HOUSE BILL NO. 265 "An Act relating to telehealth; relating to the practice of medicine; relating to medical assistance coverage for services provided by telehealth; and providing for an effective date." 2:00:10 PM REPRESENTATIVE IVY SPOHNHOLZ, SPONSOR (via teleconference), introduced the PowerPoint presentation: "HB 265: Health Care Services by Telehealth" (copy on file). She explained that the bill would continue the expansion of telehealth flexibilities to make healthcare more accessible and reduce unnecessary travel during the COVID-19 pandemic. The bill would provide a legislative framework to continue the state's success with COVID-19 related telehealth flexibilities with regard to state and federal oversight. She noted that patients used to have to go to in-patient clinics in order to receive telehealth care, but it was discovered during the pandemic that was not necessary to ensure safe healthcare in the state. Representative Spohnholz advanced to slide 2 and relayed that the presentation would cover telehealth in Alaska, the importance of HB 265, and the specific actions of the bill. She shared that the bill was a result of collaboration with stakeholders and there were over 33 letters of formal support for the bill. Representative Spohnholz discussed the current barriers to telehealth on slide 3, such as license regulations and payment barriers. The legislature had been working for years to expand access to telehealth. She noted that in SB 74 in 2016, the legislature expanded Medicaid access to behavioral healthcare and in 2020, the legislature passed HB 229 requiring insurance coverage in a private market for telehealth. Even with the improvements made through the bills, there continued to be barriers to telehealth. Barriers included the lack of telehealth parity laws, lack of coverage of some telehealth services under Medicaid, and a higher burden for audio-only visits. There were also in- person requirements for select healthcare providers that acted as a barrier to service, including prescription of controlled substances. 2:04:28 PM Representative Spohnholz turned to slide 4 to review the changes to telehealth in Alaska since COVID-19. There was a State Public Health Emergency (SPHE) and a Federal Public Health Emergency (FPHE), which both provided telehealth flexibility. She noted that FPHE was slated to expire in April of 2022 and SPHE expired in April of 2021. This made the passage of HB 265 more urgent. Currently Medicaid had temporarily expanded access to telehealth coverage and made it easier to bill for audio-only visits, but these changes were not permanent. Representative Spohnholz explained why HB 265 was needed on slide 5. She wanted to continue some of the telehealth flexibilities from the COVID-19 pandemic by making them permanent in statute. The bill would also reduce bureaucracy by eliminating the need for in-person visits for all licensed healthcare providers prior to a telehealth appointment. It would also expand Medicaid coverage of telehealth services which were reimbursed during the pandemic and increase access to behavioral healthcare. Finally, it would ensure Alaskans had an option to access quality care in a timely manner when an in-person visit was unnecessary or not possible. Representative Spohnholz moved to slide 6 to review what HB 265 would do: 1. Creates a framework for telehealth in statute. 2. Enhances the telehealth delivery of substance use disorder treatment. 3. Expands Medicaid coverage for telehealth services and modalities. Representative Spohnholz advanced to slide 7 and explained that the bill created a framework for telehealth in statute. There was a laundry list of healthcare providers that could provide telehealth services in Alaska. The bill would remove additional barriers such as unnecessary efforts to document in-person visits prior to a telehealth appointment. She spoke about the importance of having telehealth appointments available for the various types of providers eligible to provide telehealth services. For example, she had talked to a podiatrist that diagnosed a blood clot via telehealth. Representative Spohnholz thought it was important to note that HB 265 would not mandate that a patient receive care through telehealth or that a provider offer services through telehealth. For example, if there was a patient who exhibited opioid addiction problems, it would be important for a provider to meet with them in person to obtain additional information before making a diagnosis. The bill would simply remove red tape barriers to access to care. It would also extend telehealth services to emergency medical services. 2:08:52 PM Representative LeBon asked about the list of providers she had provided on slide 7, including dentist. He was trying to envision dental services being provided by telehealth. He asked how an annual dental checkup could be provided via telehealth. Representative Spohnholz responded that an annual dental checkup would not be provided via telehealth. She suggested that if there was a potential emergency, an examination could take place via telehealth. This would be helpful for individuals in rural areas to help them determine whether they needed to travel to see a dentist or if it was not an urgent problem. Representative LeBon suggested that the first step of a dental experience might be done via telehealth, but that eventually a patient would have to go see the dentist in person. 2:10:24 PM Representative Rasmussen highlighted that the provided list offered more flexibility. She offered an example of her daughter having a bad stomachache and using telehealth as a first step. She ended up admitting her daughter to the hospital based on the information she learned during the telehealth call. She thought in-person visits would still be necessary, but that telehealth could help in the short- term. Representative LeBon drew attention back to slide 5. He noted that one of the boxes indicated that the bill would eliminate in-person visits for all healthcare providers licensed with the State of Alaska prior to a telehealth appointment. He wondered if it was conceivable for a doctor from out-of-state to provide telehealth services to an Alaska resident. He asked if an in-person visit would be required prior to a telehealth appointment in this scenario. Representative Spohnholz indicated that any provider giving care in Alaska had to be licensed in Alaska, whether or not the provider resided in the state. There were already many providers who did not reside in Alaska but were eligible to provide care in the state via telehealth. The licenses were registered with the state and the providers were registered with a telemedicine registry. The bill dictated that a patient should not have to attend an in-person examination in order to receive care via telehealth. However, it needed to be clinically appropriate and there were times where it would not be appropriate; for example, Representative LeBon's example of dental care. Alternatively, it would be appropriate to use telehealth to consult an oncologist out- of-state that specialized in a particular type of cancer. A person should not have to fly out of state to receive this kind of care. Representative LeBon clarified that the out-of-state provider licensed in Alaska would not be required to have had an in-person appointment with the patient before providing telehealth services. Representative Spohnholz responded in the affirmative. 2:14:21 PM Representative Josephson asked if a licensed provider who was out-of-state and providing telehealth services in Alaska, would the provider be considered licensed in two states. Representative Spohnholz indicated that a provider could choose to be licensed only in Alaska or choose to be licensed in their home state and in Alaska. She explained that licensing laws in the United States looked to the state of residence of the patient, not the provider. Representative Josephson asked about international licensure. He wondered whether this would welcome providers from other countries to practice in Alaska. Representative Spohnholz deferred to Ms. Sara Chambers. 2:16:00 PM SARA CHAMBERS, DIRECTOR, DIVISION OF CORPORATIONS, BUSINESS AND PROFESSIONAL LICENSING, DEPARTMENT OF COMMERCE, COMMUNITY AND ECONOMIC DEVELOPMENT, clarified that as long as a provider met the criteria for state licensure, the provider could practice from any location. 2:16:48 PM Representative Spohnholz continued on slide 8 of the presentation. She reviewed how the legislation would enhance telehealth access for substance use disorder treatment. The bill would remove the in-person requirement to prescribe controlled substances through telehealth for physicians, podiatrists, osteopaths, physician assistants (PAs), and advanced practice registered nurses (APRNs). It would also allow registered practitioners such as physicians, PAs, and APRNs to prescribe medicine such as buprenorphine via telehealth without an additional healthcare provider present with the patient. She noted that she had heard from providers that it was important to prescribe these types of medicine quickly because patients could be going through opioid withdrawals and need immediate help. She reiterated that all prescribers of controlled substances were still required in the bill to comply with drug enforcement regulations. 2:18:19 PM Representative Josephson asked if the definition of controlled substances included narcotics and opioids. Representative Spohnholz responded that it did include those substances. It was important to include opioids in the definition because there were times when an opioid could be prescribed via telehealth in urgent scenarios and prescribers would still be required to comply with controlled substance regulations. Representative Josephson suggested there would be efforts to abuse such a privilege, by both patients and providers. He wondered if there were protections built into the bill that would prevent abuse of prescriptions. Representative Spohnholz agreed that it was likely that some people would try to abuse the privilege. She indicated that was why it was important to continue to require providers to participate in federal Drug Enforcement Administration (DEA) regulations and the prescription drug monitoring program (PDMP). There had been some recent advancements in this area and there was no requirement that a provider must provide medication to a patient that was thought to be seeking drugs. She deferred to her staff to provide some additional detail. 2:20:19 PM GENEVIEVE MINA, STAFF, REPRESENTATIVE IVY SPOHNHOLZ, explained that federal law required that a patient must receive behavioral health treatment as part of any prescription for medications for opioid use disorder. The bill pertained to buprenorphine in particular, which was a medication that was allowed to be prescribed via telehealth throughout the COVID-19 pandemic. Providers registered to prescribe buprenorphine were also required to submit to physical monitoring tools to ensure that misuse was not occurring, such as regular urine tests. There were additional restrictions such as the seven-day prescription for opioids, which required that there had to be a new prescription on a weekly basis. She echoed Representative Spohnholz's earlier comments regarding the importance of the requirement for providers to participate in DEA regulations and the PDMP. 2:21:43 PM Representative Josephson understood the importance of the bill and supported it. However, earlier discussions about the PDMP in the committee made it clear that the PDMP was not being followed religiously. He recalled an instance of an Eagle River provider who would have quick interactions with patients and prescribe more and more medication. He was worried about prescriptions getting out of hand. He asked if the physician would be required to look at a patient on a screen or could services be provided via a phone call. Representative Spohnholz deferred to Ms. Mina. Ms. Mina responded that prior to the COVID-19 pandemic, the DEA required that patients that received medications for opioid use disorder must receive an in-person examination. The provision was waived during the pandemic and was tied to the FPHE that was set to expire in April of 2022. Additionally, the DEA allowed audio-only prescriptions of buprenorphine during the pandemic. According to providers that she had spoken to, patients thought that in-person examinations were a crucial part of their treatment. Even if the requirement for an in-person visit prior to providing a prescription was removed, a provider could still choose to see a patient in-person first. The bill deferred to the patient-provider relationship and allowed the provider to make the decision rather than always requiring an in-person visit no matter the circumstances. She noted that access to opioid use disorder medications had been crucial in places like rural Alaska during the pandemic. 2:24:44 PM Representative Josephson thought he would likely support the bill. However, he expressed worry about the potential for bad actors. He relayed that the occurrences of abuse that he had read about were egregious. Representative Spohnholz concurred that there were bad actors and that nothing in the bill would prevent that from happening. However, there were robust prescription drug limits in place and additional enforcement mechanisms in licensing. She thought the PDMP was vital. She noted that buprenorphine was a medication assisted treatment and controlled substance and could be prescribed via telehealth under the bill. There were times where people would need to be on medication assisted treatment for many years. Some of these individuals would be living in remote areas that would make regularly visiting a provider very difficult. It was important for everyone to have access to medication assisted treatment if they needed it. Representative Wool agreed that all bad actors could not be eliminated. He suggested that a patient seeing a provider for the first time via telehealth and immediately requesting opioids would be a red flag for the provider and assumed that it would not be applicable to first-time patients. He thought that the bill would not apply to veterinarians for animal prescriptions, even though they were registered with the DEA. Representative Spohnholz responded that the bill did not apply to veterinarians. She indicated that it would be possible for a first-time patient to receive a prescription for medication assisted treatments via telehealth. She relayed that emergency room physicians shared that they often see patients who were going through withdrawals, and it was imperative to ensure that the patients received access to medication assisted treatment immediately. The situation was time-sensitive, and telehealth made it more possible to respond to the situation in a timely manner. Representative Rasmussen asked if there were other instances where it would be reasonable to expect first-time patients to be prescribed controlled substances. She provided potential examples of situations that would not qualify as a first-time visit, such as a patient receiving controlled substances after a surgery. 2:29:26 PM Representative Spohnholz explained that there were other examples where a first-time patient would need a prescription immediately, such as a patient needing Adderall, which was a controlled substance. Complete examinations with psychiatrists could occur via telehealth and could offer certainty to a provider that the patient was not seeking drugs. She did not want to unnecessarily require someone to see a provider in-person for an examination when it could be thoroughly done via telehealth. Representative Spohnholz turned to slide 9 of the presentation. She relayed that the bill would also expand Medicaid coverage for telehealth. The bill allowed for reimbursement for services that were already billable via Medicaid if the services were provided in person. Such reimbursable services included behavioral health services, home and community-based services, Medicaid waiver and demonstration services, and services provided at rural clinics and federally qualified health centers. Representative Spohnholz concluded the presentation on slide 10. She reiterated that HB 265 would ensure robust patient protection in Alaska while expanding some of the flexible services that were permitted during the COVID-19 pandemic. She thanked the stakeholders that had written letters of support for the bill. Co-Chair Merrick indicated there were invited testifiers. 2:32:44 PM NANCY MERRIMAN, EXECUTIVE DIRECTOR, ALASKA PRIMARY CARE ASSOCIATION (via teleconference), expressed support for HB 265. The Alaska Primary Care Association (APCA) supported the operations and development of Alaska's 29 federally qualified health centers. She explained that health centers provided comprehensive care including medical, dental, behavioral, pharmacy, and care coordination services. She relayed that APCA supported the bill because it increased access to primary care and behavioral health services and expanded telehealth access in Alaska. The bill would directly impact health centers by allowing for audio-only telehealth services and allowing for patients and providers to engage outside of a clinical setting if they so choose. The bill would also provide adequate reimbursement for telehealth visits including for substance and behavioral health treatments. Ms. Merriman shared that in 2020, health centers served over 105,000 patients and telehealth was the fastest growing service provided by health centers. About 40 percent of patients were seen via telehealth, and about half of total opioid use disorder patients were seen via telehealth. The majority of telehealth patients had experienced challenges accessing healthcare including a long distance to reach providers, cost of care, language, and cultural barriers. She suggested that telehealth ultimately would lead to better health outcomes, save lives, and save money. She urged support for the bill. 2:36:54 PM Representative Rasmussen asked if Ms. Merriman could identify a circumstance where a first-time patient would require a prescription for a narcotic or opioid. Ms. Merriman responded that she could return to the committee with that information. 2:37:31 PM TOM CHARD, EXECUTIVE DIRECTOR, ALASKA BEHAVIORAL HEALTH ASSOCIATION (via teleconference), relayed that the Alaska Behavioral Health Association (ABHA) fully supported the bill because it improved Alaskans' access to behavioral healthcare. He stated that the Alaska Department of Health and Social Services' (DHSS) annual Medicaid report stated there was a 134 percent increase in telehealth claims paid in FY 21 as compared to FY 20. The report noted that four out of the five top diagnosis codes delivered via telehealth were behavioral health diagnoses. The data suggested that Alaskans were struggling to access behavioral healthcare, but also pointed to the economic opportunity afforded by early intervention. National insurance companies were rushing to offer virtual-first and digital-first benefits because the companies realized that it saved money to avoid expenses like travel. It also saved money by avoiding the cost of readmission at hospitals and higher acute care. He indicated that the state DHSS reported that Medicaid travel costs decreased by $45 million from FY 20 to FY 21. By offering preventative care, savings were provided to the overall budget. The economic benefits were merely a small part of the reason ABHA supported HB 265. He hoped that members would support the legislation as well. Co-Chair Merrick appreciated hearing from the testifiers. She thanked the bill sponsor. HB 265 was HEARD and HELD in committee for further consideration. 2:40:48 PM AT EASE 2:41:31 PM RECONVENED