SB 65-LIABILITY CONSULTING HEALTH CARE PROVIDER  1:31:39 PM CHAIR WILSON announced the consideration of SENATE BILL NO. 65 "An Act relating to immunity for consulting physicians, podiatrists, osteopaths, advanced practice registered nurses, physician assistants, dentists, optometrists, and pharmacists." He stated his intent to hear an overview of the bill and take testimony and hold the bill for further consideration. He invited sponsor Senator Kiehl and his staff to the table. 1:32:13 PM SENATOR JESSE KIEHL, Alaska State Legislature, Juneau, Alaska, Sponsor of SB 65, introduced himself. 1:32:29 PM CJ HARRELL, Intern, Senator Jesse Kiehl, Alaska State Legislature, Juneau, Alaska, stated that in Alaska and other states, healthcare providers will seek the knowledge and expertise of fellow medical professionals to help them understand how to help their patients in an effective and timely manner. These conversations can be an official consultation, but more often than not, medical professionals will have what are called curbside consultations. This is when a patient's healthcare provider has an uncompensated, informal consultation with another medical professional. These consulting medical professionals are often specialists and do not have any relationship with the patient under discussion. It is a fast and effective way of sharing knowledge and expertise and is the backbone of medical care. Two years ago in Minnesota a healthcare provider who had no relationship to a patient was forced to defend themselves against a civil liability case. The fear is that by not protecting those who have no relationship to a patient and are sharing their expertise through a curbside consultation providers will no longer feel comfortable aiding fellow healthcare providers in that way. SB 65 will allow curbside consultations to continue, but without the potential to become subject to civil liability for a patient with whom they have no actual relationship. 1:33:59 PM SENATOR BEGICH commented that there had been good conversations last year about a similar bill. He sees that most of the changes were incorporated in this version of the bill. He noted he spoke to Senator Kiehl a bit about the telehealth issues. Now that the emergency order which extended telehealth is gone, he asked Senator Kiehl if the bill has any relationship to telehealth that could be explored. SENATOR KIEHL replied he doesn't see a hook to telehealth, which is generally direct patient care and if not face-to-face, camera-to-camera, which does establish a doctor patient relationship. There is a duty of care. Curbside consults frequently involve doctors on the phone, but the consulting doctor is not seeing the patient. SENATOR BEGICH clarified that in a three-person scenario, there is a curbside consult, the doctor who is dealing with the patient, and the patient. SENATOR KIEHL responded that in that scenario, the treating healthcare professional may seek a curbside consult with a colleague. This bill protects that curbside consult as long as the consulting physician is not laying hands on the patient, even virtually. Therefore, they would not be liable. SENATOR BEGICH asked what the estimated cost is to Alaskans if this bill did not pass, in terms of things like liability insurance. He asked if that is what is driving the bill. SENATOR KIEHL answered that cost of liability is one of the key drivers. The financial cost would be difficult to figure out. The potential for increased medical malpractice costs is significant, although he doesn't have a number for that. The potential cost to the healthcare system as a whole is much greater. The potential is the effect on a doctor who might previously have called a specialist about a transport or a referral for a workup. When the answer can safely be no, a lot of money is saved compared to the specialist not being available for a free consult and saying the patient must be sent. That is a risk the state needs to avoid. 1:38:03 PM SENATOR REINBOLD asked if the bill has any protection in regard to administering the mRNA vaccines. SENATOR KIEHL replied not directly, but he could see the potential implication. If a healthcare provider had a patient who is medically fragile or has complicating medical conditions and wanted to call a specialist to see if those contraindicted giving the shot, the state would want them to be able to make that call and SB 65 would help make that a safe call. SENATOR REINBOLD asked if the bill protects the person administering the shot. SENATOR KIEHL answered that that person lays hands on the patient and would retain whatever liability that person would otherwise have if there was a bad reaction that might cause liability. SENATOR REINBOLD advised that safety with vaccines will be a top issue with her. She wanted to make sure there were zero protections regarding vaccinations. The Judiciary Committee has talked about informed consent required with emergency use authorization of vaccines. She hopes the long-term effects are fine, but no one knows what they are. She is happy to know there is zero protection for those people involved with vaccines in this bill. 1:41:05 PM SENATOR HUGHES asked about a scenario in which someone in a coffee line asks a provider who has not treated or done an exam of that person for advice and that person takes that advice, but the person has an adverse reaction when following that advice. She asked if this bill could relieve that provider of liability. SENATOR KIEHL replied SB 65 would not apply to that scenario. SB 65 covers consultations between healthcare providers. SENATOR HUGHES asked him to point that out in the bill. SENATOR KIEHL responded that page 1, line 7, provides immunity to a consulting healthcare provider. Page 2, line 20, defines the consulting healthcare provider, someone who provides advice to another healthcare provider and then there is a list of licensed healthcare providers. SENATOR HUGHES referred to page 2, line 14, beginning with number 9, a written report is not created as a result of the consultation. She asked again about a coffee line conversation in which one provider speaks to another provider and a report is written and patient treated accordingly. If the patient sues, she asked if that would be considered a written report or should the bill specify the written report must be prepared by the consulting provider. SENATOR KIEHL replied that he doesn't know if that clarification would be in any way harmful. It matches the intent because the liability shield is provided to the consulting provider. It is not strictly necessary. If he understands her scenario correctly, the treating provider writes the report. Their liability rests with the treatment they provided, irrespective of the report, but he sees no harm in that clarification. SENATOR HUGHES said that she did not want to imply that healthcare providers are nefarious, but she could see that if someone took some informal advice in the coffee line and then there was an adverse result and the patient sued, that provider may try to create a report saying they received that advice from another physician in order to spread the burden of liability. She could see the need for clarification that the written report would be by the consulting provider to prevent that type of situation, even though it would be rather unlikely. She asked if Senator Kiehl would entertain that as a friendly amendment. SENATOR KIEHL responded that he had no objection to that clarification. 1:45:51 PM CHAIR WILSON called on invited testimony. 1:46:11 PM JACOB KELLY, M.D., Alaska Heart and Vascular Institute, Anchorage, Alaska, said SB 65 allows physicians to provide unencumbered clinical expertise to help patients across Alaska. Alaska's value and mission is to take care of all Alaskans regardless of location and ability to pay. This allows better local care and leads to decreased inappropriate transfers. It allows patients to be cared for where they are safer. It would ultimately reduce cost. He receives from 2 to 10 calls a night from various cities from nurse practitioners, emergency room physicians, family physicians, and other specialists. It is nice to be able to support them in their decision-making without concern about litigation when he has no access to the patient, their records or data. As a heart failure specialist, people have questions for him about how to titrate medications. It can be difficult to transfer a patient to Anchorage for an expensive visit when a slight titration of medications would lead to improved survival and quality of life. SENATOR HUGHES commented that it is important to share knowledge among experts in the field. Now that there is a precedence of a consulting provider being sued in another state, she is concerned that it might inhibit good conversations and knowledge sharing between providers. She asked if it could inhibit knowledge sharing if SB 65 does not pass. DR. KELLY agreed that it would make providers more reticent in answering specific questions. He would be more likely have a patient transported to Anchorage to one of the larger hospitals to provide care that could have been delivered locally. SENATOR REINBOLD asked if SB 65 could reduce his malpractice insurance. DR. KELLY deferred the question to Robert Craig. He said physicians see this as allowing better quality of care with fewer restrictors. It is about feeling comfortable providing care and allowing people to get the best care they can. 1:50:58 PM ROBERT CRAIG, CEO, Alaska Heart and Vascular Institute, Anchorage, Alaska, said he doesn't anticipate any change to malpractice premiums. That is not part of the motivation for support of the bill. The institute's cardiologists are on call and available for the state 24/7. That coverage is not part of a telehealth obligation; these are not their patients and the institute is not reimbursed for the call. The institute's cardiologist in Anchorage can take a call any time day or night from a treating physician. The cardiologist has no patient record or relationship, which places a special burden on their doctors to be open to potential civil liability. They are primarily interested in giving timely and accurate information to another treating physician. The option is to advise the treating physician to send the patient to Anchorage or request a formal consultation, which delays care and/or increases cost. The goal of the institute's doctors is to continue to provide a high level of cardiology service to the state's providers in a high-quality and low-cost manner. SENATOR REINBOLD commented on her intentions when the bill is heard in the next committee of referral, and expressed a desire to see malpractice premiums to go down. 1:54:39 PM STEVEN COMPTON, M.D., Secretary/Treasurer Elect, Alaska State Medical Association, Anchorage, Alaska, said he is another cardiologist at Alaska Heart and Vascular Institute but he is there representing the Alaska State Medical Association (ASMA). The institute estimates it is doing 10-20 curbside consults a day across the state. Some are urgent and some are not so bad. Sometimes the referring doctor is overly worried and the cardiologists can calm them down. Sometimes it is the reverse and a patient needs to come in right away. Many times the problem can be managed locally. Alaska has a greater need for this sort of referral network and informal consultation than any other state because of its size. Because it is so large, there are healthcare inequities. Someone who lives in a village in the Yukon does not have access to the same care as someone who lives in a big city. Alaska has excellent telecommunications and expert opinions can be provided to every corner of the state. He has been practicing in Alaska for 20 years. The consults are done for free as part of their duty to citizens of the state. About a year and a half ago their insurer asked to speak at a partner meeting. The insurer reviewed the Minnesota case that Senator Kiehl alluded to and a few others pending at the time and said this will be a problem if it is not nipped in the bud. The insurer anticipated a potential increase in rates, and said he needed to talk there needs to be a discussion about curbside consults. DR. COMPTON said the insurer said the institute could give very general ideas about how to manage a case, but if there is anything specific, the doctors could potentially be liable for anything that happens with a case. The institute's insurers are saying they should either not do this or transport everyone to Anchorage or address this legislatively. That is why they are here. This is not just a cardiology issue. Every specialty gets these calls from around the state. All providers do this and think this is an important service. He had not appreciated that until the conversation with the insurer. This is the lubrication for this whole machine and help avoid inappropriate costs and help provide excellent care in remote places. The ASMA supports SB 65. SENATOR REINBOLD thanked Dr. Compton for his work and powerful testimony. SENATOR BEGICH agreed that his testimony makes a big difference. 2:00:07 PM CHAIR WILSON opened public testimony on SB 65; finding none, he closed public testimony. He held SB 65 in committee.