HB 281-PRESCRIPTION WITHOUT PHYSICAL EXAMINATION  4:46:25 PM CHAIR OLSON 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." [Before the committee was CSHB 281(HSS).] 4:46:32 PM REPRESENTATIVE LYNN GATTIS, as sponsor, stated that HB 281 would clarify in statute that physicians may not be sanctioned for dispensing or administering prescription medications without a physical exam of the patient. This practice is called "telemedicine" and is medical care delivered by primary care physicians, licensed within Alaska. Anyone needing medical care would be a candidate for this system. She highlighted some benefits of telemedicine for working mothers with sick kids, rural homesteaders, or employees who cannot afford to take time off from work. Under HB 281, patients could obtain over the phone or online consultations in which physicians can diagnose their ailments and provide prescriptions but stipulates that physicians cannot prescribe controlled substances. Some benefits of telemedicine include convenience for the patient and affordability, with an average cost of $40 for a consultation fee rather than an emergency room visit that could cost $1,000 or more. In fact, 25 percent of the emergency room visits are for non-emergency care, she said. 4:48:05 PM REPRESENTATIVE GATTIS related a scenario in which she personally waited at the emergency room for hours to obtain after hour care. She said her physician shared his knowledge of electronic applications for use on a smart phone and was excited to hear about her telemedicine bill. She offered her belief that it is time for telemedicine. She summarized that this bill comes down to cost and access. This bill does not replace the primary care provider (PCP) relationship; however, in requesting consultation a patient enters into a doctor/patient relationship. If a patient does not have a PCP, he/she may designate a telemedicine provider as such. She highlighted some issues previously discussed in other committees including patient privacy. 4:49:06 PM REPRESENTATIVE GATTIS said the health insurance portability and accountability act (HIPPA) privacy laws apply to telemedicine providers the same as with "brick and mortar" offices. Telemedicine already exists and is being conducted in the state by the Alaska Native Tribal Health Consortium (ANTHC) and the Veterans Administration. Additionally, companies such as Home Depot and Costco use telemedicine as part of their employee plans. This reinforces that telemedicine is needed and is being used. Typically, the usual conditions treated include acute respiratory illness, skin problems, abdominal pain, back, and joint problems. These practices can favorably impact access to care in both rural and urban settings. In fact, with 20 percent of Alaska's population residing in rural areas, it is imperative that access to routine care be as quick and economical as possible. She has held conversations in her district and many of her constituents already support telemedicine. 4:51:07 PM REPRESENTATIVE SADDLER said he did not see telemedicine specifically listed in the bill. REPRESENTATIVE GATTIS suggested that telemedicine will specifically be clarified in an amendment. REPRESENTATIVE SADDLER said that his wife works in public health and has been working in telemedicine for 12 years or longer. REPRESENTATIVE HERRON appreciated the sponsor bringing this up. He offered a belated thank you to the late U.S. Senator Ted Stevens, Alaska, who had raved about telemedicine in the tribal setting, including the benefits to mental health, dental health, and therapists. Furthermore, a pilot program in a different bill will try telemedicine between the medical examiner and regional hubs. He touted telemedicine by video as a means to provide services less expensively. He said a telemedicine connection between patient and doctor is much less expensive than using the emergency room. CHAIR OLSON answered that the Kotzebue program has been a national model and has been on the cutting edge for years. 4:53:51 PM REPRESENTATIVE MILLETT asked whether nurse practitioners will be able to use telemedicine. REPRESENTATIVE GATTIS answered no; that she followed the same guidelines as if patients walked into their doctor's offices. She explained that if a nurse practitioner works under a doctor, it would work the same way under the telemedicine model. She characterized it as being a connection between the patient and his/her provider. REPRESENTATIVE MILLETT questioned this since she is recipient of ANTHC and understands that nurse practitioners work under physicians and can prescribe antibiotics. REPRESENTATIVE GATTIS answered that the federal exemption is a little different than this model. 4:54:51 PM REPRESENTATIVE JOSEPHSON asked for clarification on how this would work. He envisioned someone picks up the telephone to obtain care. He asked whether telemedicine is a business. REPRESENTATIVE GATTIS agreed telemedicine is a business, noting that doctor's offices are also businesses. She related a scenario to illustrate that mothers would not need to take kids to the doctor's office and wait, but would simply phone the doctor and provide specific details, such as the temperature and any allergies. The doctor would assess the information provided, perhaps including reviewing a telephonically submitted photo and make a diagnosis or ask the patient to come in if the doctor believes the patient may need specialist. 4:56:49 PM REPRESENTATIVE JOSEPHSON asked whether this would be an enterprise in which a brick and mortar practitioner breaks away or if this is a "doc in the box" by phone only. 4:57:11 PM REID HARRIS, Staff, Representative Lynn Gattis, Alaska State Legislature, in response to Representative Josephson, explained that the bill will allow doctors already licensed in Alaska with a "brick and mortar" business to engage in telemedicine. However, there are some large national corporations that employ doctors within the state, without any outsourcing. Thus, the bill would allow these corporations to operate in the same way other doctors do. For example, a primary care physician could set up telemedicine with per charge fees or a doctor could contact "Teladoc" or some other telemedicine corporation and ask the it to run the doctor's telemedicine portion of the business. 4:58:12 PM REPRESENTATIVE JOSEPHSON recalled previous testimony before another committee that some medicine could be prescribed for back pain. He asked for clarification on how to avoid prescription abuse with telemedicine, noting in his law practice he encountered such cases. He suggested perhaps prescription contracts were necessary. He asked how to avoid patients calling five telemedicine practices in a day to fraudulently obtain drugs. REPRESENTATIVE GATTIS answered that this bill does not address chronic back pain, and telemedicine is limited to minor issues. She deferred to Dr. DePhillips, Teladoc, to answer more fully. CHAIR OLSON listed testifiers who have signed up for questions, including telemedicine doctors and department staff from the Department of Commerce, Community & Economic Development. REPRESENTATIVE GATTIS related that a number of people have shown an interest in the bill. She offered her belief that the practice of telemedicine needs to be clarified. 5:00:32 PM HENRY DePHILLIPS, Physician, Teladoc, answered that no Drug Enforcement Administration (DEA) controlled substances are allowed to be prescribed under the bill. Most telemedicine companies that provide services in all 50 states, including Teladoc, prohibit prescribing any DEA controlled substances including narcotics and benzodiazepines. In fact, most telemedicine drugs prescribed for primary care health tend to be for sinusitis, bronchitis, and urinary tract infections and are medicines that tend to be generic such as amoxicillin or cough suppressants, which are not prone to abuse. Although Teladoc occasionally receives requests for narcotics, once these people find they are not successful in obtaining the drugs, Teladoc typically will not hear from these people again 5:02:00 PM REPRESENTATIVE JOSEPHSON referred to a memo he saw two months ago with respect to an earlier version in the Senate for SB 80, in which the state medical board opposed the bill since it tends to redefine the practice of medicine, which has at its core the physical examination of patients. DR. DePHILLIPS provided history that he thought would best answer this. In the 1990s, Internet scams occurred and people could obtain prescriptions online without any doctors being involved. The result was that all the state medical boards enacted a "prior in-person requirement" which drove most of the Internet businesses out of business. However, 15 years later, patients can be safely connected with a physician, which is what telemedicine is all about. Several medical boards have been resistent to telemedicine for two reasons. First, the medical boards, including the Alaska State Medical Board, have been concerned about patient care going to physicians who reside outside of their state. He understood that concern; however, he advised that his company's business model calls for physicians to be located in Alaska. These doctors are residents, who are licensed in Alaska to provide care for Alaskans. That has been Teladoc's business model, thus, the bill addresses that concern. DR. DEPHILLIPS related the second concern, which is that the medical boards have expressed concern about patient safety since the boards believe that not seeing the patient in person represents an unsafe encounter. He also understood this concern. However, he said he is a board-certified family physician who has practiced medicine for ten years prior to moving to the telemedicine industry. The data does not support the concern. He said, "At least in our company's experience. We're now coming up this quarter on one-half of one million telehealth consults around the 50 states." Furthermore, Teladoc covers the liability insurance for all 50 states of network physicians and has never had a liability claim. He concluded that if you put good guard rails around the program, it will work. He outlined the elements needed for telemedicine, including using safe prescribing habits, using established clinical practice guidelines, having a strong quality assurance program, and treating common uncomplicated medical problems. He related that his company has all of this, which he suspected other telemedicine companies also have, too. 5:05:02 PM DR. DEPHILLIPS said he is testifying today because the Alaska State Medical Board has been reaching out and censuring doctors who work for telemedicine companies who prescribe medications without a prior in-person visit. He stated that Teladoc initially attempted to work with the Alaska State Medical Board, but the board would not "budge" on that issue; hence, Teladoc has turned to a legislative solution. Both Representative Gattis and Senator Dyson, as sponsors, strongly believe that telehealth will benefit Alaskans. He noted clear documentation that telemedicine will increase access, especially to those who do not currently have a primary-care physician relationship. The RAND Corporation, a non-profit organization, conducted a study independent of Teladoc that has helped to demonstrate that aspect. Certainly, it is very clear that medical costs are reduced by telemedicine since one of the frequent alternatives to a telemedicine consult is a visit to the emergency room. He offered that as telehealth consults go up for employees, emergency room costs for inappropriate emergency room visits actually are reduced over time. 5:06:12 PM REPRESENTATIVE REINBOLD asked where Teladoc is located. DR. DEPHILLIPS said that he works out of Nashville, Tennessee, and his company operates nationwide, with more than half the company serving remote areas. In response to a question, he answered that he was aware that telemedicine occurs in Alaska through the Indian Health Service, [an agency within the U.S. Department of Health and Human Services, responsible for providing federal health services to American Indians and Alaska Natives] and the U.S. Department of Veterans Affairs (VA). 5:06:44 PM REPRESENTATIVE REINBOLD said it is hard to argue with telemedicine due to the benefits and some significant cost savings and people can see the benefits. However, she has worked in the health care industry for nearly two decades. She said, "This is really alarming to me - this bill. Telemedicine cannot replace a patient/doctor interaction." REPRESENTATIVE REINBOLD noted that she did not see anything in members' packets from the [Alaska State] Medical Association, the Dental Association, or the Board of Pharmacy. The State Medical Board opposes the bill. She emphasized a need to hear from insurance companies. She expressed concern about the risks, about malpractice aspects since so much care occurs in telemedicine without any physical assessment of patients. 5:08:17 PM DR. DEPHILLIPS said the Alaska [State] Medical Association discussed telemedicine with his organization. He related his understanding that ASMA is in agreement with the terms of the bill. His company markets telemedicine as an option only when it isn't possible for patients to reach their own primary care physician timely. He emphasized this as being a very important part of the Teladoc's business model. He assured members that his company isn't interested in being the primary care physician (PCP). In addition, Teladoc has many health insurance company clients, including Aetna, who offers telemedicine coverage in many other states that have clear regulatory language to allow it. In terms of patient safety experience, the data is clear. Teladoc provides the liability insurance for several hundred doctors that provide telemedicine and his company falls in the lowest-tier of their premium profile. In the 12-year history of Teladoc, the company has not had any liability claims. Secondly, while the industry has perhaps had more consults, his company has provided nearly 500,000 consults to date. Teladoc uses evidence-based clinical practice guidelines and provides a copy of the consult to the patient's own primary care physician or to the patient's health insurance company so the insurance company care managers can reach out and "hook them up" with a primary care physician. The data is pretty compelling that telemedicine seems to be safe when it is deployed with good "boundaries and guardrails." Thus, it seems to really be additive to the medical system, he said. 5:10:45 PM REPRESENTATIVE GATTIS said that this clarifies in some ways what is already happening. In fact, some doctors want legislative sanction to clarify some existing practices. She related that she worked with the Alaska State Medical Board in crafting this bill. She pointed out HB 281 considered language suggested by the State Medical Board and employs current technology, including cell phone and application uses; however, HB 281 does not include dentistry. She felt Dr. DePhillips did a good job explaining telemedicine. The bill will clarify what some practices currently provide, relating the federal government already exempts telemedicine for the VA and [IHS]. This bill will bring that type of service to rest of Alaska. 5:12:11 PM REPRESENTATIVE MILLETT offered to explain how telemedicine has worked in Alaska for Alaska Natives. For example, a person can go to the clinic in King Cove and see a health aide who can provide a prescription that saves lives. She said the telemedicine program within the Alaska Native Tribal Health Consortium (ANTHC) has a broader scope in terms of telemedicine, including using streaming video and electronically sending information back and forth. These practices help keep sick kids healthy since a disincentive exists for those without insurance due to cost of doctor visits. One advantage of telemedicine is that [Alaskans] don't end up paying health care costs for minor issues treated in the emergency room. Instead, these Alaskans can call a telemedicine doctor to treat ailments, such as strep throat. Of course, telemedicine can't be used to treat patients with broken legs, broken ribs, or heart attacks, but it will treat many types of minor medical complaints. She asked whether this bill is modeled after IHS and VA, which provide medicine in an established way. CHAIR OLSON asked whether that was Dr. DePhillip's health model for Teladoc. DR. DEPHILLIPS answered that Representative Millett is exactly correct. Currently, physicians are residents and licensed in Alaska, taking care of Alaskans under the two aforementioned federal programs. The State Medical Board in Alaska does not want to allow this practice so some doctors are seeking a legislative solution. He stated that the reality is that HB 281 allows the same Alaska resident licensed physicians to take care of the rest of the citizens in Alaska, who are not in a federal health program in the same way that the federal health programs provide service. This bill represents "a little bit of a catch up" so all Alaskans can benefit, he said. He has been working in the health care industry for over 30 years and in his experience, if a problem arises, "heads roll" in the health care industry since medicine is high profile, high visibility, and medical liability is a huge issue. No doctor or company wants to be involved with [malpractice], patient safety must come first, and there is pretty good data to demonstrate that [telemedicine] can be done safely. 5:15:39 PM DON HABEGER, Director, Division of Corporations, Business, and Professional Licensing (DCBPL), Department of Commerce, Community, & Economic Development, stated that he is the director of DCBPL until March 29, 2014. He introduced Sara Chambers, the Operations Manager for DCBPL. 5:16:32 PM CHAIR OLSON referred to page 1, line 10, of HB 281 to "physician is located in this state" and asked whether it needs to be "licensed" physician. MR. HABEGER answered that the aforementioned language is inserted in the medical chapter surrounded by a large body of qualification licensing language. In further response to a question, agreed that at first glance he believes that a licensed physician is covered. 5:17:32 PM REPRESENTATIVE SADDLER said he did not see "telemedicine" explicitly mentioned. He did not see how making a little change in the sanction's section of law does all the things that have been represented for telemedicine. He asked whether this is the only thing in the way of widespread practice of telemedicine. MR. HABEGER offered to put it in context of what the [Alaska State Medical] board currently does and the approach it takes. He said the board would argue it currently offers telemedicine; however, the board also strongly believes that the patient-to- patient contact is very important. Within the IHS model, a physician is on one end of the line and a health aide is at the other. The difference is that the health aide is knowledgeable about medicine and can observe the patient from a medical perspective. Under the bill if a health aide is not present, the board cannot sanction a licensee to prescribe drugs. 5:19:07 PM REPRESENTATIVE SADDLER asked whether other large sections of law envision telemedicine. He reiterated that he is surprised the "one little fix" would make such a big change in the practice of medicine in Alaska. MR. HABEGER explained that within the context of licensure, the qualifications and the medical examination process for licensure is quite extensive. He said that the [Alaska] State Medical board oversees licensure and the agency just does the processing. He said HB 281 provides a prohibition against bringing sanction [against a doctor] for a telemedicine contact. He reiterated that telemedicine contacts already exist and this change in law simply means that a health aide isn't required to be present at one end. He did not envision a huge expansion under the bill. REPRESENTATIVE SADDLER commented that it might just be that he is missing something. 5:20:33 PM REPRESENTATIVE JOSEPHSON said he is curious that this practice already exists. He related a scenario in which a physician in Anchorage prescribes drugs, in which the process would be that the patient calls and describes the symptoms and obtains a prescription. He related that in his own experience, as a patient, that he has never called a doctor unknown to him to obtain a prescription. He asked whether that type of activity is currently occurring in Alaska. MR. HABEGER said he would withdraw the term "already existing" although telephonic diagnosis does exist. He emphasized that the key is that the board allows a health aid or other practitioner [to prescribe medicine without the patient or physician being present]. In response to a question, he agreed that currently, any health care professional, such as a certified nurse aide (CNA), who has some training [consults with the physician telephonically about the patient and prescribes medicine to treat the patient.] 5:22:05 PM REPRESENTATIVE JOSEPHSON asked what he thinks of the State Medical Board's position that "we don't like this" when the Alaska State Medical Association says it is okay. MR. HABEGER referred to earlier comments on the State Medical Board's objection to SB 80. He said the original version of that bill included licensure of out-of-state doctors. When the board met they were soundly against that version. He recalled that the companion bill [SB 80] was later amended. He was not sure [of the board's position on the amended version of SB 80.] 5:23:07 PM REPRESENTATIVE JOSEPHSON referred to an email of January 28, 2014, from Deborah Stovern, Executive Director, State Medical Board, that also indicates that the board was concerned about the lack of contact [by the physician]. He recalled Representative Millett's reference to strep throat, noting that it would require a culture to diagnose strep throat. He further recalled when he lived in Kalskag that he had met with a [health care] aide in a cabin who performed a strep culture, presumably calling a doctor in Bethel [to consult]. He characterized it as being "bookends" or a "virtual" contact. He asked how this bill would allow for a culture. MR. HABEGER said he can't answer that. REPRESENTATIVE MILLETT offered her belief that it could happen via an application for an iPhone. 5:24:55 PM ROBERT LAWRENCE, Physician, Chief Medical Officer, Inmate Health Care, Department of Corrections (DOC), stated that prior to his state work he served the Norton Sound Health Corporation as a family physician and subsequently became the owner and cofounder of a small medical company that used and tested the technology that is before the committee today. LAURA BROOKS, M.S., Health Care Administrator, Department of Corrections, thanked the committee and the sponsor for working with the DOC. She indicated some wording [in the bill] could potentially impact the way the DOC practices every day. 5:25:27 PM MS. BROOKS explained that the DOC was one of the first agencies to start using telemedicine in order to provide improved medical services to inmates in rural areas. She explained that in 1998 the DOC's psychiatrists began using telemedicine. This practice has allowed the DOC to reduce costs since the psychiatrists had previously been traveling to remote areas several times per month. Now these doctors can provide medical care to inmates via telemedicine, which is more efficient and cost effective. MS. BROOKS expressed concern on the wording related to controlled substances, which may adversely impact the department in two areas. First, currently a psychiatrist might prescribe a controlled substance for new arrests, who currently take medication, or experience a mental health crisis. Currently, this is done via the telemedicine system, which allows the department to provide safe and immediate interventions for mental health crises. Secondly, the DOC is a 24-hour provider. In addition to telepsychiatry, the department has physicians, nurse practitioners, and physician's assistants who are on call telephonically for all DOC medical clinics and facilities, including half-way houses and community jails. Prescribing controlled substances is common for DOC providers, in particular, for those who experience withdrawal symptoms. She indicated that some intoxicated people are arrested after hours and the department doesn't have any providers on site. She estimated 3,000 prescriptions per year for detox protocols for controlled substances are made by telephone by these providers. Since telemedicine has improved the department's ability to provide services to the DOC's clientele, the department has concerns about how that section of HB 281 would impact them. 5:28:10 PM DR. LAWRENCE outlined two different forms of telemedicine. Telemedicine has long been offered in Alaska, initially as a provider-to-provider communication. For example, if a physician needed a consultant, the physician might use a telemedicine consult to obtain an answer. This bill seems to relate to the second form of telemedicine, which is a direct patient-to- provider consultation. He clarified that the department engages in the first type of telemedicine. He related a scenario to illustrate how telephonic communications have been used in rural areas, such as in Nome to treat someone who was arrested but began experiencing alcohol withdrawal, which could lead to a deadly condition of delirium tremens (DTs). In those instances the treatment is to prescribe a benzodiazepine that can prevent seizures or else the inmate must be taken to the emergency room. Thus, an unintentional consequence of HB 281 will prevent him from prescribing a controlled substance using telemedicine since he could be sanctioned by the board. He said the language needs to be clarified to address the current practices. CHAIR OLSON indicated Dr. Lawrence is working with the sponsor and his office to address those issues. 5:30:06 PM REPRESENTATIVE MILLETT asked whether the DOC could be exempted from the bill. DR. LAWRENCE answered that would be one viable option. 5:30:23 PM REPRESENTATIVE MILLETT asked whether any other state agencies perform similar functions. DR. LAWRENCE answered that in Alaska other organizations have the same model, for example, ANTHC is the other group that uses the same model and often experiences the same scenarios although the patient population may be different. CHAIR OLSON offered to keep the public testimony open. [HB 281 was held over.]