribution to both the
child and geriatric populations. She declared that it was a
responsibility of the state and society to provide these
vulnerable populations with extra protection.
4:07:23 PM
REPRESENTATIVE SEATON asked if the reimbursement fee should be
determined by each mediset kit, or by each prescription. He
asked if her prescriptions were for seven days, or longer.
DR. DUKOFF said that her patients' medications were more
actively changed, as they had not stabilized enough to return to
home, so that mediset was delivered each week.
4:09:10 PM
CHAIR HIGGINS asked if her hospital had its own pharmacy,
similar to the Pioneer Home.
DR. DUKOFF clarified that her hospital did not have its own
pharmacy.
4:10:00 PM
REPRESENTATIVE KELLER asked if the Pioneer Home used a similar
distribution to mediset.
MS. MUNDELL, noting that there was not specific representation
from the Pioneer Home, offered her belief that the Pioneer Home
used a mediset type distribution, possibly on a weekly basis.
She pointed out that some residents of the Pioneer Home were
allowed to use their pharmacy of choice.
4:11:23 PM
PAUL BROTHERTON, Manager, Anchorage Medset Pharmacy, Inc. (AMP
Pharmacy), established that the proposed bill was necessary
because there had been an emergency regulation passed on
September 7, 2011, by the State of Alaska Medicaid office, which
"severely limited providers and patient access to medset
pharmacy, by defining a rule" that only a pharmacy doing at
least 75 percent of its business in mediset could be reimbursed
for those services. He offered his belief that only three
pharmacies in Alaska qualified under this definition, which
limited access to the service. He declared that the changes in
regulation would have eliminated reimbursement to a pharmacy for
mediset services. He explained that the term "scheduled uni-
dose preparation drug dispensing service" was accurate for 7-,
28-, and 30-day dispensing cycles. He stated that the decision
to use these time frames to dispense medications was made by the
physician. He declared that these mediset services were
necessary for assisted living facilities, and for any patient
who had difficulty in complying with medication therapy. He
observed that the mediset service had improved patient
compliance, and decreased medication errors, for these patient
populations. He emphasized that the mediset program should not
be viewed as an expense; the use of the compliance packaging
program, when administered correctly, saved the state money in
several areas: fewer physician visits and fewer hospital
visits, a decrease in the necessity for patient transport, and a
decrease for the need of skilled nursing in assisted living
facilities. He reported that the seven-day dispensing cycle
reduced medication waste as there could be frequent medication
changes for this population. He summarized that the mediset
program was necessary, was the right thing to do for patient
care, and was saving the state money.
4:16:13 PM
REPRESENTATIVE REINBOLD asked Mr. Brotherton to repeat the
purpose and the date for the regulation change to require that
pharmacies had to have at least 75 percent of its business in
mediset to be reimbursed for those charges.
MR. BROTHERTON replied that, although the new regulations
technically went into effect on January 1, 2011, many of the
components did not actually take effect until September 7, 2011.
He said that all reimbursement would have ceased at that time,
if emergency regulations had not been passed which provided for
reimbursement for mediset services to those pharmacies which
provided at least 75 percent of their overall prescription
volume in mediset. He offered his belief that only three
pharmacies in Alaska would be able to meet these requirements.
REPRESENTATIVE REINBOLD expressed her alarm for the impact to
the state budget from the transportation costs for 7-day
packaging and the requirement for a 24-hour pharmacist.
MR. BROTHERTON, in response, explained that the packaging was
for seven days, with four time slots per day. He reported that
his pharmacy only delivered in the Anchorage area, but that the
other pharmacies which delivered outside the area had postage
expenses.
4:20:41 PM
CHAIR HIGGINS repeated the earlier question for regulations that
now only allowed for three pharmacies to deliver mediset
packages.
JON SHERWOOD, Medicaid Special Projects, Office of the
Commissioner, Department of Health and Social Services, said
that Chad Hope could better answer the question, as he was the
Pharmacy Manager.
4:21:04 PM
CHAD HOPE, Pharmacy Program Manager, Medical Assistance
Administration, Division of Health Care Services, Department of
Health and Social Services, opined that between three to five
pharmacies would currently qualify as mediset pharmacies.
4:21:42 PM
REPRESENTATIVE KELLER asked for "some insight into what the
fiscal note will look like."
MR. SHERWOOD replied that, as DHSS had only recently received
proposed Version P, there had not been an opportunity to develop
a fiscal note.
4:22:45 PM
REPRESENTATIVE SEATON expressed his concern for the non-local
delivery charge, and asked for a more specific definition. He
questioned whether the definition would constrain the
pharmacies.
MR. SHERWOOD said that the phrase "most cost effective method"
allowed DHSS to make a distinction between the appropriate
economical methods and the convenient, but more expensive,
methods.
4:24:12 PM
MR. HOPE offered his belief that the language of the proposed
bill combined and separated different items. He questioned
whether there was a dispensing fee, an additional compliance
packaging fee, and an additional postage or shipping fee, all
being combined and confused in the language of the proposed
bill. He declared that DHSS encouraged the use of flat rate
shipping over the use of a float plane to Kodiak. He said that
specifying a particular route of delivery could be more
economical, but could be challenged in the future. He declared
it to be a tightrope walk between the decision to allow
flexibility or to incorporate system controls which keep the
cost within the budgetary constraints.
4:25:45 PM
REPRESENTATIVE SEATON asked if there was a specification for
non-local delivery that would satisfy all the current methods
for shipping to local communities.
MR. KEITH replied that the majority of the local medisets were
delivered by staff; however, it was typical to use the USPS flat
rate, the bus, or other standard postal services for non-local
delivery.
4:27:20 PM
REPRESENTATIVE TARR asked if the earlier regulation change had
been intentionally imposed as cost containment.
MR. HOPE asked to clarify that she was referring to the
September 2011 revision. He explained that those regulations
were not intended to not reimburse for mediset services, but for
the dispensing fee to cover the cost of getting the medication
to the recipient. He read: "the dispensing fee includes only
pharmacy costs associat[ed] with ensuring the possession of the
appropriate covered outpatient drug is transferred to a Medicaid
recipient." He allowed that, as delivery was built into the
single dispensing fee, a separate fee had not been included in
the initial regulation. He declared this to be a modernization
of the reimbursement system, and reiterated that it was not an
attempt to not reimburse.
REPRESENTATIVE TARR requested clarification as to whether it was
inadvertent to not have an appropriate fee to cover enhanced
services.
MR. HOPE replied that it was not inadvertent as DHSS had
performed a survey to determine the cost to dispense, which
included the overhead, the salaries, the benefits, the building
cost, packaging, and everything else allowable. He said there
was a 100 percent response to this survey from the pharmacies in
Alaska. He reported the DHSS had tested its hypothesis that
costs associated with dispensing a prescription for unit doses,
medisets, or compliance packaging were not appreciably higher.
4:30:45 PM
REPRESENTATIVE TARR offered her belief that it was more
expensive than originally thought.
4:30:56 PM
REPRESENTATIVE REINBOLD, stating her support of mediset and
noting that this was the fourth time she had asked this question
about the dramatic cost difference for delivery systems, asked
DHSS to identify the percentage of population that required the
more expensive delivery system and "are we already paying for
that." She also asked about the requirement for a pharmacist to
be on call at all times, and if this was also already being
billed to the State of Alaska.
4:32:01 PM
MR. HOPE, in response to Representative Reinbold, said that both
the in-town delivery and the pharmacist salary were allowable
costs, which could be included in the calculation for the
dispensing fee. He opined that should more pharmacies begin to
staff for all hours and deliver prescriptions in a non-
economical way, the dispensing fee would increase as the
allowable cost would increase.
4:33:18 PM
REPRESENTATIVE REINBOLD asked if it was required for every
mediset dispensing pharmacy to have an on-call pharmacist at all
times.
MR. HOPE offered his belief that the proposed bill would require
each pharmacy with this practice to have a pharmacist available
at all hours.
MR. KEITH expressed his agreement that the proposed bill
required an on-call pharmacist be available; however, he pointed
out that each of the participating pharmacies already included
this service. With regard to the DHSS survey identifying that
the cost for dispensing medisets was no different than the cost
of dispensing retail prescriptions, he said that all the
pharmacists had fundamentally agreed that "the survey data was
flawed and that the denominators were different." He expressed
his disagreement with the findings of the DHSS survey.
4:35:14 PM
CABLE STARLINGS, Anchor House, said that he had operated a large
assisted living home for 63 adults, Anchor House, for almost 27
years. He spoke in support of HB 134. He said that the
medisets were a very important component to living successfully
in the community as the organization of the meds allowed
residents to overcome their personal obstacles and integrate
into the community from the assisted living homes. He reported
that since many assisted living homes did not have nursing
staff, the staff would monitor medication administration.
4:37:59 PM
JOANNE SULLIVAN, RN, Hope Community Resources, Inc., stated that
she was in support of HB 134. She said that many patients
required multiple types of medications and that the pharmacy
ensured that the proper dosages were taken in combination. She
pointed out that, although she was not a pharmacist or a fiscal
analyst, it was going to be more expensive for a pharmacist to
do medisets, but this was still cheaper than care givers,
assisted living, or hospital visits. She explained that refills
never allowed doctors or pharmacists to monitor for compliance,
whereas, medisets in weekly packages revealed the level of
compliance. She expressed that it was "penny-wise and pound
foolish" to attempt to conserve money by not paying mediset
distribution costs.
4:42:47 PM
REPRESENTATIVE SEATON asked if all the prescriptions were
handled by the same mediset, or did different pharmacies
distribute separate medisets.
MS. SULLIVAN replied that she had never experienced any
complaints about mediset, and that there was a much higher
likelihood for a hospital to better identify the pharmacy
provider through a mediset.
4:44:23 PM
CHAIR HIGGINS asked to clarify whether a patient could have
multiple medisets from different pharmacies.
4:45:24 PM
MR. KEITH replied that patients had choice, but that it was best
for one pharmacy to take care of the patient's entire medication
regimen. He said that a pharmacy would communicate directly
with both the patient and the caregiver to clarify that the
pharmacy was the caregiver for the mediation therapy. He noted
that should a patient choose to go to another pharmacy, then all
the medications would also be moved to that pharmacy, to ensure
the oversight and necessary clinical pharmaceutical care. He
expressed his agreement that a patient could go to any pharmacy
to fill a prescription, but he emphasized that there was a
clinical agreement with the patient for all the medication to
come from the same pharmacy, in order to allow for proper
medication management. He pointed out that should there be an
attempt to again fill the same prescription through a different
pharmacy, Medicaid and private insurance would inform the
pharmacy to reject the claim, so that it would not be filled
twice.
4:46:48 PM
PATRICIA SENNER, Family Nurse Practitioner, Alaska Nurses
Association, said that the organization was "quite appalled"
upon hearing that the reimbursement for mediset was going to be
discontinued. She declared that it was obvious there was an
increased cost for this procedure, and that the state should
bear this increased cost. She opined that this increased cost
was slight compared to the consequence of not properly taking
medication. She reported that, as most of her career work had
been in the community setting, many people were able to remain
living in the community because of the availability of the
mediset program. She expressed her support for Version P as it
allowed increased eligibility for the benefits. She suggested
that, as some patients were more stable than others, the weekly
dispensing package was most effective.
4:48:43 PM
AMY ONEY, Mama's Assisted Living Home, reiterated that the
mediset service was invaluable. She pointed out that the cost
for nurse staffing with medication management and compliance
training would not be supportable. She said that her staff was
trained to monitor. She declared that there would be
substantial risk to have the necessary quantity of drugs on
site. She stated that the mediset program allowed people to
live in assisted living and not in an institutional setting for
care.
4:51:23 PM
KATIE BALDWIN-JOHNSON, Program Officer, Alaska Mental Health
Trust Authority, Department of Revenue, pointed out the Alaska
Mental Health Trust Authority had submitted a letter of support
for HB 134, as the Trust "vehemently advocates for trust
beneficiaries to be able to reside and live as independently as
possible in the community." She declared that the mediset
program was important to many beneficiaries who needed that
level of support. She declared that the Trust was in support of
the proposed bill.
4:52:46 PM
THERESA BRINSKY, RN, Marlow Manor Assisted Living, expressed her
agreement with the earlier comments of support, and noted that
she had submitted a letter to the bill sponsor, Representative
Costello. She stated the need for this to be in statute, as
this was the third year of discussion regarding the cutting of
the mediset program. She emphasized that the mediset program
service should be in statute, and she explained how difficult it
would be for her assisted living program without mediset.
4:54:43 PM
REESE MCKINNEY offered a response to an earlier question by
Representative Seaton. He noted that, as a veteran, he could
utilize the Veterans Administration medical services. He said
that his local pharmacy would occasionally not have his
necessary medication. He questioned whether receiving
medication from different pharmacies would prove difficult for
payment reimbursement.
4:56:41 PM
SHERRY METTLER, Assisted Living Industry, offered her thanks for
the proposed bill. Pointing to page 1, lines 11-12, she
declared that this should not be limited to any living
situation. She declared that the assisted living industry was
in support of HB 134 for many reasons, which include resident
safety, frequent medication changes, cost shifting, and storage
of medications. She elaborated on the proposal for weekly
versus monthly dispensing of mediset, saying that it was
dangerous for an assisted living home, its residents, and the
community to store a high volume of medications in a non-secured
facility. She expressed her gratitude for the mediset program
and to the pharmacies which supplied the service, declaring that
this service should be reasonably compensated. She summarized:
"in this world of craziness, and budget trimming, there are just
some items that cannot be justifiably removed from the fiscal
plan. [Medisets] for vulnerable adults are one of those items."
She emphasized that this service was crucial and necessary in
the assisted living environment as the increasing level of
residential care mandated its use.
5:00:08 PM
MARY JO METTLER, Northern Lighthouse, pointed out that studies
had shown that the lack of medication adherence was the fourth
leading cause of death in the United States, with an annual cost
to the health care system of more than $150 billion. She stated
that this proposed bill was about safety, fiscal responsibility,
and common sense.
5:01:28 PM
CHRISTINA JOHNSON, Kenai Eye Care, stated her agreement with the
previous testimonies. She expressed her concern for the safety
of residents in assisted living.
5:02:01 PM
MARY NICHOLSON, Nicholson's Assisted Living Home, stated that
this proposed bill was about keeping the residents safe, well,
and out of the hospital due to any misuse of medication. She
expressed her agreement with limiting the amount of medication
stored at the assisted living facilities.
5:03:00 PM
CHAIR HIGGINS left public testimony open. He stated that HB 134
would be held over.
5:03:42 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 5:03 p.m.