Legislature(2013 - 2014)CAPITOL 106
03/28/2013 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 28, 2013
3:07 p.m.
MEMBERS PRESENT
Representative Pete Higgins, Chair
Representative Wes Keller, Vice Chair
Representative Benjamin Nageak
Representative Lance Pruitt
Representative Lora Reinbold
Representative Paul Seaton
Representative Geran Tarr
MEMBERS ABSENT
All members present
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 & 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
03/19/13 (H) Heard & Held
03/19/13 (H) MINUTE(HSS)
03/28/13 (H) HSS AT 3:00 PM CAPITOL 106
WITNESS REGISTER
CHARLES GUINCHARD, Staff
Representative Mia Costello
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented HB 134 on behalf of
Representative Costello, sponsor of the bill.
ROBIN COOK, President
Alaska Pharmacist Association
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
KATRINA BETTS
Ark of Anchorage
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.
SHERRY METTLER
Assisted Living Industry
Kenai, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
THERESA BRINSKY, RN
Marlow Manor Assisted Living
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
KAHALANI DREW
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 of HB 134.
MARY MUNDELL
Susitna Mediset Services
Wasilla, Alaska
POSITION STATEMENT: Testified during discussion of HB 134.
ACTION NARRATIVE
3:07:39 PM
CHAIR PETE HIGGINS called the House Health and Social Services
Standing Committee meeting to order at 3:07 p.m.
Representatives Higgins, Nageak, Keller, Tarr, Seaton, Reinbold,
and Pruitt were present at the call to order.
HB 134-MEDICAID PAYMENT FOR MEDISET PRESCRIPTION
3:09:27 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." [In front of the committee
was Version 28-LS0303\P, Mischel, 3/18/13, adopted as the
working document on March 19, 2013.]
3:09:41 PM
REPRESENTATIVE PRUITT moved to adopt the proposed committee
substitute (CS) for HB 134, labeled 28-LS0303\Y, Mischel,
3/23/13, as the working document.
REPRESENTATIVE SEATON objected for an explanation to the
changes.
3:10:08 PM
CHARLES GUINCHARD, Staff, Representative Mia Costello, Alaska
State Legislature, explaining the changes to the proposed
working document, directed attention to page 2, lines 3-12, of
Version Y. He explained that the Department of Health and
Social Services used criteria to consider the fee for dispensing
services of a prescription, and he shared that these criteria
had now been refined to "eliminate duplicative and ambiguous
language." He noted that language regarding the review of
returned medication packaging and the necessity for a 24 hour,
on-call pharmacist had been deleted. He reported that the
provision regarding quarterly review had been amended to allow
the review to be conducted by phone, and would ensure that a
pharmacist was not operating in excess of the scope of their
practice. He stated that the provision regarding local delivery
had been clarified to ensure the most cost effective method for
delivery.
3:12:10 PM
REPRESENTATIVE REINBOLD asked to define the most cost effective
method for delivery, as she had been under the impression that
it was to be delivery by the USPS.
MR. GUINCHARD, directing attention to page 2, line 12, said that
local delivery would use the most cost effective method. He
indicated page 2, line 13, and specified that non-local delivery
was to also use the most cost effective method, "specifically by
mail."
3:13:18 PM
REPRESENTATIVE PRUITT asked to clarify whether the definition
for mail included UPS and Fed Ex, as well as USPS.
MR. GUINCHARD, in response, stated that the proposed bill only
specified that it be the most cost effective method by mail,
when local service was not available. He offered his belief
that the method could include any of the aforementioned mail
services.
3:14:03 PM
REPRESENTATIVE SEATON directed attention to page 2, line 15, and
asked to clarify if "mail" included package delivery services.
MR. GUINCHARD, in response to Representative Seaton, indicated
that there was not a memorandum from Legislative Legal Services,
but that, although the request for changes had explicitly asked
for an insert of language to include USPS, Fed Ex, and UPS, this
language had been the response. He offered his belief that this
allowed the flexibility for use of any of the delivery services.
REPRESENTATIVE SEATON asked to have these services more clearly
defined to include those other than USPS.
MR. GUINCHARD replied that it would be done.
3:15:59 PM
REPRESENTATIVE KELLER, indicating page 1, line 9, asked if there
were any statutory guidelines for criteria to a physician that
required "scheduled unit doses in medication compliance
packaging."
MR. GUINCHARD, in response, opined that it was not clarified in
statute; however, page 1, line 11, would give DHSS the authority
to promulgate regulations specifying the eligibility for
patients.
3:17:14 PM
REPRESENTATIVE KELLER expressed his concern with any program
that was expanding its services. He declared his support for
the packaging program, but declared that he "was struggling with
the whole concept" and possibility for expansion to the cost of
prescriptions.
MR. GUINCHARD pointed to page 1, line 12, and stated that the
packaging was to assist patients "to adhere to a difficult
dosing regimen." He reported that DHSS had a category of
recipients for mediset and directed attention to a State of
Alaska letter titled, "RE: Mediset fee FAQ and guidance"
[Included in members' packets]. He read the list of
qualifications for mediset, which included: living in a
congregate home; recipient of home and community-based waiver
services; eligible for Medicaid due to a disability or
blindness; adult experiencing a serious mental illness; or,
child experiencing a severe emotional disturbance. He opined
that the intent of the sponsor was for the proposed bill to
apply to this same group of recipients.
REPRESENTATIVE KELLER requested that these criteria be included
in the proposed bill.
3:20:46 PM
MR. GUINCHARD remarked that the second major change for Version
Y was on page 2, line 13, and that Legislative Legal Services
had been requested to insert language regarding courier service
for non-local delivery.
3:21:38 PM
MR. GUINCHARD reported that the last change to Version Y had
been to delete a section which had referenced pharmacies
including prescriptions in a mediset, even if mediset had not
been noted in the prescription. This had been determined by the
sponsor to be confusing and unnecessary, as it could create some
unintended consequences. He stated that it was now necessary
for every prescription to have mediset written on it to be
included for reimbursement.
3:22:56 PM
CHAIR HIGGINS asked to clarify that there had been agreement to
bundle the five criteria for reimbursement, and he questioned if
that had occurred.
MR. GUINCHARD offered his belief that DHSS would consider all
five criteria as associated costs in its fee calculations, and
then aggregate the data to establish one fee which reflected all
five criteria.
3:24:45 PM
REPRESENTATIVE SEATON removed his objection to Version Y as the
working document. There being no further objection, the
proposed committee substitute (CS) for HB 134, labeled 28-
LS0303\Y, Mischel, 3/23/13, was adopted as the working document.
3:25:19 PM
CHAIR HIGGINS opened public testimony.
ROBIN COOK, President, Alaska Pharmacist Association, stated
that the association had been concerned with the wording in the
original bill, Version N, but these concerns had been addressed
with the revisions. She explained that the specific concerns
had included the need for a definition for a qualified pharmacy,
as all pharmacies licensed in the State of Alaska, which were
capable, should be able to provide this service to clients. She
noted the requirement that it was necessary for a pharmacy to
have 70 percent of its business as mediset, in order to be
recognized as a mediset pharmacy, had been removed. She asked
that the proposed bill clarify the services that would be
reimbursed, and to clarify whether a pharmacy would bill for
each service separately or as a bundle. She offered her belief
that, although the fee would be determined by the State of
Alaska through Medicaid, it would be fair to the pharmacy with
no hidden costs to Medicaid. She suggested that the wording
"unit dose" was incorrect, and would be better defined as "unit
of use." She expressed gratitude to the sponsor of the bill,
declaring that medisets were an important vehicle for safe and
effective care to at-risk patients. She declared support for
Version Y.
3:28:22 PM
REPRESENTATIVE SEATON asked for clarification to "unit of use."
MS. COOK explained that the definition of unit dose was a single
dose packaged as a single dose unit. She pointed out that all
of these single doses, when packaged with other single doses,
became a unit of use, the medication plan. She clarified that
"does not include a refill" was not part of the formal
definition of "unit dose." Each slot that was designated for a
specific time of the day was a "unit of use."
REPRESENTATIVE SEATON asked to clarify that a bubble pak, with
medications which all were to be taken at the same specific
time, would be designated as a "unit of use." He asked if the
proposed bill should include the terminology, "does not include
a refill," page 2, line 29.
MS. COOK replied that the terminology was nebulous and did not
belong.
REPRESENTATIVE SEATON expressed his confusion whether the
terminology regarding a refill should be removed.
3:31:40 PM
MS. COOK, in response to Chair Higgins and Representative
Seaton, said that "does not include a refill" was not in the
formal definition for "unit dose." She recommended eliminating
"does not include a refill," or using the correct terminology
for a mediset, "unit of use." She explained that "does not
include a refill" referred to one drug, a "unit dose," which was
packaged separately.
3:33:40 PM
MR. GUINCHARD, in response to Representative Tarr, brought
attention to Amendment Y.2, labeled 28-LS0303\Y.2, Mischel,
3/28/13, which read:
Page 1, line 6:
Delete "dose"
Insert "of use"
Page 1, line 10:
Delete "unit doses"
Insert "units of use"
Page 1, line 12:
Delete "difficult"
Insert "specific"
Page 2, line 25:
Delete "dose"
Insert "of use"
Page 2, line 28:
Delete the first occurrence of "dose"
Insert "of use"
Referencing page 2, line 28 in proposed Amendment 1, which
recommended deleting "dose" and inserting "of use" in Version Y,
he declared that this amended language would be the definition
for a unit of use, and he pointed out that the remainder of the
text on lines 28 and 29 of Version Y would remain the same. He
stated that the remainder of the proposed amendment would
conform to this definition change.
REPRESENTATIVE TARR opined that testimony by Ms. Cook had now
indicated that this proposed amendment was not the correct
definition, and she offered to consider a further amendment.
3:34:41 PM
CHAIR HIGGINS asked if this change from "unit dose" to "unit of
use" would correct the definition.
MS. COOK, in response, offered to supply the correct definition
for "unit of use."
3:35:10 PM
REPRESENTATIVE KELLER asked for clarification of the proposal in
Amendment 1 to delete "difficult" and insert "specific" on page
1, line 12.
MS. COOK offered her belief that "specific" would be more
effective.
REPRESENTATIVE KELLER declared that, as there were no guidelines
in the current Version Y for the appropriate use of medisets,
"this would be it." He opined that the definition which was
used in regulation should be used in this version.
3:37:04 PM
MS. COOK, in response, explained that a patient, who could not
manage medication, was often referred by a pharmacist to a
mediset pharmacy. She clarified that, although this was usually
initiated by the physician's office after many treatment
failures, the pharmacy providers could determine this was an
option.
3:37:51 PM
The committee took a brief at-ease.
3:38:37 PM
CHAIR HIGGINS brought the committee back to order.
REPRESENTATIVE PRUITT moved to adopt Amendment 1, labeled 28-
LS0303\Y.2, Mischel, 3/28/13. [Text included above]
REPRESENTATIVE SEATON objected for discussion.
MR. GUINCHARD explained that Amendment 1 was in response to
discussion with the Alaska Pharmacists Association for
substitutions which would strengthen and maintain the intent of
the bill. He pointed to the proposed change on page 1, line 6,
and noted that this was an attempt to better define "unit of
use" throughout Version Y.
3:39:58 PM
REPRESENTATIVE KELLER, pointing to the proposed change on page
2, line 25, suggested that the change would create a grammatical
error. He opined that the proper wording would be "units of
use."
MR. GUINCHARD expressed agreement for a conceptual amendment to
Amendment 1, a grammatical correction on page 2, line 25, which
would delete "unit doses" and insert "units of use."
[The committee treated Conceptual Amendment 1 as adopted.]
3:42:04 PM
MR. GUINCHARD explained that the Alaska Pharmacists Association
had suggested the change on page 1, line 12, which would delete
"difficult" and insert "specific."
REPRESENTATIVE NAGEAK asked for an explanation.
3:42:47 PM
MS. COOK, in response to Representative Nageak, explained that a
patient could have numerous medications, but if the patient was
non-compliant, they would not be receiving the necessary
treatment. She said that the proposed change would allow
packaging of a small number of medications to ensure compliance.
REPRESENTATIVE NAGEAK asked to clarify that this linked to
packaging.
MS. COOK expressed her agreement that the proposed change would
allow packaging and payment as a mediset.
3:44:26 PM
MR. GUINCHARD explained that "difficult" was a subjective term,
in that its reference was for a dosing regimen for a capable
person. He noted that a simple dosing regimen could still be
difficult for a patient not able to manage their own regimen,
and that the proposed use of "specific" would add clarity to the
proposed bill.
3:45:16 PM
REPRESENTATIVE KELLER declared his objection to proposed
Amendment 1. He asked for a definition to both "specific" and
"difficult."
CHAIR HIGGINS opened public testimony.
3:46:09 PM
REPRESENTATIVE SEATON removed his objection to proposed
Amendment 1, but requested that there be clarity for the
conceptual amendment and for the request by Representative
Keller.
3:47:07 PM
The committee took a brief at-ease.
3:47:52 PM
REPRESENTATIVE PRUITT withdrew proposed Amendment 1.
3:48:05 PM
KATRINA BETTS, Ark of Anchorage, stated that the individuals
outlined by the guidelines for waiver services and behavioral
health services had already qualified for these services to be
written into a treatment plan through a physician. She pointed
out that these individual recipient guidelines already existed.
She emphasized that the individuals really needed these services
to maintain independence and quality of life. She noted that,
without these services, there would be higher costs from
emergency room visits, jail, and other incidences. She declared
that provider agencies and physicians worked to ensure that
these supports for individuals remained in place to obtain a
quality of life.
3:50:24 PM
CHAIR HIGGINS declared that there was not any intent to
eliminate the mediset program, but to "improve upon it."
3:50:53 PM
PAUL BROTHERTON, Manager, Anchorage Medset Pharmacy, Inc. (AMP
Pharmacy) explained that the mediset program allowed a patient
to take medication out of one slot in a package for each
specific time on each specific day. He suggested amending page
2, line 24 to read: "one or more prescription medications that
have been divided by a provider into individual doses to be
taken over a specified period..." He offered his belief that
this would eliminate the necessity of the definition currently
on page 2, lines 28-29.
3:52:24 PM
REPRESENTATIVE TARR asked Ms. Betts if the revised version of
the proposed bill had persuaded her organization to testify.
MS. BETTS replied that, although her organization appreciated
the changes, it had been a scheduling conflict that had
prevented earlier testimony.
3:53:30 PM
SHERRY METTLER, Assisted Living Industry, stated her full
support for adopting this into statute, in order not to be
"revisiting this issue time and time and time again." She
declared that medisets were important to assisted living home
residents.
3:54:13 PM
THERESA BRINSKY, RN, Marlow Manor Assisted Living, referred to
her prior testimony to the House Health and Social Services
Standing Committee on March 19, 2013. She declared that there
would be a significant increase of costs in other areas,
including emergency rooms, correctional facilities, and Alaska
Psychiatric Institute, if medisets were eliminated.
3:55:36 PM
KAHALANI DREW shared that she was "first and foremost, a mother"
of eight children, seven of whom were adopted from Office of
Children Service-type organizations. She declared that, because
of her children's disabilities, she counted on the mediset
regimen for her children to function, and she offered an
anecdotal account about one of her children.
4:01:59 PM
CHAIR HIGGINS said that he would leave public testimony open.
4:02:17 PM
JON SHERWOOD, Medicaid Special Projects, Office of the
Commissioner, Department of Health and Social Services, in
response, clarified that the fiscal note had been written in
response to an earlier Committee Substitute (CS) to HB 134,
Version 28-LS0303\P, Mischel, 3/18/13, which the committee had
adopted as the working draft on March 19, 2013. He reported
that the fiscal note reflected an appropriation of $414,000 for
FY 14, which was awarded using a match of state general funds
with federal funds. He stated that this assumed that
implementing regulations were in effect for the proposed bill.
He pointed out that the fiscal note would increase in subsequent
years to $1,657,000, which would continue to be derived from the
match of state general funds with federal funds. He explained
that this increased fiscal note was the result of weekly,
instead of monthly, dispensing of medications and mediset fees,
and an increase by the providers to include the Fairbanks area.
4:04:55 PM
REPRESENTATIVE KELLER, referencing the aforementioned
regulations to be set for the mediset pharmacy providers,
offered his belief that it was necessary "to be really, really
careful" with any increased costs to health care expansion. He
asked for further explanation that "if somebody is served at a
home, or a community based waiver, and they're given a service,
give me an idea, to be eligible for a home waiver for care
really doesn't have any direct ramifications on the person that
is being served, their mental state, whether or not they have
family support, all that kind of thing, aren't really definitive
as to whether or not the service is needed or not, right?" He
asked to clarify that there was more Medicaid eligibility by
qualifying for disability under social security. He asked if
the fiscal note for expansion was beyond a geographical
expansion, and would be an increase of service to a greater
number of individuals.
MR. SHERWOOD, in response to Representative Keller, said that
the increase to the fiscal note was strictly geographic, and
would not change the scope of the mediset eligible population.
He explained that eligibility for a home and community based
waiver was determined by a nursing home level of care, or a care
facility for intellectual or developmental disabilities. He
offered his belief that DHSS "thought it was an appropriate
target group when we made our regulations." Regarding
disabilities, he stated that the social security criteria had
not changed. He noted that, with the wide range for
disabilities, some would need assistance with adherence to
medication.
4:08:51 PM
REPRESENTATIVE KELLER stated that, although mediset was a
wonderful service, his concern was for an inappropriate
expansion. He asked if Mr. Sherwood was comfortable enough with
the regulatory criteria to place it into statute. He offered
his belief that there was an incentive for both providers and
beneficiaries to have this service made available. He asked if
it was necessary to put these regulations into statute.
MR. SHERWOOD replied that DHSS did not have a position on the
language, and noted that any changes to the regulatory structure
for licensing and regulations would have to be made in statute.
4:11:18 PM
CHAIR HIGGINS asked for a response to his belief that the
mediset program was better in regulation than in statute.
MR. SHERWOOD replied that the administration did not have a
position on the proposed bill.
CHAIR HIGGINS opined that the crux of the problem was that, as
DHSS were the experts on administering programs for the state,
and that the House Health and Social Services Standing Committee
wanted to ensure that DHSS had the necessary tools, it was
necessary for the committee to understand the department's
position on the proposed bill. He offered his belief that
regulations could be more quickly adapted than statutes.
MR. SHERWOOD replied that DHSS believed it had adequate
statutory authority to provide mediset reimbursement. He noted
that, as specific criteria was not in statute, the department
had more flexibility. He reported that DHSS contended with
providing access to appropriate care, while meeting the federal
criteria, and having payment methodologies that were efficient
and cost effective. He expressed his agreement that there was a
benefit to flexibility.
4:13:59 PM
REPRESENTATIVE SEATON, referring to page 2, line 3, of the
fiscal note [included in members' packets], asked if it was more
cost effective to change medications during a monthly mediset
cycle and lose the value for unused medication or to use a more
costly weekly mediset dispensing cycle, which allowed for
changes to medication and a minimal value loss for unused
medication.
MR. SHERWOOD, in response, explained that the monthly dispensing
fee did not restrict the dispensing to once a month. It only
restricted the number of times for receiving a fee. He reported
that a new prescription for a different dosage or drug initiated
a new dispensing fee. He opined that there were not general
concerns for the dispensing fees, although he was not the expert
with the pharmacy issues.
4:16:36 PM
REPRESENTATIVE SEATON stated that he was not able to find a
basis for comparison of the weekly versus monthly dispensing
fee, with regard to the loss of medication values resulting from
changes to prescriptions.
MR. SHERWOOD offered to research the records available, and see
if that information was in the claims data.
4:18:17 PM
REPRESENTATIVE SEATON clarified that he was only requesting
estimation for wasted prescriptions, in order to give parameters
to the fiscal note.
4:19:06 PM
MARY MUNDELL, Susitna Mediset Services, stated that she
appreciated the committee support for the mediset program. She
shared that new regulations proposed by the Centers for Medicare
and Medicaid Services would decrease reimbursement by 7 percent.
She offered her belief that the information was based on an
error in the cost of dispensing survey, which resulted in the
decrease. She said that mediset pharmacies would no longer be
able to offer services with this decrease, as it was "way below
our cost of doing business." She offered to provide financial
information to better understand the importance of
reimbursements.
[HB 134 was held over.]
4:23:24 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 4:23 p.m.