HB 281-PRESCRIPTION WITHOUT PHYSICAL EXAMINATION  3:39:13 PM CHAIR HIGGINS announced that the next order of business would be HOUSE BILL NO. 281, "An Act relating to prescription of drugs by a physician without a physical examination." 3:39:32 PM REPRESENTATIVE LYNN GATTIS, Alaska State Legislature, declaring "I think it's a relatively simple bill," read from a prepared statement. She explained that proposed HB 281 would clarify in statute that physicians would not be sanctioned for dispensing or administering prescription medications without a physical examination of the patient. She stated that this practice was "called telemedicine. Telemedicine based medical care would be delivered by primary care physicians within the State of Alaska. Anyone needing medical care would be a candidate for this system." She noted the benefits for a working mother with a sick child, a rural homesteader, or an employee not able to take the time from work. She stated that the proposed bill would allow patients to obtain, through over the phone and on-line consultations when physicians were able to diagnose an ailment, any necessary prescription. She pointed out that the proposed bill would not allow physicians to prescribe controlled substances. She listed the benefits to include convenience to patients, lower cost, immediate access, and higher productivity for a healthier workforce. She noted that this would lead to quicker access for primary care for rural residents. She declared that telemedicine did not replace a relationship with a primary care provider, although a telemedicine provider could be designated as the primary care provider. This telemedicine consultation would be considered a doctor-patient relationship. She acknowledged the concerns for updates to patient background information, stating that these would also be required prior to telemedicine conferences. 3:43:34 PM REPRESENTATIVE GATTIS, in response to Representative Tarr, said that there would be testimony by individuals from other participating states. CHAIR HIGGINS pointed out that a requirement for health history and informed consent was not included in the proposed bill. He asked if there was an assumption for this to be conducted by the physician. REPRESENTATIVE GATTIS expressed her assumption that the doctor would take the relevant information necessary for "good service to me and back up their license." CHAIR HIGGINS expressed his agreement that the medical profession would ensure the proper documentation, although he surmised that it would be prudent to include this in the proposed bill. 3:46:09 PM REID HARRIS, Staff, Representative Lynn Gattis, Alaska State Legislature, shared that, as the medical community in Alaska was tight knit, any questionable performance would be quickly reviewed. Referencing paragraph (3), page 1, lines 12-14, of the proposed bill, "the person consents to sending a copy of all records of the encounter to the person's primary care provider," he offered his belief that a telemedicine provider would become the primary care physician if the patient did not have a physician, and the telemedicine provider would "take all your information." He pointed out that this information would be sent to an already existing primary care physician. 3:47:16 PM REPRESENTATIVE SEATON pointed out that the proposed bill required the physician to be in the State of Alaska. He asked whether treatment by outside physicians would allow prescriptions to be altered. REPRESENTATIVE GATTIS replied that the proposed bill did not address specialists or specialty care. She explained that telemedicine offered consultation for relatively common issues, such as respiratory illness, skin problems, and abdominal, joint, and back pain. REPRESENTATIVE SEATON, asking for clarification that Version 28- LS1234\A of the bill was in front of the committee, questioned where the aforementioned limitation to prescriptions was mentioned in the proposed bill. REPRESENTATIVE GATTIS explained that, although not mentioned specifically in the proposed bill, telemedicine only allowed the aforementioned care. 3:49:43 PM CHAIR HIGGINS, referencing paragraph (3), page 1, lines 12-14, of the proposed bill, asked who was required to send the forms, and how would they know who to send the forms. MR. HARRIS replied that, although the telemedicine provider would be required to send the forms to the designated primary care physician, the bill did not address a timeline for transmission. CHAIR HIGGINS noted that Teladoc was available to testify, and he lauded its program. He asked about the procedures and requirements for transfer of information with a program other than Teladoc, as the proposed bill would allow consultation with any telemedicine group. REPRESENTATIVE GATTIS offered her belief that, as this was the same situation with Instant Care, "we have that situation already in place with our doctors." CHAIR HIGGINS pointed out that the forms were filled out when a patient attended Instant Care and Urgent Care. REPRESENTATIVE GATTIS expressed her agreement, noting that this was the same as filling out forms on-line. She stated "that's really all this bill does, is it allows us to do it on-line, or have it done over the phone. It's the same process that we go to when we walk into a doctor's office, and tell them our health history." 3:52:36 PM REPRESENTATIVE TARR referenced the Alaska Federal Health Care Access Network (AFHCAN), the telemedicine program for the Alaska Native Tribal Health Consortium (ANTHC). She asked to better understand what was already happening with telemedicine in Alaska, and how the proposed bill would complement this program. MR. HARRIS explained that AFHCAN was "a little bit different than telemedicine." He explained that AFHCAN supplied a provider and a medical cart to assist the patient while the physician was on the other end of the phone. He said that the proposed bill only specified the patient with the physician at the other end. He relayed some complaints from rural areas that the intermediate connection with the provider and the medical cart, between the physician and the patient, was possibly not as helpful as a direct connection with the physician. REPRESENTATIVE GATTIS stated that "this relatively simple bill" clarified in statute that physicians may not be sanctioned for dispensing or administering prescription medications without a physical examination of the patient, and "quite frankly, that already happens right now." She offered her belief that many people already called their physician with their problems and symptoms, and requested prescriptions. She stated that the proposed bill "clarifies and keeps them out of hot water." 3:54:46 PM REPRESENTATIVE SEATON asked if the proposed bill restricted doctors from out of state, specifically Veterans' Administration or Indian Health Service physicians. MR. HARRIS replied that, as military and ANTHC doctors had a federal exemption which allowed them to operate, the proposed bill would clarify this for an in-state doctor. 3:56:14 PM CHAIR HIGGINS opened public testimony. HENRY DEPHILLIPS, Corporate Chief Medical Officer, Teladoc, described Teladoc as the oldest and largest telehealth company in the United States. Describing the telemedicine industry, he stated that he would clarify if there was something specific to Teladoc which did not apply to the rest of the industry. He said that the concept of telemedicine was comparable to a doctor reference, if your primary care physician was not available. He reported that Teladoc was the oldest in the telemedicine industry, operating for 12 years, and that about 15 million Americans were covered in a telemedicine program through their employer or their health insurance company. He shared that more than 500,000 consultations had taken place throughout the United States, and to date, there had not been any liability issues. He noted the telemedicine programs features which were different than traditional cross coverage, and included: no DEA controlled substances were allowed; a limited number of diagnosis were treated, primarily common, uncomplicated medical problems that were usually recurrent for the patient; the treatments were straightforward; and, the majority of prescriptions were generic, falling into three classes, antibiotics, anti-allergy medications, and inhalers. He offered his observations for the telemedicine industry, noting that there had been internet scam offerings in the late 1990s, which had allowed for prescriptions to DEA controlled substances. He reported that many state medical boards had then implemented a "prior in-person visit requirement," which entailed a physical examination. He opined that this requirement had stopped the scams. He explained that there was then a realization for the similarity of cross coverage consultations with telephonic encounters, both without the prior in-person visit. Therefore, as regulations for exceptions became necessary, emergency situations and cross coverage were exempted. At this point, attorneys for the industry ascertained that telemedicine was a cross coverage service, and was subject to that exemption. He reported that the Alaska State Medical Board had disagreed with this interpretation which leads to the current proposed legislative solution. He offered his belief that the Alaska State Medical Board had concerns that the care of Alaskans would move to doctors outside of Alaska. He shared that the Teladoc business model called for Alaskan care to be performed by physicians licensed and living in Alaska. He spoke about the perception that, if there was not a prior in-person physical exam, the quality of care would be compromised. He declared that the data argued against this perception, as the common, uncomplicated medical problems had not had any liability issues. He reported that telemedicine providers usually covered the liability insurance for the consulting doctors, and the premiums were at the lowest levels, Class I. He reminded the committee that telephonic diagnosis and treatment had occurred for many years in the cross coverage situation. He pointed to the three take home points in the Rand Corporation telemedicine study which was recently published in Health Affairs. The first point reported was that people without the option for telemedicine made emergency room visits for a non-emergency problem about 25 percent of the time. The second conclusion of the study was that telemedicine was especially valuable for people without an established relationship with a primary care physician. The third conclusion was that the cost for medical care was reduced with telemedicine. He noted that improved access and cost were two important issues in Alaska. He explained that the proposed bill would curtail intervention by the Alaska State Medical Board with telemedicine. In response to an earlier question, he noted that the telemedicine industry had worked in conjunction with the Alaska State Medical Association to arrive at the language in the proposed bill. He responded to a question regarding medical history, and expressed his agreement that although the telemedicine industry needed oversight and structure, this should be a similar standard to that applied to the in-person setting. He offered his belief that there was not a legal or regulatory requirement for a copy of the record to be sent to the primary care physician, but he emphasized that it was good medical practice. He questioned whether it was necessary to legislate the requirement in the telemedicine environment. 4:05:29 PM CHAIR HIGGINS mentioned that there was a standard of care to which physicians were held responsible, which included an intake form, a consent form, and a health history. He pointed out that, although this was not written, obeying the standard of care was necessary. DR. DEPHILLIPS expressed his agreement, and stated that the standard of care should be applied in all settings. CHAIR HIGGINS suggested that the use of telemedicine needed to be further reviewed, as the savings to Medicaid could be substantial. He pointed out that the Alaskan Native Corporations had offered telemedicine for many years, and that it was working. He stated that the public sector "should be able to do the same thing." He expressed his appreciation for the proposed bill to further the conversation. 4:06:51 PM REPRESENTATIVE TARR, reflecting on the use of emergency rooms for non-emergency visits by patients who did not have a primary care provider, asked how people could learn about the option for the use of telemedicine. DR. DEPHILLIPS opined that there would soon be "direct to consumer telemedicine, there are some start-up companies that are starting to go there." However, the majority of telemedicine programs were sponsored by health care plans and employers. He reported that Teladoc had about 1,750,000 Medicaid recipients, as well. 4:08:36 PM REPRESENTATIVE TARR asked if the proposed bill would allow Medicaid recipients to enroll. DR. DEPHILLIPS offered his understanding that the proposed bill would allow physicians in Alaska to enroll in a telemedicine program, and be compensated by Alaskans not already enrolled in a federal program. He clarified that telemedicine was already allowed in the federal programs, and could not be regulated by the Alaska State Medical Board. The proposed bill would allow patients not in a federal program to have these same opportunities. He shared that there was discussion for adding telemedicine to the Alaska Medicaid program, allowing for increased access and cost savings. He pointed out that it was necessary for passage of the proposed bill, as it would offer regulatory cover for Alaska physician licenses. 4:10:11 PM REPRESENTATIVE SEATON asked for an explanation for the operation of the telemedicine program. DR. DEPHILLIPS explained that, for the sponsored primary care model, a person would pick up the telephone and talk with a customer service intake representative, who would collect the appropriate information and medical history. The same process could be conducted on line. He shared that, during the request process, it was important to know the age of the patient and where you were calling from, so the appropriate licensed physician could respond. He pointed out that it could be required for the patient to fill out the medical history and for the doctor to review this before contact with the patient. He explained that the physician would receive and review the consultation request, and would contact the patient, by telephone audio video, which had to be a Health Insurance Portability and Accountability Act (HIPAA) compliant, secure platform. The physician would communicate in real time with the patient for as long as necessary to conclude with either a treatment plan or a reference for an in-person consultation, which resulted about 4 percent of the time. He pointed out that there was not any financial incentive for a referral. He stated that Teladoc hired highly trained, highly qualified physicians, and then empowered them to make the best decisions for each patient. 4:12:32 PM REPRESENTATIVE SEATON asked if a patient would get the same physician on a follow up call. DR. DEPHILLIPS replied that, as the Teladoc program did not want to interfere with any existing relationships with primary care physicians, Teladoc did not allow any choice for physician, similar to an emergency room or Urgent Care visit. He noted that, however, some telemedicine programs did allow selection of a physician. REPRESENTATIVE SEATON directed attention to page 1, line 10 of the proposed bill, and read: "the physician is located in this state and available to provide follow-up care." He asked how this was satisfied if the initial physician was not available for the follow up care. DR. DEPHILLIPS replied that there was a 72 hour window after the initial telemedicine consultation for direct contact between the patient and the same physician. He offered his belief that, with a physician in Alaska, the patient could directly contact the physician. The telemedicine industry was designed to get patients over the acute problem, and then back in touch with their primary care physician. He offered his belief that the proposed bill allowed this continued "safety valve" contact in Alaska, as these licensed telemedicine physicians resided in Alaska. REPRESENTATIVE SEATON expressed concern for the aforementioned wording, and suggested a change to read: "follow-up care is provided through the telemedicine group." He compared the telemedicine program to his neighborhood clinic, where he was served by whichever doctor was available. He opined that, even though the telemedicine model would not allow for the same physician, that physician would often become the primary care physician, hence the wording on page 1, line 10 of the proposed bill needed to change. 4:18:23 PM DR. DEPHILLIPS suggested viewing the telemedicine service industry as a physician cross coverage service. He recommended not to put any additional burden on the telemedicine industry that was not put on an in-person doctor. He reminded the committee that each telemedicine doctor had access to the medical records from the patient's previous visit. REPRESENTATIVE SEATON noted that the state did not have a statute requiring the prescribing doctor to be available for follow-up, whereas the proposed bill did state this. CHAIR HIGGINS, directing attention to page 1, line 10, of the proposed bill, suggested to delete "and available to provide follow up care;" which would maintain the current state standard for all the physicians. REPRESENTATIVE SEATON offered his belief that this specified something that could not always be accomplished. 4:21:04 PM REPRESENTATIVE PRUITT asked to research the intent of the bill drafter, and the intended definition of "available." DR. DEPHILLIPS shared that the language for paragraphs (1), (2), and (3) was drafted collaboratively with the Alaska State Medical Association, and he suggested discussion with the drafter. 4:22:31 PM The committee took an at-ease from 4:22 p.m. to 4:25 p.m. 4:25:27 PM CHAIR HIGGINS announced that the committee intended to hold the proposed bill. DR. DEPHILLIPS explained that the intent of the follow up care provision in the proposed bill, page 1, line 11, was to allow the opportunity to obtain medical attention if there was a problem. He shared that this could either be re-contact with the telemedicine provider or the primary care physician. CHAIR HIGGINS stated the desire of the committee to hear from the Alaska State Medical Board, the bill drafter, and the Alaska State Medical Association. REPRESENTATIVE SEATON asked whether anyone with prescriptive ability, including a physician's assistant, would also be included. 4:28:22 PM CHAIR HIGGINS left public testimony open, and stated that proposed HB 281 would be held over.