HB 265-HEALTH CARE SERVICES BY TELEHEALTH  1:40:13 PM CHAIR COSTELLO announced the consideration of CS FOR HOUSE BILL NO. 265(FIN) "An Act relating to telehealth; relating to the practice of medicine and the practice of nursing; relating to medical assistance coverage for services provided by telehealth; and providing for an effective date." She advised the public that the committee was very familiar with this issue. 1:41:15 PM REPRESENTATIVE IVY SPOHNHOLZ, Alaska State Legislature, Juneau, Alaska, sponsor of HB 265, stated that in the interest of time she would bypass the presentation. She presented the legislation paraphrasing the following sponsor statement for CSHB 265(FIN): The COVID-19 pandemic relaxed Alaska's telehealth laws and enabled broader access to behavioral health and specialty care, created cost-savings from reduced travel, and increased the convenience of high-quality health care to patients across the state. However, Alaskans have faced barriers to telehealth appointments due to regulatory hurdles across professions and inconsistent Medicaid coverage for services delivered via telehealth. Furthermore, COVID- 19 related flexibilities were regulatory suspensions and not permanent. HB 265 maintains these pandemic-related telehealth flexibilities and expands Alaska Medicaid coverage of telehealth services in statute as follows. 1) Creates a new section on telehealth for all health care providers licensed with the State of Alaska that removes the requirement for an in-person visit and documentation of a barrier to an in-person visit prior to the delivery of telehealth. 2) Allows telehealth follow-up visits from physicians licensed in another state who have established a physician-patient relationship and conducted an in- person physical examination with an Alaska patient. 3) Ensures telehealth availability for services related to opioid use disorder and controlled substances for certain providers. 4) Increases telehealth access for Alaska Medicaid beneficiaries by ensuring coverage for services for behavioral health, home and community-based services, rural health clinics, federally qualified health centers, and other programs eligible for Alaska Medicaid reimbursement. Ensures payment parity and Medicaid coverage for telehealth modalities (e.g., appointments over the Internet, phone, etc.). 5) There is no requirement to deliver services through telehealth, and both the provider and the patient may choose to limit or decline a telehealth encounter. Comprehensive telehealth delivery has revolutionized health care in Alaska by creating another tool for providers to care for patients when they cannot physically be together. HB 265 will continue to modernize the state's health care system to the benefit of all Alaskans. 1:44:13 PM REPRESENTATIVE IVY SPOHNHOLZ stated that HB 265 aligns the statute regarding controlled substances via telehealth with the federal Drug Enforcement Agency (DEA) regulations so Alaska providers have to comply with just one set of regulations. DEA regulations require an in-person examination prior to prescribing a controlled substance, and the bill ensures that people have access via telehealth to controlled substances once they have established a relationship with a provider. The bill supports the marketplace for telehealth by ensuring equal pay for equal work, but allows lower Medicaid payments when services are not comparable. This supports reduced health care spending. She noted that between FY 2020 and FY2021, Medicaid increased telehealth spending and reduced Medicaid travel for a net savings of 38 percent or $46 million. 1:45:34 PM REPRESENTATIVE SPOHNHOLZ highlighted the narrow exception crafted in HB 265 to allow Alaskans to receive follow-up care with doctors they have seen from out of state. The Alaska State Medical Association supports this change to help eliminate unnecessary travel. The Division of Corporations, Business, and Professional Licensing has oversight and the ability to recoup costs in the event there is a bad actor licensed in another state. The bill also allows more flexibility in the mode of delivery of telehealth and it protects the patient/provider relationship. Nothing in the bill requires the provider to deliver care via telehealth or the patient to receive care via telehealth. REPRESENTATIVE SPOHNHOLZ underscored that HB 265 does not allow non-Alaskan providers to practice in Alaska without state licensure. This was important to stakeholders, and the telemedicine business registry for Alaska shows that 84 percent of registrants are Alaskan providers and the 16 percent of non- Alaskan providers are licensed in Alaskan. The bill also does not increase access to controlled substances. Both prescription drug limits and the Prescription Drug Monitoring Program (PDMP) remain in place, and DEA regulations still require in-person examinations before an opioid is prescribed. She highlighted that providers throughout the state report being able to provide high-quality care to Alaskan patients. She said the invited and public testimony will talk about how telehealth has increased access to care without a reduction in quality. REPRESENTATIVE SPOHNHOLZ extended her thanks to the diverse group of stakeholders her office had been working with over the last 18 months to get HB 265 passed. She added that the robust expansion the bill proposes could not have been accomplished without the partnership with both DCCED and DHSS. 1:49:16 PM CHAIR COSTELLO turned to invited testimony and recognized Dr. Melinda Rathkopf, the director of the Allergy, Asthma, and Immunology Center of Alaska. 1:49:37 PM DR. MELINDA RATHKOPF, Director, Allergy, Asthma, and Immunology Center of Alaska (AAICA), Anchorage, Alaska, stated that she has been practicing medicine at AAICA for 16 years and she wanted to share how telehealth has made it easier for the clinic to serve the entire state. She explained that the clinic has satellite clinics and had already started looking into telehealth before the pandemic. They had purchased some of the software and hardware, which made the transition easier. DR. RATHKOPF said she wanted to speak to the bill to stress the importance of pay parity for telehealth. Her clinic accepts all payment options and it's challenging to continue to provide care as the cost of everything continues to rise except reimbursements. It wouldn't be sustainable if they go down. She explained that by paying in parity she can block a half day and see patients in outlying areas via telehealth and still pay the ongoing costs to maintain the brick and mortar office in Anchorage. Doing telehealth doesn't eliminate the need to pay her receptionist and other staff or order supplies. These costs are ongoing regardless of the mode of delivery of care. She said allowing parity in pay will continue to be key in continuing to be able to provide annual and follow up service for instate physicians. DR. RATHKOPF stated that allowing out-of-state providers to provide follow-up care works well for her business. For example, she sees some rare immune deficiency patients some of whom have to utilize services through Seattle. It's been very helpful for these high risk patients to get follow-up care without having to take time to fly down and risking potential exposures during that flight. She described HB 265 as a very good compromise that allows Alaska physicians to provide care for their patients while also allowing those patients to receive care from an out- of-state provider when it's appropriate. 1:54:13 PM CHAIR COSTELLO commented that it seems that her particular specialty lends itself to in-person visits. She asked her to talk about what happens differently for her patients when they have a telehealth appointment versus an in-person appointment. DR. RATHKOPF responded that she was initially concerned about not being able to lay her hands on her patients, but quite a bit of an exam can be done over video and her patients have a primary physician who has done an in-person exam. She acknowledged that certain procedures like skin and pulmonary testing require an in-person visit, but pointed out that allergists treat a lot of diseases that do not require any testing. She advised that one reason her clinic started telehealth pre-pandemic was to screen out those who had to be seen in person versus via telehealth. Sometimes she determines a patient really needs an in-person visit but the telehealth option cuts down up to 75 percent of the people that will require travel or need to be put on a waitlist so she can travel to meet them. Telehealth makes her more efficient both at her satellite clinics and her office. 1:56:22 PM SENATOR STEVENS referenced a book he'd been reading on longevity that offers statistical evidence that patients who have a personal relationship with their doctor live longer than those who do not have that type of relationship. He asked if she had any further reflection on the importance of a personal relationship with a doctor. DR. RATHKOPF said her experience is that doctor/patient relationships that were established in person can easily continue online. What she believes would be very difficult is to establish a relationship in the telehealth model where the patient calls a national line and gets a different provider each call. She assured the committee that most providers in Alaska that are participating in telehealth are using it to support established patients. 1:58:53 PM SENATOR MICCICHE stated that when he worked on an early telehealth bill he was led to believe that telehealth would be at a lower cost because there wouldn't be the facility and materials costs and the visits would be shorter than in-person visits. He asked for her logic on why pay parity is the correct path. 2:00:11 PM DR. RATHKOPF said it would be difficult to justify blocking half or a whole day clinic to treat telehealth patients if she weren't paid the equivalent because she could easily fill the clinic with in-person patients. She said most providers squeeze telehealth into blocks during the day, but the overhead costs still exist and the telehealth appointments generally take the same amount of time as the in-person visits. She explained that when she sees patients in person she can have three patients in separate exam rooms at the same time whereas with telehealth it's a one-on-one appointment. Telehealth is not a cost savings for the provider and without pay parity it would be too easy for providers to say they didn't want to do telehealth. 2:02:50 PM SENATOR MICCICHE said the argument was very convincing and he'd like her to send the chair that explanation in writing. DR. RATHKOPF agreed to do so. CHAIR COSTELLO asked the sponsor if she had anything to add. 2:03:18 PM REPRESENTATIVE SPOHNHOLZ said she had two things to add. First, she clarified that the cost savings between FY2020 and FY2021 was 23 percent, not 38 percent but the $48 million savings was correct. Second, she said the testimony and questions about pay parity target the underlying issue of ensuring that patients continue to receive treatment from their established providers and that Alaskan providers continue to be able to provide the care. She shared her personal experience using telehealth when she had COVID-19 last month and was able to see both her long-time physician and a specialist. She agreed with Dr. Rathkopf's explanation of the need for pay parity and highlighted her earlier testimony that 84 percent of telehealth care in Alaska is provided by Alaska-based organizations and providers. CHAIR COSTELLO asked Genevieve Mina to present the sectional analysis for HB 265. 2:05:19 PM GENEVIEVE MINA, Staff, Representative Ivy Spohnholz, Alaska State Legislature, Juneau, Alaska, read the sectional analysis for CSHB 265(FIN), version E: [Original punctuation provided.] Section 1 Adds a new section on telehealth under Title 8 for all health care providers licensed with the State of Alaska. Subsection (a) removes the requirement for an in- person visit prior to a telehealth appointment. Subsection (b) narrowly exempts physicians licensed in another state to deliver health care services via telehealth if there is an established physician- patient relationship, an in-person physical exam, and the services are related to ongoing treatment or follow-up care related to past treatment. The language also references new enforcement language in Section 2. Subsections (c) and (d) create limits for a telehealth appointment. If a telehealth appointment falls outside of a provider's authorized scope of practice, they may refer a patient to an appropriate clinician. The cost of a service delivered through telehealth must be the same as if it were delivered in person. ? Subsections (e), (f), and (g) ensure that only authorized providers licensed with the State of Alaska can prescribe controlled substances (e.g., buprenorphine, Adderall, etc.) via telehealth without conducting an in-person visit. These providers must comply with the state and federal laws regarding the prescription of controlled substances via telehealth. o Subsection (e) pertains to providers in Title 8, Chapter 64 (Medicine) (i.e., physicians, podiatrists, osteopaths and physician assistants). o Subsection (f) pertains to Advanced Practice Registered Nurses (APRNs) in Title 8, Chapter 68 (Nursing). Subsection (h) removes requirements to document all attempts for an in-person visit and prevents the department or board from limiting the physical setting of a health care provider delivering telehealth. ? Subsection (i) confirms that health care providers under this section are not required to deliver telehealth services. ? Subsection (j) provides definitions for all health care providers applicable to this section, specifies that the provider must be licensed in good standing, and defines telehealth. Section 2 Creates AS 08.64.33 defining the State Medical Board's authority to enforce against exempted physicians in Section 1 and ensures these providers must comply with Alaska laws for licensed physicians. o Subsection (a) describes the grounds for the board to sanction a physician licensed in another state providing telehealth services in Section 1: if they violate Alaska laws for Alaska-licensed physicians; exceed the defined scope of telehealth services in Section 1; or prescribe, administer, or dispense a controlled substance to an Alaska patient located in the state. o Subsection (b) and (c) ensures that the board can enforce exempted physicians in the same manner as Alaska-licensed physicians. In addition to this authority, they can issue a ceaseand-desist order and notify the licensing authority for each state the physician is licensed. o Subsection (d), (e), (g), and (h) details the board's disciplinary actions for exempted physicians, mirroring similar language regarding sanctions for Alaska-licensed physicians. o Subsection (f) ensures that the board can recover costs related to the proceedings and investigation directly from an exempted physician in Section 1. 2:09:21 PM Section 3 Amends language related to the prescription of controlled substances via telehealth under the State Medical Board. This deletes language requiring an additional health care provider to assist a patient during a telehealth appointment with a physician or physician assistant regarding the prescription, dispensing, and administration of controlled substances. 2:09:45 PM Section 4-5 Adds sections related to the prescription of controlled substances via telehealth under the Board of Nursing. This does not change the Board of Nursing's authority or the scope of practice for APRNs ensures regulatory equity between the Board of Nursing and the State Medical Board regarding the prescription of controlled substances via telehealth for all DEA- registered practitioners. ? Section 4 amends the Board of Nursing's regulatory authority to include controlled substances via telehealth in Section 5, mirroring statutory language for the State Medical Board. ? Section 5 creates a new section AS 08.68.710 defining the telehealth prescriptive authority of APRNs in statute. This section removes the regulatory in-person requirement for APRNs under 12 AAC 44.925(c), mirroring the deletion of language for the State Medical Board in Section 3. 2:10:50 PM Section 6 Adds a new section on telehealth under Title 18 for emergency medical services. This section removes the requirement for an in-person examination prior to a telehealth encounter. This section replicates the same provisions on cost, scope of services, documentation, physical setting, and patient protections as Section 1. Section 7 Adds a new section on telehealth payment under Title 47 for Alaska Medicaid. ? Subsection (a) requires the Department of Health to pay for telehealth services in the same manner as an in person service for the following: behavioral health services, home and community based services (HCBS), services provided by a community health aide or community health practitioner, behavioral health aide or behavioral health practitioner, dental health aide therapist, chemical dependency counselor, non-HCBS services covered under a federal waiver or demonstration, other services provided by an individual or entity eligible for department certification and Medicaid reimbursement, and services provided at rural clinics and federally qualified health centers. 2:11:59 PM This subsection also allows for a telehealth visit to be conducted through any means which could be useful in a patient-provider relationship, including an audio-only (i.e., phone call) appointment. ? Subsection (b) requires the department to adopt regulations regarding payment of telehealth services. This provision also allows the department to limit or restrict Medicaid coverage under this section if a service delivered via telehealth cannot be safely delivered according to substantial medical evidence, or if the federal government will not reimburse the delivery of the service via telehealth. ? Subsection (c) specifies that the coverage of services in Alaska Medicaid must be HIPAA compliant. Section 8-9 Adds sections on telehealth under Title 47 for grantees that deliver community mental health services, or facilities approved by the department to deliver substance use disorder treatment. Both sections replicate the same telehealth provisions on cost, scope of services, patient protections, documentation, and physical setting as Section 1. ? Section 8 creates AS 47.30.585 to include entities approved to receive grant funding by the Department of Health to deliver community mental health services. ? Section 9 creates AS 47.37.145 to include public or private treatment facilities approved by the Department of Health to deliver services addressing substance use disorders. Section 10 Provides an immediate effective date. 2:13:32 PM CHAIR COSTELLO referenced Section 1(d) and shared a constituent's experience of flying to Seattle and having a telemedicine appointment while in the Board Room at the airport because the physician was not licensed in Alaska. Following the appointment, her constituent got back on a plane to return to Alaska. She said she brought it up because there are Alaskans who have established relationships with physicians that are not licensed in Alaska and when COVID-19 happened those Alaskans weren't able to travel to get care from those physicians. She asked the sponsor to talk about the balance the bill strikes in that regard and whether it also allows telemedicine counseling and mental health appointments to be conducted by an attending physician who is not licensed in Alaska. 2:15:02 PM REPRESENTATIVE SPOHNHOLZ replied that constituent's experience is the reason for the provision in Section 1 of the bill. She described the work to get stakeholders to agree to this narrow exception and shared that her focus was to reduce unnecessary travel while ensuring that Alaska licensees wouldn't bear the cost of investigations into potential bad actors from out-of- state. The bill authorizes the State Medical Board to recoup the costs of those investigations. She clarified that the bill does not provide an exception for counseling and behavioral health care via telemedicine when the provider is not licensed in Alaska. Licensing for the professionals that typically provide this type of care is simpler and less time consuming than for medical doctors. According to the chair of the Psychology Board, it takes about six weeks to get an Alaska license as a psychologist, whereas the barrier is higher and it takes a lot longer to become licensed as a physician in Alaska. CHAIR COSTELLO asked Pam Ventgen whether the Alaska State Medical Association supports the current version of HB 265. 2:18:19 PM PAM VENTGEN, Executive Director, Alaska State Medical Association (ASMA), Anchorage, Alaska, answered yes; ASMA fully supports the current version of HB 265. ASMA worked closely with the many stakeholders to craft the narrow language to allow out- of-state specialists to continue to care for their Alaska patients via telemedicine. 2:19:52 PM CHAIR COSTELLO asked the sponsor to talk about the urgency and timeliness of this legislation, and thus the reason for the immediate effective date. REPRESENTATIVE SPOHNHOLZ explained that both DCCED and DHSS indicated they would be able to implement the legislation within the 90-day window of an immediate effective date. This will ensure that Alaskans continue to have access to the care they have been receiving after the federal public health emergency expires on July 22, 2022. SENATOR MICCICHE noted that a constituent who is an optometrist contacted his office to articulate the concern that the [Board of Examiners in Optometry] did not feel that all examinations can take place online via video. He asked how the bill proposes to address those limited situations. 2:21:38 PM REPRESENTATIVE SPOHNHOLZ agreed that not all examinations are appropriate for online. The decision in HB 265 was to provide a framework for telehealth and leave the regulations for the many individual license types to the appropriate board because they have the expertise and understand the scope of practice better than legislators. SENATOR MICCICHE summarized that certain procedures could be excluded from telehealth through regulation. REPRESENTATIVE SPOHNHOLZ confirmed that was the intention because it would be too onerous to define every license type by statute. CHAIR COSTELLO recognized Christopher Dietrich as the next person invited to testify. 2:24:40 PM CHRISTOPHER DIETRICH, Medical Director, Orion Behavioral Health (OBH), Palmer, Alaska, testified by invitation in support of HB 265. He stated that he is a member of the American Academy of Physician Assistants and on the board for PAs in Virtual Medicine and Telemedicine. He opined that from a behavioral health perspective, HB 265 will break down barriers to patient care, particularly with controlled substances. OBH has many patients from rural areas who currently have to travel to the clinic to meet with a nurse and get medication to maintain their behavioral health even when they have been taking the medication for years. The bill will eliminate the need for much of this travel, make it more likely that patients stay on their medication, and reduce behavioral health crises. He also spoke in support of payment parity for care delivered via telemedicine. 2:27:55 PM PHILIP LICHT, President and CEO, Set Free Alaska (SFA), Wasilla, Alaska, testified by invitation in support of HB 265. He stated that SFA offers substance abuse and mental health services in both MatSu and Homer. It provides residential and outpatient care for adults and behavioral health services for children. In 2016, SFA began exploring telehealth as a way to remove barriers, such as lack of transportation, in an effort to improve access to care. Individuals who need treatment for substance abuse often don't have a driver's license, so getting to an intensive outpatient treatment program several times a week is extremely challenging. He cited a study from Massachusetts that found that living more than a mile from their intensive outpatient treatment center made it significantly less likely that the client would complete their treatment. Clearly, not many Alaskans who need treatment live within that critical radius. When SFA started offering telehealth care they saw a significant increase in show rates both pre and during the pandemic. The point is that telehealth increases the likelihood of successful outcomes for individuals who need substance abuse and mental health services. MR. LICHT mentioned payment parity and highlighted that SFA's experience has been that telehealth is a little more expensive to provide. Personnel costs and overhead remain the same, but there has been an increase in costs due to the Zoom subscription and the technology and hardware that's needed. Internet speed is critical and it's more practical for each clinician to have dual monitors so they can have clinical notes on one screen and the clients on the other. For SFA it is very important that telehealth appointments are reimbursed at the same rate as in- person visits. 2:31:55 PM NANCY MERRIMAN, Executive Director, Alaska Primary Care Association (APCA), Anchorage, Alaska, provided the following testimony in support of HB 265: The Alaska Primary Care Association (APCA) supports the operations and development of Alaska's 29 Health Centers (also commonly referred to as Community Health Centers or Federally Qualified Health Centers). Health Centers provide comprehensive whole person care, which includes medical, dental, behavioral, pharmacy and care coordination services. APCA and Alaska's Health Centers support HB265 because it increases access to primary care and behavioral health services and expands telehealth in Alaska. This legislation: ? Includes a range of telehealth modalities, including audio-only, now & into the future ? Allows patients and providers to engage in telehealth services outside a clinic setting if they so choose ? Provides adequate reimbursement for telehealth visits, providing new points of access to whole person care, including behavioral health and substance use disorder treatment. In the most recent year of full reporting, 2020, Alaska's Health Centers served 105,000 patients through 450,000 visits delivering medical, dental, behavioral health, substance use disorder treatment and other care. Behavioral health and substance use disorder services are Health Centers' fastest growing area of service. 40% of these visits were accommodated via telehealth. In the subspecialty of substance use disorder services, 45% of visits were via telehealth. Alaska's Health Centers have weathered many emerging challenges brought on by the pandemic and APCA appreciates the actions taken by the Department of Health Social Services, which have allowed Health Centers to reach their patients via telehealth. The temporary telehealth policy changes allowed Health Centers to be recognized as telehealth treating providers; to furnish some behavioral health services via audio-only technology; and to be paid for telehealth services furnished to Medicaid beneficiaries under the Health Centers' unique payment system, called the prospective payment system (PPS). APCA supports HB265 as this key legislation allows these temporary telehealth provisions to become permanent for patients and providers in Alaska. Health Centers, by definition, serve hard-to-reach communities. The majority of Health Center patients experience a range of challenges in accessing health care that include facing long distances to reach local providers, cost of care, transportation, language, and cultural barriers. In Alaska, over half of Health Center patients are racial/ethnic minorities, a majority are low-income, and most patients live in rural communities. Health Centers can best serve their patient populations if they have the ability to use technology to better support their patients. Additionally, workforce shortages, particularly in the behavioral health sector, impact Health Centers uniquely as nonprofit safety-net providers, and telehealth allows Health Centers to use their clinical workforce most nimbly. In 2021, a cohort of health centers reported that [of] their telehealth interactions, 59 percent occurred by phone and 41 percent by audio and video. Through the pandemic, demand for tele-behavioral health now represents 35 percent of all telehealth usage. Health Centers have witnessed how telehealth has provided stronger continuity of care for patients, reduced travel costs, has resulted in fewer dropped visits and a reduction in delayed (and more costly) care. We understand that delivering quality whole person care ultimately leads to better health outcomes, saves lives and in the long run, it saves on cost. MS. MERRIMAN urged the committee to support HB 265. 2:35:51 PM CHAIR COSTELLO opened public testimony on HB 265. 2:36:10 PM JAYNE ANDREEN, President, Alaska Public Health Association (APHA), Douglas, Alaska, stated that she was testifying from a personal perspective as well as on behalf of APHA in support of HB 265. She shared that she and her husband had to make four trips to Seattle for care in 2021. This was difficult and time consuming despite having a good relationship with the out-of- state provider. On the last trip they spent 10 minutes with the specialist who said they were following the treatment plan and that it was too bad the appointment couldn't have been done on the phone. They left Juneau at 5:30 a.m. that morning and got back to Juneau that evening at 9:30 p.m. MS. ANDREEN emphasized that it was critical for Alaska to have a good telehealth system that maintains Alaska's standards. For this reason, she wholeheartedly supported HB 265. 2:37:57 PM LARRY JOHANSEN, representing self, Ketchikan, Alaska, stated that he was testifying in support of HB 265 because it will save him money and allow him to receive the health care he needs. He shared that he was diagnosed with Parkinson Disease 14 years ago and has been able to keep the symptoms under control with expert specialty care that is not available in Alaska. Early on he was told he should move to Seattle, but he loves Alaska and doesn't want to leave. He was living in Haines late last winter when he got sick and had to go to Seattle to get the specialty treatment he needed. He advocated for Alaskans to be able to access the specialty care they need via telehealth using audio and video and online computer-aided treatment. He restated his strong support for HB 265. 2:44:19 PM CHAIR COSTELLO closed public testimony on HB 265. 2:44:35 PM SENATOR STEVENS moved to report HB 265, work order 32-LS0754\E, from committee with individual recommendations and attached fiscal note(s). CHAIR COSTELLO found no objection and CSHB 265(FIN) was reported from the Senate Labor and Commerce Standing Committee. She thanked the sponsor and her staff for the background work that was done on the bill and voiced her personal support for telemedicine for Alaskans. REPRESENTATIVE SPOHNHOLZ thanked the chair and committee for supporting the bill and offered to answer any additional questions. CHAIR COSTELLO noted that Senator Micciche asked Dr. Rathkopt to follow up in writing about the cost for her office to provide telemedicine compared to in-person visits. That information would be forwarded to the next committee of referral. REPRESENTATIVE SPOHNHOLZ said she'd make sure the committee received the information.