ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  March 26, 2019 3:05 p.m. MEMBERS PRESENT Representative Ivy Spohnholz, Co-Chair Representative Tiffany Zulkosky, Co-Chair Representative Matt Claman Representative Harriet Drummond Representative Geran Tarr Representative Sharon Jackson Representative Lance Pruitt MEMBERS ABSENT  All members present COMMITTEE CALENDAR  HOUSE BILL NO. 22 "An Act extending the termination date of the Statewide Suicide Prevention Council; and providing for an effective date." - HEARD & HELD HOUSE BILL NO. 29 "An Act relating to insurance coverage for benefits provided through telehealth; and providing for an effective date." - HEARD & HELD HOUSE BILL NO. 97 "An Act relating to the prescription of drugs by a physician assistant without physical examination." - HEARD & HELD HOUSE BILL NO. 86 "An Act relating to a state-owned inpatient mental health treatment hospital; and providing for an effective date." - BILL HEARING RESCHEDULED TO 3/28/19 PREVIOUS COMMITTEE ACTION  BILL: HB 22 SHORT TITLE: EXTEND SUICIDE PREVENTION COUNCIL SPONSOR(s): REPRESENTATIVE(s) TARR 02/20/19 (H) PREFILE RELEASED 1/7/19 02/20/19 (H) READ THE FIRST TIME - REFERRALS 02/20/19 (H) HSS, FIN 03/26/19 (H) HSS AT 3:00 PM CAPITOL 106 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 BILL: HB 97 SHORT TITLE: TELEHEALTH: PHYSICIAN ASSISTANTS; DRUGS SPONSOR(s): REPRESENTATIVE(s) KREISS-TOMKINS 03/15/19 (H) READ THE FIRST TIME - REFERRALS 03/15/19 (H) HSS, L&C 03/26/19 (H) HSS AT 3:00 PM CAPITOL 106 WITNESS REGISTER LINDA DAY, Audit Manager Legislative Audit Division Legislative Agencies and Offices Anchorage, Alaska POSITION STATEMENT: Testified during discussion of HB 22. BEVERLY SCHOONOVER, Acting Executive Director Statewide Suicide Prevention Council Division of Behavioral Health Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Testified during discussion of HB 22. BARBARA FRANKS, Chairperson Statewide Suicide Prevention Council Ninilchik, Alaska POSITION STATEMENT: Testified during discussion of HB 22. NICOLE BORROMEO, Executive Vice President and General Council Alaska Federation of Natives (AFN) Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 22. BRENDA MOORE Statewide Suicide Prevention Council Anchorage, Alaska POSITION STATEMENT: Testified during discussion of HB 22. SAM TRIVETTE Juneau Suicide Prevention Coalition Juneau, Alaska POSITION STATEMENT: Testified in support of HB 22. MONIQUE ANDREWS Statewide Suicide Prevention Council Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 22. KRISTINA JAGER Juneau, Alaska POSITION STATEMENT: Testified in support of HB 22. PATTY OWEN Alaska Public Health Association (ALPHA) Juneau, Alaska POSITION STATEMENT: Testified in support of HB 22. BERNICE NISBETT, Staff Representative Ivy Spohnholz Juneau, Alaska POSITION STATEMENT: Introduced the Sectional Analysis for HB 29 on behalf of the sponsor, Representative Spohnholz. LORI WING-HEIER, Director Juneau Office Division of Insurance Department of Commerce, Community & Economic Development Juneau, Alaska POSITION STATEMENT: Testified and answered questions during discussion of HB 29. VICTORIA KNAPP, Chief Operations Officer Mat-Su Health Services, Inc. Wasilla, Alaska POSITION STATEMENT: Testified in support of HB 29. AROM EVANS, MD Orion Behavioral Health Network Eagle River, Alaska POSITION STATEMENT: Testified in support of HB 29 and HB 97. ROBERT BARATTA National Consultant Teladoc Health Richmond, Virginia POSITION STATEMENT: Testified during discussion of HB 29. CYNTHIA MARK Teladoc Health Michigan POSITION STATEMENT: Testified in support of HB 29. CHRISTOPHER DIETRICH, Assistant Medical Director Orion Behavioral Health Network Eagle River, Alaska POSITION STATEMENT: Testified in support of HB 29 and HB 97. REID HARRIS, Staff Representative Jonathan Kreiss-Tomkins Alaska State Legislature POSITION STATEMENT: Presented HB 97 on behalf of the bill sponsor, Representative Kreiss-Tomkins. DEBORAH STOVERN, Executive Administrator State Medical Board Division of Corporations, Business, and Professional Licensing Department of Commerce, Community & Economic Development Anchorage, Alaska POSITION STATEMENT: Answered questions during discussion of HB 97. ACTION NARRATIVE 3:05:16 PM CO-CHAIR ZULKOSKY called the House Health and Social Services Standing Committee meeting to order at 3:05 p.m. Representatives Zulkosky, Spohnholz, Tarr, and Drummond were present at the call to order. Representatives Claman, Pruitt, and Jackson arrived as the meeting was in progress. HB 22-EXTEND SUICIDE PREVENTION COUNCIL  3:05:48 PM CO-CHAIR ZULKOSKY announced that the first order of business would be HOUSE BILL NO. 22, "An Act extending the termination date of the Statewide Suicide Prevention Council; and providing for an effective date." 3:06:33 PM REPRESENTATIVE TARR introduced HB 22, as the sponsor of the bill, and stated that the proposed bill was more than simply an extension for the termination date of the Statewide Suicide Prevention Council. She pointed to the recent 2019 Alaska statistics for suicide prevention which indicated that one person died by suicide every 44 hours. She reported that this was the fifth leading cause of death in Alaska, while being the leading cause of death in ages 15 - 24. She added that Alaska was second in the nation with suicide deaths per capita. She pointed to an increase in the recent rate of suicide, declaring that this was an impact upon too many Alaskans. She emphasized the need for a Suicide Prevention Council, and that even more needed to be done. She pointed to the 20,976 calls during 2018 to the CARE line, an annual increase of almost 30 percent. She reported that the Statewide Suicide Prevention Council was comprised of 14 individuals, which included 4 legislators, as non-voting members. 3:10:13 PM REPRESENTATIVE TARR paraphrased from the sponsor statement [Included in members' packets][original punctuation provided], which read: House Bill 22 would extend the termination date of the Statewide Suicide Prevention Council to 2027, ensuring another eight years of support for suicide prevention efforts in Alaska. The Council would otherwise be terminated on June 30, 2019. According to the Alaska Department of Health and Social Services Section of Epidemiology, the suicide rate in Alaska increased by 13 percent between 2012 and 2017, making suicide the leading cause of death for Alaskans between the ages of 10 and 64. As a matter of public health, the state has a responsibility to address this disturbing trend and must actively continue to pursue strategies to prevent suicide in Alaska. The Statewide Suicide Prevention Council was created in 2001 and consists of 14 public and private members, including four state legislators. Under AS 44.39.350, the Council is statutorily responsible for: ? Advising legislators and the Governor on ways to improve Alaskans' health and wellness by reducing suicide; ? Improving public awareness of suicide and risk factors; ? Enhancing suicide prevention efforts; ? Working with partners and faith-based organizations to develop healthier communities; ? Creating a statewide suicide prevention plan and putting it in action; and ? Building and strengthening partnerships to prevent suicide. The Council holds public meetings, publishes a 5-Year State Suicide Prevention Plan, and works with schools and community groups to provide resources that educate Alaskans on how to prevent suicide. Last year, the Council partnered with the Alaska Community Foundation and Alaska Children's Trust to continue the GCI Suicide Prevention Grant Program. Nine grants were funded in 2017 across the state, totaling $100,000. The Council also helped secure funding for a 5-year grant from the National Institute of Mental Health to create the Alaska Native Collaborative Hub for Resilience Research, which will help Alaska Native communities share knowledge, guide research, and identify culturally-relevant suicide prevention strategies in rural Alaska. Terminating the Statewide Suicide Prevention Council would jeopardize the state's efforts at addressing this heartbreaking, but preventable, issue. I respectfully ask for your support of HB 22 this year. REPRESENTATIVE TARR pointed out that there was a recommendation by the Legislative Audit Division to extend the council for eight years. She directed attention to the fiscal note, labeled OMB Component Number 2651 [Included in members' packets] and explained that this included not only the expenditures for staffing, but the bulk was directed for grants to the Department of Education and Early Development. She concluded and pointed to the checklists [Included in members' packets] for families, communities, and individuals which offered ways to make a difference for Alaskans impacted by suicide. 3:15:16 PM REPRESENTATIVE JACKSON asked if the $648,000 requested on the fiscal note was an annual request. REPRESENTATIVE TARR replied, "that's true, yes." She directed attention to the grants and benefits line, noting that this was the bulk of the requested funding and that it was for "really, really important work in the schools." REPRESENTATIVE JACKSON expressed her concern that this money be directed toward education, but instead be directed toward mental services. She offered her belief that investment through the schools may not be the best place to funnel the money as it may be the "last place young people want to talk about it because they will feel ridicule." She declared the need to shift the perspective as the suicide numbers were not coming down. She stated her support for the proposed bill and added that she would be a member of the council. 3:18:32 PM REPRESENTATIVE TARR said that she would follow up with her and explained that there was now an understanding for "the trauma informed approach" to be effective. She noted that some of the materials had been developed for educators. She acknowledged that although the program infrastructure appeared to be the same, the actual work completed through these grants was now very relevant and based on what was currently understood as the best practices. She expressed her hope that this was the best and most effective use of the dollars. REPRESENTATIVE JACKSON replied that she would wait to hear from the various organizations. REPRESENTATIVE TARR offered that there could be responses from the testifiers directed toward her concerns. 3:20:28 PM REPRESENTATIVE CLAMAN shared his agreement with the expansion to an eight-year renewal, noting that there was a cost to the shorter time frames. REPRESENTATIVE TARR replied that the issues facing the council were very challenging and took time and generational change. 3:21:41 PM LINDA DAY, Audit Manager, Legislative Audit Division, Legislative Agencies and Offices, directed attention to the sunset audit of the Suicide Prevention Council [Included in members' packets] dated August 3, 2018. She explained that the purpose of a sunset audit was to determine whether a board or commission was serving the public interest and whether it should be extended. She declared that the Statewide Suicide Prevention Council was authorized by statute to serve in an advisor capacity to the Alaska State Legislature and the governor regarding suicide awareness and prevention. She reported that it had been found that overall the council operated in the public's interest by actively broadening the public's awareness of suicide prevention and coordinating the efforts of other suicide prevention entities which included state agencies, regional groups, coalitions, and local communities. She added that the council had fulfilled its statutory duty by issuing the 2018 - 2022 Suicide Prevention plan while working closely with the stakeholders to add and refine the plan's strategies, resources, and indicators. She directed attention to page 4 of the audit which listed the schedule of expenditures and funding sources. She noted that the council was funded by general fund appropriations for about $650,000 in FY18, with the majority of its expenditures for suicide awareness prevention programs with the Department of Education and Early Development. She pointed to pages 9 - 10 of the audit which listed a detailed list of the council activities, and she shared two administrative recommendations. On page 12, it was recommended that the executive director develop and implement procedures to ensure that public notice for the meetings was published accurately and in a timely manner. Also, on page 12, it was recommended that the chair of the council develop and implement written procedures to ensure performance evaluations were completed annually for the executive director, as this was required in statute. She concluded by stating that the division recommended an extension for the council termination date of eight years. 3:25:50 PM BEVERLY SCHOONOVER, Acting Executive Director, Statewide Suicide Prevention Council, Division of Behavioral Health, Department of Health and Social Services, reported that she had only been acting executive director for two months. 3:26:50 PM BARBARA FRANKS, Chairperson, Statewide Suicide Prevention Council, shared her personal story as a mother of a child who died by suicide. She noted that she had travelled more than 700,000 miles in Alaska for trainings to teach the signs for how to help someone. She reported that there had been 2,224,408 calls to the national helpline in 2018. 3:31:09 PM CO-CHAIR SPOHNHOLZ thanked Ms. Franks for sharing her personal experience, stating how important this was, and she shared her own personal experiences with suicide. She pointed out the difficulty for knowing what to say to someone impacted by a suicide and the need for honest, transparent conversations about suicide as the way to address the issue over the long term. 3:32:55 PM NICOLE BORROMEO, Executive Vice President and General Council, Alaska Federation of Natives (AFN), stated the support of AFN for three main reasons: Alaska Natives and American Indians are the only ethnic populations specifically listed as at-risk for suicide by the U.S. Substance Abuse and Mental Health Services Administration. Since suicide disproportionately affects Alaska Natives and American Indians, the suicide prevention council connects the public to state government resources, raises awareness, increases outreach, and helps secure funding for projects and programs that help our communities develop community and culturally relevant programs to build our collective resilience. She stated support of continuation of the council and support to the Alaska Native Health Board's efforts to expand the membership of the council to include a subject matter expert in prevention who has experience working in the tribal health care system. Finally, AFN was supportive of HB 22 because the council promoted community wellness and used the most current data and research to inform its upstream approach. She stated that there had been too many instances where suicide had reached epidemic levels throughout Alaska and that all Alaskans needed to know that suicide was preventable. 3:35:12 PM CO-CHAIR ZULKOSKY opened public testimony. 3:35:40 PM BRENDA MOORE, Statewide Suicide Prevention Council, reported that she was the representative to the council from the Alaska Mental Health Board. She stated that prevention was primarily about reducing risk and building resilience and that the council worked to coordinate, advocate, and educate. She relayed that the grants were for primary prevention and had touched the lives of more than 200,000 people. These learning modules allowed the public to understand the signs and symptoms of suicide, and the impacts of toxic stress and trauma that create a greater risk for suicide. She explained that a key role for the council was to coordinate among the various local groups. She cautioned that there were other chronic illnesses that also needed prevention. She declared that it was necessary to develop resiliency and deal with trauma and toxic stress, hence the need to start with youth. She emphasized that the work with Department of Education and Early Development was key to addressing primary prevention. 3:41:10 PM SAM TRIVETTE, Juneau Suicide Prevention Coalition, said that there had been a suicide death in Juneau today and shared a personal experience with suicide. He stated his support for HB 22. He said that there had been progress made in many areas around the state, pointing out that, as the CARE line calls had dramatically increased, people were willing to call and connect with experts. He offered his belief that the programs in the schools had "opened up kids, they understand the signs of suicide" and that there were programs that dealt with sources of strength and resilience. He reported that several hospitals and clinics were screening for suicide prevention. He added that the council was developing new programs that were extremely effective and would become best practices. 3:46:01 PM MONIQUE ANDREWS, Statewide Suicide Prevention Council, stated that she was a member of the Alaska Army National Guard and she shared how the suicide prevention efforts were working in the military. She reported that the increase of suicides in Alaska was on par with the national and the military increase. She said that although there were a multitude of variables contributing to the increase, the efforts for prevention intervention were not in vain. She pointed out that most military recruiters were working with 15 - 24-year olds, which was the most vulnerable group as they were still physically and emotionally developing. This was also the highest group for suicide. She stated that the Suicide Prevention Council worked in the schools with this age group to teach skills of resiliency and effective communication, and that these skills were taken with them into the military. She pointed out how stressful it was for these young people in the military and the need for these skills. She spoke about the perceptions of prevention, as many people thought that prevention was solely intervention. She declared that prevention happened even before a crisis, while there were still other options and resources available, and that the council provided an avenue to connect with these resources. 3:52:25 PM KRISTINA JAGER shared her personal story as a survivor of suicide and that she had worked in the mental health field with individuals in crisis for the past seven years. She relayed that the council gave hope and provided a consolidated, concerted, strategic plan to "recast the net upstream" as primary prevention was the key. She stated the importance of getting to youth before the at-risk period of their lives so they would have the necessary coping and resilience skills. She declared that it was crucial to continue to provide the grant funding to the Department of Education and Early Development for primary prevention. She stated support for HB 22. 3:55:31 PM PATTY OWEN, Alaska Public Health Association (ALPHA), stated support for extension of the council until 2027 and she read from a prepared statement [original punctuation provided]: The Alaska Public Health Association (ALPHA) is a non- profit membership organization with over 150 health members dedicated to improving the health and well- being for all Alaskans. ALPHA is also the state affiliate of the American Public Health Association. ALPHA strongly supports HB 22, to extend Alaska's Statewide Suicide Prevention Council to June 30, 2027. As outlined in Alaska Statute 44.29.350, the functions of the Council are necessary to improve health and wellness throughout the state by reducing suicide and its effects on individuals, families and communities. The Statewide Suicide Council has done a remarkable job of raising awareness; coordinating and improving statewide prevention programs and resources; collaborating with national, state and local stakeholders and resources; and developing, updating, and implementing statewide prevention plans. Reducing suicide rates in Alaska has been one of the goals of the State's Healthy Alaskans 2020 and is also a priority of ALPHA. Unfortunately, despite best efforts, suicide rates in Alaska remain high and still much higher than the national average. It is crucial that the Statewide Suicide Council continue its work and remain the primary entity in Alaska for Alaska's collective approach to preventing suicide. 3:57:31 PM CO-CHAIR ZULKOSKY closed public testimony. [HB 22 was held over.] HB 29-INSURANCE COVERAGE FOR TELEHEALTH  3:57:51 PM CO-CHAIR ZULKOSKY announced that the next order of business would be HOUSE BILL NO. 29, "An Act relating to insurance coverage for benefits provided through telehealth; and providing for an effective date." 3:58:30 PM The committee took an at-ease from 3:58 p.m. to 4:00 p.m. 4:00:11 PM REPRESENTATIVE SPOHNHOLZ introduced HB 29 as the sponsor of the bill, stating that this bill increased access to and reduced the cost of health care by requiring insurers to reimburse providers for delivering health care services via telehealth. She added that telehealth was already covered and provided for by Medicaid and the Indian Health Services. She pointed out that it was so effective in these markets that it should be covered in its entirety in the private market as it increased access to health care in Rural Alaska. She shared a PowerPoint titled "House Bill 29 Insurance Coverage for Telehealth." She directed attention to slide 2, "Telehealth: Why is this important?" and pointed out that it would reduce the cost of health care by reducing travel expenses. She said that it could be used for primary, specialty, and behavioral health care. She noted that this also supported necessary innovations and transformations in health care. She pointed out that this could reduce emergency room visits. She added that the state plan did not provide for tele-health. 4:03:37 PM BERNICE NISBETT, Staff, Representative Ivy Spohnholz, paraphrased from the Sectional Analysis to HB 29 [Included in members' packets], which read: Section 1. AS 21.42.422 has been amended to require insurance coverage for health benefits provided through telehealth technology. Section 2. AS 21.42.422 is a new subsection that defines health care insurer as a person transacting the business of health care insurance except for a nonfederal governmental plan. It also adds the definition of telehealth under 47.05.270(e) as 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 between providers who are physically separated from the recipient or from each other or between a provider and a recipient who are physically separated from each other. Section 3 The changes to Section 1 of this bill applies to health care insurance plans that are offered, issued, delivered, or renewed on or after the effective date. Section 4 The effective date is July 1, 2020. 4:05:21 PM REPRESENTATIVE CLAMAN asked if Department of Commerce, Community & Economic Development and the administration were in support of the proposed bill. 4:05:43 PM LORI WING-HEIER, Director, Juneau Office, Division of Insurance, Department of Commerce, Community & Economic Development, in response to Representative Claman, said that Department of Commerce, Community & Economic Development was very much in support of anything that would provide access to health care yet lower the cost at the same time. She acknowledged that the department was in support of the proposed bill. 4:06:05 PM REPRESENTATIVE PRUITT asked if it was possible to mandate this. MS. WING-HEIER reported that the Division of Insurance estimated that insured plans, which the division regulated, covered about 15 percent of Alaskans. REPRESENTATIVE PRUITT asked why there was a need to mandate this to the insurance companies, as it offered a cost savings. MS. WING-HEIER replied that this would increase access to Rural Alaska, especially for specialties and would reduce the overall costs if it could address common things and eliminate the need to visit the provider. She reported that there were data projections for virtual hospitals in the future with recuperation at home, although there were not any numbers to support this. In response to the need for a mandate, she reported that any conversation for new services prompted discussions and sometimes it was necessary to push for the offering of newer products or services. REPRESENTATIVE PRUITT asked about the options. He acknowledged that, although Moda Health had submitted a letter of support, they would not be required to provide this with their plan for the state. He questioned whether there would be support from the providers who would be required to offer telehealth. He shared his difficulty for understanding why a cost saving measure would need to be mandated. MS. WING-HEIER explained that previous attempts to deliver telehealth had not been provided by all insurance providers and that this mandate would ensure parity. REPRESENTATIVE PRUITT asked how to prevent individuals from recruiting the use of telehealth services without allowing for the best interests of the patient. He opined that the introduction of money through a mandate brought with it those who would take advantage. 4:10:51 PM MS. WING-HEIER expressed agreement that there were bad actors making "big dollars out of it" and this included doctors and insurance agents. She stated that it was necessary to use due diligence and take the necessary actions against those bad players. REPRESENTATIVE PRUITT asked how to ensure that her division had the tools to "take action as needed if there are those bad players that come up." He asked if it would be necessary for statute changes to allow the authority to pursue these people, some of whom may not even be in the state. MS. WING-HEIER reported that the agency had four investigators and she declared they were "a critical part of us being able to look at people that are the bad actors in the state. When they cross state lines, we end up working with the U.S. Attorney General or with the FBI, and that's not uncommon." She declared that these federal agencies "actually have the jurisdiction." 4:13:29 PM REPRESENTATIVE JACKSON asked if this would cover all Alaskans or just those through certain health care facilities or certain insurance companies. REPRESENTATIVE SPOHNHOLZ replied that the intent of the proposed bill was to ensure that insurers operating in the private market be required to cover telehealth services. She reported that telehealth services were already authorized and paid for under Medicaid, as well as tribal health. This proposed bill would expand the market for access to telehealth into the private market. She stated that self-insured plans which were governed by federal law, including the insurance plan by the State of Alaska, could not be included in state law. MS. WING-HEIER said that the State of Alaska had adopted a tele- doc option in its retirement and benefit plan. REPRESENTATIVE JACKSON declared that this was beneficial and saved a lot of time, travel, and money. She asked that this be shared with our federal delegation. REPRESENTATIVE SPOHNHOLZ expressed her intention to coordinate with the federal delegation. She expressed agreement that the state plan now allowed tele-doc, which she described as "a virtual form of an urgent care," although this was not quite the complete service that she supported for lasting relationships. 4:17:28 PM REPRESENTATIVE CLAMAN asked about the tele-doc coverage. REPRESENTATIVE SPOHNHOLZ, in response, explained that it depended on the provider. She said that Aetna had a requirement that providers go through a process to determine participation in telehealth. REPRESENTATIVE CLAMAN said that it was available if they followed the steps. He noted that there was a zero fiscal note and asked if there would be additional costs due to enforcement authority. MS. WING-HEIER replied that it was not expected to change the workload. 4:19:54 PM VICTORIA KNAPP, Chief Operations Officer, Mat-Su Health Services, Inc., stated that they relied on telehealth to provide specialty psychiatric services for individuals with mental health issues. She noted that there were "huge shortages of psychiatric providers in the State of Alaska." She reported that they had providers both in-state and out-of-state who were licensed in the State of Alaska. She declared that they were a safety net provider and had gone to telehealth services several years prior due to a shortage of available in-person psychiatric providers. She added that, as they did not want to have a wait list for psychiatric services, they moved to telehealth services. She noted that, on those occasions when a private health plan did not cover these services, the patient had to decide whether to make out of pocket payment or not receive the services. She expressed a desire for everyone to be covered for telehealth. 4:21:54 PM AROM EVANS, MD, Orion Behavioral Health Network, said that his organization primarily provided services for children and adolescents. He said there was a need for medical service providers for children, and that many of them were out of state and could only be accessed through telehealth. He stated his support for HB 29. He said that tele-doc was an important and useful service but that it was a very different service than telehealth. With tele-doc, as it was an on-demand service and you could not schedule a follow-up appointment, you may not have the same provider. 4:23:48 PM REPRESENTATIVE TARR asked whether, since with telehealth there were no in-person meetings, there was a potential to not build a strong relationship that would make the care as effective. DR. EVANS said they used a hybrid model as they maintained four physical clinics around the state. He acknowledged that many patients and family members needed that reassurance and they treated this on a case by case basis. 4:26:02 PM REPRESENTATIVE JACKSON asked about genetic work-ups through telehealth. DR. EVANS explained that genetic work-ups were conducted primarily in the laboratory, as they reviewed symptoms to determine the necessary tests, and these work-ups included a physical exam that could be provided by a local doctor. 4:27:09 PM ROBERT BARATTA, National Consultant, Teladoc Health, referenced the earlier discussion for fraud and abuse, and pointed out that prior to access of the service, there had to be a valid physician - patient relationship established. He pointed out that Alaska had such a statute as well as guidelines from the State Board of Medicine, for the way this relationship must be established. For reimbursement, the service had to be provided in accordance with that valid relationship. He pointed out that most insurance plans had the authority to make sure that it was medically necessary. REPRESENTATIVE JACKSON asked about the difference between charges from a tele-doc and an office visit. MR. BARATTA explained that there was a tele-medicine platform which a patient could access through their computer for a virtual visit with a physician. He said it mimicked the experience of a visit to an Urgent Care center with a board certified and Alaska licensed physician. 4:30:02 PM CO-CHAIR ZULKOSKY opened public testimony. 4:30:24 PM CYNTHIA MARK, Teladoc Health, emphasized that it was possible to establish an on-going relationship with an Alaska provider through telehealth and to see that same provider on an on-going basis. She stated support for HB 29, pointing out that it was good policy and good legislation. 4:32:02 PM CHRISTOPHER DIETRICH, Assistant Medical Director, Orion Behavioral Health Network, stated his support for HB 29. He offered an example of a patient released from API (Alaska Psychiatric Institute) who moved to Rural Alaska, and the option for telehealth. 4:33:44 PM CO-CHAIR ZULKOSKY closed public testimony. [HB 29 was held over.] HB 97-TELEHEALTH: PHYSICIAN ASSISTANTS; DRUGS  4:34:07 PM CO-CHAIR ZULKOSKY announced that the final order of business would be HOUSE BILL NO. 97, "An Act relating to the prescription of drugs by a physician assistant without physical examination." 4:34:29 PM CO-CHAIR SPOHNHOLZ moved to adopt the proposed committee substitute (CS) for HB 97, labeled 31-LS0695\M, Marx, 3/21/19 as the working draft. CO-CHAIR ZULKOSKY objected for discussion. 4:34:53 PM REID HARRIS, Staff, Representative Jonathan Kreiss-Tomkins, stated that HB 97 was "about increasing patient access to care, particularly for rural and medically underserved areas." He directed attention to maps [Included in members' packets] which portrayed that the entire state, except for the Railbelt, was considered to be a medically underserved area. He stated that it could be problematic for many rural communities to find fair and cheap access to health care. He paraphrased from the Sponsor Statement [Included in members' packets] which read: The 2016 Medicaid Reform bill (SB 74) provided for the use of telehealth by revising Alaska statutes to require the Alaska Board of Medicine to adopt regulations and guidelines for physicians rendering a diagnosis, providing treatment, or prescribing, dispensing, or administering a prescription drug to a person without conducting a physical examination under AS 08.64.364. Unintentionally, SB 74 only addressed physicians, and the Board issued guidelines that made different requirements for physician assistants (PAs) and physicians, citing a lack of legislative intent that the provisions of SB 74 should apply to PAs. The omission of PAs from the Medicaid Reform bill led to them being subject to limitations on the use of telemedicine. Specifically, the Medical Board released guidelines stating that physician assistants could not treat a patient via telemedicine without first conducting an in-person examination, or with a collaborating physician or other practitioner in the same group practice. House Bill 97 aligns the law with the intent of the Medicaid Reform bill, clarifying that PAs can provide telemedicine in the same manner as physicians. Under HB97, the PA would be subject to the same statutory oversight as physicians regarding the practice of telemedicine, as well as the same disciplinary sanctions when appropriate. Alaska, with its vast geographical challenges and limited access to vital healthcare, stands to benefit from this legislation. HB 97 will increase patient access to care, extending the reach of medicine to medically underserved areas. MR. HARRIS pointed out that, although it was legislative intent to allow physician assistants (PAs) to practice telemedicine, the "Medical Board didn't see it that way hence we have these two fix-it bills before both bodies." MR. HARRIS directed attention to the PA Scope of Practice document [Included in members' packets] and paraphrased from the document, which read: A broad, generalist medical education prepares PAs to take medical histories, perform physical examinations, order and interpret laboratory tests, diagnose illness, develop and manage treatment plans for their patients, prescribe medications and assist in surgery. MR. HARRIS stated that PAs could prescribe Schedule II - V medications, and he paraphrased from the "Drug Schedule" [Included in members' packets], which read: Schedule I  Schedule I drugs, substances, or chemicals are defined as drugs with no currently accepted medical use and a high potential for abuse. Some examples of Schedule I drugs are: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), 3,4- methylenedioxymethamphetamine (ecstasy), methaqualone, and peyote Schedule II Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence. These drugs are also considered dangerous. Some examples of Schedule II drugs are: Combination products with less than 15 milligrams of hydrocodone per dosage unit (Vicodin), cocaine, methamphetamine, methadone, hydromorphone (Dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, and Ritalin Schedule III Schedule III drugs, substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence. Schedule III drugs abuse potential is less than Schedule I and Schedule II drugs but more than Schedule IV. Some examples of Schedule III drugs are: Products containing less than 90 milligrams of codeine per dosage unit (Tylenol with codeine), ketamine, anabolic steroids, testosterone Schedule IV Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence. Some examples of Schedule IV drugs are Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, Tramadol Schedule V Schedule V drugs, substances, or chemicals are defined as drugs with lower potential for abuse than Schedule IV and consist of preparations containing limited quantities of certain narcotics. Schedule V drugs are generally used for antidiarrheal, antitussive, and analgesic purposes. Some examples of Schedule V drugs are: cough preparations with less than 200 milligrams of codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin MR. HARRIS explained that a Physician Assistant must have an active and collaborative plan that was maintained with a supervisor and, under the guidance of their collaborating physician, would be authorized to prescribe Schedule II - V drugs. He added that the PA must have an authorization and license from the Drug Enforcement Administration. He summarized and stated that the proposed bill would allow approximately 700 licensed PAs in Alaska to provide telemedicine in the same manner as physicians and extend the reach of medicine to patients in underserved areas. He pointed to the supporting letters from physician assistants practicing in rural areas [Included in members' packets]. He reported that the State Medical Board assumed a neutral position on the proposed bill, and that the fiscal note for $5300 was for the first year only, to pay for legal fees and to update the regulations. 4:41:29 PM REPRESENTATIVE JACKSON asked if this proposed bill could be part of the telehealth bill as it allowed for physician assistants to prescribe drugs. 4:42:06 PM CO-CHAIR SPOHNHOLZ replied that the proposed bill was in a different section of law, even though it intersected to allow physician assistants to participate in telehealth. 4:42:28 PM REPRESENTATIVE CLAMAN asked why the bill did not include nurse practitioners as they were also allowed to prescribe medications. MR. HARRIS explained that registered nurse practitioners were not overseen by the State Medical Board. CO-CHAIR SPOHNHOLZ interjected that nurse practitioners were already allowed to practice telehealth, adding that nurses were overseen by the Board of Nursing. She stated that physician assistants were the only group of providers that had been inadvertently omitted in earlier legislation, Senate Bill 74. REPRESENTATIVE CLAMAN asked if nurse practitioners had been allowed to practice telehealth in Senate Bill 74. CO-CHAIR SPOHNHOLZ replied, "yes." 4:43:37 PM MR. HARRIS, in response to Representative Jackson, directed attention to the AAPA guidelines [Included in members' packets] and paraphrased from the Education and Experience, which read: The intensive PA program curriculum is modeled on the medical school curriculum. The typical PA program extends over 27 continuous months and begins with classroom instruction in basic medical sciences. This is followed by rotations in medical and surgical disciplines including family medicine, internal medicine, general surgery, pediatrics, obstetrics and gynecology, emergency medicine and psychiatry. PA students complete at least 2,000 hours of supervised clinical practice in various settings and locations by graduation. Almost all PA programs now award master's degrees, and by 2020 all programs must do so. 4:45:01 PM REPRESENTATIVE PRUITT asked if PAs would be required to use the drug database. MR. HARRIS said that was correct. REPRESENTATIVE PRUITT asked why the PAs had been omitted from previous legislation. MR. HARRIS offered his understanding that the legislative intent was for physicians to engage in telemedicine with an assumption, incorrect as it was, that PAs working under the physician would also be allowed. After passage of Senate Bill 74, the State Medical Board stated that the new language would not include PAs because they were not directly named. 4:46:54 PM DEBORAH STOVERN, Executive Administrator, State Medical Board, Division of Corporations, Business, and Professional Licensing, Department of Commerce, Community & Economic Development, said that the State Medical Board did not feel that "they could make the call that the legislative intent was to include physician assistants because the language of the statute said physicians only." She offered her understanding the proposed bill was an attempt to correct that. REPRESENTATIVE PRUITT asked for clarification that, although the intent may have been there, she could not "jump to that conclusion because the statute wasn't clear enough." He asked if this was "clean-up" and if she did support this opportunity. MS. STOVERN said that was her understanding of the position by the State Medical Board on this legislation. She pointed out that the State Medical Board had reviewed Senate Bill 44, which was identical legislation, and had issued a letter of support. 4:49:24 PM REPRESENTATIVE PRUITT asked for clarification to the changes in the proposed committee substitute. MR. HARRIS replied that the proposed committee substitute added a section with an effective bill date of March 1, 2020, which had been requested by the division. 4:50:25 PM The committee took a brief at-ease. 4:50:46 PM CO-CHAIR ZULKOSKY removed her objection. There being no further objection, the proposed committee substitute (CS) for HB 97, labeled 31-LS0695\M, Marx, 3/21/19 was adopted as the working draft. 4:51:05 PM REPRESENTATIVE TARR asked if the State Medical Board had concerns with the prescription of drugs by physician assistants or with other interactions with the patient. 4:51:56 PM MS. STOVERN said that the State Medical Board had issues with both subject to the collaborative plan between the supervising physician and the physician assistant. REPRESENTATIVE TARR asked if the collaborative practice was necessary for both issues. MS. STOVERN replied, yes it was correct that the physician assistant would only have authority for whatever the supervising physician allowed. 4:53:35 PM CHRISTOPHER DIETRICH, Orion Behavioral Health Network, stated that currently the PA could not establish care without a face to face examination and that the proposed bill would now allow this. 4:55:09 PM REPRESENTATIVE TARR questioned whether the requirement for the first face to face meeting was the snafu. MR. DIETRICH expressed his agreement that the proposed bill would clarify this and expedite the necessary care. 4:56:09 PM AROM EVANS, MD, Orion Behavioral Health, stated his support for proposed HB 97 and that his practice had the collaborative plan in place. [HB 97 was held over.] 4:57:48 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 4:58 p.m.