SB 175-HEALTH CARE SERVICES BY TELEHEALTH   1:36:03 PM CHAIR WILSON announced the consideration of SENATE BILL NO. 175 "An Act relating to telehealth; relating to the practice of medicine; relating to medical assistance coverage for services provided by telehealth; and providing for an effective date." 1:36:33 PM At ease 1:37:30 PM CHAIR WILSON reconvened the meeting and solicited a motion. 1:37:34 PM SENATOR COSTELLO moved to adopt the committee substitute (CS) for SB 175, work order 32-LS1421\G, Version G, as the working document. 1:37:47 PM CHAIR WILSON objected for discussion purposes. 1:38:33 PM CHAIR WILSON stated that, as sponsor, he would present the summary of changes for SB 175 from Version I to Version G. It read as follows: [Original punctuation provided.] Version 32-LS1421\G (Senate Health and Social Services Committee Substitute) 6 distinct changes from first 32-LS1421\I to 32- LS1421\G 1) The ability to prescribe, dispense, or administer botulinum toxin (Botox) via telehealth is removed. a. Page 2, Line 21: Removed "botulism toxins". 1:38:54 PM CHAIR WILSON continued to review the changes in SB 175 from Version I to Version G. 2) Language regarding Alaska Medicaid services in Section 4 is cleaned up. a. Page 5, Lines 24 and 25: Removed facsimile to remove fax as a modality for Alaska Medicaid. b. Page 5, Lines 5 and 6: Removed "and other federal waivers or demonstrations" and added a separate line for "services covered under federal waivers and demonstrations other than home and community-based services. c. Page 5, line 17: Deleted "the Community Health Aide Program Certification Board" and replaced it with "a certifying entity for behavioral health professionals in the state specified by the department in regulations" 3) Language regarding prescribing via telehealth for APRNs is tightened and clarified. Does not expand the prescribing powers of APRNs. a. Page 2, Lines 25: Added "if the advanced practice registered nurse complies with AS 08.68.710." 1:40:18 PM b. New section 3 (does not exist in version I): Creates a new section under Title 8, Chapter 68 (Nursing) defining the telehealth prescriptive authority of APRNs in statute. This section aligns the regulatory authority of the Board of Nursing with the State Medical Board regarding the prescription of controlled substances via telehealth. 4) Language was added to require applicable licensing boards and DHSS to adopt regulations necessary to implement sections 3-6 of the Act (including the Medicaid provisions) no later than June 30, 2023. 1:41:04 PM CHAIR WILSON continued to review the changes in SB 175 from Version I to Version G. a. New section 11 (does not exist in version I): Adds language to detail when each entity must adopt regulations. b. Adds a new effective date for section 11. New section 11 takes effect immediately 5) Added 7-year sunset on Medicaid pay parity. a. New Section 6 and 7 with effective date of June 30th, 2030: Sunset's language relating to Medicaid pay parity for telehealth. 6) Changed language throughout to refer to Department of Health. 1:42:17 PM SENATOR BEGICH asked whether these changes were made in collaboration with the department and the sponsor. CHAIR WILSON noted that the department staff present was nodding in agreement, and he sponsored SB 175 and agrees with the changes. 1:42:48 PM SENATOR HUGHES asked for clarification on Medicaid pay parity and the sunset date. CHAIR WILSON stated that pay parity would allow telehealth to receive the same payment for services as in-person practitioners for seven years and then sunset. This was based on best practices for pay parity and would allow the stakeholders time to work on this issue. SENATOR HUGHES suggested a shorter time for non-Medicaid telehealth patients. She wondered whether pay parity should be three or four years rather than seven. CHAIR WILSON answered that he envisioned it would take two years for the department to develop regulations to set rates. He noted that the department staff was nodding in agreement. 1:44:26 PM SENATOR HUGHES related her understanding that Medicaid sets the tone for other insurers. She expressed concern about high health care costs, so the sooner savings were seen, the better for the state. She asked whether private medical practice and insurance could provide savings earlier than seven years. 1:46:00 PM CHAIR WILSON directed attention to an article in members' packets from the National Council of State Legislatures (NCSL) on best practices regarding pay parity. He offered to resend the information if need be. He noted that a floor amendment removed pay parity from SB 56, the bill extending the COVID-19 disaster emergency. He stated that research had shown that many entities do not wish to engage in telehealth because it was more profitable to continue to practice in person. 1:47:21 PM HEATHER CARPENTER, Healthcare Policy Advisor, Office of the Commissioner, Department of Health and Social Services (DHSS), Juneau, Alaska, stated that the department held several conversations with Chair Wilson and the sponsor of the companion House bill. The department had expressed some concern but had not focused on the number of years. She said the department understood the desire to develop the infrastructure for telehealth. She explained that Medicaid currently pays the same for in-person and telehealth services. She indicated that it would modernize the Medicaid program by moving away from fee- for-service to value-based and bundled payments for managed care. The department felt it would be helpful if the limitation for paying the same for in-person versus telehealth does not exist into perpetuity. She related her understanding that Chair Wilson came up with a reasonable compromise for the department. 1:48:27 PM SENATOR HUGHES maintained her concern about the length of time because telehealth was initiated in many places at least ten years ago. She expressed concern that seven years was too long to allow for infrastructure and adjustments. She wondered if the sponsor would consider shortening that timeframe but indicated that she would not stop the bill because of it. She emphasized that health care costs are one of the state's major problems. CHAIR WILSON indicated that he was working with the sponsor of the companion bill on that issue. He said he hoped to marry the bills in the next committee of referral, the Senate Labor & Commerce Committee. 1:49:54 PM CHAIR WILSON [removed his objection]; he found no further objection; and the committee substitute (CS) for SB 175, Version G was adopted as the working document. 1:50:17 PM SENATOR REINBOLD moved to adopt Amendment 1, work order 32- LS1421\G.1. 32-LS1421\G.1 Foote 3/22/22 AMENDMENT 1 OFFERED IN THE SENATE BY SENATOR REINBOLD TO: CSSB 175(HSS), Draft Version "G" Page 1, line 9: Delete "without" Insert "only after" 1:50:19 PM CHAIR WILSON objected for discussion purposes. 1:50:22 PM SENATOR REINBOLD explained that Amendment 1 would require an in- person visit before providing telehealth services. She offered her view that this protects physicians in Alaska. 1:50:47 PM CHAIR WILSON stated that the purpose of previous versions of the bill was to allow those physicians who have established network care to practice, allowing the expansion of telehealth for Alaskans. He said the language in Version G requires the physician to be an Alaskan provider who practices in Alaska. 1:51:39 PM SARA CHAMBERS, Director, Division of Corporations, Business, and Professional Licensing, Department of Commerce, Community and Economic Development, Juneau, Alaska, stated that Version G made many changes that are not in the House version of the bill. She explained that Amendment 1 would remove "without." However, the language "without" reinforces the statutes regarding health care providers in AS 08. The boards have adopted regulations allowing telehealth care without requiring an in-person visit. She noted that Chair Wilson indicated this also allows Teladoc physicians who are licensed in Alaska but may not physically be in Alaska to provide health care to Alaskans, which is currently allowed. She related that Teladoc is a large health care provider part of the state employee health network that uses Alaska-licensed physicians. She explained that removing "without" and inserting "after" would mean they could no longer practice in Alaska. Instead, these physicians would need to be physically present in Alaska to provide health care for Alaskans. 1:53:51 PM CHAIR WILSON noted that these physicians must be licensed in the State of Alaska to practice medicine using telehealth. 1:54:04 PM MS. CHAMBERS answered yes; these physicians must be licensed in the state unless they practice medicine through the Indian Health Service (IHS) or the military. 1:54:20 PM SENATOR HUGHES raised the issue of health care costs. She asked the record to reflect her support for Alaskan physicians and providers. However, she said it is a concern that Alaska physicians charge from 100 to 300 percent more for services than out-of-state providers. She highlighted her desire to create competition. She said she would oppose Amendment 1 because a telehealth provider might be helpful to Alaskans. She noted that a telehealth provider might provide a specialty not provided in Alaska. She highlighted that the state should not stop Alaskans from seeking more affordable care. 1:55:41 PM SENATOR REINBOLD stated that she would never undercut Alaska physicians. She read Section 1 (a): A health care provider other than a physician licensed in another state may provide health care services within the health care provider's authorized scope of practice to a patient in this state through telehealth without first conducting an in-person visit. SENATOR REINBOLD offered her view that it was easy to miss many things in telehealth and that medical personnel learn much more with in-person patient care. 1:57:13 PM SENATOR COSTELLO referred to page 3, lines 2-5, subsection (i), which does not force health care providers or patients to use telehealth but leaves it up to the patient to decide. 1:57:43 PM SENATOR REINBOLD stated that it is expensive to move to Alaska and set up a practice only to have people make phone calls to the Lower 48. She maintained her support for Amendment 1. 1:58:06 PM A roll call vote was taken. Senators Reinbold voted in favor of the motion to adopt Amendment 1, and Senators Hughes, Begich, Costello and Wilson voted against it. Therefore, Amendment 1 failed on a 1:4 vote. CHAIR WILSON announced that Amendment 1 failed on a vote of 1 yea and 4 nays. 1:58:46 PM SENATOR COSTELLO emphasized that an out-of-state medical doctor who provides telehealth to a patient in the state must have an established relationship and have previously conducted a physical examination. She related her understanding that a physician must have a connection to the patient or an Alaskan physician. She asked if that was correct. CHAIR WILSON answered no. He indicated that it was similar to the Alaska Care plan, Teladoc, so all the members under Alaska Care could call Teladoc and reach health care providers licensed in Alaska. 2:00:00 PM SENATOR COSTELLO clarified that she was referring to medical professionals who are licensed outside the state. She interpreted the bill to mean that the physician must have an established physician-patient relationship and have previously conducted a physical examination in person. MS. CHAMBERS explained that subsection (b) creates a carve-out that does not currently exist that would allow physicians not licensed in Alaska to deliver telehealth services. Currently, out-of-state physicians can be physically in another state, but the physician must be licensed in Alaska. 2:01:02 PM SENATOR REINBOLD read subsection (a) "A health care provider other than a physician licensed in another state may provide health care services within the health care provider's authorized scope of practice to a patient located in the state through telehealth without first conducting an in-person visit." She asked whether this could apply to international health care providers. 2:01:57 PM MS. CHAMBERS referred to page 3, line 7, to the definition of health care provider, which applies to those licensed in the state. She stated that the health care provider referenced in Section 1, on page 1, line 6, related to a person practicing any listed profession who holds a license in Alaska. A person traveling internationally could provide telehealth so long as they are in good standing in Alaska. 2:02:54 PM At ease 2:03:32 PM CHAIR WILSON reconvened the meeting. 2:03:38 PM SENATOR REINBOLD moved to adopt Amendment 2, work order 32- LS1421\G.3. 32-LS1421\G.3 Foote 3/30/22 AMENDMENT 2 OFFERED IN THE SENATE BY SENATOR REINBOLD TO: CSSB 175(HSS), Draft Version "G" Page 10, following line 17: Insert a new subsection to read: "(f) Nothing in this section authorizes an individual employed by an entity permitted to provide telehealth under this section to prescribe, dispense, or administer through telehealth a controlled substance listed in AS 11.71.140 - 11.71.190." Reletter the following subsection accordingly. Page 11, following line 12: Insert a new subsection to read: "(f) Nothing in this section authorizes an individual employed by a facility permitted to provide telehealth under this section to prescribe, dispense, or administer through telehealth a controlled substance listed in AS 11.71.140 - 11.71.190." Reletter the following subsection accordingly. 2:03:41 PM CHAIR WILSON objected for discussion purposes. 2:03:44 PM SENATOR REINBOLD explained that Amendment 1 would insert a new subsection (f), which she read. 2:04:19 PM SENATOR HUGHES emphasized the importance of being careful with controlled substances. She said her daughter, a physician, just prescribed a controlled substance via telehealth. She said it would have been unethical for her not to provide the needed treatment for her patient in a rural setting. She stated that she would oppose Amendment 2. 2:05:10 PM SENATOR BEGICH agreed with Senator Hughes that allowing a telehealth provider to prescribe means the patient only needs to meet with one in-person provider, but that the second provider could be via telehealth. He offered his view that Amendment 2 would place an undue burden on people who might not be able to access an in-person provider. He highlighted the importance of being cautious about opioids but would oppose Amendment 2 based on the provider's ethical duty. 2:06:02 PM SENATOR REINBOLD maintained that given the opioid crisis, it was important to get a handle on controlled substances. She said allowing someone to prescribe controlled substances from out-of- state via telehealth was alarming. She offered her view that it should require an in-person visit. 2:06:55 PM A roll call vote was taken. Senator Reinbold voted in favor of the motion to adopt Amendment 2, and Senators Hughes, Begich, Costello, and Wilson voted against it. Therefore, Amendment 2 failed on a 1:4 vote. CHAIR WILSON announced that Amendment 2 failed on a vote of 1 yea and 4 nays. 2:07:19 PM CHAIR WILSON asked Ms. Chambers to provide the committee with information on how the Prescription Drug Monitoring Program (PDMP) would work with telehealth prescriptions for controlled substances. CHAIR WILSON held SB 175 in committee.