HB 145-EXPAND PHARMACIST AUTHORITY  3:25:42 PM CO-CHAIR ZULKOSKY announced that the next order of business would be HOUSE BILL NO. 145, "An Act relating to the Board of Pharmacy; relating to health care services provided by pharmacists and pharmacy technicians; and relating to the practice of pharmacy." 3:25:54 PM CO-CHAIR SNYDER presented HB 145, as prime sponsor. She explained that the intent of HB 145 is to increase access to care and to protect pharmacists and ensure that pharmacists can be reimbursed for providing services that they are permitted to provide. She went on to read from the Sponsor Statement [hard copies included in committee packets], which read as follows [original punctuation provided]: Passage of House Bill 145, "The Pharmacist Mobilization Act," increases access to care and ensures Alaska's pharmacists are reimbursed when providing services. I am introducing it at the request of the Alaska Pharmacists Association in partnership with the Alaska Board of Pharmacy and the University of Alaska/Idaho State Doctor of Pharmacy Program. The coronavirus pandemic has shown that pharmacists can engage at an elevated level to help deliver necessary healthcare to all Alaskans. Pharmacists have provided COVID-19 testing, vaccinations, and telehealth visits, and have helped patients manage chronic health conditions. This bill will update outdated statute so pharmacists can continue providing these services. HB 145 defines the patient care services that pharmacists and pharmacy support staff can independently provide, allows pharmacist technicians to administer vaccines when under the direct supervision of a licensed pharmacists, and empowers the Board of Pharmacy to regulate pharmacists, student pharmacists, and pharmacy support staff who provide these services. Furthermore, the bill updates the current provider anti-discrimination statute to support insurance coverage of these patient care services when provided by a pharmacist. Currently, pharmacists are one of the only healthcare professionals not listed in this statute. HB 145 largely updates outdated statutes to align with current practices. Its passage benefits Alaskans by increasing healthcare access during and after the pandemic. Please support this common sense, housekeeping bill that will help your local, patient- oriented pharmacies continue to provide essential services. 3:29:12 PM ALLIANA SALANGUIT, Staff, Representative Liz Snyder, Alaska State Legislature, provided the sectional analysis of HB 145 on behalf of Representative Snyder, prime sponsor. She summarized the Sectional Analysis [hard copies provided in committee packets], which read as follows [original punctuation provided]: Sec. 1: Adds language to AS 08.80.030(b) Powers and Duties of the Board, statute that outlines the Board of Pharmacy's powers, that allows the Board of Pharmacy to adopt rules to regulate the independent monitoring of drug therapy and independent pharmacist prescribing of vaccines and naloxone. Sec. 2: Adds a new subsection to AS 08.80.045 Nonprescription Drugs that aligns statute with the current practice of pharmacists recommending non- prescription medications and devices for treating minor and self-limited conditions. Sec. 3: Amends AS 08.80.155 Emergency Permit to increase the Board of Pharmacy's flexibility to grant emergency licenses for all relevant licenses used in pharmacies. Sec. 4: Amends AS 08.80.168(a) Administration of Vaccines and Related Emergency Medications by adding "prescribe" to existing vaccine administration statute. Sec. 5: Amends AS 08.80.168(b) by replacing "dispense" with "prescribe and administer" in regards to administering an opioid overdose drug. Sec. 6: Adds a new subsection to AS 08.80.168 that allows a pharmacy technician to administer a vaccine or related emergency medication but only if they have been authorized by the Board of Pharmacy to do so AND if they are under the direct supervision of a licensed pharmacist who meets the requirements in AS 08.80.168 (a). Sec. 7: Adds language to AS 08.80.297(a) Prescription Prices Available to Consumer that allows personnel who are not licensed pharmacists to disclose the cost of filling a prescription when directed by a pharmacist working at the same institution. Sec. 8: Amends AS 08.080 Pharmacists and Pharmacies by adding a new section, AS 08.80.337 Other Patient Care Services, that: ? Allows a pharmacist to provide patient care services for a disease or condition with an existing diagnosis under an agreement made with and approved by a practitioner ? Limits patient care services that pharmacists can provide to those that are minor, selflimiting, and have a CLIA-waived laboratory test which guides clinical decision making. ? Provides language that allows pharmacists to be reimbursed for providing these services 04/07/21 Sec. 9: Amends AS 08.80.480 Definitions by removing "dosage form" as a definition of "equivalent drug product". This allows pharmacists to make minor, non-therapeutic changes to prescriptions using clinical judgement and expertise without contacting the prescriber for verbal or written approval. This does not allow a pharmacist to substitute a dosage form that would negatively impact patient outcomes, safety, or cost effectiveness. Examples of appropriate substitutions under this section include changing from a tablet form of medication to a capsule form of the same medication and strength. Sec. 10: Amends AS 08.80.480(30) by adding "dispensing" and "independent prescribing" to the definition of the "Practice of Pharmacy" to align with the changes made in Section 4 & 5 (AS 08.80.168) of this bill. These additions better represent actual provision of naloxone and vaccine by pharmacists. Sec. 11: Amends AS 21.36.090(d) Unfair Discrimination to include "pharmacists" as protected health care providers in the provider anti-discrimination statute. This aligns the state statute with federal statute (CFR 438.12) and afford pharmacists the same protection as all other healthcare providers when engaging health plans for covered services such as ordering laboratory tests, point-of-care testing, vaccine prescribing and administration, preventative health services, managing minor self-limiting conditions, and participating in collaborative disease state management. 3:33:30 PM GRETCHEN GLASPY, Pharm.D., President, Alaska Pharmacists Association, testified in support of HB 145. She explained that the Alaska Pharmacists Association (APA) represents over 200 pharmacists, pharmacy technicians, and student pharmacists statewide. She said that she earned her Doctor of Pharmacy in 2007 and has been a practicing pharmacist in Alaska since 2014. Currently, she works as the Clinical Informatics Pharmacist at Bartlett Regional Hospital in Juneau, Alaska, which requires her to merge information technology with clinical pharmacy practice. She continued that HB 145 came about through collaboration between the APA, the Board of Pharmacy, and the University of Alaska Anchorage/Idaho State Doctor of Pharmacy Program. The Board of Pharmacy began reviewing statutes at the request of State of Alaska Governor Mike Dunleavy; however, the COVID-19 pandemic highlighted the ways in which the statutes are out of date in regard to pharmacy practice. She continued that it also seeks to add pharmacists to the Provider Antidiscrimination Statute, as pharmacists are one of the only providers not currently listed. She concluded that HB 145 would allow pharmacists to engage at a much higher level, both during and after COVID-19. 3:35:33 PM JUSTIN RUFFRIDGE, Pharm.D., Board Member, State Board of Pharmacy, testified in support of HB 145. He explained that he is a pharmacist in Alaska and owner of a few pharmacies around the state. He shared that, from the perspective of the State Board of Pharmacy, HB 145 is an imperative piece of legislation in order to properly regulate the pharmacy profession. The expanded authority of the board that the bill proposes is not currently represented well by the current statute, he opined, and said that the board was told that statutory adjustments must be made in order to regulate certain professions. He added that the board considers the proposed bill to be a "housekeeping" bill and that there is enough support for it to pass. 3:37:39 PM TOM WADSWORTH testified in support of HB 145 and added that, although he is an educator at the University of Alaska Anchorage (UAA), the views are his own and do not reflect UAA. He said that he is a practicing pharmacist of 19 years and an educator of pharmacy students. He explained that the first class of pharmacy students in the UAA system were graduated in 2020, and another class will graduate in a few weeks [in 2021]. He explained that pharmacists receive professional graduate training of 4 years, with at least 2,000 hours of experiential training, and most go on to begin post-graduate residency programs, which offer additional training. Beyond that, he continued, pharmacists can become board certified in various fields, such as primary care and pediatrics. Over half of all practicing pharmacists now practice outside of the pharmacy community, he said, and the statutes do not reflect this reality. Many pharmacists work in primary care in tribal or veteran health care in capacities that have nothing to do with dispensing medications, but instead focus on general health, wellness, and medication management. He expressed that these pharmacists are filling a vital need in Alaska, and pharmacists can be a solution to healthcare shortages. 3:40:52 PM AMY PAUL, Pharm.D., Faculty Clinical Pharmacist, Providence Family Medicine Center, testified in support of HB 145. She shared that Providence Family Medicine Center (PFMC) is a patient-centered medical home and the only family medicine residency in the state of Alaska. She said that her practice includes 36 resident positions and about 30 faculty and staff positions, and the center services over 10,000 Alaskans in the Anchorage, Alaska area. The number one resource to treat patients is medications, she opined, however most medical school graduates receive only about a semester of pharmacology, yet these graduates are expected to appropriately choose and utilize the most optimal medication therapy for patients. Due to her position, she is able to work alongside physicians in Alaska and help determine the most appropriate medication for patients. She noted that primary care physicians, partially due to the time restraints at play, have to address the "what" when diagnosing a patient, but are not able to address the "why." She shared that she is able to fill this void and meet with patients, educate patients about their diseases, and offer ideas for lifestyle changes, so that patients can receive the most benefit with the least side effects. MS. PAUL offered an example of this in which she met with a patient who had been diagnosed with diabetes for over 20 years and had never been taught to use an insulin pen at mealtimes. She helped this patient learn how to use the device and she was also able to help this patient obtain a glucose monitor so that the patient could have more data on appropriate doses. She also spoke to this patient about quitting smoking, and together developed a plan to help the patient quit. Later, she continued, this patient sent her a message expressing how she wished every clinic had "a pharmacist like you." She concluded with the hope that it is obvious that utilizing clinical pharmacists to optimize patient care like this allows for providers to meet with patients about acute needs, and allows for patient and provider satisfaction. Unfortunately, many of these services are not reimbursed by insurance due to current regulations, despite the fact that the same services are reimbursed when provided by a different type of clinician. This makes these kinds of services unsustainable in primary care facilities, she expressed, but the patients who have experienced services provided by a pharmacist in the private sector understand the benefits. 3:46:54 PM REPRESENTATIVE MCCARTY asked Mr. Wadsworth about a letter from Sara Chambers, Division Director of Department of Commerce, Community, & Economic Development (DCCED) [hard copy included in the committee packet]. He quoted line 3, paragraph 3 of the letter, which read as follows [original punctuation provided]: Since this statute specifically calls out vaccinations and related emergency medications, it effectively prohibits pharmacists from independently rendering other patient care services. REPRESENTATIVE MCCARTY asked whether Mr. Wadsworth could address this statement about the concern of professional licensing. MR. WADSWORTH answered that that opinion came about as a result of an inquiry by the Board of Pharmacy from the Department of Law as the board attempted to promulgate some regulations. What the letter effectively states and the reason for including it, he continued, is that HB 145 would not expand pharmacist prescriptive authority. The three items listed for prescriptive authority stand at vaccines, Naloxone, and situations that exist under the pharmacist collaborative agreement. He explained that the collaborative agreement allows for pharmacists to enter into a practice in collaboration with a primary provider, which allows the pharmacists to write prescriptions for treatment, like the example Dr. Paul shared earlier in the committee meeting. He said that model of interpreting statute or regulation essentially says that, if those items are specifically stated, then every other prescriptive authority is excluded from the statute. CO-CHAIR SNYDER offered clarification that the letter from Sara Chambers was received by the committee in response to some questions that arose in a House Labor and Commerce Standing Committee meeting on April 12, 2021. She shared that Representative Kaufman had expressed concern that HB 145 would "open the barn door," and the letter was intended to assuage his fears. 3:51:19 PM SARA CHAMBERS, Director, Commercial Business Professional Licensing (CBPL), Department of Commerce, Community & Economic Development, explained that the question refers to current law and the proposed legislation and reiterated that it was in response to the earlier House Labor and Commerce Standing Committee meeting. She asked for further clarification on the type of additional information Representative McCarty was seeking. REPRESENTATIVE MCCARTY responded that he is curious about the proposition in the bill that would expand the services that pharmacists would be able to administer, which he said he understands was crafted with legal counsel. Alternatively, he said that Ms. Chambers' letter says that according to legal counsel, pharmacists cannot practice beyond the three criteria mentioned previously. CO-CHAIR SNYDER responded that there is specific language about Naloxone and vaccinations in HB 145. The remaining services mentioned in the bill, she continued, are consistent with the practice of pharmacy as it is in its current state. The bill works to provide some clarification and details around the practice of pharmacy so that the board is then empowered to regulate the field, she added. MS. CHAMBERS offered clarification that, because this question was raised in a different committee, the letter address the state of the current law and does not address HB 145. The current law states that there are restrictions to what pharmacists can do because vaccinations and emergency medications are specifically stated. The question was not an interpretation of the bill, and she presumed that this is where the confusion lies. 3:54:51 PM REPRESENTATIVE PRAX offered his understanding that the assumption is that pharmacists can't "do anything" until given permission and told that the proper regulations are in place. He asked whether it's true that pharmacists need to be given permission to do something beyond the normal scope of practice. MR. WADSWORTH responded that when one reads the Pharmacy Act, which is what HB 145 seeks to amend, it's clear that there is already a definition about pharmaceutical care and patient care services. There needs to be a differentiation between medication and prescriptive authority, he continued, as there are many providers that offer patient care services that do not prescribe medicine, such as social workers. Similarly, he said, pharmacists provide patient care services but do not necessarily prescribe medication. He explained that Dr. Paul is already performing the actions that are proposed in HB 145, but the intended consequence of the bill is to expand the definition of pharmaceutical care and bring clarity to the definition of "patient care services," which are the services that pharmacists can do independently that do not result in a prescription, such as smoking cessation or diabetes education. He said that these services are already in statute, but are not delineated with enough clarity, which is what brings about the "Negative- Implication Canon" indicated in Ms. Chambers' letter. He explained that clarity is sought after so that the board can promulgate and regulate these issues. MR. RUFFRIDGE added that the board speaks the easiest on this issue since that is where the "Negative-Implication Canon" term first originated. The request for the letter to be included in the packet of information is to ensure that there are no questions as to what pharmacists can and should be able to do, he said. Pharmacists are not seeking to expand the authority to prescribe medications; there is already a means by which to do this. He noted that in other meetings across the state, there have been similar questions raised on whether expanding pharmacists' authority is what is being proposed. Consequently, the board sought a legal opinion on whether there would be any way that a pharmacist would obtain expanded prescriptive authority, and it is a definitive "no." The answer, he relayed, is that pharmacists may prescribe only under a collaborative practice agreement, for vaccines, or for Naloxone. He continued that HB 145 is regarding the other area of pharmacists' duties [patient-care services] that many pharmacists are already actively engaged in across the state. He said that the board has attempted to regulate what those services look like, who is engaged in the services, and what requirements exist in order to engage in the services, but since it is not well-defined in statue, the board cannot regulate it. 4:00:05 PM REPRESENTATIVE SPOHNHOLZ asked Mr. Ruffridge and Mr. Wadsworth what the most common services are that are not being reimbursed, and whether reimbursement is being denied by both private and public payors. MR. RUFFRIDGE replied that there were a wide variety of issues that arose during the COVID-19 pandemic through his professional capacity as a pharmacist. For example, COVID-19 testing was the most prominent issue, and as pharmacists are not able to credential or contract for Clearwave [a patient engagement platform] COVID-19 tests due to the current statutory limitations, many insurance companies chose to not cover a pharmacist who was asking for a Clearwave test. He expressed that the pharmacist community was restricted in this way until federal action was taken, and that federal action is limited. He shared his understanding that in order to engage pharmacists in the future and to ensure that this problem does not happen again in the future, action is needed. In addition to the "worrisome" case of COVID-19 testing, he added that there is a large number of other areas in which pharmacists are engaged in, such as the diabetes testing mentioned earlier in the meeting by Dr. Paul, but pharmacists continue to be engaged in these avenues at a lower level due to the inability to contract or credential with health plans such as Clearwave because pharmacists are not recognized. MR. WADSWORTH added that there is an active program inside the tribal programs and the VA where pharmacists have been operating as clinical pharmacists and already providing the services that Dr. Paul mentioned earlier in the meeting. These pharmacists work alongside the nurses, physician's assistants (PA), and physicians, and have been operating in this capacity for at least three decades. He noted that this uptick has not been seen in the private sector, and that Dr. Paul is one of three primary care pharmacists in a private practice setting in all of Alaska. He said that the reason for this is due to the difficulty experienced by pharmacists attempting to enroll with the health plan on their medical benefit in the same way that a PA or a nurse practitioner or physician would enroll. Many states, he continued, have addressed this issue, and in the state of Washington, for example, insurance companies are allowing pharmacists to enroll with commercial insurances. For this reason, these pharmacists are able to submit the same claims that a physician would, because these services are now recognized as in the scope of practice as it falls under the collaborative practice agreement. He explained that this is how Dr. Paul operates. The difficulty comes when some commercial payors and some state payors are either not able to enroll, or those services are being deemed as not eligible due to a "so- called" scope of practice issue. He noted that HB 145 would allow pharmacists to offer more services at which they excel, but cannot currently offer due to restrictions. 4:05:47 PM CO-CHAIR ZULKOSKY opened public testimony on HB 145. 4:06:10 PM CHARLES MCKEE, testified on HB 145. He spoke about a personal legal case that he said came about because Governor Dunleavy "veto-ed Medicaid/Medicare." He explained that he went to the hospital in an emergency situation and there were no funds available for his medical bills. 4:08:35 PM KYLE POHL, MD, had his testimony in support of HB 145 presented by Kylie Goff. Ms. Goff said that Dr. Pohl works for the Alaska Native Tribal Health Consortium, but his comments being relayed by Ms. Goff are his own. Ms. Goff said Dr. Pohl has provided a full spectrum of pediatric care throughout the state of Alaska for the past five years, practicing in Anchorage, Alaska, Nome, and the surrounding villages. He has noticed that, at all of these locations, he could not be as effective as he is without the help of an "outstanding group of pharmacists." His work in rural Alaska has relied heavily on the support of skilled pharmacists, and the pediatric well-child immunization campaign has been the result of a combined effort of physicians and pharmacists. Through this campaign, the number of children who are up to date on immunizations has drastically increased, as well as the number of children who have been provided a well- child check, which offers screening on critical birth and development and routine lab studies in the region. A program has also been created to help care for the complex adult population, which includes strategies to manage chronic diseases such as diabetes, heart disease, hypertension, and chronic kidney disease. Pharmacists have been critical in helping to create pathways to improve screening for cervical cancer, colon cancer, breast cancers, and many other diseases, and have been critical in each stage of the process. 4:11:04 PM NATALIE MCCAY, Pharm.D., testified in support of HB 145. She shared that she is a pharmacy technician at Petersburg Rexall Drug (PRD) in Petersburg, Alaska. She noted that PRD is locally owned by two sisters, and said that she has noticed that the owners are often the first people that patients come to with questions or to ask for advice. She opined that HB 145 is especially important for rural communities such as Petersburg, and that allowing pharmacists to provide additional healthcare services will provide increased access for patients where it can otherwise be limited. She added that allowing technicians to administer vaccines while supervised would allow more of the community to get vaccinated, which is especially important during the COVID-19 pandemic. 4:12:16 PM SUSAN WHEELER, Pharm.D., testified in support of HB 145. She said that she is a pharmacist working at the Yukon Kuskokwim Corporation (YKC). She shared that the pharmacists at YKC are already providing many of the services that would be impacted by changes proposed in HB 145. The pharmacists are fully integrated with the other providers, nurses, and healthcare professionals in the corporation; however, due to an inability to enroll pharmacists as billing providers, YKC is unable to receive compensation for the services provided by its pharmacists. She shared her understanding that pharmacists are the most readily available healthcare professionals, yet at this time in Alaska, pharmacists are the only healthcare professionals that are not listed in the provider antidiscrimination statutes. This means that the most readily available healthcare professionals are compensated minimally, if at all, for providing the same services that would be otherwise covered if provided by other healthcare professionals, she said. She explained that the lack of compensation makes it difficult to provide the uncompensated services that pharmacists are well- prepared and eager to provide. She noted that this makes these services less readily available, which may prevent some patients from receiving some of the services that pharmacists could quickly, easily, and competently provide. 4:14:18 PM DIRK WHITE, Pharm.D., testified in support of HB 145. He shared that he and his wife have been practicing in a community pharmacy in Sitka, Alaska, over 30 years. He expressed that the field has changed immensely throughout his lifetime, and predicted that more changes are to come. He commented that regulations need to be updates to reflect those changes, and to anticipate future changes. He noted that, in addiction to testing for COVID-19, pharmacists would like to also be able to test for streptococcus ("strep"), for the flu, testing for diabetics, lipid panels, and more. He opined that HB 145 would allow for these changes to happen. 4:16:02 PM DOUG BARTKO, Pharm.D., testified in support of HB 145. He stated that he had a small pharmacy in Wasilla, Alaska from the 1990s through the year 2008, and one of the largest problems he had was receiving rejection of claims when billing insurance companies. He said that HB 145 would give student pharmacists status as a provider, and reiterated that pharmacists are the only healthcare professionals without provider status. 4:17:22 PM BARRY CHRISTENSEN, Pharm.D., testified in support of HB 145. He said that he is a community pharmacist in Ketchikan, Alaska, and he and his family have practiced as pharmacists since Ketchikan was founded over 47 years ago. He is a second-generation pharmacist, and two of his daughters have also become pharmacists. He disclosed that he is also co-chair of the legislative committee for the Alaska Pharmacist Association. He said pharmacy has changed significantly since his father began practicing in 1974, and that HB 145 recognizes the changes and that modern pharmacists are in a better position to help patients meet pharmaceutical needs. He opined that pharmacists need the statutory language in HB 145 in order to best serve patients. 4:18:38 PM RENEE ROBINSON, testified in support of HB 145. She said that she is an associate professor at the University of Alaska/Idaho State University College of Pharmacy. She also serves as president-elect of the Alaska Pharmacists Association, as well as the co-principal investigator on a CDC and Department of Health and Social Services funded seven-month demonstration project that supports reimbursement of pharmacists providing health services to ensure an increased access to rural and underserved Alaskans. Her career has also included the training of future pharmacists. She opined that HB 145 would resolve long-standing regulatory issues that impede continued progress. 4:20:36 PM CO-CHAIR ZULKOSKY, after ascertaining that there was no one else who wished to testify, closed public testimony on HB 145. CO-CHAIR ZULKOSKY announced that HB 145 was held over.