Legislature(2003 - 2004)
05/03/2004 01:36 PM Senate HES
| Audio | Topic |
|---|
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
SENATE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
May 3, 2004
1:36 p.m.
TAPE (S) 04-27&28
MEMBERS PRESENT
Senator Fred Dyson, Chair
Senator Lyda Green, Vice Chair
Senator Gary Wilken
Senator Bettye Davis
Senator Gretchen Guess
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
CS FOR HOUSE BILL NO. 511(HES) am
"An Act relating to the certificate of need program for health
care facilities; and providing for an effective date."
HEARD AND HELD
PREVIOUS COMMITTEE ACTION
BILL: HB 511
SHORT TITLE: CERTIFICATE OF NEED PROGRAM
SPONSOR(s): REPRESENTATIVE(s) SAMUELS
02/16/04 (H) READ THE FIRST TIME - REFERRALS
02/16/04 (H) HES, FIN
03/02/04 (H) HES AT 3:00 PM CAPITOL 106
03/02/04 (H) Heard & Held
03/02/04 (H) MINUTE(HES)
03/04/04 (H) HES AT 3:00 PM CAPITOL 106
03/04/04 (H) Heard & Held
03/04/04 (H) MINUTE(HES)
03/18/04 (H) HES AT 3:00 PM CAPITOL 106
03/18/04 (H) Moved CSHB 511(HES) Out of Committee
03/18/04 (H) MINUTE(HES)
03/24/04 (H) HES RPT CS(HES) 3DP 1DNP 2NR
03/24/04 (H) DP: KAPSNER, CISSNA, WILSON; DNP: WOLF;
03/24/04 (H) NR: GATTO, COGHILL
03/29/04 (H) FIN AT 1:30 PM HOUSE FINANCE 519
03/29/04 (H) Heard & Held
03/29/04 (H) MINUTE(FIN)
03/31/04 (H) FIN AT 1:30 PM HOUSE FINANCE 519
03/31/04 (H) Moved CSHB 511(HES) Out of Committee
03/31/04 (H) MINUTE(FIN)
04/01/04 (H) FIN RPT CS(HES) 4DP 2NR 2AM
04/01/04 (H) DP: MEYER, HAWKER, HARRIS, WILLIAMS;
04/01/04 (H) NR: FATE, FOSTER; AM: STOLTZE, CHENAULT
04/26/04 (H) MOVED TO BOTTOM OF CALENDAR
04/26/04 (H) NOT TAKEN UP 4/26 - ON 4/27 CALENDAR
04/27/04 (H) NOT TAKEN UP 4/27 - ON 4/28 CALENDAR
04/28/04 (H) TRANSMITTED TO (S)
04/28/04 (H) VERSION: CSHB 511(HES) AM
04/29/04 (S) READ THE FIRST TIME - REFERRALS
04/29/04 (S) HES, FIN
04/30/04 (S) HES AT 1:30 PM BUTROVICH 205
04/30/04 (S) Heard & Held
04/30/04 (S) MINUTE(HES)
05/03/04 (S) HES AT 1:30 PM BUTROVICH 205
WITNESS REGISTER
Mayor John Williams
City of Kenai Peninsula Borough
144 North Binkley Street
Soldotna, AK 99669
210 Fidalgo Ave., St. 200
Kenai, AK 99601
POSITION STATEMENT: Testified on CSHB 511(HES) am
Blaine Gilman
Attorney representing Lord's Ranch
Kenai, AK
POSITION STATEMENT: Testified on CSHB 511(HES) am
Jeff Kinion
CEO of Alaska Open Imaging Center
6911 DeBarr Road
Anchorage, AK 99504
POSITION STATEMENT: Testified on CSHB 511(HES) am
Doctor Val Christensen
Alaska Open Imaging Center
6911 DeBarr Road
Anchorage, AK 99504
POSITION STATEMENT: Testified on CSHB 511(HES) am
George Larsen
Valley Hospital
515 Dahlia Avenue
Palmer, AK99645
POSITION STATEMENT: Supports CSHB 511(HES) am
Brian Slocum
Tanana Valley Clinic Administrator
1001 Nobel Street
Fairbanks, AK 99701
POSITION STATEMENT: Testified on CSHB 511(HES) am
Mike Powers
Fairbanks Memorial Hospital
650 Cowles Street
Fairbanks, AK 99701
POSITION STATEMENT: Testified on CSHB 511(HES) am
Robert Gould
Fairbanks Memorial Hospital
650 Cowles Street
Fairbanks, AK 99701
POSITION STATEMENT: Supports CSHB 511(HES) am
Rick Solie
Volunteer Trustee, Greater Fairbanks Hospital Foundation
665 Knightsbridge Road
Fairbanks, AK 99709
POSITION STATEMENT: Testified on CSHB 511(HES) am
Doctor Kurt Hediger
AK Chiropractic Society President
Anchorage, AK
POSITION STATEMENT: Opposes CSHB 511(HES) am
Doctor Robert Bridger
Alaska Open Imaging Center
6911 DeBarr Road
Anchorage, AK 99504
POSITION STATEMENT: Opposes CSHB 511(HES) am
Paul Brenner
Central Peninsula General Hospital
250 Hospital Place
Soldotna, AK 99669
POSITION STATEMENT: Testified on CSHB 511(HES) am
Doctor Helen Bedder
No address provided
POSITION STATEMENT: Opposes CSHB 511(HES) am
Joel Gilbertsen, Commissioner
Department of Health &
Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Explained aspects of CSHB 511(HES) am
Janet Clarke
Department of Health & Social Services
PO Box 110601
Juneau, AK 99801-0601
POSITION STATEMENT: Testified on CSHB 511(HES) am
Doctor Chris Conover
Assistant Research Professor of Public Policy Studies
Box 90253
Duke University
Durham, NC 27708
POSITION STATEMENT: Testified on CSHB 511(HES) am
Charlie Franz
CEO, South Peninsula Hospital
Homer, AK
POSITION STATEMENT: Testified on CSHB 511(HES) am
ACTION NARRATIVE
TAPE 04-27, SIDE A
CHAIR FRED DYSON called the Senate Health, Education and Social
Services Standing Committee meeting to order at 1:36 p.m.
Present were Senators Green, Wilken, Davis and Chair Dyson.
Senator Guess arrived momentarily.
CSHB 511(HES) am -CERTIFICATE OF NEED PROGRAM
CHAIR FRED DYSON announced CSHB 511(HES) am to be up for
consideration. He recognized Kenai Mayor John Williams and asked
how far along the two adolescent facilities projects were that
he spoke about during the previous hearing.
JOHN WILLIAMS, Mayor of the City of Kenai, replied the city was
in a land purchase process that began about three months ago.
Architects had already spent considerable time rendering
drawings for the projects and he knew that both companies had
spent considerable time in anticipation of the project.
CHAIR DYSON said he asked that because some of the committee
members believe that it's a bit unjust to change rules in
midstream so they were looking for some way to keep those
companies from being subject to new rules. He suggested that he
and others listening think about how they might grandfather in
those people who had begun a process and made commitments
without opening the door too wide.
MAYOR WILLIAMS expressed his appreciation and said he thought
the commissioner was well aware of how many beds are needed as
well as how many beds are planned and in progress. When they
suggested a January 1, 2005 effective date during the previous
meeting, he wasn't aware whether the date would or would not
accommodate any other projects that might have been started, but
there should be some leeway for accommodation.
CHAIR DYSON asked Mayor Williams to stand by and called on Mr.
Gilman.
BLAINE GILMAN from Kenai said he is an attorney representing the
Lord's Ranch, which is a non-profit based out of Arkansas that
runs a residential treatment facility and an out-patient
counseling facility. Both are for children.
The Lord's Ranch is in the process of trying to develop and
build a 30 bed facility in Kenai. They started the process in
November 2003 when they applied to purchase a piece of city
property. They re concerned that if this legislation passes then
they will miss the entire 2004 construction season. He asked the
committee to think about the fact that they must still go
through a licensing process so the department does have
oversight over this type of facility. To date they have gone
through re-platting, surveys, and an appraisal of the property
and they really want to continue to move forward with the
project. He has seen data indicating there are over 500 Alaska
children in facilities outside the state evidencing the fact
that there is a terrific need for this type of facility in
Alaska.
CHAIR DYSON announced that he would like everyone to keep their
remarks to three minutes because of the number of people that
wanted to testify.
JEFF KENYON, CEO of Alaska Open Imaging Center, reported that he
has been involved with the delivery of medical care for about 30
years. Four years ago he left hospital employment to become
independent.
He said he has seen hospitals hold back on purchasing and
installing new technology until competition spurred them to make
the move. Valley Hospital is such an example. Although they were
asked to consider installing a bone density unit to evaluate
osteoporosis over several budgetary request cycles, they took no
action until the service was offered by the competition. At that
time it took just months for Valley Hospital to install the
equipment.
PET scanning is one of the most expensive technologies there is
and Providence Hospital was reluctant to bring a scanner in
until a competitor did so. They offered Providence Hospital a
"cost competitive, cooperative arrangement only to have the
hospital negatively react and commit to a $2.8 million machine
and duplicate the service, which by the way, was not CON
[certificate of need] approved." Competition has benefited the
people of Alaska and has increased the level of technology and
care and competition works to decrease costs, he stated.
He charged that the Department of Health and Social Services
(DHSS) in cooperation with multimillion dollar out of state
hospitals are organizing for a double standard monopoly that
will ultimately be very expensive for the citizens of the state.
HB 511 is an effort to steamroller this process without giving
legislators the time or information that would make it possible
to analyze the facts to make a sound decision. "Competition
drives the level and the delivery of health care up while
driving the cost of health care down. Competition works where
the CON was designed to, but never did," he concluded.
1:46 pm
SENATOR GRETCHEN GUESS asked Mr. Kenyon to explain how the CON
might jeopardize competition if it's supposed to result in
adequate capacity within a community.
MR. KENYON replied, "We don't feel that the delivery of the
certificate of need in Alaska is a fair approach and equally
represented to all companies." He said he understands that
Providence Hospital has tremendous influence on both DHSS and
the advisory board for CONs and they have tremendous influence
behind HB 511. Because of this, his company won't be allowed the
opportunity to fairly expand and grow.
SENATOR GUESS interpreted that to mean that it's not so much the
CON itself rather it's the current process of how CONs are
applied that is problematic.
MR. KENYON didn't agree and advised that their philosophy is for
free enterprise and competition to be the regulating force for
which services are needed and which are delivered. Through the
CON regulation process undue expense and time and unfair
evaluations are the problem.
SENATOR GUESS asked how his business deals with the uninsured
and the underinsured.
MR. KENYON replied their philosophy is to take care of the
patient first and work out the details later. They work out
individual payment plans and are also write off uncollected
debts.
CHAIR DYSON added that he understands that they give a discount
to those people who pay cash.
MR. KENYON said he thought there was a slight discount for
prompt pay.
CHAIR DYSON noted that is in contrast to most facilities that
charge 30 to 40 percent more for patients that pay their own
bills [the uninsured].
DOCTOR VAL CHRISTIANSON said he is a board certified diagnostic
radiologist who is currently working for Alaska Open Imaging
Center. When he was in the Air Force he was the chairman of
radiology and nuclear medicine at Elmendorf. He left the state
briefly but after his retirement he moved his family back to
Alaska because he thought he could make a significant
contribution to the improvement of health care in Alaska. His
commitment is based on the ideal of a free and open market for
business competition and free enterprise. He continued:
HB 511 definitely represents collusion with intent of
restraint of trade and is the antithesis of the
American free enterprise that we all believe in as
well as our Alaska model of 'North to the Future.' It
does indeed represent a giant leap backwards to the
era of 'Might Makes Right.'
HB 511 guarantees monopolistic control in the medical
imaging market with the two-tier price fixing system
and essential gouging of the Alaska public. This is
the business equivalent of telling John Dow he can't
open the automobile repair shop because we already
have a qualified Ford dealer or a qualified Chevy
dealer in town who is sufficient, thank you very much.
In recent House testimony on Thursday night,
Representative Samuels stated for fairness on the
front end and sounded very good, but in reality it
absolutely destroys fairness on the back end. What he
didn't mention is from here on out a small independent
facility would have no chance, essentially, to acquire
new equipment or replace old equipment in a world
dominated by hospital deep pockets and critical
connections.
Previous to his final speech that night, a
Representative from Fairbanks, who admitted to sitting
on the hospital board up there, stated there is a 30
percent increase in the chance of errors including
services of hospitals. He gave no documentation of
that whatsoever, which is somewhat untenable without
citation of a mainstream or a peer review study. There
are indeed several big mainstream peer review studies
published in the Journal of American Medical
Association which has filtered down to the popular
press such as Readers Digest that document very high
and unacceptable errors in hospital services including
radiology departments.
That Representative also stated that 33 states
presently in the Lower 48 have a certificate of need
program. What he didn't mention was that originally 49
of the 50 states had CON programs and that the federal
administrators dropped the federal CON programs in the
1980s and the rest of the states have followed suit.
These programs have been proven not to work down
there.
He also stated that medical economics work differently
and have been arguing against free enterprise. That is
true. Medical economics have been shown to operate
differently. What he didn't state was why. The main
reason they work differently is because of a problem
of self-referral. Self-referral means that a doctor
sees a patient in his clinic and refers that patient
to his own imaging center or his own laboratory
testing center. This is even worse if the hospital
owns the equipment.
Alaska Open Imaging Center does not do this and cannot
do this because our radiologists don't make that
initial patient visit and don't control referrals.
Independent outpatient centers do imaging more
efficiently, more economically and with a higher
standard of care. They are not subject to the cost of
the CON, which can run up to $100,000 for the
bureaucratic costs, all of which are passed along to
the patients.
Independent outpatient centers are not involved in
over utilization and inflated costs associated with
self-referrals. It's my belief, and others also, the
hospitals should stick to what they do best, which is
inpatient care of critically ill people including any
needed imaging. They should not attempt monopolistic
control of all business enterprise especially in the
outpatient imaging arena for the purpose of cost
shifting.
HB 511 is being ramrodded through just as quickly as
possible because the powers behind it do not want
[indisc] to have time to read the studies or learn the
facts behind it. It threatens my livelihood personally
and I feel it threatens Alaska patients and payers on
their behalf and everybody stands to lose big time
with this.
SENATOR GUESS asked him to comment further on how he believes
CON creates a two-tiered system because, "no matter what
situation, you're not going to have perfect competition in
medical economics. You're always going to have oligopolies."
She assured him she wasn't trying to give him a hard time she
was simply trying to understand how a CON would deny him his
livelihood.
DOCTOR CHRISTIANSON replied one of their findings is that there
is a two-tier system between inpatient hospital pay for Medicaid
and Medicare as opposed to outpatient. As far as the impact on
his livelihood, he said that if his company wanted to purchase a
very expensive piece of equipment for one of their facilities
and they weren't already in that market place but a hospital
was, it would be difficult for them to justify why they should
have the equipment instead of the hospital. Another point is
that when it comes time for them to replace a piece of
equipment, such as an MRI, Providence Hospital is right there
and has the certificate of need so there is no way they could
compete for a new CON to replace the equipment. "We would
basically go out of business at that point," he said.
CHAIR DYSON recognized George Larsen in Mat-Su.
GEORGE LARSEN stated that he supports the bill as presented.
He noted that there have been references to Triad having deep
pockets, but he clarified that the community and Triad have had
a joint venture that was established because Valley Hospital
wasn't able to generate sufficient money for replacements.
Imaging is one of the areas in which a hospital can make some
profit and provide an offset to areas such as emergency rooms
that draw down the entire organization. If they couldn't rely on
imaging to generate profit, they would have to rely more heavily
on the state, he said.
CHAIR DYSON asked him if he works at Valley Hospital.
MR. LARSEN replied he is the chief executive officer at Valley
Hospital.
CHAIR DYSON asked him to clarify whether or not he just
represented that Valley Hospital charges more for imaging than
the service costs to offset services that don't pay for
themselves.
MR. LARSEN replied, "That is true and that's where we're
charging a little bit more. It's competitive with the market in
Anchorage." If they weren't able to make a profit on imaging and
offset losses in departments like emergency rooms, medical
surgical units, and obstetrics they wouldn't be able to operate.
They look at the full system rather than the separate parts, he
said.
CHAIR DYSON asked how much discount on imaging services they
give third party payers such as insurance companies over a self-
payer.
MR. LARSEN said he would have to go to his billing department to
get that information for certain, but he thought that with
Medicare and Medicaid they receive in the neighborhood of 50 to
55 percent of the bill. On the other hand, he said, they give
discounts to self-payers in the form of write offs. In 1999 they
wrote off $2.9 million, in 2000 they wrote off $4.6 million, and
in 2001 they wrote off $4 million.
CHAIR DYSON restated his question, which was what discount they
give insurance companies.
MR. LARSEN said Medicare and Medicaid pay 50 to 55 percent so
the receive a 45 or 50 percent discount. Blue Cross Blue Shield
receives between 3 and 6 percent off charges he said.
SENATOR GUESS asked why they couldn't price services to make a
reasonable profit in the departments that lose money so they
wouldn't have to overcharge in departments that do make money.
MR. LARSEN said some of it has to do with the market. In the
medical surgical unit a room costs over $1,000 per day and they
believe they're priced at what the market can bear.
BRIAN SLOCUM, administrator of the Tanana Valley Clinic in
Fairbanks, reported that they are the largest multi specialty
group in the state and they too provide care for indigent
patients. In 2003 this amounted to about 4.6 percent of their
net revenue and he knew that Fairbanks Memorial Hospital
reported that about 1.8 percent of patient revenue was
uncompensated. Contractual adjustments for Medicare and Medicaid
amounted to another $5.6 million for the clinic, he said.
He said his point is that the CON application in Alaska needs
revision because it's fatally flawed and has outlived its
usefulness. In 1999 his clinic was turned down when they applied
for a CON. During a subsequent appeal, depositions uncovered a
number of precepts. First, the CON program has no risk standards
that are used to evaluate applications. According to sworn
testimony, DHSS used to employ 25 people for planning and CON
review. Now there is a single person and they aren't able to
provide current updates of CON standards for a review. He
pointed out that even multi million dollar projects have no
written standards to use for evaluation purposes.
He was aware that the CON coordinators assured Senator Green
that confidentiality is provided when competing applicants file
multiple CON applications simultaneously. However, in sworn
testimony the CON coordinator admitted that he sent application
data from the Tanana Clinic to Fairbanks Memorial Hospital and
other CON applicants for editing. Although his company
protested, their objections were ignored.
Finally, he pointed to a CON review dated February 10, 2004 in
which the coordinator decided that a CON would be required for a
group of physicians because the present value of the equipment
they were applying for exceeded $1 million. Although it's been
stated multiple times that hospitals want to level the playing
field because doctors don't need a CON when leasing equipment,
the CON coordinator apparently anticipated the Legislature and
changed the requirements. "This is all too characteristic of the
CON program," he said.
MIKE POWERS, administrator of Fairbanks Memorial Hospital,
testified via teleconference to say that he would like to speak
to the philosophic issues of CON and comments about them
restricting competition and being a monopolistic control
measure. "A number of things have been said about the unique
rules of health care economics. They essentially require four
conditions to be met. Buyers and sellers are well informed,
buyers and sellers are numerous, buyers and sellers are
independent and there is easy entry and exit from the market."
Not one of those conditions is met in health care. Patients make
infrequent decisions about health care issues and so are not
informed. There are many sole community providers and so there
aren't many buyers and sellers in a community. The whole role of
insurance puts a barrier between the buyer and seller. If
Fairbanks Memorial were to try to exit from the ER or neo-natal
market, there would be public outrage. Because those basic
conditions aren't met there's a need for some kind of
regulation.
The question of cost subsidies is anathema to business, but
departments such as the ER are badges of honor to a hospital.
"We're proud of the ER and we're proud of taking care of burns,
neo-natal, Medicare and Medicaid and all comers." However, he
said he takes issue with niche providers that cherry pick labor
in an 8 to 5 operation while the hospital operates all hours to
take care of the entire community. Empirical evidence suggests
that niche providers target less costly patients, which raises
the issue of a few shareholders benefiting versus access to many
in the community.
Questions about ethics and self-referral have come up, but the
federal government is calling for an 18 month moratorium as a
result of the adverse impact of niche providers. A General
Accounting Office study in Florida shows that doctors that own
diagnostic imaging equipment charge 54 percent more for Medicare
scans, 28 percent more for CT scans, and 25 percent more for
ultrasounds. The study indicates that 83 percent of all
specialty hospitals and 55 percent of general hospitals are
located in states without certificate of need. Some states are
moving back to CON because they found that managed care in the
80s and 90s didn't work.
In conclusion he said they would like the committee to
conceptually make the rules fair for all organizations.
SENATOR GUESS asked him to comment on what keeps Fairbanks
Memorial Hospital from pricing ER services to reflect the costs
plus a reasonable profit.
MR. POWERS replied it's the heavy reliance on the government
payers such as Medicaid and Medicare that don't pay for the cost
of the care. Those costs have to be recovered somewhere else so
you over price in other areas.
CHAIR DYSON commented that that is a remarkable statement.
MR. POWERS replied, "It's a sad, unfortunate societal dilemma
that unfortunate legislators find themselves in and can't fully
fund the Medicaid program."
CHAIR DYSON asked if he just said that because Medicare and
Medicaid reimbursements don't cover the cost of services you
have to put those charges on somebody else and that is either
the self payer or the insurance third party payer.
MR. POWERS replied, "All costs, all charges are placed equally
on all payers it's just that some refuse to pay for those."
CHAIR DYSON said that includes Medicare and Medicaid.
MR. POWERS agreed.
SENATOR GUESS questioned whether the prices charged in the ER
are reflective of the cost of services plus a reasonable profit.
MR. POWERS said they are.
ROBERT GOULD reported that he is the associate administrator of
finance and operation [for Fairbanks Memorial Hospital] so he
fills the CFO role and also has operational responsibility for
imaging, surgery, ER etc. He said he supports the bill because,
in his view, it levels the playing field, which is not currently
the case.
Using imaging as an example he advised that the hospital is in
the process of building an imaging center and they are
restricted to building up to the current community need. They
are unable to build in extra services or build for anticipated
growth, but a business without a CON could come in and draw
business away from the hospital without going through the CON
process. Although there have been charges that this restricts
competition, the fact is that anybody that goes through the CON
process that can show need can get approval for their project.
"The fact of the matter is that if there is capacity in
Fairbanks, even after we're done with our imaging center,
someone else could come in, apply for a certificate of need and
as long as they can show need, they can have the services. Under
the current legislation, the way it is now, for imaging it isn't
required. They could just build on top of what we've already
built and shown a need for."
He said he would challenge the statement that a CON can cost up
to $100,000 because they've done a number of them and if they've
spent more than $10,000 on any one he would be very surprised.
He also challenged the idea that Fairbanks Memorial Hospital is
a monopoly and that they don't foster competition. If
competition brings lower costs then the costs in Anchorage
should be the lowest in the state, but Fairbanks Memorial
Hospital is actually the low cost full service provider in
Alaska.
He stated that there are four areas in health care that pay.
Whether it's right or wrong, Medicare, Medicaid and other payers
have placed a premium on imaging, surgery, pharmacy and lab
services. Those are the only services a hospital would provide
if they were in business solely for the money because those are
the only services in health care that make the money needed to
sustain the facility.
CHAIR DYSON remarked that when he said that the hospital builds
capacity up to the need he assumed that it meant the need of the
people in the area, but he probably meant the need as defined in
the CON.
MR. GOULD replied when they applied for a CON it was to fill the
needs that they thought they could support and that weren't
being met.
CHAIR DYSON asked if that was the need that was defined in the
CON.
MR. GOULD said that when they applied for the CON it was to fill
the need they thought they could support related to the needs
that were not offered in the community at that time. "What I
meant is that we were building up to what we believed the
customers in Fairbanks need at this time. What we could justify
based on the numbers."
CHAIR DYSON acknowledged that they were both looking at and
using the numbers in the same way. He asked whether it's
legitimate for someone else to come along and meet a need that
the hospital didn't recognize.
MR. GOULD asked what that might be.
CHAIR DYSON said it would be someone else offering the same
service and meeting needs that Fairbanks Memorial Hospital
didn't have the capacity to meet. "You object to them coming and
taking the new business?" he questioned.
MR. GOULD replied he wouldn't object to that, but he would
object if they went through the CON process to show need for two
MRIs only to have someone else enter the picture and began
taking business away from the hospital by offering MRI services
without going through the CON process.
SENATOR GUESS asked why he believes the four areas he mentioned
are profitable because they heard that prices are under cost but
they're all the market can bear. Also, they've heard that it's
really recovery and not prices that are under cost.
MR. GOULD explained that Medicare reimbursement is higher in
those four areas and most providers elect to use the Medicare
regulations to determine reimbursement. Charges, he added, are
becoming less relevant in health care because Medicare and
Medicaid give a flat fee in each area. For instance, Medicaid
reimburses Fairbanks Memorial Hospital 52 percent of charges and
Medicare reimburses 50 percent of charges.
RICK SOLIE, volunteer trustee on the Greater Fairbanks Hospital
Foundation, stated this is a very important issue for their
community hospital. He said he would first clarify several
issues he heard during the hearing on Friday.
The foundation contracts with Banner Health System to run the
hospital for about 3.5 percent, which is average to low for this
service. The notion that Banner Health is making a great deal of
money from this contract is not accurate or fair. ".... health
care and hospital economics is not a free market and so to
employ the standard of free competition on it is not fair
because it isn't true. What is true though, is to have a
rigorous discussion of some of the benefits that competition
gives you and that is cost quality and access."
TAPE 04-27, SIDE B
2:21 pm
Specifically as it relates to Fairbanks:
We're trying to help our communities and trying to
have imaging systems and in Fairbanks we're working
hard on a cardiology program trying to figure out a
way to make that work. We have audited statements from
Medicaid rates that show our hospital with the lowest
inpatient rates. That's across the board, that's the
overall picture.
On the outpatient side, our hospital has lower rates
than Anchorage on the outpatient side. And this is a
town that you would argue doesn't have competition,
yet our prices are lower. Specifically on the MRI, - I
can't speak to Anchorage I know [Alaska] Open Imaging
is touting cheaper prices - I know our experience in
Fairbanks is that the MRI prices at our hospital are
between 20 and 40 percent lower than those at the
clinic across town. So I would suggest that
competition in whatever form you might call it is not
bringing lower prices in Fairbanks. What it does do is
hurt our ability to provide those services like the
ER, the neo-natal care, the psychiatric care, the
cancer care - an awful lot of those things that we
look to. I would encourage the committee to be careful
as you look at this bill because we don't want to
start to take apart a system that at least in
Fairbanks we've spent some 34 years in building.
We support this bill. I think it closes up the lease
provision and the diagnostic provision. It creates a
level playing field. You can argue about the wisdom of
the CON. [But] honestly, I don't think this is the day
to do that. This is a better day to at least create a
level playing field and let's have some discussion
about whether it's deductibles or medical savings
accounts or ways to move a free market into the health
care sector. But it is not a free market today so on
cost - and I didn't even get to quality and access
because my time ran out - we have 98 percent board
certified medical staff. We take all comers and I
would be happy to answer questions.
SENATOR GREEN asked for his interpretation of what the new
language does for the lease issue and how it differs from the
current situation.
MR. SOLIE said that's in Section 2 and his understanding is that
under current law it would allow for an ambulatory surgery
facility to be constructed if the facility was leased or the
equipment was leased. He wasn't clear on the monetary total, but
"it's the lease provision that allows for the skirting around
the CON need."
SENATOR GREEN wondered whether his reference to lease was a
specific reference to Fairbanks Memorial Hospital.
MR. SOLIE replied it is specific because under current law there
are two ways that it doesn't apply uniformly. Those are
diagnostics and the lease provision. This bill would level that
playing field, he said.
SENATOR GREEN asked whether Fairbanks Memorial Hospital had ever
leased facilities.
CHAIR DYSON added, "Or equipment."
MR. SOLIE advised the foundation leases the hospital to Banner
Health System and they pay the hospital a lease fee. He said he
wasn't sure whether that answered the question.
CHAIR DYSON said that in Section 2 he understands that there is
a $1 million threshold and if you're under that amount you
wouldn't have to go through the CON process. Some people have
figured out that you could lease the equipment so that money
comes from the operating budget and you stay under $1 million.
Those that believe that the lease issue allows unfair
competition, say that loophole should be closed. Senator Green
just asked whether Fairbanks Memorial ever leases equipment.
SENATOR GREEN added, "Or anything."
MR. SOLIE said the foundation isn't leasing any real estate and
he would have to defer to the finance officer regarding the
leasing of equipment. Their concern is that whether or not you
like the CON, it doesn't apply to the ability to build a
facility or obtain equipment through a lease mechanism.
SENATOR GREEN asked whether the foundation ever leased anything
to the hospital that didn't go through the CON process.
MR. SOLIE asked whether she was speaking of the cancer center.
SENATOR GREEN replied she didn't know anything about his
foundation.
MR. SOLIE explained the foundation is the owner of the facility
and the equipment. Generally the hospital applied for the CONS,
but sometimes the foundation has assumed that role.
SENATOR GUESS said she would like to spend time on Section 2 at
some point because 'purchasing equipment' isn't referenced under
'expenditure'. It's just leasing that is referenced.
CHAIR DYSON agreed with her reading.
SENATOR GUESS asked that the sponsor's staff explain why you
wouldn't need a CON if you purchased $1 million in equipment,
but you would if you lease the equipment.
CHAIR DYSON said the department could speak to it, but he
thought that since you wouldn't have to go through the CON
process if you were under $1 million, people were avoiding that
threshold by leasing equipment.
DOCTOR KURT HEDIGER, AK Chiropractic Society President,
testified via teleconference to say he practices throughout the
state as a vacation chiropractic physician and is opposed to the
bill in its current form.
Although the CON may have been necessary at some point, it's a
dinosaur in 2004 and the $1 million threshold is low in today's
dollars. The bill would negatively impact his patients and his
business and would give an edge to established health care
facilities and stifle upstart businesses. It appears to be anti
competitive and amounts to government support for the status
quo. "The consumer will continue to have limited choices and
health care costs could only go up as quality and patient
satisfaction actually will decline."
To his knowledge, just Fairbanks Memorial Hospital has
restrictions against chiropractic referrals and such impedance
to access is frustrating because it delays treatment, increases
costs and puts the patient at risk. Alaska Open Imaging
increases capacity and choice for Mat Su, Kenai and Anchorage.
The focus should be on the patient's best interest and that is
competitive health care through competition accessibility and
the use of innovative technology. He emphasized he believes that
including "independent diagnostic facility" is wrong.
With only one provider you can't expect prices to go down. With
that in mind, he questioned how hospitals made a profit before
imaging like MRIs and CT scans. All businesses assume risk but
if this bill passes, hospitals in Alaska will have their profit
margin protected by statute.
CHAIR DYSON asked what he believes a reasonable threshold to be
if the $1 million is too low.
DOCTOR HEDIGER suggested it should be adjusted for cost of
living increases and could be five times the amount it is for
larger businesses.
DOCTOR ROBERT BRIDGES from Alaska Open Imaging Center testified
via teleconference that he started the business in 2001.
Countering the claim regarding over charging on self-referrals,
he said can't self-refer. His work is always returned to the
referring physicians so if he does a good job and the patient is
happy he may get the next referral. His work undergoes peer
review every day for every procedure and provides a form of
checks and balances.
When the business first opened in Wasilla, they had an open MRI
magnet just like the one at Providence Hospital. Later they
added a CT scanner that was similar to the one at Providence.
Seven months later Valley Hospital fired the radiology group
that had been working there for 17 years because the hospital
could have been offering these services all along, but they
didn't because they didn't want to or they didn't know how.
When his business moved into Anchorage they added another open
MRI scanner because Providence had abandoned open imaging and
their patients had to go to Wasilla for a scan. Next they added
a CT scanner and finally in March 2003 they installed a Positron
Emission Tomography scanner. As board certified in nuclear
medicine and a nuclear engineer he said they were very qualified
to do this.
Providence Hospital talked about installing a PET scanner for
five years and for three years they could have done so.
Referring to their CON application for renewal in December 2002,
he said they admitted they had done nothing on this project but
they needed a renewal because the price had ballooned to $4.5
million. "Providence followed in our footsteps and using their
taxed for profit wing, legally circumvented the CON and leased a
$2.8 million PET scanner that fits in a mobile trailer behind
the hospital. It could be done. We did it because we took the
time, we knew what to do and we delivered on this, much needed
services."
He said his business takes care of Medicare and Medicaid
patients and patients that are difficult because of their size
and/or claustrophobic tendencies yet the hospital says they
cherry pick. The CON won't work, he said, because it restricts
access to the equipment he needs to practice medicine and it
restricts patient access. The CON does not help Valley Hospital
because people can vote with their feet, get in a car and go to
Anchorage. "Before we came on the scene, half of all the
outpatient and daily medical services in the valley were going
to Anchorage. .... People want choice, they want an opportunity
for better more diversified medicine in the state."
The playing field is already equal, he said. Using the CON is
capricious and will bring waste and cronyism.
UNIDENTIFIED SPEAKER commented that someone said that outside
corporations were making money in Alaska and she would point out
that Providence arrived in Alaska in 1905. With reference to the
charge that hospitals are monopolistic, she said we're really
talking about what is best for communities. Senator Guess has
been asking about competition and the services that aren't self-
supporting. People can and do vote with their feet as the
previous speaker pointed out, but it's hospitals that are open
all hours of every day and every night and the public expects
full services to be available in the hospital. To do that, the
hospital has to have the ability to provide those services.
As Mr. Gould said, there are four areas that are profitable and
facility providers don't control that. Medicare and Medicaid and
someone up in federal offices decides what they believe is
important. Imaging is an important area and therefore provides
an opportunity to support areas that aren't profitable.
In conclusion, she said she hopes the committee can support the
bill.
PAUL BRENNER, vice president of quality management at Central
Peninsula General Hospital, said he supports the bill. The CON
has worked for many years and guarantees a level playing field.
It will help eliminate duplication of services in small
communities and help curtail rising medical costs.
DOCTOR HELEN BEDDER testified via teleconference to say she is
strongly opposed to CONs and most physicians are opposed as
well. She reminded members that Alaska has few restrictions on
physicians, which is one reason why doctors are attracted to the
state. CONs are restrictions on the ability to practice. All the
hospitals are talking about CONs leveling the playing field, but
she doesn't see why hospitals believe they play on a level field
because most of them are non-profit. Hospitals receive a
percentage of what they charge from Medicare and Medicaid while
independent surgery centers are paid a flat rate that is set by
Medicare and Medicaid. The result is that hospitals are paid
higher. Hospitals have a natural advantage in terms of referrals
that independent practitioners don't have.
With regard to the question Senator Guess asked about how CON
shuts down competition, she pointed out that a Fairbanks
physician applied for a CON only to have Fairbanks Memorial
Hospital take away his hospital privileges, which eliminated his
ability to earn a living.
SENATOR GUESS asked if she believes that it's the CON process
that's the problem rather than the CON itself.
DOCTOR BEDDER replied she really doesn't believe the concept
itself is fair, but the process definitely isn't fair. CON was
initiated years ago as a federal program to determine how costs
and charges were determined. Most states have done away with CON
because it's no longer part of what is needed to determine
costs. The CON in Alaska is archaic and is being maintained by
Providence and Fairbanks Memorial in an effort to control the
market and make sure there isn't any competition. Competition
works and reduces prices.
CHAIR DYSON asked the commissioner to come forward.
JOEL GILBERTSEN, Commissioner of the Department of Health &
Social Services, introduced himself and asked Janet Clarke to
sit with him. He said:
There have been a number of things stated today and I
think it's fair to say that there have been different
perspectives put on issues by organizations. As the
State of Alaska it's not really our business to pick
amongst providers. We want to make sure we have a fair
process. I know there have been criticisms of the
process around certificate of need and I think it's
fair to say the department has to work continuously on
a daily basis to improve that process. That said, as
an administration, as a department, we support this
legislation.
The legislation touches upon a number of issues, one
of which I wanted to speak to, which is residential
psychiatric treatment center care. Right now we are
engaged in an effort called, "Bring the Kids Home."
Bring kids home from out of state and these are kids
with residential placements out of state because of a
lack of continuum care including residential
placements in state. We believe we can serve these
kids better here in Alaska. We believe it's better for
them therapeutically, but it's also better policy.
What we also know is that while there might be 400
plus kids in residential placements out of state, we
do not need 400 beds in state. In fact we believe our
system rushes children into residential placements
because we haven't had the continuum of care. We
haven't had a good gate keeping system. We don't have
good therapeutic foster care programs and group homes.
We need to invest in these things. They are cheaper
than residential care and they're better for many of
them.
As we engage in this effort to bring these children
home we want to make sure we have a system that is
geographically responsive to the needs of the
children. But is also acknowledges that we have to
have the appropriate amount of beds in state.
Certificate of need does have its critics and
supporters. I support CON; I think it's a good way for
a state to have a public process and in turn give
adequate access to care across the state.
I know there have been comments around competition.
Competition brings a lot to many different markets. I
think for health care, competition greatly increases
choice and choice for the consumers. Does it
necessarily benefit cost? Not in all cases. In some
cases it does but not in all cases. One of the things
we have in health care and are painfully aware of - I
know the Chairman is aware of this because I've had
conversations about this with him - but outside of the
cash payer, most individuals really do not select
their health care or the location of their health care
based on cost. There is an intermediary between the
price and the consumer. It's called insurance. Some
times it's provided by the State and sometimes by
their provider, but they do normally shop not based on
cost but on access.
Quality is a key component when making their choice.
Who has the better facility? Location, convenience
other amenities, but not necessarily cost. So we do
have some concerns about as we move forward and
supporting CON policy that we're developing this
residential system in state that is cost efficient,
that the state the primary payer. And for these kids
we are the payer. Particularly after 30 days of
residency status.
The other provisions we support and I want be here
with Janet to answer questions of the committee or to
comment on things that you may want to hear from us.
CHAIR DYSON said he had a couple of questions beginning with
page 2, line 3. He questioned why they should care how many
times a business or person relocates their capacity in an area.
Janet Clarke with the Department of Health & Social Services
said they brought an analysis of Sections 1 and 2 from the
assistant attorney general who advises them on CON. She said he
could join them at the table if the Chair would like.
CHAIR DYSON said that's fine, but it's a philosophical question.
Who cares whether they move every day as long as they're in the
area and providing the service, he questioned.
COMMISSIONER GILBERTSON said it's fair to ask as long as the
size and scope of practice remains the same and the geographic
location is the same. The state's primary concern with
certificate of need is whether or not that capacity is needed.
MS. CLARKE said current law doesn't allow that.
CHAIR DYSON said he knew that, but the philosophical question
remains. Why is just one move allowed?
MS. CLARKE suggested the sponsor might want to answer that
question.
CHAIR DYSON then asked for comments on whether the $1 million
threshold is obsolete.
COMMISSIONER GILBERTSON replied it's a fair question, but when
you look at the purpose of what CON is serving that threshold is
as proper and relevant today as when it was originally designed.
Originally CONs were for hospitals and nursing homes. Costs in
those facilities have increased a great deal and if CONs were
only addressing those facilities then the threshold isn't as
valid, but it's not completely invalid. Hospitals are now
competing in a different area. It's not about constructing a
hospital it's about purchasing equipment so the threshold is
still legitimate.
Now there are areas of new services such as ambulatory surgical
centers and residential psychiatric treatment centers. He said
these are boutique services that provide clearly defined
services, but aren't of the broad scope that a hospital would
provide. For those smaller facilities the $1 million is a viable
threshold. As the market has changed and as hospitals have begun
to provide other services the threshold is correct.
CHAIR DYSON asked about when a facility just leases a building
as Fairbanks Memorial is doing.
COMMISSIONER GILBERTSON explained, the legislation is an effort
"to ensure that whether you are purchasing it or you are leasing
it, if you are acquiring for use for health care service,
property with a value of over $1 million in its present day
value, or equipment, that should be equally treated under the
certificate of need law." This bill clarifies that, he said.
CHAIR DYSON announced that Doctor Conover was waiting to give
testimony and since he was removed from Alaska by several time
zones he would like to allow him time to testify.
DOCTOR CHRIS CONOVER, assistant research professor of public
policy from Duke University, testified via teleconference and
advised members that he and Professor Sloan conducted two
studies of CONs for Delaware and Michigan. He stated:
There are three principle reasons used to justify CONs
that have been discussed - quality, access and cost.
The chief one is cost, but then people often talk
about quality and access.
Our report from Michigan systematically refutes the
evidence regarding CONs from every public CON study to
date. Included among these were six studies that
looked at CON's impact on the diffusion of CT scanners
and four studies focused on CON's affects on the
supply of MRIs.
DOCTOR CONOVER advised that he would submit the information for
the record rather than going through each study individually. He
then continued to say:
On the CT studies, there was one study written by
proponents of CON who in their study acknowledged that
there were probably some very real non-economic
patient costs of the Massachusetts approach to
rationing scanners. These may have included long waits
in addition to the inconvenience and discomfort of
having to be transported from a hospital without a
scanner to a hospital with one. They also noted that
since limited availability of scanners forced
prioritization of patients, some patients who might
have benefited from CT were not scanned. Many of the
alternatives to scanning involved more risk and
discomfort to the patient such an angiography.
A critical shortcoming of all of these studies is that
they count the number of units rather than directly
measuring the impact of CON on cost. This is somewhat
equivalent to estimating consumer expenditures on
gasoline based on the number of available filling
stations. The presumption in these studies is that
more units mean more services, which translates into
higher costs. But the example of gas stations
illustrates the potential fallacy of that approach. In
the case of gas stations, prices tend to actually be
lower when there are two gas stations competing across
the corner from one other. Even though, logically, one
might think the duplication of facilities would result
in higher prices.
While medical care is not the same as gasoline,
various FTC studies have shown that hospital prices
and costs are higher in areas where there is a
monopoly provider compared to areas where there is
head to head competition, which is precisely why the
FTC regulates hospital consolidation - to prevent anti
competitive affect.
Moreover, even if one could demonstrate that reducing
the supply of imaging services results in lower
spending on these services, this is not tantamount to
proving that regulation has saved you money. On the
contrary, if imaging is a substitute for more
expenses, more invasive procedures and/or growing
imaging can reduce [end of tape]
TAPE 04-28, SIDE A
3:06 pm
It is worth noting that there are no volume benchmarks
for CTs or MRI services established by either the
Joint Commission on Accreditation of Health Care
Organizations or the American College of Radiology. So
even if CON were effective in holding down the supply
of CT or MRI services, there is no good reason to
suppose this would confer an improvement in quality of
care.
A final thought worth considering is this; only 21
states now regulate CT scanners, 24 regulate PET
scanners and 30 regulate MRIs. Of the states that
opted not to regulate these technologies, [did they
make] a foolhardy choice? Are their citizens paying
higher costs for enduring levels of quality care
because these images do not now fall under CON review?
I am aware of no such evidence. Unfortunately, the
kind of definitive study that could nail down the
answer to the question that will basically be
considered by the committee today has not been done.
Such a study is feasible and could be completed in
roughly a year's time. Frankly, given the availability
of this evidence, I myself would be more inclined to
drop regulation of imaging technology in-hospital than
I would be to expand this regulation to non-hospital
entities. The best approach of all might be to do the
research that could definitively nail down this
question of whether regulating these technologies
saves money or adds to cost once all costs are taken
into account. It is not at all clear what harm would
be done by deferring a decision so the answer to the
right question can be determined.
CHAIR DYSON asked Doctor Conover to FAX a copy of his research
paper and his written comments and he would distribute copies to
the committee members. He questioned whether he knew of any
states that had particular success in handling these issues and
whether there were paradigms available that Alaska might find
useful.
DOCTOR CONOVER replied the states they worked for looked at CON
globally and didn't specifically focus on imaging technology.
Michigan asked them to look at MRIs so they did address them in
their report. The evidence on MRIs is mixed, but they were all
focused on hospital based MRI units and half of the MRIs that
are in use are outside hospitals.
SENATOR GUESS asked if he is recommending that they eliminate
imaging technology from the CON process rather than expanding
the CON process to include them.
DOCTOR CONOVER replied if the committee feels compelled to take
action he believes it would be preferable to level the playing
field by taking away regulation in a sector rather than adding
it to a different sector.
SENATOR BETTYE DAVIS asked whom he was representing.
DOCTOR CONOVER said Sam Corsmell contacted him, but he didn't
know which facility he runs.
CHAIR DYSON assured him his question wasn't pejorative, but he
wanted to know whether he was remunerated for his testimony.
DOCTOR CONOVER said he was compensated for his time to appear.
SENATOR DAVIS announced that she had a question for the
commissioner.
CHAIR DYSON said he did too and if she didn't mind, he would go
first. He questioned whether the major reason for the
legislation didn't relate to the expansion of adolescent
facilities and the desire to get them in under the CON process.
COMMISSIONER GILBERTSON said Representative Samuels introduced
the legislation and DHSS began working with Representative
Samuels' office after he had introduced the bill. They support
the entire bill, but the department is most interested in the
RPTC language.
CHAIR DYSON asked whether the present licensing process would
allow DHSS to issue a directive saying they would only license
so many beds in a certain area.
COMMISSIONER GILBERTSON said no; licensing is based on strict
standards of meeting the clinical requirements for a facility.
Right now there is a cap on long-term care beds, but that's done
through the CON process.
CHAIR DYSON brought up his concern about the people who already
started the process in Kenai and asked if there was a way to
lend certainty to their process so they don't lose the
construction season.
COMMISSIONER GILBERTSON interjected that he didn't know enough
about the proposal to say with certainty that they could or
could not make this construction season. "That said, there are -
based on just informal communications - since there is no CON
process right now, providers are not required to come to the
state and let us know what you are planning. A number have
voluntarily to say, 'These are things we're considering.' If you
were to add all of them up, I think we have easily seen between
500 and 600 beds that are at some conceptual stage or closer to
development in the state right now."
DHSS has developed a policy for interpreting the effective date
for projects that are underway or have reached some level of
decision-making within the organization. The policy is that
projects are grandfathered in as long as legitimate construction
has started, a full set of architectural drawings are completed
and that the entity that is building the facility has a building
permit in hand. In addition, they must complete construction
within two years of breaking ground. It doesn't mean that
everyone will get in, but they are putting the CON process
forward so that as psychiatric treatment center beds are brought
on line in Alaska the kids' needs are met first.
SENATOR DAVIS asked if it was the sponsor's idea or his to put
adolescent psychiatric treatment centers under the CON process.
COMMISSIONER GILBERTSON said they had a process underway to look
at statutorily expanding, through a governor's bill, residential
psychiatric treatment centers. Representative Samuels introduced
his legislation first so they began working with him using a
committee substitute on the House side.
SENATOR DAVIS asked if most of the 500 some children that would
return to the state would be located in south central Alaska.
COMMISSIONER GILBERTSON replied the children in out of state
placement are disproportionately Alaska Native and they come
from rural communities. Simply based on the population of
Anchorage, the need for residential facilities would be weighted
in that community if the sole desire were to have the children
close to home. That isn't always the case though, and there are
always a variety of clinical reasons for why a child is placed
in a certain place. "Our goal largely is that we want to have
the care given as close to home as possible with the
acknowledgement that it's a continuum of care and that there are
levels of care below the semi-secure residential treatment
center. And as the child is working their way back to their
community, you want to make sure that they have the after-care
and the support services in every community for the kids."
SENATOR WILKEN asked if there was a letter of intent with the
legislation.
MS. CLARKE replied the House adopted a letter of intent that
related to CON. It establishes a task force to look at the
process and the procedures and standards to improve the
effectiveness of the program. The letter of intent also
indicates that the Legislature urges DHSS to expeditiously
update the CON regulations, which is what Senator Green has
mentioned many times.
SENATOR WILKEN asked for a copy.
SENATOR GUESS asked how she would learn more about the process
by which they make a decision. After reading through the
regulations and the statute, she was still uncertain about what
evaluation methods are used and how a final decision is made.
COMMISSIONER GILBERTSON acknowledged the question is very
appropriate. The State is currently in the process of finalizing
an actual process for defining the criteria for this type of
facility, he said.
MS. CLARKE added the statute requires them to look at need.
Although no written standards have been adopted in Alaska, they
are in the process of developing them.
CHAIR DYSON asked Mr. Franz from Homer whether he could give his
testimony on Wednesday.
CHARLIE FRANZ said he wouldn't be available then, but his
testimony wouldn't take long.
CHAIR DYSON told him to go ahead and apologized for keeping him
waiting for so long.
MR. FRANZ stated he is the chief executive officer of South
Peninsula Hospital in Homer and the chairman of the board of
directors of the hospital and nursing home association and he
serves on the DHSS assembled task force to look at developing
standards for the CON process. "With that background, I would
like to speak to you in favor of HB 511," he said.
It's a good bill that helps to preserve access to a full range
of hospital-based health care, he said. It does this by
including the independent diagnostic and testing facilities,
which levels the playing field and gives equal treatment under
the law. Independent diagnostic facilities would have to
demonstrate a need instead of simply opening a facility and
competing for these lucrative services that hospitals provide.
He took issue with the argument that independent diagnostic
testing facilities are only an issue in larger communities. He
pointed out that Homer has that problem.
CHAIR DYSON thanked all the participants and encouraged the
committee members that were interested in offering amendments to
get them drafted quickly and distribute them to other committee
members and the administration so they could move the bill
forward.
MS. CLARKE pointed out that she distributed a letter dated
5/3/04 providing the information requested of her at the
previous meeting.
CHAIR DYSON thanked her and adjourned the meeting at 3:28 pm.
CSHB 511(HES) am was held in committee.
| Document Name | Date/Time | Subjects |
|---|