HB 281-PRESCRIPTION WITHOUT PHYSICAL EXAMINATION  4:02:29 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)]. 4:02:39 PM REPRESENTATIVE LYNN GATTIS, Alaska State Legislature, stated that HB 281 clarifies in statute that physicians cannot be sanctioned for dispensing or administering prescription medications without conducting a physical exam of the patient if some basic stipulations are met in a practice called telemedicine. Under HB 281, care would be delivered by primary care physicians licensed in Alaska, and patients would be able to obtain over the phone or on-line consultations in which physicians can diagnose an ailment and if necessary, prescribe prescription medicine; however, physicians could not prescribe controlled substances. At the last hearing, a concern was raised about overprescribing. She reported that her information shows that the national average prescribing rate for common uncomplicated diagnoses is 82 percent in the "brick and mortar" setting, and 77 percent in the telehealth setting, per Teladoc's 156,000 consultations. The efficient quality of the system comes down to cost and access for the average citizen. These practices can have favorable impacts because of access to care for individuals living in rural and urban settings. 4:04:32 PM CHAIR OLSON reported that his office received concerns from the Department of Corrections (DOC). He anticipated a forthcoming amendment that will be considered at a later hearing. LAURA BROOKS, Health Care Administrator, Office of the Commissioner, Department of Corrections, introduced herself. 4:05:39 PM The committee took an at-ease from 4:05 to 4:21 p.m. due to audio issues. 4:21:17 PM ROBERT LAWRENCE, Doctor; Chief Medical Officer; Inmate Health, Department of Corrections, with respect to DOC, discussed different forms of telemedicine. One type of telemedicine that has been practiced in the state involves provider-to-provider communications, in which a nurse contacts a physician and orders are given over the phone or via Internet. A second type of telemedicine involves direct patient to medical provider communication, specifically when a patient has a preexisting relationship with the provider; however, this bill introduces a new form of telemedicine to the state, in which a patient is allowed to contact a medical provider without having a preexisting doctor-to-patient relationship. DR. LAWRENCE said DOC's concern is that the HB 281 inadvertently hampers the department's ability to provide services in rural Alaska using telemedicine in ways that are already approved by the medical board, specifically in terms of controlled substances. For example, a physician in the DOC often will be called for a prescription involving a controlled substance for a patient in a remote DOC facility. The department needs to retain the ability to give the prescriptions at a distance instead of sending the inmates to an emergency room or to ask other providers to be available. Secondly, the department is affected by the requirement on page 2 that the physician must be physically located in the state in order to render care over the phone or by other means. Those are the two primary concerns, he said, and he understood the sponsor is working to accommodate those. He appreciated working with the sponsor on these issues. CHAIR OLSON acknowledged that the committee is working with the sponsor and DOC on the aforementioned changes to the bill. 4:24:55 PM KATE BURKHART, Executive Director, Alaska Mental Health Board, Department of Health and Social Services (DHSS), stated the Alaska Mental Health Board (AMHB) is the state planning council for issues related to mental health. She said the board has reviewed the bill and appreciates the sponsor's support for telemedicine. She recalled earlier testimony about the types and forms of telemedicine in the state. The AMHB acknowledged that while the bill doesn't speak directly to tele-psychiatry, it was important to place on the record how tele-psychiatry works and its importance to patients. MS. BURKHART explained that tele-psychiatry in the publically- funded behavioral health system is integral to mental health services. In many communities, the ability to recruit and retain psychiatrists is hampered by geography and compensation. She reported the current vacancy rate for psychiatrists is almost 25 percent and many communities wait years to find a psychiatrist. Community behavioral health centers and federally qualified health centers that offer mental health services often contract with psychiatrists who are licensed psychiatrists in Washington but often practice in the Pacific Northwest. In addition, psychiatrists from the University of Washington and Children's Hospital are frequently contracted with to provide tele-psychiatry services. These psychiatrists often prescribe medications in the course of mental health treatment and some are controlled substances; however, these drugs are not what this bill intends to prevent being diverted into inappropriate uses; rather, they are anti-anxiety medications and similar medications that are part of an ongoing course of treatment. MS. BURKHART stated that psychiatrists practicing through telemedicine work in conjunction with community behavioral health centers, where clients present and are impaneled at a community behavioral health center for mental health services such as therapy, case management, life skills, and rehabilitative services. She further stated that psychiatrists provide medications necessary to stabilize and manage chronic health conditions, which is part of an ongoing relationship. In fact, tele-psychiatry is not used in acute psychiatric situations, but is part of ongoing care, although tele- psychiatry is sometimes used in those situations in Bush Alaska when a psychiatric emergency arises. In community behavioral health centers, the importance of tele-psychiatry is to provide ongoing mental health treatment. Although the bill does not speak directly to psychiatry, the AMHB felt it was important to provide an overall context of how tele-psychiatry works and the importance of providing this access to rural Alaskans. 4:29:07 PM CHAIR OLSON recalled a number of people in the medical community in the late 1970s came to Alaska through the Bureau of Indian Affairs or the military. He said these doctors received tuition repayment for each year they stayed in Alaska, with about 75 percent remaining in the state. He asked whether that type of program is currently happening. MS. BURKHART replied that issues related to recruitment of psychiatrists that he addresses includes practitioners who are now retiring. She explained that recruiting doctors in the early or middle part of their career is more difficult if the doctors have not had experience in Alaska. Some attempts have been made to establish a psychiatric residency in Alaska, since doctors tend to practice in a close proximity of their residency; however, the board has not been able to establish that residency. The state has a relationship with the Western Washington WWAMI program to help with recruitment, but part of the issue is the cost of living and conditions. For example, Fairbanks has struggled for years to recruit and retain psychiatrists, in part because the military is a competitive employer and pays a higher salary, thus the hospital and community behavioral health center and tribal providers have had trouble competing. In Ketchikan, Community Connections provides services to people with developmental disabilities and early childhood mental health, but also contracts with a psychiatrists at Children's Hospital. Although the Ketchikan community has recently had two psychiatrists, neither is a child psychiatrist. She reported that all of the psychiatrists providing services in the publically-funded system are licensed in the state, which is the quality assurance mechanism. 4:32:09 PM REPRESENTATIVE JOSEPHSON referred to the description of tele- psychiatry, and he recalled that people in Alaska used providers in Washington State. He asked whether the provider would have licensure in Juneau. MS. BURKHART stated that the integrated behavioral health regulations require that the client be present at the behavioral health center and a clinician is with them during the appointment, in part, to navigate equipment and ensure continuity of care. The state will not reimburse the appointment without this method. Therefore, a client is not being served at home with the tele-psychiatrist appointment. 4:33:39 PM REPRESENTATIVE HERRON said that in his region communities have contracted for services from someone in Minnesota. He asked for the average vacancy rate in the Lower 48 and how it compares to the 25-percent vacancy rate for psychiatrists in Alaska. MS. BURKHART recalled the board had a presentation on the vacancy rate, and an expected vacancy in the community health system is 10 percent and anything over that requires planning efforts. In the health care industry in Alaska, they are looking at those fields with 11 percent or over, but psychiatry has the highest rate. REPRESENTATIVE HERRON asked whether this is a national trend. MS. BURKHART said it depends on the community and the subspecialty. For example, geriatric psychiatry has often been in demand and is provided through tele-psychiatry in Alaska, but the practice is robust in Florida. She offered to provide the national average on vacancy rates for psychiatrists. 4:35:35 PM CHAIR OLSON, after first determining no one else wished to testify, closed public testimony on HB 281. [HB 281 was held over.]