Legislature(2019 - 2020)BUTROVICH 205
02/14/2020 01:30 PM Senate HEALTH & SOCIAL SERVICES
Note: the audio ![]()
and video ![]()
recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.
| Audio | Topic |
|---|---|
| Start | |
| HB29 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | HB 29 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
February 14, 2020
1:32 p.m.
MEMBERS PRESENT
Senator David Wilson, Chair
Senator Cathy Giessel
Senator Mike Shower
Senator Tom Begich
MEMBERS ABSENT
Senator Natasha von Imhof, Vice Chair
COMMITTEE CALENDAR
HOUSE BILL NO. 29
"An Act relating to insurance coverage for benefits provided
through telehealth; and providing for an effective date."
- HEARD & HELD
PREVIOUS COMMITTEE ACTION
BILL: HB 29
SHORT TITLE: INSURANCE COVERAGE FOR TELEHEALTH
SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ
02/20/19 (H) PREFILE RELEASED 1/11/19
02/20/19 (H) READ THE FIRST TIME - REFERRALS
02/20/19 (H) HSS, L&C
03/26/19 (H) HSS AT 3:00 PM CAPITOL 106
03/26/19 (H) Heard & Held
03/26/19 (H) MINUTE(HSS)
03/28/19 (H) HSS AT 3:00 PM CAPITOL 106
03/28/19 (H) Moved HB 29 Out of Committee
03/28/19 (H) MINUTE(HSS)
03/29/19 (H) HSS RPT 3DP 1NR
03/29/19 (H) DP: CLAMAN, DRUMMOND, SPOHNHOLZ
03/29/19 (H) NR: PRUITT
04/12/19 (H) L&C AT 3:15 PM BARNES 124
04/12/19 (H) -- MEETING CANCELED --
04/15/19 (H) L&C AT 3:15 PM BARNES 124
04/15/19 (H) Scheduled but Not Heard
04/24/19 (H) L&C AT 3:15 PM BARNES 124
04/24/19 (H) Heard & Held
04/24/19 (H) MINUTE(L&C)
04/26/19 (H) L&C AT 3:15 PM BARNES 124
04/26/19 (H) <Bill Hearing Canceled>
04/29/19 (H) L&C AT 3:15 PM BARNES 124
04/29/19 (H) Moved HB 29 Out of Committee
04/29/19 (H) MINUTE(L&C)
04/30/19 (H) L&C RPT 5DP 2NR
04/30/19 (H) DP: HANNAN, STUTES, FIELDS, WOOL,
LEDOUX
04/30/19 (H) NR: REVAK, TALERICO
05/07/19 (H) TRANSMITTED TO (S)
05/07/19 (H) VERSION: HB 29
05/08/19 (S) READ THE FIRST TIME - REFERRALS
05/08/19 (S) HSS
02/14/20 (S) HSS AT 1:30 PM BUTROVICH 205
WITNESS REGISTER
REPRESENTATIVE IVY SPOHNHOLZ
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: HB 29 Sponsor.
KASEY CASORT, Intern
Representative Ivy Spohnholz
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Provided an overview of HB 29.
SARAH BAILEY, Supervisor
Life and Health Section
Division of Insurance
Department of Commerce, Community and Economic Development
Juneau, Alaska
POSITION STATEMENT: Answered questions about HB 29.
VICTORIA KNAPP, Chief Operations Officer
Mat-Su Health Services
Wasilla, Alaska
POSITION STATEMENT: Testified in support of HB 29.
STEWART FERGUSON, Ph.D., Chief Information Officer
Alaska Native Tribal Health Consortium
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 29.
ANITA HALTERMAN, President
Alaska Collaborative for Telehealth and Telemedicine (AKCTT)
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 29.
CLAUDIA TUCKER, Vice President
Government Affairs
Teladoc Health
Greenwich, Connecticut
POSITION STATEMENT: Testified in support of HB 29.
ACTION NARRATIVE
1:32:07 PM
CHAIR DAVID WILSON called the Senate Health and Social Services
Standing Committee meeting to order at 1:32 p.m. Present at the
call to order were Senators Giessel, Begich, and Chair Wilson.
Senator Shower arrived shortly thereafter.
HB 29-INSURANCE COVERAGE FOR TELEHEALTH
1:32:37 PM
CHAIR WILSON announced the consideration of HOUSE BILL NO. 29,
"An Act relating to insurance coverage for benefits provided
through telehealth; and providing for an effective date."
He stated his intent to hear an initial overview, a sectional
analysis, and invited and public testimony. He called
Representative Spohnholz and her staff to the table.
1:33:18 PM
REPRESENTATIVE IVY SPOHNHOLZ, Alaska State Legislature, Juneau,
Alaska, HB 29 sponsor, said this bill is about increasing access
to care and reducing the cost of health care for Alaskans by
requiring insurers to cover telehealth in the state of Alaska.
Access to telehealth with Medicaid was one of the core elements
of Senate Bill 74, the Medicaid reform bill that passed in 2016,
and is provided by and covered by Alaska's tribal health system.
It has been so effective in those markets that it should be
expanded to the private insurance market also.
REPRESENTATIVE SPOHNHOLZ explained that telehealth services are
important to increase access to health care in rural Alaska, to
address behavioral health issues, to support health care
transformation in the state of Alaska, and to reduce unnecessary
travel. That means Alaskans will have access to health care even
if there is no provider of that health care in their community.
This is particularly important in rural Alaska and for the
substance abuse and behavioral health crisis. HB 29 supports a
hub and spoke model of health care delivery in which primary
care can be provided in a community and other providers can be
consulted via telehealth. Improving access can reduce
unnecessary emergency room (ER) visits. New technologies allow
providers to take temperatures and do other things via
telehealth. A telehealth provider could look at a wound to help
decide if it is serious enough to go to the emergency room or
whether a butterfly bandage could be used on the wound overnight
until getting stitches the next day.
REPRESENTATIVE SPOHNHOLZ said the Alaska Native Tribal Health
Consortium quantified the cost savings for its use of telehealth
at $12.4 million in FY 2019. In over eight years, $70 million
has been saved in unnecessary travel and unnecessary care with
telehealth. She wants to bring that innovation to the private
market. Expanding access to telehealth is also important for
transforming the health care system. Lori Wing-Heier, Director
of Division of Insurance, calls the future of the hospital
virtual. Some health care providers, even in urban Alaska, are
encouraging people with communicable diseases to stay home and
get their health care via telehealth. A telehealth visit is
easier and better for people who have the flu, for example.
REPRESENTATIVE SPOHNHOLZ shared that for all the reasons that
she described, there is a broad range of support for HB 29. HB
29 is supported by health care providers including Orion Health,
Mat-Su Health Services, Teladoc, Dr. Jill Gaskill, Medical Park
Family Practice; insurers like Moda Health; and organizations
like the Alaska State Hospital and Nursing Home Association, the
Alaska Native Health Board, Mind Matters Research, the Alaska
Commission on Aging, the Mat-Su Health Foundation, and AARP.
1:38:07 PM
KASEY CASORT, Intern, Representative Ivy Spohnholz, Alaska State
Legislature, Juneau, Alaska, said Alaska faces unique challenges
with accessing health care, including geography and limited
transportation infrastructure. Alaska has some of the highest
health care costs in the country because patients often have to
travel to access care, especially because Alaska's small
population means there are fewer providers and even fewer
specialists in its communities.
MS. CASORT reviewed slide 2, How Does Telehealth Work:
Interactive: a patient and provider connect through a
secure video or audio call. This is often used for
behavioral health services and is especially helpful
for patients with limited mobility, like the elderly
or Alaskans living with disabilities.
Store-and-forward: the provider sends images, sounds,
or pre-recorded video to a patient or other provider
for analysis. This can be used to get expert opinions.
Self-monitoring: patients record their symptoms for
remote monitoring. This is particularly helpful for
high-risk patients, such as someone who no longer
needs hospitalization but needs monitoring.
MS. CASORT said that according to the Department of Health and
Social Services (DHSS) FY 2019 annual Medicaid reform report,
the top diagnoses and conditions treated via telehealth last
year were behavioral health followed by injuries, poisonings,
and ear infections.
MS. CASORT said telehealth is being used all over the state,
especially within the tribal health system. Nontribal health
systems have also been adopting telehealth. Over a decade ago,
Providence became Alaska's base hospital offering telehealth-
based stroke assessments statewide. Its web-based system can
connect neurologists with distant stroke patients 24 hours a
day. Providence has submitted a letter of support for HB 29.
Telehealth is on the rise because it works and is a huge cost
saver. Although most providers, unfortunately, do not track
their cost savings associated with telehealth, a study by the
Alaska Native Tribal Health Consortium found that telehealth
averted the need for travel in 40 percent of cases and that
number increases to 75 percent when patients are seeing
specialists. She reviewed slide 3, and said the same study found
that 65 percent of patients were seen the same day and half of
patients are seen within an hour.
MS. CASORT reviewed slide 5, Benefits of Telehealth:
• Saves on health care travel costs
• Faster access to critical provider and specialists
• Better access to health care in rural, remote, and
urban areas
• Allow contagious patients to stay home and still get
care
• Better, faster access means a potential reduction in
suicides, domestic violence, and other serious events
• Improves training and support for home caregivers
• Zero impact on the state budget
1:41:42 PM
MS. CASORT said some providers are reluctant to invest in
telehealth technology because not all insurers reimburse for
telehealth health services. There is a disparity between public
and private access to telehealth because Medicaid does cover
telehealth services, but private insurers do not consistently
cover these services. That is where HB 29 comes in.
She reviewed slide 6, Purpose of HB 29. She said the bill will
increase access to health care, allow patients to see their
primary care physicians, and decrease the cost of travel for
health care.
MS. CASORT gave the following sectional analysis on slides 6-9:
Section 1:
An insurer in the state of Alaska that offers health
care insurance plans in the group or individual market
will provide coverage for benefits delivered via
telehealth by a licensed provider without the
requirement of an initial in-person meeting
Section 2:
Health care insurer and telehealth are added to AS
21.42.422.
Telehealth has the same definition in AS 47.05.270(e).
"The practice of health care delivery, evaluation,
diagnosis, consultation, or treatment, using the
transfer of health care data through audio, visual, or
data communications, performed over two or more
locations."
Sections 3 and 4:
Effective July 1, 2020.
MS. CASORT shared that she has received no verbal or written
opposition for HB 29. She has spoken to the largest insurers in
Alaska and none have expressed opposition. In fact, Moda Health
has submitted a letter of support. As Representative Spohnholz
mentioned, this bill has broad support from health care
providers, insurers, and health care organizations.
1:44:11 PM
SENATOR BEGICH asked how the bill accounts for meeting HIPAA
(Health Insurance Portability and Accountability Act)
requirements.
MS. CASORT explained that all providers of telehealth in Alaska
must be licensed in Alaska and must be registered with the
telehealth business registry. In order to do that, providers
must use HIPAA-approved telemedicine technology, which includes
video conferencing or instant messaging or email-type services.
Providers encrypt their data and monitor for data breaches to
receive a certification for being HIPAA-compliant. Services that
are not HIPAA-compliant are not legally allowed.
SENATOR BEGICH pointed out that people may find telehealth
technologies difficult to access or utilize, perhaps because of
education or skillset. There are areas in Alaska with low
bandwidth. He asked if the bill takes that disparity into
account. He is not in opposition to the bill. He is just
wondering if the bill looks at that issue.
REPRESENTATIVE SPOHNHOLZ replied the bill does not address
access in terms of the underlying technology. It allows for
reimbursement for services provided via telehealth. There are a
variety of efforts now to improve access to broadband in rural
Alaska. The technologies are evolving quickly. The number of
HIPAA-compliant software has expanded significantly in the last
few years. Many of the companies that have done
videoconferencing for businesses are expanding into telemedicine
because it is such a significant market. Every American needs
health care. Telemedicine is the future, so the market will
provide some of those solutions. There are also governmental
efforts to deal with the issues he raised.
SENATOR BEGICH asked if the insurance industry would support the
bill.
MS. CASORT responded that industry representatives she has
spoken to expressed either neutrality or support.
SENATOR BEGICH said he hopes that telehealth will be part of the
developing coronavirus plan. It ought to be, considering the
issue of quarantine and an invasive virus.
1:47:59 PM
SENATOR SHOWER spoke about the problems of identity theft and
how that applies to health care data. He asked about the process
to prove who is at the other end of the line.
REPRESENTATIVE SPOHNHOLZ responded that all providers delivering
health care through telemedicine are required to use HIPAA-
compliant software, which is designed to protect someone's
identity and any information. There is always the risk of
breech. The technology is evolving constantly and so are the
hackers. It is a valid concern, but the ability to protect
people's privacy with technology is growing. The tribal health
system has been providing health care through telehealth for
many years, as have other providers. The whole impetus of the
bill originated after she was elected to the legislature. She
called her health care provider in Anchorage to schedule a
telehealth visit and her provider said that could not be done
because it was not covered by her insurance. She learned that
not only was it not covered by her insurance, which is no longer
the case, but she also learned a lot about the technology
required to ensure privacy. Her health care provider did not
have that software to deliver that service, so it was a two-part
problem.
SENATOR SHOWER said he wondered how the identity of the person
who calls the health provider would be verified. He assumes
there are protocols to identify someone's identity.
1:51:57 PM
CHAIR WILSON said the presentation referred to three types of
telehealth services. He knows that tribal health, and some
behavioral health, visits are interactive. Patients go to a
provider for a consult and the provider verifies the identity of
someone in person. The state has a service through Teladoc with
a two-step identification process for due diligence. Companies
do take steps to try to avoid someone falsely claiming to be
someone else. He said he knows a company that does a biometric
scan through a phone for telemedicine. Someone with
identification data for another person could pose as that
person, which is alarming. It is hard to get companies to invest
in things like biometric scans for validation purposes.
SENATOR SHOWER stated that he is cautious about forcing the
private market to do things that are not appropriate. He noted
that Representative Spohnholz made a comment that not everyone
wants to do this. He asked if there are any companies who do not
want to do this but are being forced to. He said HB 29 sounds
good in terms of saving money and access, but he is trying to
think of a potential catch and whether the legislature is
overstepping its bounds.
REPRESENTATIVE SPOHNHOLZ answered that insurance companies are
beginning to provide the service, but there is unequal coverage.
Health care providers are reticent to make investments in the
necessary infrastructure, particularly the HIPAA-compliant
software or any other electronic equipment, if the companies
can't be sure that they can recoup their investments when
providing these services. This bill is about creating the
clarity for the insurance providers that the state does want
them to cover this service in Alaska. This is an access and
equity issue. People in the private market should have the same
access to low-cost, quality health care services that those
covered by Medicaid. The other piece is predictability in the
market for health care providers. Providers need to know what
will be covered and what will not be covered. The legislature
made a huge policy call when it allowed coverage for telehealth
for behavioral health. Then that coverage was expanded for all
health care services. That was largely within Medicaid. The bill
says the legislature now wants to expand that to everyone else
so health care providers in the private market can make the
investments in the kinds of equipment and HIPAA-compliant
software needed to provide telehealth, since the investment can
be recouped.
1:57:06 PM
CHAIR WILSON said his interpretation of Senator Shower's
question was whether asking providers to make this
infrastructure investment could increase costs for consumers.
SENATOR SHOWER agreed; there is a cost attached even if it does
not cost the state.
REPRESENTATIVE SPOHNHOLZ replied that health care providers are
being asked to make investments but need certainty about
compensation to recoup the capital cost. The cost that Senator
Showers is referring to is for insurance companies. She has
tried to illustrate the significant savings from reducing
unnecessary travel. The Alaska Native Tribal Health Consortium
estimates it saved the state of Alaska $12.4 million in FY 2019
as a result of using telehealth and $70 million over the last
eight years. For people in Senator Shower's district, people
could use their phones and HIPAA-compliant software to have a
wound looked at when considering whether a long drive to Mat-Su
Regional from Talkeetna is necessary at 10 p.m. She has been in
that situation. She was in Talkeetna with her husband, wondering
whether he needed to go to a hospital. Alaska spends a lot of
money on travel expenses for health care. The state of Alaska
has saved a lot of money with telehealth in the public sector.
That should be extended to those in the private market as well.
1:59:39 PM
SENATOR BEGICH pointed out that that could be a savings for the
insurance industry because the costs of covered services would
be less. That lowers the burden on insurance companies and
should increase profit margins, which might lead to lower costs
in the long run for the consumer. Legislators are always
concerned that if the legislature mandate something it could end
up costing more. In this case, legislators could be mandating
something that will profit the insurance industry, the patient,
and the state.
REPRESENTATIVE SPOHNHOLZ added that Moda Health submitted a
letter of support. The cost of medical travel is expensive. Just
to eliminate a couple of medevacs a year will save significant
money. One medevac can cost $100,000 in Alaska. Just eliminating
a few of those would pay for the bottom line for an insurance
company and individual Alaskans.
CHAIR WILSON shared that when he was getting his MBA in health
services administration, the Medicaid cost of travel to the
state was just above $50 million. When he graduated, it was $56
million. Now, the state is approaching almost $70 million a year
for Medicaid travel.
2:01:42 PM
SENATOR GIESSEL said she views this from the perspective of a
private health care provider and an advocate for the state
budget. Her questions are only to highlight challenges, not to
disparage the good the sponsor is trying to accomplish. She
agreed that the points on slide 5 about the benefits of
telehealth are spot on, except she would argue that the last
point, the zero impact on the state budget, may not be 100
percent true.
SENATOR GIESSEL said that questions have revolved around the
infrastructure that providers will need, HIPAA-compliant
communications tools. There are providers who are reluctant to
even invest in electronic medical records. This is much like an
investment in the North Slope with drilling a well and cash
flow. Digging a well takes money and then it takes of several
years to make a profit. The same applies for investment in this
kind of infrastructure. While it may not be a direct cost to the
state, it is a cost to the private provider. When legislators
initially talked about authorizing telehealth in Alaska, one of
the caveats was that the provider providing that health care
without being in contact with the patient must transmit a record
of that visit to the primary health care provider, who may not
be the person providing the telehealth visit. She wants to make
sure that is not being eroded.
SENATOR GIESSEL said she interprets Representative Spohnholz's
reference to Teladoc as Alaska hire. That was a discussion when
legislators talked about telehealth. Teladoc is a Lower 48
organization with Lower 48 providers of various certifications.
She asked if these providers were eroding Alaska hire and access
to Alaska physicians and other health care providers. She agreed
with Representative Spohnholz about the Alaska Native Tribal
Health Consortium. It has done phenomenal work with telehealth
for many years. Although she acknowledged the ANTHC has had
those savings, it is also a closed system that is federally
funded. About eight years ago she took a health care provider
from Greenland to various facilities around Anchorage. He
observed that Alaska has three health care systems, each with
different rules: the private health care system, Medicaid, and
Native health. She is not sure the ANTHC system will translate
to the state.
SENATOR GIESSEL then referred to the 80th percentile rule. She
related that she introduced a bill to change that rule, working
with the Division of Insurance. Her question is how the 80th
percentile rule will impact reimbursement if the telehealth
provider is outside of the network and will that help costs.
Also, Alaska Retirement and Benefits pays at the 90th
percentile. That is a little known fact that is not fully
appreciated, so the state of Alaska pays a little more.
SENATOR GIESSEL said it is hard to diagnosis an ear infection
over the phone for an infant without doing a urine analysis for
infection. Telehealth won't necessarily alleviate the necessity
of contacting a physical health care provider in a clinic. "That
is not to say I don't support this. There are caveats here that
we have to appreciate and perhaps find answers to, like
reimbursement rates," she said.
2:07:59 PM
REPRESENTATIVE SPOHNHOLZ said telehealth does not eliminate the
need for every emergency room visit or every clinic visit. It
never will. Telehealth increases access to care, and it can
reduce travel and unnecessary emergency room visits a lot of the
time. Sometimes telehealth can encourage people to go to an
emergency room or get the level of care needed, such as
Nurseline. Telehealth is the next level of Nurseline. People who
call the AlaskaCare [Employee Health Plan] Nurseline get high-
quality advice from health care providers who are experts in
their field about the level of care the patient needs and a
high-quality telehealth visit is the next step. She underscored
how important telehealth is for access to behavioral health care
because Alaska has a shortage of providers. A psychiatrist will
never be in Healy, but someone could call a psychiatrist from
Healy in a HIPAA-compliant software environment. She said
telehealth will increase access to care.
REPRESENTATIVE SPOHNHOLZ, in response to the 80th percentile,
said the bill does not change the underlying fundamentals of the
health care economic system, but provides a very specific, small
fix. Two of the three systems of health care in Alaska already
have access to telehealth. However, parties in the private
market do not have access to it. She said her own experience of
not being able to access health care via distance from a
provider she has seen for 20 years nudged her to push this
conversation along.
REPRESENTATIVE SPOHNHOLZ reframed Senator Giessel's question
about Alaska hire by asking whether Alaska could end up with a
system of health care providers from the Lower 48 who nudge out
providers in the state of Alaska. She also would like Alaska to
have experienced professionals in all ranges of specialties
available. However, she also wants to make sure that health care
providers who are functionally small businesses have a stable
marketplace. She noted of the 369 providers licensed in the
telemedicine business registry, 254 are Alaskans. That means 69
percent of the telehealth providers are Alaskan-based. Alaska
still has a shortage of some health care providers, including
psychiatrists. The Anchorage Community and Mental Health
Services (ACMHS) provide mental health services in Fairbanks but
struggles to recruit enough psychiatrists, so ACMHS has a
psychiatrist on contract in Arizona. Although the ACMHS would
prefer to use an Alaskan psychiatrist, Alaska's residents need
access to specialists.
2:12:45 PM
REPRESENTATIVE SPOHNHOLZ said HB 29 would only require that
insurers for the private market cover telehealth, which is about
17 percent of the market. It is not undermining any of the
safeguards to ensure that people are getting good care.
REPRESENTATIVE SPOHNHOLZ acknowledged that information
technology systems and the electronic equipment are expensive,
but the health care market wants to do this. Dr. Jill Gaskill
previously testified that she likes providing telehealth health
care. It is part of the delivery model at her Medical Park
Family Practice in Anchorage. She tells people who have the flu
to stay home and use telemedicine. Health care providers need
assurance that insurance will cover telehealth for all patients
and not just some. When that happens, providers can make
decisions based on what is best for the patient and not on
insurance coverage. The health care providers and small business
owners must make decisions, not the insurance companies.
REPRESENTATIVE SPOHNHOLZ explained that there is zero impact to
the state budget because this does not require any capital
equipment. The state's health plan already covers telehealth, as
does Medicaid, which is the bulk of health care services in the
state. She was unsure if the retirees' plan covers telehealth,
but the bill does not require the state to build any new
infrastructure. The bill simply says that insurance companies in
Alaska should cover telehealth services. She said she is
considering a committee substitute that would require telehealth
pay parity within the private market.
2:16:08 PM
MS. CASORT explained that telehealth pay parity would ensure
that insurance companies reimburse providers at the same rate as
in-person.
REPRESENTATIVE SPOHNHOLZ agreed that several providers asked to
be compensated at the same rate as an in-person consultation.
SENATOR GIESSEL shared that she is pondering pay parity with an
in-person visit since the overhead costs are quite different.
For example, medical assistants do not bring patients into the
room since rooms are not being used.
SENATOR BEGICH asked for confirmation that the bill does not
mandate that a company provide telehealth.
REPRESENTATIVE SPOHNHOLZ answered that is correct.
SENATOR BEGICH said medical costs are quite high in Alaska. He
assumed that telehealth out of state would be less expensive,
but telehealth could become more attractive to providers who are
reimbursed for those services. He said he would rather use
telehealth services from a provider in Alaska than one in the
Lower 48, just in case further care was needed. He expressed
interest in the overlap between providers who are in network and
those who are not.
2:19:41 PM
REPRESENTATIVE SPOHNHOLZ replied that the committee would have
an opportunity to talk with individual providers at the next
hearing. Although she cannot speak for them, several providers
told her that the ability to decide which kinds of technology to
invest in will provide fiscal certainty.
REPRESENTATIVE SPOHNHOLZ, in reference to pay parity, said an
in-person visit may include a medical assistant, but telehealth
providers still will incur costs to maintain their software.
Telehealth is often provided from a clinic, such as community
mental health centers. These providers indicate that their
offices must pay to have someone at both ends of a telehealth
visit. For example, if a patient comes to a clinic in Talkeetna
for a telehealth consultation at the Heart Institute in
Anchorage, someone is onsite in Talkeetna and in Anchorage. It
is difficult to anticipate all the costs associated due to the
wide-ranging telehealth services. She asked Ms. Casort to
mention the most frequently offered telehealth services.
MS. CASORT added that the most frequent telehealth services are
for behavioral health, injuries, such as broken bones in the
hands and arms, poisonings, and ear infections.
SENATOR GIESSEL said that for several decades, the Girdwood
Clinic has taken an X-rays and transmitted them to a radiologist
in Anchorage. In addition, the nurse practitioner had an
otoscope that can transmit a picture to an ear, nose, and throat
specialist in Anchorage to diagnose ear infections.
SENATOR GIESSEL elaborated on the network costs. If someone
calls a hospital with a telemedicine question, even though the
hospital may be in the caller's network, the emergency room
doctor may be in a separate group not in the caller's network.
She explained that is how patients get surprise bills, usually
paid at a very high rate. However, that is a different subject,
she said.
CHAIR WILSON said members have raised questions that can be
answered in future hearings. He said he understood the pay
parity issue. He worked for an entity that had behavioral health
consultations with Alaska Psychiatric Institute. The entity
always took a loss on those visits because it was never
reimbursed at the appropriate rates.
2:25:07 PM
SARAH BAILEY, Supervisor, Life and Health Section, Division of
Insurance, Department of Commerce, Community and Economic
Development (DCCED), Juneau, Alaska, introduced herself.
CHAIR WILSON said certain telehealth providers will only handle
patients in the state. He asked if there were any state
regulations barring providers from seeing Alaskans when these
patients are not in the state or preventing insurance companies
from paying for those visits.
MS. BAILEY replied she was not aware of the provider
requirements. The insurance contract for insurers would indicate
which providers are in network, out of network, or not covered.
It would depend on the circumstances and the contract language.
2:26:50 PM
VICTORIA KNAPP, Chief Operations Officer, Mat-Su Health
Services, Wasilla, Alaska, said she works for a federally-
qualified health center in Wasilla with a satellite clinic in
Big Lake. The center uses telemedicine for psychiatric
evaluations and psychiatric medication management. The center
went to a telemedicine model about four years ago because they
were unable to find psychiatric providers in Alaska. Some
providers use telepsychiatry, both in Alaska and out of state. A
person comes into the office, is seen by a medical assistant,
and then sent to a room to connect via computer to either a
psychiatrist or psychiatric nurse practitioner. The center has
been very successful using this model. She said staying on
psychiatric medications is the key for patients to function
normally, including maintaining employment and managing
symptoms. If insurance carriers do not cover telepsychiatry but
cover in-person psychiatric services, it often means patients
are unable to receive psychiatric care when needed because of
the shortage of providers. The wait list in the Mat-Su Borough
is very long, she said.
2:29:02 PM
STEWART FERGUSON, Ph.D., Chief Information Officer, Alaska
Native Tribal Health Consortium, Anchorage, Alaska, said he has
been a member, vice-president, and president of the Board of the
American Telemedicine. Much of what he is going to share comes
from 20 years of experience in operating a statewide telehealth
program to serve the Alaska Tribal Health System, which has been
using telehealth since 2001. The system has served 135,000
patients at over 200 locations. Questions with telehealth are
often is the cost of telehealth worth it and why are people
doing it. When tribal health built the system, they asked
doctors how they would know if telehealth gave value. The answer
was that if they are still using it, then it provides value
because doctors are not interested in wasting time and money.
After 20 years, over five-and-half thousand providers have used
the system with over 400,000 patient encounters. Annually, there
are about 38,000 telehealth encounters.
DR. FERGUSON said the tribal health consortium has developed
some efficient processes. The committee heard some data earlier,
but it has actually gotten better. The Alaska Native Medical
Center turns around 50 percent of the consults in 60 minutes and
80 percent within the same day. That level of care exceeds that
of an in-person visit. No one can get a specialty consult in 60
minutes in Anchorage or Seattle, but someone can in a rural
location. They have embraced the store-and-forward model where
they capture information and send it. That has been very
effective. They started doing that in rural Alaska because of
bandwidth challenges, but they have done more live video
conferencing lately as bandwidth improves. They do about 2,400
follow up visits each year with patients from the Alaska Native
Medical Center, and it is used extensively for primary care. The
Alaska Native Medical Center provides over 40 pediatric surgical
and adult medical services and accepts specialty consults over
video conferencing. They, as a tribal health system, are
investing in expansion this year and are deploying over 120 more
video conferencing units specifically to address opioid and
substance use treatment, as well as education and broadening
mental health offerings.
DR. FERGUSON said the ability of telehealth to save on travel is
extremely important, but not all telehealth saves travel. They
find that about 15 to 20 percent of telehealth causes travel,
but that's good travel because they are catching something
earlier in the disease state and oftentimes avoiding unnecessary
complications or expenses of medevacs. When they try to estimate
travel savings, they ask providers on every encounter if it
impacted patient travel, so they can precisely estimate what
cases prevented travel, where the patient was, the age of the
patient, and the provider location to get fairly accurate
estimates on travel savings. When they look at the Alaska
Medicaid population that they serve in the tribal health system,
they estimate a total travel savings in FY 2019 of $12.4 million
through all of their telehealth efforts and a total savings for
the past eight years of $70 million, and that's just Medicaid.
If they look at all the patients they serve in Alaska, they
estimate a total travel savings in FY 2019 of about $27 million
and a total of $156 million in the past years. That is a
pessimistic view because they only count travel when a provider
says it saves travel. If they counted all their cases, as many
in the lower 48 do, they could roughly double those figures.
When patients travel, they run the risk of accidents, but they
also lose workdays and children miss school.
2:33:44 PM
DR. FERGUSON shared that an analysis of 5,925 telehealth
specialty consults billed to Alaska Medicaid showed that for
every five telehealth encounters, they prevented four lost
workdays and one lost school day. So, looking at an eight-year
history of all the patients in the tribal health system, they
have saved about 245,000 workdays and 61,000 school days for
patients using telehealth.
DR. FERGUSON said they applaud the language in HB 29 that
removes the need for an in-person exam prior to telehealth. They
have some evidence to support this. Dr. Phil Hofstetter, an
audiologist at the Norton Sound Regional Hospital, led a
groundbreaking 20-year retrospective study which looked at the
waiting time for new referrals to see a specialist in person. He
looked at the changes in wait time when he implemented
telehealth to do that initial exam. Prior to telehealth, for a
10-year period, 47 percent of new patient referrals waited five
months or longer to see a specialist. Once telehealth was
implemented, that dropped to 8 percent. Three years later, as
they improve processes, it is now 3 percent. So, moving from the
requirement for in-person exam to a virtual visit saves time,
improves outcomes, and allows more patients to be treated.
DR. FERGUSON said they have done similar studies looking at
diabetic retinal exams, village-based hearing exams, and triage
models using virtual visits with a specialist to access care and
treatment without an in-person visit. Every single study that
has been done demonstrates faster treatment path, lower cost,
greater access, and improved outcomes. None of this is possible
without connectivity. The Alaska tribal health organizations, in
fact all rural organizations, depend on a subsidy program that
is regulated by the FCC (Federal Communications Commission) and
funded through the Universal Service Administrative Company
(USAC). The cost for connectivity in rural Alaska is 50-100
times higher than the Anchorage rates for connectivity. USAC
subsidizes that additional cost beyond the Anchorage rate for
health care organizations, schools, and libraries, but homes are
not subsidized. That is the great digital divide. In the lower
48, people are talking about 5g and 6g. In Alaska, 50 percent of
villages do not even have 3g and when they do have connectivity,
it is expensive and restricted to monthly allotments.
DR. FERGUSON said they have demonstrated they can move
telehealth into homes. They take care of end-of-life or
palliative care patients in that way. An extremely vulnerable
population is newborns. Those with congenital abnormalities or
respiratory issues account for 70 percent of all Medicaid costs
for children in their first year of life. Bringing specialists
and subspecialists into the home is a strong step toward taking
care of that vulnerable population. The Norton Sound School
District is trying to treat ear disease in a place with the
highest rates in the world by bringing the health care system
into the schools.
2:37:01 PM
DR. FERGUSON said his staff is working on the next generation of
tools and apps to do all this. They intend in the coming year to
empower their patients to participate in their health care from
their homes. The FCC for the first time is offering free
licenses to tribes and tribal organizations to license radio
spectrums in their villages. That allows the health care system
to get into their homes, the last mile issue. Low earth orbit
satellites may offer solutions to connect villages to the rest
of the world. Together, these technologies could revolutionize
connectivity for all of Alaska with low-cost, high-performance
bandwidth.
DR. FERGUSON said:
Why am I saying this? We invest, in the tribal health
system, and I know that Providence and other providers
do the same, we invest millions of dollars each year
in connectivity and telehealth technologies because we
know it works. But, unfortunately, in the past,
federal, and state policies have greatly lagged the
advances in investment in telehealth technology and
program design. For example, the department recently
proposed telemedicine regulations that, thankfully,
have been withdrawn that would have eliminated
reimbursement for store-and-forward processes,
something that accounts for 90 percent of our
telehealth. This is troubling and we should instead be
protecting and supporting our telehealth progress and
infrastructure. We truly are a state of innovators and
we've built successful telehealth programs because we
work together, all of us, to meet the common goal of
better health closer to home. I'll finish by saying I
applaud this committee for considering a bill that can
expand the users of telehealth. I would ask all of you
on this committee and all of our legislators to stay
connected to the advances in what's happening in
technology and health care. I believe together we will
build and provide better health care.
SENATOR GIESSEL asked who reimburses for the telehealth provided
by the Alaska Native Tribal Health Consortium.
DR. FERGUSON answered that they do seek reimbursement through
all payers. They have been thankful that Medicaid has reimbursed
for telehealth since 2001 as have many other payers. He knows of
at least one payer that does not reimburse. The power of this
bill is that all payers would reimburse.
2:39:12 PM
CHAIR WILSON asked if he knew of beneficiaries who seek
telehealth services when out of the Indian Health Services
coverage area. He gave the example of someone who might get ill
or injured while on a trip to Florida and want a health consult.
DR. FERGUSON answered that he is not aware of patients who seek
care through telehealth when outside of the state.
CHAIR WILSON said the Alaska Native Medical Center saw a lot of
nonbeneficiaries through the Anchorage service unit. He asked if
that service is still available for nonbeneficiaries who receive
that through dual IHS and CHC facilities.
DR. FERGUSON replied he thought the issue Senator Wilson was
addressing was whether a nonbeneficiary who is seen at a primary
care site can be referred to the Alaska Native Medical Center.
The center does take nonbeneficiaries. That change happened some
years ago.
2:41:40 PM
CHAIR WILSON opened public testimony on HB 29.
2:42:39 PM
ANITA HALTERMAN, President, Alaska Collaborative for Telehealth
and Telemedicine (AKCTT), Anchorage, Alaska, said telemedicine
is a mode of delivery. Standards of practice don't change, or
shouldn't, based on that mode of delivery. The Alaska
Collaborative for Telehealth and Telemedicine is highly
supportive of HB 29. The collaborative asks that there be
consideration of licensing issues moving forward so as not to
limit access to providers who may not be subject to an Alaskan
license. AKCTT also asks that payment parity issues be
addressed. It is critical for the success of telemedicine.
Payment parity will ensure that practices in the lower 48 will
not undermine the infrastructure available here in Alaska. She
would like the state to maintain the providers in the state and
payment parity will ensure that those practices will not be
eroded. New modes of delivery do save insurance companies money.
Kaiser Permanente, a self-insured provider in the lower 48,
expanded the use of telemedicine because it drives cost savings
for insurance companies and drives better health outcomes.
Alaska could benefit in the same way if it moves forward with
this type of legislation.
MS. HALTERMAN said the American Medical Association has been
pleading for medical boards to remove barriers to telemedicine.
Boards are slowly responding but not fast enough for Alaska. A
fee-for-service environment does not motivate change. When
insurance companies don't pay for telemedicine for their
patients, patients may be dumped on Medicaid programs for
services that insurance companies would typically provide.
Medicaid bears the brunt of funding care through cost avoidance
for telemedicine because that scope of delivery is not available
through an insurance company and insurers often don't pay for
travel. Patients who are unable to receive their services
through insurance companies often fall on hard times. If they
are sick, they may lose their insurance and Medicaid ends up
footing the bill. AKCTT will be writing a letter of support for
HB 29. Hospitals are starting to explore relationships with out-
of-state contractors and are providing these services and
piloting programs. Those should be expanded to the entire state
and that will create cost savings for Medicaid.
SENATOR BEGICH asked her to elaborate on her first point.
MS. HALTERMAN asked if he meant her statement regarding
consideration of licensing issues moving forward so as not to
limit access to providers who may not be subject to an Alaskan
license. She continued to say:
We are facing a changed environment and right now
there's the possibility that with the expansion of
telemedicine, there will be new delivery methods
available using new provider types. For instance, with
remote patient monitoring, many of the providers that
may be subject to those kinds of services are not
subject to licensure. They're an atypical service
provider under the Social Security Act. So, I would
just caution to be careful about being too restrictive
with licensing requirements in this particular
statute.
SENATOR BEGICH said he would talk to the sponsor after the
meeting to get more clarity about the issue.
SENATOR GIESSEL said she had the same question.
2:48:50 PM
CLAUDIA TUCKER, Vice President, Government Affairs, Teladoc
Health, Greenwich, Connecticut, said she was also the chair of
the American Telemedicine Association policy board. Teladoc
operates in all 50 states and 120 countries, so it has a good
perspective on telemedicine. In reference to security measures,
employees can only access the Teladoc portal through their
health plan, so Teladoc verifies that. Teladoc also makes sure
that their physicians provide patients with their licensure
number and credentials. While Teladoc is in health care, it
really is a technology company that is focused on health care.
MS. TUCKER said Teladoc has resident physicians in Alaska. When
a call comes in from an Alaska resident, the first chance to
pick up that call goes to a physician who is an Alaskan
resident. If that physician does not pick it up, another
physician who is licensed in Alaska will pick up the call.
Teladoc gives preference to Alaskan physicians. Teladoc strongly
supports HB 29. It believes that if providers provide a service,
they should be reimbursed. However, Teladoc realizes that there
are savings in telemedicine. While a bricks-and-mortar visit
might be $145, an average visit with Teladoc or its competitors
is about $49. Teladoc cautions that the committee should not set
the floor. If telehealth physicians are willing to accept less,
they shouldn't be forced to take more. The savings will be taken
from the patient and the health plan.
2:51:27 PM
CHAIR WILSON closed public testimony and held HB 29 in
committee.
CHAIR WILSON made upcoming committee announcements.
2:52:51 PM
There being no further business to come before the committee,
Chair Wilson adjourned the Senate Health and Social Services
Standing Committee at 2:52 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB029 Sectional Analysis ver A 2.25.19.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB029 Sponsor Statement 2.25.19.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB029 Supporting Document-Letter of Support 2.25.19.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB029 Fiscal Note DCCED-DOI 3.22.2019.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB029 Letter of Support Moda Health 03.25.2019.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB029 Presentation 03.25.2019.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB029 Letter of Support ACoA 03.25.2019.pdf |
HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup ADN Article.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup Letters of Support.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Bill Version A.PDF |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Fiscal Note.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Presentation.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sectional.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sponsor.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup Letters of Support.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup ADN Article.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Bill Version A.PDF |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Fiscal Note.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Presentation.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sectional.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup Letter of Support AARP.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup ADN Article.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup Letters of Support.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Bill Version A.PDF |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Fiscal Note.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sectional.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB 29.Sponsor.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29 PowerPoint 2.13.20.pptx |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB 29 Handout 2.12.2020.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB 29 Dr Jill Gaskill Letter of Support.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB 29 Moda Letter of Support.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB 29 MMR Letter of Support.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB 29 ANHB Letter of Support.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB29 ASHNHA Letter of Support.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB 29 ACOA Letter of Support.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| HB 29 MSHF Letter of Support.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |
| FN HB 29 DCCED 1.15.20.pdf |
SHSS 2/14/2020 1:30:00 PM |
HB 29 |