HB 145-EXPAND PHARMACIST AUTHORITY  3:41:55 PM CO-CHAIR SPOHNHOLZ announced that the next order of business would be HOUSE BILL NO. 145, "An Act relating to the Board of Pharmacy; relating to health care services provided by pharmacists and pharmacy technicians; and relating to the practice of pharmacy." 3:42:29 PM REPRESENTATIVE SNYDER, as prime sponsor, introduced HB 145, which she described as a "housekeeping bill" as it pertains to the business of pharmacy and pharmacy services. She paraphrased the sponsor statement, which read as follows [original punctuation provided]: Passage of House Bill 145, "The Pharmacist Mobilization Act," increases access to care and ensures Alaska's pharmacists are reimbursed when providing services. I am introducing it at the request of the Alaska Pharmacists Association in partnership with the Alaska Board of Pharmacy and the University of Alaska/Idaho State Doctor of Pharmacy Program. The coronavirus pandemic has shown that pharmacists can engage at an elevated level to help deliver necessary healthcare to all Alaskans. Pharmacists have provided COVID-19 testing, vaccinations, and telehealth visits, and have helped patients manage chronic health conditions. This bill will update outdated statute so pharmacists can continue providing these services. HB 145 defines the patient care services that pharmacists and pharmacy support staff can independently provide, allows pharmacist technicians to administer vaccines when under the direct supervision of a licensed pharmacists, and empowers the Board of Pharmacy to regulate pharmacists, student pharmacists, and pharmacy support staff who provide these services. Furthermore, the bill updates the current provider anti-discrimination statute to support insurance coverage of these patient care services when provided by a pharmacist. Currently, pharmacists are one of the only healthcare professionals not listed in this statute. HB 145 largely updates outdated statutes to align with current practices. Its passage benefits Alaskans by increasing healthcare access during and after the pandemic. Please support this common sense, housekeeping bill that will help your local, patient- oriented pharmacies continue to provide essential services. 3:45:13 PM ALLIANA SANGUIT, Staff, Representative Liz Snyder, Alaska State Legislature, on behalf of Representative Snyder, prime sponsor, detailed the sectional analysis of HB 145 [original punctuation provided]: Sec. 1: Adds language to AS 08.80.030(b) Powers and Duties of the Board, statute that outlines the Board of Pharmacy's powers, that allows the Board of Pharmacy to adopt rules to regulate the independent monitoring of drug therapy and independent pharmacist prescribing of vaccines and naloxone. Sec. 2: Adds a new subsection to AS 08.80.045 Nonprescription Drugs that aligns statute with the current practice of pharmacists recommending non- prescription medications and devices for treating minor and self-limited conditions. Sec. 3: Amends AS 08.80.155 Emergency Permit to increase the Board of Pharmacy's flexibility to grant emergency licenses for all relevant licenses used in pharmacies. Sec. 4: Amends AS 08.80.168(a) Administration of Vaccines and Related Emergency Medications by adding "prescribe" to existing vaccine administration statute. Sec. 5: Amends AS 08.80.168(b) by replacing "dispense" with "prescribe and administer" in regards to administering an opioid overdose drug. Sec. 6: Adds a new subsection to AS 08.80.168 that allows a pharmacy technician to administer a vaccine or related emergency medication but only if they have been authorized by the Board of Pharmacy to do so AND if they are under the direct supervision of a licensed pharmacist who meets the requirements in AS 08.80.168 (a). Sec. 7: Adds language to AS 08.80.297(a) Prescription Prices Available to Consumer that allows personnel who are not licensed pharmacists to disclose the cost of filling a prescription when directed by a pharmacist working at the same institution. Sec. 8: Amends AS 08.080 Pharmacists and Pharmacies by adding a new section, AS 08.80.337 Other Patient Care Services, that: ? Allows a pharmacist to provide patient care services for a disease or condition with an existing diagnosis under an agreement made with and approved by a practitioner ? Limits patient care services that pharmacists can provide to those that are minor, selflimiting, and have a CLIA-waived laboratory test which guides clinical decision making. ? Provides language that allows pharmacists to be reimbursed for providing these services 04/07/21 Sec. 9: Amends AS 08.80.480 Definitions by removing "dosage form" as a definition of "equivalent drug product". This allows pharmacists to make minor, non- therapeutic changes to prescriptions using clinical judgement and expertise without contacting the prescriber for verbal or written approval. This does not allow a pharmacist to substitute a dosage form that would negatively impact patient outcomes, safety, or cost effectiveness. Examples of appropriate substitutions under this section include changing from a tablet form of medication to a capsule form of the same medication and strength. Sec. 10: Amends AS 08.80.480(30) by adding "dispensing" and "independent prescribing" to the definition of the "Practice of Pharmacy" to align with the changes made in Section 4 & 5 (AS 08.80.168) of this bill. These additions better represent actual provision of naloxone and vaccine by pharmacists. Sec. 11: Amends AS 21.36.090(d) Unfair Discrimination to include "pharmacists" as protected health care providers in the provider anti-discrimination statute. This aligns the state statute with federal statute (CFR 438.12) and afford pharmacists the same protection as all other healthcare providers when engaging health plans for covered services such as ordering laboratory tests, point-of-care testing, vaccine prescribing and administration, preventative health services, managing minor self-limiting conditions, and participating in collaborative disease state management. 3:49:30 PM TOM WADSWORTH, PharmD, Chief Administrative Officer, University of Alaska/Idaho State University Doctor of Pharmacy Program, informed the committee that his testimony doesn't represent any official position of the University of Alaska and that he was speaking as a practicing pharmacist and educator. He explained that the Doctor of Pharmacy program trains students in every area proposed under HB 145, noting that graduates of the program are prepared to engage in a variety of patient care settings. He said that only about half of all practicing pharmacists are engaged in the community setting such as what one would find at a Walgreen's or Safeway pharmacy; pharmacists are often embedded inside physician clinics doing medicine management or post- diagnostic disease management. Pharmacists can specialize in pediatrics, oncology, infectious diseases, and psychiatry, he explained, and in each case are medication experts tasked with improving the medication experience for the patient. He expressed that HB 145 is a needed update to pharmacy practice laws, empowering the Board of Pharmacy to regulate patient care services not related simply to dispensing. 3:51:59 PM GRETCHEN GLASPY, PharmD, President, Alaska Pharmacists Association, testified in support of HB 145. She informed the committee that the Alaska Pharmacists Association represents over 250 pharmacists, pharmacy technicians, and student pharmacists in Alaska. She said she has been a pharmacist for 15 years and is presently with Bartlett Regional Hospital as a clinical informatics pharmacist, or expert in pharmaceutical technology. She stated her strong support for HB 145. 3:53:24 PM JUSTIN RUFFRIDGE, PharmD, Board of Pharmacy, explained that the Board of Pharmacy was tasked with regulating support for pharmacists' COVID-19 response and having the emergency regulations in place to take effect post-pandemic to facilitate recovery and expanding access to healthcare. One of the most difficult areas, he said, was consistent friction due to state statutes existing in conflict with current pharmacy practices. Current statutes, he said, are largely relevant only to dispensing pharmacists, without considering the many other areas of pharmaceutical practice. He characterized HB 145 as legislation that would empower the Board of Pharmacy to continue to regulate pharmacies, pharmacists, pharmacy technicians, and interns at the highest possible level. 3:55:27 PM REPRESENTATIVE NELSON asked for further explanation of Section 7 of HB 145. DR. RUFFRIDGE explained that there is a wide variety of opportunity for multiple individuals to use information related to the cost of filling a prescription. Pharmacy technicians are highly trained, he explained, and are usually engaged in computer-based activity of billing, looking up prices, and ordering medication. A pharmacist concentrates on the medicine, looking out for things like interactions or side effects. He characterized pharmacy technicians as "more adept and more in the nitty gritty of the billing" than pharmacists and stated that this is one of the ways the statutes could be aligned with current practices. 3:57:53 PM CO-CHAIR SPOHNHOLZ pointed out that most people visiting a pharmacy speak with the pharmacy tech instead of a pharmacist. 3:58:12 PM REPRESENTATIVE KAUFMAN expressed concern that parts of the proposed legislation would encroach on primary care. REPRESENTATIVE SNYDER replied that, while physicians and physician groups have been contacted, no comments have been received. 3:59:29 PM DR. WADSWORTH explained that there is already a definition in statute that addresses the duties of a pharmacist in providing pharmaceutical care or drug therapy, in what is called "other patient care services" for the intent of prevention and treatment of disease. The goal of Section 8 of HB 145, he said, is to determine exactly what patient care services the language refers to. He said there are no activities outlined in Section 8 that have not been practiced by pharmacists for at least the past 20-30 years; however, pharmacists in the private sector have experienced difficulties in engaging health plans for reimbursement, so such services have mainly been practiced by pharmacists within organizations such as tribal health organizations or U.S. Veterans Affairs facilities. He noted that in a free market, services without a revenue stream cease being offered. Dr. Wadsworth directed attention to Section 8, subsection (a), describing a collaborative agreement to provide patient care services along with a practitioner, which he said is in accord with already-existing statutes and regulation around what's referred to as the "pharmacist collaborative authority," in effect since 2002. DR. WADSWORTH addressed Section 8, subsection (b), which he said defines what patient care services a pharmacist may provide independently, noting that the subsection does not contain any activity not already practiced by pharmacists. Areas such as general health and wellness, smoking cessation, over-the-counter recommendations, or disease prevention, he said, all are non- prescriptive areas; minor or self-limiting conditions such as athlete's foot are often presented to pharmacists. He discussed certain types of tests performed by pharmacists and pointed out that if HB 145 were to fail, these tests would still be performed by pharmacists, just without reimbursement from health care insurers. Collaborative agreements such as the pharmacist collaborative authority, he said, are currently reviewed by the Board of Pharmacy and the Board of Medicine; the clarity that HB 145 would provide regarding independent patient care services would allow pharmacists to engage with health care plans and companies to provide services. For instance, he said, a patient who goes to a Soldotna pharmacy for a COVID-19 test would be able to have it covered by insurance. 4:05:04 PM REPRESENTATIVE KAUFMAN asked whether subsection (b) could lead pharmacists to believe they have more authority than they actually do. 4:06:27 PM MR. RUFFRIDGE responded that the Board of Pharmacy discussed subsection (b) in depth with providers, physicians, and practitioners across the state. The intent, he said, is not to promote prescription of medications outside of the current purview of pharmacists. The vagueness of the subsection is to allow for the "multitude of situations" encountered every day by pharmacists to be covered by the proposed legislation. He pointed out that under current statute, smoking cessation recommendations could not specifically be made by a pharmacist. REPRESENTATIVE KAUFMAN asked to be provided with more information. 4:09:06 PM CO-CHAIR FIELDS commented that he had the same question when he initially read the proposed legislation, and expressed that HB 145 seems to "strike the right balance." 4:09:38 PM REPRESENTATIVE MCCARTY expressed support for HB 145 discussed having pharmacists offer eye exams. 4:11:09 PM CO-CHAIR SPOHNHOLZ clarified that the invited testifiers are Doctors of Pharmacy, not of medicine. She then asked whether HB 145 would allow pharmacists to perform eye exams. 4:12:10 PM DR. WADSWORTH replied that HB 145 does not specifically propose eye exams to be included in the covered activities, but that it would not be above the purview of a pharmacist to have an eye chart and perform a simple eye exam. CO-CHAIR SPOHNHOLZ pointed out that Representative McCarty's question referred to a test currently administered by people not trained in healthcare or optometry, such as employees of the Department of Motor Vehicles. DR. WADSWORTH agreed and noted that there is a precedent for every item in Section 8. He pointed out that the Board of Pharmacy would be the regulator of the statute. He then said that diabetes or high blood pressure screenings are performed by pharmacists as part of the general disease prevention activities in Section 8. 4:14:15 PM REPRESENTATIVE SNYDER emphasized that HB 145 would update the statute to reflect current, modern practices. 4:14:42 PM CO-CHAIR SPOHNHOLZ announced that HB 145 was held over.