SB 44-TELEHEALTH: PHYSICIAN ASSISTANTS; DRUGS  2:13:02 PM CHAIR REINBOLD reconvened the meeting. She announced that the final order of business would be SENATE BILL NO. 44, "An Act relating to the prescription of drugs by a physician assistant without physical examination." 2:13:05 PM SENATOR COSTELLO clarified the original version of SB 44 was before the committee. Senator Bishop objected for discussion purposes. 2:13:15 PM SENATOR CATHY GIESSEL, Alaska State Legislature, Juneau, stated that this bill relates to telehealth and physician assistants. She said that while she is a health care professional, she is not a physician assistant (PA) and derives no benefit from the bill. She described this bill as a "clean up bill" that will increase access to care throughout Alaska. She paraphrased from her sponsor statement for SB 44, which read: The 2016 Medicaid Reform bill (Senate Bill 74) provided for the use of telehealth by revising Alaska statutes to require the Alaska Board of Medicine to adopt regulations and guidelines for physicians rendering a diagnosis, providing treatment, or prescribing, dispensing, or administering a prescription drug to a person without conducting a physical examination under AS 08.64.364. 2:14:19 PM Consequently, the omission of PAs from the Medicaid Reform bill has led to them being subject to limitations on the use of telemedicine. Specifically, the Medical Board released guidelines stating that physician assistants could not treat a patient via telemedicine without first conducting an in-person examination personally, or with a collaborating physician or other practitioner in the same group practice. 2:14:54 PM SENATOR GIESSEL said that physician assistants (PAs) have been prohibited from practicing telemedicine. She explained that physician assistants are a type of clinician that developed during the Vietnam War. These were medics who went to Vietnam and had to practice very high-level medical care. Actually, they replaced doctors in the war field. They came back to the US with these skills. Physicians realized that these medics were highly skilled. She referred to a document in members' packets labeled "AAPA." The American Academy of Physician Assistants (AAPA) discusses the education and experience of physician assistants. PAs are required to have 27 continuous months of education, including classroom education in medical sciences, and to perform rotations in medical and surgical disciplines, family medicine, internal medicine, general surgery, pediatrics, and obstetrics. These medical professionals must have at least 2,000 hours of clinical practice in various settings and almost all physician assistant programs are master's degree programs. In fact, it will be required by the year 2020. After graduation, they must pass the physician assistant national certifying exam and be licensed by the state. Every two years they must complete 100 hours of continuing medical education and every ten years they must take an exam to recertify. She characterized these physician assistants as medical professionals with substantive education. 2:17:02 PM SENATOR GIESSEL referred to medical board guidelines for collaborating physicians and physician assistants in members' packets. She said that physician assistants (PAs) must practice under the supervision of a collaborating physician. They must have an active collaborative plan, which describes the nature of the relationship, the scope of practice, where they will be practicing, and what controlled substances they can prescribe. Physician assistants have the authority and ability to apply to the Drug Enforcement Administration to obtain authorization to prescribe controlled substances. They may or may not choose to do so, but if they do, their collaborating physicians oversee the prescribing authority. 2:18:12 PM SENATOR GIESSEL related the controlled substances physician assistants are authorized to prescribe, including schedule II through schedule V drugs. She offered to provide the document, but basically explained that schedule II includes drugs such as oxycodone and morphine, schedule III includes drugs such as codeine, schedule IV includes drugs such as Darvon, and Schedule V includes drugs such as Robitussin with codeine. 2:19:01 PM SENATOR GIESSEL explained that the bill would expand telemedicine to physician assistants (PAs). She continued to review her sponsor statement, as follows: SB 44 amends the law, aligning with the intent of the Medicaid Reform bill, to clarify that physician assistants can provide telemedicine in the same manner as physicians. Under SB 44, the physician assistant would be subject to the same statutory oversight as physicians regarding the practice of telemedicine, as well as the same disciplinary sanctions when appropriate Senate Bill 44 will increase patient access to care, particularly for rural and medically-underserved areas. The bill will allow PAs to use telemedicine, extending the reach of medicine to underserved areas. This is particularly important in Alaska, with vast geographical challenges and limited access to vital healthcare. She referred to HRSA document in members' packets. Alaska is a health professional shortage area. 2:20:40 PM SENATOR BIRCH asked for further clarification on whether this would cover nursing and nurse practitioners. SENATOR GIESSEL said that nurse practitioners have independent practice in Alaska and can open their own clinics and have no limitations on prescriptive authority. They can obtain Drug Enforcement Administration (DEA) numbers that allow them to prescribe controlled substances, which has been in place since 1983. They often practice with physician assistants (PA) and often perform the same work, but PAs are under the state medical board and require supervision. 2:21:44 PM SENATOR COSTELLO appreciated the history of PAs. She watched a Vietnam War documentary and can see many individuals came back from that war with an arsenal of experience in the field. She said "patient" is replaced with "person" However, on page 3, line 13 of the bill relates to the term "physician-patient relationship." She asked whether the term "patient" is defined in statute or if it is a commonly-understood term. SENATOR GIESSEL said that law uses the term "person" and "patient" as medical terminology and often refers to them as clients. She characterized it as a term of art whereas person is a legal term. However, physician-patient relationship in used in other places in the medical statutes. 2:23:32 PM JANE CONWAY, Staff, Senator Cathy Giessel, Alaska State Legislature, Juneau, paraphrased the sectional analysis, which read as follows: Senate Bill 44 Sectional Analysis (vsn U) Telehealth: Physician Assistants; Drugs Section 1: Amends AS 08.64.101(a)(6) by requiring the board to adopt regulations for a physician assistant practicing telehealth under AS 08.64.364, and that the regulations must use a recognized national model for standards of telehealth care. Section 2: Amends AS 08.64.364(a) by saying that disciplinary action cannot be directed toward a physician assistant for prescribing drugs via telehealth if the drugs are not controlled substances, if follow up care can be provided from its medical group, and if consent has been given by the patient for care and sharing of records to the primary care provider. Section 3: Amends AS 08.64.364(b) by saying that a physician assistant may administer botulinum toxin (Botox) if they meet all the requirements set out in 08.64.364 and is supervised by an appropriate licensed health care provider Section 4: Amends AS 08.64.364(c) by renumbering and adds that a physician or physician assistant may not prescribe, dispense or administer a prescription drug via an Internet questionnaire or email message without having a prior patient/doctor relationship. 2:25:47 PM SENATOR COSTELLO said that it seems that the guidelines that were written by the board just need to be updated to include PAs. she asked whether the sponsor has considered adding an immediate effective date. MS. CONWAY said that this bill would become effective after the governor signs the bill. 2:26:21 PM SENATOR BIRCH asked whether administering Botox is a change. SENATOR GIESSEL answered that Botox requires the presence of a licensed health care provider who is authorized to administer that medication. This is current law for physicians and the bill adds PAs. Currently, physicians can prescribe, dispense, and administer a controlled substance or botulinum toxin when an appropriate licensed health care provider is present with the person. This language is listed separately because these are heavy duty medications being administered. 2:27:43 PM CHAIR REINBOLD opened public testimony on SB 44. 2:29:38 PM CHERISE HUG, Physician Assistant (PA), Orion Behavioral Health Network, Eagle River, stated she is a PA in Anchorage and works in child and adolescent psychiatry. About half of her time is spent in person and the other half is spent providing telemedicine to remote communities throughout the state. She said PAs are allowed to provide telemedicine, but they cannot prescribe medications without having a face-to-face relationship. She said this has created a burden and difficulty for patients in rural communities to access care. She said that the delay can be detrimental to families. Currently, if she provides an initial evaluation via telemedicine, she cannot start any medication. This causes delays and hinders patient care. It requires patients to travel and adds significant travel costs to patient care. 2:31:33 PM SENATOR BIRCH asked for her experience with audio or video transmission and if it is an effective means of providing care. MS. HUG answered that she uses an Internet-based service that has a video connection. She said they have good cameras, but it depends on what patients have at their end. She explained that the quality of the video tends to be pretty good. She said that she often works with other clinics and patients can go to a community health office for the telehealth appointment. SENATOR BIRCH asked how patients receive their prescriptions. DR. HUG answered that patients use mailout pharmacy services via Walgreens and Southcentral Foundation. The patient's provider ships the medication directly to the patient. 2:34:19 PM SHIGONE BEIGHLE, Physician Assistant (PA), Orion Behavioral Health Network, Anchorage, echoed Ms. Hug's testimony. She stated that about 50 percent of her patients are pediatric psychiatric patients in rural communities. She was raised in a rural community of 500 in Aniak. She said that at age 13 she lost three peers to suicide. Her school had a population of 50 between 7th-12th grades. She said that the loss of three students in one year was significant. She said that Alaska has the highest rate of teen suicide and Alaska Natives and rural communities have the highest rates. She said that her organization provides care via telehealth to children throughout the state, including Barrow and King Cove. This service provides opportunities she wished had been available to depressed teens during her high school years. She related a patient experience, in which a child under the age of 10 had three depressive stints at North Star Behavioral Health (North Star) with limited out-patient care and delayed access stabilization and care. Although North Star provided the initial care, the child will face delays for stabilized care and maintenance if she cannot not write prescriptions until she meets face-to-face with the child. She said that in these situations, the parents and medical staff are already dealing with an unstable child or a child in need. She said adding travel is expensive and adds undue burdens for those working to help children in crisis. She said that she got into the field of medicine and psychiatry because of the great need in Alaska and her desire to serve the rural population. She expressed gratitude for the services that her organization provides and the telehealth services it provides. She expressed concern that medical professionals see patients and then cannot do anything, which is detrimental to patients. She said, "Maybe not being seen and doing nothing is almost the same." 2:37:20 PM CHAIR REINBOLD recalled a friend's experience at a hospital emergency room, with very high costs for services. She hoped that telemedicine would help reduce costs. She hoped to further discuss emergency room costs and the trauma psychiatric patients experience in those situations. 2:38:56 PM CHAIR REINBOLD held public testimony open on SB 44. 2:39:19 PM SENATOR GIESSEL referred to six letters of support from physician assistants in rural Alaska that are in members' packets. [SB 44 was held in committee.]