SB 91-TELEHEALTH: MULTIDISCIPLINARY CARE TEAM  3:31:18 PM CHAIR WILSON announced the consideration of SENATE BILL NO. 91 "An Act relating to telehealth; relating to multidisciplinary care teams; and relating to the practice of medicine." 3:31:53 PM SENATOR MATT CLAMAN, District H, Alaska State Legislator, Juneau, Alaska, sponsor of SB 91, introduced the legislation by paraphrasing the sponsor statement. Senate Bill 91 expands telehealth providers and services available to Alaskans. Last year, the legislature passed House Bill 265, which created a framework in statute for telehealth and ensured Alaskans' access to critical health care. In the summer of 2022, Senator Claman was contacted by a constituent who was recently diagnosed with Amyotrophic Lateral Sclerosis (ALS). Upon receiving her diagnosis, Sheila Swanson flew to Seattle to receive specialty treatment. Sheila was told that she could continue to receive care from the physician via telehealth, but would need to fly to Seattle to receive in-person care from the other seven members of her multidisciplinary ALS care team, including a respiratory therapist, speech language pathologist, and physical therapist. Senate Bill 91 would allow out-of-state multidisciplinary care team members to provide telehealth services. The bill applies to two different situations, the first situation being on-going treatment or follow-up care from an out-of-state physician or member of their disciplinary care team related to health care services previously provided by the physician to the patient. Senate Bill 91 requires that the physician and patient have an established physician-patient relationship and the physician has had a previous in-person visit with the patient. The second situation outlined in the bill is when a patient receives care for a suspected or diagnosed life-threatening condition. To receive treatment from a non-physician member of the multidisciplinary care team, Senate Bill 91 requires a documented referral to the member of the multidisciplinary care team by either a physician licensed in Alaska or through a physician licensed out-of-state with whom the patient has a previously-established relationship. Senate Bill 91 amends the statute passed by House Bill 265 by adding "multidisciplinary care teams" as an option for telehealth. Alaskans deserve to receive the appropriate care in their local support network when possible, and Senate Bill 91 will expand these options. 3:35:08 PM EMMA POTTER, Staff, Senator Matt Claman, Alaska State Legislature, Juneau, Alaska, presented the sectional analysis for SB 91. Section 1 AS 08.02.130. Telehealth Amends subsection (b) to expand who may provide health care services through telehealth. An out of state member of the physician's multidisciplinary care team may provide telehealth services under the following conditions: (1) for on-going treatment or follow-up care by the member of the physician's multidisciplinary care team if the physician and patient have an established physician-patient relationship and the physician has previously conducted an in-person visit; or (2) for a visit regarding a suspected or diagnosed life-threatening condition for which the patient has been referred to the physician licensed in another state or a member of the physician's multidisciplinary care team and the visit involves communication with the patient regarding diagnostic or treatment plan options or analysis of test results for the life-threatening condition. Section 2 AS 08.02.130. Telehealth Amends the definition of "health care provider" in this section to include a member of a multidisciplinary care team that includes a physician licensed in another state who meets the requirements of (b)(1) of this section. Section 3 AS 08.02. Miscellaneous Provisions Adds new sections AS 08.02.135: Grounds for imposition of disciplinary sanctions of out-of-state multidisciplinary care team members and AS 08.02.140: Disciplinary sanctions for out-of-state multidisciplinary care team member. 3:36:43 PM SENATOR TOBIN asked for the definition of "multidisciplinary care team" and whether it was established in statute. 3:37:06 PM SENATOR CLAMAN said the term is not specifically defined, but the practical meaning is anybody in the care team that the primary physician relies on to provide care and treatment for the patient. SENATOR TOBIN opined that it would be helpful if it was more prescriptive. 3:37:48 PM SENATOR CLAMAN responded that his concern is that side rails to direct who could be part of a treatment team runs the risk of excluding somebody that a primary care physician might deem very beneficial. CHAIR WILSON asked whether the language in Section 2 would allow people who are located both in-state and out-of-state to be part of the multiple disciplinary care team and, if so, what that might mean for licensing. 3:40:09 PM SENATOR CLAMAN replied those are good thoughts but the purpose is to make sure that people who are facing conditions like his constituent are able to have the care team that works for them. 3:40:50 PM SENATOR GIESSEL noted that the fiscal note includes the cost for a full-time investigator 3 which seems to mean that licenses will be examined. She asked if the bill would waive licensure for members of the multidisciplinary care team if the primary physician held licenses in Alaska and Washington state, for example. SENATOR CLAMAN mentioned the telehealth law that authorizes physicians not licensed in Alaska to provide care via telehealth in certain circumstances. His constituent receives highly specialized care from her primary physician in Seattle who is not licensed in Alaska. That physician has put together a team of people in other practices who specialize in treating ALS. SB 91 would allow the physician licensed in Washington and the other seven Washington-licensed specialists to provide care to his constituent via telehealth. Those individuals would be subject to investigation by the investigator 3 which the fiscal note describes. 3:43:32 PM SENATOR GIESSEL expressed skepticism and concern about waiving licensure for an unknown roster of health care providers and that somebody in Alaska would be paying for the licensing investigator. SENATOR CLAMAN relayed that his constituent's private health insurance carrier said it would pay for the physician, but not the other seven providers on her care team unless she flies to Seattle. She's been making the trip, but at some point her condition may prevent travel. He clarified that this had nothing to do with the state Medicaid program. He acknowledged his answer did not address Senator Giessel's concern about the cost to add an investigator 3 position. CHAIR WILSON noted that the bill describes "life-threatening condition" a little differently than the language in House Bill 265 which is the existing telehealth law. 3:46:09 PM MS. POTTER clarified that SB 91 does not change the definition of "life threatening condition" that was used in House Bill 265. The reference in paragraph (2) of Section 1 describes the situation by which a patient may receive telehealth care. It does not reference the life threatening condition that was defined in House Bill 265. 3:46:43 PM CHAIR WILSON referenced Section 3 and questioned how sanctions imposed on out-of-state providers could be enforced. 3:47:39 PM MS. POTTER replied that the telehealth law authorizes the State Medical Board to impose disciplinary sanctions on out-of-state physicians. SB 91 addresses a broader range of providers that would be overseen by more than a single board, so the bill identifies the department as the entity that provides oversight and is authorized to impose sanctions. 3:48:32 PM CHAIR WILSON turned to invited testimony on SB 91. 3:49:01 PM BROOK LAVENDER, Care Services Coordinator, North Puget Sound & Alaska, ALS Association, Girdwood, Alaska, related her experience working with Alaskans who suffer from ALS and are forced to make daily decisions that affect their overall wellbeing and quality of life. Many Alaskans with ALS have had to move to another state to receive care from a multidisciplinary care team. The complex treatments they require often are not available where they live or there is a significant wait to receive the care. SB 91 seeks to improve access to care by expanding the use of telehealth and telemedicine. This would allow Alaskans to receive care from specialists in other states without having to travel. She noted that the Veterans Administration currently authorizes care from a multidisciplinary team for veterans living in Alaska. She emphasized that increasing access to care for people with terminal illnesses and rare diseases is a matter of equity; all Alaskans should have access to the type of care they need to manage their disease and improve their quality of life. The data shows that investing in telehealth and telemedicine improves health outcomes and helps reduce health care costs. Passing SB 91 would send a message that Alaska is committed to supporting its citizens by making it easier to access the care they need. She urged the committee to pass SB 91. 3:51:58 PM BEVERLY WOOLEY, representing self, Big Lake, Alaska, stated that before retirement she worked in public health for more than 30 years. As such, she was testifying to voice support for SB 91 to expand telehealth for providers and Alaskans. She related that her goal was always to ensure all Alaskans have access to health care services that they need in the most cost-effective way possible. SB 91 facilitates that goal. She described her personal need to access care from her out-of-state multidisciplinary care team due to complications from breast cancer treatment. There are only a few of these specialists in the US. She flew to Ohio to establish care with a physician who pioneered the surgical procedure she needs. The surgery is scheduled this fall but she also needs additional pre- as well as post-surgery care, some of which will be provided by members of her multidisciplinary care team. If SB 91 passes, she could receive care from these providers via telehealth. If it doesn't pass, she will have to spend the time and considerable money to travel to Ohio for each service. If she were to convince the doctor to provide the services himself, it would take away the time he has to provide the services that he alone is able to provide. She opined that in light of the physician shortages, it was sensible to allow members of the physician's multidisciplinary team to provide the services via telehealth that they routinely provide during in-person appointments. She urged the committee to support SB 91 which will help ensure that Alaskans receive the medical care they need for serious and life-threatening conditions without incurring needless travel expenses and time away from home and work. 3:57:16 PM EMILY NENON, Alaska Government Relations Director, American Cancer Society Cancer Action Network, Anchorage, Alaska, stated that she worked on the telehealth legislation that passed last year, and she was able to report that people with life- threatening conditions were using the narrow provision to receive the care they need. An issue that has come up since that bill passed is that it's often somebody other than the physician who is providing much of the care. She cited examples to illustrate the need for the narrow expansion of the provision. She also expressed appreciation for the provisions in SB 91 that provide additional patient protections to ensure that the care that's provided is up to professional standards. She thanked the committee for considering the bill. 3:59:25 PM CHAIR WILSON opened public testimony on SB 91. 3:59:44 PM ERICK CORDERO, Vice President of Operations, Alaska Policy Forum (APF), Palmer, Alaska, stated that APF urges this committee to adopt policies that reduce health care costs and increase access to care for all Alaskans. He said people learned a lot about telehealth and remote health care services during the COVID-19 pandemic. This led policymakers to pass legislation in 2022 to temporarily allow some use of telehealth, but more needs to be done. Alaskans living in rural areas who are homebound and immunocompromised should have access to health care providers of their choosing and on a timely basis. Currently most Alaskans are only able to access specialists, second opinions, or team- based care via telehealth by traveling out of the state. This is costly, time-consuming, and not beneficial to the person's health. Expanding the telehealth law to include a multidisciplinary care team will give Alaskans access to more care professionals at a lower cost. He thanked the committee for considering SB 91. 4:01:30 PM CHAIR WILSON closed public testimony on SB 91. CHAIR WILSON asked Sylvan Robb if she agreed that the bill would allow anyone to say they were part of a multidisciplinary care team as long as they had an established relationship. Once that's established, the professional licensing division would allow that individual to offer their services within Alaska via telehealth. 4:02:22 PM SYLVAN ROBB, Director, Division of Corporations Business and Professional Licensing, Department of Commerce Community and Economic Development, Juneau, Alaska, responded that she interpreted the language in the bill to say that. She added that Alaska statutes require anybody who practices via telehealth within the state to register with the telehealth registry so the division has a record of those individuals. 4:02:55 PM CHAIR WILSON asked how many out-of-state physicians had signed up with the telehealth registry. MS. ROBB replied that she did not know how many people were on that registry. She also clarified that the registry existed prior to the passage of the telehealth bill. CHAIR WILSON asked what impact SB 91 would have on the department in terms of additional costs since the department would be tasked with investigations and enforcement as opposed to the separate boards and commissions. 4:03:59 PM MS. ROBB confirmed that in the FY24 budget, investigations shift from being paid by the licensees of the particular profession to being paid with general funds. The DCCED fiscal note represents the department's best estimate of what the cost might be for investigations of out-of-state providers. 4:04:32 PM SENATOR GIESSEL asked if there was a fee to sign up for the telehealth registry. MS. ROBB replied it's a $50 fee. 4:04:46 PM SENATOR GIESSEL asked what the application form for the registry looks like. MS. ROBB replied that it's not very involved but the applicant is required to have an Alaska business license which can be obtained online. 4:05:37 PM SENATOR GIESSEL asked what kind of questions the application asks about criminal background and negligent practice. MS. ROBB clarified that the telemedicine business registry application is a business registry, not individuals. If a practice covers a number of different providers, they are not to apply individually. A sole provider must apply under their business. The requirements are to have an Alaska business license and to identify the primary health care code that the business will provide. She said she'd follow up if she learns there is other information the applicant has to provide for the registration. 4:07:00 PM SENATOR GIESSEL stated that as a former member of the Board of Nursing she was dumb founded. She is a fan of telehealth but based on what she's heard, there is no assurance that the undefined clinicians would be qualified. She said it's understandable that the VA provides this for veterans living in Alaska because it has a national licensure. Alaska has a state licensure so a licensee's credentials can be checked. She commented that Ms. Robb's answers heightened her concern. CHAIR WILSON asked whether the department or a board or commission could verify the out-of-state credentials for somebody who applies to provide telehealth services in Alaska. 4:08:59 PM MS. ROBB paraphrased the statutory requirements for the telehealth registry: Sec. 44.33.381. Telemedicine business registry.  (a) The department shall adopt regulations for establishing and maintaining a registry of businesses performing telemedicine services in the state. (b) The department shall maintain the registry of businesses performing telemedicine services in the state. The registry must include the name, address, and contact information of businesses performing telemedicine services in the state. She said she didn't believe the department would have the authority to request additional information about an applicant's credentials without additional authorization. 4:09:36 PM CHAIR WILSON asked about the possibility of the department developing another registry of out-of-state telehealth providers and members of their multidisciplinary care teams that would address Senator Giessel's concerns about safety and the licensee paying the cost of investigations and background checks. 4:10:17 PM MS. ROBB confirmed that the department could develop such a registry if it had the statutory authority and funding for the personnel. She added that registering with the existing registry is required for both in-state and out-of-state providers of telehealth services in Alaska. CHAIR WILSON stated that the concern is about due diligence to ensure the safety of Alaskans who are receiving telehealth care services from out-of-state providers. CHAIR WILSON asked the sponsor if he had any closing comments. SENATOR CLAMAN offered to answer questions. 4:11:55 PM SENATOR DUNBAR mentioned Senator Giessel's safety concerns and asked how much he envisions tort or medical malpractice law to be a factor if the bill were to pass and somebody on the multidisciplinary care team provided inadequate care and a patient in Alaska was hurt. He commented, "It seems like they would have pretty good cause to, frankly, sue the shirt off of that doctor." SENATOR CLAMAN said he didn't believe the bill would change the analysis of whether a physician is liable for malpractice. Should the bill pass, the more likely question would be whether somebody like a physical therapist in Seattle who is providing telehealth services would be subject to a medical malpractice action in Alaska. He opined that they probably would be subject to jurisdiction in Alaska because they registered with the telehealth provider network and they gained a benefit from providing that service. He opined that a secondary question was in which jurisdiction to file the lawsuit. 4:14:42 PM SENATOR DUNBAR asked if it was fair to say that a physician would be at the center of the multidisciplinary care team. 4:14:57 PM SENATOR CLAMAN agreed. 4:15:02 PM SENATOR DUNBAR asked if it was fair to say that the original telehealth bill relied on the fact that the specialty physicians would be of high quality compared to similar specialists in any other state. SENATOR CLAMAN suggested that Chair Wilson was better able to answer the question. CHAIR WILSON responded that he carried the companion bill and that was the intent. SENATOR DUNBAR opined that it would be the physician and the state that licensed that physician who would be held responsible, so SB 91 seems to expand on what the legislature deemed was okay last year. He summarized his colleague's concern that this bill opens the net so wide that it risks including care providers who might not provide care that is safe for Alaskans. 4:16:28 PM SENATOR CLAMAN said he wasn't sure there would ever be a complete answer to the question but he believes that both the physician at the core of the multidisciplinary care team and the physical therapist in the example would be subject to civil malpractice. The policy question is whether to allow somebody with cancer, for example, to be served by members of an out-of- state multidisciplinary care team who have expertise in the area. This recognizes there is some regulatory authority over the person who joined the telehealth network to provide specialty care that isn't available in Alaska. 4:18:21 PM SENATOR GIESSEL said she understands that telehealth solves the problem of limited access to specialty care providers in Alaska, but the state licenses health care professionals for the sole purpose of protecting the public. Noting the discussion about civil liability, she said her interest is to prevent malpractice and fraud. She mentioned diploma mills and the highly skilled specialty physicians that she knows who willfully committed malpractice. She opined that the public relies on the state to examine credentials and ensure that the licensed professionals who practice in Alaska provide safe care. The system does not rely on a single investigator. She said she supports the intent of SB 91, but pieces of it need to be fixed to ensure public safety. 4:20:05 PM SENATOR CLAMAN said he and Senator Giessel probably agree that the legislature's role is not to monitor malpractice litigation. He believes that the bill strikes the right balance between providing reasonable access to care for critically ill Alaskans who need specialty care that an out-of-state multidisciplinary care team can provide via telehealth and providing as much supervision as possible for the cost. He described SB 91 as a rational approach, but that didn't mean he wasn't open to discussion about trying to strike a balance that's more satisfactory to the members of the committee. 4:22:13 PM SENATOR GIESSEL commented that during the COVID-19 pandemic there was a definite increase in the instances of health care providers misrepresenting their credentials. 4:22:47 PM SENATOR TOBIN asked whether the Prescription Drug Monitoring Program (PDMP) in Alaska communicates with the PDMP in other states so medical providers have all the information they may need about their patients. MS. ROBB answered that the Alaska PDMP communicates with the PDMPs in other states that use the same vendor and the same software, but she didn't know what that number was. She offered to follow up with the information. SENATOR TOBIN said she'd appreciate the information because the PDMP is another mechanism to ensure the safety of Alaskans. CHAIR WILSON asked which database would have the information about a prescription that is written by an out-of-state telehealth provider for a patient in Alaska. 4:25:09 PM MS. ROBB explained that physicians who are licensed in Alaska are required to register with the Alaska PDMP. CHAIR WILSON observed that under the telehealth bill and SB 91, if it passes, multiple care providers who are not licensed in Alaska but may have prescribing authority would not have to register with the Alaska PDMP. 4:25:44 PM MS. ROBB replied that those physicians covered by the telehealth bill that are allowed to treat patients without being licensed in Alaska are not required to register with the Alaska PDMP. MS. ROBB followed up on an earlier question, reporting that at the end of FY2022, 1,525 entities were registered with the telemedicine registry. CHAIR WILSON asked whether the businesses have to renew the registration periodically. MS. ROBB replied that the registration is perpetual. 4:26:53 PM SENATOR CLAMAN asked how many of the 1,525 registrants were from out-of-state versus in-state. MS. ROBB said she didn't know but she would follow up with the information. 4:27:20 PM CHAIR WILSON held SB 91 in committee.