HB 281-PRESCRIPTION WITHOUT PHYSICAL EXAMINATION  2:05:19 PM CHAIR STEVENS announced the consideration of HB 281. [CSHB 281(L&C) was before the committee.] He said it was the first hearing on the bill. The intent is to have the sponsor introduce the bill, take public testimony, and look to the will of the committee. 2:05:35 PM REPRESENTATIVE LYNN GATTIS, Alaska State Legislature, Juneau, Alaska, sponsor of HB 281. She said HB 281 is the companion bill to SB 80 and is, essentially, Section 2 of that bill. She noted that she has provided a comparison table of HB 281 and SB 80. She related that HB 281 clarifies in statue that physicians may not be sanctioned for dispensing or administering prescription medications without a physical examination of the patient. This practice is called telemedicine. She explained that telemedicine-based medical care would be delivered by primary care physicians located in Alaska. Anyone needing medical care would be a candidate for this system. She gave examples of who might benefit and be able to attain over- the-phone or online consultations where physicians can diagnose an ailment and, if necessary, provide a prescription. This bill stipulates that physicians would not be able to prescribe controlled substances. She listed the benefits of telemedicine: convenience for the patient, affordability, rapid access, higher productivity from a healthy workforce, and primary care access for rural residents. The efficient quality comes down to cost and access. She pointed out that telemedicine does not replace the relationship with a primary care provider. By requesting a consultation and filling out an intake form, consent and medical history forms, a person is entering into a doctor/patient relationship. If a patient does not have a primary care provider, they may designate a telemedicine provider as such. Patient privacy, the Health Insurance Portability and Accountability act (HIPA), and privacy laws apply to telemedicine. She noted that telemedicine already exists and is working in Alaska. Alaska has been one of the pioneers of telemedicine. The Alaska Native Tribal Health Consortium, the Veterans Administration, and the military, use telemedicine. Outside of the state, major employees like Home Depot and Costco use telemedicine. She gave examples of medical conditions of people who seek telemedicine: acute respiratory illness, uterine track infections, skin problems, abdominal pain, and back and joint problems. She said 20 percent of Alaska's population lives in rural areas and needs quick and economical medical care. 2:09:56 PM CHAIR STEDMAN noted that the committee is familiar with the concept of telemedicine. REPRESENTATIVE GATTIS said the bill has not been heard in the Senate Health and Social Services Committee. She emphasized that there is a difference between the two bills. She explained that HB 281 requires physicians to be located in Alaska. Another difference is SB 80 required that physicians bill insurance companies, a provision not included in HB 281. CHAIR STEDMAN noted one zero fiscal note from Department of Commerce, Community and Economic Development (DCCED). 2:11:56 PM SENATOR MICCICHE asked why out-of-state doctors cannot be used. REPRESENTATIVE GATTIS replied that the bill has gone through various House committees and Alaska doctors said they wanted to protect Alaskan doctors. SENATOR MICCICHE reported that currently there are several thousand people using doctors who would no longer be allowed to use them. REPRESENTATIVE GATTIS said the Native Health Consortium has a federal exemption that allows them to go out of state for telemedicine. SENATOR MICCICHE said several companies also use out-of-state physicians. REPRESENTATIVE GATTIS deferred to Dr. DePhillips to discuss Costco and Home Depot. SENATOR MICCICHE said they were not the only companies. 2:13:56 PM DR. HENRY DEPHILLIPS, Corporate Chief Medical Officer, Teladoc, Nashville, Tennessee, answered questions related to HB 281. Dr. DePhillips responded to Senator Micciche's question by explaining that there a three large telemedicine companies and two of those three have put together a national network of physicians. He said Teladoc has several Alaska physicians. He noted Teladoc has a difference in interpretation of the Alaska Medical Board rules than the Board does, which is what prompted the bill. He said Teladoc has been operating in Alaska for a while under the "cross coverage exemption." He said Teladoc and other companies are looking for regulatory coverage through the bill, which would include Alaska licensed and resident physicians. He reported that Teladoc worked closely with the Alaska Medical Association and agreed that the care of Alaskans should be rendered by Alaska physicians. 2:15:52 PM SENATOR MICCICHE asked why telemedicine is limited to physicians, especially in rural areas. DR. DEPHILLIPS said nurse practitioners, physician assistants and others, are not included because Teladoc made a conscious business decision to keep the standard of patient care very high. He said they knew they would be a target and they have been a target over the last 12 years. Toledo's model is a physician-only model, as are the other two companies. Another reason is because the Medical Board censured physicians doing telemedicine, which is the reason behind the need for the legislation. He thought lower level providers were regulated by a different board. SENATOR MICCICHE inquired about dispensing controlled substances via telemedicine. He brought up a concern regarding post-op care medications. DR. DEPHILLIPS said that is a topic that has been discussed with the Department of Corrections and others during the evolution of the bill. He stated it is a balancing act. The concern was with past history of internet prescribing controlled substances. He said it was Toledo's decision not to allow DEA controlled substances. He believed the other two companies also have that policy. It keeps the abuse issue at bay and makes the Medical Boards happy. He noted the Department of Corrections allows DEA controlled substances to be prescribed via telemedicine because there is a clinically trained person on site. The bill provides for that exception. 2:19:38 PM SENATOR MICCICHE used an example of a post-op patient in rural Alaska who requires medication back in the village. He asked if there is a way for controlled substances to be prescribed. DR. DEPHILLIPS said there is currently not a way for controlled substances to be prescribed using telemedicine. He observed that if someone post-op in a village requires pain control requiring a controlled substance, they would also need an in-person assessment. He concluded that there is currently not a vehicle to dispense a controlled substance. 2:21:30 PM JENNIFER MEYHOFF, Alaska Association of Health Underwriters, Anchorage, Alaska, testified in support of HB 281. She opined that telemedicine has the potential to help contain high health care costs. SARA CHAMBERS, Director, Division of Corporation, Business, and Professional Licensing, Department of Commerce, Community and Economic Development (DCCED), Juneau, Alaska, answered questions related to HB 281. CHAIR STEDMAN asked if the department has any concerns about the bill. MS. CHAMBER said the department does not have concerns. She said she believes the State Medical Board has gone on record with their concerns. CHAIR STEDMAN closed public testimony. REPRESENTATIVE GATTIS concluded that HB 281 is not a catch-all and not a hospital, but brings Alaska into the 21st Century and will provide access to low-level health care. She shared a story about her experience with telemedicine. 2:25:20 PM At ease 2:28:03 PM SENATOR MICCICHE moved to report CS for HB 281 from committee with individual recommendations and attached zero fiscal note. CHAIR STEDMAN announced that without objection, CSHB 281(L&C) is reported from the Senate Health and Social Services Standing Committee.