HB 123-DISCLOSURE OF HEALTH CARE COSTS  2:04:48 PM CHAIR CLAMAN announced that the final order of business would be HOUSE BILL NO. 123, "An Act relating to disclosure of health care services and price information; and providing for an effective date." [Before the committee was CSHB 123, Version D.] 2:05:27 PM REPRESENTATIVE KREISS-TOMKINS requested that Amendment 1 be moved to the bottom of the amendments stack because he recently received "fresh data" he would like to circulate amongst the committee members and the bill sponsor. 2:05:48 PM REPRESENTATIVE REINBOLD moved to adopt Amendment 2, Version 30- LS0380\I.3, which read as follows: Page 3, line 18, following "municipal,": Insert "federal," Page 3, line 24: Delete ""health care facility" does not include" Page 3, line 25, through page 4, line 3: Delete all material. REPRESENTATIVE FANSLER objected. 2:06:16 PM REPRESENTATIVE REINBOLD noted that during her discussion with the sponsor she mentioned this amendment and the sponsor did not offer opposition. This amendment, she explained, removes the federal exemption and keeps everyone on the same page. 2:06:41 PM The committee took a brief at-ease. 2:09:13 PM CHAIR CLAMAN noted that the initial question of Representative Reinbold was whether the bill sponsor supported or did not support Amendment 2. 2:09:51 PM REPRESENTATIVE IVY SPONHOLTZ, Alaska State Legislature, said she does not support Amendment 2 because it is in conflict with the Supremacy Clause of the United States Constitution [Article VI, Clause 2], which read as follows: This Constitution, and the laws of the United States which shall be made in pursuance thereof; and all treaties made, or which shall be made, under the authority of the United States, shall be the supreme law of the land; and the judges in every state shall be bound thereby, anything in the Constitution or laws of any State to the contrary notwithstanding. REPRESENTATIVE SPOHNHOLZ continued that there is not a bright line separating government institutions from private institutions in this bill, but rather it separates out federally funded organizations. She opined it would put the state in the position of defending costly lawsuits which is not in the best interests of the state. 2:10:48 PM REPRESENTATIVE REINBOLD said that her impression, during their discussion on this bill, was that Representative Spohnholz did not have any strong feelings one way or another. She stressed that federal dollars are private tax dollars; therefore, the private sector dollars would fund public facilities, and this amendment eliminates exemptions for public facilities funded by private dollars. Also, she commented, sometimes with state facilities there are matches, such as Medicaid dollars, which is also the peoples' money. She opined that, at a minimum, it is only fair that public facilities be on the same playing field as the private sector. 2:12:12 PM REPRESENTATIVE LEDOUX related that she understands page 3, line 18, and inserting federal, but she doesn't follow when it comes to [Section 1, AS 18.15.360(h)], page 3, lines 24-25, and page 4, lines 1-3, which read as follows: (A) the Alaska Pioneers' Home and the Alaska Veterans' Home administered by the department under AS 47.55; (B) an assisted living home as defined in AS 47.33.l990; (C) a nursing facility licensed by the department to provide long-term care; (D) a facility operated by an Alaska tribal health organization; and (E) a hospital operated by the United States Department of Veterans Affairs or the United States Department of Defense, or any other federally operated hospital or institution; REPRESENTATIVE LEDOUX asked how a nursing facility licensed by the department to provide long-term care would be federal. 2:12:59 PM REPRESENTATIVE SPOHNHOLZ answered "that it is not," and clarified that she was speaking to the first section of which inserts "federal." The second section would delete out the Pioneers' Homes, Veterans' Homes, assisted living homes, and nursing facilities, in particular. She said she chose not to include those facilities because everyone living in those facilities knew exactly what their stay would cost, no one goes into a long term care facility or the Pioneers' Home without knowing the exact daily cost. Therefore, having it posted on the wall was not additional information. In the case of the tribal health organizations and subparagraph (E), it was her understanding that the tribal health organizations were largely federally funded, and she actually received verbal feedback that a lawsuit would probably ensue because it viewed itself as part of a federal entity. She said she chose not to take that on because her primary focus was on the individual marketplace and having the most opportunity to make a big difference. 2:15:04 PM REPRESENTATIVE LEDOUX referred to a nursing facility licensed by the department to provide long term care, and opined that with some of these facilities possibly basic "stuff" was provided, but there's the "other stuff" that's provided upon request for necessity. She said she was thinking of her folks in California, when her father broke his hip he went into a long term care facility and was billed for specific services. It wasn't just that he had to pay "X" amount of dollars in order to enter the place, and she asked how the facilities are run in Alaska. REPRESENTATIVE SPOHNHOLZ opined that the facilities tend to be that the patient pays for the level of care they need, there may be some individual distinctions, but the pricing tends to be based on the level of care for the patient. She explained there are different pricings for different levels of care, and generally speaking, the patient knows the cost, and their bill doesn't change dramatically from one month to another, unless there was a major medical event. She explained that she was not discussing that level of care, but rather care such as, routine and/or elective care when going to the traditional health care provider. It was her intent, she said, to focus in on that routine and/or elective care, of which makes up the bulk of the particular kind of marketplace this bill could influence. 2:18:06 PM REPRESENTATIVE KOPP referred to Amendment 2 and inserting the word "federal," and noted that any person or provider eligible under the federally funded Indian Health Service program does not compete in the marketplace with respect to price transparency. Also, with respect to the word "federal," how would this impact military hospitals, such as the hospital on Joint Base Elmendorf-Richardson (JBER). He said he was not familiar with how TRICARE works currently, and opined that with the intent being marketplace transparency he was unsure how it aligned with a military hospital posting a price disclosure. 2:19:26 PM REPRESENTATIVE SPOHNHOLZ remarked that they were discussing two distinct elements when talking about this one specific population served through TRICARE, the Veterans Affairs, or the United States Department of Defense (DoD) delivered health care services. In the case of the federal facilities operated on bases, or just outside of the military bases in the case of the Department of Veterans Affairs, those are excluded on page 4, lines 1-3, [subparagraph (E)], which read as follows: (E) a hospital operated by the United States Department of Veterans Affairs or the United States Department of Defense, or any other federally operated hospital or institution; REPRESENTATIVE SPOHNHOLZ pointed out that those were treated as separate because they are federal institutions. Although, in the event a veteran with TRICARE received approval for some sort of care outside of the military system and visited a private provider in the marketplace, the veteran should be able to see that information. TRICARE can be used within the private market, with some restrictions outside of military installations, but she said she did not know all of the details. 2:20:51 PM REPRESENTATIVE KOPP referred to Amendment 2, page 1, lines 4-5, deleting subparagraphs (D) and (E), and asked whether there would be a problem leaving subparagraphs (A), (B), and (C). REPRESENTATIVE SPOHNHOLZ advised that the way the bill was drafted was actually the inverse because ... REPRESENTATIVE KOPP clarified that he asked the question backwards. REPRESENTATIVE SPOHNHOLZ responded that she did not object to his suggestion, although she did not believe anyone moves into an assisted living home without first receiving the exact cost, how they are charged for services, and how the services will be paid. Therefore, she remarked, the need for transparency was not the same when compared to the needs at the Pioneers' Home or an assisted living home, and walking into an emergency room at the hospital and considering an MRI, or to the local doctor for additional bloodwork. 2:23:01 PM CHAIR CLAMAN explained that when his family had to determine which assisted living community center would be best for his parents, his siblings talked to approximately four and six different assisted living centers, and they knew the exact price for each center. 2:23:54 PM REPRESENTATIVE EASTMAN referred to federal jurisdiction and opined that it made sense for the Department of Veterans Affairs to determine what goes on in its facilities, and to keep those standards consistent state-to-state. Which, he commented, is different from the federal medical facilities not competing with the private sector in the marketplace because they absolutely do compete in this state. For example, he said, the Alaska Native Medical Center (ANMC) provides treatment for federally eligible beneficiaries and also any number of different people. It is the only hospital in Anchorage with the ability to serve multiple trauma cases simultaneously, and it can compete with other aspects of the private sector. He offered concern with the idea that transparency was needed for all of the various facilities covered under this bill because transparency was already working well, such as with a senior center. He said he hoped for consistency and equity in applying these requirements to everyone in Alaska, and if the legislature made the requirement to post prices, that requirement should be made for everyone regardless of the facility. In the event the word "federal" was not inserted at line 18, he said, there would be no need for any of the federal references in subparagraphs (D) or (E. 2:31:21 PM REPRESENTATIVE FANSLER related that he could see a difference between subparagraphs (A), (B), and (C), and what this bill was attempting to provide in that he could not walk into an assisted living facility and have his broken arm examined unless he lived there. The bill encourages transparency in the situation of an elective surgery and the patient would know where they would want to go based on that transparency. As for subparagraphs (D) and (C), he could see their complete difference, obviously, with the Supremacy Clause. Perhaps, he suggested, when facilities are required to post fees, if the federal facilities suddenly were no longer taking in the patients they once did because it didn't have that transparency, he pointed out, that chances are that the free market would pull them into the transparency on its own. 2:33:10 PM REPRESENTATIVE REINBOLD offered that she was open to a friendly amendment, but in reviewing the Supremacy Clause she would like the Department of Law to weigh in. She opined that the Supremacy Clause had nothing to do with this and that it was an overuse of that clause. However, she said she would go to the United States Constitution, Amendment IX and X, which read as follows: Amendment IX The enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people. Amendment X The powers not delegated to the United States by the Constitution, nor prohibited by it to the states, are reserved to the states respectively, or to the people. REPRESENTATIVE REINBOLD asked whether it was the sponsor's intention that the private sector be required to publically post their CPT codes and fees, while the public sector, using private sector dollars, would not be required to post those codes and fees. 2:34:23 PM REPRESENTATIVE SPOHNHOLZ pointed out that page 3, lines 18-24, read as follows: (2) "health care facility" means private, municipal, or state hospital, psychiatric hospital, independent diagnostic testing facility, residential psychiatric treatment center ... REPRESENTATIVE SPOHNHOLZ continued that it is a long list, several of which include public entities. She pointed out that she had said several times that the distinction was not between public and private institutions. She reiterated that the only entities carved out, specifically due to the Supremacy Clause, are federal in nature, and she stressed that was the only distinction. REPRESENTATIVE REINBOLD asked that the Department of Law weigh in on the Supremacy Clause because she believed it was a misuse of the Supremacy Clause. 2:35:09 PM REPRESENTATIVE LEDOUX pointed out that she did not pretend to be an expert in the Supremacy Clause, but there is a long line of judicial precedent stating that the state can't make the federal government do things. For example, she said, the state cannot tax the federal government, and while the states do not always have to adhere to what the federal government tells them what to do, the state cannot make the federal government do things. 2:35:53 PM CHAIR CLAMAN commented that he completely agrees with Representative LeDoux about the Supremacy Clause, and as he offered during the last hearing, he intends to move this bill out of committee today. He pointed out that the question of the Supremacy Clause came up during the last hearing on this bill and Representative Reinbold could have followed up with the Department of Law or Legislative Legal and Research Services before today. He stated that there was no reason to call Legislative Legal and Research Services during this hearing because the courts have consistently ruled, again and again, exactly as Representative LeDoux described. REPRESENTATIVE REINBOLD argued that it is important for the Department of Law or Legislative Legal and Research Services to weigh in on the Supremacy Clause, and the committee needs to discuss the Constitution of the United States, Amendments IX and X. She then described herself as a federalist "and I do believe that the -- the rights that are not absolutely specifically ... and I see nothing in the constitution that says that -- that they can't, you know, post, or they shouldn't be transparent with -- with public dollars. It just -- it just seems to me outlandish to be using that Supremacy Clause in this case." She said the committee needs [this bill] to be on a fair playing field. 2:38:27 PM A roll call vote was taken. Representatives Eastman and Reinbold voted in favor of adopting Amendment 2. Representatives Fansler, Kopp, Kreiss-Tomkins, LeDoux, and Claman voted against it. Therefore, Amendment 2 failed to be adopted by a vote of 2-5. 2:39:07 PM REPRESENTATIVE REINBOLD moved to adopt Amendment 3, Version 30- LS0380\I.4, which read as follows: Page 1, line 1, following "information;": Insert "relating to health care insurers;" Page 2, line 1, following "AS 18.23.400": Insert "and AS 21.96.125" Page 4, following line 21: Insert a new bill section to read: "* Sec. 3. AS 21.96 is amended by adding a new section to read: Sec. 21.96.125. Disclosure of health care  services and price information by health care  insurers. (a) A health care insurer shall annually (1) compile a list describing, by procedure code, including a brief description in plain language that an individual with no medical training can understand, the 50 most common health care services covered by the insurer in this state in the previous calendar year and the total cost to the insurer for each of those health care services during that period; (2) publish and update the list on the insurer's Internet website by January 31 each year; and (3) submit the list by January 31 each year to the Department of Health and Social Services for entry in the database under AS 18.15.360(a). (b) The Department of Commerce, Community, and Economic Development may adopt regulations under AS 44.62 (Administrative Procedure Act) to implement this section. (c) A health care insurer that fails to comply with the requirements of this section is liable for a civil penalty. The Department of Health and Social Services may impose a civil penalty of not more than $150 for each day after March 31 that a health care insurer fails to provide and post information as required under (a) of this section. The total penalty may not exceed $2,500. A person penalized under this subsection is entitled to a hearing conducted by the office of administrative hearings under AS 44.64. (d) In this section, (1) "health care insurer" has the meaning given in AS 21.54.500; (2) "health care service" has the meaning given in AS 18.23.400; (3) "insured" means an individual covered by a health care insurance policy." Renumber the following bill section accordingly. REPRESENTATIVE FANSLER objected 2:39:25 PM REPRESENTATIVE REINBOLD explained that Amendment 3, requires a posting of the prices paid by the insurance companies. 2:39:52 PM REPRESENTATIVE SPOHNHOLZ offered that while she appreciates the intent of expanding price transparency, unfortunately, in looking at Amendment 3, she could not support it at this time. She noted that lines 15-16 ask for the total cost to the insurer for each of those health care services during that period, and she was unsure what that meant because there are a variety of definitions of health care costs are out there. She asked whether Amendment 3 referenced the total amount they've paid out, in which case that would be getting into a totally different issue than under HB 123, because it is about informing consumer price transparency. She noted that it could also mean what the insurers are paying to different providers, and that would vary depending upon whether or not that providers was within a preferred provider network or out of the provider network. She related that a lot of time was spent in determining how to have a clean, clear bill that was understandable by the end user, and Amendment 3 muddies the water. 2:41:20 PM REPRESENTATIVE LEDOUX asked Representative Reinbold to explain Amendment 3 because she was unsure whether the amendment was so doctors could see what the insurance companies were going to pay, or whether the consumer would see what the insurance company pays. REPRESENTATIVE REINBOLD explained that doctors will post their rack rate fee, the CPT codes, except doctors receive different reimbursements from insurers for their different types of insurance patients. Unfortunately, she said, patient's will "freak out" over the posted charge, not understanding that is not the amount the doctor is actually reimbursed, and it becomes more complicated under managed care. For example, while working in a doctor's business office in Texas, the office was only allowed to charge $400 and the rack rate fee may have been $10,000 because it had negotiated a low price. The amendment allows that the reimbursable price the insurance companies pay be transparent, she said. 2:43:50 PM REPRESENTATIVE LEDOUX offered that while she was sympathetic to what this amendment was trying to do, but was complicated in its manner because around here things are sometimes accomplished through baby steps. She remarked that she will not support this amendment because, in the context of this bill, it would not work. 2:44:51 PM REPRESENTATIVE EASTMAN referred to page 2, line 3, wherein the fine appears to have tripled and asked why it went from $50 per day to $150 per day. REPRESENTATIVE REINBOLD noted that she had not requested that language and asked that the drafter explain the difference. 2:45:28 PM REPRESENTATIVE SPOHNHOLZ pointed out that this amendment requires the health care insurer to post information allowing patients to see what the insurer would charge for the service. In that manner, a person would have to review the doctor's rack rates and then review their insurer's website to determine what the insurer would pay. Essentially, she related, her source at the Department of Health and Social Services advised that an all payor claims database would be required to mesh this amendment with the bill. 2:46:49 PM REPRESENTATIVE REINBOLD advised that her intention is to include insurers because the third party insurance company pays the bills. She commented that the amendment is fair if the goal is to get true transparency and make this a consumer friendly bill. 2:48:26 PM REPRESENTATIVE EASTMAN commented that Amendments 1 and 3 appear to be going in the same direction, yet applying different language to get there. CHAIR CLAMAN interjected that Amendment 1 has nothing to do with information from insurance carriers, and Amendment 3 is all about information from insurance carriers. He pointed out that Representative Eastman cannot claim they address the same issue as they are completely different. REPRESENTATIVE EASTMAN opined that they do, and that obtaining information from insurers appears to be a fairly important part of this whole equation. He related that when he visits a doctor's office, that office queries his insurance company for information and relays that information to him. He said, "I work with them on whether or not I'm gonna actually contract with them for the services." His concern with the bill, unamended, is that it runs into the "bridge too far problem." He explained that there was an idea to go straight from Britain to Berlin, during World War II, by way of several bridges. Unfortunately, the forces were unable to reach the last bridge, and; therefore, the whole idea and effort crumbled because they never got there. He related that if the legislature doesn't actually get to the point of an Alaska resident receiving helpful information, then it appears like a lot of effort and it doesn't get the legislature where it needs to be. 2:50:50 PM REPRESENTATIVE KOPP suggested that this amendment raises questions in that the health care insurance market negotiates rates for procedures individually with health care facilities and employers. Certainly, he commented, those rates are different depending upon volume, how well the health care program is managed, history with the insurer, and a host of issues. He suggested getting an insurance expert online and ask whether the legislature can do this because it will get into market proprietary information between insurance companies. Also, he said, possibly the committee would be interfering with insurers as to the market by requiring them to disclose their negotiated rates for a whole host of entities, such as health care facilities or employers. 2:52:24 PM CHAIR CLAMAN commented that the House Health and Social Services Standing Committee heard this bill and the insurance companies said little, but they did say there were significant privacy issues between commercial relationships, the insurance companies, and their insured. He commented that he recognizes the sponsor's intent for more transparency as to health care costs and insurance costs, and rather than try to globally fix everything, the sponsor prefers to take baby steps toward improved transparency. He related that the [amendment] requires Premera, Blue Cross Blue Shield of Alaska to voice how much it paid in the state last year for all of the completed blood counts, and to give a total number. He suggested this amendment asks that, instead of letting the consumer know the average price for a complete blood count paid by insurance company "X," it would provide the total number of the many hundreds of thousands of people they provide insurance for, and the consumer would not be helped. CHAIR CLAMAN advised that Ms. Glover was online regarding the $150 penalty. He said he believes the committee could agree to change the figure to $50 consistent with the bill, and treat it as an informal amendment. 2:55:50 PM CHAIR CLAMAN asked the committee to agree that on page 2, line 3, delete "$150" and insert "$50." There being no objection, the informal amendment was adopted. 2:56:28 PM REPRESENTATIVE REINBOLD opined that Chair Claman said something about insurance companies not wanting to disclose their information due to it being proprietary information, even though a lot of doctors don't want to do that either due to sticker shock. She commented that people believe the rate posted is the amount the doctor receives and it turns the patient against the doctor. Unfortunately, she said, the patient doesn't know their doctor has far more specialties, went through 10-20 more years of schooling with loans, or that the doctor may take a Medicare patient and only receive 10 percent of the rack rate posted. She argued that if the legislature doesn't require government facilities to meet the same standards as the private sector, they don't have to comply. The fact that these doctors may post a $500 fee, they may only receive $50 for their service because the insurance company negotiated a deal where it racks in hundreds of millions of dollars and takes no risk. Yet, she pointed out, it is the doctors seeing the patients, the doctors have the insurance, the doctors have to deal with the follow up, and now the insurance companies "get scot-free clean." She stressed that it would be completely misguided if the insurance companies were not included in this bill. 2:58:59 PM A roll call vote was taken. Representatives Eastman, Reinbold, Kopp voted in favor of adopting Amendment 3. Representatives LeDoux, Fansler, Kreiss-Tomkins, and Claman voted against it. Therefore, Amendment 3 failed to be adopted by a vote of 3-4. 2:59:31 PM REPRESENTATIVE REINBOLD moved to adopt Amendment 4, Version 30- LS0380\I.5, which read as follows: Page 2, line 11, following "charged": Insert "and the amount the provider actually received" Page 2, line 16, following "charged": Insert "and the amount the provider actually received" REPRESENTATIVE FANSLER objected. 2:59:35 PM REPRESENTATIVE REINBOLD referred to her comments regarding a posted fee of $500, and explained that the doctor may only receive $50 or write off the entire fee, and Amendment 4 requires "the amount the provider actually received" because that information is important for the patients. Some patients may believe their doctors are millionaires, not knowing they may have extensive education loans, and insurance costs to pay. She related that the insurance companies treat doctors "horrendously," the sticker shock can be high, and the amendment requires the amount the providers actually received for their services to be posted. 3:00:52 PM REPRESENTATIVE EASTMAN commented that Amendment 4 moves the committee closer to actual transparency by requiring all doctors to post the actual amount they receive from the insurer, thereby allowing an even playing field. 3:02:34 PM REPRESENTATIVE LEDOUX said she was sympathetic to what this amendment was trying to do, but if the committee was really concerned about the impact on the private sector, she was hesitant to ask doctors to post the amount they actually receive from insurers, Medicaid, Medicare, or workers' compensation insurance. In response to Representative Eastman's argument that doctors certainly have the opportunity to explain their rack rates during the patient's visit, she pointed out that there is nothing in the bill prohibiting physicians from posting all of those rates. 3:03:59 PM REPRESENTATIVE KREISS-TOMKINS noted that Amendments 3 and 4, appear to approach health care price transparency from the insurance side of the equation, as opposed to the provider side, and agreed that it was important to approach it in both directions. Amendment 4 is elegant in its simplicity, he described, but the element he struggles with was what Represented LeDoux pointed out, that different insurers have different rates and no one has any idea how much anything costs. He commented that he was unsure this bill was the correct vehicle because it was more of a provider based bill. He then read the language in the amendment "and the amount the provider actually received," and asked how Representative Reinbold saw that being implemented and practiced. REPRESENTATIVE REINBOLD responded that if this was a provider based bill, because most providers hate this bill, and it will make patients "freak out" at the sticker shock. In response to Representative LeDoux comment that nothing prohibits the doctor from discussing their rates, she answered that some doctors may not want to tell their patients they receive $50 for a Medicare patient, $55 for a veteran, and $200 for a lawyer. She opined that doctors want to discuss the patient's medical and emotional issues, and not get into this "price fixing, this anti-trust, this movement toward -- I think this is a much bigger issue, like with stark laws and anti-trust laws, and all sorts of other things." She said she believes that even with this amendment, "it's none of our business." 3:07:52 PM REPRESENTATIVE EASTMAN surmised that, currently the bill states the discounted price charged, and this amendment would then add the amount the provider received, and commented that he hoped the committee was not worried about having too much transparency. There is a medical facility in his district with a history of "being on the high side," but with that information available it would give patients the opportunity to ask why the prices are high. He described the bill as helpful in starting conversations so that 10 years from now the population would not be looking at the same problem. 3:09:41 PM REPRESENTATIVE KOPP commented that a couple of years ago he threw his lower back out, and the chiropractor advised it would be $80 if he self-paid, or $260 would be billed to the insurance company. He commented that Amendment 4 gets right at this issue because if the committee was really looking at transparency in the marketplace, at some point it must be recognized there is a business relationship, which is not inherently evil or nefarious, with third party payor insurance companies. Currently, patients are not directly paying physicians, and if the goal is transparency without including the insurer in any manner, it does make it harder to get there, he commented. While realizing Amendment 4 was problematic, he said he would support the amendment. REPRESENTATIVE REINBOLD commented that she would stick with Representative Kopp's good comments. 3:11:40 PM REPRESENTATIVE FANSLER maintained his objection. 3:11:47 PM A roll call vote was taken. Representatives Eastman, Reinbold, and Kopp voted in favor of adopting Amendment 4. Representatives Kreiss-Tomkins, LeDoux, Fansler, and Claman voted against it. Therefore, Amendment 4 failed to be adopted by a vote of 3-4. 3:12:46 PM REPRESENTATIVE KREISS-TOMKINS withdrew Amendment 1, labeled 30- LS0380\I.2 [prior to offering a motion to adopt the amendment]. REPRESENTATIVE KREISS-TOMKINS commented that after reviewing actual CPT codes in a facility realized that many of the CPT codes are diagnostic and testing in nature and that none of the "meat and potatoes" procedures the committee was interested in actually made the top 50 CPT codes. After reviewing a workers' compensation medical fee schedule which included all of the meat and potatoes procedures, such as MRIs, X-rays, stitches for a laceration, he drafted an amendment to maintain the simplicity of the bill and integrates all of that information The Alaska State Hospital and Nursing Association (ASHNA) worked closely with his office to provide a list of the top 10 grossing procedures at a sample facility, and from a different facility, and there was 100 percent overlap between the top 10 grossing procedures and the top 50 most common procedures. Therefore, Amendment 1 is redundant; however, he opined, the way to get there is using NTCI data which comes from workers' compensation. It listed the 10 top grossing procedures within different AMA service categories, and the four largest AMA service categories in health care include: surgery at 31 percent of all health care costs; physical medicine at 29 percent; evaluation and management at 16 percent; and radiology at 13 percent. Those four AMA service areas account for the preponderance of medical costs. He summarized that today is not the day, but he felt it was important to put on the record that possibly there is a way to get at the meat and potatoes procedures while still working within the parameters of the simplicity in this legislation. 3:15:59 PM CHAIR CLAMAN advised that the bill was back before the committee with no amendments attached, and asked for further comments or discussion. 3:16:12 PM REPRESENTATIVE EASTMAN said that Representative Kreiss-Tomkins solution was not before the committee, and he could not support the bill. In determining how to get from "where we are" to a more transparent system and possibly more economical pricing in dealing with the cost of delivering health care, he said this bill "gets us somewhere" but was unsure whether it moves the state closer to where it wants to be and was possibly pulling the committee farther away. The bill imposes more government regulations, institutes the threat of fines on health care facilities, and the problem of the disparity between what is expected of the state's facilities and state departments and what is being asked of the private sector hasn't been solved. For example, the sponsor made an effective date of HB 123 at January 1, and on that date the requirements would be instituted for health care facilities with total penalties not to exceed $2,500, but the fiscal note has a department that will not have the regulations in place for it to uphold its end of the bargain until July 1, 2019. He said he will vote against the bill. 3:19:44 PM REPRESENTATIVE REINBOLD offered that the bill is coming from a "fabulous place," but her philosophy is that this will have some negative unintended consequences in patients against their doctors due to fees. She described it as a double standard when asking the private sector to post fees without requiring public facilities to also post fees, and that the is being missed if the bill doesn't include insurance companies, which are the key third party payor, as part of this government solution. She referred to the Constitution of the State of Alaska, Article 1, Section 22, and commented, "It is the legislature's job to not infringe on privacy of our citizens" and this may be on the verge of that infringement. 3:23:22 PM REPRESENTATIVE FANSLER moved to report CSHB 123(HSSS), Version 30-LS0380\I, out of committee with individual recommendations and the accompanying fiscal notes. REPRESENTATIVE EASTMAN objected. 3:23:35 PM A roll call vote was taken. Representatives Kopp, Kreiss- Tomkins, LeDoux, Fansler, and Claman voted in favor of CSHB 123. Representatives Eastman and Reinbold voted against it. Therefore, CSHB 123(HSS) was reported out of the House Judiciary Standing Committee by a vote of 5-2.