SB 91-TELEHEALTH: MULTIDISCIPLINARY CARE TEAM  4:20:36 PM CHAIR WILSON reconvened the meeting and 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." He noted that this was the second hearing and there were two amendments for the committee to consider. 4:21:17 PM CHAIR WILSON moved to adopt Amendment A.6 ("Amendment 1"), work order 33-LS0193\A.6. 33-LS0193\A.6 Bergerud 4/5/23 AMENDMENT 1 OFFERED IN THE SENATE BY SENATOR WILSON Page 6, following line 29: Insert new bill sections to read:  "* Sec. 4. AS 44.33.381(b) is amended to read: (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. The department may  renew every three years the registration of a business  that meets all renewal requirements established by  regulation and pays a renewal fee every three years.  * Sec. 5. AS 44.33.381 is amended by adding a new subsection to read: (d) The department shall charge the following fees for businesses performing telemedicine services in the state: (1) initial registration fee, $100; (2) renewal fee, $100; (3) fee to report changes in the business's registration information, $50."  4:21:31 PM SENATOR KAUFMAN objected for purposes of discussion. 4:21:35 PM CHAIR WILSON explained that Amendment 1 changes the registration fee for the telehealth registry to $100 and adds a $100 renewal fee every three years. The existing $50 fee for a business to change its registration information remains the same. 4:22:18 PM SENATOR TOBIN referenced paragraph (3) in Section 5 of the amendment and commented that charging $50 to update a business's registration information might keep some businesses from making updates. She asked for more information. CHAIR WILSON suggested that Sylvan Robb speak to question because the provision was existing language. 4:23:28 PM SYLVAN ROBB, Director, Division of Corporations, Business & Professional Licensing, Department of Commerce, Community, and Economic Development (DCCED), Juneau, Alaska, stated that the current fee to register with the telemedicine registry is $50. SENATOR TOBIN said she'd like to look at the statute. 4:24:00 PM At ease. 4:26:45 PM CHAIR WILSON reconvened the meeting. 4:26:51 PM SENATOR TOBIN read subsection (a) of AS 44.33.381 relating to the telemedicine business registry which did not mention fees. She articulated her reservations about placing a fee in statute rather than regulation, and noted that many businesses update their information every two years and the amendment calls for a three-year renewal. She asked the Chair if he would entertain a conceptual amendment to change "every three years" to "every two years" on lines 7 and 9 and allow the fees to be set in regulation. CHAIR WILSON suggested breaking the items into two conceptual amendments. He added that his hesitation is that the department might not get around to updating the fees timely. 4:28:35 PM SENATOR TOBIN agreed to make two motions. She moved to adopt Conceptual Amendment 1 to Amendment 1. CONCEPTUAL AMENDMENT 1 TO AMENDMENT 1  Page 1, lines 7 and 9 replace 3 years with 2 years. 4:29:02 PM CHAIR WILSON asked if there was any objection; he found none and Conceptual Amendment 1 to Amendment 1 was adopted. 4:29:12 PM At ease. 4:29:56 PM CHAIR WILSON reconvened the meeting. 4:30:00 PM SENATOR TOBIN moved Conceptual Amendment 2 to Amendment 1. CONCEPTUAL AMENDMENT 2 TO AMENDMENT 1  Page 1, line 13, following: "initial registration fee, $100;" Insert: "adjusted for inflation set by the department;" 4:30:28 PM CHAIR WILSON objected for purposes of discussion. 4:30:38 PM SENATOR KAUFMAN asked how the fee would be determined. CHAIR WILSON opined that it would be done through the regulatory process. He asked Ms. Robb to speak to that process. 4:31:00 PM MS. ROBB confirmed that most fees are in regulation and adjusted periodically, to ensure that the fee is roughly equal to the cost to administer the program. She advised that the telemedicine business registry was not administratively burdensome and confirmed that if the registration is renewed every two years, the fee would be reviewed on that schedule as well. 4:32:09 PM SENATOR KAUFMAN warned about making incremental changes that cost more than the revenue that's realized. 4:32:24 PM SENATOR GIESSEL suggested a further amendment to add the inflation adjustment to the renewal fee on line 14 of Amendment 1. She moved to adopt Conceptual Amendment 3 to Amendment 1. CONCEPTUAL AMENDMENT 3 TO AMENDMENT 1  Page 1, line 14, following: "renewal fee, $100;" Insert: "adjusted for inflation set by the department;" 4:32:36 PM CHAIR WILSON found no objection and Conceptual Amendment 3 to Amendment 1 was adopted. 4:32:52 PM CHAIR WILSON removed his objection to the two conceptual amendments Senator Tobin offered. He found no further objection and Amendment 1, as amended, was before the committee. 4:33:13 PM SENATOR DUNBAR commented that changing the renewal from every three years to every two years results in a 50 percent increase in the renewal fee and he hopes that is enough for the department to recoup its costs. He referenced the fee for changing the business's registration information in subsection (d)(3) and suggested the committee consider eliminating it because providing updated information is behavior that should be encouraged. CHAIR WILSON deferred to Ms. Robb since the provision was already in regulation. 4:34:19 PM MS. ROBB opined that since the change fee was in the current regulations, it was difficult to say whether eliminating it would change behavior. SENATOR DUNBAR asked how often the $100 renewal fee is charged currently. MS. ROBB replied that the telemedicine business registry is perpetual. The registration does not expire so there is no renewal fee. Responding to an additional question, she confirmed that Amendment 1 adds the renewal fee. SENATOR DUNBAR asked if she agreed that, should the amendment pass and the registration is renewed every two years, the department will get updated information about the businesses every two years. 4:35:23 PM MS. ROBB agreed. SENATOR DUNBAR asked if she believes that the renewal process will be sufficient to collect the data that's needed or if the provision in paragraph (3) to report changes in the registration information is also needed. 4:35:51 PM MS. ROBB responded that she views it as a policy call. She added that the data on the telemedicine business registry isn't used very much, but if that were to change it would be beneficial to have up-to-date data. 4:36:25 PM SENATOR DUNBAR suggested the committee remove paragraph (3) from Amendment 1. 4:36:45 PM SENATOR GIESSEL said a reason for keeping paragraph (3) and collecting a $50 to update a healthcare business's registration information is that email addresses and names sometimes change and it's helpful to licensees and the division to have that information recorded somewhere. CHAIR WILSON opined that the $50 change fee would be insignificant for most healthcare businesses. SENATOR DUNBAR asked the bill sponsor for his view of subsection (d)(3) of Amendment 1 which imposes a $50 fee for a business to report changes in their business registration information. 4:38:24 PM SENATOR CLAMAN responded that in light of all the proposed changes, he views the $50 change fee as a disincentive for businesses to provide the information. He added that he was always hesitant to legislate things that are usually done by regulation. Thus he would support an amendment to remove paragraph (3) on lines 15 and 16 of Amendment 1. 4:39:53 PM SENATOR DUNBAR asked for confirmation that the department could impose a similar change fee through regulation. CHAIR WILSON said that's correct. 4:40:09 PM SENATOR DUNBAR moved to adopt Conceptual Amendment 4 to Amendment 1. CONCEPTUAL AMENDMENT 4 TO AMENDMENT 1  Page 1, lines 15-16: Delete: "(3) fee to report changes in the business's registration information, $50." 4:40:23 PM CHAIR WILSON objected for purposes of discussion. He said wanted the business registry to remain viable and he thought it was reasonable for a business to pay a fee for the department to process changes in its registry information. He added that he was hesitant to rely on the department imposing a fee through regulation because that process is so slow. 4:42:11 PM SENATOR GIESSEL agreed with his thoughts; the cost of state government is increasing and the Division of Corporations, Business & Professional Licensing is shorthanded, so the $50 fee could make a difference in funding the activities related to the bill. 4:42:45 PM CHAIR WILSON asked for further discussion; he found none and asked for roll call vote on Conceptual Amendment 4 to Amendment 1. 4:43:01 PM A roll call vote was taken. Senators Dunbar and Tobin voted in favor of Conceptual Amendment 4 to Amendment 1 and Senators Giessel, Kaufman, and Wilson voted against it. The vote was 2:3. 4:43:23 PM CHAIR WILSON announced that on a vote of 2 yeas and 3 nays, Conceptual Amendment 4 to Amendment 1 failed. CHAIR WILSON asked for further discussion on Amendment 1 as amended; he found none. 4:43:44 PM SENATOR KAUFMAN removed his objection. 4:43:44 PM CHAIR WILSON found no further objection and Amendment 1 as amended, was adopted. 4:43:49 PM CHAIR WILSON solicited a motion for Amendment A.8 (Amendment 2") by Senator Giessel. 4:43:54 PM SENATOR GIESSEL moved to adopt Amendment A.8 ("Amendment 2"), work order 33-LS0193\A.8, to SB 91. 33-LS0193\A.8 Bergerud 4/6/23 AMENDMENT 2 OFFERED IN THE SENATE Page 1, line 8, following "AS 08.01.087.": Insert "A member of a physician's  multidisciplinary care team may provide a health care  service through telehealth to a patient located in  this state only if the health care service is not  otherwise available in the state." Page 3, lines 3 - 5: Delete "that includes a physician licensed in  another state who meets the requirements of (b)(1) of  this section" Page 3, following line 5: Insert new bill sections to read:  "* Sec. 3. AS 08.02.130(j) is amended by adding a new paragraph to read: (5) "member of a multidisciplinary care team" means an audiologist, speech-language pathologist, behavior analyst, professional counselor, dietitian, nutritionist, naturopath, marital and family therapist, podiatrist, osteopath, physician assistant, nurse, pharmacist, psychologist or psychological associate, or a social worker who is a member of a team that includes a physician licensed in another state who meets the requirements of (b)(1) of this section.  * Sec. 4. AS 08.02.130 is amended by adding a new subsection to read: (k) A member of a multidisciplinary care team shall register with the department before providing telehealth services to a patient located in the state. To register with the department, a member of a multidisciplinary care team shall submit (1) the name of the physician leading the multidisciplinary care team; (2) the area of health care in which the member of the multidisciplinary care team will be practicing and proof of licensure in a state or territory of the United States in that area; (3) any applicable fees, as determined by the department." Renumber the following bill section accordingly. 4:43:57 PM CHAIR WILSON objected for purposes of discussion. 4:44:01 PM SENATOR GIESSEL stated that her goal is to ensure that to every extent possible, Alaskans are providing the telehealth services that are offered in Alaska. The provision on page 1, lines 2-4 clarifies that the members of a physician's multidisciplinary care team may provide health care through telehealth to a patient in Alaska only if the service is not available in Alaska. The language on page 1, line 12 through page 2, line 4 identifies the professions that logically would be part of a multidisciplinary care team that provides telehealth services. She said not all of the professions initially identified in the bill were logical for telehealth services. Section 4 defines the requirements for the members of a multidisciplinary care team which includes registering with the department. The amendment also removes the provision on page 3, lines 3-5 of the bill because it's redundant. CHAIR WILSON asked if there were any questions 4:46:44 PM SENATOR DUNBAR asked which professions were removed from the list of telehealth providers. 4:46:57 PM SENATOR GIESSEL directed attention to the health care providers identified on page 2 line 20 through page 3, line 1 of the bill. The professions removed from that list include chiropractor, dental hygienist, dentist, direct-entry midwife, dispensing optician, physical therapist, and occupational therapist. 4:47:34 PM SENATOR DUNBAR said the list makes sense with the exception of physical therapist and perhaps occupational therapist. He asked if she could think of any circumstances where those services could be provided through telehealth. He cited his personal experience with physical therapy that only initially was in- person; thereafter he was given pictures to use as a guide. 4:48:28 PM SENATOR GIESSEL said it's a good point but physical therapists also have to assess the patient's progress, and that's generally hands-on. The same applies to occupational therapy assessments. CHAIR WILSON asked her to clarify that an in-state physical therapist could offer telehealth services. SENATOR GIESSEL answered yes. 4:49:31 PM SENATOR KAUFMAN offered his understanding that smart phone technology is capable of measuring one's eyes, so optometry services could be delivered via telehealth. He was aware of statutes in Texas that addresses optometry services via telehealth. SENATOR GIESSEL described the differences between an optician, an optometrist, and an ophthalmologist. 4:50:57 PM SENATOR KAUFMAN asked how businesses that provide glasses by mail would fit. CHAIR WILSON responded that the purpose is to allow out-of-state providers to provide services for life-threatening conditions. He didn't consider ordering glasses through the mail in that category. 4:51:41 PM SENATOR DUNBAR asked the bill sponsor whether any of the professions that the amendment excludes would have affected the multidisciplinary care team for his constituent who has ALS and others in similar circumstances that prompted the bill. 4:52:29 PM SENATOR CLAMAN stated that his constituent who has ALS has both a physical therapist and an occupational therapist on her multidisciplinary care team and she sometimes uses telehealth for those services. In addition, the ALS group in Alaska and the American Cancer Society raised questions about the first provision in the amendment regarding a member of the multidisciplinary care team only providing health care services through telehealth to an Alaskan if the health care services are not otherwise available in the state. Both organizations asked whether it was the insurance company or the patient who would have the burden of showing that the service was not otherwise available. To Senator Kaufman's question about telehealth services for optometry and the possibility of using an iPhone app, he said significant brain cancer can affect brain function and it's reasonable to think that somebody in that circumstance would want to see the optician who saw them last. He articulated concern with Section 3 of the amendment, pointing out that making a list of the professions that can be part of a multidisciplinary care team could unintentionally be either over-inclusive or under-inclusive. He argued that the best way to strike a balance between providing care for the patient who wants the care and maximizing the use of providers in Alaska wherever possible was through Section 4 of Amendment 2. 4:58:29 PM SENATOR GIESSEL noted that she had neglected to mention that optometrist was not on the list in Section 3. 4:59:00 PM SENATOR DUNBAR asked Senator Claman if his concern could be alleviated by amending the language on page 1, lines 2-4 of the amendment. 4:59:31 PM SENATOR CLAMAN said his initial thought was to change the language on page 1, line 4 from "not otherwise available in the state." to "not reasonably available in the state." However, he would like to hear from the American Cancer Society and the ALS group in Alaska first, because those organizations have first- hand experience working with highly specialized multidisciplinary care teams and the people who leave the state to receive very specialized care. 5:00:26 PM At ease. 5:00:58 PM CHAIR WILSON reconvened the meeting and advised that the committee's time had run out for the day. 5:01:08 PM CHAIR WILSON held SB 91 in committee with Amendment 2 pending.