HB 209-INSURANCE COVERAGE FOR TOBACCO CESSATION  3:07:38 PM CHAIR KELLER announced that the first order of business would be HOUSE BILL NO. 209, "An Act requiring a health care insurer to provide coverage for tobacco cessation treatment." 3:08:13 PM REPRESENTATIVE HERRON, introducing HB 209 as the prime sponsor of the bill, emphasized that dependence on tobacco was chronic, and it negatively affected the health, productivity, and well- being of all Alaskans who indulged in its use. He reported that tobacco was a leading cause of death for Alaskans, more than suicide, motor vehicle crashes, and liver disease combined. He added that the negative economic impact was huge, as it cost Alaskans more than $300 million in direct medical expenditures, with an additional $177 million in lost productivity. He declared "it's a hard habit to kick." He clarified that the proposed bill offered Alaskans an opportunity for the resources to end their tobacco addiction, through cessation treatments offered by insurance companies. He offered to listen to testimony whether to mandate this. 3:11:28 PM CHAIR KELLER expressed his concern with a mandate for private insurance. He asked to clarify that Representative Herron would offer proposed HB 209 as an insurance policy option to buy, not as a mandated coverage. 3:12:03 PM REPRESENTATIVE HERRON confirmed that testimony would determine if it was practical to delete "provide", and insert "offer," in the bill. 3:12:48 PM CHAIR KELLER asked if there was other insurance coverage which had to be available, but was not mandated. REPRESENTATIVE HERRON replied that he would research this. CHAIR KELLER offered his belief that there was other coverage, and he expressed a desire to know how this had been received. 3:13:28 PM REPRESENTATIVE SEATON directed attention to the proposed bill, page 2, Section 1, subsection (c)(3), which read: "Coverage for tobacco cessation treatment may not require an individual to participate in a counseling session in order to receive coverage for medication;" and asked for clarification with page 1, proposed Section 1, subsection (b)(1), which read: "coverage for a course of tobacco cessation treatment must include the cost of not less than four tobacco cessation counseling sessions provided by a qualified counselor ...." 3:14:36 PM LIZ CLEMENTS, Staff, Representative Bob Herron, Alaska State Legislature, replied that the insurance company would be required to cover at least four counseling sessions per course of treatment, but that individual consumers would not be forced to attend counseling sessions as a condition of the treatment coverage. She declared that experience had shown that success was higher when the participant was able to determine "how they choose to quit." 3:18:10 PM REPRESENTATIVE SEATON, directing attention to page 1, line 9, proposed Section 1(b)(1), "not less than four tobacco cessation counseling sessions provided by a qualified counselor," asked if there was a limit to the number of counseling sessions. Directing attention to proposed Section 1(b)(2), "over the counter medication or prescribed medication," he asked if the transition between paragraphs (1) and (2) was for "and," "or," or "and/or." 3:19:04 PM MS. CLEMENTS, in response to Representative Seaton, agreed that the minimum number of counseling sessions requiring coverage would be four. She offered her belief that proposed HB 209 should include "and" between Section 1(b)(1) and (2). 3:19:51 PM CHAIR KELLER suggested a similar review for the transitions between paragraphs (1), (2), (3), and (4) of proposed Section 1(c) as well. REPRESENTATIVE SEATON suggested that Legislative Legal and Research Services be consulted. 3:20:35 PM REPRESENTATIVE HERRON clarified that proposed HB 209 did not want to legislate over the counter medications. 3:20:57 PM CHAIR KELLER opened public testimony. 3:21:11 PM LOIS KEITHLY, Director, Massachusetts Tobacco Control Program, Surveillance and Evaluation Director, Tobacco Control Program, Massachusetts Department of Public Health, reported that, in 2006, a cessation benefit had been developed for the Medicaid population. She declared that access to all FDA-approved medications, "with 16 face to face counseling sessions," and low co-payments, had resulted in 40 percent use of the benefit, and a smoking prevalence decrease of 10 percent. She relayed that a review of the claims data from those smokers utilizing the benefit found a 46 percent decrease in the possibility of hospitalization for heart attack and a 49 percent decrease in the probability of hospitalization for acute coronary heart disease. She directed attention to a recent return of investment study by George Washington University which applied the findings of the aforementioned Medicaid benefit. The report estimated that every dollar spent for the benefit resulted in a $3.12 savings for decreased cardiac hospitalization. She opined that this was strong evidence that encouraging smokers to quit could offset health care costs. 3:25:33 PM REPRESENTATIVE SEATON asked to have the George Washington University study forwarded to the committee. 3:25:57 PM REPRESENTATIVE MILLER asked to clarify the savings. 3:26:33 PM MS. KEITHLY, in response to Representative Miller, replied that the savings reflected every dollar spent, which included medications, counseling, promotion, and staff time, which compared to the costs of the aforementioned acute cardiac conditions. REPRESENTATIVE MILLER summarized that "it was profitable." 3:27:35 PM REPRESENTATIVE SEATON asked if the counseling sessions were local, or centralized, and if the project paid the participants' transportation costs. MS. KEITHLY replied that, in Massachusetts, transportation was never considered a cost. She reported that only 1 - 3 percent of the claims were for counseling, and the claims could only be submitted if the counseling was conducted in a hospital or community health setting. CHAIR KELLER asked if the program was provided by a government or a private insurance plan. MS. KEITHLY replied that this was a Medicaid program, which had been mandated by the Massachusetts State Legislature. 3:30:07 PM CHAIR KELLER agreed to the benefits for tobacco cessation, but acknowledged the question of who would pay for the program. 3:30:22 PM CHAIR KELLER closed public testimony. 3:30:42 PM REPRESENTATIVE SEATON asked if a program benefit would include transportation for the tobacco counseling sessions. REPRESENTATIVE HERRON offered to clarify this in proposed HB 209. 3:31:59 PM CHAIR KELLER asked if other private medical insurance would cover counseling for similar programs. MS. CLEMENTS replied that she would research this. REPRESENTATIVE MILLETT asked if the State of Alaska covered tobacco cessation programs. MS. CLEMENTS replied that she would defer to the Department of Health and Social Services. 3:33:23 PM CHAIR KELLER asked if there was medical insurance coverage for over the counter medications. Directing attention to proposed Section 2, he offered his belief that lack of a requirement for pre-authorization implied that a person "could buy a tobacco cessation medication and then just directly submit the bill for the coverage. It just seems like that's out of the norm." REPRESENTATIVE HERRON replied that he would research this. 3:35:02 PM REPRESENTATIVE MILLETT, directing attention to the over the counter medication, asked if cost was an issue for tobacco cessation. MS. CLEMENTS replied that several people had indicated that cost was a primary impediment. 3:35:41 PM REPRESENTATIVE MILLETT asked if there was any money from the 1998 Tobacco Master Settlement Agreement award to offer for payment toward over the counter tobacco cessation products. MS. CLEMENTS replied that she would research this. 3:36:32 PM CHAIR KELLER opened public testimony. 3:36:46 PM JAMIE MORGAN, Senior Government Relations Director, American Heart Association (AHA), Western States Affiliate, testified that the AHA supported proposed HB 209. She said that addressing the problem of smoking was a core component of the AHA mission, and that "unrestricted access to smoking cessation treatment dramatically improves the success of the patient attempts, in some cases more than a doubling of the odds for successfully quitting." She reported that after one year of smoking cessation, the excess risk of coronary disease caused by smoking was reduced by half, and after 15 years, these coronary disease risks were similar to those who had never smoked. She stated that smoking was the leading cause of preventable death and a major risk factor for heart disease, stroke, and cancer. She said that unrestricted access to evidence based cessation treatment lead to a greater likelihood for successfully quitting smoking. She offered her belief that proposed HB 209 would "mean improved public health, cost reduction for treating chronic disease, and it will result in widespread economic gain." She urged support for proposed HB 209. 3:38:53 PM REPRESENTATIVE MILLER, reflecting that many ailments were negatively impacted by tobacco use, asked if smoking increased the incidence of miscarriages. MS. MORGAN replied that this was correct. 3:40:25 PM PAT REYNAGA, Nurse, Lead Advocacy Volunteer, American Cancer Society, Cancer Action Network, stated that "tobacco has had and continues to have devastating, adverse health effects on Alaskans." She shared that in prior years, the legislature had supported comprehensive programs, and she stated that tobacco cessation coverage was one of the most cost effective health insurance benefits, and that cessation was possible with evidence based programs. 3:41:13 PM CHAIR KELLER asked how many times a smoker would try to quit before success. MS. REYNAGA replied that there were up to 10 attempts, and she pointed out that 71 percent of Alaskan adult smokers wanted to quit. 3:42:24 PM SHEELA TALLMAN, Premera Blue Cross, testified that Premera Blue Cross was in opposition to the current proposed version of HB 209. She said that Premera had submitted a letter outlining its concerns, and offering suggested amendments to the proposed bill. She reported that Premera currently provided comprehensive coverage to programs focused on wellness and prevention. She relayed that the majority of Premera plans covered tobacco cessation counseling and treatment programs, as well as certain prescription drugs. She said that the federal Patient Protection and Affordable Care law declared that insured and self-insured health plans must include preventive services such as tobacco cessation and counseling without cost sharing. She expressed concern that the proposed bill removed cost control tools such as prior authorization. She pointed out that federal law stated that nothing would prohibit insurers from implementing reasonable medical management techniques, and that the proposed bill went against this. 3:45:07 PM REPRESENTATIVE MILLER asked for specifics about the cost sharing and cost control measures. MS. TALLMAN, in response, said that cost sharing referenced any out of pocket cost to a member. She defined cost control tools as medical management techniques which included pre- authorization and frequency of services and treatments, in order for insurers to manage overall costs. 3:47:10 PM REPRESENTATIVE MILLETT asked if insurance plans covered over the counter drugs. MS. TALLMAN replied that she was not sure with respect to smoking cessation. She offered her belief that many of these could also be paid for through health care flexible spending accounts. 3:48:03 PM REPRESENTATIVE MILLETT asked whether Premera supported that the proposed bill contained no connection between mandatory tobacco cessation counseling and use of over the counter medications. MS. TALLMAN replied that the majority of the Premera plans covered cessation counseling and treatment programs. REPRESENTATIVE MILLETT opined that the two should go hand in hand. 3:50:29 PM CHAIR KELLER closed public testimony. [HB 209 was held over.]